Publications

BACKGROUND: Postoperative delirium is the most common complication following surgery amongst older adults, and has been consistently associated with increased mortality and morbidity, cognitive decline, loss of independence and increased health-care costs. We sought to identify preoperative predictors that could identify individuals at high risk for postoperative delirium, which could guide clinical decision-making and enable targeted interventions to potentially decrease delirium incidence and postoperative delirium-related complications.

METHODS: Preoperative resting-state electroencephalograms (EEGs) and the Montreal Cognitive Assessment were collected from a prospective observational cohort of 85 older adults (12 cases of delirium) undergoing elective surgery. Four machine learning models were tested and the model with the highest f1-score was subsequently validated in an independent, prospective cohort of 51 older adults (6 cases of delirium) undergoing elective surgery.

RESULTS: Occipital alpha powers have higher f1-score (0.57 ± 0.07) than frontal alpha powers (0.47 ± 0.07), EEG spectral slowing (0.48 ± 0.08), or modelling of EEG power spectral density into periodic and aperiodic components (0.44 ± 0.09) in the training cohort. Occipital alpha powers plus cognitive scores were able to predict postoperative delirium with area under the receiver operating characteristic curve (AUC) (0.94, 95% CI: [0.86-0.99]), sensitivity (0.83, 95% CI: [0.50-1.00]) and specificity (0.91, 95% CI: [0.82-0.98]) in the validation cohort, and outperformed models incorporating occipital alpha powers alone or cognitive scores alone.

CONCLUSIONS: Whilst the sample size is small and findings require confirmation in larger studies, our results suggest that the thalamocortical circuit exhibits different EEG patterns under stressors, with occipital alpha powers potentially reflecting baseline vulnerabilities.

IMPORTANCE: Millions of Americans provide health and function-related help to family (broadly defined). These "care partners" provide critical support; however, they are rarely identified or supported in care delivery.

OBJECTIVES: Conduct a multi-site evaluation of a portal-based intervention designed to identify, engage, and support care partners in primary care settings.

DESIGN: Three days before a visit, patients were sent a portal notification inviting them to complete a questionnaire. Participants reporting caregiving responsibilities were provided a link to the Caregiver Intensity Index™ (CII), an assessment of caregiving intensity with local resources. In-clinic materials were available with information about accessing the CII.

SETTING: Five primary care practices at two health care organizations.

PARTICIPANTS: All patients age 18 + years of age at organization 1 and 21 + at organization 2.

MAIN OUTCOMES: Intervention reach: proportion and characteristics of patients completing the pre-visit survey. Intervention effectiveness: proportion of patients completing the CII.

RESULTS: The demonstration was implemented at 5 primary care practices between September 30, 2022, and May 31, 2024. At Organization 1, 19,407 patients received the pre-visit portal based questionnaire and 8,905 completed it at least once (response rate = 45.9%). At Organization 2, 12,047 patients received the questionnaire; 7,819 completed it at least once (response rate = 64.9%). The majority of pre-visit questionnaires were completed by patients. Patients assisted by care partners in completing the survey were older and less likely to speak English as a first language. About 1 in 5 respondents (16.9% at Organization 1 and 22.8% at Organization 2) reported caregiving responsibilities. Of these respondents, 36.9% and 27.3% completed the CII. Across both organizations, 61% of patients accessing and completing the CI through any of the available means (QR codes on in office materials, link in the pre-visit survey, link in the after-visit summary document) moderate caregiving intensity. Among all participants completing the CII 16.2% (Organization 1) and 19.5% (Organization 2) clicked on at least one resource.

CONCLUSION: To our knowledge, this pilot represents the first-of-its-kind effort to identify and support patients with caregiving responsibilities through a portal-based intervention. Our demonstration suggests a simple portal questionnaire, with the CII linked to resources, and supported with in-clinic materials, may successfully identify, engage, and support care partners, with minimal changes to clinician workflow. This approach may also offer an opportunity to digitally engage more vulnerable patients. As efforts to improve support for care partners gain traction, incorporation of this portal-based intervention offers an opportunity for widespread engagement and support.

OBJECTIVES: Delirium, an acute disorder of attention and cognition, is a preventable contributor to poor outcomes in older adults including future cognitive decline. The goal of this study was to examine the cognitive impact of postoperative delirium.

DESIGN, SETTING, PARTICIPANTS: A secondary analysis of the randomized clinical trial STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) which included two hundred hip fracture repair patients was conducted.

MEASUREMENTS: Cognitive changes one year after surgery were examined. Modified Clinical Dementia Rating (CDR) and postoperative delirium status were adjudicated by a consensus panel. Delirium Rating Scale-Revised-98(DRS-R-98) was used to measure delirium severity. Data were analyzed using a random-intercept linear spline model, with Mini Mental State Examination (MMSE) and dementia severity (using CDR Sum of Boxes [CDR-SB]), as outcomes.

RESULTS: 36.5% of the overall cohort experienced delirium. When stratified by baseline cognitive status, delirium was associated with a faster rate of decline in MMSE and worsening in CDR-SB in cognitively unimpaired participants, but not in participants with baseline cognitive impairment. We found an estimated delirium associated change in MMSE of 1.52 points and CDR-SB of 1.22 points within one year after surgery associated with postoperative delirium after hip fracture repair in cognitively normal participants.

CONCLUSIONS: This study provides evidence that postoperative delirium is associated with a faster rate of cognitive decline, particularly in cognitively unimpaired individuals. This work highlights the importance of delirium prevention and management strategies in improving long-term cognitive outcomes in older adults.

IMPORTANCE: The Dietary Approaches to Stop Hypertension (DASH) eating plan lowered blood pressure (BP) among Black adults in a controlled environment, but to date, there are no grocery shopping strategies that replicated its health effects in a community setting.

OBJECTIVE: The Groceries for Black Residents of Boston to Stop Hypertension (GoFresh) trial was conducted to determine the effects of low sodium-DASH groceries on systolic BP.

DESIGN, SETTING, AND PARTICIPANTS: This parallel-group randomized clinical trial was conducted in Boston from August 2022 to September 2025 among Black residents of urban communities with few grocery stores, a systolic BP of 120 to less than 150 mm Hg, a diastolic BP less than 100 mm Hg, and no hypertension treatment. Data were analyzed from June through October 2025.

INTERVENTIONS: Participants were randomly assigned to 12 weeks of home-delivered, DASH-patterned groceries ordered weekly with dietitian counseling without emphasizing cost or three $500 stipends every 4 weeks intended for self-directed grocery shopping.

MAIN OUTCOMES AND MEASURES: The primary comparison was the difference in the 3-month change in model-estimated office systolic BP (based on 3 measurements over at least 2 visits) between interventions. Adherence was assessed via 24-hour urine collection. Secondary outcomes included diastolic BP, body mass index (BMI), hemoglobin A1c levels, and low-density lipoprotein (LDL) cholesterol. Maintenance of effects was assessed 3 months after intervention cessation.

RESULTS: Among 180 participants, (mean [SD] age, 46.1 [13.3] years; 102 female [56.7%]; 180 self-reported Black [100%]; 12 Hispanic [6.7%]), 175 individuals (97.2%) completed the primary outcome assessment. Mean (SD) baseline systolic BP and diastolic BP were 130.0 (6.7) mm Hg and 79.8 (8.1) mm Hg. At 3 months, the mean systolic BP changed -5.7 mm Hg (95% CI, -7.4, to-3.9 mm Hg) in the DASH-patterned group and -2.3 mm Hg (95% CI, -4.1 to -0.4 mm Hg) in the self-directed group (difference in changes, -3.4 mm Hg; 95% CI, -5.9 to -0.8 mm Hg; P = .009). Compared with the self-directed group, after 3 months the DASH-patterned group changed mean diastolic BP by -2.4 mm Hg (95% CI, -4.2 to -0.5 mm Hg), urine sodium level by -545 mg/24 h (95% CI, -1041 to -50 mg/24 h), and LDL cholesterol by -8.0 mg/dL (95% CI, -13.7 to -2.3 mg/dL) (to convert LDL cholesterol to millimoles per liter, multiply by 0.0259). Effects were not maintained 6 months after the intervention was initiated. No effects occurred in BMI or hemoglobin A1c level.

CONCLUSIONS AND RELEVANCE: In this study, a program of home-delivered, DASH-style groceries plus dietitian counseling decreased BP and LDL cholesterol levels beyond comparable monetary compensation. However, effects were not maintained after the intervention ended.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05121337.

BACKGROUND: Targeted, digital recruitment strategies such as tailored websites using motivational themes may improve recruitment in clinical trials, but their effectiveness remains unclear. We hypothesized that themes emphasizing community well-being, personal health benefits, or access to perks would increase engagement and prescreening sign-ups compared with a standard contribution to science message in a clinical trial focused on Black adults.

METHODS: We implemented A/B testing of website themes for recruitment in two randomized trials testing the dietary approaches to stop hypertension diet intervention on blood pressure among Black adults. Website themes were derived from predeveloped motivational categories and included (1) contribution to science (control group), (2) community well-being, (3) personal blood pressure improvement, and (4) access to perks (groceries or cash). A/B randomization directed visitors to a theme randomly between June and December 2024. Using an open-source Web analytics platform, we captured data on 2 primary outcomes: (1) sign-up rate defined as the proportion of unique visitors who completed the trial's prescreening form and (2) engagement defined as (a) mean pageviews per session and (b) mean time spent on site per session. We compared themes using the Welch t tests with statistical significance assessed as 2-tailed P<0.05.

RESULTS: Among 11 484 visitors over 6 months, the themes of community well-being (13.8%), personal blood pressure improvement (14.1%), and access to perks (13.1%) all attracted higher sign-up rates than contribution to science (11.1%; P<0.05 for all comparisons). All alternative themes also led to significantly higher mean pageviews compared with the contribution to science theme (P<0.05 for all comparisons), while mean time on site was similar across all themes (range, 52-55 seconds with P>0.05 for all comparisons). There were no statistical differences noted across the 3 alternative motivational themes for these outcomes.

CONCLUSIONS: Tailored websites with digital messages emphasizing community well-being, personal health benefits, and access to perks significantly improved engagement and prescreening sign-up rates, demonstrating that they may enhance recruitment within cardiovascular research.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT05393232 and NCT05121337.

This commentary on a case canvasses federal and some organizational rules applicable to health record keeping and considers these in light of "open notes." Accuracy of information in health records, accountability for remediating inaccuracies, and ownership are considered as key areas of ethics investigation.

INTRODUCTION: Hip fractures are common among older adults; and while urgent fracture fixation is recommended, it is often weighed against preoperative optimization needs. Previous studies have reported conflicting findings on the association between time to surgery and mortality risk. In this study, we investigated the association between surgical timing and mortality. We also explored the relationship between time to surgery and secondary outcomes, including length of stay and hospital readmission.

METHODS: We conducted a retrospective cross-sectional study of 967 adults aged ≥ 65 who underwent hip fracture repair between 2018 and 2023. Time to surgery (in days) was the primary exposure. Multivariable Cox proportional hazards models were used to assess associations with 30-day, 90-day, and 365-day mortality. Firth penalized logistic regression was used to examine associations with secondary outcomes, including length of stay >7 days and 30-day readmission.

RESULTS: For 30-day, 90-day, and 365-day mortality, each additional day of delay in surgery was associated with an increased risk of mortality, with adjusted hazard ratios (HR) of 1.15 (95% CI [1.02, 1.30], P = .02), 1.13 (95% CI [1.02, 1.26], P = .02), and 1.09 (95% CI [1.01, 1.19], P = .03), respectively. Similarly, each additional day of delay was associated with an increased risk of a length of stay >7 days and readmission within 30 days of discharge, with adjusted odds ratios (OR) of 2.26 (95% CI [1.89, 2.74]) and 1.16 (95% CI [1.05, 1.29]), respectively.

CONCLUSION: Delaying surgery in older adults increases the risk of mortality, along with a potential elevated risk of prolonged hospital stays and readmission. We recommend that, when safe, surgery should be performed promptly for these patients.

BACKGROUND: Identifying the cause of dyspnea (i.e., cardiac vs. non-cardiac) can be challenging in the absence of significant resting cardiac abnormalities. Exercise cardiovascular magnetic resonance (Ex-CMR) enables quantification of cardiac volumetric indices under physiological stress. Using Ex-CMR, we sought to develop a non-invasive imaging marker, referred to as the myocardial dynamic index (MDI), and to demonstrate its potential for evaluating cardiac dyspnea.

METHODS: MDI is a metric derived from Ex-CMR work-volume loop model that integrates rest and stress left ventricular (LV) end-diastolic and end-systolic volumes with workload measured during supine exercise, while accounting for body size and LV mass. To evaluate MDI as a marker of cardiac dyspnea, we retrospectively analyzed data from a prospective multicenter study measuring MDI in patients with cardiac or non-cardiac dyspnea. All had invasive exercise testing before Ex-CMR. Cardiac dyspnea was defined by established invasive and non-invasive criteria, including HFpEF (early to advanced) and HFmrEF. Non-cardiac dyspnea patients had normal invasive hemodynamics and cardiac function. Univariable and multivariable logistic regression identified clinical and imaging predictors of cardiac dyspnea. A base model incorporating clinical and rest CMR variables was compared to a model that included the base model plus MDI. Diagnostic performance was assessed using receiver operating characteristic analysis and compared using the DeLong test. MDI scan/re-scan reproducibility over one year, inter- and intra-observer reproducibility, and correlation with VO₂ max were evaluated.

RESULTS: Among 93 patients (66 with cardiac dyspnea, 27 with non-cardiac dyspnea), MDI was lower in patients with cardiac dyspnea (25.9±9.5 vs. 45.1±10.7 mL·W/g/m², p<0.0001). The base model included age, body mass index, NYHA class, and left atrial strain. In multivariable analysis, MDI emerged as the only independent predictor of cardiac dyspnea when added to the base model. Inclusion of MDI improved the AUC from 0.86 to 0.93 (p=0.012), while MDI alone yielded an AUC of 0.91. A strong correlation was observed between MDI and the VO₂ max index (r=0.84, p<0.0001). Reproducibility was excellent.

CONCLUSION: Ex-CMR MDI is independently associated with cardiac dyspnea and strongly correlates with the VO₂ max index. It aids in differentiating cardiac from non-cardiac dyspnea and provides incremental diagnostic value beyond conventional clinical and resting imaging parameters.