Publications

BACKGROUND: Impostor phenomenon (IP) is defined as self-doubt among high-achieving individuals. Previous studies have shown a high prevalence of IP among resident physicians, which can negatively impact the learning environment of academic teaching hospitals.

OBJECTIVES: This study explores how medical team leaders can help resident physicians overcome IP.

METHODS: A survey was conducted from February to June 2024 among internal medicine (IM), general surgery, and obstetrics and gynecology residents at Beth Israel Deaconess Medical Center. Using pragmatic qualitative analysis, the study identified leadership strategies that help alleviate IP.

RESULTS: Out of 125 respondents (49% response rate), 70% were IM residents, 14% OB-GYN, and 16% general surgery residents. Higher PGY levels were associated with lower odds of frequent IP, with an odds ratio of 0.71 (95% confidence interval of 0.51-0.97). Gender and specialty were not significantly associated with higher IP frequency. Effective leadership strategies included normalizing IP, providing specific feedback, demonstrating trust, and fostering a safe space to discuss negative thoughts.

CONCLUSION: Team leaders can help with learners' IP by normalizing it, taking time to give specific and constructive feedback, empowering the learner through trust, and creating a safe space to discuss negative self-perceptions. Imposter phenomenon declines with increased experience throughout residency. Future work needs to explore how to effectively train all resident and faculty team leaders with these strategies and their impact on medical student and intern wellness, especially in high-risk specialties and training levels.

BACKGROUND: Orthostatic hypotension (OH) is associated with cardiovascular disease, particularly among older adults. While a standing transthoracic echocardiogram (TTE) could theoretically identify changes in cardiac output to diagnose cardiogenic OH, there are no established protocols for orthostatic TTEs and their feasibility is unknown.

METHODS AND RESULTS: We recruited 115 patients scheduled for elective outpatient TTE. Consenting participants, who were able to stand safely, underwent their scheduled recumbent TTE, followed by a standing TTE, performed within 1-2 minutes of standing. The focused TTE used the apical window to measure velocity time integral across the aortic valve to assess cardiac output. Blood pressure (BP) was measured in the supine and standing positions and patients were asked about symptoms of dizziness and lightheadedness. OH was defined as a change in standing minus supine systolic BP ≤-20 mm Hg or in diastolic BP of ≤-10 mm Hg. Of the 115 enrolled participants, 102 (89%) completed the standing echocardiogram protocol. Among those completing, mean age was 63.4 (SD, 14.8) years (38% were ≥ 70 years), 48% women, and 34% had a BMI ≥ 30 kg/m2. There were 21% with OH. Upon standing, systolic BP changed by -5.9 mm Hg (95% CI: -9.5, -2.2), diastolic BP by 2.4 mm Hg (-0.1, 4.8), and cardiac output by -0.4 L/min (95% CI: -0.7, -0.1). Change in cardiac output (per 1 L/min) was associated with a higher odds of systolic OH (OR: 1.60; 95% CI: 1.05, 2.42), but not diastolic OH (OR: 1.21; 95% CI: 0.63, 2.32).

CONCLUSIONS: Standing TTE is safe, well-tolerated, and feasible in the ambulatory setting. Moreover, TTE changes in cardiac output are associated with systolic OH. This clinical assessment shows promise for distinguishing OH etiologies and could inform further research on treatments to prevent OH.

PurposeDelirium is a common yet preventable complication of hospitalization, surgery and illness that is associated with poor outcomes. Older adults with Alzheimer's Disease and Related Dementias (ADRD) are especially vulnerable to delirium and experience greater delirium severity, yet no existing assessment tool is specifically designed to evaluate this vulnerable population. This study will validate two new delirium severity instruments, the Delirium Severity (DEL-S) rating for all older adults and the Delirium Severity Rating in ADRD (DEL-S-AD) for patients with dementia.Design/Setting and ParticipantsThe Better ASsessment of ILlness II (BASIL II) study is an innovative prospective cohort study that measures cognitive function, delirium, delirium severity, demographics, clinical and functional variables and clinical outcomes. Participants include older adults from 3 unique yet complementary clinical sites: medical inpatients, elective surgery inpatients, or skilled nursing facility residents.MethodsPerformance of DEL-S and DEL-S-AD items in older adults with cognition ranging from no impairment to moderate impairment will be determined. Analyses will include psychometric characteristics of DEL-S and DEL-S-AD items, harmonization of the two scales and validation against reference standard diagnoses.Conclusions and ImplicationsResults from this study will help accurately measure delirium severity, a critically important, graded outcome. The DEL-S-AD instrument holds broad applications in persons with and without ADRD to monitor delirium severity in clinical settings, and as an outcome measure in future clinical treatment trials and pathophysiologic studies. Ultimately, the DEL-S and DEL-S-AD have the potential to improve health care for the vulnerable, growing population of older adults with cognitive impairment worldwide.

OBJECTIVES: Guidelines recommend women consider their breast cancer risk and life expectancy when deciding on breast cancer screening (e.g., intervals, when to stop) and prevention medication. We previously developed a competing-risk model to predict 10-year breast cancer risk and non-breast cancer death in women > 55 years to support decision-making. Here, we aimed to develop a decision aid (DA) website incorporating our model's risk estimates.

METHODS: We designed the DA based on international standards using the free R package Shiny. We included a risk-assessment page, risk estimates, and decision support on breast cancer screening and prevention medications. We recruited national experts, Boston-area primary care practitioners (PCPs), and female patients > 55 years without breast cancer history to provide feedback on the DA via questionnaire or personal interview. We used thematic analysis to identify themes in participants' open-ended comments until reaching thematic saturation. Study questionnaires assessed DA helpfulness and ease-of-use.

RESULTS: Forty-five (53.6 %) of 84 eligible patients approached participated. Their mean age was 65.9 years (SD 7.9), 31 (68.9 %) were non-Hispanic White, and 31 (68.9 %) graduated college. Of 52 experts/PCPs contacted, 30 participated. Participants found the DA helpful (35/44 patients [79.5 %] and 28/29 [96.6 %] experts/PCPs) and easy-to-use (39/45 patients [86.7 %] and 28/29 PCPs/experts, [96.6 %]). They described the DA as "informative" and liked the "tailored-risk information." They suggested changes to simplify the DA and to better individualize the decision-support. We iteratively revised the website. We could not program some recommended changes using the free R application.

CONCLUSIONS: We developed an informative and easy-to-use breast cancer screening and prevention medication DA website (https://bcrisk55plus.shinyapps.io/risktool/) for women > 55 using free software. Next, we will program the website using HTML code and test its effects prospectively.

PRACTICE IMPLICATIONS: We anticipate that use of the DA will help women > 55 with breast cancer screening and prevention decisions.

BACKGROUND: Timely primary care follow-up after hospitalization is recommended to monitor recovery and coordinate care. Whether follow-up differs for vulnerable populations, such as those with frailty and those discharged to skilled nursing facilities (SNF) prior to returning home, is not known.

METHODS: Retrospective cohort study using a 100% sample of traditional Medicare beneficiaries discharged from hospital to home or from hospital to SNF and then home, between 2010 and 2022. The primary outcome was the receipt of a primary care visit within 30 days of return to home, measured overall and stratified by disposition (discharged home vs. to SNF then home) and by frailty (defined by a claims-based frailty index). Multivariable logistic regression models were used to estimate changes in outcomes over time, overall and stratified by disposition and frailty.

RESULTS: The cohort included 94,248,326 discharges (80.1% age ≥ 65 years, 55.1% female, 36.7% frail) of which 21.5% were discharged to SNF and then home. Between 2010 and 2022, primary care follow-up increased from 51.5% to 57.5% for patients discharged directly home and from 24.3% to 28.4% for patients discharged to SNF then home. In adjusted analyses, compared to those discharged directly home, patients discharged to SNF and then home had an 8.2% point (pp) (95% CI, -8.5 to -7.9) lower predicted probability of ambulatory follow-up in 2022. Among patients discharged directly home, no difference was evident in follow-up between frail and non-frail patients (54.6% vs. 54.1%); difference 0.4 pp (95% CI, -0.1 to 1.0). In contrast, among patients discharged to SNF then home, frail patients had a lower predicted probability of follow-up (42.8% vs. 48.9%); difference - 6.1 pp (95% CI, -7.0 to -5.2).

CONCLUSIONS: Frail patients and patients requiring a short-term SNF stay after hospitalization are less likely to receive timely follow-up upon return to home than other patient groups.

Estimating the magnitude of placebo responses across pharmacological and nonpharmacological trials is important for understanding their influence on trial outcomes. Yet, the extent to which more intense placebo interventions like sham acupuncture yield larger analgesic responses than placebo pills, and the factors predicting these responses, remain unclear. This meta-analysis investigated the magnitude and predictors of placebo analgesia responses in pharmacological vs acupuncture trials. Analyses included individual patient data from the placebo arm of 11 randomized controlled trials (RCTs): 9 pharmacological RCTs using placebo pills (N = 2021) and 2 acupuncture RCTs using sham acupuncture (N = 747). All trials were conducted in patients with chronic nociceptive pain (osteoarthritis, N = 2068; low back pain, N = 700). The placebo response was calculated as the change in pain intensity (0-100) between baseline and week 12. A random effects model demonstrated that placebo pills and patients with osteoarthritis exhibited smaller placebo responses than sham acupuncture and patients with low back pain (both P < 0.001, marginal effects). A mixed effects model showed that route of administration interacted significantly with baseline pain, premature termination, and the presence of adverse events. Together, predictors explained 20% to 25% of the individual variance in placebo responses, whereas 75% to 80% remained unaccounted for. In summary, sham acupuncture accounted for slightly larger placebo responses than placebo pills. Since basic trial and patient parameters explained only a small portion of this variability, we might need to start considering the patient's perception of the treatment-including cognition and emotions-to better predict placebo analgesia responses.

BACKGROUND: Age-related cognitive decline results in significant clinical and public health costs. Cognitive decline predisposes individuals to dementia and leads to difficulties with activities of daily living and increased hospitalizations. While a few dietary interventions have shown considerable promise at delaying cognitive decline, studies of the effects of long-term blueberry consumption on brain health among older adults have been limited and equivocal.

OBJECTIVE: To test the hypothesis that a 24-week intervention with blueberry powder versus placebo will improve (i) plasma biomarkers of brain health and (ii) cognitive performance in older adults.

METHODS: This randomized, double-blind, placebo-controlled trial will be conducted in older Americans aged 65-99 years old. Sixty-seven participants will be randomly assigned to receive either blueberry powder (20 g/d - equivalent of one (1) cup of fresh blueberries) or a placebo powder (20 g/d) for 24 weeks. Participants will undergo four clinic visits (baseline and 8 weeks, 16 weeks, and 24 weeks after randomization) for cognitive assessments, blood pressure measurements, and blood sample collections. Primary outcomes will be plasma levels of neurofilament light chain (NFL) and phosphorylated tau protein (pTau-181). Secondary outcomes will be plasma levels of glial fibrillary acidic protein (GFAP) and non-esterified fatty acids (NEFA); blood pressure during visits; and cognitive function.

CONCLUSION: Findings from this trial will answer the question whether a long-term intervention with blueberry powder can improve (i) plasma biomarkers of brain health and (ii) cognitive function in older adults.

INTRODUCTION: Triple-negative breast cancer (TNBC) often shows significant response to neoadjuvant chemotherapy (NACT), creating opportunities for axillary de-escalation. This study investigates axillary de-escalation and the factors influencing its use in TNBC.

METHODS: Patients with cT1-cT2, cN1 TNBC treated between 2012 and 2020 were identified from the National Cancer Database. Nodal response rates, including achievement of ypN0, were analyzed. Logistic regression identified clinical and sociodemographic factors associated with axillary management.

RESULTS: Among 12,742 patients undergoing axillary lymph node dissection (ALND), 31.7% achieved nodal pathologic complete response (pCR). These patients were more also likely to achieve breast tumor pCR. Treatment across multiple facilities was associated with a higher likelihood of attempted axillary de-escalation. ALND rates steadily declined between 2014 and 2020.

CONCLUSION: Despite achieving nodal pCR after NACT, many patients with TNBC underwent ALND. These findings underscore the need to refine criteria and increase adoption of axillary de-escalation strategies in TNBC.

BACKGROUND: Mechanisms of injury due to hypertension (HTN) in pregnancy remain poorly characterized. This study examined trends in markers of cardiac injury (high-sensitivity troponin I, hs-cTnI), strain (N-terminal pro-B-type natriuretic peptide, NT-proBNP), and inflammation (high-sensitivity C-reactive protein, hs-CRP) in pregnancies with and without HTN.

METHODS: This prospective, 1:1 case-control study enrolled pregnant women with and without HTN (24-32 weeks gestation) from 2019-2022. HTN was defined by a clinical diagnosis of HTN or baseline blood pressure (BP)≥140/90 mmHg. Serum was collected at baseline, pre-delivery, and postpartum day 1. Mixed effects tobit models compared log-transformed hs-cTnI, NT-proBNP, and hs-CRP across HTN groups and over time, adjusted for age and BMI.

RESULTS: Mean baseline BP was 130.5 (17.5)/88.2 (13.5) mmHg for the HTN group (n=38, 86.8% chronic, 13.2% gestational HTN), and 112.0 (9.8)/70.9 (8.2) mmHg for those without HTN (n=38). Over pregnancy, the HTN group had higher hs-cTnI than those without HTN (2.12 [0.43] vs. 1.07 [0.25], Δ1.05 [95%CI: 0.07-2.03] ng/L). Compared to baseline, hs-cTnI increased at pre-delivery and postpartum for both groups. Overall, the two groups had similar NT-proBNP (HTN: 39.0 [4.5] vs. no HTN: 35.6 [4.3] pg/mL) and hs-CRP (HTN: 12.0 [1.7] vs. no HTN: 9.9 [1.5] mg/L). For both groups, NT-proBNP and hs-CRP increased from baseline to postpartum (NT-proBNP, HTN: 127% [58-227%], no HTN: 120% [51-219%]; hs-CRP: HTN: 550% [343-853%], no HTN: 664% [415-1034%]).

CONCLUSION: HTN was associated with markers of cardiac injury during pregnancy, while delivery alone led to increases in markers of strain and inflammation. These biomarker changes associated with HTN in pregnancy may represent potential mechanisms to explain adverse cardiovascular events.