Publications

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.

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.

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: High dietary purine intake is linked to hyperuricemia and gout, 2 significant global public health concerns. In 2023, the United States Department of Agriculture (USDA) Methods and Application of Food Composition Laboratory released the "USDA and Office of Dietary Supplements- National Institutes of Health (NIH) Database for the Purine Content of Foods (Release 1.0)." However, current data on the purine contents in highly consumed United States foods are still lacking.

OBJECTIVES: This study was designed to provide accurate, representative, and up-to-date purine composition data in commonly consumed United States foods.

METHODS: Sixty-one foods (3-8 samples per food) were obtained through USDA sample procurement programs and convenience sampling in the United States. Selected raw meat samples were cooked using common methods. Four purine bases (adenine, guanine, hypoxanthine, and xanthine) and uric acid were quantified using hydrophilic interaction liquid chromatography coupled with tandem high-resolution mass spectrometry.

RESULTS: Total purine content ranged from 96 mg/100 g to 448 mg/100 g in meat and seafood, with cooking altering levels due to water and fat loss. The total purine contents in legumes and vegetables ranged from 9 mg/100 g to 72 mg/100 g, whereas purines in milk, yogurt, cheeses, and eggs were negligible. Crab was the only food containing a significant amount of uric acid at 32 mg/100 g of food. The variation of purine contents and profiles both between different foods and within the same foods can be significant. The purine content and profile in certain food products changed over time, likely due to reformulation.

CONCLUSIONS: The data from this study filled critical knowledge gaps, which were used to update the "USDA and Office of Dietary Supplements-NIH Database for the Purine Content of Foods (Release 2.0)." Findings from this study will assist with more accurate estimations of dietary purine intake, provide useful insights for formulating dietary guidelines for the prevention and management of hyperuricemia and gout, and support future clinical and epidemiologic research.

BACKGROUND: Physical inactivity is highly prevalent in heart failure (HF) and chronic obstructive pulmonary disease (COPD) and is associated with poor outcomes, including worsened quality of life, increased hospitalizations, readmissions, and mortality. Accessible interventions that improve physical activity are needed. Mind-body strategies are well-suited for promoting physical activity; they show promise for targeting key health behavior change processes.

OBJECTIVE: The aim of this study was to examine the feasibility and acceptability of a web-based pedometer-mediated mind-body intervention (Mindful Steps) for promoting walking among individuals with HF and COPD.

METHODS: In this pilot randomized controlled trial, participants with chronic, stable HF and COPD were randomized to Mindful Steps or usual care in a 2:1 ratio. Mindful Steps is a 12-month multimodal intervention that includes a pedometer with individualized step-count goals, live mind-body exercise (MBE) classes, and a web platform with mind-body videos, motivation messages, and educational tips. Feasibility (recruitment rate, retention), intervention acceptability, and intervention adherence were the primary outcomes. Exploratory outcomes assessed at baseline, 3-, 6-, 9-, and 12-months included daily step counts, cognitive-behavioral/psychosocial measures, health-related quality of life, and self-reported physical function. Participants were enrolled in the study from April 2019 to July 2021. The study was converted to all-digital during the pandemic after March 2020.

RESULTS: Forty-one participants were randomized to Mindful Steps (n=26) or usual care (n=15). The recruitment rate was 3% (43/178), and overall study retention was 76% (31/41). In the intervention group, over 12 months, 58% (15/26) met a predefined benchmark for MBE class adherence (attending >70% of classes). Participants engaged most consistently with the MBE classes, the pedometer, and mind-body videos. There was a positive signal regarding group differences in the change in daily step counts from baseline, favoring intervention at 3 months (estimate=2038.77 steps per day between groups, 95% CI 289.76-3788.77), 6 months (estimate=3031.45, 95% CI 1261.15-4801.74), and 9 months (estimate=2703.80, 95% CI 862.97-4544.62). There were also positive signals regarding group differences in the change from baseline favoring intervention in the following outcomes: emotional awareness (estimate=0.88, 95% CI 0.15-1.61) and body listening (estimate=1.16, 95% CI 0.25-2.07) at 3-months; internal motivation (estimate=1.03, 95% CI 0.01-2.04) and pressure/tension at 6-months (estimate=-1.59, 95% CI -2.55 to -0.63); and exercise self-efficacy at 12 months (estimate=1.77, 95% CI 0.20-3.33).

CONCLUSIONS: Mindful Steps was largely feasible, acceptable, and had adequate intervention engagement. There were positive signals favoring the multimodal web intervention for daily step counts, interoceptive awareness, internal motivation, and exercise self-efficacy that will inform hypotheses in future studies. A pivot to fully remote conduct during the pandemic was successful. A larger trial examining the efficacy of Mindful Steps for promoting physical activity is warranted.

TRIAL REGISTRATION: ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/study/NCT03003780.

INTRODUCTION: Understanding how perceived interpersonal discrimination may affect women's cardiovascular health is key to informing prevention strategies, especially during mid-life when cardiovascular conditions emerge more frequently than in prior life stages.

METHODS: Participants are 451 women in Project Viva. In 2021-2022, participants completed the 9-item, race-neutral Williams Everyday Discrimination Scale (WEDS) via survey; total score ranged from 9 to 54, with higher scores indicating higher perceived discrimination. In 2022-2024, we collected in-person measures of body mass index (BMI), blood pressure and sleep duration (via actigraphy) and quality (via Patient-Reported Outcomes Measurement Information System sleep disturbance and sleep-related impairment forms). We defined obesity as BMI ≥30 kg/m2, hypertension as blood pressure ≥130/80 mm Hg or use of antihypertensive medications and short nightly sleep duration as sleep of <7 hours each night. We examined associations between WEDS (individual item and total scores) and cardiovascular outcomes using linear (continuous outcomes) or modified Poisson (binary outcomes) models.

RESULTS: At outcome measurement, women had a mean (SD) age of 55.8 (4.9) years and WEDS score of 14.9 (5.9); 74% self-identified as non-Hispanic White and 10% as non-Hispanic Black. After adjusting for age at outcome assessment, household income and education, a 10-point increment in total WEDS score was associated with a higher obesity risk (RR=1.40, 95% CI 1.10 to 1.79), higher BMI (β=1.62 kg/m2, 95% CI 0.50 to 2.74), shorter nightly sleep duration (β=-0.23 hours, 95% CI -0.41 to -0.06) and higher sleep disturbance (β=0.99, 95% CI -0.01 to 1.99) and sleep-related impairment t-scores (β=2.28, 95% CI 0.95 to 3.61). Most individual WEDS items were consistently associated with higher BMI and higher sleep impairment.

CONCLUSIONS: Higher perceived interpersonal discrimination was associated with higher BMI, risk of obesity, shorter sleep duration and poorer sleep quality among mid-life women. These findings underscore the association between interpersonal discrimination and cardiovascular health and highlight the importance of interventions aimed at reducing discrimination.

Individuals with dementia have a heightened hip fracture and fall risk but whether markers of brain injury are associated with hip fracture and falls is unknown. We tested the hypothesis that higher circulating brain injury markers were associated with increased risk of hip fracture and fall hospitalizations. Brain injury markers were measured in 2141 participants (mean age 77.9 yr; 60% women). Brain injury markers included neurofilament light chain (NfL), a marker of axonal injury; glial fibrillary acidic protein (GFAP), a marker of astrocytic injury; total Tau, whose many functions include neuron microtubule stabilization; and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), a major protein of neurons. Incident hip fractures and hospitalizations for falls were identified through participant report and confirmed with medical records or medicare claims. Hazard ratios were computed for a doubling exposure (log2 transformed brain injury marker) using multivariable-adjusted Cox models. After a median follow-up of 11 yr, 304 incident hip fractures and 284 incident fall hospitalizations occurred. Doubling of GFAP and NfL were associated with a 22% (p = .048) and 42% (p < .001) higher risk of hip fracture, respectively. Additional adjustment for cognitive function, gait speed, grip strength, inflammatory markers, and depressive symptoms had no effect on results. Models that adjusted for all 4 brain markers showed that only NfL was independent of the other markers. Neurofilament light chain was also associated with a 47% increase risk of hospitalization for falls. There was no association of total Tau or UCH-L1 with hip fracture or falls. GFAP was also unrelated to fall hospitalizations. Neurofilament light chain was independently associated with an incident risk of hip fracture and fall hospitalizations. These results suggest that subclinical degrees of brain injury may contribute to falls and hip fracture. Future research is needed to test whether the association between NfL and hip fracture is independent of falls.

Hypertensive disorders are a common complication of pregnancy, with secondary hypertension estimated to impact around 1% of pregnancies. There are numerous causes of secondary hypertension including chronic kidney disease, renal artery stenosis, primary aldosteronism, Cushing syndrome, pheochromocytomas, thyroid disorders, obstructive sleep apnea, coarctation of the aorta, and medication side effects. Identifying the underlying cause of hypertension in pregnancy is critical to determine the appropriate treatment. This review will focus on the pregnancy specific diagnosis and management considerations for secondary hypertension.