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.

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.

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: 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.