Research

Type 2 diabetes mellitus (T2DM) affects cognition and resting-state functional connectivity (rsFC). Intranasal insulin (INI) has emerged as a potential treatment for T2DM-related cognitive decline. We aimed to evaluate the effect of INI treatment on rsFC with medio-prefrontal (mPFC) and left/right hippocampus (lHPC/rHPC), and their relationship with the cognition, hemoglobin A1c (HbA1c), and homeostatic model assessment of insulin resistance (HOMA-IR) and walking speed. An MRI sub-study of the MemAID trial was conducted, involving a 24-week treatment with either intranasal insulin or placebo. Blood oxygen level-dependent (BOLD) functional MRI (fMRI) images were acquired on eighteen DM subjects at baseline and eleven DM subjects (eight DM-INI patients and three DM-Placebo) at the end-of-treatment. Compared to DM-Placebo treated subjects, DM-INI patients showed increased mPFC-postcentral rsFC, lHPC-frontal rsFC, lHPC-postcentral rsFC, rHPC-frontal rsFC, and lHPC-mPFC rsFC (p < 0.05). The decreased HOMA-IR, which was observed in the MemAID trial, was associated with increased mPFC-basal ganglia rsFC (p < 0.05). This sub-study provides insights into potential mechanisms of INI effects on rsFC that require validation in a larger trial.

Remote blood pressure (BP) monitoring, or blood pressure measurement outside of a clinical setting, has been an evolving approach to monitor BP outside of a clinical setting, allowing for a better understanding of day-to-day fluctuations in BP. This technology at home allows for detection of instantaneous fluctuations in BP that could be predictive of cardiovascular disease events. It also holds potential for more accurate diagnosis of hypertension and improved titration of antihypertensive medications. Home BP monitoring has traditionally focused on cuffed devices, but new technologies based on cuffless, wearable devices are emerging. These have novel applications clinically for continuous and intermittent blood pressure measurement. Although there are validation protocols for cuff-based devices, these do not always apply to cuffless devices, and both types require unique assessments for accurate BP measurements. Nevertheless, remote BP monitoring, including evolving cuffless devices, represents an intriguing prospect for monitoring BP and characterizing changes in patients' BP overtime. However, the overall clinical importance and application of instantaneous BP measurements remains unknown. The purpose of this review is to describe the current state of remote BP monitoring and evolving technologies in this field.

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: Migraine is a major cause of disability and efficacious interventions are needed. In this mechanistic study, we investigate the combined, and potentially synergistic, effects of a multimodal intervention combining Mindfulness-Based Stress Reduction (MBSR) and transcutaneous auricular Vagal Nerve Stimulation (taVNS) for migraine.

METHODS: We utilize a modified double-blinded, placebo-controlled, 2 × 2 factorial randomized longitudinal design to assess the effects of an 8-week MBSR intervention with concomitant Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS) taVNS on migraine pathophysiology primary outcomes. We will enroll 150 patients with migraine (4-20 headache days/month). After a run-in month of daily diaries, we expect to randomly assign N = 96 participants to one of four treatment groups: (1) MBSR+RAVANS taVNS, (2) MBSR+Sham taVNS, (3) Nature Education Control (NEC) + RAVANS taVNS, or (4) NEC + Sham taVNS. Before and after intervention, participants have three in-person assessments (a 7 T MRI scan, an autonomic/sensory testing (AST) visit, and a 3 T PET-MRI scan). The primary outcomes for this study assess (1) central sensitization (brainstem/cortical response to trigeminal sensory afference), (2) autonomic dysfunction (High Frequency-Heart Rate Variability (HF-HRV) response to stressors), and (3) neuroinflammation (PET[11C]PBR28 signal).

RESULTS: Funded by NIH (P01AT009965), registered (NCT03592329). Final longitudinal outcomes will be collected by May 2025.

CONCLUSION: This mechanistic study is designed to investigate both independent and synergistic neurobiological effects of MBSR and RAVANS taVNS interventions on three distinct pathophysiological mechanisms of migraine. This research will elucidate the mechanistic and potentially synergistic effects of behavioral interventions (e.g., mindfulness) and device-based treatments (e.g., taVNS) for migraine.

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.