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Blood AJ, Chang LS, Hassan S, Chasse J, Stern G, Gabovitch D, Zelle D, Colling C, Aronson SJ, Figueroa C, Collins E, Ruggiero R, Zacherle E, Noone J, Robar C, Plutzky J, Gaziano TA, Cannon CP, Wexler DJ, Scirica BM. Randomized Evaluation of a Remote Management Program to Improve Guideline-directed Medical Therapy: The Diabetes Remote Intervention to Improve Use of Evidence-based Medications (DRIVE) Trial. Circulation 2024. [PMID: 38583146 DOI: 10.1161/circulationaha.124.069494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Several sodium-glucose transport protein 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D); however, utilization remains low despite guideline recommendations. METHODS A randomized, remote implementation trial in the Mass General Brigham network enrolled patients with T2D at high CV and /or kidney risk. Patients eligible for, but not prescribed, SGLT2i or GLP-1 RA were randomly assigned to simultaneous virtual patient education with concurrent prescription of SGLT2i or GLP-1 RA ("simultaneous") or two months of virtual education followed by medication prescription ("education-first") delivered by a multi-disciplinary team driven by non-licensed navigators and clinical pharmacists who prescribed SGLT2i or GLP-1 RA using a standardized treatment algorithm. The primary outcome was the proportion of patients with prescriptions for either SGLT2i or GLP-1 RA by 6 months. RESULTS Between March 2021 and December 2022, 200 patients were randomized. Mean age was 66.5 years, 36.5% were female, 22.0% were non-White. Overall, 30.0% had cardiovascular CV disease, 5.0% had cerebrovascular disease, and 1.5% had both. Mean estimated glomerular filtration rate (eGFR) 77.9 mL/min/1.73m2 and mean urine/albumin creatinine ratio (UACR) 88.6mg/g. After two months, 69/200 (34.5%) patients received a new prescription for either SGLT2i or GLP-1 RA: 53.4% of patients in the simultaneous arm vs. 8.3% of patients were in the education-first arm (p<0.001). After six months, 128/200 (64.0%) received a new prescription: 69.8 % of patients in the simultaneous arm vs. 56.0% of patients in education-first (p<0.001). Patient self-report of taking SGLT2i or GLP-1 RA within six months of trial entry was similarly higher in the simultaneous versus education-first arm (69 /116; 59.5% vs 37/84; 44.0%; p<0.001) Median time to first prescription was 24 (IQR 13, 50) vs 85 days (IQR 65, 106), respectively (p<0.001). CONCLUSIONS In this randomized trial, a remote team-based program that identifies patients with T2D and high CV or kidney risk, provides virtual education, and prescribes SGLT2i or GLP-1 RA improves GDMT. These findings support greater utilization of virtual team-based approaches to optimize chronic disease management.
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Affiliation(s)
- Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Lee-Shing Chang
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Shahzad Hassan
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jacqueline Chasse
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gretchen Stern
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Daniel Gabovitch
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - David Zelle
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Caitlin Colling
- Diabetes Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Personalized Medicine, Mass General Brigham, Cambridge, MA
| | - Christian Figueroa
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Emma Collins
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Ryan Ruggiero
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Jorge Plutzky
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Thomas A Gaziano
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Christopher P Cannon
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Blood AJ, Chang LS, Colling C, Stern G, Gabovitch D, Feldman G, Adan A, Waterman F, Durden E, Hamersky C, Noone J, Aronson SJ, Liberatore P, Gaziano TA, Matta LS, Plutzky J, Cannon CP, Wexler DJ, Scirica BM. Methods, rationale, and design for a remote pharmacist and navigator-driven disease management program to improve guideline-directed medical therapy in patients with type 2 diabetes at elevated cardiovascular and/or kidney risk. Prim Care Diabetes 2024; 18:202-209. [PMID: 38302335 DOI: 10.1016/j.pcd.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
AIM Describe the rationale for and design of Diabetes Remote Intervention to improVe use of Evidence-based medications (DRIVE), a remote medication management program designed to initiate and titrate guideline-directed medical therapy (GDMT) in patients with type 2 diabetes (T2D) at elevated cardiovascular (CV) and/or kidney risk by leveraging non-physician providers. METHODS An electronic health record based algorithm is used to identify patients with T2D and either established atherosclerotic CV disease (ASCVD), high risk for ASCVD, chronic kidney disease, and/or heart failure within our health system. Patients are invited to participate and randomly assigned to either simultaneous education and medication management, or a period of education prior to medication management. Patient navigators (trained, non-licensed staff) are the primary points of contact while a pharmacist or nurse practitioner reviews and authorizes each medication initiation and titration under an institution-approved collaborative drug therapy management protocol with supervision from a cardiologist and/or endocrinologist. Patient engagement is managed through software to support communication, automation, workflow, and standardization. CONCLUSION We are testing a remote, navigator-driven, pharmacist-led, and physician-overseen management strategy to optimize GDMT for T2D as a population-level strategy to close the gap between guidelines and clinical practice for patients with T2D at elevated CV and/or kidney risk.
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Affiliation(s)
- Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Lee-Shing Chang
- Endocrinology Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Caitlin Colling
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Gretchen Stern
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Gabovitch
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Guinevere Feldman
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Asma Adan
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Paul Liberatore
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Thomas A Gaziano
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lina S Matta
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Jorge Plutzky
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christopher P Cannon
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Deborah J Wexler
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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3
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Unlu O, Shin J, Mailly CJ, Oates MF, Tucci MR, Varugheese M, Wagholikar K, Wang F, Scirica BM, Blood AJ, Aronson SJ. Retrieval Augmented Generation Enabled Generative Pre-Trained Transformer 4 (GPT-4) Performance for Clinical Trial Screening. medRxiv 2024:2024.02.08.24302376. [PMID: 38370719 PMCID: PMC10871450 DOI: 10.1101/2024.02.08.24302376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background Subject screening is a key aspect of all clinical trials; however, traditionally, it is a labor-intensive and error-prone task, demanding significant time and resources. With the advent of large language models (LLMs) and related technologies, a paradigm shift in natural language processing capabilities offers a promising avenue for increasing both quality and efficiency of screening efforts. This study aimed to test the Retrieval-Augmented Generation (RAG) process enabled Generative Pretrained Transformer Version 4 (GPT-4) to accurately identify and report on inclusion and exclusion criteria for a clinical trial. Methods The Co-Operative Program for Implementation of Optimal Therapy in Heart Failure (COPILOT-HF) trial aims to recruit patients with symptomatic heart failure. As part of the screening process, a list of potentially eligible patients is created through an electronic health record (EHR) query. Currently, structured data in the EHR can only be used to determine 5 out of 6 inclusion and 5 out of 17 exclusion criteria. Trained, but non-licensed, study staff complete manual chart review to determine patient eligibility and record their assessment of the inclusion and exclusion criteria. We obtained the structured assessments completed by the study staff and clinical notes for the past two years and developed a workflow of clinical note-based question answering system powered by RAG architecture and GPT-4 that we named RECTIFIER (RAG-Enabled Clinical Trial Infrastructure for Inclusion Exclusion Review). We used notes from 100 patients as a development dataset, 282 patients as a validation dataset, and 1894 patients as a test set. An expert clinician completed a blinded review of patients' charts to answer the eligibility questions and determine the "gold standard" answers. We calculated the sensitivity, specificity, accuracy, and Matthews correlation coefficient (MCC) for each question and screening method. We also performed bootstrapping to calculate the confidence intervals for each statistic. Results Both RECTIFIER and study staff answers closely aligned with the expert clinician answers across criteria with accuracy ranging between 97.9% and 100% (MCC 0.837 and 1) for RECTIFIER and 91.7% and 100% (MCC 0.644 and 1) for study staff. RECTIFIER performed better than study staff to determine the inclusion criteria of "symptomatic heart failure" with an accuracy of 97.9% vs 91.7% and an MCC of 0.924 vs 0.721, respectively. Overall, the sensitivity and specificity of determining eligibility for the RECTIFIER was 92.3% (CI) and 93.9% (CI), and study staff was 90.1% (CI) and 83.6% (CI), respectively. Conclusion GPT-4 based solutions have the potential to improve efficiency and reduce costs in clinical trial screening. When incorporating new tools such as RECTIFIER, it is important to consider the potential hazards of automating the screening process and set up appropriate mitigation strategies such as final clinician review before patient engagement.
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Affiliation(s)
- Ozan Unlu
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jiyeon Shin
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Mass General Brigham Personalized Medicine, Cambridge, MA
| | - Charlotte J Mailly
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Mass General Brigham Personalized Medicine, Cambridge, MA
| | - Michael F Oates
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Mass General Brigham Personalized Medicine, Cambridge, MA
| | - Michela R Tucci
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Matthew Varugheese
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Kavishwar Wagholikar
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Research Information Science and Computing, Mass General Brigham, Somerville, MA
| | - Fei Wang
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Mass General Brigham Personalized Medicine, Cambridge, MA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
- Mass General Brigham Personalized Medicine, Cambridge, MA
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4
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Cho J, Noonan SH, Fay R, Apovian CM, McCarthy AC, Blood AJ, Samal L, Fisher N, Orav JE, Plutzky J, Block JP, Bates DW, Rozenblum R, Tucci M, McPartlin M, Gordon WJ, McManus KD, Morrison-Deutsch C, Scirica BM, Baer HJ. Implementation of a Scalable Online Weight Management Programme in Clinical Settings: Protocol for the PROPS 2.0 Programme (Partnerships for Reducing Overweight and Obesity with Patient-Centered Strategies 2.0). BMJ Open 2023; 13:e077520. [PMID: 38135330 DOI: 10.1136/bmjopen-2023-077520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION There is an urgent need for scalable strategies for treating overweight and obesity in clinical settings. PROPS 2.0 (Partnerships for Reducing Overweight and Obesity with Patient-Centered Strategies 2.0) aims to adapt and implement the combined intervention from the PROPS Study at scale, in a diverse cross-section of patients and providers. METHODS AND ANALYSIS We are implementing PROPS 2.0 across a variety of clinics at Brigham and Women's Hospital, targeting enrolment of 5000 patients. Providers can refer patients or patients can self-refer. Eligible patients must be ≥20 years old and have a body mass index (BMI) of ≥30 kg/m2 or a BMI of 25-29.9 kg/m2 plus another cardiovascular risk factor or obesity-related condition. After enrolment, patients register for the RestoreHealth online programme/app (HealthFleet Inc.) and participate for 12 months. Patients can engage with the programme and receive personalized feedback from a coach. Patient navigators help to enrol patients, enter updates in the electronic health record, and refer patients to additional resources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is guiding the evaluation. ETHICS AND DISSEMINATION The Mass General Brigham Human Research Committee approved this protocol. An implementation guide will be created and disseminated, to help other sites adopt the intervention in the future. TRIAL REGISTRATION NUMBER NCT0555925.
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Affiliation(s)
- JoAnn Cho
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah H Noonan
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard Fay
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Ashley C McCarthy
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander J Blood
- Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Naomi Fisher
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - John E Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Jorge Plutzky
- Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason P Block
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - David Westfall Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ronen Rozenblum
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Michela Tucci
- Accelerator for Clinical Transformation, Mass General Brigham, Boston, Massachusetts, USA
| | - Marian McPartlin
- Accelerator for Clinical Transformation, Mass General Brigham, Boston, Massachusetts, USA
| | - Willam J Gordon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine D McManus
- Department of Nutrition, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Benjamin M Scirica
- Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Heather J Baer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
- Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
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5
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Hassan S, Anwar W, Mehta S, Hanif MI, Kamouh A, Blood AJ. Postoperative outcomes, predictors and trends of mortality and morbidity in patients undergoing hip fracture surgery with underlying aortic stenosis: a nationwide inpatient sample analysis. BMC Cardiovasc Disord 2023; 23:535. [PMID: 37919652 PMCID: PMC10623838 DOI: 10.1186/s12872-023-03584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures. METHODS A retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS. RESULTS From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p < 0.001). Risk factors such as congestive heart failure (OR, 2.3[CI, 2.1-2.6]), age above 85 years (OR, 3.2[CI, 2.2-4.7]), cardiac arrhythmias (OR, 2.4[CI, 2.2-2.6]), end-stage renal disease (OR, 3.4[CI, 2.7-4.1]), malnutrition (OR, 2.3[CI, 2.1-2.7]) and AS (OR, 1.2[CI, 1.08-1.5] were associated with increased adjusted odds of postoperative mortality. AS was linked to higher adjusted odds of postoperative mortality (OR, 1.2 [CI, 1.1-1.5]) and complications such as acute myocardial infarction (OR, 1.2 [CI, 1.01-1.4]), cardiogenic shock (OR, 2.0[CI, 1.4-2.9]) and acute renal failure (OR, 1.1[CI, 1.02-1.2]). While hospital stay duration was comparable in both groups (average 5 days), the AS group incurred higher costs (mean $50,673 vs $44,607). The presence of acute heart failure in patients with AS and hip fracture significantly increased mortality, hospital stay, and cost. A notable decline in postoperative in-hospital mortality was observed in both groups from 2008-2019 though the rate of major in-hospital complications rose. CONCLUSION AS significantly influences postoperative in-hospital mortality and complication rates in hip fracture patients. While a reduction in postoperative mortality was observed in both AS and non-AS cohorts, the incidence of major in-hospital complications increased across both groups.
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Affiliation(s)
- Shahzad Hassan
- Boston Medical Center, One Boston Medical Center Pl, Boston University School of Medicine, , Boston, MA, 02118, USA.
| | - Waqas Anwar
- Rawalpindi Medical University, Rawalpindi, 46000, Punjab, Pakistan
| | - Shivani Mehta
- Department of Internal Medicine, Wayne State University/Trinity Health Oakland, Pontiac, MI, 48341, USA
| | - Muhammad Iftikhar Hanif
- Department of Interprofessional Health Sciences and Health Administration, Seton Hall University, South Orange, NJ, 07079, USA
| | - Abdallah Kamouh
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Florence, SC, 29505, USA
| | - Alexander J Blood
- Department of Medicine, Division of Cardiology, Newton Wellesley Hospital, Newton, MA, 02462, USA
- Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
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6
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Lee SG, Blood AJ, Cannon CP, Gordon WJ, Nichols H, Zelle D, Scirica BM, Fisher NDL. Remote Cardiovascular Hypertension Program Enhanced Blood Pressure Control During the COVID-19 Pandemic. J Am Heart Assoc 2023; 12:e027296. [PMID: 36915035 PMCID: PMC10111523 DOI: 10.1161/jaha.122.027296] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Background The COVID-19 pandemic disrupted traditional health care; one fallout was a drastic decrease in blood pressure (BP) assessment. We analyzed the pandemic's impact on our existing remote hypertension management program's effectiveness and adaptability. Methods and Results This retrospective observational analysis evaluated BP control in an entirely remote management program before and during the pandemic. A team of pharmacists, nurse practitioners, physicians, and nonlicensed navigators used an evidence-based clinical algorithm to optimize hypertensive treatment. The algorithm was adapted during the pandemic to simplify BP control. Overall, 1256 patients (605 enrolled in the 6 months before the pandemic shutdown in March 2020 and 651 in the 6 months after) were a median age of 63 years old, 57% female, and 38.2% non-White. Among enrolled patients with sustained hypertension, 51.1% reached BP goals. Within this group, rates of achieving goal BP improved to 94.6% during the pandemic from 75.8% prepandemic (P<0.0001). Mean baseline home BP was 141.7/81.9 mm Hg during the pandemic and 139.8/82.2 prepandemic, and fell ≈16/9 mm Hg in both periods (P<0.0001). Maintenance during the pandemic was achieved earlier (median 11.8 versus 19.6 weeks, P<0.0001), with more frequent monthly calls (8.2 versus 3.1, P<0.0001) and more monthly home BP recordings per patient (32.4 versus 18.9, P<0.0001), compared with the prepandemic period. Conclusions A remote clinical management program was successfully adapted and delivered significant improvements in BP control and increased home BP monitoring despite a nationally observed disruption of traditional hypertension care. Such programs have the potential to transform hypertension management and care delivery.
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Affiliation(s)
- Simin Gharib Lee
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | - Alexander J Blood
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | - Christopher P Cannon
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
- Harvard Medical School Boston MA
| | - William J Gordon
- Harvard Medical School Boston MA
- Division of General Internal Medicine and Primary Care Brigham and Women's Hospital Boston MA
| | | | - David Zelle
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
- Harvard Medical School Boston MA
| | - Benjamin M Scirica
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
- Harvard Medical School Boston MA
| | - Naomi D L Fisher
- Harvard Medical School Boston MA
- Division of Endocrinology, Diabetes and Hypertension Brigham and Women's Hospital Boston MA
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7
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Blood AJ, Cannon CP, Gordon WJ, Mailly C, MacLean T, Subramaniam S, Tucci M, Crossen J, Nichols H, Wagholikar KB, Zelle D, McPartlin M, Matta LS, Oates M, Aronson S, Murphy S, Landman A, Fisher NDL, Gaziano TA, Plutzky J, Scirica BM. Results of a Remotely Delivered Hypertension and Lipid Program in More Than 10 000 Patients Across a Diverse Health Care Network. JAMA Cardiol 2023; 8:12-21. [PMID: 36350612 PMCID: PMC9647559 DOI: 10.1001/jamacardio.2022.4018] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
Importance Blood pressure (BP) and cholesterol control remain challenging. Remote care can deliver more effective care outside of traditional clinician-patient settings but scaling and ensuring access to care among diverse populations remains elusive. Objective To implement and evaluate a remote hypertension and cholesterol management program across a diverse health care network. Design, Setting, and Participants Between January 2018 and July 2021, 20 454 patients in a large integrated health network were screened; 18 444 were approached, and 10 803 were enrolled in a comprehensive remote hypertension and cholesterol program (3658 patients with hypertension, 8103 patients with cholesterol, and 958 patients with both). A total of 1266 patients requested education only without medication titration. Enrolled patients received education, home BP device integration, and medication titration. Nonlicensed navigators and pharmacists, supported by cardiovascular clinicians, coordinated care using standardized algorithms, task management and automation software, and omnichannel communication. BP and laboratory test results were actively monitored. Main Outcomes and Measures Changes in BP and low-density lipoprotein cholesterol (LDL-C). Results The mean (SD) age among 10 803 patients was 65 (11.4) years; 6009 participants (56%) were female; 1321 (12%) identified as Black, 1190 (11%) as Hispanic, 7758 (72%) as White, and 1727 (16%) as another or multiple races (including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown, other, and declined to respond; consolidated owing to small numbers); and 142 (11%) reported a preferred language other than English. A total of 424 482 BP readings and 139 263 laboratory reports were collected. In the hypertension program, the mean (SD) office BP prior to enrollment was 150/83 (18/10) mm Hg, and the mean (SD) home BP was 145/83 (20/12) mm Hg. For those engaged in remote medication management, the mean (SD) clinic BP 6 and 12 months after enrollment decreased by 8.7/3.8 (21.4/12.4) and 9.7/5.2 (22.2/12.6) mm Hg, respectively. In the education-only cohort, BP changed by a mean (SD) -1.5/-0.7 (23.0/11.1) and by +0.2/-1.9 (30.3/11.2) mm Hg, respectively (P < .001 for between cohort difference). In the lipids program, patients in remote medication management experienced a reduction in LDL-C by a mean (SD) 35.4 (43.1) and 37.5 (43.9) mg/dL at 6 and 12 months, respectively, while the education-only cohort experienced a mean (SD) reduction in LDL-C of 9.3 (34.3) and 10.2 (35.5) mg/dL at 6 and 12 months, respectively (P < .001). Similar rates of enrollment and reductions in BP and lipids were observed across different racial, ethnic, and primary language groups. Conclusions and Relevance The results of this study indicate that a standardized remote BP and cholesterol management program may help optimize guideline-directed therapy at scale, reduce cardiovascular risk, and minimize the need for in-person visits among diverse populations.
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Affiliation(s)
- Alexander J. Blood
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Cannon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - William J. Gordon
- Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Charlotte Mailly
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Taylor MacLean
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Samantha Subramaniam
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michela Tucci
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer Crossen
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hunter Nichols
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David Zelle
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Marian McPartlin
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lina S. Matta
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael Oates
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Samuel Aronson
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Shawn Murphy
- Harvard Medical School, Boston, Massachusetts
- Laboratory of Computer Science, Massachusetts General Hospital, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
- Research Information Science and Computing, Mass General Brigham, Boston, Massachusetts
| | - Adam Landman
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Naomi D. L. Fisher
- Harvard Medical School, Boston, Massachusetts
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas A. Gaziano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Benjamin M. Scirica
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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8
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Wagholikar KB, Ainsworth L, Zelle D, Chaney K, Mendis M, Klann J, Blood AJ, Miller A, Chulyadyo R, Oates M, Gordon WJ, Aronson SJ, Scirica BM, Murphy SN. I2b2-etl: Python application for importing electronic health data into the informatics for integrating biology and the bedside platform. Bioinformatics 2022; 38:4833-4836. [PMID: 36053173 PMCID: PMC9563689 DOI: 10.1093/bioinformatics/btac595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/15/2022] [Accepted: 08/31/2022] [Indexed: 11/14/2022] Open
Abstract
MOTIVATION The i2b2 platform is used at major academic health institutions and research consortia for querying for electronic health data. However, a major obstacle for wider utilization of the platform is the complexity of data loading that entails a steep curve of learning the platform's complex data schemas. To address this problem, we have developed the i2b2-etl package that simplifies the data loading process, which will facilitate wider deployment and utilization of the platform. RESULTS We have implemented i2b2-etl as a Python application that imports ontology and patient data using simplified input file schemas and provides inbuilt record number de-identification and data validation. We describe a real-world deployment of i2b2-etl for a population-management initiative at MassGeneral Brigham. AVAILABILITY AND IMPLEMENTATION i2b2-etl is a free, open-source application implemented in Python available under the Mozilla 2 license. The application can be downloaded as compiled docker images. A live demo is available at https://i2b2clinical.org/demo-i2b2etl/ (username: demo, password: Etl@2021). SUPPLEMENTARY INFORMATION Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Kavishwar B Wagholikar
- Harvard Medical School, Boston, MA 02115, USA.,Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - David Zelle
- Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Kira Chaney
- Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Jeffery Klann
- Harvard Medical School, Boston, MA 02115, USA.,Massachusetts General Hospital, Boston, MA 02114, USA
| | - Alexander J Blood
- Harvard Medical School, Boston, MA 02115, USA.,Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | | | | - William J Gordon
- Harvard Medical School, Boston, MA 02115, USA.,Mass General Brigham, Boston, MA 02199, USA.,Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Benjamin M Scirica
- Harvard Medical School, Boston, MA 02115, USA.,Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Shawn N Murphy
- Harvard Medical School, Boston, MA 02115, USA.,Massachusetts General Hospital, Boston, MA 02114, USA
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9
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De Armas R, Blood AJ, Subramaniam S, Zelle D, Aronson S, Crossen J, Chasse J, Oates M, Gordon W, Cannon C, Scirica B, Fisher N. Effectiveness of a remote care program in the management of patients with resistant hypertension or multiple medication intolerances. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A remote hypertension (HTN) program, designed and implemented at Mass General Brigham (MGB), has demonstrated improved HTN control, reduced need for in-person visits, and increased access to care. The program excluded patients with resistant HTN or multiple intolerances/allergies to guideline-directed therapies, whose blood pressure (BP) is difficult to manage.
Purpose
To develop a more intensive but still remote program (“HTN-Plus”) for patients with resistant HTN or intolerances/allergies to multiple medications, and to assess its effectiveness for BP control.
Methods
From 10/2020 through 11/2021, we identified a subset of hypertensive patients from the total pool of those enrolled in our remote HTN management program, who required more personalized and intensive therapy than the overall remote management program provided. We developed ancillary management for these patients, who included: 1) patients with apparent resistant HTN (ARH), ie with uncontrolled BP despite maximum tolerated doses of at least three anti-HTN medications including a diuretic, and 2) patients with multiple medication intolerances or allergies that precluded appropriate triple therapy or limited dose-optimization. A nurse practitioner provided education and advice on BP measurement technique, lifestyle modifications, and adherence. Evaluation for primary aldosteronism (PA) was undertaken in those with ARH.
Results
We enrolled 3658 patients with uncontrolled HTN, of whom 117 qualified for the HTN-Plus program. The average BP on entry was 143/80 mmHg. 68% had apparent resistant HTN and 32% had multiple medication intolerances/allergies. Among all patients, 30% had incorrect BP-measurement technique upon interview, 10% who were tested for PA had a positive screening test, 56% had a history suggestive of an unmanaged secondary cause, and only 6% admitted imperfect adherence, but urine testing was not done. 74% of patients completed the program meaning they were reachable through the end and did not drop out. Across the program, 72 new medications were started, and 84 medication titrations were made. 50% of patients who enrolled in HTN-plus achieved BP <130/80 mmHg. 22% achieved BP control with education and coaching alone. For patients who completed the program, the average entry and final BPs were 139/78 mmHg and 126/70 mmHg respectively, with an average BP decrease of 13/8 mmHg.
Conclusions
In patients who remain hypertensive despite maximally tolerated guideline-directed medication utilization, our intensified but still entirely remote HTN management program helped patients reach their BP goal through education, coaching, and medication management. Nearly a quarter were able to achieve BP control with education and coaching alone. These results suggest that a significant value of remote care in patients with resistant HTN or medication intolerances/allergies lies in ongoing education and coaching, for which more cost-effective solutions may be considered.
Funding Acknowledgement
Type of funding sources: Private hospital(s). Main funding source(s): Mass General Brigham as part of quality improvement initiative
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Affiliation(s)
- R De Armas
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - A J Blood
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - S Subramaniam
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - D Zelle
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - S Aronson
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - J Crossen
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - J Chasse
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - M Oates
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - W Gordon
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - C Cannon
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - B Scirica
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - N Fisher
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
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10
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Lee SG, Blood AJ, Kochar A. Negotiation for the Early-Career Cardiologist. J Am Coll Cardiol 2022; 80:1110-1113. [PMID: 36075682 DOI: 10.1016/j.jacc.2022.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/26/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Simin Gharib Lee
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Alexander J Blood
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Newton Wellesley Hospital, Newton, Massachusetts, USA
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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11
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Wagholikar KB, Zelle D, Ainsworth L, Chaney K, Blood AJ, Miller A, Chulyadyo R, Oates M, Gordon WJ, Aronson SJ, Scirica BM, Murphy SN. Use of automatic SQL generation interface to enhance transparency and validity of health-data analysis. Informatics in Medicine Unlocked 2022; 31. [PMID: 35874460 PMCID: PMC9306316 DOI: 10.1016/j.imu.2022.100996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Analysis of health data typically requires development of queries using structured query language (SQL) by a data-analyst. As the SQL queries are manually created, they are prone to errors. In addition, accurate implementation of the queries depends on effective communication with clinical experts, that further makes the analysis error prone. As a potential resolution, we explore an alternative approach wherein a graphical interface that automatically generates the SQL queries is used to perform the analysis. The latter allows clinical experts to directly perform complex queries on the data, despite their unfamiliarity with SQL syntax. The interface provides an intuitive understanding of the query logic which makes the analysis transparent and comprehensible to the clinical study-staff, thereby enhancing the transparency and validity of the analysis. This study demonstrates the feasibility of using a user-friendly interface that automatically generate SQL for analysis of health data. It outlines challenges that will be useful for designing user-friendly tools to improve transparency and reproducibility of data analysis.
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12
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Waugh JL, Hassan A, Kuster JK, Levenstein JM, Warfield SK, Makris N, Brüggemann N, Sharma N, Breiter HC, Blood AJ. An MRI method for parcellating the human striatum into matrix and striosome compartments in vivo. Neuroimage 2021; 246:118714. [PMID: 34800665 PMCID: PMC9142299 DOI: 10.1016/j.neuroimage.2021.118714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Abstract
The mammalian striatum is comprised of intermingled tissue compartments, matrix and striosome. Though indistinguishable by routine histological techniques, matrix and striosome have distinct embryologic origins, afferent/efferent connections, surface protein expression, intra-striatal location, susceptibilities to injury, and functional roles in a range of animal behaviors. Distinguishing the compartments previously required post-mortem tissue and/or genetic manipulation; we aimed to identify matrix/striosome non-invasively in living humans. We used diffusion MRI (probabilistic tractography) to identify human striatal voxels with connectivity biased towards matrix-favoring or striosome-favoring regions (determined by prior animal tract-tracing studies). Segmented striatal compartments replicated the topological segregation and somatotopic organization identified in animal matrix/striosome studies. Of brain regions mapped in prior studies, our human brain data confirmed 93% of the compartment-selective structural connectivity demonstrated in animals. Test-retest assessment on repeat scans found a voxel classification error rate of 0.14%. Fractional anisotropy was significantly higher in matrix-like voxels, while mean diffusivity did not differ between the compartments. As mapped by the Talairach human brain atlas, 460 regions were significantly biased towards either matrix or striosome. Our method allows the study of striatal compartments in human health and disease, in vivo, for the first time.
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Affiliation(s)
- J L Waugh
- Division of Pediatric Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States; Division of Child Neurology, University of Texas Southwestern, Dallas, TX, United States; Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Mood and Motor Control Laboratory, Boston, MA, United States; Martinos Center for Biomedical Imaging, United States; Massachusetts General Hospital, Charlestown, MA, United States.
| | - Aao Hassan
- Division of Pediatric Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - J K Kuster
- Mood and Motor Control Laboratory, Boston, MA, United States; Laboratory of Neuroimaging and Genetics, United States; Martinos Center for Biomedical Imaging, United States; Rheumatology, Allergy and Immunology Section, Massachusetts General Hospital, Boston, MA, United States.
| | - J M Levenstein
- Mood and Motor Control Laboratory, Boston, MA, United States; Martinos Center for Biomedical Imaging, United States; Yale School of Medicine, New Haven, CN, United States; Wellcome Centre for Integrative Neuroimaging, National Institutes of Health, Bethesda, MD, United States.
| | - S K Warfield
- Department of Radiology, United States; Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - N Makris
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Center for Morphometric Analysis, United States; Martinos Center for Biomedical Imaging, United States; Departments of Neurology and Psychiatry, Charlestown, MA, United States.
| | - N Brüggemann
- Department of Neurology, University of Oxford, Oxford, United Kingdom; Institute of Neurogenetics, University of Lübeck, Lübeck, Germany.
| | - N Sharma
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Massachusetts General Hospital, Charlestown, MA, United States.
| | - H C Breiter
- Laboratory of Neuroimaging and Genetics, United States; Warren Wright Adolescent Center, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| | - A J Blood
- Mood and Motor Control Laboratory, Boston, MA, United States; Laboratory of Neuroimaging and Genetics, United States; Martinos Center for Biomedical Imaging, United States; Departments of Neurology and Psychiatry, Charlestown, MA, United States.
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13
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Gordon WJ, Blood AJ, Chaney K, Clark E, Glynn C, Green R, Laurent JS, Mailly C, McPartlin M, Murphy S, Nichols H, Oates M, Subramaniam S, Varugheese M, Wagholikar K, Aronson S, Scirica BM. Workflow Automation for a Virtual Hypertension Management Program. Appl Clin Inform 2021; 12:1041-1048. [PMID: 34758494 PMCID: PMC8580734 DOI: 10.1055/s-0041-1739195] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objectives
Hypertension is a modifiable risk factor for numerous comorbidities and treating hypertension can greatly improve health outcomes. We sought to increase the efficiency of a virtual hypertension management program through workflow automation processes.
Methods
We developed a customer relationship management (CRM) solution at our institution for the purpose of improving processes and workflow for a virtual hypertension management program and describe here the development, implementation, and initial experience of this CRM system.
Results
Notable system features include task automation, patient data capture, multi-channel communication, integration with our electronic health record (EHR), and device integration (for blood pressure cuffs). In the five stages of our program (intake and eligibility screening, enrollment, device configuration/setup, medication titration, and maintenance), we describe some of the key process improvements and workflow automations that are enabled using our CRM platform, like automatic reminders to capture blood pressure data and present these data to our clinical team when ready for clinical decision making. We also describe key limitations of CRM, like balancing out-of-the-box functionality with development flexibility. Among our first group of referred patients, 76% (39/51) preferred email as their communication method, 26/51 (51%) were able to enroll electronically, and 63% of those enrolled (32/51) were able to transmit blood pressure data without phone support.
Conclusion
A CRM platform could improve clinical processes through multiple pathways, including workflow automation, multi-channel communication, and device integration. Future work will examine the operational improvements of this health information technology solution as well as assess clinical outcomes.
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Affiliation(s)
- William J Gordon
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States.,Mass General Brigham, Boston, Massachusetts, United States
| | - Alexander J Blood
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Kira Chaney
- Mass General Brigham, Boston, Massachusetts, United States
| | - Eugene Clark
- Mass General Brigham, Boston, Massachusetts, United States
| | - Corey Glynn
- Mass General Brigham, Boston, Massachusetts, United States
| | - Remlee Green
- Mass General Brigham, Boston, Massachusetts, United States
| | | | | | | | - Shawn Murphy
- Harvard Medical School, Boston, Massachusetts, United States.,Mass General Brigham, Boston, Massachusetts, United States.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Hunter Nichols
- Mass General Brigham, Boston, Massachusetts, United States
| | - Michael Oates
- Mass General Brigham, Boston, Massachusetts, United States
| | | | | | - Kavishwar Wagholikar
- Harvard Medical School, Boston, Massachusetts, United States.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Samuel Aronson
- Mass General Brigham, Boston, Massachusetts, United States
| | - Benjamin M Scirica
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States.,Mass General Brigham, Boston, Massachusetts, United States
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14
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Mandawat A, Chattranukulchai P, Mandawat A, Blood AJ, Ambati S, Hayes B, Rehwald W, Kim HW, Heitner JF, Shah DJ, Klem I. Progression of Myocardial Fibrosis in Nonischemic DCM and Association With Mortality and Heart Failure Outcomes. JACC Cardiovasc Imaging 2021; 14:1338-1350. [PMID: 33454264 DOI: 10.1016/j.jcmg.2020.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/15/2020] [Accepted: 11/04/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The purpose of this study was to assess whether the presence and extent of fibrosis changes over time in patients with nonischemic, dilated cardiomyopathy (DCM) receiving optimal medical therapy and the implications of any such changes on left ventricular ejection fraction (LVEF) and clinical outcomes. BACKGROUND Myocardial fibrosis on cardiovascular magnetic resonance (CMR) imaging has emerged as important risk marker in patients with DCM. METHODS In total, 85 patients (age 56 ± 15 years, 45% women) with DCM underwent serial CMR (median interval 1.5 years) for assessment of LVEF and fibrosis. The primary outcome was all-cause mortality; the secondary outcome was a composite of heart failure hospitalization, aborted sudden cardiac death, left ventricular (LV) assist device implantation, or heart transplant. RESULTS On CMR-1, fibrosis (median 0.0 [interquartile range: 0% to 2.6%]) of LV mass was noted in 34 (40%) patients. On CMR-2, regression of fibrosis was not seen in any patient. Fibrosis findings were stable in 70 (82%) patients. Fibrosis progression (increase >1.8% of LV mass or new fibrosis) was seen in 15 patients (18%); 46% of these patients had no fibrosis on CMR-1. Although fibrosis progression was on aggregate associated with adverse LV remodeling and decreasing LVEF (40 ± 7% to 34 ± 10%; p < 0.01), in 60% of these cases the change in LVEF was minimal (<5%). Fibrosis progression was associated with increased hazards for all-cause mortality (hazard ratio: 3.4 [95% confidence interval: 1.5 to 7.9]; p < 0.01) and heart failure-related complications (hazard ratio: 3.5 [95% confidence interval: 1.5 to 8.1]; p < 0.01) after adjustment for clinical covariates including LVEF. CONCLUSIONS Once myocardial replacement fibrosis in DCM is present on CMR, it does not regress in size or resolve over time. Progressive fibrosis is often associated with minimal change in LVEF and identifies a high-risk cohort.
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Affiliation(s)
- Aditya Mandawat
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Pairoj Chattranukulchai
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Anant Mandawat
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Sindhoor Ambati
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA
| | - Brenda Hayes
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA
| | - Wolfgang Rehwald
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA
| | - Han W Kim
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - John F Heitner
- Department of Cardiology, New York Methodist Hospital, Brooklyn, New York, USA
| | - Dipan J Shah
- Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Igor Klem
- Duke Cardiovascular Magnetic Resonance Center Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
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15
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Desai AS, Maclean T, Blood AJ, Bosque-Hamilton J, Dunning J, Fischer C, Fera L, Smith KV, Wagholikar K, Zelle D, Gaziano T, Plutzky J, Scirica B, MacRae CA. Remote Optimization of Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2020; 5:1430-1434. [PMID: 32936209 DOI: 10.1001/jamacardio.2020.3757] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Optimal treatment of heart failure with reduced ejection fraction (HFrEF) is scripted by treatment guidelines, but many eligible patients do not receive guideline-directed medical therapy (GDMT) in clinical practice. Objective To determine whether a remote, algorithm-driven, navigator-administered medication optimization program could enhance implementation of GDMT in HFrEF. Design, Setting, and Participants In this case-control study, a population-based sample of patients with HFrEF was offered participation in a quality improvement program directed at GDMT optimization. Treating clinicians in a tertiary academic medical center who were caring for patients with heart failure and an ejection fraction of 40% or less (identified through an electronic health record-based search) were approached for permission to adjust medical therapy according to a sequential titration algorithm modeled on the current American College of Cardiology/American Heart Association heart failure guidelines. Navigators contacted participants by telephone to direct medication adjustment and conduct longitudinal surveillance of laboratory tests, blood pressure, and symptoms under supervision of a pharmacist, nurse practitioner, and heart failure cardiologist. Patients and clinicians declining to participate served as a control group. Exposures Navigator-led remote optimization of GDMT compared with usual care. Main Outcomes and Measures Proportion of patients receiving GDMT in the intervention and control groups at 3 months. Results Of 1028 eligible patients (mean [SD] values: age, 68 [14] years; ejection fraction, 32% [8%]; and systolic blood pressure, 122 [18] mm Hg; 305 women (30.0%); 892 individuals [86.8%] in New York Heart Association class I and II), 197 (19.2%) participated in the medication optimization program, and 831 (80.8%) continued with usual care as directed by their treating clinicians (585 [56.9%] general cardiologists; 443 [43.1%] heart failure specialists). At 3 months, patients participating in the remote intervention experienced significant increases from baseline in use of renin-angiotensin system antagonists (138 [70.1%] to 170 [86.3%]; P < .001) and β-blockers (152 [77.2%] to 181 [91.9%]; P < .001) but not mineralocorticoid receptor antagonists (51 [25.9%] to 60 [30.5%]; P = .14). Doses for each category of GDMT also increased from baseline in the intervention group. Among the usual-care group, there were no changes from baseline in the proportion of patients receiving GDMT or the dose of GDMT in any category. Conclusions and Relevance Remote titration of GDMT by navigators using encoded algorithms may represent an efficient, population-level strategy for rapidly closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor Maclean
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexander J Blood
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joshua Bosque-Hamilton
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline Dunning
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina Fischer
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana Fera
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - David Zelle
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas Gaziano
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jorge Plutzky
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Benjamin Scirica
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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16
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Blood AJ, Fischer CM, Fera LE, MacLean TE, Smith KV, Dunning JR, Bosque-Hamilton JW, Aronson SJ, Gaziano TA, MacRae CA, Matta LS, Mercurio-Pinto AA, Murphy SN, Scirica BM, Wagholikar K, Desai AS. Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. Clin Cardiol 2019; 43:4-13. [PMID: 31725920 PMCID: PMC6954374 DOI: 10.1002/clc.23291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Alexander J Blood
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina M Fischer
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana E Fera
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor E MacLean
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline R Dunning
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Samuel J Aronson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Thomas A Gaziano
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lina S Matta
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ana A Mercurio-Pinto
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shawn N Murphy
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Benjamin M Scirica
- Cardiovascular Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kavishwar Wagholikar
- Massachusetts General Hospital, Boston, Massachusetts.,Research Information Science and Computing, Partners Healthcare, Somerville, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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17
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Fischetti CE, Kamyszek RW, Shaheen S, Oshlag B, Banks A, Blood AJ, Bytomski JR, Boggess B, Lahham S. Evaluation of a Standardized Cardiac Athletic Screening for National Collegiate Athletic Association (NCAA) Athletes. West J Emerg Med 2019; 20:810-817. [PMID: 31539339 PMCID: PMC6754195 DOI: 10.5811/westjem.2019.7.43190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/10/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Sudden cardiac death is a rare cause of death in young athletes. Current screening techniques include history and physical exam (H and P), with or without an electrocardiogram (ECG). Adding point of care cardiac ultrasound has demonstrated benefits, but there is limited data about implementing this technology. We evaluated the feasibility of adding ultrasound to preparticipation screening for collegiate athletes. METHODS We prospectively enrolled 42 collegiate athletes randomly selected from several sports. All athletes were screened using a 14-point H and P based on 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, ECG, and cardiac ultrasound. RESULTS We screened 11 female and 31 male athletes. On ultrasound, male athletes demonstrated significantly larger interventricular septal wall thickness (p = 0.002), posterior wall thickness (p <0.001) and aortic root breadth (p = 0.002) compared to females. Based on H and P and ECGs alone and a combination of H and P with ECG, no athletes demonstrated a positive screening for cardiac abnormalities. However, with combined H and P, ECG, and cardiac ultrasound, one athlete demonstrated positive findings. CONCLUSIONS We believe that adding point of care ultrasound to the preparticipation exam of college athletes is feasible. This workflow may provide a model for athletic departments' screening.
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Affiliation(s)
- Chanel E Fischetti
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | | | - Stephen Shaheen
- Duke University Medical Center, Department of Surgery, Durham, North Carolina
| | - Benjamin Oshlag
- New York Presbyterian Hospital/Columbia University Medical Center, Department of Emergency Medicine, New York, New York
| | - Adam Banks
- Duke University Medical Center, Department of Medicine, Durham, North Carolina
| | - A J Blood
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts
| | - Jeffrey R Bytomski
- Duke University Medical Center, Department of Community and Family Medicine, Durham, North Carolina
| | - Blake Boggess
- Duke University Medical Center, Department of Community and Family Medicine, Durham, North Carolina
| | - Shadi Lahham
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
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18
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Waugh JL, Kuster JK, Makhlouf ML, Levenstein JM, Multhaupt-Buell TJ, Warfield SK, Sharma N, Blood AJ. A registration method for improving quantitative assessment in probabilistic diffusion tractography. Neuroimage 2019; 189:288-306. [PMID: 30611874 DOI: 10.1016/j.neuroimage.2018.12.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 12/26/2018] [Accepted: 12/28/2018] [Indexed: 01/07/2023] Open
Abstract
Diffusion MRI-based probabilistic tractography is a powerful tool for non-invasively investigating normal brain architecture and alterations in structural connectivity associated with disease states. Both voxelwise and region-of-interest methods of analysis are capable of integrating population differences in tract amplitude (streamline count or density), given proper alignment of the tracts of interest. However, quantification of tract differences (between groups, or longitudinally within individuals) has been hampered by two related features of white matter. First, it is unknown to what extent healthy individuals differ in the precise location of white matter tracts, and to what extent experimental factors influence perceived tract location. Second, white matter lacks the gross neuroanatomical features (e.g., gyri, histological subtyping) that make parcellation of grey matter plausible - determining where tracts "should" lie within larger white matter structures is difficult. Accurately quantifying tractographic connectivity between individuals is thus inherently linked to the difficulty of identifying and aligning precise tract location. Tractography is often utilized to study neurological diseases in which the precise structural and connectivity abnormalities are unknown, underscoring the importance of accounting for individual differences in tract location when evaluating the strength of structural connectivity. We set out to quantify spatial variance in tracts aligned through a standard, whole-brain registration method, and to assess the impact of location mismatch on groupwise assessments of tract amplitude. We then developed a method for tract alignment that enhances the existing standard whole brain registration, and then tested whether this method improved the reliability of groupwise contrasts. Specifically, we conducted seed-based probabilistic diffusion tractography from primary motor, supplementary motor, and visual cortices, projecting through the corpus callosum. Streamline counts decreased rapidly with movement from the tract center (-35% per millimeter); tract misalignment of a few millimeters caused substantial compromise of amplitude comparisons. Alignment of tracts "peak-to-peak" is essential for accurate amplitude comparisons. However, for all transcallosal tracts registered through the whole-brain method, the mean separation distance between an individual subject's tract and the average tract (3.2 mm) precluded accurate comparison: at this separation, tract amplitudes were reduced by 74% from peak value. In contrast, alignment of subcortical tracts (thalamo-putaminal, pallido-rubral) was substantially better than alignment for cortical tracts; whole-brain registration was sufficient for these subcortical tracts. We demonstrated that location mismatches in cortical tractography were sufficient to produce false positive and false negative amplitude estimates in both groupwise and longitudinal comparisons. We then showed that our new tract alignment method substantially reduced location mismatch and improved both reliability and statistical power of subsequent quantitative comparisons.
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Affiliation(s)
- J L Waugh
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States; Dept. of Neurology, Massachusetts General Hospital, Boston, MA, United States; Division of Child Neurology, Boston Children's Hospital, United States; Harvard Medical School, Boston, MA, United States; Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States.
| | - J K Kuster
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States; Dept. Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States.
| | - M L Makhlouf
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States; Dept. Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard-MIT HST Program, United States; Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States.
| | - J M Levenstein
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States; Dept. Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States.
| | - T J Multhaupt-Buell
- Dept. of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - S K Warfield
- Department of Radiology, Boston Children's Hospital, United States; Harvard Medical School, Boston, MA, United States.
| | - N Sharma
- Dept. of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - A J Blood
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States; Laboratory of Neuroimaging and Genetics, Massachusetts General Hospital, Charlestown, MA, United States; Dept. Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States.
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19
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Abstract
Given the high prevalence of heart failure (HF) and the profound impact on morbid, mortality, and health care costs, strategies to improve outcomes and reduce cost have become progressively more attractive. Reducing HF hospitalizations as a study outcome has gained traction in recent years. The basic hypothesis of these investigations is that HF hospitalizations are preventable and harmful. This article examines advancements in pharmacotherapy, medical devices, and health care delivery techniques targeting reductions in HF hospitalizations and evaluates the role and implications of hospitalization in the natural history of HF.
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Affiliation(s)
- Alexander J Blood
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Ariane M Fraiche
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Zubin J Eapen
- Department of Medicine, Duke University Medical Center, Durham, NC, United States.
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20
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Krasuski RA, Blood AJ, Parikh K, Elkin R, Zdradzinski M, Bashore T. PULMONARY VASCULAR RESPONSE TO NITRIC OXIDE AND SUBSEQUENT RESPONSE TO ADVANCED MEDICAL THERAPY IN INCIDENT PATIENTS WITH PULMONARY HYPERTENSION. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35288-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Blood AJ, Krasuski RA. Is it time to reconsider combination lipid therapy in high-risk diabetic patients? Curr Opin Lipidol 2016; 27:310-1. [PMID: 27145105 DOI: 10.1097/mol.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alexander J Blood
- aInternal Medicine bAdult Congenital Heart Center, Duke University Medical Center, Durham, North Carolina, USA
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22
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Siskind E, Huntoon K, Shah K, Villa M, Blood AJ, Lumerman L, Fishbane L, Goncharuk E, Oropallo A, Bhaskaran M, Sachdeva M, Jhaveri KD, Calderon K, Nicastro J, Coppa G, Molmenti EP. Partial closure of skin wounds after kidney transplantation decreases the incidence of postoperative wound infections. Int J Angiol 2013; 21:85-8. [PMID: 23730135 DOI: 10.1055/s-0032-1315797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Wound infections are a major cause of morbidity after kidney transplantation. The purpose of our study was to evaluate an improved technique of wound closure. Data corresponding to 104 consecutive live donor kidney recipients were prospectively collected and analyzed. Our routine standard technique involved closure of the abdominal wall muscle and fascia in one layer with interrupted nonabsorbable full thickness sutures. No drains were used. The skin was closed with interrupted 2-0 nylon sutures 4 to 5 cm apart, leaving the skin and subcutaneous tissue in between partially open. Patients were allowed to shower starting on the first postoperative day. Examination of the wounds was continued for at least 1 month postoperatively, and then routinely as needed. All patients were thoroughly informed preoperatively of our technique. There were no immediate postoperative wound infections. There were no instances of dehiscence, evisceration, or need for revision. All patients were able to continue with their routine daily activities. Cosmetic results were satisfactory in all cases. We did not experience any patient complaints with respect to our technique. Patient satisfaction scores conducted by Press Ganey and Associates ranked in the 99 percentile with respect to peers undergoing kidney transplantation. Three patients returned six months postoperatively with suture granulomas which were treated nonoperatively. Partial closure of the skin wound with no associated drains is an effective and cosmetically desirable way to decrease the incidence of postoperative infections in kidney transplantation.
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Affiliation(s)
- Eric Siskind
- Department of Transplantation, Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset, New York
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23
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Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci U S A 2001; 98:11818-23. [PMID: 11573015 PMCID: PMC58814 DOI: 10.1073/pnas.191355898] [Citation(s) in RCA: 1178] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We used positron emission tomography to study neural mechanisms underlying intensely pleasant emotional responses to music. Cerebral blood flow changes were measured in response to subject-selected music that elicited the highly pleasurable experience of "shivers-down-the-spine" or "chills." Subjective reports of chills were accompanied by changes in heart rate, electromyogram, and respiration. As intensity of these chills increased, cerebral blood flow increases and decreases were observed in brain regions thought to be involved in reward/motivation, emotion, and arousal, including ventral striatum, midbrain, amygdala, orbitofrontal cortex, and ventral medial prefrontal cortex. These brain structures are known to be active in response to other euphoria-inducing stimuli, such as food, sex, and drugs of abuse. This finding links music with biologically relevant, survival-related stimuli via their common recruitment of brain circuitry involved in pleasure and reward.
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Affiliation(s)
- A J Blood
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada.
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24
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Abstract
Ordinary listeners, including infants, easily distinguish consonant from dissonant pitch combinations and consider the former more pleasant than the latter. The preference for consonance over dissonance was tested in a patient, I.R., who suffers from music perception and memory disorders as a result of bilateral lesions to the auditory cortex. In Experiment 1, I.R. was found to be unable to distinguish consonant from dissonant versions of musical excerpts taken from the classical repertoire by rating their pleasantness. I.R.'s indifference to dissonance was not due to a loss of all affective responses to music, however, since she rated the same excerpts as happy or sad, as normal controls do. In Experiment 2, I.R.'s lack of responsiveness to varying degrees of dissonance was replicated with chord sequences which had been used in a previous study using PET, in examining emotional responses to dissonance. A CT scan of I.R.'s brain was co-registered with the PET activation data from normal volunteers. Comparison of I.R.'s scan with the PET data revealed that the damaged areas overlapped with the regions identified to be involved in the perceptual analysis of the musical input, but not with the paralimbic regions involved in affective responses. Taken together, the findings suggest that dissonance may be computed bilaterally in the superior temporal gyri by specialized mechanisms prior to its emotional interpretation.
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Affiliation(s)
- I Peretz
- Department of Psychology and Institut universitaire de gériatrie de Montréal, University of Montreal, Quebec, Canada.
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25
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Blood AJ, Zatorre RJ, Bermudez P, Evans AC. Emotional responses to pleasant and unpleasant music correlate with activity in paralimbic brain regions. Nat Neurosci 1999; 2:382-7. [PMID: 10204547 DOI: 10.1038/7299] [Citation(s) in RCA: 540] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Neural correlates of the often-powerful emotional responses to music are poorly understood. Here we used positron emission tomography to examine cerebral blood flow (CBF) changes related to affective responses to music. Ten volunteers were scanned while listening to six versions of a novel musical passage varying systematically in degree of dissonance. Reciprocal CBF covariations were observed in several distinct paralimbic and neocortical regions as a function of dissonance and of perceived pleasantness/unpleasantness. The findings suggest that music may recruit neural mechanisms similar to those previously associated with pleasant/unpleasant emotional states, but different from those underlying other components of music perception, and other emotions such as fear.
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Affiliation(s)
- A J Blood
- Neuropsychology/Cognitive Neuroscience Unit, Montreal Neurological Institute, McGill University, PQ, Canada.
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26
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Abstract
Optical intrinsic signal imaging (OIS) was used to investigate physiologic interactions between spatially and functionally distinct cortical somatosensory systems. The OIS response magnitude was evaluated after simultaneous stimulation of single whiskers and forelimb digits. Whisker C1 was deflected at a frequency of 10 Hz for 2 seconds while low- or high-intensity vibratory stimuli were applied to forelimb digits. The OIS responses to simultaneous whisker and forelimb stimulation were compared with lone whisker stimulated controls. Overall, addition of a second stimulus caused decreases in barrel cortex response magnitude. Three different response patterns were detected within individual trial sets. Modulation of barrel cortex evoked potentials provided evidence that changes in OIS responses observed here may be partially influenced by vascular responses to changes in neuronal activity. However, OIS responses in the barrel region during lone forelimb stimulation that were unaccompanied by evoked potentials suggested the possibility of independent vascular dynamic influences on response modulation. This study demonstrates that cortical responses at the level of primary sensory processing may be significantly influenced by activity in adjacent regions. Furthermore, it reveals that vascular and neuronal characteristics of interregional modulation do not co-localize and may produce responses in which one component increases while the other decreases.
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Affiliation(s)
- A J Blood
- Department of Neurology, UCLA School of Medicine, Los Angeles, California 90095-1769, USA
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27
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Abstract
The time course of optical intrinsic signals was examined in order to characterize the evolution of response in human and rodent cortex. Both subtraction/ratio and principal component analyses were used to construct time-course curves. The time course began at a prestimulus baseline, responded with a finite delay, overcompensated, reduced to a maintenance level, and then disappeared. The magnitude, spatial involvement, and principal components demonstrated similar time-course curves both in human and in rodent. For acute stimuli, peak response was reached between 2 and 3 s and returned to baseline by 6 s poststimulation. The shape of the time-course curve is consistent with the need to satisfy neuronal demand and the contributions of vascular smooth muscle properties to the response behavior. The temporal delays and nonlinear phenomena observed in the time-course curves are consistent with a hydraulic model of neurovascular supply/demand behavior.
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Affiliation(s)
- A F Cannestra
- Department of Neurology, University of California at Los Angeles, School of Medicine 90095-1769, USA
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28
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Abstract
Optical imaging of intrinsic signals was performed in the barrel cortex of the rat during whisker deflections of varying frequencies (1 to 20 Hz) and durations (0.1 to 5 s). A dose-response relationship was shown between these stimuli and the characteristics of the optically recorded intrinsic signal response. At constant frequencies, longer stimulus durations increased response magnitude, as defined by mean pixel value in statistically determined regions of interest. At constant durations, higher stimulus frequencies increased response magnitude. Response magnitude was also increased by greater numbers of deflections. When stimulus number was constant, there were no differences in response magnitude, regardless of stimulus frequency and duration. Spatial extent of responses, as defined by number of pixels in regions of interest, did not differ between stimulus frequencies, durations, or numbers. Comparison of the time to reach peak intrinsic signal response after stimulus onset ("time-to-peak") suggested that higher frequencies were associated with faster time-to-peak. Registration of intrinsic signal responses with cytochrome oxidase-stained whisker barrels demonstrated that responses were located over the barrel corresponding to the stimulated whisker. In summary, we have shown that the absolute number of stimuli delivered to the system is, at least for short stimulus periods (< or = 5 s), a determining factor for the magnitude of these responses, whereas stimulus frequency appears to influence time-to-peak response.
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Affiliation(s)
- A J Blood
- Department of Neurology, UCLA School of Medicine 90024, USA
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29
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Abstract
We have examined the relationship between cerebral blood volume (CBV) and electrophysiology over primary somatosensory cortex (S-I) in the rat. We did this by comparing the spatial characteristics and time course of activity-related changes in plasma fluorescence, intrinsic optical reflectance signals, and single unit electrophysiology in S-I to identical stimuli. S-Is of urethane-anesthetized male Sprague-Dawley rats were exposed, and fluorescent Texas Red dextran dye (MW 70,000) was administered intravenously. Subsequently, foredigit electroshock or vibrissal deflection was associated with fluorescence increases over contralateral forelimb or posteromedial barrel subfield cortex. Fluorescence was delayed and prolonged, indicating that CBV increases at 1-1.5 s and peaks 2-2.5 s after the onset of stimulation in both regions. When stimulus intensity was adjusted to produce barely detectable fluorescence foci (10% above back-ground), significant electrophysiologic spiking was seen. At these parameters, fluorescence change overlay areas of increased cortical layer III cell firing on single unit recordings. However, surface boundaries of the smallest observable fluorescence foci at their peak spatial extents consistently overspilled electrophysiologic center receptive fields. Corresponding intrinsic optical reflectance decreases were seen at 610 and 850 nm, exhibiting similar timing and colocalizing closely with fluorescence increase at both wavelengths after identical stimuli. These signals similarly overspilled electrophysiologic activity. Thus, we observed delayed increases in vascular fluorescence (related to CBV) over activated cortex. The smallest detectable fluorescence changes overspilled the center receptive field boundaries and were associated with appreciable electrophysiologic firing. In addition, the striking spatial and temporal similarity between intrinsic optical reflectance and fluorescence activity suggests that changes in intrinsic cortical reflectance are strongly related to changes in CBV.
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Affiliation(s)
- S M Narayan
- Department of Neurology, UCLA School of Medicine 90024-1769, USA
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30
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Abstract
Novel neuroimaging techniques are extending the scope for studying dynamic brain function. We have developed a system which enables the repeatable imaging of rapid function in rodent primary somatosensory cortex (S-I), based on activity-related changes in its optical reflectance (intrinsic signals). The S-I cortices of anesthetized male Sprague-Dawley rats were exposed. Images were acquired with a slow-scan, cooled, charge-coupled device camera (CCD) through filters at 550, 610, and 850 nm before, during, and after contralateral stimulation (vibrissal deflection or forepaw stimulation). Images were divided by prestimulus controls and then averaged across 9-27 trials to produce maps of stimulus-related reflectance change. Optical activity had magnitude 10(-3) of baseline reflectance and consistently comprised two distinct spatiotemporal components over cortex, depending on paradigm. The diffuse signal at 610 nm begins 0.5-1 s after stimulus onset and has a duration of 4-5 s. The second signal is macrovenous and is delayed by 1 s. Similar response patterns were observed at 550 and 850 nm. Evoked potentials, recorded at sites inside and outside the zone of optical activity, confirmed the functional nature of these signals. Using a CCD we have imaged functional reflectance changes over rodent S-I which commence, peak, and extinguish over a time scale of seconds. This optical activity is consistent with the etiologies of microvascular recruitment and chromophore redox change.
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Affiliation(s)
- S M Narayan
- Department of Neurology, UCLA School of Medicine 90024, USA
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