eScholarship@UMassChan
eScholarship@UMassChan is a digital archive for UMass Chan Medical School's research and scholarship, including journal articles, theses, datasets and more. We welcome submissions from our faculty, staff, and students. eScholarship@UMassChan is a service of the Lamar Soutter Library, Worcester, MA, USA. See also our open access journal publishing services.
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Recent Publications
Publication Digital Assessment of Cognitive Health in Outpatient Primary Care: Usability Study(2025-03-12)Background: Screening for cognitive impairment in primary care is important, yet primary care physicians (PCPs) report conducting routine cognitive assessments for less than half of patients older than 60 years of age. Linus Health's Core Cognitive Evaluation (CCE), a tablet-based digital cognitive assessment, has been used for the detection of cognitive impairment, but its application in primary care is not yet studied. Objective: This study aimed to explore the integration of CCE implementation in a primary care setting. Methods: A cohort of participants was recruited from the upcoming schedules of participating PCPs at UMass Memorial Medical Center. Eligibility criteria included individuals aged ≥65 years; ability to read, write, and speak in English or Spanish; no previous diagnosis of cognitive impairment; and no known untreated hearing or vision impairment. Research coordinators collected consent from participants and facilitated the screening process. PCPs reviewed reports in real time, immediately before the scheduled visits, and shared results at their discretion. A report was uploaded to each participant's REDCap (Research Electronic Data Capture; Vanderbilt University) record and linked to the encounter in the electronic health record. Feedback from patients and their caregivers (if applicable) was collected by a tablet-based survey in the clinic before and after screening. Participating PCPs were interviewed following the completion of the study. Results: The screened cohort included 150 patients with a mean age of 74 (SD 7) years, of whom 65% (97/150) were female. The CCE identified 40 patients as borderline and 7 as positive for cognitive impairment. A total of 84 orders were placed for select laboratory tests or referrals to neurology and neuropsychology within 20 days of CCE administration. Before the assessment, 95% (143/150) of patients and all 15 caregivers expressed a desire to know if their or their loved one's brain health was declining. All except one patient also completed the postassessment survey. Among them, 96% (143/149) of patients reported finding the CCE easy to complete, and 70% (105/149) felt that the experience was beneficial. In addition, 87% (130/149) of patients agreed or strongly agreed that they wanted to know their CCE results. Among the 7 participating PCPs, 6 stated that the CCE results influenced their patient care management, and all 7 indicated they would continue using the CCE if it were made available after the study. Conclusions: We explored the integration of the CCE into primary care visits, which showed minimal disruption to the practice workflow. Future studies will be warranted to further validate the implementation of digital cognitive impairment screening tools within primary care settings in the real world.Publication Awake Prone Positioning in Adults With COVID-19: An Individual Participant Data Meta-Analysis(2025-03-10)Importance: The impact of awake prone positioning (APP) on clinical outcomes in patients with COVID-19 and acute hypoxemic respiratory failure (AHRF) remains uncertain. Objective: To assess the association of APP with improved clinical outcomes among patients with COVID-19 and AHRF, and to identify potential effect modifiers. Data sources: PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through August 1, 2024. Study selection: Randomized clinical trials (RCTs) examining APP in adults with COVID-19 and AHRF that reported intubation rate or mortality were included. Data extraction and synthesis: Individual participant data (IPD) were extracted according to PRISMA-IPD guidelines. For binary outcomes, logistic regression was used and odds ratio (OR) and 95% CIs were reported, while for continuous outcomes, linear regression was used and mean difference (MD) and 95% CIs were reported. Main outcomes and measures: The primary outcome was survival without intubation. Secondary outcomes included intubation, mortality, death without intubation, death after intubation, escalation of respiratory support, intensive care unit (ICU) admission, time from enrollment to intubation and death, duration of invasive mechanical ventilation, and hospital and ICU lengths of stay. Results: A total of 14 RCTs involving 3019 patients were included; 1542 patients in the APP group (mean [SD] age, 59.3 [14.1] years; 1048 male [68.0%]) and 1477 in the control group (mean [SD] age, 59.9 [14.1] years; 979 male [66.3%]). APP improved survival without intubation (OR, 1.42; 95% CI, 1.20-1.68), and it reduced the risk of intubation (OR, 0.70; 95% CI, 0.59-0.84) and hospital mortality (OR, 0.77; 95% CI, 0.63-0.95). APP also extended the time from enrollment to intubation (MD, 0.93 days; 95% CI, 0.43 to 1.42 days). In exploratory subgroup analyses, improved survival without intubation was observed in patients younger than age 68 years, as well as in patients with a body mass index of 26 to 30, early implementation of APP (ie, less than 1 day from hospitalization), a pulse saturation to inhaled oxygen fraction ratio of 155 to 232, respiratory rate of 20 to 26 breaths per minute (bpm), and those receiving advanced respiratory support at enrollment. However, none of the subgroups had significant interaction with APP treatment. APP duration 10 or more hours/d within the first 3 days was associated with increased survival without intubation (OR, 1.85; 95% CI, 1.37-2.49). Conclusions and relevance: This IPD meta-analysis found that in adults with COVID-19 and AHRF, APP was associated with increased survival without intubation and with reduced risks of intubation and mortality, including death after intubation. Prolonged APP duration (10 or more hours/d) was associated with better outcomes.Publication The Chitranjan S. Ranawat Award: Factors That Predict Outcome Five Years Following Total Knee Arthroplasty(2025-03-09)Background: Previous reports have identified several potential predictors of pain and function after total knee arthroplasty (TKA). However, the results of these studies are conflicting, and most have a short follow-up after TKA. The purpose of this study was to identify factors predictive of pain and function five years after TKA. Methods: A multicenter cohort of 3,688 primary unilateral TKA patients from a comparative effectiveness consortium was enrolled. Demographic data, medical and musculoskeletal comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at five years, including the Short-Form Health Survey 36-item (SF-36) and the Knee Disability and Osteoarthritis Outcome Score (KOOS) pain and activities of daily living (ADL) function scores. Multivariate regression models with a 95% confidence interval were used to identify independent predictors of KOOS pain and function scores at five years. Results: The analysis identified the factors that were independently predictive for KOOS pain score at five years: age, insurance, race, Charlson comorbidity index (CCI), back pain, number of other painful hip and knee joints, contralateral knee pain, preoperative SF-36 mental component summary (MCS), and baseline KOOS pain scores. For KOOS ADL, the following predictive factors were identified: age, body mass index, insurance, race, CCI, back pain, number of other painful joints, contralateral knee pain, ipsilateral hip pain, preoperative SF-36 MCS, and physical component summary (PCS) scores, and baseline KOOS ADL scores. Conclusion: We have identified the factors that each independently predict less improvement in pain and function five years after TKA. These potentially modifiable factors, such as musculoskeletal comorbidities, can be targeted with preoperative patient optimization programs to improve patient outcomes and patient satisfaction after primary TKA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making and in setting appropriate patient expectations preoperatively.Publication "It's within your own power": shared decision-making to support transitions to buprenorphine(2025-03-07)Introduction: Buprenorphine is an effective first-line treatment for opioid use disorder (OUD) that substantially reduces morbidity and mortality. For patients using illicitly-manufactured fentanyl (IMF), however, transitioning to buprenorphine can be challenging. Evidence is lacking for how best to make this transition in the outpatient setting. A shared decision-making (SDM) approach has been found to benefit patients with OUD but has not been studied for buprenorphine initiation. We sought to explore participants' experiences with a SDM approach to buprenorphine initiation. Methods: Participants were seeking care at a low barrier, telehealth buprenorphine clinic. Clinicians implemented a standardized SDM approach whereby they offered patients using IMF three options for buprenorphine initiation (traditional, low-dose, and QuickStart). They elicited patient goals and preferences and discussed the pros and cons of each method to come to a shared decision. Patients meeting study criteria were invited to participate in semi-structured qualitative interviews 1-2 weeks after the initial visit. Interviews focused on experiences with the clinical visit, suggestions for enhancing the treatment experience, and patient factors affecting the method they chose. Interviews were coded and analyzed using reflexive thematic analysis. Results: Twenty participants completed interviews. Participants' mean age was 33, they were 50% female, predominantly white (16 [80%]), and most had Medicaid insurance (19 [95%]). We identified three important themes. First, participants found SDM acceptable and a positive addition to their OUD treatment. They felt their opinion mattered and reported that SDM gave them important control over their care plan. Second, patient goals, preferences, and past experiences with buprenorphine-associated withdrawal impacted what type of buprenorphine initiation method they chose. Finally, participants had advice for clinicians to improve SDM counseling. Participant recommendations included ensuring patients are informed that withdrawal (or "feeling sick") can occur with any initiation method, that buprenorphine will eventually "block" fentanyl effects once at a high enough dose, and that clinicians provide specific advice for tapering off fentanyl during a low dose initiation. Conclusions: For patients with OUD using IMF, shared decision-making is an acceptable approach to buprenorphine initiation in the outpatient setting. It can enhance patient autonomy and lead to an individualized approach to OUD care.Publication Senescent-like microglia limit remyelination through the senescence associated secretory phenotype(2025-03-07)The capacity to regenerate myelin in the central nervous system diminishes with age. This decline is particularly evident in multiple sclerosis (MS), a chronic demyelinating disease. Whether cellular senescence, a hallmark of aging, contributes to remyelination impairment remains unknown. Here, we show that senescent cells accumulate within demyelinated lesions after injury, and treatments with senolytics enhances remyelination in young and middle-aged mice but not aged mice. In young mice, we observe the upregulation of senescence-associated transcripts, primarily in microglia and macrophages, after demyelination, followed by a reduction during remyelination. However, in aged mice, senescence-associated factors persist within lesions, correlating with inefficient remyelination. Proteomic analysis of the senescence-associated secretory phenotype (SASP) reveals elevated levels of CCL11/Eotaxin-1 in lesions of aged mice, which is found to inhibit oligodendrocyte maturation. These results suggest therapeutic targeting of SASP components, such as CCL11, may improve remyelination in aging and MS.