Mary Jo Pugh, PhD, RN, Investigator at the Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS COIN) at the Salt Lake City VA,
SALT LAKE CITY — As an investigator at the Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS COIN) at the Salt Lake City VA, the longitudinal studies that Mary Jo Pugh, PhD, RN, has helped build during her 25-year career have demonstrated that traumatic brain injury (TBI) greatly increases a patient’s risk for a host of comorbidities, most notably chronic cardiovascular disease.
Exactly why this is the case remains a mystery, but Pugh said she believes identifying patients who are most at risk is an important first step in treating or even preventing these comorbidities—something she hopes to help make possible in the near future.
Formerly an Air Force nurse, Pugh had been planning for a lifelong career in the military. Hit by a car while training for a triathlon, she was severely injured and subsequently medically retired. Forced to rethink her future, she went on to earn her master’s degree in developmental counseling and later a PhD in developmental psychology. Moving to Boston, she applied for a job as a health statistician at the Bedford, VA.
“[Dr. Dan Berlowitz], the person who would be my mentor, said what I really should do is a fellowship in health services research,” Pugh said. “He told me, ‘Work for me for a year and, if I think you’re good at it, in a year you’ll be in a fellowship.’ He put his research program at least six months behind to give me that opportunity.”
Berlowitz’s program examined complex comorbidities, notably epilepsy, in geriatric patients. As part of it, Pugh received her first publication in health services, as well as her first career award and VA grant. But she would eventually find a different, more personal, research niche.
Married to a member of the Air Force, Pugh was still very much connected to the active duty community and regularly heard stories about health crises in young servicemembers and veterans.
“Hearing their stories made me realize that I needed to look at this idea of complex comorbidities … in the newer cohort of veterans,” she said.
In the early 2000s, there wasn’t the same drive to examine the long-range impact of TBI as there is today. However, in research focusing on Gulf War Illness, Pugh was able to compare clusters of comorbidities in patients with and without TBI, showing that these clusters were much more prevalent in those who had a brain injury as part of their medical history.
“Those with TBI were more likely to die, in general, more likely to die from suicide and more likely to die from accidents,” she explained.
She used these results as a foundation to look at TBI more broadly. By the late 2010s, the reality of TBI as a chronic condition was becoming accepted, and in recent years Pugh and her collaborators have focused on linking TBI to a higher risk for cardiovascular disease, stroke and death by both. Results of one study released earlier this year found a link between TBI and atrial fibrillation, which can increase clotting and heightens the risk for stroke.
“That was focused really on young people and women. … So we really need to dig into that and figure out what it is with younger people and women where [these] potentially inflammatory processes are systemic, not just in the brain,” Pugh said.
Exactly why TBI results in a higher risk for cardiovascular disease is unknown, but Pugh is working to make connections with other experts that she hopes will begin answering that question.
“We’re working with researchers at the Uniformed Services University, especially Dr. Mark Haigney, a cardiologist who’s helping us think systematically about cardiovascular disease,” Pugh said. “We do need to be looking at the biological underpinnings at this point. With his help, I think we can get to the right people.”
That doesn’t mean that patients and clinicians need to wait for those answers in order for Pugh’s research to have a positive impact.
“We have guys on my team doing some low-technology AI work,” she explained. “In the next year, we’ll be developing cardiovascular risk scores [for TBI patients]. We’ll be using that to develop some kind of tool that clinicians can use to understand risk.”
She added, “We need precision medicine for TBI, but I don’t think we’re quite there yet. If we were to have some kind of algorithm … we could target people who are at greatest risk earlier.”
That algorithm could be in clinicians’ hands in only a few years, barring complications, Pugh said.
As for what targeting at-risk patients looks like, VA has embraced Whole Health in recent years, and Pugh believes this might be a way to address the multitudinous ways that TBI can impact veterans.
“We might want to funnel people with TBI history [into a Whole Health program], so we can look at cardiovascular disease risk factors … and so they don’t end up with this multi-morbidity down the road,” she said.
By preventing cardiovascular disease, clinicians might also be able to stave off some of the cognitive problems TBI has been linked to, such as vascular dementia.
“I would love to start having intervention trials to test the prevention models,” Pugh said. “Putting people with high risk for cardiovascular disease and stroke into a Whole Health model and seeing what that does for their physical and mental health.”
She already has her eye on a colleague who might be able to help take the research to that next level.
This, she said, exemplifies the benefits of working at VA. “There are so many frustrations, but the ability to use the data to make a difference for the lives of veterans, and even the clinicians who care for them, is the most amazing opportunity ever for a researcher.”
