Cannabis Use and Inhalational Anesthesia Administration in Older Adults: A Propensity Matched Retrospective Cohort Study.

BACKGROUND: Cannabis use is associated with higher intravenous anesthetic administration. Similar data regarding inhalational anesthetics are limited. With rising cannabis use prevalence, understanding any potential relationship with inhalational anesthetic dosing is crucial. We compared average intraoperative isoflurane/sevoflurane minimum alveolar concentration equivalents between older adults with and without cannabis use. METHODS: The electronic health records of 22,476 surgical patients ≥65 years old at the University of Florida Health System between 2018-2020 were reviewed. The primary exposure was cannabis use within 60 days of surgery, determined via i) a previously published natural language processing algorithm applied to unstructured notes and ii) structured data, including International Classification of Disease codes for cannabis use disorders and poisoning by cannabis, laboratory cannabinoids screening results, and RxNorm codes. The primary outcome was the intraoperative time-weighted average of isoflurane/sevoflurane minimum alveolar concentration equivalents at one-minute resolution. No a priori minimally clinically important difference was established. Patients demonstrating cannabis use were matched 4:1 to non-cannabis use controls using a propensity score. RESULTS: Among 5,118 meeting inclusion criteria, 1,340 patients (268 cannabis users and 1,072 nonusers) remained after propensity score matching. The median and interquartile range (IQR) age was 69 (67, 73) years; 872 (65.0%) were male, and 1,143 (85.3%) were non-Hispanic White. The median (IQR) anesthesia duration was 175 (118, 268) minutes. After matching, all baseline characteristics were well-balanced by exposure. Cannabis users had statistically significantly higher average minimum alveolar concentrations than nonusers [mean±SD: 0.58±0.23 versus 0.54±0.22, respectively; mean difference=0.04; 95% confidence limits, 0.01 to 0.06; p=0.020]. CONCLUSION: Cannabis use was associated with administering statistically significantly higher inhalational anesthetic minimum alveolar concentration equivalents in older adults, but the clinical significance of this difference is unclear. These data do not support the hypothesis that cannabis users require clinically meaningfully higher inhalational anesthetics doses.

Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study.

INTRODUCTION: Cannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels and opioid doses within 24 hours of surgery. METHODS: We conducted a propensity score-matched retrospective cohort study using electronic health records data of 22 476 older surgical patients with at least 24-hour hospital stays at University of Florida Health between 2018 and 2020. Of the original cohort, 2577 patients were eligible for propensity-score matching (1:3 cannabis user: non-user). Cannabis use status was determined via natural language processing of clinical notes within 60 days of surgery and structured data. The primary outcomes were average Defense and Veterans Pain Rating Scale (DVPRS) score and total oral morphine equivalents (OME) within 24 hours of surgery. RESULTS: 504 patients were included (126 cannabis users and 378 non-users). The median (IQR) age was 69 (65-72) years; 295 (58.53%) were male, and 442 (87.70%) were non-Hispanic white. Baseline characteristics were well balanced. Cannabis users had significantly higher average DVPRS scores (median (IQR): 4.68 (2.71-5.96) vs 3.88 (2.33, 5.17); difference=0.80; 95% confidence limit (CL), 0.19 to 1.36; p=0.01) and total OME (median (IQR): 42.50 (15.00-60.00) mg vs 30.00 (7.50-60.00) mg; difference=12.5 mg; 95% CL, 3.80 mg to 21.20 mg; p=0.02) than non-users within 24 hours of surgery. DISCUSSION: This study showed that cannabis use in older adults was associated with increased postoperative pain levels and opioid doses.

Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes.

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p = 0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90 days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

Relationship between arm span to height ratio, aortic root diameter, and systolic blood pressure in collegiate athletes.

Study objective: Sudden cardiac death is the most common cause of non-traumatic death in collegiate athletes. Marfan syndrome poses a risk for sudden cardiac death secondary to aortic root dilation leading to aortic dissection or rupture. Arm span to height ratio (ASHR) > 1.05 has been proposed as a screening tool for Marfan syndrome in pre-participation examinations (PPE) for collegiate athletes but limited data exists on the association between ASHR and aortic root diameter (ARD). This study examines the relationship between ASHR and ARD and assesses for predictors of ARD. Design: Retrospective chart review. Setting: National Collegiate Athletic Association Division I University. Participants: 793 athletes across thirteen sports between 2012 and 2022 evaluated with PPE and screening echocardiogram. Interventions: Not applicable. Main outcome measures: (1) Relationships between ASHR, SBP, BSA, and ARD amongst all athletes as well as stratified by ASHR >1.05 or ≤1.05 using univariate analysis. (2) Predictors of ARD using multivariate analysis using linear regression. Results: 143 athletes (18 %) had ASHRs > 1.05. Athletes with ASHR > 1.05 had higher ARD (2.99 cm) than athletes with ASHR ≤ 1.05 (2.85 cm). Weak correlations were noted between ASHR, ARD, and SBP. Multivariate analysis showed that BSA, male sex, and participation in swimming were predictors of ARD. ASHR was not predictive of ARD in regression analysis. Conclusions: These findings showed a tendency towards higher ARD in athletes with ASHR >1.05 but this observation was not statistically significant in multivariate analysis.

What's Up Your Sleeve? A Scoping Review of White Coat Contamination and Horizontal Microbial Transmission.

OBJECTIVES: White coats have been suggested to serve as fomites carrying and transmitting pathogenic organisms and potentially increasing the risk of healthcare-associated infections (HAIs). We aimed to examine the current evidence regarding white coat contamination and its role in horizontal transmission and HAIs risk. We also examined handling practices and policies associated with white coat contamination in the reviewed literature. METHODS: We conducted a literature search through PubMed and Web of Science Core Collection/Cited Reference Search, and manually searched the bibliographies of the articles identified in electronic searches. Studies published up to March 3, 2021 that were accessible in English-language full-text format were included. RESULTS: Among 18 included studies, 15 (83%) had ≥100 participants, 16 (89%) were cross-sectional studies, and 13 (72%) originated outside of the United States. All of the studies showed evidence of microbial colonization. Colonization with Staphylococcus aureus and Escherichia coli was reported in 100% and 44% of the studies, respectively. Antibacterial-resistant strains, including methicillin-resistant Staphylococcus aureus and multidrug-resistant organisms were reported in 8 (44%) studies. There was a lack of studies assessing the link between white coat contamination and HAIs. The data regarding white coat handling and laundering practices showed inconsistencies between healthcare facilities and a lack of clear policies. CONCLUSIONS: There is robust evidence that white coats serve as fomites, carrying dangerous pathogens, including multidrug-resistant organisms. A knowledge gap exists, however, regarding the role of contaminated white coats in HAI risk that warrants further research to generate the evidence necessary to guide the current attire policies for healthcare workers.

Relationship of Psychological Characteristics to Daily Life Ischemia: An Analysis From the National Heart, Lung, and Blood Institute Psychophysiological Investigations in Myocardial Ischemia.

OBJECTIVE: Cardiac ischemia during daily life is associated with an increased risk of adverse outcomes. Mental stress is known to provoke cardiac ischemia and is related to psychological variables. In this multicenter cohort study, we assessed whether psychological characteristics were associated with ischemia in daily life. METHODS: This study examined patients with clinically stable coronary artery disease (CAD) with documented cardiac ischemia during treadmill exercise (n = 196, mean [standard deviation] age = 62.64 [8.31] years; 13% women). Daily life ischemia (DLI) was assessed by 48-hour ambulatory electrocardiophic monitoring. Psychological characteristics were assessed using validated instruments to identify characteristics associated with ischemia occurring in daily life stress. RESULTS: High scores on anger and hostility were common in this sample of patients with CAD, and DLI was documented in 83 (42%) patients. However, the presence of DLI was associated with lower anger scores (odds ratio [OR] = 2.03; 95% confidence interval [CI] = 1.12-3.69), reduced anger expressiveness (OR = 2.04; 95% CI = 1.10-3.75), and increased ratio of anger control to total anger (OR = 2.33; 95% CI = 1.27-4.17). Increased risk of DLI was also associated with lower hostile attribution (OR = 2.22; 95% CI = 1.21-4.09), hostile affect (OR = 1.92; 95% CI = 1.03-3.58), and aggressive responding (OR = 2.26; 95% CI = 1.25-4.08). We observed weak inverse correlations between DLI episode frequency and anger expressiveness, total anger, and hostility scores. DLI was not associated with depression or anxiety measures. The combination of the constructs low anger expressiveness and low hostile attribution was independently associated with DLI (OR = = 2.59; 95% CI = 1.42-4.72). CONCLUSIONS: In clinically stable patients with CAD, the tendency to suppress angry and hostile feelings, particularly openly aggressive behavior, was associated with DLI. These findings warrant a study in larger cohorts, and intervention studies are needed to ascertain whether management strategies that modify these psychological characteristics improve outcomes.

Blood pressure characteristics of collegiate female athletes: A call for more focused attention on young women's health.

Background: There is a paucity of data describing the association between blood pressure (BP) and cardiac remodeling in female collegiate athletes. Methods: This retrospective cohort review describes the BP characteristics and echocardiographic features of female collegiate athletes during preparticipation evaluation. We evaluated data from 329 female athletes at two National Collegiate Athletic Association (NCAA) Division I universities who underwent preparticipation evaluation that included medical history, physical examination, 12-lead electrocardiography, and 2-dimensional transthoracic echocardiography. BP values were divided into categories of normal, elevated, stage 1 and stage 2 hypertension based on 2017 ACC/AHA Guidelines. Left ventricular mass index was calculated and indexed to body surface area and further classified into concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. Results: Normal BP values were noted in 184 (56%) female athletes, 88 (26.7%) had elevated BP and 57 (17.3%) had BP values indicating stage 1 or 2 hypertension. The majority of participants were white (n = 136, 73.9%). There was significantly higher body surface area in female athletes with higher BP values: 1.85 ± 0.18 in the stage 1 and 2 hypertension range, 1.82 ± 0.18 in the elevated BP range versus 1.73 ± 0.16 in the normal BP range (p < 0.001). Conclusions: There was a trend toward higher incidence of concentric and eccentric hypertrophy in athletes with higher than normal BP, however no statistical significance was noted. Elevated BP values were frequent among female collegiate athletes, and there is evidence of cardiac remodeling associated with higher BP values.

Functional heart recovery in an adult mammal, the spiny mouse.

BACKGROUND: Ischemic heart disease and the resulting heart failure continue to carry high morbidity and mortality, and a breakthrough in our understanding of this disorder is needed. The adult spiny mouse (Acomys cahirinus) has evolved the remarkable capacity to regenerate full-thickness skin tissue, including microvasculature and cartilage, without fibrosis or scarring. We hypothesized that lack of scarring and resulting functional regeneration also applies to the adult Acomys heart. METHODS AND RESULTS: We compared responses of the Acomys heart to CD1 outbred Mus heart following acute left anterior descending coronary artery ligation to induce myocardial infarction. Both Acomys and Mus hearts showed decreased ejection fraction (EF) after ligation. However, Acomys hearts showed significant EF recovery to pre-ligation values over four weeks. Histological analysis showed comparable infarct area 24-h after ligation with a similar collateral flow in both species' hearts, but subsequently, Acomys displayed reduced infarct size, regenerated microvasculature, and increased cell proliferative activity in the infarcted area. CONCLUSIONS: These observations suggest that adult Acomys displays remarkable cardiac recovery properties after acute coronary artery occlusion and may be a useful model to understand functional recovery better. TRANSLATIONAL PERSPECTIVE: Adult Acomys provides a novel mammalian model to further investigate the cardioprotective and regenerative signaling mechanisms in adult mammals. This opens the door to breakthrough treatment strategies for the injured myocardium and help millions of patients with heart failure secondary to tissue injury with irreversible damage.

Association of 1-Year Blood Pressure Variability With Long-term Mortality Among Adults With Coronary Artery Disease: A Post Hoc Analysis of a Randomized Clinical Trial.

Importance: Accumulating evidence indicates that higher blood pressure (BP) variability from one physician office visit to the next (hereafter referred to as visit-to-visit BP variability) is associated with poor outcomes. Short-term measurement (throughout 1 year) of visit-to-visit BP variability in high-risk older patients may help identify patients at increased risk of death. Objective: To evaluate whether short-term visit-to-visit BP variability is associated with increased long-term mortality risk. Design, Setting, and Participants: The US cohort of the International Verapamil SR-Trandolapril Study (INVEST), a randomized clinical trial of 16 688 patients aged 50 years or older with hypertension and coronary artery disease, was conducted between September 2, 1997, and December 15, 2000, with in-trial follow-up through February 14, 2003. The study evaluated a calcium antagonist (sustained-release verapamil plus trandolapril) vs ß-blocker (atenolol plus hydrochlorothiazide) treatment strategy. Blood pressure measurement visits were scheduled every 6 weeks for the first 6 months and biannually thereafter. Statistical analysis was performed from September 2, 1997, to May 1, 2014. Exposures: Visit-to-visit systolic BP (SBP) and diastolic BP variability during the first year of enrollment using 4 different BP variability measures: standard deviation, coefficient of variation, average real variability, and variability independent of the mean. Main Outcomes and Measures: All-cause death, assessed via the US National Death Index, beginning after the exposure assessment period through May 1, 2014. Results: For the present post hoc analysis, long-term mortality data were available on 16 688 patients (9001 women [54%]; mean [SD] age, 66.5 [9.9] years; 45% White patients, 16% Black patients, and 37% Hispanic patients). During a mean (SD) follow-up of 10.9 (4.2) years, 5058 patients (30%) died. All 4 variability measures for SBP were significantly associated with long-term mortality after adjustment for baseline demographic characteristics and comorbidities. After comparison of lowest vs highest variability measure quintiles, the magnitude of the association with death remained statistically significant even after adjustment for baseline demographic characteristics and comorbidities (average real variability: adjusted hazard ratio [aHR], 1.18; 95% CI, 1.08-1.30; standard deviation: aHR, 1.14; 95% CI, 1.04-1.24; coefficient of variation: aHR, 1.15; 95% CI, 1.06-1.26; variability independent of the mean: aHR, 1.15; 95% CI, 1.05-1.25). The signal was stronger in women compared with men. Associations of diastolic BP variability measures with death were weaker than for SBP and were not significant after adjustment. Conclusions and Relevance: This study suggests that, in a large population of older patients with hypertension and coronary artery disease, short-term visit-to-visit SBP variability was associated with excess long-term mortality, especially for women. Efforts to identify and minimize visit-to-visit SBP variability may be important in reducing excess mortality later in life. Trial Registration: ClinicalTrials.gov Identifier: NCT00133692.

Preparticipation Cardiac Evaluation Findings in a Cohort of Collegiate Female Athletes.

Knowledge of cardiovascular adaptations in athletes has predominantly focused on males, with limited data available on females who compromise a substantial percentage of all collegiate athletes. A multicenter retrospective cohort review of preparticipation cardiovascular screening data of 329 National Collegiate Athletic Association Division I female athletes was performed. This included physical exams, electrocardiograms, and echocardiograms. Female athletes in class IB sports had elevated systolic blood pressure (p = 0.01). For electrocardiograms, 7 (2%) had abnormal findings: 100% were white; 6 of 7 (86%) participated in IIC sports. Black athletes had longer PR intervals (p ≤ 0.001), whereas white athletes had longer QTc and QRS durations (p = 0.02 and 0.01, respectively). Athletes in IC and IIC sports had longer QTc intervals (p = 0.01). For echocardiographic parameters, no differences were noted based on race. However, significant differences were noted based on classification of sport: athletes in class IC sports had higher left-atrial volume indexes and E/A ratios. Athletes in class IB and IIC had increased left-ventricular wall thicknesses and aortic root dimensions. In conclusion, among one of the largest cohorts of collegiate female athlete preparticipation cardiac screening data to date, significant differences in various parameters based on classification of sport and race were observed. These categorizations should be considered when interpreting cardiovascular screening in female collegiate athletes to improve screening and guide future research.

Prognostic Value of Computed Tomography Versus Echocardiography Derived Right to Left Ventricular Diameter Ratio in Acute Pulmonary Embolism.

BACKGROUND: Computed Tomography (CT) Pulmonary Angiography is the most commonly used diagnostic study for acute pulmonary embolism (PE). Echocardiogram (ECHO) is also used for risk stratification in acute PE, however the diagnostic performance of CT versus ECHO for risk stratification remains unclear. METHODS: CT and ECHO right ventricle (RV) and left ventricle (LV) diameters were measured in a retrospective cohort of patients with acute PE. RV:LV diameter ratios were calculated and correlation between CT and ECHO RV:LV ratio was assessed. Sensitivity and specificity for the composite adverse events endpoint of mortality, respiratory failure requiring intubation, cardiac arrest, or shock requiring vasopressors within 30 days of admission were assessed for CT or ECHO derived RV:LV ratio alone and in combination with biomarkers (troponin or B-type natriuretic peptide). RESULTS: A total of 74 subjects met the inclusion criteria and had a mean age of 62±18 years. The proportion of patients with RV:LV >1 was similar when comparing CT (37.8%) versus ECHO (33.8%) (P = 0.61). A statistically significant correlation was found between CT derived and ECHO derived RV:LV diameter ratio (r = 0.832, P < 0.001). The sensitivity and specificity to predict 30-day composite adverse events for CT versus ECHO derived RV:LV diameter ratio >1 together with positive biomarker status was similar with sensitivity and specificity of 87% and 41% versus 87% and 42%, respectively. CONCLUSIONS: In patients with acute PE, CT and ECHO RV:LV diameter ratio correlate well and identify similar proportion of PE patients at risk for early adverse events. These findings may streamline risk stratification of patients with acute PE.

Aspirin in Primary Prevention: What Changed? A Critical Appraisal of Current Evidence.

Aspirin has been the mainstay of both secondary and primary prevention of cardiovascular disease for half a century. In 2018, 3 trials showed a modest reduction in cardiovascular outcomes that appeared counterbalanced by the risk of clinically significant bleeding. The latest ACC/AHA primary prevention guidelines downgraded their recommendation for aspirin use in primary prevention to that of physician preference. Despite the consistent and robust evidence previously supporting the use of aspirin in cardiovascular disease prevention, little discussion has been given to mechanisms or analytic explanations for this revision of recommendations. In this review, we explore 3 possible mechanisms that may have contributed to the alteration of our perception of aspirin's role in primary prevention. These include changes in the population potentially using aspirin in primary prevention, changes in cardiovascular disease and its presentation, and changes in aspirin itself. Here we present a translational look at knowledge gaps that should be addressed to better guide contemporary aspirin use in primary prevention. In conclusion, based on these considerations, the current recommendations might be improved by recalibration of the cardiovascular risk threshold above which aspirin should be recommended for primary prevention, including the incorporation of newer risk assessment modalities such as calcium scoring. A second enhancement would be developing a bleeding risk calculator to support clinicians' assessment of risk vs benefit. The use of enteric-coated aspirin vs noncoated aspirin should also be reassessed.

Chronic elevation of cardiac troponin I predicts the extent of coronary disease in hemodialysis patients presenting with acute enzyme elevation.

Introduction: Elevation of cardiac troponin I (cTn-I) is associated with coronary artery disease (CAD) in asymptomatic patients with end-stage renal disease (ESRD) receiving hemodialysis. We aim to investigate the diagnostic value of chronically elevated cTn-I in ESRD patients presenting with an acute rise in serum cTn-I levels. Methods: We performed a retrospective analysis of 364 patients. Using coronary angiography, we correlated baseline elevation of cTn-I with the severity of CAD when hemodialysis patients present with acute symptomatic elevation in serum cTn-I. Results: In hemodialysis patients presenting with a rise in serum cTn-I above baseline levels, 59% had severe CAD, and 17% had no angiographic evidence of CAD. Hemodialysis patients with severe CAD had significantly higher baseline cTn-I levels compared to patients with non-severe CAD or normal coronaries (p < 0.0001). Baseline elevation of cTn-I in the severe CAD group was correlated with the degree of CAD occlusion (r2 0.56, p < 0.0001), fitting a positive linear model. Furthermore, baseline cTn-I differentiates between patients with and without severe CAD with a test accuracy of 0.72 (95% CI, 0.69-0.75, p < 0.001). At a value of ≥0.2 ng/mL (cutoff for myocardial necrosis), the specificity of baseline cTn-I for underlying severe CAD was 0.95. Conclusions: Elevated baseline cTn-I has good accuracy for anticipating more advanced angiographic CAD when hemodialysis patients present with a symptomatic rise in serum cTn-I above baseline levels. Baseline elevation of cTn-I can be used for cardiac disease risk management in hemodialysis patients presenting with symptoms suggestive of CAD.

Acute right ventricular failure: a novel presentation of methadone-induced cardiotoxicity.

As methadone use increases, the potential for methadone-induced cardiotoxicity (MIC) may rise. We describe a case of acute right ventricular (RV) failure leading to cardiogenic shock after methadone overdose. This presentation was followed by full RV recovery. This previously undescribed presentation highlights the challenges involved with MIC, its diagnosis and its management.