Preliminary Evidence for the Sequentially Mediated Effect of Racism-Related Stress on Pain Sensitivity Through Sleep Disturbance and Corticolimbic Opioid Receptor Function.

Sleep disturbance predicts worse pain outcomes. Because sleep disturbance inequitably impacts Black adults - with racism as the upstream cause - understanding how racism-related stress impacts pain through sleep might help minimize racialized pain inequities. This preliminary study examined sequential mediation of the effect of racism-related stress on experimental pain through sleep disturbance and corticolimbic µOR function in pain-free non-Hispanic Black (NHB) and White (NHW) adults. Participants completed questionnaires, actigraphy, positron emission tomography, and sensory testing. We reproduced findings showing greater sleep disturbance and pain sensitivity among NHB participants; greater sleep disturbance (r = .35) and lower pain tolerance (r=-.37) were significantly associated with greater racism-related stress. In a sequential mediation model, the total effect of racism-related stress on pain tolerance (ß=-.38, P = .005) weakened after adding sleep disturbance and ventromedial prefrontal cortex (vmPFC) µOR binding potential (BPND) as mediators (ß = -.18, P = .16). The indirect effect was statistically significant [point estimate = -.003, (-.007, -.0003). Findings showed a potential sequentially mediated effect of racism-related stress on pain sensitivity through sleep disturbance and vmPFC µOR BPND. As policy efforts are enacted to eliminate the upstream cause of systemic racism, these results cautiously suggest that sleep interventions within racism-based trauma informed therapy might help prevent downstream effects on pain. PERSPECTIVE: This preliminary study identified the effect of racism-related stress on pain through sleep disturbance and mu-opioid receptor binding potential in the ventromedial prefrontal cortex. Findings cautiously support the application of sleep interventions within racism-based trauma-informed therapy to prevent pain inequities as policy changes function to eliminate all levels of racism.

Selected Transesophageal Echocardiographic Parameters of Left Ventricular Diastolic Function Predict Length of Stay Following Coronary Artery Bypass Graft-A Prospective Observational Study.

(1) Importance: Abnormal left ventricular (LV) diastolic function, with or without a diagnosis of heart failure, is a common finding that can be easily diagnosed by intra-operative transesophageal echocardiography (TEE). The association of diastolic function with duration of hospital stay after coronary artery bypass (CAB) is unknown. (2) Objective: To determine if selected TEE parameters of diastolic dysfunction are associated with length of hospital stay after coronary artery bypass surgery (CAB). (3) Design: Prospective observational study. (4) Setting: A single tertiary academic medical center. (5) Participants: Patients with normal systolic function undergoing isolated CAB from September 2017 through June 2018. (6) Exposures: LV function during diastole, as assessed by intra-operative TEE prior to coronary revascularization. (7) Main Outcomes and Measures: The primary outcome was duration of postoperative hospital stay. Secondary intermediate outcomes included common postoperative cardiac, respiratory, and renal complications. (8) Results: The study included 176 participants (mean age 65.2 ± 9.2 years, 73% male); 105 (60.2%) had LV diastolic dysfunction based on selected TEE parameters. Median time to hospital discharge was significantly longer for subjects with selected parameters of diastolic dysfunction (9.1/IQR 6.6−13.5 days) than those with normal LV diastolic function (6.5/IAR 5.3−9.7 days) (p < 0.001). The probability of hospital discharge was 34% lower (HR 0.66/95% CI 0.47−0.93) for subjects with diastolic dysfunction based on selected TEE parameters, independent of potential confounders, including a baseline diagnosis of heart failure. There was a dose−response relation between severity of diastolic dysfunction and probability of discharge. LV diastolic dysfunction based on those selected TEE parameters was also associated with postoperative cardio-respiratory complications; however, these complications did not fully account for the relation between LV diastolic dysfunction and prolonged length of hospital stay. (9) Conclusions and Relevance: In patients with normal systolic function undergoing CAB, diastolic dysfunction based on selected TEE parameters is associated with prolonged duration of postoperative hospital stay. This association cannot be explained by baseline comorbidities or common post-operative complications. The diagnosis of diastolic dysfunction can be made by TEE.

Nutrition for Hospital Workers During a Crisis: Effect of a Plant-Based Dietary Intervention on Cardiometabolic Outcomes and Quality of Life in Healthcare Employees During the COVID-19 Pandemic.

The study tested the effects of a vegan diet on cardiometabolic outcomes and quality of life among healthcare employees during the COVID-19 pandemic. Overweight hospital employees were enrolled and randomly assigned (in a 1:1 ratio) to an intervention group, which was asked to follow a low-fat vegan diet, or a control group, asked to make no diet changes. However, due to COVID-19 disruptions, all participants remained on their usual diets from March to June (12 weeks), creating a de facto control period, and all (n = 12) started the vegan diet with online classes in June, which continued for 12 weeks. Nine participants completed all final assessments. A crossover ANOVA was used for statistical analysis of differences in cardiovascular health during the control period and during the intervention. Despite the ongoing crisis, body weight decreased (treatment effect -5.7 kg [95% CI -9.7 to -1.7]; P = .01); fasting plasma glucose decreased (-11.4 mg/dL [95% CI -18.8 to -4.1]; P = .007); total and LDL-cholesterol decreased (-30.7 mg/dL [95% CI -53.8 to -7.5]; P = .02; and -24.6 mg/dL [-44.8 to -4.3]; P = .02, respectively); diastolic blood pressure decreased (-8.5 mm Hg [95% CI -16.3 to -.7]; P = .03); and quality of life increased (P = .005) during the intervention period, compared with the control period. A vegan diet improved cardiometabolic outcomes and quality of life in healthcare workers at the height of the COVID-19 pandemic.

Racial disparities in sleep-related cardiac function in young, healthy adults: implications for cardiovascular-related health.

STUDY OBJECTIVES: Considerable evidence shows that individuals from marginalized racial/ethnic groups in the United States experience greater rates of sleep disturbance and cardiovascular complications. Because sleep is a modifiable factor that is critically involved in cardiovascular health, improved understanding of the association between sleep and cardiovascular health during early adulthood can prevent cardiovascular disparities. This study examined racial/ethnic differences in cardiovascular function during sleep using heart rate and heart-rate-variability analyses. METHODS: Participants in this laboratory-based sleep study included healthy, "good sleepers" who were in early adulthood and resided in the United States at the time of participation (14 non-Hispanic Black [NHB; age = 30.9 (6.6), 57% female], 12 Asian [Asian, age = 26.0 (5.2), 42% female], and 24 non-Hispanic white [NHW; age = 24.6 (5.8), 79% female]). RESULTS: After adjusting for demographic factors and an apnea-hypopnea index, we found significantly higher heart rate within NREM Stage 2 (N2) (b = -22.6, p = .04) and REM sleep (b = -25.8, p =.048) and lower heart rate variability during N2 sleep (b = -22.6, p = .04) among NHB individuals compared with NHW individuals. Furthermore, NHB and Asian participants demonstrated significantly lower percent of time in slow wave sleep (SWS) compared with NHW participants (NHB: b = -22.6, p =.04; Asian: b = -22.6, p = .04). Individuals' percent of time in SWS significantly mediated differences in heart rate during N2 (indirect = 0.94, 95% CI [0.03, 2.68]) and REM sleep (indirect = 1.02, 95% CI [0.04, 3.04]). CONCLUSIONS: Our results showed disparities in sleep-related cardiovascular function in early adulthood that are mediated by SWS. These data suggest targeting sleep health in early adulthood might help reduce cardiovascular disease burden on individuals from marginalized groups.

An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center's Response to the Opioid Crisis.

Increased utilization of prescription opioids for pain management has led to a nationwide public health crisis with alarming rates of addiction and opioid-related deaths. In the surgical setting, opioid prescriptions have been implicated as a contributing factor to the opioid epidemic. The authors developed an innovative model to address aspects of pain management and opioid utilization during preoperative evaluation, acute surgical hospitalization, and postoperative follow-up for chronic opioid users. This program involves multidisciplinary teams that include acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation services. It also features a novel infrastructure for triage and pain management education and treatment. Individualized patient plans are devised that can include preoperative opioid weaning, regional anesthesia that minimizes opioid use, and multimodal techniques for surgical pain treatment. Multidisciplinary programs such as this have the potential to both improve perioperative pain control and prevent escalation of opioid use among chronic opioid users.

Intra-Aortic Missile After Gunshot Wound to Chest: An Interesting Case of Traumatic Cardiac Injury.

Missile embolus to the heart, although uncommon, is one of the most challenging scenarios in trauma. We describe a 36-year-old man who presented with a gunshot wound to the left chest and a chest x-ray revealing a foreign body in the mediastinum. A median sternotomy was performed and an injury to the left ventricle was identified. After intraoperative echocardiography and fluoroscopy confirmed a foreign body in the aortic root, cardiopulmonary bypass was implemented. A bullet was retrieved from the noncoronary sinus of the aortic valve. Injuries to the anterior leaflet of the mitral valve and left ventricle were repaired.

Are Anesthesia Providers Ready for Hypnosis? Anesthesia Providers' Attitudes Toward Hypnotherapy.

This study sought to measure current attitudes toward hypnosis among anesthesia providers using an in-person survey distributed at a single grand rounds at a single academic teaching hospital. One hundred twenty-six anesthesia providers (anesthesiologists and nurse anesthetists) were included in this study. A 10-question Institutional Review Board (IRB)-approved questionnaire was developed. One hundred twenty-six (73% of providers at the meeting) anesthesia providers completed the survey. Of the respondents, 54 (43%) were anesthesiologists, 42 (33%) were trainees (interns/residents/fellows) in anesthesia, and 30 (24%) were nurse anesthetists. Over 70% of providers, at each level of training, rated their knowledge of hypnosis as either below average or having no knowledge. Fifty-two (42%) providers agreed or strongly agreed that hypnotherapy has a place in the clinical practice of anesthesia, while 103 (83%) believed that positive suggestion has a place in the clinical practice of anesthesia (p < .0001). Common reasons cited against using hypnosis were that it is too time consuming (41%) and requires special training (34%). Only three respondents (2%) believed that there were no reasons for using hypnosis in their practice. These data suggest that there is a self-reported lack of knowledge about hypnosis among anesthesia providers, although many anesthesia providers are open to the use of hypnosis in their clinical practice. Anesthesia providers are more likely to support the use of positive suggestion in their practice than hypnosis. Practical concerns should be addressed if hypnosis and therapeutic verbal techniques are to gain more widespread use.

Utilization of AngioVac and snare for eradication of a mobile right atrial thrombus.

Although there are multiple etiologies of a right atrial thrombus, the presence of a central venous catheter increases the risk for its development. Once diagnosed, an assessment of patient-specific factors will aid in dictating the appropriate management strategy. In cases of chronic disease or adherent thrombotic masses, thrombolytic therapy might not result in complete resolution of the clot burden and could lead to a devastating embolic event. Accordingly, we present a case of a right atrial thrombus not amenable to medical therapy that was removed only after concomitant utilization of an AngioVac Aspiration System (Vortex Medical, Norwell, MA) and percutaneous snare catheterization.

Cerebral near-infrared spectroscopy monitoring and neurologic outcomes in adult cardiac surgery patients: a systematic review.

BACKGROUND: Near-infrared spectroscopy is used during cardiac surgery to monitor the adequacy of cerebral perfusion. In this systematic review, we evaluated available data for adult patients to determine (1) whether decrements in cerebral oximetry during cardiac surgery are associated with stroke, postoperative cognitive dysfunction (POCD), or delirium; and (2) whether interventions aimed at correcting cerebral oximetry decrements improve neurologic outcomes. METHODS: We searched PubMed, Cochrane, and Embase databases from inception until January 31, 2012, without restriction on languages. Each article was examined for additional references. A publication was excluded if it did not include original data (e.g., review, commentary) or if it was not published as a full-length article in a peer-reviewed journal (e.g., abstract only). The identified abstracts were screened first, and full texts of eligible articles were reviewed independently by 2 investigators. For eligible publications, we recorded the number of subjects, type of surgery, and criteria for diagnosis of neurologic end points. RESULTS: We identified 13 case reports, 27 observational studies, and 2 prospectively randomized intervention trials that met our inclusion criteria. Case reports and 2 observational studies contained anecdotal evidence suggesting that regional cerebral O(2) saturation (rSco(2)) monitoring could be used to identify cardiopulmonary bypass cannula malposition. Six of 9 observational studies reported an association between acute rSco(2) desaturation and POCD based on the Mini-Mental State Examination (n = 3 studies) or more detailed cognitive testing (n = 6 studies). Two retrospective studies reported a relationship between rSco(2) desaturation and stroke or type I and II neurologic injury after surgery. The observational studies had many limitations, including small sample size, assessments only during the immediate postoperative period, and failure to perform risk adjustments. Two randomized studies evaluated the efficacy of interventions for treating rSco(2) desaturation during surgery, but adherence to the protocol was poor in one. In the other study, interventions for rSco(2) desaturation were associated with less major organ injury and shorter intensive care unit hospitalization compared with nonintervention. CONCLUSIONS: Reductions in rSco(2) during cardiac surgery may identify cardiopulmonary bypass cannula malposition, particularly during aortic surgery. Only low-level evidence links low rSco(2) during cardiac surgery to postoperative neurologic complications, and data are insufficient to conclude that interventions to improve rSco(2) desaturation prevent stroke or POCD.

Intraoperative transesophageal echocardiography and ventricular assist device insertion.

A decade after cardiac surgery was established, transesophageal echocardiography (TEE) was developed and used to evaluate perioperative cardiac performance. It has become an invaluable tool to provide real-time information in the cardiac operating room. TEE provides practical and useful information prior to insertion as well as after placement of the device. Additionally, during episodes of device malfunction or hemodynamic instability, TEE can be extremely useful in defining the etiology of the problem. As ventricular assist devices (VADs) have undergone evolution in design and as more VADs are being implanted, the development of specific indications for TEE use during device placement is a relevant issue. Formal guidelines for use of TEE during VAD insertion are yet to be adopted or implemented, but for now TEE remains an essential tool for managing this patient population.

Update on ventricular assist devices.

PURPOSE OF REVIEW: Over the past two decades, medicine has seen a robust increase in the use of ventricular assist devices. The purpose of this review is to update the information concerning these devices, their advantages and disadvantages as well as their complications. This is essential, as the demand for these devices is increasing due to the increasing number of patients with end-stage heart failure and limited number of donor hearts available for transplantation. RECENT FINDINGS: First-generation devices consisted of large, cumbersome consoles requiring patient immobilization and often times hospitalization in an ICU setting. Second-generation models focused on patient mobility and discharge from hospital with an improvement in infection rates as well as 1 and 2-year survival rates. Designs for newer devices are focusing on full implantation without percutaneous lines, axial flow mechanisms and patient comfort. Additionally, total artificial hearts are being designed for the treatment of biventricular failure. The indications for ventricular assist devices are also being expanded to include destination therapy and alternatives to cardiac transplantation, as the supply of organs continues to be limiting. SUMMARY: This paper reviews the characteristics, outcomes and design of ventricular assist devices.