The Influence of Preoperative Physical Activity on Intraoperative Brain Function in Cardiac Surgical patients.

Background Preoperative physical activity and intraoperative brain health are recognized to influence postoperative delirium (POD). Electroencephalogram (EEG) burst suppression and cerebral desaturation are indicators of abnormal intraoperative brain health. Our study aimed to investigate the associations between preoperative physical activity and intraoperative EEG burst suppression and cerebral desaturation. Methods We retrospectively analyzed data from 67 patients from one of the institutions participating in a multisite randomized controlled trial, PANDORA, involving patients undergoing cardiac surgery. The preoperative PCS12 score calculated using the SF12 questionnaire was used as an indicator of preoperative physical activity. Intraoperative EEG and cerebral oximetry data (not the current standard of care in this facility) were collected, and the anesthesiologists were blinded to the information. We analyzed the following associations between the PCS12 score and i) burst suppression duration, ii) the number of cerebral desaturations, and iii) the number of observations with concurrent cerebral desaturation and burst suppression using a generalized linear model. The results are presented as percentage changes in outcomes, and a 95% C.I. p value < 0.05 was considered to indicate statistical significance. Results Each unit increase in the PCS12 score was associated with a 3.3% decrease in the duration of burst suppression (-3.3 [-5.3, -1.2], p value = 0.002). The duration of burst suppression decreased by 29.2% with each successive quartile increase in the PCS-12 score, indicating a dose‒response relationship (-29.2 [-41.6, -16], p < 0.001). Specifically, the patients in the last three quartiles exhibited a 55.4% reduction in BSD compared to those in the first quartile (-55.4 [-74.4, -24.6], p = 0.002) (Fig. 2). We did not observe any significant association between the PCS12 score and cerebral desaturation. Conclusion Decreased preoperative physical activity, as measured by the SF-12 questionnaire, is significantly associated with increased EEG burst suppression duration. Preoperative physical activity did not show any association with cerebral desaturations and concurrent cerebral desaturation and burst suppression. Clinical Trial information ClinicalTrials.gov Identifier- NCT04093219 https://clinicaltrials.gov/ct2/show/NCT04093219 Principal Investigator - Balachundhar Subramaniam Date of registration - September 13, 2019.

Technology-enhanced mindfulness-based collaborative social reasoning to improve adolescents' social-emotional competencies.

This study reports the preliminary efficacy of an innovative school-based, technology-enhanced social-emotional learning program called "mindfulness-based collaborative social reasoning" (MBCSR) for middle school students. MBCSR was developed by an interdisciplinary team of educational psychologists, mindfulness researchers, computer scientists, and health experts. We integrated the strengths of contemplative approaches, collaborative small group discussions, learning technology, and multidimensional assessments of students' social-emotional outcomes. Using a quasi-experimental design, the study was implemented in four sixth-grade English language arts classrooms (2 experimental and 2 business-as-usual control; N = 74) in a public middle school in the Midwest of the United States. It was co-implemented by researchers and teachers, with sessions occurring for 45 minutes, once per week, for 8 weeks. The MBCSR group showed greater self-efficacy for using Upa-yoga and mindful breathing to regulate their emotions and behaviors ( η p 2 $$ {\eta}_p^2 $$ = .13), and lower externalizing ( η p 2 $$ {\eta}_p^2 $$ = .07) and bullying behaviors ( η p 2 $$ {\eta}_p^2 $$ = .09) at the posttest compared to the control group, after controlling for baseline differences. Students in the experimental group overall showed positive and relaxed emotional and physiological states during the sessions. There were no significant differences between the two groups in mindfulness, emotional regulation, and social skills. This program sets an example for integrating social-emotional learning and academic learning into students' daily content instruction.

Blood pressure fragmentation as a new measure of blood pressure variability: association with predictors of cardiac surgery outcomes.

Background: Fluctuations in beat-to-beat blood pressure variability (BPV) encode untapped information of clinical utility. A need exists for developing new methods to quantify the dynamical properties of these fluctuations beyond their mean and variance. Objectives: Introduction of a new beat-to-beat BPV measure, termed blood pressure fragmentation (BPF), and testing of whether increased preoperative BPF is associated with (i) older age; (ii) higher cardiac surgical risk, assessed using the Society of Thoracic Surgeons' (STS) Risk of Morbidity and Mortality index and the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE II); and (iii) longer ICU length of stay (LOS) following cardiac surgery. The secondary objective was to use standard BPV measures, specifically, mean, SD, coefficient of variation (CV), average real variability (ARV), as well a short-term scaling index, the detrended fluctuation analysis (DFA) ⍺1 exponent, in the same type of analyses to compare the results with those obtained using BPF. Methods: Consecutive sample of 497 adult patients (72% male; age, median [inter-quartile range]: 67 [59-75] years) undergoing cardiac surgery with cardiopulmonary bypass. Fragmentation, standard BPV and DFA ⍺1 measures were derived from preoperative systolic blood pressure (SBP) time series obtained from radial artery recordings. Results: Increased preoperative systolic BPF was associated with older age, higher STS Risk of Morbidity and Mortality and EuroSCORE II values, and longer ICU LOS in all models. Specifically, a one-SD increase in systolic BPF (9%) was associated with a 26% (13%-40%) higher likelihood of longer ICU LOS (>2 days). Among the other measures, only ARV and DFA ⍺1 tended to be associated with longer ICU LOS. However, the associations did not reach significance in the most adjusted models. Conclusion: Preoperative BPF was significantly associated with preoperative predictors of cardiac surgical outcomes as well as with ICU LOS. Our findings encourage future studies of preoperative BPF for assessment of health status and risk stratification of surgical and non-surgical patients.

Pro: Individualized Optimal Perfusion Pressure-Maximizing Patient Care During Cardiopulmonary Bypass.

Cardiopulmonary bypass (CPB) has revolutionized cardiac surgery but poses challenges such as hemodynamic instability and adverse clinical outcomes. Achieving optimal perfusion during CPB ensures adequate oxygen delivery to vital organs. Although mean arterial pressure is a key determinant of perfusion pressure, clear guidelines for optimal perfusion have yet to be established. Autoregulation, the organ's ability to maintain consistent blood flow, plays a vital role in perfusion. Individual variability in autoregulation responses and intraoperative factors necessitate an individualized approach to determining the autoregulation range. Continuous assessment of autoregulation during surgery allows for personalized perfusion targets, optimizing organ perfusion. Exploring techniques like multimodal intravenous anesthesia guided by electroencephalogram can enhance perfusion maintenance within the auto-regulatory range. By adopting an individualized approach to perfusion targets on CPB, we can improve outcomes and enhance patient care.

Intraoperative Use of Phenylephrine versus Ephedrine and Postoperative Delirium: A Multicenter Retrospective Cohort Study.

BACKGROUND: The treatment of intraoperative hypotension with phenylephrine may impair cerebral perfusion through vasoconstriction, which has been linked to postoperative delirium. The hypothesis was that intraoperative administration of phenylephrine, compared to ephedrine, is associated with higher odds of postoperative delirium. METHODS: A total of 103,094 hospitalized adults undergoing general anesthesia for noncardiac, non-neurosurgical procedures between 2008 and 2020 at two tertiary academic healthcare networks in Massachusetts were included in this multicenter hospital registry study. The primary exposure was the administration of phenylephrine versus ephedrine during surgery, and the primary outcome was postoperative delirium within 7 days. Multivariable logistic regression analyses adjusted for a priori defined confounding variables including patient demographics, comorbidities, and procedural factors including magnitude of intraoperative hypotension were applied. RESULTS: Between the two healthcare networks, 78,982 (76.6%) patients received phenylephrine, and 24,112 (23.4%) patients received ephedrine during surgery; 770 patients (0.8%) developed delirium within 7 days. The median (interquartile range) total intraoperative dose of phenylephrine was 1.0 (0.2 to 3.3) mg and 10.0 (10.0 to 20.0) mg for ephedrine. In adjusted analyses, the administration of phenylephrine, compared to ephedrine, was associated with higher odds of developing postoperative delirium within 7 days (adjusted odds ratio, 1.35; 95% CI, 1.06 to 1.71; and adjusted absolute risk difference, 0.2%; 95% CI, 0.1 to 0.3%; P = 0.015). A keyword and manual chart review-based approach in a subset of 45,465 patients further validated these findings (delirium incidence, 3.2%; adjusted odds ratio, 1.88; 95% CI, 1.49 to 2.37; P < 0.001). Fractional polynomial regression analysis further indicated a dose-dependent effect of phenylephrine (adjusted coefficient, 0.08; 95% CI, 0.02 to 0.14; P = 0.013, per each µg/kg increase in the cumulative phenylephrine dose). CONCLUSIONS: The administration of phenylephrine compared to ephedrine during general anesthesia was associated with higher odds of developing postoperative delirium. Based on these data, clinical trials are warranted to determine whether favoring ephedrine over phenylephrine for treatment of intraoperative hypotension can reduce delirium after surgery.

Isha yoga practices, vegan diet, and participation in Samyama meditation retreat: impact on the gut microbiome & metabolome - a non-randomized trial.

BACKGROUND: Growing evidence suggests a role for gut bacteria and their metabolites in host-signaling responses along the gut-brain axis which may impact mental health. Meditation is increasingly utilized to combat stress, anxiety, and depression symptoms. However, its impact on the microbiome remains unclear. This study observes the effects of preparation and participation in an advanced meditation program (Samyama) implemented with a vegan diet including 50% raw foods, on gut microbiome and metabolites profiles. METHODS: There were 288 subjects for this study. Stool samples were collected at 3-time points for meditators and household controls. Meditators prepared for 2 months for the Samyama, incorporating daily yoga and meditation practices with a vegan diet including 50% raw foods. Subjects were requested to submit stool samples for 3 time points - 2 months before Samyama (T1), right before Samyama (T2), and 3 months following Samyama (T3). 16 s rRNA sequencing was used to study participants' microbiome. Alpha and beta diversities along with short-chain fatty acid (SCFA) were assessed. Metabolomics were performed on a mass spectrometer coupled to a UHLPC system and analyzed by El-MAVEN software. RESULTS: Alpha diversity showed no significant differences between meditators and controls, while beta diversity showed significant changes (padj = 0.001) after Samyama in meditators' microbiota composition. After the preparation phase, changes in branched short-chain fatty acids, higher levels of iso-valerate (padj = 0.02) and iso-buytrate (padj = 0.019) were observed at T2 in meditators. Other metabolites were also observed to have changed in meditators at timepoint T2. CONCLUSION: This study examined the impact of an advanced meditation program combined with a vegan diet on the gut microbiome. There was an increase in beneficial bacteria even three months after the completion of the Samyama program. Further study is warranted to validate current observations and investigate the significance and mechanisms of action related to diet, meditation, and microbial composition and function, on psychological processes, including mood. TRIAL REGISTRATION: Registration number: NCT04366544 ; Registered on 29/04/2020.

Understanding the Intricacies of Delivering Compassionate Care in the Intensive Care Unit and What Hinders It: A Qualitative Study of Members of 2 Critical Care Societies.

BACKGROUND: Patient-centered care is increasing in importance especially in the post-coronavirus disease 2019 (COVID-19) pandemic era. We sought to understand factors affecting compassionate care faced by intensivists in the intensive care unit (ICU). METHODS: Using survey methodology incorporating 3 real-life case vignettes, responses were elicited to difficult ethical and moral dilemmas in the ICU setting. Members of 2 critical care societies in the United States and Europe were included in the survey. RESULTS: Responses from 323 intensivists (32% out of 1000 members who opened the initial email invitation) around the world were analyzed thematically. Conflicts between patient choices and suggested medical care, institutional/work constraints restricting compassionate care and leading to burnout, and personal variables influencing compassionate care were the themes that emerged from our investigation. The results demonstrate that intensivists have compassion for their patients and want to provide patient-centered care, but also experience stress due to their limited ability to improve their patients' conditions. CONCLUSIONS: Compassionate attitudes can be hindered by an underlying worry about the decision made by the patient and their family, a lack of confidence in making hard moral decisions, and the burdens of burnout.

Dose-dependent relationship between intra-procedural hypoxaemia or hypocapnia and postoperative delirium in older patients.

BACKGROUND: Previous studies indicated an association between impaired cerebral perfusion and post-procedural neurological disorders. We investigated whether intra-procedural hypoxaemia or hypocapnia are associated with delirium after surgery. METHODS: Inpatients ≥60 yr of age undergoing anaesthesia for surgical or interventional procedures between 2009 and 2020 at an academic healthcare network in the USA (Massachusetts) were included in this hospital registry study. The primary exposure was intra-procedural hypoxaemia, defined as peripheral oxygen saturation <90% for >2 cohering min. The co-primary exposure was hypocapnia during general anaesthesia, defined as end-tidal carbon dioxide pressure ≤25 mm Hg for >5 cohering min. The primary outcome was delirium within 7 days after surgery. RESULTS: Of 71 717 included patients, 1702 (2.4%) developed postoperative delirium, and hypoxaemia was detected in 2532 (3.5%). Of 42 894 patients undergoing general anaesthesia, 532 (1.2%) experienced hypocapnia. The occurrence of either hypoxaemia (adjusted odds ratio [ORadj]=1.71; 95% confidence interval [CI], 1.40-2.07; P<0.001) or hypocapnia (ORadj=1.77; 95% CI, 1.30-2.41; P<0.001) was associated with a higher risk of delirium within 7 days. Both associations were dependent on the magnitude, and increased with event duration (ORadj=1.03; 95% CI, 1.02-1.04; P<0.001 and ORadj=1.01; 95% CI, 1.00-1.01; P=0.005, for each minute increase in the longest continuous episode, respectively). There was no association between occurrence of hypercapnia and postoperative delirium (ORadj=1.24; 95% CI, 0.90-1.71; P=0.181). CONCLUSIONS: Intra-procedural hypoxaemia and hypocapnia were dose-dependently associated with a higher risk of postoperative delirium. These findings support maintaining normal gas exchange to avoid postoperative neurological disorders.

Effect of breathing intervention in patients with COVID and healthcare workers.

Background: Regulated breathing facilitates ventilation and reduces breathlessness. However, the effect of Yogic breathing on patients with COVID remains unclear. We aimed to evaluate the efficacy of two breathing protocols, i.e., short breathing technique (SBT) and long duration breathing technique (LBDT). Methods: Three groups including COVID-positive patients, COVID-recovered patients, and healthcare workers (HCWs) were included in the study and segregated into Yoga and control groups. SBT was administered to COVID-positive patients. Both SBT and LBDT were administered to COVID-recovered patients and HCWs. A total of 18 biochemical parameters, a 6-min walk test (6MWT), and a 1-min sit-stand test (1MSST) were assessed on 0th, 7th, and 15th days, where biochemical parameters were the primary outcome. Pre-post estimation of neuropsychological parameters (nine questionnaires) and heart rate variability (HRV) were carried out. The paired t-test or Wilcoxon rank test was applied for pre-post comparison and the Student's t-test or Mann-Whitney U test was used for group comparison. Repeated measures test was applied for data recorded at three time points. Results: A significant elevation in white blood cell (WBC) count was observed in COVID-positive intervention (p < 0.001) and control groups (p = 0.003), indicating no role of intervention on change in WBC number. WBC count (p = 0.002) and D-dimer (p = 0.002) significantly decreased in the COVID-recovered intervention group. D-dimer was also reduced in HCWs practicing Yogic breathing as compared to controls (p = 0.01). D-dimer was the primary outcome, which remained below 0.50 µg/ml (a cutoff value to define severity) in the COVID-positive yoga group (CYG) and decreased in the COVID-recovered yoga group (RYG) and the HCW yoga group (HYG) after intervention. A 6-min walk test (6MWT) showed an increase in distance covered among the COVID-positive patients (p = 0.01) and HCWs (p = 0.002) after intervention. The high-frequency power (p = 0.01) was found to be reduced in the COVID-positive intervention group. No significant change in neuropsychological parameters was observed. Conclusion: Yogic breathing lowered D-dimer, which is helpful in reducing thrombosis and venous thromboembolism in patients with COVID-19 besides lowering the chances of vaccine-induced thrombotic thrombocytopenia in vaccinated individuals. The breathing intervention improved exercise capacity in mild to moderate cases of COVID-19. Further studies can show if such breathing techniques can influence immunity-related genes, as reported recently in a study. We suggest that Yogic breathing may be considered an integrative approach for the management of patients with COVID. Trial registration: http://ctri.nic.in/Clinicaltrials/login.php, identifier: CTRI/2020/10/028195.

Online guided meditation training (Isha Kriya) improves self-reported symptoms of anxiety and depression within 2 weeks of practice-An observational study.

Introduction: Anxiety and depression have increased dramatically 2-3-fold with the COVID-19 pandemic. There is an urgent need for safe, cost-effective, and scalable approaches to alleviate this parallel mental health pandemic. Meditation has previously been shown to reduce stress, anxiety, and depression symptoms. Furthermore, online delivery of mind-body interventions will be impactful in addressing disparities in access to mental healthcare. In this observational pilot study, we investigate the impact of a digitally delivered guided meditation followed by daily practice on symptoms of anxiety and depression. Methods: Initially, 57 male and 202 female subjects enrolled in this study. Participants attended a webinar where they learned the Isha Kriya meditation practice. They were subsequently requested to perform the intervention daily for 6 weeks. Subjects were given scales to assess anxiety and depression at baseline, 2, 4, and 6 weeks following the training. The changes in the self-reported anxiety and depression scores were examined by the linear mixed effect models. Results: Participants completed survey responses for the following time points: baseline (n = 82), week 2 (n = 58), week 4 (n = 37), and week 6 (n = 28). During the 6 weeks of the study over 68% of subjects were compliant with their daily practice. When comparing baseline with week 2, the mean anxiety scores decreased from 25.4 to 16.8 (p < 0.01, d = 1.31). Similarly, mean depression scores decreased from 15 to 8.81 (p < 0.01, d = 0.9). The reduced scores for both anxiety and depression were maintained at weeks 4 and 6. Conclusion: This preliminary study assesses the effectiveness of online meditation training on self-reported symptoms of anxiety and depression. After 2 weeks of practice, those with baseline anxiety and depression showed significant improvement with a large effect size. The results from weeks 4 and 6 show sustained reduced anxiety and depression symptoms. These findings suggest that daily Isha Kriya practice could alleviate symptoms of these conditions. Future studies utilizing randomized control trials should be conducted to rigorously evaluate the benefits of this meditation practice on anxiety and depression. Trials registration: ClinicalTrials.gov, identifier: NCT05065476.

Intensivists' perceptions of what is missing in their compassionate care during interactions in the intensive care unit.

BACKGROUND: We proposed that the behaviors that demonstrate compassionate care in the intensive care unit (ICU) can be self-assessed and improved among ICU clinicians. Literature showing views of intensivists about their own compassionate care attitudes is missing. METHODS: This was an observational, prospective, cross-sectional study. We surveyed clinicians who are members of professional societies of intensive care using the modified Schwartz Center Compassionate Care Scale® (SCCCS) about their self-reported compassionate care. A modified SCCCS instrument was disseminated via an email sent to the members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine between March and June 2021. RESULTS: Three hundred twenty-three clinicians completed the survey from a cohort of 1000 members who responded (32.3% response rate). The majority (54%) of respondents were male physicians of 49 (+ - 10 SD) years of age and 19 (12 + - SD) years in practice. The mean SCCCS was 88.5 (out of 100) with an average score of 8 for each question (out of 10), showing a high self-assessed physician rating of their compassionate care in the ICU. There was a positive association with age and years in practice with a higher score, especially for women ages 30-50 years (P = 0.03). Years in practice was also independently associated with greater compassion scores (p < 0.001). Lower scores were given to behaviors that reflect understanding perspectives of families and patients and showing caring and sensitivity. In contrast, the top scores were given to behaviors that included conducting family discussions and showing respect. CONCLUSION: Physicians in the ICU self-score high in compassionate care, especially if they are more experienced, female, and older. Self-identified areas that need improvement are the humanistic qualities requiring sensitivity, such as cognitive empathy, which involves perspective-taking, reflective listening, asking open-ended questions, and understanding the patient's context and worldview. These can be addressed in further clinical and ICU quality improvement initiatives.

Perceived Stress, Resilience, and Wellbeing in Seasoned Isha Yoga Practitioners Compared to Matched Controls During the COVID-19 Pandemic.

Background: Yoga practices, including breathing, meditation, and posture protocols (asanas), have been shown to facilitate physical and mental wellbeing. Methods: Seasoned yoga practitioners were recruited from the Isha Foundation. Recruitment of the comparison group was achieved using snowball sampling and were not yoga practitioners. Participants in the non-yoga group were randomized to a 3-min Isha practice or a comparator group asked to perform 15-min of daily reading. Participants completed a series of web-based surveys (REDCap) at baseline, 6, and 12 weeks. These surveys include validated scales and objective questions on COVID-19 infection and medical history. The validated questionnaires assess for: perceived stress (PSS), mood states [anxiety and depression (PHQ-4), joy (DPES-Joy subscale)], mindfulness attention and awareness (MAAS), resilience (BRS), mental wellbeing (WEMWBS) and recovery from traumatic event (PTGI). Weekly activity diaries were employed as a tool for collecting compliance information from study participants. Perceived stress scale scores were identified as primary outcome for this study. Findings: The median Perceived Stress Scale (PSS) score for the yoga practitioners compared to the active and placebo comparators was significantly lower at all time-points: baseline: 11 [IQR 7-15] vs. 16 [IQR 12-21] in both the active and placebo comparators (p < 0.0001); 6 weeks: 9 [IQR 6-13] vs. 12 [IQR 8-17] in the active comparator and 14 [IQR 9-18] in the placebo comparator (p < 0.0001); and 12 weeks: 9 [IQR 5-13] vs. 11.5 [IQR 8-16] in the active comparators and 13 [IQR 8-17] in the placebo comparator (p < 0.0001). Among the randomized participants that were compliant for the full 12 weeks, the active comparators had significantly lower median PSS scores than the placebo comparators 12 weeks [10 (IQR 5-14) vs. 13 (IQR 8-17), p = 0.017]. Further, yoga practitioners had significantly lower anxiety at all three-time points (p < 0.0001), lower depression at baseline and 6 weeks (p < 0.0003), and significantly higher wellbeing (p < 0.0001) and joy (p < 0.0001) at all three-time points, compared to the active and placebo comparator groups. Interpretation: The lower levels of stress, anxiety, depression, and higher level of wellbeing and joy seen in the yoga practitioners compared to the active and placebo comparators illustrate the impact of regular yoga practices on mental health even during the pandemic. Trial Registration: ClinicalTrials.gov, identifier: NCT04498442.

Anesthetics to Prevent Lung Injury in Cardiac Surgery: A Randomized Controlled Trial.

OBJECTIVES: To investigate if sevoflurane based anesthesia is superior to propofol in preventing lung inflammation and preventing postoperative pulmonary complications. DESIGN: Randomized controlled trial. SETTING: Single tertiary care university hospital. PARTICIPANTS: Forty adults undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Patients were randomized in a 1:1 ratio to anesthetic maintenance with sevoflurane or propofol. MEASUREMENTS AND MAIN RESULTS: Blood and bronchoalveolar lavage fluid was sampled before and after bypass to measure pulmonary inflammation using a biomarker panel. The change in bronchoalveolar lavage concentration of tumor necrosis factor alpha (TNFα) was the primary outcome. Secondary outcomes included lung inflammation defined as changes in other biomarkers and postoperative pulmonary complications. There were no significant differences between groups in the change in bronchoalveolar lavage TNFα concentration (median [IQR] change, 17.24 [1.11-536.77] v 101.51 [1.47-402.84] pg/mL, sevoflurane v propofol, p = 0.31). There was a significantly lower postbypass concentration of plasma interleukin 8 (median [IQR], 53.92 [34.5-55.91] v 66.92 [53.03-94.44] pg/mL, p = 0.04) and a significantly smaller postbypass increase in the plasma receptor for advanced glycosylation end products (median [IQR], 174.59 [73.59-446.06] v 548.22 [193.15-852.39] pg/mL, p = 0.03) in the sevoflurane group compared with propofol. The incidence of postoperative pulmonary complications was 100% in both groups, with high rates of pleural effusion (17/18 [94.44%] v 19/22 [86.36%], p = 0.39) and hypoxemia (16/18 [88.88%] v 22/22 [100%], p = 0.11). CONCLUSIONS: Sevoflurane anesthesia during cardiac surgery did not consistently prevent lung inflammation or prevent postoperative pulmonary complications compared to propofol. There were significantly lower levels of 2 plasma biomarkers specific for lung injury and inflammation in the sevoflurane group.

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID-19 patients: A retrospective cohort study.

BACKGROUND: Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium. METHODS: Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels. RESULTS: A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/212) patients received PP. Mechanical ventilation (OR 3.81 [1.16-12.52]) and PP (OR 7.38 [2.4-22.68]) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP. CONCLUSION: PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium. IMPLICATION STATEMENT: PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.

OBJECTIVE: To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. BACKGROUND: It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. METHODS: A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. RESULTS: In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. CONCLUSIONS: Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.

Short Term Effects of Inner Engineering Completion Online Program on Stress and Well-Being Measures.

Introduction: The Covid-19 pandemic has been a major disruptor of routine life, resulting in increased stress and predisposing people to negative outcomes, such as insomnia, anxiety and hopelessness. Mind-body interventions have improved concentration, emotional balance, and positive emotions, with an enhanced sense of productivity, and self-confidence. We therefore hypothesized that exposure to an online mind-body intervention, "Inner Engineering Completion Online (IECO)," would reduce stress and promote well-being. Methods: This prospective cohort study enrolled participants registered for the IECO courses, which for the first time were delivered remotely, online. Participants learned a 21-min meditation practice called Shambhavi Mahamudra Kriya during the course, which incorporates controlled breathing and mediation techniques. Each enrolled participant was asked to complete self-reported electronic surveys at three key time points: at the time of consent, immediately after completing IECO, and 6 weeks after IECO completion. Effects of IECO practice were assessed using four well-validated neuropsychological scales: Perceived Stress Scale (PSS), Positive Emotion/Relationship/Engagement Scale (PERMA) Profiler, Pittsburgh Sleep Quality Index (PSQI), and Mindful Attention Awareness Scale (MAAS). A Signed Rank test was used to analyze the survey data and P-values of < 0.05 were considered statistically significant. Results: Of the 375 participants interested in participation, 164 participants were eligible. Sixty-eight participants completed surveys at all time points and were identified as compliant participants. The baseline median score for PSS in compliant participants (n = 95) was 13.5 (IQR 9, 18); immediate post-IECO median PSS score was 12 (IQR 8, 16) demonstrating a 1.5 unit decrease in PSS scores (p-value = 0.0023). Similarly, comparing PSS scores in compliant participants (n = 68) for immediate Post IECO [11.5 (IQR 8, 15.5)] to PSS scores at six weeks [8 (IQR 4.5, 12.5)] showed a statistically significant 3.5-unit decrease, indicating a reduction in stress upon routine practice of the intervention (p < 0.0001). Conclusion: Incorporating the remotely delivered mind-body intervention Shambhavi Mahamudra Kriya into daily life via the IECO program over as few as 6 weeks produced a significant stress reduction, improvement in sleep quality and mindfulness. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT04189146].

Advanced Meditation and Vegan Diet Increased Acylglycines and Reduced Lipids Associated with Improved Health: A Prospective Longitudinal Study.

Introduction: Samyama is an Isha Yoga 8-day residential meditation/yoga retreat combined with 60 days of preparation with vegan diet. We showed earlier Samyama retreat was associated with lower systemic inflammation and favorable lipid profiles along with other physical and mental health benefits. There is no mechanistic study on the impact of an advanced meditative process on multiple blood lipids and their implications on meditation-related improved physical and mental wellbeing. Methods: Sixty-four Samyama participants on vegan diet had blood sampled immediately before and immediately after the 8-day retreat for lipidomic analysis. The complex plasma lipidome was characterized using high-resolution mass spectrometric analysis and tandem mass spectrometry. Results: Pre- and post-Samyama blood samples of 64 Samyama participants were analyzed. Acylglycines (acetyl, propionyl, butyryl, and valeryl) were increased in the plasma post-Samyama compared with pre-Samyama (p < 0.001). Levels of glycerophosphocholines, glycerophosphoethanolamines, di-unsaturated ethanolamine plasmalogens, cholesterol esters, acylcarnitines, and acylgylcerines (triacylglycerols and diacylglycerols) decreased after the Samyama meditation. Plasma levels of glycerophosphoserines or glycerophosphoinositols were unchanged. Conclusion: An 8-day advanced meditation retreat resulted in increased acylglycines, an endocannabinoid-like fatty acid amide associated with increased cellular anandamide levels, anti-inflammation, analgesia, and vascular relaxation. Other serum lipid levels, including some that are associated with increased risk of atherosclerosis, were reduced following the Samyama program. ClinicalTrials.gov Registration: Identifier: NCT04366544.

Postoperative pulmonary complications with adjuvant regional anesthesia versus general anesthesia alone: a sub-analysis of the Perioperative Research Network study.

BACKGROUND: Adjuvant regional anesthesia is often selected for patients or procedures with high risk of pulmonary complications after general anesthesia. The benefit of adjuvant regional anesthesia to reduce postoperative pulmonary complications remains uncertain. In a prospective observational multicenter study, patients scheduled for non-cardiothoracic surgery with at least one postoperative pulmonary complication surprisingly received adjuvant regional anesthesia more frequently than those with no complications. We hypothesized that, after adjusting for surgical and patient complexity variables, the incidence of postoperative pulmonary complications would not be associated with adjuvant regional anesthesia. METHODS: We performed a secondary analysis of a prospective observational multicenter study including 1202 American Society of Anesthesiologists physical status 3 patients undergoing non-cardiothoracic surgery. Patients were classified as receiving either adjuvant regional anesthesia or general anesthesia alone. Predefined pulmonary complications within the first seven postoperative days were prospectively identified. Groups were compared using bivariable and multivariable hierarchical logistic regression analyses for the outcome of at least one postoperative pulmonary complication. RESULTS: Adjuvant regional anesthesia was performed in 266 (22.1%) patients and not performed in 936 (77.9%). The incidence of postoperative pulmonary complications was greater in patients receiving adjuvant regional anesthesia (42.1%) than in patients without it (30.9%) (site adjusted p = 0.007), but this association was not confirmed after adjusting for covariates (adjusted OR 1.37; 95% CI, 0.83-2.25; p = 0.165). CONCLUSION: After adjusting for surgical and patient complexity, adjuvant regional anesthesia versus general anesthesia alone was not associated with a greater incidence of postoperative pulmonary complications in this multicenter cohort of non-cardiothoracic surgery patients.