Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

Background:  There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery.  There is limited evidence in this regard for cardiac surgery.  A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death.  However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods:  The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites.  The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery.  One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25).  The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients.  The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review.  Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion:  The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.

Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

Background:  There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery.  There is limited evidence in this regard for cardiac surgery.  A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death.  However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods:  The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites.  The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery.  One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25).  The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients.  The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review.  Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion:  The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.

Point-of-care handheld ophthalmic ultrasound in the diagnosis and evaluation of raised intracranial pressure and Terson syndrome: a description of two cases

BACKGROUND

Ultrasound (US) examination of the eye can be used to detect and monitor elevated intracranial pressure (ICP) and its consequences. Elevated ICP is transmitted to the contiguous optic nerve and its sheath (dura mater), thus underlying the development of papilledema and a widened sheath diameter. The US measurement of the optic nerve sheath diameter (ONSD) has previously been validated to diagnose and monitor raised ICP. The occurrence of vitreous hemorrhage in association with subarachnoid hemorrhage (SAH)-i.e., Terson syndrome-can also be easily diagnosed using ophthalmic US. Because of its relevance in anesthesia and critical care, we describe how to perform the technique illustrated by two cases.

CASE PRESENTATIONS

A 72-yr-old man with hydrocephalus secondary to a SAH developed raised ICP following the removal of an external ventricular drainage (EVD) system. Daily ONSD measurements using handheld US allowed us to diagnose and monitor the progression and resolution of the intracranial hypertension following the placement of a second EVD system. We also describe the steps used to obtain ONSD measurements during the ophthalmic US examination of a 53-yr-old woman who presented with a stage IV SAH with concomitant bilateral vitreous hemorrhages or Terson syndrome.

CONCLUSION

Ophthalmic US using a handheld device to measure and monitor ONSD at the bedside is useful in diagnosing and monitoring the progression of intracranial hypertension following EVD removal in a patient with hydrocephalus secondary to SAH. Ophthalmic US can also be used to identify concomitant vitreous hemorrhage that is associated with a worse prognosis.

The impact of the senior companion program on quality of life outcomes for frail older adults and their families

The Senior Companion Quality of Care Evaluation assessed the impact of a federally funded senior volunteer program on quality of life outcomes for frail clients and their families. Telephone interviews were conducted with national samples of frail Senior Companion Program (SCP) clients, family members, and comparison group participants. Multivariate procedures were used to examine study outcomes. SCP clients benefited significantly from the program at 3 months, though fewer positive effects were reported at 9 months. SCP family members benefited only modestly from the program. The SCP has been considered a low-cost way of matching the needs of community-based frail older adults with the skills of senior volunteers. Now, it has been shown to have some favorable effects on client well-being. These findings may take on greater significance given the desire to expand the SCP through the USA Freedom Corps Initiative.

Regional differences in cardiovascular mortality in Minnesota

Cardiovascular disease is the leading cause of death in the United States. Initial results from our health survey in the Red River Valley of Minnesota suggested elevated cardiovascular mortality in men and women in younger age groups there compared with the rest of the state. Similarly, earlier published longitudinal studies of cardiovascular mortality in Minnesota revealed increased cardiovascular mortality in counties west of a diagonal line drawn through the tip of the arrowhead region (northeast Minnesota) to the southwest corner of the state. In this study we examined cardiovascular mortality by geographic region with respect to economic factors, residence patterns, and ethnic group. Since these regions vary in geology and major land use, environmental factors were considered as well. Our present data show a significant elevation in cardiovascular mortality from 1987-1997 in men and women aged 25-59 in northwest and northeast Minnesota counties compared with central-metro counties. In contrast, south-central Minnesota shows a rate of cardiovascular mortality for that age group similar to that seen in the central-metro region. The increase in cardiovascular deaths from myocardial infarct in the younger groups in the more rural, less affluent areas of northwest Minnesota is nearly two times higher than in the central-metro counties. Genetic factors may play a role in the increased mortality recorded for northeast Minnesota. Environmental contaminants such as pesticides are additional considerations. Finally, our data suggest the need to address long-standing regional cardiovascular mortality differences and rural health care access in Minnesota.

Altered kinetics of contraction of mouse atrial myocytes expressing ventricular myosin regulatory light chain

To investigate the role of myosin regulatory light chain isoforms as a determinant of the kinetics of cardiac contraction, unloaded shortening velocity was determined by the slack-test method in skinned wild-type murine atrial cells and transgenic cells expressing ventricular regulatory light chain (MLC2v). Transgenic mice were generated using a 4.5-kb fragment of the murine alpha-myosin heavy chain promoter to drive high levels of MLC2v expression in the atrium. Velocity of unloaded shortening was determined at 15 degrees C in maximally activating Ca2+ solution (pCa 4.5) containing (in mmol/l) 7 EGTA, 1 free Mg2+, 4 MgATP, 14.5 creatine phosphate, and 20 imidazole (ionic strength 180 mmol/l, pH 7.0). Compared with the wild type (n = 10), the unloaded shortening velocity of MLC2v-expressing transgenic murine atrial cells (n = 10) was significantly greater (3.88 +/- 1.19 vs. 2.51 +/- 1.08 muscle lengths/s, P < 0.05). These results provide evidence that myosin light chain 2 regulates cross-bridge cycling rate. The faster rate of cycling in the presence of MLC2v suggests that the MLC2v isoform may contribute to the greater power-generating capabilities of the ventricle compared with the atrium.

Effects of total replacement of atrial myosin light chain-2 with the ventricular isoform in atrial myocytes of transgenic mice

BACKGROUND

In contrast to their well-known and critical role in excitation-contraction coupling of vascular smooth muscle, the effects of the myosin light chains on cardiomyocyte mechanics are poorly understood. Accordingly, we designed the present experiment to define the cardiac chamber-specific functional effects of the ventricular isoform of the regulatory myosin light chain (MLC2v).

METHODS AND RESULTS

Postnatal transgenic cardiac-specific overexpression of MLC2v was achieved by use of the alpha-myosin heavy chain promoter. Enzymatically disaggregated atrial and ventricular mouse myocytes were field-stimulated at multiple frequencies, and mechanical properties and calcium kinetics were studied by use of video edge detection and FURA 2-AM, respectively. MLC2v overexpression resulted in complete replacement of the atrial with the ventricular isoform of the regulatory myosin light chain at the steady-state mRNA and protein levels in the atria of transgenic mice. Mechanical properties of transgenic atrial myocytes were enhanced to the level of ventricular myocytes of control animals in association with modest decreases in the amplitude of the calcium transient.

CONCLUSIONS

MLC2v modulates chamber-specific contractility by enhanced calcium sensitivity and/or improved cross-bridge cycling of the thin and thick filaments of the cardiomyocyte.

Transgenic remodeling of the contractile apparatus in the mammalian heart

The structure-function relationships of the sarcomeric proteins in the mammalian cardiac compartment remain ill-defined because of the lack of a suitable model in which they can be readily manipulated or exchanged in vivo. To establish the validity of the transgenic paradigm for remodeling the mammalian heart, the murine alpha -cardiac myosin heavy chain gene promoter was used to express a ventricular myosin light chain-2 transgene (MLC2v) in both the atria and ventricles of the adult animal. Expression resulted in high levels of the transgene's transcript in both compartments. In the ventricle, the transgene was expressed against the background expression of the normal isoform. In the atrium, the transgene's expression would be ectopic, in that normally, MLC2v expression is restricted to the ventricle. Ectopic expression of the transgene in the atria resulted in a complete replacement of the atrial myosin light chain-2 protein isoform, although the endogenous isoform's steady state transcript levels were unchanged. In contrast, ventricular expression of the transgene had no effect at the protein level, despite an eightfold increase in MLC2v transcript levels. The data show that sarcomeric protein stoichiometry is maintained rigorously via posttransciptional regulation and that protein replacement can be achieved through a single transgenic manipulation.

Structural and developmental analysis of two linked myosin heavy chain genes

We have identified at the molecular level two murine myosin heavy chain (MHC) genes which encode adult skeletal isoforms. As is the case for the murine cardiac MHC genes, the genes are closely linked, head to tail. To identify the isoform encoded by each gene, we located and sequenced the 3' termini and assessed the genes' temporal and tissue-specific expression patterns using probes specific for the 3' untranslated regions. These analyses indicate that the myosin encoded by the gene located 5' in the linked pair is the murine 2A isoform. The isoform encoded by the 3'-most gene of the linked pair appears to encode an additional isoform that is expressed in a number of adult skeletal muscles. The pattern of expression of the 3'-most gene indicates that it is tightly controlled developmentally. Transcripts from this gene, when compared to those from the MHC2A and beta-MHC genes, are the predominant MHC transcripts found in the diaphragm, tongue, soleus, and masseter, indicating that it encodes a major skeletal MHC isoform.

AMTEC: a cooperative effort in medical technology education

A committee in the St. Louis Metropolitan area has been established to promote communication and cooperation among the area's existing hospital-based programs in medical technology. Area Medical Technology Education Coordinators (AMTEC) was established three years ago primarily to facilitate the administrative functions of medical technology education and to serve as an instrument for the exchange of ideas. Its primary undertaking has been the central processing of applications to the area programs, as an aid in the admission process. In addition, a continuing education program sponsored by the committee has been established, and various "curriculum sharing" activities have been sponsored for the students enrolled in the schools. Future plans for the committee include sponsoring an on-going evaluation process of graduates by employers, and establishing a criterion-referenced question pool. The authors describe the experiences of the committee to date and plans for the implementation of future goals.