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Monday, April 25, 2011
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Monday, April 25, 2011
J. Lance Lichtor
Note:  The article that is discussed appears in this month’s issue of Anesthesiology and was also selected as an editors’ choice in the journal Science Translational Medicine

Postoperative cognitive dysfunction (POCD) may be an issue for both the very young and the very old.  The evidence to show that this might occur largely comes from work with animals.  Given this initial work, the next step is to understand the mechanism for these findings.  Humans generally receive anesthesia when they are undergoing a surgical procedure.  The relevance of most animal studies of POCD to humans is unclear since the animals do not also undergo a surgical procedure.

In this month’s issue of Anesthesiology, an article was published where an animal model that involved both anesthesia and arthroplasty surgery was used to test the hypothesis that overexpression of a specific protein, heat shock protein 72 (Hsp72), could prevent or reduce POCD.  For some background, in a recent review in Anesthesiology, evidence was provided to show how Hsp72 might be involved in the development of cerebral ischemia.(1)  Hsp72 proteins are also thought to be involved in the proliferation of certain cancer cells.(2)

In the current study, wild-type mice and Hsp72 overexpressing transgenic mice (Hsp72-Tg) were randomly allocated to one of three groups:  control, isoflurane anesthesia alone (A), or anesthesia with tibial fracture and pinning (S).  The Hsp72-Tg mice had Hsp72 brain levels that were ten times that of wild-type mice.  The mice in groups A and S received buprenorphine intraperitoneally and the mice in group S also received an application of local anesthesia until day 3 postoperatively.  Before surgery, the mice learned the association between a tone and a mild shock.  Memory was assessed 1, 3 and 7 days after anesthesia; aspects of learning were either non-hippocampal- or hippocampal-dependant.  After 1 or 7 days, mice were sacrificed and immunoreactivity in the hippocampus was measured.

On day 1, hippocampal-dependent and –independent memory for wild-type group S mice was less compared to the Hsp72-Tg mice.   On day 3 when the effect was more notable, in both groups S and A, hippocamapal-dependent and –independent memory was less for wild-type mice compared to the Hsp72-Tg mice.  No differences were seen on day 7.  Activated microglia were more prominent in the animals that underwent surgery, though no genotype effect was seen.

The fact that Hsp72 over-expression results in full maintenance of memory after surgery and anesthesia is fascinating.  The mechanistic basis for these findings is unclear.

1.  Giffard RG, Han RQ, Emery JF, Duan M, Pittet JF: Regulation of apoptotic and inflammatory cell signaling in cerebral ischemia: The complex roles of heat shock protein 70. Anesthesiology 2008; 109:339–48

2.  Sherman M: Major heat shock protein Hsp72 controls oncogene-induced senescence. Ann N Y Acad Sci 2010; 1197: 152-7

3. Vizcaychipi MP, Xu L, Barreto GE, Ma D, Maze M, Giffard RG: Heat Shock Protein 72 Overexpression Prevents Early Postoperative Memory Decline after Orthopedic Surgery under General Anesthesia in Mice. Anesthesiology 2011; 114: 891-900

Thursday, April 21, 2011
L. Jane Easdown
An increasing number of medical students and residents are seeking opportunities to work in global health through international electives.(1, 2) In recent surveys, 25% of US medical students and 40% of UK students now have some sort of international experience before residency.(3) In residency selection it is common to look for such activities as a measure of altruism. Service or teaching in developing countries is popular for several reasons. Trainees enjoy working in different healthcare environments and seeing new diseases and treatments. They also experience more autonomy abroad than they would have at home. For those who teach, it is an opportunity to serve as a resource for others. Students often comment on how their teaching activities benefit them as much or more than those they teach. In addition, there is a growing interest in medical education about health disparity both nationally and internationally. Also, who doesn’t enjoy traveling to exotic locales? What pedagogical purpose does an international elective serve? A literature survey of US and Canadian trainees demonstrated an increase in knowledge of tropical disease and, more importantly, a change in attitude towards public health, cross-cultural communication, and serving the disadvantaged. (4) The globalization of our world has led to infectious diseases that may have been confined within discrete borders in the not-so-distant past but now traverse continents. Our own population is also more diverse due to broader immigration facilitated by the increased ease and affordability of travel. This international experience can, therefore, theoretically benefit both those at home as well as abroad.

In a recent letter to The Lancet, the question was raised as to whether the medical student electives in developing countries contribute to global health and training since the impact of these electives has been under-researched and under-assessed.(5) Many doctors have received little or no training in international health prior to these rotations. Further, there may be little coordination of a given community’s particular needs with incoming physicians. There are additional concerns about sending trainees abroad, including security and health risks. Supervision may be inadequate and lead to overextension of talents.(6) Everyone agrees, however, that these electives could potentially be a boon to underserved areas if community needs could be better matched to the specific skill sets of those physicians intending to embark on international electives.

Do you feel that all trainees should have some training in global health? How can we make more efficient use of these trainees by matching their skills with particular local needs? Do you send medical students or residents to areas of the developing world? How are they trained and how are they assessed? What advantages do you see of this approach to medical education now and/or in the future? Your comments are always welcome.

1. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P: Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med 2009; 84: 320-5.
2. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P: Global health in medical education: a call for more training and opportunities. Acad Med 2007; 82: 226-30.
3. Banerjee A: Medical electives: a chance for international health. J R Soc Med 2010; 103: 6-8.
4. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ: Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med 2003; 78: 342-7.
5. Banerjee A, Banatvala N, Handa A: Medical student electives: potential for global health? Lancet 2011; 377: 555.
6. Edwards R, Piachaud J, Rowson M, Miranda J: Understanding global health issues: are international medical electives the answer? Med Educ 2004; 38: 688-90.

Additional resource
Anonymous Educating doctors for world health. Lancet 2001; 358: 1471.

Thursday, April 21, 2011
J. Lance Lichtor
Posted by J. Lance Lichtor, M.D.
Though not originally designed for that purpose, the American Society of Anesthesiologists Physical Status Classification System is used to predict risk. The Surgical Apgar score, originally based on based on blood loss, heart rate, and blood pressure, was designed to predict the risk of major complications or death within 30 days of surgery. A group of authors from Vanderbilt University used their perioperative electronic information system to validate the Surgical Apgar score. They analyzed general and vascular surgical patients and found that it can predict outcome after surgery.

Both this study and it's accompanying editorial are published ahead of print and will appear in the June issue of Anesthesiology.  The study abstract is below.

Disclaimer: Articles appearing in this Published Ahead-of-Print section have been peer-reviewed and accepted for publication in this journal and posted online before print publication. Articles appearing here may contain statements, opinions, and information that have errors in facts, figures, or interpretation. Accordingly, Lippincott Williams & Wilkins, the editors and authors and their respective employees are not responsible or liable for the use of any such inaccurate or misleading data, opinion or information contained in the articles in this section.

Reynolds PQ, Sanders NW, Schildcrout JS, Mercaldo ND, St Jacques PJ: Expansion of the Surgical Apgar Score Across All Surgical Subspecialties as a Means to Predict Postoperative Mortality. Anesthesiology 2011

Background: A surgical scoring system, akin to the obstetrician’s Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties.

Methods: Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients’ death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score.

Results: Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient’s American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties.

Conclusion: A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

Wednesday, April 20, 2011
Keith Ruskin
Posted by Keith Ruskin, M.D.
“Thank you for calling the Tobacco Quitline. Press 1 if you smoke cigarettes. Press 2 if you smoke cigars. Press 3 if you’ve had a bad day in the OR and need to step outside for a cigarette right now!”

Everyone, including smokers, understands that tobacco is bad for your health. The surgical procedure that a smoker needs may, in many cases, be directly related to tobacco use. Smokers undergoing surgery have higher carbon monoxide levels and are at greater risk for pulmonary complications after surgery. They are also at increased risk for wound infections and other surgical complications. It makes sense, therefore, to use the perioperative period as a “teachable moment” to educate our patients about the benefits of quitting as well as to give them a tool to assist them in quitting. Anesthesiologists interact patients for only a limited period of time, but while they are our patients, we may have an ideal opportunity to help them cease smoking.

The United States Public Health Service has developed clinical practice guidelines around a technique called the “5 A’s”:
  • Ask about tobacco use.
  • Advise the patient to quit.
  • Assess the patient’s willingness to quit.
  • Assist each patient with a specific cessation plan.
  • Arrange for follow-up.
Although this particular technique has been shown to be effective, we see most patients for only a brief period of time in the presurgical testing clinic and then again on the day of their surgery. Most of our patients’ time in the clinic may be spent with physician extenders such as advanced practice nurses and physician assistants. We, as anesthesiologists, require a tobacco intervention that is both brief and one that can be delivered by any healthcare provider.

Warner et al. may have filled that need by developing an intervention called “Ask, Advise, and Refer,” in which patients are asked about tobacco use, advised to quit, and then referred to a telephone quitline. In this month’s issue of Anesthesiology, an article by Warner et al. discusses the effectiveness of a brief intervention designed to get patients who smoke to call a telephone quitline. The study group was composed of patients who smoked. They were advised to quit, educated about quitline services, and then referred to a tobacco quitline. In many cases, a referral was faxed during the visit. Patients who called the quitline were given counseling and tobacco replacement therapy (e.g., nicotine gum or patches). Patients in the control group were advised to abstain, educated about the benefits of quitting, and then given a brochure with information about telephone counseling services. The primary outcome of the study was whether or not the patients made that first call; secondary outcomes included smoking cessation for 30 and 90 days.

Warner’s tobacco cessation intervention was effective: Almost 20% of the patients who received the quitline referral made the call and completed the first counseling session. Fewer reported that they had ceased smoking altogether; in fact, there was no statistical significance between the groups.  However, the intervention group trended to greater effectiveness and a larger and more statistically representative study in the future might reveal a subtle benefit. Both healthcare providers and a focus group of surgical patients helped to develop the intervention, which is probably one reason why it was as effective as it was. This paper is important because convincing a smoker to seek help is the first step towards quitting, and a short, focused intervention is what we can do best in the presurgical testing clinic.
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About the Author

J. Lance Lichtor, M.D
J. Lance Lichtor, M.D. is a professor of anesthesiology and pediatrics at The University of Massachusetts Medical School. He is the web editor and an associate editor for Anesthesiology.

Other Contributors
 Alan Jay Schwartz, MD MSEd Alan Jay Schwartz, MD MSEd
Alan Jay Schwartz, MD MSEd is director of education & program director, pediatric anesthesiology fellowship in the Department of Anesthesiology and Critical Care Medicine at The Children's Hospital of Philadelphia and is Professor of Clinical Anesthesiology and Critical Care at The University of Pennsylvania School of Medicine
 Amr Abouleish, MD, MBA Amr Abouleish, MD, MBA
Amr Abouleish, MD, MBA is professor & and the Michael Phillips Family Chair in the Department of Anesthesiology, The University of Texas Medical Branch
  Keith J Ruskin, MD
Keith J Ruskin, MD is professor of anesthesiology and neurosurgery, Yale University School of MEdicine and is a FAA Designated Aviation Medical Examiner

Andrew Davidson, MBBS MD FANZCA
Andrew Davidson, MBBS MD FANZCA is Director of Clinical Research and Senior Staff Anaesthetist, Royal Children's Hospital and Associate Professor, Department of Paediatrics, University of Melbourne, Melbourne Australia. He is also The 2011 Lennard Travers Professor, Australian and New Zealand College of Anaesthetists and an associate Editor for Anesthesiology.


L Jane Easdown, MD
Dr. L. Jane Easdown is Associate Professor of Anesthesiology for the Dept. of Anesthesiology at Vanderbilt University. She is a member of the board for the Society for Education in Anesthesia (SEA), a member of the ASA patient safety editorial board and a reviewer for the journal Simulation in Healthcare.


Edward J. Mascha, PhD.
Edward J. Mascha, PhD, is an Assistant Staff Biostatistician in the Department of Quantitative Health Sciences at Cleveland Clinic, with a joint appointment in the Cleveland Clinic’s Anesthesia Institute’s Department of Outcomes Research. He serves as a statistical reviewer for Anesthesiology, Anesthesia and Analgesia and the Journal of Vascular Surgery.

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