2018 Covers & Artwork

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December 2018, Volume 128, Issue 6

Despite the long-held belief systems passed down from generations of educators on the principles of cerebral autoregulation, it is apparent that we are still deconstructing its mystique. Whereas the cover image composites an artistic representation of cerebral perfusion akin to basic hydraulics and plumbing, so many layers of superimposed biologic complexity steer us away from basic presumptions. One of these, cerebrovascular stenosis, so alters arterial compliance that one wonders whether myogenic response systems that autoregulate cerebral perfusion pressure are in fact still in play. The feature article in this month's issue aims to answer this very question.
Naveen Nathan, MD
Cover Editor and Illustrator

November 2018, Volume 128, Issue 5

The concept of multimodal anesthesia is not new. However, its relevance is underscored today more than ever. We now recognize the limitations of drugs and techniques not just at the individual level, but that of the global scale, ie, the opiate crisis. Furthermore, we have also redefined success from the vantage point of the patient, in other words, the restoration of functional outcomes, not simply the mere survival of surgical and anesthetic insult. In view of this context, multimodal anesthesia exploits multiple agents and techniques that summate to produce these outcomes, while simultaneously reducing their undesirable consequences. If ever there was a visual motif that could evoke such a balanced approach it would decidedly be the mandala. The radial symmetry of the design is symbolic of our responsibility to consider all options in the pursuit of multimodal care. The 3-sided yin-yang alludes to the 3 cardinal goals of general anesthesia defined by the review article in this month's issue. Though the confluence of unconsciousness, analgesia, and immobility represent our clinical goals, how we get there may truly be as much a work of art as it is a discipline of science.
Naveen Nathan, MD
Cover Editor and Illustrator

October 2018, Volume 127, Issue 4

A rather morbid thought cuts through the stylistically whimsical nature of this month's cover as we perceive the faint semblance of a skull within the moon's shadow. We all welcome the respite of sleep to unburden the mind and evacuate the ills of the day. For many patients with obstructive sleep apnea, that slumber mutates into the nightmarish distillate of risk as they self-asphyxiate. More treacherous yet is the road back from artificial, drug-induced sleep, the purview of anesthesiologists in the postanesthetic care unit. If so inclined, one may search for the molecular structures of rocuronium, propofol, fentanyl, and sevoflurane within the constellations of the cover illustration.
Naveen Nathan, MD
Cover Editor and Illustrator

September 2018, Volume 127, Issue 3

A clean, streamlined approach was used for this month's cover image to reflect the simplicity of swallowing one's prescribed medication on the morning of surgery. It is doubtful that patients realize this straightforward, habitual task implies so much for their perioperative destiny, particularly when it comes to the question of continuing versus withholding ACE inhibitors and ARBs. A meta-analysis in this month's issue dives further into the haystack in our continuing search for a recognizable needle.
Naveen Nathan, MD
Cover Editor and Illustrator

August 2018, Volume 127, Issue 2

Despite its familiar placement within our lexicon, POCD has yet to penetrate deeper roots of understanding. Our insight into molecular mechanisms, causal relationships, and outcomes is still immersed in obscurity. The cavernous, fractal design incorporated into this month's cover image simultaneously evokes the objective geometry of cognition as well as the innumerable, darkened pathways that lead to its disarray. The 3D fractal image used in this illustration derives from the work of Piro4D and can be found at: https://pixabay.com/en/industry-fractals-geometry-graphic-1589790/.
Naveen Nathan, MD
Cover Editor and Illustrator

July 2018, Volume 127, Issue 1

As the story arc of blood transfusion practice began in the 19th century and subsequently evolved into the component therapy we are now familiar with, it closes in on what appears to be a circular path. This issue reconsiders the merits of whole blood transfusion as informed by the logistics of the austere military environment, a clinical sphere that has kept the use of whole blood alive and well. A review this month compels the idea that whole blood may in fact harbor a value greater than the sum of its component parts.
Naveen Nathan, MD
Cover Editor and Illustrator

June 2018, Volume 126, Issue 6

As we march into new frontiers of outcome-focused health care, a new uncertainty emerges: what outcomes are, in fact, relevant? The answer ostensibly depends on who you ask. A review in this month's journal on patient-reported outcomes after surgery underscores a concerning thought; that the individual spheres of priority and definitions of success according to a surgeon, an anesthesiologist, and the patient, may not overlap as much as we like. Our perspective on clinical management as anesthesiologists demands that we now open the aperture and take in the full story arc of the perioperative experience. Short of being a patient ourselves, we may do well to entertain walking in their shoes (or hospital-issued gown) for a change.
Naveen Nathan, MD
Cover Editor and Illustrator

May 2018, Volume 126, Issue 5

Articles in this month's issue address perioperative ocular complications. A review contained herein as well discusses the dynamic influences of surgical and anesthetic interventions and intraocular pressure, a major determinant of ocular perfusion pressure. The cover image is meant to address the uncertainty of perioperative concerns that extends beyond the cardinal goals of preserving cardiorespiratory and neurophysiologic homeostasis. Unlike basic physiologic measurements of pulmonary and cardiovascular indices, the eye enjoys no such scrutiny. There is no monitor to continuously assess its integrity. Ergo, that which cannot be measured, cannot be known. The original cover image, which has been modified and retouched, was acquired through pixabay.com at https://pixabay.com/en/eye-pupil-iris-see-close-brown-1392209/.
Naveen Nathan, MD
Cover Editor and Illustrator

April 2018, Volume 126, Issue 4

This month's cover image portrays the transformation of an antiquated, old-world map into the recognizable geography of modern times. Regrettably, only the richest countries have enjoyed the metamorphosis at the hands of the two physicians tasked with modernizing this mural. There is no intended subtlety in the metaphor at play here. Much like the fragile, oxidized parchment on which loosely identifiable continents were rendered centuries ago, so too suffers the majority of the world's population who endure the prison of need and deprivation. The articles contained herein offer us an aerial perspective on the roles, needs, and considerable disparity of anesthesia services across the globe.
Naveen Nathan, MD
Cover Editor and Illustrator

March 2018, Volume 126, Issue 3

This month's issue offers an instructive pair of narrative review articles on cardiac arrest, specifically in the perioperative setting. On the cover, we see a rhythm devolve into dis-coordinated fibrillation. As it is devoured into the black hole of uncertainty, what emerges on the other end is a reasoned, contextual decision tree that guides our management of the likeliest etiologies of cardiac arrest that occur perioperatively. The complete demise of hemodynamic stability in any patient rattles the psyche of even the most steadfast clinician. Despite the horror of such events, we may exploit our knowledge of the unique setting in which they occur to arrive at the most appropriate treatment algorithms expediently. A background stock image of a mathematical grid was used in developing this month's cover, copyright attributed as follows: 123RF Stock Photo (https://www.123rf.com/profile_studiom1).
Naveen Nathan, MD
Cover Editor and Illustrator

February 2018, Volume 126, Issue 2

As anesthesiologists, we are somewhat handicapped in that our interventions eliminate the ability to finely discriminate the dose-response relationship of our anesthetic drugs, at least in any way beyond the dichotomy of 'asleep' versus 'light'. Once we pass the threshold of the general anesthetic state, our understanding of the patient's instantaneous depth of anesthesia disappears into the dark matter of the unknowable. Although brain function monitors offer the temptation of using a digital depth gauge to reflect our imposed drug burden, they are defined as much by their limitations as their utility.
Naveen Nathan, MD
Cover Editor and Illustrator

January 2018, Volume 126, Issue 1

As medicine continues to reach greater depths of specialization, it has become clear that no one conventional pathway can prepare tomorrow's physicians for the entire bandwidth of specialty care. That has become most evident with the notions of focused training in pediatric cardiac anesthesia. The cover image incorporates the concept of the modified Penrose triangle, popularized by the likes of M. C. Escher, to convey the sheer complexity of congenital heart disease. His 1961 work entitled Waterfall has been assumed as the construct of the pathway of blood flow in the transposition of the great vessels. Here, we see elements that represent heart valves, a ductus arteriosus, and a ventricular septal defect that allows for mixing of blood.
Naveen Nathan, MD
Cover Editor and Illustrator