The mechanism of consciousness and its disruption during physiologic, pharmacologic, and pathologic states of unconsciousness is of fundamental importance. Anesthesiologists, who manipulate conscious states hundreds of millions of times each year in operating rooms around the world, are uniquely positioned to provide key insights into how the electrical and chemical activities of the brain are translated to the subjective experiences of the mind. This month’s featured article discusses key outstanding questions related to consciousness—including theoretical foundations, measurement of neural information, and the relationship of conscious experience to the physical world—and provides recommendations for how anesthesiologists can advance this foundational science. Additional empirical articles demonstrate how general anesthetics can be used to experimentally probe both level and content of consciousness. Current investigations and data support the hypothesis that both consciousness and unconsciousness reflect events at the scale of networks, as depicted in the cover art.
George A. Mashour, MD, PhD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

The focus of this month’s feature article is the future of perioperative precision medicine. Science is undergoing a reproducibility crisis. Several clinical trials have not been replicable. One of the several reasons is the lack of in-depth mechanistic aspects of diseases and therapies. Disease state happens not only from derangements at the molecular level, but also from the surrounding milieu. “Perioptome” is the terminology that integrates the perioperative genomics, metabolomics, and biomarkers with the clinically manifesting phenomics that we experience as practitioners. Perioperative precision medicine is a broad-based concept that incorporates identification, modulation, and management of the perioptome, to devise better predictive pathways for patient care after surgery. The technological revolution has offered us the best chance to obtain in-depth granularity into delineating these clinical phenotypes with the help of electronic health records, portable personal devices, and individual patient-reported outcomes. Although it may not be easy, it is time is to move beyond clinical statistical significance to individualized trials whenever and wherever feasible.
Miklos D Kertai, MD, PhD, and Pal Nirvik, MBBS, MD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month's featured article considers the challenges of designing, conducting, and interpreting clinical trials. Better still, solutions and a pathway forward are provided. Most would agree that clinical research is essential to the progress of knowledge and the practice of medicine. However, large, definitive randomized trials—the accepted gold standard and currency of evidence-based medicine—are expensive, and most take too long to complete. Anesthesia clinical trial networks have been created across the world, providing shared expertise, centralized data management and statistical analysis, infrastructure, and other resources to improve the efficiency and value of clinical trials. Innovations in clinical trial design, digital technologies, consumer engagement, and implementation science are also changing how we design and conduct clinical trials. This month's art cover depicts the value of digital health and global collaborations for the future of clinical trials.
Paul S. Myles, MD


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month’s cover art depicts the various categories of Health Services Research (HSR), which is defined as a multidisciplinary field that studies how economic systems, organizational structures and processes, emerging health technologies, and personal behaviors affect the delivery of care in the “real world” and ultimately, overall health of our patients. The cover specifically depicts the research continuum from basic research to translational research to clinical research to health services research. If we accept that the ultimate goal of this research continuum is to improve the health of our patients, it is clear that it’s not enough (for example) to develop a new treatment and then show its clinical superiority over existing treatment. In fact, we would go so far as to call this a surrogate outcome that is easy to measure but does not reflect the real goal of the research continuum. Indeed, HSR measures (for example) effective execution of knowledge translation, and this construct is frequently difficult because of the silo mentality that is embedded in our health care system. Knowledge translation requires a fully integrated system to execute the care, and that is difficult when various specialties “compete” rather than “collaborate.” Surgeons have already embraced HSR—we hope that this themed issue will contribute to the development of perioperative HSR in anesthesiology, foster more consideration of how we effectively translate the knowledge from scientific endeavors into high-quality care, and act as an impetus for the development of grant mechanisms directed at this area.


Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

This month's cover art depicts teamwork in action and is emphasized in two lead articles. As anesthesiologists, our practice of medicine requires us to be collaborators, communicators, and consensus builders. As accentuated by stresses imposed by the ongoing global pandemic, our value proposition as resilient, skilled, dynamic, and trusted leaders in healthcare has gained new public attention. These qualities uniquely poise anesthesiologists to rise to leadership positions within increasingly integrated health systems. At the same time, as leaders, we need to keep our balance, especially in the current turbulent times as we care for our patients, our colleagues, and our communities. The best health system CEOs are able to listen, delegate, mentor and celebrate the successes of others. As anesthesiologists and health system leaders, we have learned the important lesson that it's not about "winning" but about finding solutions. Effective leadership frequently avoids the use of "command and control" that is an externalized and often rigid, coercive, and non-collaborative leadership style. Rather, we see ourselves as servant leaders, those who deemphasize self and prioritize the needs of others as part of a larger healthcare team. You may wonder which of the 5 individuals on the cover art might represent the health system leader...a worthy conversation topic!

Joanne M. Conroy, MD
Michael R. Mathis, MD

Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

The focus of this month's featured article is the intersection of one of the key foundational practices of anesthesia care, intraoperative opioid administration, and administration practice patterns. Using a large dataset from the Multicenter Perioperative Outcomes Group (MPOG), the authors have characterized and quantified variability in intraoperative opioid practice patterns using a Bayesian analysis. Their work demonstrates the significant variability in practice between institutions and forms a strong foundational background for future research in this area. This month's art cover depicts this complex intersection, visually conveying distributions and variability of practice patterns, opioid formulations, and patients.

Bhiken I. Naik, Kai Kuck, Leif Saager,
Sachin Kheterpal, Karen B. Domino,
Karen L. Posner, Anik Sinha, Ami Stuart,
Chad M. Brummett, Marcel E.
Durieux, Michelle T. Vaughn, and
Nathan L. Pace, and the MPOG EOS
Investigator Group

Cover art composed by
Naveen Nathan, MD