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The gender-based pay gap among physicians and other professionals is well-documented. Even after adjustments for experience, age, work hours, academic rank, and productivity, the difference in salaries for men and women physicians has persisted over time, and even widens over the course of a physician’s career (Rotenstein et al., 2019). Medscape’s 2020 Physician Compensation Report found that male full-time primary care and specialist doctors earned 25% and 31% more, respectively, than their female counterparts (Kane, 2020). Gender-based pay disparities also persist in academic medicine, where female medical school faculty “neither advance as rapidly nor are compensated as well” as professionally similar male colleagues (Ash et al., 2004). Very few studies have focused on the wage gap specifically among anesthesiologists, but a new study published in August in Anesthesia & Analgesia did just that and sought to examine whether a significant gender wage gap still existed for anesthesiologists in the United States. The study, funded by the American Society of Anesthesiologists (ASA), shows that a significant wage gap is associated with gender when it comes to the compensation of physician anesthesiologists, even after adjusting for potential confounders like age and geographic practice region (ASA, 2021).

In 2018, study authors surveyed 28,812 physician members of the ASA to evaluate the association between compensation and gender, and to identify potential causes for wage disparities (Hertzberg et al., 2021). The primary variable of interest in their model was gender, while compensation by gender was the primary outcome of interest. Compensation was defined as “the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions,” and respondents could select a range in $50,000 increments or provide a point estimate of their compensation (Hertzberg et al., 2021). Researchers controlled for potential confounding variables, which are factors that might have an impact on the outcome of a study; for this study, race, number of dependent children or adults, hours worked, academic rank, and US census region were just a few of the variables that researchers controlled for. Researchers found that, on average, women anesthesiologists receive $32,617 less than their male counterparts in compensation each year (Hertzberg et al., 2021). In addition, women anesthesiologists are 56 percent less likely than male anesthesiologists to be paid at the highest salary range in the field. “Unfortunately, nothing has changed in terms of equalizing compensation for women anesthesiologists,” said Linda B. Hertzberg, M.D., the lead author of the study. “This study found that over a 30-year career, the gap could represent almost a million-dollar shortfall for women anesthesiologists. Bias, either explicit or implicit, persists and affects women’s compensation” (ASA, 2021).

Many physician-leaders have pushed for transparency around salary data, focused coaching, and equitable promotion to address the gender pay gap in medicine (Rotenstein et al., 2019). The study authors referenced the ASA’s 2019 “Statement on Compensation Equity Among Anesthesiologists” as a useful source for actionable items. Its recommendations include “identifying existing policies, procedures, leadership and culture that promote compensation equity” along with “[providing] implicit bias training for all who make compensation decisions,” among other practices (ASA, 2019). The ASA plans to repeat this gender compensation survey in five years to examine the effects of these recommendations, many of which are applicable across specialties and even outside of the medical field.

References 

American Society of Anesthesiologists (ASA). (2019, October 23). Statement on Compensation Equity Among Anesthesiologists. American Society of Anesthesiologists. https://www.asahq.org/standards-and-guidelines/statement-on-compensation-equity-among-anesthesiologists.  

American Society of Anesthesiologists (ASA). (2021, August 10). Women Anesthesiologists Less  Likely to be at High End of Salary Range; Gender Pay Gap Continues, Reflects Reduced Pay of $32,600 Yearly. Newswise. https://www.newswise.com/articles/women-anesthesiologists-less-likely-to-be-at-high-end-of-salary-range-gender-pay-gap-continues-reflects-reduced-pay-of-32-600-yearly.  

Ash, A., Carr, P., Goldstein, R., Friedman, R. & (2004). Compensation and Advancement of  Women in Academic Medicine: Is There Equity?. Annals of Internal Medicine, 141 (3), 205-212. Hertzberg, L. B., Miller, T.R., Byerly, S., Rebello, E., Flood, P., Malinzak, E.B., Doyle, C.A., Pease,  S., Rock-Klotz, J.A., Kraus, M.B., Pai, S. (2021, August 6). Gender Differences in Compensation in Anesthesiology in the United States: Results of a National Survey of Anesthesiologists. Anesthesia & Analgesia. DOI:10.1213/ANE.0000000000005676.  

Kane, L. (2020, May 14). Medscape Physician Compensation Report 2020. Medscape.  https://www.medscape.com/slideshow/2020-compensation-overview-6012684#13.

Newitt, P. (2021, August 11). Women anesthesiologists receive $32,617 less than men annually,  study says. Becker’s ASC Review. https://www.beckersasc.com/anesthesia/women-anesthesiologists-receive-32-617-less-than-men-annually-study-says.html.  

Rotenstein, L.S., Dudley, J. (2019, November 4). How to Close the Gender Pay Gap in U.S.  Medicine. Harvard Business Review. https://hbr.org/2019/11/how-to-close-the-gender-pay-gap-in-u-s-medicine.  

As recreational drug use and substance use disorder (SUD) rise, and as the current state of the world continues to favor this rise, the issue of screening and proper treatment of patients with substance use disorders comes to the forefront of medicine ⁴. Behind marijuana, methamphetamine is the most common illicit drug of choice worldwide ². Methamphetamines work on the dopaminergic and serotonergic pathways in the brain to induce, in small doses, its therapeutic effects: arousal, reduced fatigue, positive mood, and short-term improvement in cognition and focus. However, in larger doses, methamphetamine can lead to anxiety and paranoia, aggression, hypertensive and hypotensive states, psychotic symptoms ², and various cardiovascular effects such as arrhythmias, aortic dissection, and acute coronary syndrome ⁵. Given the state of substance abuse and the surging rates attributed to the COVID-19 pandemic ⁴, it is becoming increasingly likely that health professionals, including anesthesia providers, will encounter patients who use methamphetamine and the myriad of complications with which they can present.

These patients may pose a significant challenge in the field of anesthesia. There are specific considerations that have been outlined in the overall management of patients with acute methamphetamine intoxication ^1,4. A downstream effect of acute methamphetamine intoxication is the surge of catecholamines that act on receptive tissues to produce some of its effects. Catecholamines are mediators of the cardiovascular system: when levels are high, patients present with hypertension. After use, catecholamines can become depleted, making patients hypotensive ^1,5. It is important to either reduce catecholamine depletion or restore patients to a normotensive state. Benzodiazepine and vasopressors (epinephrine, norepinephrine) are recommended in this case. Beta-blockers for hypertension are currently contraindicated with acute intoxication due to the possibility of coronary spasm1.

Benzodiazepines have other many therapeutic uses in the case of acute methamphetamine intoxication. They are recommended preoperatively in the setting of sedation or restraint of patients experiencing unrelated or use-related paranoia, aggression, or psychosis^1,4. In these cases, physical restraint is generally contraindicated due to the increased cardiovascular stress of methamphetamine intoxication. Benzodiazepines also act to antagonize the effects of dopamine activity in the brain, which can help to dampen the effects of the drug in the short-term¹.

Methamphetamine use also carries the risk of developing rhabdomyolysis, an illness involving the death of muscle fibers and the harmful release of cellular content into circulation ³. This complication is thought to be precipitated by a number of factors, namely, decreased fluid intake, diffuse vasoconstriction from decreased cardiac output, and the toxic effects of methamphetamines on the muscle itself. This complication is an indication for intraoperative fluid bolus and close monitoring for metabolic acidosis ^3,4. Unchecked, this complication can advance to kidney failure and death ⁴.

With any serotonergic drugs, there is the additional risk of serotonin syndrome or serotonin toxicity where serotonin excess in the body leads to the sympathetic consequences such as hypertension, tachycardia, diaphoresis, and agitation. Fentanyl, another serotonergic drug, should also be considered carefully when used with patients with methamphetamine SUD. Benzodiazepines as well as serotonin antagonists can be considered in the case that a patient presents with serotonin toxicity ⁴.

Lastly, patients may be prescribed methamphetamine in low doses for certain conditions. Care providers have been directed to continue medications perioperatively, as there has been little to no evidence to indicate a danger to a patient using methamphetamines as prescribed ^1,4.

References 

1.  Beaulieu, P. Anesthetic implications of recreational drug use. Can J Anesth/J Can Anesth 64, 1236–1264 (2017). https://doi.org/10.1007/s12630-017-0975-0 

2.  Cruickshank, C.C. and Dyer, K.R. (2009), A review of the clinical pharmacology of methamphetamine. Addiction, 104: 1085-1099. https://doi.org/10.1111/j.1360-0443.2009.02564.x 

3.  Eilert, R.J., Kliewer, M.L. Methamphetamine-induced Rhabdomyolysis. Int Anesthesiol Clin. 2011;49:52–56. https://doi.org/10.1097/AIA.0b013e3181ffc0e5 

4.  Krogh, J., Lanzillota-Rangeley, J., Paratz, E., Reede, L., Stone, L., Szokol, J., . . . Kearney, J. (2021). Practice Considerations for the Anesthesia Professional for Methamphetamine Substance Use Disorder Patients. Newsletter: The Official Journal of Anesthesia Patient Safety Foundation, 36(2), 67-73. https://www.apsf.org/article/practice-considerations-for-the-anesthesia-professional-for-methamphetamine-substance-use-disorder-patients/. 

5.  Moran, S., Isa, J., Steinemann, S. Perioperative Management in the Patient with Substance Abuse. Surgical Clinics of North America. Volume 95, Issue 2,2015, 417-428. https://doi.org/10.1016/j.suc.2014.11.001. 

Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS), which damages the immune system and renders the infected individual vulnerable to future infections.¹ AIDS was first recognized in 1981 when young gay men began rapidly succumbing to opportunistic infections (OIs).² In the following years, researchers isolated a new human retrovirus from lymphoid ganglions that was confirmed to be the cause of AIDS and that enabled blood tests for HIV.³ HIV is only transmitted through body fluids such as blood, semen, and breast milk.⁴ In 2020, there were approximately 37.6 million people living with HIV and 690,000 deaths from AIDS-related illness.⁵ Current treatment methods for HIV significantly improve life expectancy, though vaccine development is still in progress.

HIV targets CD4+ T cells via a high affinity interaction between the envelope glycoprotein gp120 on its surface and the CD4 molecule on the T cell membrane. After this binding, viral nucleocapsids release the viral genome and enzymes, such as reverse transcriptase, into the target cell, which interact to synthesize viral double-stranded DNA. The viral DNA is translocated into the nucleus and integrated into the host genome, resulting in viral genes being transcribed and translated into the viral proteins that form virions, which bud off from the host cell membrane and can infect other cells.⁶ HIV can also infect monocytes, which are large phagocytic white blood cells, by interacting with their CCR5 co-receptors.⁷

As is the case for any foreign pathogen, the body’s immune system mounts both an innate and adaptive immune response to HIV. However, since HIV targets some of the very components critical to the immune response, such as CD4+ T cells and tissue macrophages, the response is inherently limited (HIV has also evolved mechanisms to evade type I interferons, an important component of the immune system’s antiviral arsenal).⁸ The destruction of these immune cells is what can ultimately culminate, usually several years after HIV infection, in AIDS.

No cure or vaccine for HIV currently exists, but antiretroviral therapy (ART) is an extremely effective treatment for the virus. Several classes of these drugs exist, all of which interfere with the virus’s ability to replicate.⁹ ART is recommended for all people with HIV regardless of how long they’ve been infected and can lower one’s viral load to undetectable levels, which also makes it virtually impossible to transmit the virus to a sexual partner.¹⁰ In a highly controversial 2018 experiment, Chinese scientist He Jiankui used CRISPR-Cas9 gene editing technology to disable the CCR5 gene in human embryos, a technique that could theoretically induce HIV immunity but will likely not reach patients in the near future due to current prohibitions enforced by most governments against gene editing in human embryos.¹¹

A viable HIV vaccine has not been developed since the beginning of the HIV epidemic nearly four decades ago. HIV, as an RNA virus, replicates with low fidelity; approximately one mutation is generated during each round of genome replication.¹² As such, it is difficult to engineer a vaccine that can keep up with each iteration of the virus. An additional complication is the lack of a model for natural immunity since total recovery from HIV infection is effectively impossible. Researchers therefore cannot use an immune response such as antibody production to learn how the immune system can effectively eliminate HIV.¹³ Two HIV vaccines are currently in clinical trials, with expected completion occurring within the next few years¹⁴: one hopes that they will prove successful.

References

1.  “HIV/AIDS.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 13 Feb. 2020, www.mayoclinic.org/diseases-conditions/hiv-aids/symptoms-causes/syc-20373524.
2. Sharp, P. M., and B. H. Hahn. “Origins of HIV and the AIDS Pandemic.” Cold Spring Harbor Perspectives in Medicine, vol. 1, no. 1, 2011, doi:10.1101/cshperspect.a006841.
3. Barre-Sinoussi, F, et al. “Isolation of a T-Lymphotropic Retrovirus from a Patient at Risk for Acquired Immune Deficiency Syndrome (AIDS).” Science, vol. 220, no. 4599, 1983, pp. 868–871., doi:10.1126/science.6189183.
4. Cachay, E. R. “Human Immunodeficiency Virus (HIV) Infection – Infections.” Merck Manuals Consumer Version, Merck Manuals, Apr. 2021, www.merckmanuals.com/home/infections/human-immunodeficiency-virus-hiv-infection/human-immunodeficiency-virus-hiv-infection.

“Burnout” is a frequently-used term for a psychological issue that includes “emotional exhaustion, depersonalization, and a sense of reduced accomplishment in day-to-day work.”¹ Prior to 2020, healthcare worker burnout was already gaining recognition as a growing problem. For example, a 2017 Medscape report demonstrated that nearly two-thirds of physicians reported feeling burnt out, depressed, or both.² To make matters worse, the ongoing COVID-19 pandemic has only exacerbated the issues contributing to healthcare provider burnout. For over a year, healthcare workers have frequently had more demanding hours, worked in environments that are understaffed and lack adequate resources, and experienced increased exposure to death and other psychologically traumatic events. Resulting attrition as workers leave or take a break from the field can then further exacerbate stressors among remaining healthcare providers.

An article published by the Washington Post earlier this spring sought to call attention to growing healthcare provider attrition.³ According to a poll taken of 1,327 healthcare workers, roughly three in ten were considering leaving the profession – a number that is shocking given the investment of time and money required to practice in the first place. A few of the physicians and nurses who had already decided to quit their jobs were able to explain their reasoning in an interview with the journalists. Some common themes were the psychological stress and trauma of the day-to-day job, frustration toward some people’s unwillingness to cooperate in slowing the spread of COVID-19, and the constant danger of infection. Other issues, such as understaffing, demanding hours, and a sense of being underappreciated and underprepared were also mentioned. Moreover, for those physicians who experience burnout and remain practicing, their chances of becoming addicted to alcohol or other substances, experiencing relational issues, and/or having reduced patient satisfaction are increased.¹

Occasionally, physicians themselves are at high risk for COVID-19 – take, for example, Justin Meschler, a retired doctor who was interviewed by the Washington Post.³ He mentioned that he was overweight and suffered from both asthma and a heart condition, all of which are risk factors for a life-threatening COVID-19 infection. The looming anxiety of this threat coupled with the other stresses of the job led him to hang up his stethoscope at age 48, far earlier than he would have otherwise anticipated.

The growing prevalence of healthcare provider burnout and attrition has led to calls for changes to the workplace. In fact, in recent years, numerous studies have sought to establish the components of an effective burnout prevention program which could be integrated into both public and private healthcare environments. One of the most promising avenues for preventing attrition is integrating preventative practices into daily life: for example, limiting the number of hours one can work in a day to less than 16, or normalizing the practice of mindfulness exercises in the workplace.^4,5 Moreover, healthcare workers that feel appreciated by their patients and co-workers are less likely to experience burnout.⁶ Therefore, team-building exercises and other practices which encourage mutual appreciation (such as keeping a gratitude journal) might also be encouraged. Ultimately, these small habits and changes may go a long way in alleviating healthcare attrition, though there is still much to learn.

References

1. Maslach, C.; Jackson, S.E.; Leiter, M.P. Maslach Burnout Inventory Manual, 3rd ed.; Consulting Psychologists Press: Palo Alto, CA, USA, 1996.

2. Medscape National Physician Burnout & Depression Report 2018. (2018). Retrieved from https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235

3. Wan, W. (2021, April 23). Burned out by the pandemic, 3 in 10 health-care workers consider leaving the profession. Retrieved from https://www.washingtonpost.com/health/2021/04/22/health-workers-covid-quit/

4. Weaver, M.D.; Landrigan, C.P.; Sullivan, J.P. The association between resident physician work-hour regulations and physician safety and health. Am. J. Med. 2020, 133, e343–e354.

5. Amanullah, S.; McNally, K.; Zelin, J.; Cole, J.; Cernovsky, Z. Are Burnout Prevention Programs for Hospital Physicians needed? Asian J. Psychiatry 2017, 26, 66–69.

6. McMurray, J.; Linzer, M.; Konrad, T.; Douglas, J.; Shugerman, R.; Nelson, K. The Work Lives of Women Physicians. J. Gen. Intern. Med. 2000, 15, 372–380.

Enhanced recovery after surgery (ERAS) programs aim to expedite patients’ recovery and reduce their morbidity following surgical procedures [1]. These protocols have led to demonstrably fewer complications and shortened hospitalization stays in the United States and Europe [2]. ERAS has challenged the perception of medical teams as specialized and separate silos by encouraging hospitals to follow a more collaborative framework across all levels of professionals [3]. An essential component of enhanced recovery programs is the use of multimodal analgesia, which can involve turning to regional anesthesia [1].

A primary goal of ERAS anesthesia protocols is greater anesthesiologist involvement throughout a patient’s hospital stay [3]. Currently, the norm is that anesthesia providers are largely limited to interacting with patients only during surgery [3]. Once the surgery is over, the anesthesia provider will often move on to the next patient [3]. ERAS strives to break this norm by giving anesthesia teams the time and encouragement to check in with patients following surgery [3]. By interacting with patients more, anesthesiologists can learn about the efficacy of their treatments, especially over the long term [3]. Regional anesthesia often requires a team approach, supporting its suitability in ERAS contexts [4].

Beyond patient interactions, enhanced recovery programs also prescribe changes to fluid protocol and pharmacologic administration [3]. Contrary to the long-held belief that patients should fast the night before surgery, ERAS dictates that patients should drink carbohydrates two hours before receiving anesthesia [3]. Medical teams should also minimize opioid use, avoid long-acting preoperative sedatives, and administer short-acting anesthetics instead of longer-acting ones [3]. Collectively, these changes may encourage patients to eat and drink sooner after surgery and reduce nausea [3].

Surgeons created ERAS to improve patient outcomes following colorectal surgery, but now, medical institutions apply the program in other surgical contexts as well [3]. Still, due to its origins, most of the research conducted about ERAS programs relates to colorectal procedures. Helander et al. conducted a study analyzing fifteen institutions following ERAS protocols in New Zealand to determined which types of regional anesthesia techniques are most commonly used in the context of colorectal surgeries [1]. Thoracic epidural analgesia (TEA) came first, followed by transversus abdominis plane (TAP) block [1]. ERAS programs commonly advocate for TEA, due to its associations with improved intestinal blood flow, reduced opioid use, lower surgical stress, diminished risk of paralytic ileus, and improved analgesia [1]. The anesthesiologists studied used TAP blocks during laparoscopic procedures [1]. Anesthesia teams treating colorectal surgery patients should consider these anesthetic approaches when working under ERAS protocols. Still, physicians should remember that no concrete evidence exists yet to suggest that any anesthetic techniques are strictly preferable, so caution is advised [2].

Many research studies have demonstrated the positive impact of ERAS protocols on patient outcomes and experiences [1]. One such analysis, conducted by Grant et al., attempted to quantify process measure compliance for anesthesia protocols [5]. While the overall compliance rate was low, increased compliance by anesthesiologists to a formal anesthesia protocol reduced the length of hospital stays [2, 5]. A study of postoperative opioid use found that ERAS interventions led to hospitals using more opioid-free and multimodal forms of anesthesia during colorectal surgery [6]. However, postoperative opioid prescription rates did not decrease, indicating that protocols may need to be improved further [6]. To meaningfully combat the opioid epidemic, protocols could instruct clinicians to study patient histories, past opioid use, and in-hospital pain scores when prescribing postoperative pain medication [6].

Nevertheless, the number of studies on the efficacy of anesthesia-related components of ERAS protocols remains low [2]. To improve ERAS scholarship and promote better patient outcomes, medical institutions should invest in leadership, educational programs, and innovation [2]. By doing so, anesthesiologists and their peers may administer better quality healthcare to each of their patients.

References 

[1] E. M. Helander et al., “Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery,” Journal of Laparoendoscopic & Advanced Surgical Techniques, vol. 27, no. 9, p. 898-902, July 2017. [Online]. Available: https://doi.org/10.1089/lap.2017.0339. 

[2] G. P. Joshi and H. Kehlet, “Enhanced Recovery Pathways: Looking Into the Future,” Anesthesia & Analgesia, vol. 128, no. 1, p. 5-7, January 2019. [Online]. Available: https://doi.org/10.1213/ANE.0000000000003746. 

[3] O. Ljungqvist, “ERAS–Enhanced Recovery After Surgery,” Journal of Parenteral and Enteral Nutrition, vol. 38, no. 5, p. 559-566, February 2014. [Online]. Available: https://doi.org/10.1177/0148607114523451. 

[4] F. Carli and A. Clemente, “Regional anesthesia and enhanced recovery after surgery,” Minerva Anestesiologica, vol. 80, no. 11, p. 1228-1233, February 2014. [Online]. Available: https://pubmed.ncbi.nlm.nih.gov/24492666/. 

[5] M. C. Grant et al., “The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results From an Enhanced Recovery After Surgery for Colorectal Surgery Cohort,” Anesthesia & Analgesia, vol. 128, no. 1, p. 68-74, January 2019. [Online]. Available: https://doi.org/10.1213/ANE.0000000000003458. 

[6] D. Brandal et al., “Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study,” Anesthesia & Analgesia, vol. 125, no. 5, p. 1784-1792, November 2017. [Online]. Available: https://doi.org/10.1213/ANE.0000000000002510. 

Roughly a year after the COVID-19 pandemic brought a halt to routine drug plant visits, the Food and Drug Administration (FDA) is under pressure from the pharmaceutical industry to address the increasing backlog of uncompleted drug inspections [1]. The FDA postponed site surveillance inspections in March 2020 [2]. Four months later, only “mission-critical inspections” (those required to approve potential COVID-19 tests, treatments, or vaccines, critical drugs in short supply, and new drugs developed for serious conditions on fast-track approval) were resumed [2]. Inspection data reveals that between October 1, 2019 and September 30, 2020, only 28 biologics plant inspections were conducted, compared with 116 the year prior [2]. Similarly, the FDA only completed 349 drug facility inspections in 2020, in contrast to 779 in 2019 [2]. The constraints to FDA inspections is concerning because inspections are required before a medication can earn FDA approval [1]. Furthermore, inspections serve as a vital tool to guarantee the safety of new drugs entering the market, as well as medications already available [1]. 

Over the past two decades, the majority (70%) of pharmaceutical manufacturing in the United States has moved to India and China [1]. In October 2019, the FDA discussed obstacles to ensuring drug and device safety in a global supply chain that is predominantly located offshore [3]. For years before the COVID-19 pandemic, the FDA’s overseas inspection program lagged behind its domestic program [3]. Unlike domestic inspections, which are usually unannounced, the FDA’s overseas inspections are typically announced 12 weeks before they occur [3]. From 2016 to 2018, the FDA performed 10% fewer foreign inspections [3]. From March to September 2020, the FDA only inspected three overseas plants [1]. 

The quality and reliability of drugs sourced abroad has repeatedly been called into question [3]. For more than a decade, the Government Accountability Office has listed the FDA’s difficulty in ensuring the safety of American drugs sourced overseas in its “High Risk Series” [3]. Although the pandemic has caused a major supply chain disruption, drug shortages in the United States of critical medications produced overseas have been reported before [3]. In 2018, there was a documented shortage of the antibiotic piperacillin-tazobactam due to an explosion in the sole Chinese plant producing the medication [3]. 

The stress of the COVID-19 pandemic has exacerbated previously existing problems in the United States public health system, especially in regard to the supply of essential medications [4]. At the very beginning of the pandemic in January 2020, more than 100 drugs were in short supply according to the FDA [4]. Unlike previous shortages that were typically due to manufacturing problems, these shortages triggered by the COVID-19 pandemic were driven by unexpected sharp increases in demand that exceeded manufacturers’ production capacity [4]. Moreover, travel restrictions that have limited the FDA’s ability to inspect drug-manufacturing plants overseas have further put a strain on the availability of medications [4]. 

In late January 2021, pharmaceutical industry leaders directly asked FDA officials to find a solution to the inspection issue [1]. The backlog of drugs that have not been inspected has delayed the availability of several new therapies [1]. In recent months, the FDA has deferred or denied at least six drug approvals because it could not inspect manufacturing sites [1]. The delayed therapies included a regenerative skin therapy for adults with deep second-degree burns, a cholesterol medication for people who cannot tolerate statins, and treatments for endometrial cancer [1]. 

The focus of many policy initiatives during the COVID-19 pandemic has been on expanding domestic production of pharmaceuticals [4]. A proposal has been introduced to Congress to nationalize generic drug manufacturing [4]. 

References 

1. Smalley, S. (2021). Drug industry pushes FDA to solve growing inspection backlog. https://www.politico.com/news/2021/03/02/fda-pandemic-drug-inspection-471979 

2. Shanley, A. FDA Inspections Remain Stalled During the COVID-19 Pandemic. 

3. Rickert, J. (2020). On Patient Safety: COVID-19 Exposes the Dangerous State of Drug and Device Supply Chains. Clinical Orthopaedics and Related Research, 478(7), 1419. doi:10.1097/CORR.0000000000001327 

4. Socal, M., Sharfstein, J., & Greene, J. (2021). The Pandemic and the Supply Chain: Gaps in Pharmaceutical Production and Distribution. American Journal of Public Health, 111(4), 635-639. doi:10.2105/ajph.2020.306138 

Nearly two centuries after Dr William Morton gave the first public demonstration of ether anesthesia in Boston in 1846, anesthetics are now used daily in thousands of hospitals. Despite our limited understanding of their mechanisms of action, intraoperative awareness under general anesthesia remains a rare occurrence, with a reported incidence of 0.1-0.2% (1). Leading to many complications including post-traumatic stress disorder (PTSD), such incidents, albeit rare, are extremely dangerous and represent the cause for 2% of all legal claims against anesthesia providers (2). 

Preoperatively, to minimize chances of intraoperative awareness under anesthesia, a thorough patient evaluation is critical. This should include 1) a focused history, 2) a physical examination, 3) identifying patients at risk for intraoperative awareness, and 4) informing selected patients of the possibility of intraoperative awareness (1). To this end, certain physical characteristics, including age, sex, American Society of Anesthesiologists (ASA) physical status (IV/V), drug resistance/tolerance, and a limited hemodynamic reserve, as well as certain procedures (e.g. caesarean delivery, cardiac surgery, trauma surgery) and anesthetic techniques (e.g. rapid-sequence induction, reduced anesthetic dose) have been associated with intraoperative awareness. In addition, a preoperative checklist protocol for anesthesia equipment should be adhered to in order to ensure that the desired anesthetic drugs and doses are appropriately delivered.

Intraoperatively, it is then key to closely monitor consciousness levels; a slew of methods have been developed to this end, including clinical techniques, conventional monitoring techniques, and brain activity monitoring, both natural and evoked.

Clinical techniques used to assess intraoperative consciousnesses include assessing patient movement, response to commands, open eyes, eyelash reflexes, pupillary diameters, perspiration, and tearing. Conventional monitoring techniques consist of ASA standard physiologic monitoring, including by pulse oximetry, electrocardiography, non-invasive blood pressure measurement, and temperature monitoring (1). 

Furthermore, natural brain activity monitoring can be carried out using frontal electroencephalographic (EEG) recordings. Typically, a series of signal processing algorithms are applied to generate a single “index” of consciousness – 100 corresponding to the awake state and 0 to an isoelectric EEG. In contrast, another EEG-based marker, the “bispectral index” (BIS) (3), reflects a proprietary algorithm that converts a single channel of a frontal EEG into the BIS index of hypnotic level; however, the high cost per person and the low specificity in preventing awareness episodes do not allow for its everyday use (2).  A number of alternative measures can also be used to assess levels of consciousness. First, entropy can be assessed, describing the irregularity, complexity, or unpredictability characteristics of a signal (4); both standard entropy (SE) and response entropy (RE) can be calculated within different frequency bands of EEG recordings to predict states of awareness. Next, a number of systems based on the classification of EEG patterns can be used. These include: 

1. the Narcotrend system, based on the visual classification of EEG patterns associated with various stages of sleep

2. the patient state index (PSI), based on the observation of reversible spatial changes in the power distribution of quantitative EEG recordings

3. the SNAP II index, based on a spectral analysis of a single-channel EEG recording (5)

4. the cerebral state monitor, a handheld device that analyzes a single channel EEG cerebral state “index” (6). 

In addition, evoked brain activity monitoring can also be used as a proxy for patient consciousness. The most common method used to this end is auditory evoked potentials (AEPs), which are the electrical responses of nervous system to auditory stimuli delivered via headphones. The isolated forearm technique (IFT) is an alternative. In this method, a tourniquet is applied to the patient’s upper arm and inflated above systolic blood pressure prior to administering muscle relaxants. Movement of the arm, either spontaneously or to a command, indicates wakefulness, although not necessarily explicit awareness (7). 

Finally, in rare cases of intraoperative awareness under anesthesia, both intraoperatively and postoperatively, certain measures should be taken in response. Intraoperatively, this primarily includes the intraoperative administration of benzodiazepines or scopolamine to patients who may have become conscious; scopolamine must be administered with caution since it may result in unintended side effects, including the emergence of delirium. Postoperatively, this includes providing a postoperative questionnaire on behalf of practitioners to patients to define the episode of awareness and, thereafter, offering postoperative counseling or psychological support (1,2).

In conclusion, intraoperative monitoring and responding to patient consciousness should rely on multiple modalities spanning clinical techniques, conventional monitoring systems, and brain activity recording.

References

1. Practice Advisory for Intraoperative Awareness and Brain Function Monitoring. Anesthesiology. 2006

2. Kotsovolis G, Komninos G. Awareness during anesthesia: How sure can we be that the patient is sleeping indeed? Hippokratia. 2009. 

3. Pillai A. Bispectral Index. In: Understanding Anesthetic Equipment and Procedures: A Practical Approach. 2015. 

4. Entropy. What is Entropy. 

5. Nievas IFF, Spentzas T, Bogue CW. SNAP II index: An alternative to the COMFORT scale in assessing the level of sedation in mechanically ventilated pediatric patients. J Intensive Care Med. 2014; 

6. Anderson RE, Jakobsson JG. Cerebral state monitor, a new small handheld EEG monitor for determining depth of anaesthesia: A clinical comparison with the bispectral index during day-surgery. Eur J Anaesthesiol. 2006; 

7. Anaesthesia UK : Isolated forearm technique [Internet]. Available from: https://www.frca.co.uk/article.aspx?articleid=100495

8. Monitoring Consciousness: Using BIS^TM during Anesthesia | Medtronic [Internet]. Available from: https://www.medtronic.com/covidien/en-us/clinical-education/catalog/monitoring-consciousness-using-bispectral-index-during-anesthesia-bis-pocket-guide-clinicians.html

9. Pavel MA, Petersen EN, Wang H, Lerner RA, Hansen SB. Studies on the mechanism of general anesthesia. Proc Natl Acad Sci U S A. 2020 Jun 16;117(24):13757–66. 

Substance abuse disorders can reduce one’s quality of life, threaten relationships, increase risk of comorbid mental illness, and impair one’s ability to perform work-related tasks. Unfortunately, physicians can be at heightened risk for developing substance abuse disorders. One 20-year longitudinal study found that practicing physicians were more likely to take tranquilizers, sedatives, and stimulants than their counterparts.^[1] Another study found that 73 percent of doctors had taken some form of non-prescribed psychoactive drug.^[2] A shocking report from the Medical College of Wisconsin identified that 15.8 percent of their anesthesiologists had diagnosable substance abuse problems.¹

Research has also shown that susceptibility to substance abuse and substance of choice vary with specialty. Overall, around 10 percent of physicians will suffer from substance abuse at some point during their careers.^[3] Hughes et al. performed a comprehensive self-report study of over 600,000 physicians and broke down rates of drug abuse by specialty.^[4] Here were their findings:

Anesthesiologists: Overall, approximately 7.8 percent of anesthesiologists struggled with substance abuse. However, these physicians were much more likely to abuse opioids specifically, possibly as a result of their increased access to these substances.

Psychiatrists: This specialty had the highest proportion of physicians with substance abuse problems, at almost 15 percent. Psychiatrists also had a threefold preference for benzodiazepines as compared to other doctors. It is not clear why psychiatrists were significantly more susceptible than other specialties, but Hughes et al. postulated that it was the result of their ease of access to prescriptions and normalized relationship with medication.

Pediatrics: Around 6.8 percent of pediatric doctors self-reported substance abuse issues, one of the lowest percentages of all specialties.

Surgeons: Along with pediatrics, surgery had an extremely low rate of substance abuse; only 5.5 percent of surgeons had fallen victim to addiction and/or dependency. 

Emergency medicine: Physicians working in emergency medicine had a relatively high rate of substance abuse, totaling 12.4 percent. They were also significantly more likely to take illicit drugs, such as marijuana or cocaine. Hughes et al. suggested that the reason for this may have been the inherently stressful and demanding nature of their day-to-day work.

These findings point towards the need for interventional support systems and preventative programs for physicians with substance abuse problems, particularly ones tailored to certain specialties. Physician health programs have had notable success in fighting addiction, with over 78 percent of enrolled physicians remaining substance free at a five-year follow-up.^[5] These resources should therefore be considered an integral part of any clinical setting.

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References

^[1] Valliant GE, Brighton JR, McArthur C: Physicians use of mood-altering drugs: A 20-year follow-up report. N Engl J Med 282:365-370, 1970. doi:10.1056/NEJM197002122820705

^[2] Lutsky I, Hopwood M, Abram SE, et al: Psychoactive substance abuse among American anesthesiologists: A 30-year retrospective study. Can J Anesth 40:915-921, 1993

^[3] Baldisseri, M.R. Impaired healthcare professional. Critical Care Medicine, 35(2 Suppl), S106-S116, 2013

^[4] Patrick H. Hughes MD, Carla L. Storr ScD, Nancy A. Brandenburg PhD, Dewitt C. Baldwin Jr. MD, James C. Anthony PhD & David V. Sheehan MD. Physician Substance Use by Medical Specialty, Journal of Addictive Diseases, 18:2, 23-37, 1999

^[5] Reading EG: Nine years’ experience with chemically dependent physicians: The New Jersey experience. MD Med J 41:325-329, 1992

Anesthesia for cardiac surgery has traditionally relied on high-dose opioids to mitigate the body’s sympathetic response to surgery [1]. However, recent studies have suggested that opioids extend postoperative intubation, resulting in increased morbidity [1]. Moreover, in-hospital exposure to opioids have been linked to increased dependency [1]. Regional cardiac analgesia techniques, also known as fast-track cardiac anesthesia (FTCA), have emerged as a promising alternative to traditional IV opioids for controlling perioperative pain [2]. 

The use of FTCA techniques in cardiac surgery dates back to 1954 when one of the first heart surgeries was performed under thoracic epidural analgesia (TEA) [3]. Advantages of TEA include decreased incidence of adverse cardiovascular events (e.g. stroke and myocardial ischemia), fewer respiratory complications, decreased risk of renal failure, lower infection rates, and earlier hospital discharge [3]. Additionally, TEA can continuously provide analgesia throughout the perioperative period [3]. Several clinical trials have confirmed the safety of TEA, but concerns remain over potential complications, such as spinal cord compression caused by a hematoma or abscess [3,4].  A meta-analysis examining the difference in rates of mortality and myocardial infarction after cardiac surgery for patients receiving TEA with general anesthesia, intrathecal analgesia with general anesthesia, or general anesthesia alone was published in 2004 [5]. The study examined 1,178 patients and concluded that there was no difference in rates of mortality or myocardial infarction in those who receive TEA versus general anesthesia only [5]. However, patients who received TEA were found to have decreased pulmonary complications, fewer cardiac dysrhythmias, and reduced pain scores [5]. A follow-up meta-analysis completed in 2011 yielded results consistent with the previous study [4]. 

Another well-studied FTCA technique is the paravertebral block [6]. Paravertebral block of the spinal nerve roots provides similar analgesia to TEA without the risk of hypotension or hematoma [6]. Additional benefits of paravertebral blocks include reduced opioid exposure and risk of perioperative myocardial infarction [1]. Other FTCA techniques that have been studied include parasternal, pectoral, and erector spinae plane blocks [1]. These techniques require further investigation but show a potential to further reduce the risk of adverse complications [1]. 

Pain following cardiac surgery may be intense, typically peaking on the first postoperative day [2]. Inadequate analgesia during the postoperative period can result in many adverse hemodynamic, metabolic, immunologic, and hemostatic alterations [2]. Techniques available for postoperative analgesia include local anesthetic infiltration via catheters placed at the incision site, nerve blocks, IV opioids, nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, and alpha-adrenergic agonists [2]. The American Society of Anesthesiologists Task Force on Acute Pain Management in the Perioperative Setting recommends a multimodal analgesia approach to provide superior analgesic efficacy with fewer adverse effects [2]. 

In an attempt to reduce postsurgical pain, researchers have also investigated the effect of remifentanil infusion during cardiac surgery on postoperative pain scores [7]. Remifentanil infusion has been associated with reduced postoperative pain, allowing patients to avoid the need for a nerve block [7]. Buprenorphine infusion has also been shown to reduce pain immediately following cardiac surgery [7]. 

References 

1. Caruso, T., Lawrence, K., & Tsui, B. (2019). Regional anesthesia for cardiac surgery. Current Opinion in Anaesthesiology, 32(5), 674-682. doi:10.1097/aco.0000000000000769 

2. Chaney, M. (2006). Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery. Anesthesia & Analgesia, 102(1), 45-64. doi:10.1213/01.ane.0000183650.16038.f6 

3. Liu, H., Emelife, P., Prabhakar, A. et al. (2019). Regional anesthesia considerations for cardiac surgery. Best Practice & Research Clinical Anaesthesiology, 33(4), 387-406. doi:10.1016/j.bpa.2019.07.008 

4. Svircevic, V., Nierich, A., Moons, K. et al. (2009). Fast-Track Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients. Anesthesia & Analgesia, 108(3), 727-733. doi:10.1213/ane.0b013e318193c423 

5. Liu, S., Block, B., & Wu, C. (2004). Effects of Perioperative Central Neuraxial Analgesia on Outcome after Coronary Artery Bypass Surgery. Anesthesiology, 101(1), 153-161. doi:10.1097/00000542-200407000-00024 

6. Bigeleisen, P., & Goehner, N. (2015). Novel approaches in pain management in cardiac surgery. Current Opinion in Anaesthesiology, 28(1), 89-94. doi:10.1097/aco.0000000000000147 

7. Anwar, S., & O’ Brien, B. (2021). The Impact of Remifentanil Infusion During Cardiac Surgery on the Prevalence of Persistent Postsurgical Pain. Journal of Cardiothoracic and Vascular Anesthesia, 35(2), 467-469. doi:10.1053/j.jvca.2020.09.131 

Coronavirus is a diverse category of viruses, to which the novel coronavirus is but the latest addition. These viruses are named for their crown-shaped form, which comes from a series of spindly projections that emerge from the virus’s surface. Most often, these viruses are present in animals such as bats, which may pass them along to humans if the virus mutates [1]. The virus that causes COVID-19 causes severe acute respiratory syndrome, lending it the name SARS-CoV-2. Whether a SARS 3 will emerge remains to be seen, but lessons and research from past experience should accelerate future efforts toward prevention and treatment.

The first coronavirus outbreak that caused severe acute respiratory syndrome (SARS-CoV) came in 2002. Widely known as SARS, this virus originated from bats and spread quickly to humans. Like the new coronavirus (SARS-CoV-2), the original SARS virus targeted ACE-2 receptors and was transmitted through droplets passed from one individual to another. However, the fatality and transmission rates for SARS-CoV-2 are more than three times that of the original SARS virus [2]. Several other coronaviruses emerged between the original SARS outbreak and the outbreak of SARS-CoV-2 in late 2019, though most only cause mild cold-like symptoms. 

The timing of an outbreak of a new SARS-related coronavirus (presumably titled SARS-CoV-3) is impossible to predict. Most likely, it will originate in bats or other animals, which will then pass it to humans. The degree to which it will affect the human hosts and how fast it spreads are difficult to ascertain. However, both the speed by which it is contained and the speed of vaccine production are within our control. 

Both SARS and COVID-19 can provide useful lessons on the need for quick containment. In the case of SARS, inadequate public surveillance allowed the virus to spread unchecked. Once systems were put in place to quarantine affected individuals and stop international transit, the virus was able to be contained [3]. The virus that causes COVID-19 was quickly identified, and the genome sequenced within two weeks of the first reported case [4]. However, the shape of the spike proteins on the SARS-CoV-2 virus bind 10 times more tightly than that of the SARS-CoV virus, greatly speeding up its ability to infect hosts [5]. Nonetheless, the implementation of early warning systems and fast sequencing can help to identify a future strain and contain its spread. 

If a new coronavirus were to develop into a pandemic, new advancements in vaccine development during the COVID-19 pandemic would likely lead to the quick development of a vaccine. The newest vaccines for SARS-CoV-2 use mRNA instead of inactivated or weakened agents that resemble the disease-causing microorganism. These vaccines can be developed rapidly and have exceptionally high efficacy rates. Indeed, the BNT162b2 mRNA vaccine was found to be 95% effective in preventing COVID-19 [6]. If a SARS 3 were to emerge, mRNA could likely be used to quickly produce highly effective vaccines. 

There are signs that SARS-CoV-2 is mutating—in December, the U.K. reported that a new, highly transmittable strain had been identified. The new strain does not appear to be more dangerous, and most mRNA vaccines are still expected to work on the new variant. However, future mutations may make it difficult for certain drugs, including Regeneron’s antibody treatment, to remain effective [7]. While this development warrants caution and investigation, it does not mean that a new SARS virus has emerged—instead, this is simply a mutation of the existing virus. 

References 

[1] Zhu, Zhixing, et al. “From SARS and MERS to COVID-19: A Brief Summary and Comparison of Severe Acute Respiratory Infections Caused by Three Highly Pathogenic Human Coronaviruses.” Respiratory Research, vol. 21, no. 1, 2020, doi:10.1186/s12931-020-01479-w.  

[2] Ceccarelli, M, et al. “Differences and Similarities between Severe Acute Respiratory Syndrome (SARS)-CoronaVirus (CoV) and SARS-CoV-2. Would a Rose by Another Name Smell as Sweet?” European Review for Medical and Pharmacological Sciences, vol. 24, no. 5, 2020, pp. 2781–2783., doi:10.26355/eurrev_202003_20551.  

[3] Heymann, David L. “The International Response to the Outbreak of SARS in 2003.” Philosophical Transactions of the Royal Society B, vol. 359, no. 1447, 2004, pp. 1127–1129., doi:10.1098/rstb.2004.1484.  

[4] Lisa Schnirring | News Editor | CIDRAP News | Jan 11, 2020. “China Releases Genetic Data on New Coronavirus, Now Deadly.” CIDRAP, 11 Jan. 2020, www.cidrap.umn.edu/news-perspective/2020/01/china-releases-genetic-data-new-coronavirus-now-deadly.  

[5] Wrapp, Daniel, et al. “Cryo-EM Structure of the 2019-NCoV Spike in the Prefusion Conformation.” Science, vol. 367, no. 6483, 2020, pp. 1260–1263., doi:10.1126/science.abb2507. 

[6] Polack, Fernando P., et al. “Safety and Efficacy of the BNT162b2 MRNA Covid-19 Vaccine.” New England Journal of Medicine, vol. 383, no. 27, 2020, pp. 2603–2615., doi:10.1056/nejmoa2034577.  

[7] Starr, Tyler N., et al. “Prospective Mapping of Viral Mutations That Escape Antibodies Used to Treat COVID-19.” bioRxiv, 2020 (preprint), doi:10.1101/2020.11.30.405472.