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Breast cancer is one of the most commonly diagnosed cancers and the second leading cause of cancer-related death in women. [1] As surgical resection is the primary method of treatment for these patients, there is a high risk of blood-borne metastasis. This occurs when trauma to the central tumor causes tumor cells to shed and enter the bloodstream, circulating and then exiting into distant regions of the body. [2] Additionally, surgical operations have been shown to decrease natural killer cell function and T cell response for one to four weeks after surgery. These immunosuppressive effects put cancer patients in the postoperative state at a higher risk of developing metastases. As a result, there is significant interest in potential modifications to breast cancer surgery that decrease the risk of negatively affecting a patient’s cancer status with minimal side effects. One area of interest is the effect of lidocaine on breast cancer cells.

Several retrospective studies have suggested regional anesthesia may have a positive effect on cancer relapse and recurrence. Regional anesthesia is administered by injecting local anesthetic at a target location to temporarily disrupt pain signals from a specific region of the body. Potential benefits include reducing surgical stress from neuroendocrine and immunological disturbances, reducing the use of systemic anesthesia and opiates (which have been shown to hinder cell immunity), as well as having a direct inhibitory effect on cancer cells. [1]

In an in vitro experiment, three human breast cancer cell lines were isolated and grown in culture plates. These breast cancer cells were treated with increasing doses of lidocaine, an anesthetic that is commonly used for regional anesthesia. Lidocaine significantly reduced cell viability in all three cell lines, as measured by the MTT colorimetric assay. The anesthetic was also shown to inhibit cell migration, as exposed cells demonstrated reduced wound closure compared to control cells. The same researchers then conducted an in vivo experiment in mice to further assess the effects of lidocaine on human breast cancer cells. Cancer cells were injected intraperitoneally, and the global tumor volume was measured. Mice injected with lidocaine exhibited prolonged survival times and developed significantly smaller tumors than control mice. [3] At the conclusion of these molecular and preclinical experiments, these researchers suggest lidocaine may have a protective effect against human breast cancer cells.

Lidocaine is an amide anesthetic routinely administered for topical or surface anesthesia, and is injected into the subarachnoid and epidural spaces to block sensory and motor neural transmission. [4] Cytotoxicity assays performed on natural killer (NK) cells demonstrated that clinically relevant concentrations of lidocaine increases performance of NK cells, which are a crucial pillar of the immune response. [4,5] One in vitro study on human hepatocellular carcinoma cells found cancer cells treated with lidocaine exhibited a decrease in Bcl-2 levels with a concurrent increase in Bax concentrations. These two molecules are part of the Bcl-2 family, a group of regulatory proteins modulating cell death, composed of inhibitors (Bcl-2) and promoters (Bax). It was further observed that treated cultures with cancer cells exhibited a significant increase in caspase-3, a “death protease” catalyzing the cleavage of many key cellular proteins. [6] Matrix-metalloproteinase 9 (MMP-9) is a proteolytic enzyme which plays a crucial role in tumor metastasis by regulating pathological remodeling processes involving inflammation and fibrosis. [7] Another in vitro study demonstrated lidocaine can significantly decrease the secretion of MMP-9 by repressing the activity of tumor necrosis factor ɑ (TNF-ɑ), a proinflammatory cytokine. [8]

The cancer microenvironment is extraordinarily complex, involving many molecular cascades and organ systems. Although lidocaine has been shown to have a protective effect against human breast cancer cells, the extant literature has thus far been restricted to artificial and preclinical experimentation. As such, further clinical research is needed to determine lidocaine’s true benefit. What’s more, there is a lack of research on the specific mechanisms by which lidocaine takes effect on cancer cells. Investigating these can help explain the beneficial properties of lidocaine in cancer progression.

References

1. Li, Ru, et al. “Effects of Local Anesthetics on Breast Cancer Cell Viability and Migration.” BMC Cancer, vol. 18, no. 1, June 2018, p. 666. BioMed Central, https://doi.org/10.1186/s12885-018-4576-2

2. Choy, A., and P. McCulloch. “Induction of Tumour Cell Shedding into Effluent Venous Blood Breast Cancer Surgery.” British Journal of Cancer, vol. 73, no. 1, Jan. 1996, pp. 79–82. www.nature.com, https://doi.org/10.1038/bjc.1996.14

3. Chamaraux-Tran, Thiên-Nga, et al. “Antitumor Effects of Lidocaine on Human Breast Cancer Cells: An In Vitro and In Vivo Experimental Trial.” Anticancer Research, vol. 38, no. 1, Jan. 2018, pp. 95–105. ar.iiarjournals.org, https://ar.iiarjournals.org/content/38/1/95

4. Zhang, Caihui, et al. “Local Anesthetic Lidocaine and Cancer: Insight Into Tumor Progression and Recurrence.” Frontiers in Oncology, vol. 11, 2021. Frontiers, https://www.frontiersin.org/articles/10.3389/fonc.2021.669746

5. Ramirez, Maria F., et al. “The Effect of Clinically Therapeutic Plasma Concentrations of Lidocaine on Natural Killer Cell Cytotoxicity.” Regional Anesthesia & Pain Medicine, vol. 40, no. 1, Jan. 2015, pp. 43–48. rapm.bmj.com, https://doi.org/10.1097/AAP.0000000000000191

6. Xing, Wei, et al. “Lidocaine Induces Apoptosis and Suppresses Tumor Growth in Human Hepatocellular Carcinoma Cells In Vitro and in a Xenograft Model In Vivo.” Anesthesiology, vol. 126, no. 5, May 2017, pp. 868–81. DOI.org (Crossref), https://doi.org/10.1097/ALN.0000000000001528

7. Yabluchanskiy, Andriy, et al. “Matrix Metalloproteinase-9: Many Shades of Function in Cardiovascular Disease.” Physiology, vol. 28, no. 6, Nov. 2013, pp. 391–403. PubMed Central, https://doi.org/10.1152/physiol.00029.2013

8. Piegeler, T., et al. “Clinically Relevant Concentrations of Lidocaine and Ropivacaine Inhibit TNFα-Induced Invasion of Lung Adenocarcinoma Cells in Vitro by Blocking the Activation of Akt and Focal Adhesion Kinase.” British Journal of Anaesthesia, vol. 115, no. 5, Nov. 2015, pp. 784–91. DOI.org (Crossref), https://doi.org/10.1093/bja/aev341

The relationship between physical therapy (PT) and recovery from surgery is complicated; whether there is a need for it after surgery is informed by several factors such as age, type of surgery and type of PT. Many types of surgery don’t need PT after at all, in fact. The need is larger when the surgery affects the musculoskeletal system in particular.

Orthopedic surgery often benefits from PT to assist with recovery. In their study, Hankins and Moloney attempt to delineate the best time to initiate physical therapy for optimized recovery from hip surgery in elderly patients. Earlier enrollment in physical therapy was directly linked to shorter hospital stays. If physical therapy began the day after the surgery, Hankins and Moloney explain that the patient was discharged two or three days earlier. Delaying physical therapy increased patient postoperative complications like delirium and pneumonia. Hankins and Moloney further found that delayed physical therapy was linked to poor mobility two months post-surgery and high mortality six months after the surgery. Thus, patients, especially elderly patients, need PT after hip surgery, with the most benefit coming from started physical therapy as soon as possible.¹

Villalta et al.’s findings not only agree with but also examine a wider demographic than the study by Hankins and Moloney. In the general population, early movement after orthopedic surgeries enhances recovery. Furthermore, aquatic physical therapy is superior to land physical therapy. Different types of orthopedic surgical procedures benefit from postoperative physical therapy. These include rotator cuff repair, anterior cruciate ligament reconstruction, hip replacement, and knee replacement. They demonstrated a key aspect of patient outcome – the early onset of physical therapy did not have adverse effects on patient wounds or wound healing time.

Compared to land physical therapy, aquatic physical therapy optimized patient recovery from hip and knee replacement surgeries not by reducing swelling or pain but by reducing the likelihood of adverse events on wound healing. Although aquatic physical therapy has been demonstrated to improve recovery from rotator cuff repair surgery because muscle activity is reduced, clinicians still hesitate to implement it because the limbs need to be immersed. Physicians fear this will delay wound healing. Aquatic physical therapy began on postoperative day 6 or 14 for the two groups making up the study cohort. Post-op day 14 participants had fewer complications from aquatic physical therapy compared to post-op day 6, suggesting that aquatic PT may be better after the surgical site has more time to heal. ²

Patients emerging from orthopedic surgery are not the only ones who benefit from physical therapy. In a study published by Hulzebos et al., it was found that cardiac surgery patients who participated in preoperative physical therapy enjoyed protection from postoperative pneumonia. This result is consistent with previous studies. This is an important benefit since the geriatric population easily succumbs to pneumonia. This vulnerability is an ever-present concern for physicians.³ Hoogeboom et al. explains that physical therapy strengthens lung capacity and reduces the onset of pneumonia. Their study agrees with the preceding body of work that PT both before and after the surgery reduces length of hospital stay as well as the associated risks of surgical complications following cardiovascular, abdominal, thoracic, and orthopedic surgery, with a need for starting PT early in the postoperative period specifically.

To refine current research into the benefits of physical therapy, more researchers need to consider how physical therapy can serve the general population and not just the geriatric population.⁴

References

1. Hankins ML, Moloney GB. Early initiation of physical therapy after geriatric hip fracture surgery is associated with shorter hospital length of stay and decreased thirty-day mortality. Injury. 2022 Dec;53(12):4086-4089. doi: 10.1016/j.injury.2022.09.040. Epub 2022 Sep 25. PMID: 36192201.
2. Villalta EM, Peiris CL. Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013 Jan;94(1):138-48. doi: 10.1016/j.apmr.2012.07.020. Epub 2012 Aug 7. PMID: 22878230.
3. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012 Nov 14;11(11):CD010118. doi: 10.1002/14651858.CD010118.pub2. PMID: 23152283; PMCID: PMC8101691.
4. Hoogeboom TJ, Dronkers JJ, Hulzebos EH, van Meeteren NL. Merits of exercise therapy before and after major surgery. Curr Opin Anaesthesiol. 2014 Apr;27(2):161-6. doi: 10.1097/ACO.0000000000000062. PMID: 24500337; PMCID: PMC4072442.

A looming shortage of anesthesiologists globally may affect the accessibility of healthcare in the next ten years. The American Association of Medical Colleges predicts that there will be a workforce gap of as many as 12,500 anesthesiologists in the United States by 2033 (3). Similarly, a study from the UK suggests that there will be a shortage of 11,000 anesthetic staff members by 2040, preventing 8.25 million operations from taking place (3). Growing shortages of anesthesiologists globally could significantly impact the availability of surgeries and other medical procedures, especially in rural and low-income areas. The COVID-19 pandemic has pushed many healthcare workers to exit the workforce in the past few years by creating a more stressful working environment in hospitals and clinics (3). A changing world population and limited training opportunities in anesthesiology are other factors to consider. In order to recruit and retain skilled anesthesiologists, healthcare systems worldwide need to evolve to support the well-being and work-life balance of both the profession’s older and newer members.

Various factors have contributed to the growing workforce gap for anesthesiologists. An aging population has correlated with an increasing demand for surgical and anesthesia services that has outpaced the number of anesthesiologists entering the profession (5). Furthermore, the uneven distribution of anesthesiologists across regions means that rural and lower-income areas face more significant challenges in ensuring that anesthesiologists are available to provide perioperative care (5).

Additionally, the limited number of residency slots and lack of funding for medical education in the United States have restricted the number of anesthesiologists entering the field yearly (2). In 2022, 43% of medical students who applied for an anesthesiology residency did not match with a residency program (2). Although the US Congress has started working toward creating more residency positions, accredited institutions that can provide residencies may not receive federal funding for these spots, disincentivizing them from making more residencies available (2). Education and clinical training is crucial globally to address anesthesiologist shortages.

In the United Kingdom, a study published by the Association of Anaesthetists found that more anesthesiologists were retiring early in the last few years (3). The top factors contributing to the decision to retire included health and well-being, workload, and burnout, suggesting that anesthesiologists’ working environments fail to prioritize clinicians’ health and well-being (3). In particular, the study argues that anesthesiology departments must provide more significant support for older clinicians experiencing health issues, fatigue, or hearing and vision loss (3).

Creating systems and structures that allow anesthesiologists to “pace their careers” may help retain experienced anesthesiologists, who can help mentor younger members of the field (3). For example, anesthesiology departments can create policies that support older doctors experiencing menopause and ensure that equipment is easily accessible for older anesthesiologists experiencing hearing or vision loss (3). Furthermore, increasing residency positions in anesthesiology is critical for maintaining the anesthesiology workforce in the coming years (2). A study on anesthesiology residency programs found that expanding residency programs resulted in significant cost savings for healthcare organizations, considering that the cost per hour of clinical coverage for residents is far lower than that of paying nurse anesthetists overtime (2). Accordingly, the study suggests that institutions might consider expanding their residency programs even if they do not receive additional federal funding (2).

Improving recruitment and retention strategies for anesthesiologists and offering more robust support to clinicians is imperative to ensure that there will be enough anesthesiologists for necessary medical procedures in the upcoming years. It is also important to distribute existing anesthesiologists, as low resource areas tend to experience exacerbated shortages of skilled healthcare providers. Drawing providers to such areas can increase equitable access and improve anesthesiologist shortages globally.

References

1. “Action needed to avert anesthetist shortage of 11,000 by 2040, which could affect over 8 million operations.” Medical Xpress, Sept 28 2022,
2. “Additional anesthesiology residency positions may help hospitals save costs, address projected workforce shortages of anesthesia care professionals.” ASA Monitor, Jan 27, 2023, https://www.asahq.org/about-asa/newsroom/news-releases/2023/01/additional-anesthesiology-residency-positions-may-help-hospitals-save-costs
3. Davies, et al. “Age and the anaesthetist: considerations for the individual anaesthetist and workforce planning.” Anaesthesia, 29 Sept 2022, vol. 77, no. 11, pp. 1259-1267.
4. “How Physician Shortages Could Change the Future of Anesthesiology.” Anesthesiology News, Sept 19 2020, https://www.anesthesiologynews.com/Policy-and-Management/Article/01-20/How-Physician-Shortages-Could-Change-The-Future-of-Anesthesiology/59531
5. Simoneaux, Richard. “Are We Facing an Anesthesiologist Shortage?” ASA Monitor, January 2022, https://pubs.asahq.org/monitor/article-abstract/86/1/1/118103/Are-We-Facing-an-Anesthesiologist-Shortage?redirectedFrom=fulltext
6. “The Anesthesia Provider Shortage.” Medicus, June 7, 2023, https://medicushcs.com/resources/the-anesthesia-provider-shortage

Mepivacaine is a local anesthetic that is used to block sensation and pain during surgery, often as spinal anesthesia. It is also used in dental surgery. There are several local anesthetics available that fulfill the same roles, such as bupivacaine, but each has a specific pharmacological profile. 

Research conducted by Schwenk et al. found that mepivacaine is superior to bupivacaine in hip arthroplasty (joint surgery of the hip). The former enables earlier ambulation during recovery from spinal anesthesia. This difference is observed because bupivacaine causes greater sensory impairment, thereby delaying ambulation and discharge. ¹  

Another study compared mepivacaine and bupivacaine during egg retrieval. Spinal anesthesia can be used for oocyte retrieval since there is an increased chance for fertilization (27%) compared to general anesthesia (15%). During transvaginal oocyte retrieval, patients received the spinal mepivacaine–fentanyl combination instead of the traditional bupivacaine—fentanyl combination.  Menshawi & Fahim found that the cocktail of mepivacaine was superior to the one with bupivacaine as the primary agent. Recovery from mepivacaine was faster than bupivacaine. Both the sensory and motor block resolved quickly enough to reduce the time to ambulation and hospital discharge.  

Calkins et al. arrived at the same conclusion as both of the previous studies. Their research also showed that mepivacaine leads to faster recovery in patients following hip arthroplasty. In addition to shorter stays in the post-acute care units, patients did not experience complications, like urinary catheterization, or require overnight stay. On the other hand, the bupivacaine group experienced more neurologic complications like spinal headache. This data agrees that using mepivacaine spinal anesthesia improves surgery results. 

Mepivacaine is also used in dental surgery and is typically administered as a 3% solution without any vasoconstrictors or as a 2% solution with vasoconstrictors such as 1:20,000 levonordefrin and 1:100,000 adrenaline. Lidocaine, another local anesthetic commonly used in dental procedures, is always available as a 2% solution with 1:100,000 or 1:50,000 adrenaline. Su et al. found that the 2% solution of mepivacaine with 1:100,000 adrenaline was far superior to its counterpart lidocaine with 1:100,000 adrenaline. This may be because mepivacaine’s low vasodilation reduced bleeding and systematic toxicity while improving the depth and duration of anesthesia. Milder vasodilation facilitates higher concentrations of mepivacaine. Although the superior effects of mepivacaine to lidocaine was in the context of its combination with vasoconstrictors like adrenaline, the results are still notable. Because anesthesia tends to use cocktails during surgery, examining the drug of impact within its cocktail mixture makes for a more accurate representation of how its results will play out in the field. ³ 

In dental surgeries, articaine has been proven to produce anesthesia more swiftly compared to mepivacaine. Articaine’s thiophene ring allows for enhanced lipid membrane permeability and metabolism in the plasma of cells enhances the efficacy of the drug. ⁴ On the other hand, mepivacaine is an amide so needs to be initially metabolized in the liver. Both mepivacaine and articaine block sodium channels on nerve membranes, thereby blocking the transmission of nerve impulses. The literature agrees that the following advantages of mepivacaine make it the number one choice for surgeons: rapid onset so that anesthesia is delivered in a short time, intermediate duration for faster recovery, less vasodilation thereby reducing toxicity, less cardiotoxicity than bupivacaine and it is usable without epinephrine for patients who have contraindications to vasoconstrictors (e.g., certain heart conditions). 

References 

1. Schwenk ES, Kasper VP, Smoker JD, Mendelson AM, Austin MS, Brown SA, Hozack WJ, Cohen AJ, Li JJ, Wahal CS, Baratta JL, Torjman MC, Nemeth AC, Czerwinski EE. Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation. Anesthesiology. 2020 Oct 1;133(4):801-811. doi: 10.1097/ALN.0000000000003480. PMID: 32852904. 

2. Menshawi, M.A., Fahim, H.M. Spinal mepivacaine versus bupivacaine for ultrasound guided transvaginal oocyte retrieval. A comparative study. Ain-Shams J Anesthesiol 12, 22 (2020). https://doi.org/10.1186/s42077-020-00068-9 

3. Su N, Liu Y, Yang X, Shi Z, Huang Y. Efficacy and safety of mepivacaine compared with lidocaine in local anaesthesia in dentistry: a meta-analysis of randomised controlled trials. Int Dent J. 2014 Apr;64(2):96-107. doi: 10.1111/idj.12087. Epub 2014 Jan 16. PMID: 24428507; PMCID: PMC9376404. 

4.Gazal G. Is Articaine More Potent than Mepivacaine for Use in Oral Surgery? J Oral Maxillofac Res. 2018 Sep 30;9(3):e5. doi: 10.5037/jomr.2018.9305. PMID: 30429965; PMCID: PMC6225598. 

Healthcare providers interface with patients of all ages, ethnicities, genders, and sexual orientations, and thus it is important that the demographic makeup of these providers reflects the patients they care for and that patients feel comfortable and understood by their providers. This claim is backed by data; multiple studies have shown that female patients have better outcomes when treated by female physicians, across all specialties³. Another retrospective analysis of 1.8 million hospital births found that pairing a newborn with a physician of the same race reduces in-hospital mortality by 50%, as well as decreasing communication barriers between patients and physicians, and increasing healthcare utilization by these patients². Anesthesiology providers, in particular, interact with patients during some of their most vulnerable moments: immediately before and immediately after surgery, managing their perioperative pain, and caring for them in the ICU setting. Thus diversity, equity and inclusion initiatives are even more important in the field of anesthesia, for patient safety and satisfaction.  

Despite the well-demonstrated importance of diversity in medicine, there are still significant disparities in many specialties, including anesthesia. For example, even though gender parity is much better in matriculants to medical schools in the United States in modern times, there remains a large gender gap in practicing anesthesiologists¹. 64.3% of all anesthesiologists are men, with only 36.6% being women and no data on other gender identities¹. Women are also largely overlooked for leadership positions. For example, only 13% of department chair positions are held by women¹. Furthermore, in 2020, anesthesiology residents who identified as American Indian/Alaskan Native, Black/African American and Hispanic/Latino combined made up less than 15% of all anesthesiology residents across the country¹. The barriers to increased diversity in anesthesia are in large part like the barriers in medicine as a whole; they are historic and institutional in nature¹. For most of their history, higher education institutions denied admission to minorities and women¹. While that is not the case today, standardized testing and legacy admissions have been shown to overwhelmingly benefit wealthy, White applicants¹. Despite both departmental and national DEI initiatives, these historic barriers have been difficult to overcome¹.  

Nonetheless, there is important work being done to overcome these barriers. For example, a national imitative, Raising Anesthesiology Diversity and Antiracism (RADAR), launched in 2022⁴. This program is a joint effort from the departments of anesthesiology at University of Michigan and Washington University in St. Louis, and it aims to engage and support historically marginalized medical students, trainees, and early faculty in the field of anesthesiology⁴. It also aims to address the problem from the top: RADAR provides anti-racism training and resources to senior leadership⁴. There is also a call to action for departments across the country to join in this initiative, so it becomes and remains a widespread and sustainable effort⁴. While this program is too new to study the outcomes of it, national initiatives are an important way to keep improving diversity in the field of anesthesias⁴.  

References 

1. Estime SR, Lee HH, Jimenez N, Andreae M, Blacksher E, Navarro R. Diversity, equity, and inclusion in anesthesiology. Int Anesthesiol Clin. 2021 Oct 1;59(4):81-85. doi: 10.1097/AIA.0000000000000337.  

2. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020 Sep 1;117(35):21194-21200. doi: 10.1073/pnas.1913405117.  

3. Tsugawa, Y., Jena, A.B., Figueroa, J.F., Orav, E.J., Blumenthal, D.M., Jha, A.K., 2017. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Internal Medicine 177, 206.https://doi.org/10.1001/jamainternmed.2016.7875 

4. Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA. Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg. 2022 Jun 1;134(6):1185-1188. doi: 10.1213/ANE.0000000000005817. 

Value-based care and fee-for-service refer to two different models of healthcare delivery that define how healthcare providers are compensated for the care that they provide. In a fee-for-service model, healthcare providers are paid for each service or procedure they perform (5). Fee-for-service has been the standard model of healthcare for many years, but it has come under scrutiny for its potential to drive up healthcare costs, contribute to the overuse of services, and devalue quality compared to quantity. Value-based care has been offered as an alternative to fee-for-service that focuses on the quality of care delivered to patients, rather than the quantity of services provided (5). Value-based care incentivizes healthcare providers to focus on prevention and keep patients healthy, rather than treating patients after they are already ill. 

Value-based care can be defined as a payment model in which healthcare providers are paid based on patient health outcomes (5). Physicians and other providers give a patient “value” when they create improvement in that patient’s health outcomes by improving their functionality and quality of life and providing emotional and physical relief from their symptoms (3). In a value-based care model, providers may be more focused on, and thus more effective at, helping patients achieve better health and implement healthier habits that can protect them from illness (5). 

Value-based healthcare offers the possibility of improving patients’ quality of care and boosting population health at a large scale. A core pillar of value-based care is the idea that a multidisciplinary team of healthcare providers and other staff should work together to deliver coordinated, comprehensive care (3). This multidisciplinary team may include physicians, pharmacists, psychologists, dietitians, and members that don’t directly provide care to patients, such as case managers and social workers (1). These team members work collaboratively to help the patient improve their health outcomes, providing support with navigating the healthcare system at every step (5). Furthermore, value-based care emphasizes prevention and wellness strategies that can reduce the incidence of chronic illness and long-term conditions, resulting in a healthier population and reduced healthcare costs (1). 

At present, fee-for-service remains the longstanding healthcare delivery system in place. Transitioning to a value-based care system from a fee-for-service system would require a significant amount of resources and buy-in from healthcare staff members and executives (1). Furthermore, the healthcare delivery infrastructure currently in place does not have the capacity to support multidisciplinary care structures and value-based care at a large scale. 

Fee-for-service may still offer some benefits. For example, proponents of the system say that the model incentivizes providers to work quickly and efficiently, ensuring that patients receive prompt care. However, the current model is highly flawed, and implementing value-based care may make healthcare more equitable and accessible to diverse populations and ensure that healthcare provides measurable benefits to patients. 

In order to implement value-based care at an organizational level, hospitals need to design coordinated solutions that can meet the needs of high-risk patients (3). Most importantly, caregivers must collaborate to address both clinical and nonclinical factors affecting patients’ health outcomes (3). Nonclinical factors that are often overlooked by the current healthcare delivery model include environmental factors, socioeconomic status, transportation, and lifestyle factors like smoking and alcohol use. Additionally, healthcare organizations can keep track of the cost of their care compared to the health outcomes that result from their services in order to improve the cost-efficiency and effectiveness of their care (3).  

References 

1. Balasubramanian, Sai. “What Is Value Based Care, And Why Is The Healthcare Industry Suddenly So Interested In It?” Forbes, 25 Dec, 2022, www.forbes.com/sites/saibala/2022/12/25/what-is-value-based-care-and-why-is-the-healthcare-industry-suddenly-so-interested-in-it/?sh=770211e855d2 

2. “Implications of Value-Based Care, Fee-for-Service Reimbursement Models Amid COVID-19.” AJMC, 1 Mar 2021, www.ajmc.com/view/implications-of-a-value-based-care-fee-for-service-reimbursement-model-amid-covid-19 

3. Teisberg, Elizabeth et al. “Defining and Implementing Value-Based Health Care: A Strategic Framework.” Academic medicine : journal of the Association of American Medical Colleges vol. 95,5 (2020): 682-685. doi:10.1097/ACM.0000000000003122 

4. Werner, et al. “The Future of Value-Based Payment: A Road Map to 2030.” Penn Leonard Davis Institute of Health Economics, 17 Feb 2021, ldi.upenn.edu/our-work/research-updates/the-future-of-value-based-payment-a-road-map-to-2030/ 

5. “What is Value-Based Healthcare?” NEJM Catalyst, 1 Jan 2019. catalyst.nejm.org/doi/full/10.1056/CAT.17.0558 

Stroke is a relatively rare but debilitating consequence of surgery [1]. Albeit more common after cardiac surgery, patients who have undergone non-cardiac procedures are also at risk of experiencing stroke [2]. With stroke affecting functions such as vision, movement, and cognitive ability, not to mention carrying the risk of death, the importance of understanding the incidence of stroke after surgery and how best one can prevent it is evident [3]. 

Decades of research have revealed common risk factors that may increase a patient’s chance of experiencing stroke after both cardiac and non-cardiac surgery [4]. These factors include old age; female sex; and history of neurological disorders like migraine [4]. Modifiable risk factors include timing of surgery after a previous stroke; intraoperative poor systemic oxygenation; and intraoperative hypertension [4]. By making informed decisions concerning these latter factors, practitioners may be able to reduce their patients’ likelihood of stroke after surgery.   

Despite these commonalities, patients who receive cardiac surgery nevertheless have a higher chance of suffering from a postoperative stroke [4]. Fortunately, stroke following cardiac surgery is a well-researched phenomenon, so medical professionals have a great deal of instruction to rely on when treating cardiac surgery patients.  

Researchers have noted what characteristics make patients undergoing surgical aortic valve replacement (AVR) and coronary surgery more likely to suffer a stroke [5, 6]. In the AVR context, Idrees and colleagues noted the association between a patient’s heightened risk of postoperative stroke and comorbidities such as prior heart failure, carotid stenosis, endocarditis, hypercoagulation, and neurologic dysfunction [5]. Meanwhile, in cases of coronary surgery, Biancari et al.’s research suggested that severe bleeding requiring blood transfusion is associated with a heightened risk of stroke after surgery [6]. The extent to which these risk factors overlap across various types of cardiac operations is unclear.  

Additional evidence has emerged recently identifying genetic polymorphisms that may also heighten the risk of stroke following cardiac surgery [1]. By analyzing the genetics of 1,635 patients, among which twenty-eight postoperative strokes occurred following cardiopulmonary bypass surgery, Grocott and colleagues identified a significant association between common genetic variants of C-reactive protein and postoperative stroke [1]. This finding was not only compelling for screening purposes; it also indicated that inflammation may play an important role in stroke after cardiac surgery, given the link between the polymorphisms identified and patients’ predisposition for inflammation [1]. 

As for non-cardiac surgery, researchers have identified various other risk factors for stroke. For instance, intraoperative and routine use of preoperative metoprolol is associated with an increased risk of stroke after noncardiac surgery [2]. Current tobacco use, body mass index of 35-40 kg/m², and dialysis are also risk factors that may apply as well [7]. 

By keeping these associations in mind, medical professionals can better understand a particular patient’s unique risk of experiencing a stroke. This knowledge may inform what preventive measures a provider takes, such as administering oral anticoagulants or strictly controlling the patient’s blood pressure, two suggestions raised in the cardiac surgery context [8]. While preventive measures may never reduce the risk of stroke to zero, they nevertheless help decrease the likelihood that a patient will experience a debilitating and possibly deadly stroke after surgery. 

References 

[1] H. P. Grocott et al., “Genetic Polymorphisms and the Risk of Stroke After Cardiac Surgery,” Stroke, vol. 36, pp. 1854-1858, July 2005. [Online]. Available: https://doi.org/10.1161/01.STR.0000177482.23478.dc.  

[2] G. A. Mashour et al., “Perioperative Metoprolol and Risk of Stroke after Noncardiac Surgery,” Anesthesiology, vol. 119, pp. 1340-1346, December 2013. [Online]. Available: https://doi.org/10.1097/ALN.0b013e318295a25f.  

[3] “Effects of Stroke,” Johns Hopkins Medicine. [Online]. Available: https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/effects-of-stroke.  

[4] S. Ko, “Perioperative stroke: physiology and management,” Korean Journal of Anesthesiology, vol. 71, no. 1, pp. 3-11, February 2018. [Online]. Available: https://doi.org/10.4097%2Fkjae.2018.71.1.3.  

[5] J. J. Idrees et al., “Trends, Predictors, and Outcomes of Stroke After Surgical Aortic Valve Replacement in the United States,” The Annals of Thoracic Surgery, vol. 101, no. 3, pp. 927-935, March 2016. [Online]. Available: https://doi.org/10.1016/j.athoracsur.2015.08.024.  

[6] F. Biancari et al., “Bleeding, transfusion and the risk of stroke after coronary surgery: A prospective cohort study of 2357 patients,” International Journal of Surgery, vol. 32, pp. 50-57, August 2016. [Online]. Available: https://doi.org/10.1016/j.ijsu.2016.06.032.  

[7] G. A. Mashour, A. M. Shanks, and S. Kheterpal, “Perioperative Stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery,” Anesthesiology, vol. 114, pp. 1289-1296, July 2011. [Online]. Available: https://doi.org/10.1097/ALN.0b013e318216e7f4.  

[8] C. Isabel, D. Calvet, and J. Mas, “Stroke prevention,” La Presse Médicale, vol. 45, no. 12, pp. e457-e471, December 2016. [Online]. Available: https://doi.org/10.1016/j.lpm.2016.10.009.  

Trauma is the most common indication for surgery and anesthesia of an acutely intoxicated individual, but other types of surgical emergencies can result from drug misuse, including vascular dissection and hemorrhagic complications linked to certain stimulants. There are particular perioperative and anesthetic considerations to be made for a patient who is acutely intoxicated with one or multiple substances (including but not limited to alcohol, cannabinoids, amphetamines, opioids, benzodiazepines, cocaine, hallucinogens) or with a history of substance use dependency or disorder ¹.  

Alcohol use is particularly common in the United States, with fourteen percent of the adult American population suffering from alcoholism ². Particular attention is required for any patient undergoing anesthesia who is alcohol intoxicated. Anesthesiologists need to take into consideration the acute and/or chronic effects of alcohol use at all stages of the patient’s treatment. 

A patient who is acutely alcohol-intoxicated presents with a unique set of challenges to the administration of anesthesia. First, the patient may have a depressed consciousness level, making it hard to interact with them, obtain a medical history prior to the procedure, or obtain informed consent. Alcohol consumption can also produce a significant degree of psychomotor impairment.  

In the most extreme cases, if a procedure cannot be delayed until the effects of intoxication have cleared up, the patient may have to be treated as if they lacked the capacity to take an informed decision. In addition, a certain degree of alcohol-fueled confusion, aggression, and psychomotor impairment mean that the patient may be at risk of causing injury to others or themselves ³.  

Furthermore, an intoxicated patient may be at increased risk of vomiting due to either anesthesia or the drug. The need to secure the airway for imaging or ongoing management means that intubation is often indicated. 

During the operation, the findings of a recent retrospective chart review have demonstrated the presence of alcohol-induced hemodynamic dysregulation in intoxicated trauma patients suffering from a presumed intra-abdominal injury ⁴. It is thus critical for the anesthesiologist to be prepared to support blood pressure in order to maintain adequate perfusion in acutely intoxicated patients.  

Chronic alcohol misuse also creates special considerations for surgery and anesthesia. A history of alcohol use should always be sought preoperatively in all adults and adolescents presenting for surgery. The CAGE questionnaire can be used to this end. A score of >2 is strongly indicative of alcohol use at a level likely to incur significant medical or social consequences. 

Based on a patient’s condition, preoperative vitamins or medications may be indicated to better control vitals ⁵. Intraoperatively, rapid sequence induction is also often indicated, and chronic alcohol use tends to increase dose requirements for general anesthetic agents. 

Historically, it has been believed that chronic heavy alcohol use is associated with a 2 to 5-fold increase in post-operative complications, linked to higher rates of admission to intensive care units and increased lengths of hospital stays ⁵. In particular, a recent retrospective, single-center cohort study at a Level 1 trauma center found that the need for postoperative mechanical ventilation increased in the acutely intoxicated trauma patients ⁶. Various targeted interventions should be leveraged in order to minimize the incidence of post-operative complications. 

Finally, at any stage of the operation, alcohol withdrawal is a potentially life-threatening complication that must be diagnosed and actively managed ⁵. Confusion and delirium may be signs of such acute alcohol withdrawal syndrome, which prophylactic treatment may help prevent ⁷. 

References  

1. Anesthesia for patients with substance use disorder or acute intoxication – UpToDate. Available at: https://www.uptodate.com/contents/anesthesia-for-patients-with-substance-use-disorder-or-acute-intoxication. (Accessed: 8th May 2023) 

2. ALCOHOL AND ANESTHESIA | Anesthesia Experts. Available at: https://anesthesiaexperts.com/uncategorized/alcohol-anesthesia/. (Accessed: 8th May 2023) 

3. Thapar, P., Zacny, J. P., Choi, M. & Apfelbaum, J. L. Objective and subjective impairment from often-used sedative/analgesic combinations in ambulatory surgery, using alcohol as a benchmark. Anesth. Analg. (1995). doi:10.1097/00000539-199506000-00005 

4. Mardini, J. et al. Alcohol Intoxicated Trauma Patients: Hemodynamic Effects of General Anesthesia. Anesth. Clin. Res. 11, 1–3 (2020). DOI: 10.35248/2155-6148.20.11.974 

5. Chapman, R. & Plaat, F. Alcohol and anaesthesia. Contin. Educ. Anaesth. Crit. Care Pain 9, 10–13 (2009). doi:10.1093/bjaceaccp/mkn045 

6. Wolf, B. D., Munnangi, S., Pesso, R., McCahery, C. & Oad, M. Are Intoxicated Trauma Patients at an Increased Risk for Intraoperative Anesthetic Complications? A Retrospective Study. Anesthesiol. Res. Pract. 2020, (2020). doi: 10.1155/2020/2157295. 

7. Spies, C. D. & Rommelspacher, H. Alcohol withdrawal in the surgical patient: Prevention and treatment. Anesthesia and Analgesia (1999). doi:10.1213/00000539-199904000-00050 

When a patient undergoes surgery, the procedure itself and the effects of anesthesia place a certain degree of stress on the body which may result in elevated blood sugar (glucose) levels ¹. This phenomenon of hyperglycemia tends to be associated with increased rates of mortality and morbidity in critically ill patients. In addition to the negative health effects, patients may also then experience longer hospital stays and increased costs ². The early identification of at-risk patients is key to preventing negative outcomes ². It is also essential, however, to better understand the underlying causes, manifestations, and post-surgery implications of blood sugar levels in surgery patients.  

Diabetic individuals have a particularly high risk for blood sugar complications following a surgical procedure. However, individuals free of diabetes or with undiagnosed diabetes may also experience elevated post-surgical glucose levels, along with the clinical challenges they present. 

A major complication that is associated with high blood sugar post-surgery is surgical site infection ³. Researchers have found postoperative hyperglycemia to be the most important risk factor for surgical site infection in general surgery and in colorectal cancer surgery patients. Serum glucose levels in excess of 110 milligrams per deciliter were indeed clearly linked to higher rates of post-surgical infection. However, prospective studies are needed in order to generate stronger conclusions. If hyperglycemia is confirmed in future prospective studies with better postoperative glucose data to represent an independent risk factor for postsurgical infection in surgery patients, this would indicate a modifiable variable to potentially reduce the incidence of postoperative infection.  

Interestingly, a recent study highlighted the dangers of hyperglycemia in the case of vascular surgery in particular ⁴. On average, one in five patients undergoing vascular procedures were found to suffer from postoperative hyperglycemia. This postoperative hyperglycemia was associated with adverse events after lower extremity vascular procedures in patients both with and without diabetes. Consequences of elevated blood sugar post-surgery included infection, increased hospital use, and mortality. No difference was found, however, with respect to hospital readmission. The researchers concluded that postoperative glucose management may represent an important quality marker for improving outcomes following lower extremity vascular procedures. 

Current recommendations for the perioperative management of glucose from national societies are varied, but most suggest that tight glucose control may not be beneficial, as mild hyperglycemia appears to be well-tolerated ⁵. 

Indeed, although hyperglycemia is associated with worse outcomes, the treatment of hyperglycemia with insulin infusions has not yielded consistent benefits ⁵. Despite promising early results suggesting lower mortality and other advantages linked to the tight control of glucose levels, later investigations failed to identify any changes in mortality or other postsurgical consequences when hyperglycemia was aggressively treated with insulin.  

In light of these conflicting data, it is unclear what the best protocol is to manage blood sugar in surgery patients and improve post-surgery outcomes. There is agreement, however, that hypoglycemia is an undesirable complication of intensive insulin therapy and should be avoided. In addition, the risk of increased glucose variability should be well-understood given the increased risk for worse outcomes. 

Additional research remains to be carried out in order to best ensure that blood sugar is well controlled among surgical patients and maximize their health outcomes across a variety of clinical contexts.  

References 

1. High Blood Sugar Levels After Surgery. Available at: https://www.verywellhealth.com/after-surgery-infection-and-glucose-3970391. (Accessed: 14th April 2023) 

2. Diabetes Complicates Postsurgical Recovery, but Study Suggests Method to Identify Those at Risk. Available at: https://www.ajmc.com/view/diabetes-complicates-postsurgical-recovery-but-study-suggests-method-to-identify-those-at-risk. (Accessed: 14th April 2023) 

3. Ata, A., Lee, J., Bestle, S. L., Desemone, J. & Stain, S. C. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch. Surg. 145, 858–864 (2010). doi: 10.1001/archsurg.2010.179. 

4. Vogel, T. R., Smith, J. B. & Kruse, R. L. The association of postoperative glycemic control and lower extremity procedure outcomes. J. Vasc. Surg. 66, 1123–1132 (2017). doi: 10.1016/j.jvs.2017.01.053.  

5. Duncan, A. E. Hyperglycemia and Perioperative Glucose Management. Curr. Pharm. Des. 18, 6195 (2012). doi: 10.2174/138161212803832236. 

Insulin is a life-saving medication essential to the management of diabetes, a chronic condition that affection millions of Americans. The cost of insulin has risen dramatically in the last decade, however. A report by the Health Care Cost Institute reveals that the average price of insulin doubled from 2012 to 2016—making it difficult for many people to afford. More recently in 2019, the average price of insulin had reached $300 per vial (many people with diabetes require multiple vials of insulin every month). Therefore, insulin prices in the U.S. has emerged as a topic of controversy and great concern in recent years.  

The average price in the U.S., across all types of insulin, has been revealed to be more than ten times higher than the average price in every other country of the world. In fact, the closest any country has come, reportedly, to paying the $98.70 United States average was the $21.48 average in Chile (1). With millions of Americans struggling to afford basic household needs in the wake of COVID-19, these prices have only decreased by 5% between 2020 and 2021 (2). 

One report on this crisis shared the tragic story of a young man who was first diagnosed with type 1 diabetes at the age of 23 while working as a restaurant manager in Minnesota. By the age of 26, he was no longer eligible to remain on his mother’s health care insurance plan. The health insurance he qualified for came with a $7,600 deductible and a monthly premium of $440, which was beyond reach financially, leading to his decision to forego insurance and purchase insulin out of pocket. He attempted to ration his insulin due to financial constraints and was eventually found dead as a result of diabetic ketoacidosis (3).  

High insulin prices in the U.S. are caused by several factors. First, there is a lack of price regulation in the pharmaceutical industry, thereby allowing drug manufacturers to set their own prices. Second, the insulin market is very complex, involving multiple intermediaries such as wholesalers, insurers, and pharmacy benefit managers, each of which adds to the final cost of insulin. Finally, inconsistent insurance coverage, for insulin and health care in general, can exacerbate the situation (4). 

The exorbitant cost of insulin has fuelled widespread public anger and calls for reform. Certain advocates push for tighter regulation of medication prices, while others suggest alternative solutions, such as the development of generic versions of the medication or the importation of insulin from other countries into the U.S. 

In an attempt to reduce some of the burden, some initiatives try to help people patients with diabetes gain access to affordable insulin. Certain pharmaceutical companies offer patient assistance programs ensuring free or reduced-cost insulin to eligible individuals, for example, while some states have passed laws capping the cost of insulin or requiring insurers to cover the medication at no cost to patients. 

While the Biden administration, states, insurers, and insulin manufacturers have made efforts to cut insulin prices, Food and Drug Administration (FDA) approvals of biosimilars and generics have been the greatest drivers in the decrease in insulin prices in the U.S. (2). 

In the future, additional work remains to be done to continue to continue to drive insulin costs down and ensure basic health care access to all Americans.   

References  

1. The Astronomical Price of Insulin Hurts American Families | RAND [Internet]. [cited 2023 Mar 16]. Available from: https://www.rand.org/blog/rand-review/2021/01/the-astronomical-price-of-insulin-hurts-american-families.html 

2. How Much Does Insulin Cost? Here’s How 28 Brands and Generics Compare – GoodRx [Internet]. [cited 2023 Mar 16]. Available from: https://www.goodrx.com/healthcare-access/research/how-much-does-insulin-cost-compare-brands 

3. Rajkumar SV. The High Cost of Insulin in the United States: An Urgent Call to Action. Mayo Clin Proc. 2020 Jan 1;95(1):22–8. https://doi.org/10.1016/j.mayocp.2019.11.013 

4. Cefalu WT, Dawes DE, Gavlak G, Goldman D, Herman WH, Van Nuys K, et al. Insulin access and affordability working group: Conclusions and recommendations. Diabetes Care. 2018. doi: 10.2337/dci18-0019