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Traditionally, anesthesia care for surgical patients has lacked in continuity, with negative impacts on patient safety and well-being. On top of this, high health care costs have been a major complaint – driven in part by complications, longer than necessary stays, and preventable readmissions¹. To address these challenges, the perioperative surgical home (PSH) has emerged as a recent innovation in perioperative care delivery. This model is defined as a “patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience”. A PSH leadership team, consisting of key figures from anesthesia, surgery, and hospital management teams, coordinates the pre-, intra-, and post-operative elements of surgical care under one unique organizational umbrella². This model of care was envisioned by leaders of the American Society of Anesthesiologists’ Committee on Future Models of Anesthesia Practice to address the standards of a new health care paradigm emphasizing healthy patients, satisfied providers, enhanced population health, and lower health care costs³.

Preoperatively, the PSH model of care includes patient engagement, the use of evidence-based protocols, thorough patient and stakeholder education, and the creation of a transitional care plan. Intraoperatively, the PSH model of care capitalizes on identifying the personnel best tailored to patient status and surgery type, optimizes supply chain operations and efficiency, and oversees the implementation of standardized protocols. Postoperatively, the PSH model of care ensures the right level of care, integrated pain management procedures, and prevention of any surgical complications. Finally, long-term, the PSH model of care oversees the smooth coordination of discharge plans, patient education, seamless transition to the appropriate context of care, and efficient functional rehabilitation of patients.

Though assessments of the perioperative surgical home model have not yet been carried out in a systematic and widespread way given its novelty, a recent 2020 study sought out to compare characteristics across various PSH models⁴. These shared characteristics included an emphasis on preoperative patient education, standardization of care protocols across all surgical phases, use of opioid-sparing analgesia, and collaborative staffing. Overall, PSH program implementation was confirmed to be associated with a decreased length of hospital stay, reduced administration of postoperative opioids, minimized resource utilization, improved operational efficiency, and decreased postoperative complication and mortality rates. Indeed, and in light of the University of California Irvine Health’s experience implementing a PSH model for example, the PSH model appears to offer a very bright future for the field of anesthesia¹. Nevertheless, PSH implementation programs have not yet been meaningfully associated with reductions in readmission rates, and, despite some claims of an association between a PSH model of care and savings to hospitals and health care management, findings related to cost reductions following PSH implementation have remained largely ambivalent.

In conclusion, early evidence indicates that, through care coordination, protocol standardization, and patient-centered lens, PSH programs can improve patient postoperative recovery outcomes and decrease hospital stays. In addition to its goal of revitalizing the anesthesiology specialty given the expanded role of anesthesiologists in its model of care5, the perioperative surgical home aims to ensure a continuous, seamless coordination of care for a more efficient and positive patient experience.

References 

1.  Kain ZN, Vakharia S, Garson L, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg. 2014. doi:10.1213/ANE.0000000000000190 

2.  Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: How can it make the case so everyone wins? BMC Anesthesiol. 2013;13. doi:10.1186/1471-2253-13-6 

3.  Perioperative Surgical Home (PSH). https://www.asahq.org/psh.

4.  Cline KM, Clement V, Rock-Klotz J, Kash BA, Steel C, Miller TR. Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home. J Clin Anesth. 2020. doi:10.1016/j.jclinane.2020.109760 

5.  Kwon MA. Perioperative surgical home: A new scope for future anesthesiology. Korean J Anesthesiol. 2018. doi:10.4097/kja.d.18.27182 

Obstructive sleep apnea (OSA), which affects 17% of women and 34% of men in the United States, is characterized by recurring episodes of collapse of the upper airway, resulting in hypopnea (reduced breathing) or apnea (no breathing) lasting at least 10 seconds, during sleep. Its most common symptom is sleepiness during the day—which has shown to contribute to impaired work and driving performances in patients—but the disorder can lead to even more serious consequences: OSA is associated with an increased incidence of hypertension, type 2 diabetes, atrial fibrillation, heart failure, coronary heart disease, stroke, and death.¹ It is also a major concern if a patient needs anesthesia care. As a result, developing effective treatments for sleep apnea is an important area of medical research and innovation.

Appropriate treatments for sleep apnea can vary based on the severity of its presentation. For some patients, certain behavioral measures can result in a significant reduction in OSA symptoms. For instance, because obesity is a common risk factor for OSA and because weight-loss interventions have been associated with improvements in the severity of OSA, the American Thoracic Society recommends in their guidelines that clinicians incorporate weight management strategies into their treatment of overweight or obese adults with OSA.² Independently of weight loss, exercise has also been associated with decreased severity in mild to moderate OSA,³  as well as abstaining from alcohol and restricting sleep to a side or prone position.^1,4 For symptomatic OSA of any severity, positive airway pressure (PAP) devices are a primary therapy; PAP devices provide positive pressure to the airway through a mask to patients during sleep to keep the airway open and have been shown to reduce comorbidities such as high blood pressure in addition to alleviating the symptoms.^5,6 Bariatric surgery to modify the upper airway is often recommended for symptomatic patients unable to tolerate PAP therapy, with the most extensively studied procedure being uvulopalatopharyngoplasty, a process involving the resection of the uvula and part of the soft palate.¹ It is notable that more invasive treatments for OSA, such as surgical interventions, have been postponed or forgone for many patients during the COVID-19 pandemic.⁷ 

Finally, hypoglossal nerve stimulation (HNS) therapy has recently been proposed as a potential treatment for OSA that could address the airway collapsibility associated with the disease without altering upper airway anatomy. This therapy, which involves a single surgical procedure to implant the device, has the potential to provide multilevel upper airway improvement and has shown early success within limited subsets of the OSA population.⁸ Another novel device designed to alleviate the symptoms of OSA was approved earlier this year by the U.S. Food and Drug Administration for marketing: the eXciteOSA device, designed for “tongue strengthening.” This device, used while the patient is awake, contains four electrodes which give muscle stimulation in a series of electrical pulses and is meant to increase the muscle tone of the tongue, which could actively work to help keep the airway open during sleep. While this device has only been used to aid those with mild sleep apnea and has not yet been proven to alleviate symptoms other than snoring, it is still an exciting development for a disorder for which novel treatments are sorely needed.⁹ 

References 

(1)  Gottlieb, D. J.; Punjabi, N. M. Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA 2020, 323 (14), 1389. https://doi.org/10.1001/jama.2020.3514. 

(2)  Hudgel, D. W.; Patel, S. R.; Ahasic, A. M.; Bartlett, S. J.; Bessesen, D. H.; Coaker, M. A.; Fiander, P. M.; Grunstein, R. R.; Gurubhagavatula, I.; Kapur, V. K.; Lettieri, C. J.; Naughton, M. T.; Owens, R. L.; Pepin, J.-L. D.; Tuomilehto, H.; Wilson, K. C. The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2018, 198 (6), e70–e87. https://doi.org/10.1164/rccm.201807-1326ST. 

(3)  Lee-Iannotti, J. K.; Parish, J. M. Exercise as a Treatment for Sleep Apnea. Journal of Clinical Sleep Medicine 2020, 16 (7), 1005–1006. https://doi.org/10.5664/jcsm.8582. 

(4)  Srijithesh, P. R.; Aghoram, R.; Goel, A.; Dhanya, J. Positional Therapy for Obstructive Sleep Apnoea. Cochrane Database of Systematic Reviews 2019. https://doi.org/10.1002/14651858.CD010990.pub2. 

(5)  Weaver, T. E.; Maislin, G.; Dinges, D. F.; Bloxham, T.; George, C. F. P.; Greenberg, H.; Kader, G.; Mahowald, M.; Younger, J.; Pack, A. I. Relationship Between Hours of CPAP Use and Achieving Normal Levels of Sleepiness and Daily Functioning. Sleep 2007, 30 (6), 711–719. https://doi.org/10.1093/sleep/30.6.711. 

(6)  Martínez-García, M.-A.; Capote, F.; Campos-Rodríguez, F.; Lloberes, P.; Díaz de Atauri, M. J.; Somoza, M.; Masa, J. F.; González, M.; Sacristán, L.; Barbé, F.; Durán-Cantolla, J.; Aizpuru, F.; Mañas, E.; Barreiro, B.; Mosteiro, M.; Cebrián, J. J.; de la Peña, M.; García-Río, F.; Maimó, A.; Zapater, J.; Hernández, C.; Grau SanMarti, N.; Montserrat, J. M. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA 2013, 310 (22), 2407. https://doi.org/10.1001/jama.2013.281250. 

(7)  Bastier, P.-L.; Aisenberg, N.; Durand, F.; Lestang, P.; Abedipour, D.; Gallet de Santerre, O.; Couloigner, V.; Bequignon, E. Treatment of Sleep Apnea by ENT Specialists during the COVID-19 Pandemic. European Annals of Otorhinolaryngology, Head and Neck Diseases 2020, 137 (4), 319–321. https://doi.org/10.1016/j.anorl.2020.05.001. 

(8)  Whelan, R.; Soose, R. J. Implantable Neurostimulation for Treatment of Sleep Apnea. Otolaryngologic Clinics of North America 2020, 53 (3), 445–457. https://doi.org/10.1016/j.otc.2020.02.007. 

(9)  Mundell, E.; Reinberg, S. FDA Approves “Tongue Strengthening” Device for Certain Sleep Apnea Patients. Medical Press. February 8, 2021. 

Lidocaine is an intermediate-acting local anesthetic commonly used in surgical, obstetrical, and diagnostic procedure.¹ This tertiary amine was first synthesized in the 1940s and quickly replaced several anesthetics in use at the time as a safer alternative.² It is commonly administered with epinephrine to extend its duration of action and help prevent bleeding.³  

Lidocaine induces numbing by diffusing through neural sheaths and localizing to sodium channels, thus blocking the influx of sodium ions and preventing nerve depolarization.⁴ It has been found to have reduced efficacy in inflammatory conditions, which may be caused by an increase in blood flow or more acidic conditions that decrease the amount of un-ionized lidocaine molecules (the charged form is much less effective at diffusing through the cell membrane and subsequently acting on sodium channels).³  

It is most commonly used as a local numbing agent. In dental applications, a dilute solution is injected as close to the target nerve as possible. It is also commonly used to relieve the pain of post-herpetic neuralgia, the pain that can last months after a shingles infection, in the form of a transdermal patch.⁵ These patches usually consist of 5% lidocaine and can be used to treat pain from other sources, like post-operative nerve pain and compressed nerves. Traditionally, it has also been known to treat ventricular arrythmias, particularly ventricular tachycardia and multiple ventricular extrasystoles.⁶ However, more recent research suggests that, contrary to what was once believed, administering lidocaine prophylactically has a negligible effect on people who have experienced a myocardial infarction.⁷ 

Though rare, adverse side effects of lidocaine have been observed. Most side effects are caused by toxic levels of lidocaine concentration in the plasma.³ This local anesthetic reaches toxic concentrations most easily when administered into the intercostal space, as it reaches the intravascular compartment most rapidly this way (as opposed to administration through the caudal, epidural, and subcutaneous spaces).³ More so than other anesthetics, lidocaine is associated with transient radicular irritation syndrome,⁸ which is lower extremity pain experienced after receiving spinal anesthesia.⁹ The drug is metabolized in the liver by the cytochrome CYP3A4, so any drugs that are also ligands of this can cause elevated lidocaine serum levels and may cause toxicity.¹⁰ 

It has several contraindications. There are several cases in the literature of lidocaine-induced methemoglobinemia,¹¹ a condition in which the iron in hemoglobin is stabilized in the ferric (Fe³⁺) form and cannot bind oxygen, which leads to tissue hypoxia.¹² At high concentrations, it and other oxidizing drugs can convert hemoglobin to methemoglobin. Becker et al. stress the importance of hemodynamic monitoring when administering lidocaine with epinephrine or other vasoconstrictors, as, even in small doses, they can cause significant cardiovascular effects.³ 

Foo et al. recently published a guide to using it intravenously in Anaesthesia, in which they recommend that infusions be given only in settings with continuous monitoring and after approval by the hospital.¹³ Lidocaine, the authors conclude, is a reliable and safe anesthetic that should be used by medical practitioners under the right conditions whenever it is needed. 

References 

1. “Lidocaine (Local) Monograph for Professionals.” Drugs.com.  

2. Calatayud, J., and González, A. “History of the Development and Evolution of Local Anesthesia Since the Coca Leaf.” Anesthesiology, vol. 98, no. 6, 2003, pp. 1503–1508., doi:10.1097/00000542-200306000-00031.  

3. Beecham GB, Bansal P, Nessel TA, et al. Lidocaine. [Updated 2021 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539881 

4. Lidocaine: A Common Local Anesthetic. The University of Reading. 

5. “Lidocaine Transdermal Patch: MedlinePlus Drug Information.” MedlinePlus, U.S. National Library of Medicine, medlineplus.gov/druginfo/meds/a603026.html.  

6. Gianelly, R., et al. “Effect of Lidocaine on Ventricular Arrhythmias in Patients with Coronary Heart Disease.” New England Journal of Medicine, vol. 277, no. 23, 1967, pp. 1215–1219., doi:10.1056/nejm196712072772301.  

7. Martí-Carvajal, A., et al. “Prophylactic Lidocaine for Myocardial Infarction.” Cochrane Database of Systematic Reviews, 2015, doi:10.1002/14651858.cd008553.pub2.  

8. Zaric, D, et al. “Transient Neurologic Symptoms (TNS) Following Spinal Anaesthesia with Lidocaine versus Other Local Anaesthetics.” Cochrane Database of Systematic Reviews, 2003, doi:10.1002/14651858.cd003006.  

9. Lambert, D. “Transient Radicular Irritation Remains a Danger.” Anesthesia Patient Safety Foundation, 20 Oct. 2019, www.apsf.org/article/transient-radicular-irritation-remains-a-danger/. 

10. Fang, P., et al. “Functional Assessment of CYP3A4 Allelic Variants on Lidocaine Metabolism in Vitro.” Drug Design, Development and Therapy, Volume 11, 2017, pp. 3503–3510., doi:10.2147/dddt.s152366.  

11. Chowdhary, S., et al. “Risk of Topical Anesthetic–Induced Methemoglobinemia.” JAMA Internal Medicine, vol. 173, no. 9, 2013, p. 771., doi:10.1001/jamainternmed.2013.75.  

12. Barash, M., et al. “Lidocaine-Induced Methemoglobinemia: A Clinical Reminder.” The Journal of the American Osteopathic Association, 2015, doi:10.7556/jaoa.2015.020.  

13. Foo, I., et al. “The Use of Intravenous Lidocaine for Postoperative Pain and Recovery: International Consensus Statement on Efficacy and Safety.” Anaesthesia, vol. 76, no. 2, 2020, pp. 238–250., doi:10.1111/anae.15270. 

Over the course of the last year, the COVID-19 pandemic has drastically changed the healthcare landscape. The virus’ ability to spread rapidly throughout the population has discouraged many Americans from receiving healthcare in crowded hospitals and clinics. Instead, they have opted for telehealth, an alternative introduced decades ago that has only recently seen its popularity peak due to COVID-19.

Statistics from multiple studies and the CDC show a significant increase in telehealth visits at the start of 2020. The CDC obtained and analyzed data from the four largest telehealth providers in the country. Telehealth visits increased by 50% during the first 13 weeks of 2020 from January to March, compared with the same period in 2019. Week 13 of 2020 saw an increase of 154% compared with the same week in 2019 [1]. The timing of this increase is significant, since people started to have a heightened alertness of this novel coronavirus around this time in March. Another study examined telehealth visits to providers at the UCSF Cancer Center during pre- and post-COVID-19 periods. The researchers defined the pre-COVID-19 period as the weeks from January 1st to March 13, 2020. The post-COVID-19 period was defined as the weeks from March 16 to May 31, 2020. During the pre-COVID-19 period, 23,988 ambulatory episodes and 2284 video visits were recorded. During the post-COVID-10 period, 20,567 ambulatory episodes and 12,946 video visits were recorded [2]. The decrease in in-person visits and the massive increase in video visits are indicative of patients’ acceptance of telehealth as a way to receive care.

Demographic data reveals that age plays a significant role in telehealth access. Adults aged 18-49 increased their use of telehealth from 2019 to 2020, while there was no increase for adults older than 49 years old [1]. Despite the pandemic, older adults statistically still prefer in-person medical visits, which can be explained partly by lack of knowledge and access to technology. Lonergan et al. observed that minorities, including African American, Hispanic, and Asian patients were quick to utilize and adapt to the benefits of telehealth; all three of these groups saw greater increases in telehealth visits compared to white patients [2]. Out of these minorities, Hispanics had the highest usage. Furthermore, telehealth usage increased by 493% for patients living in urban areas during the post-COVID-19 period, but only increased by 260% for patients living in rural areas [2].

Although some chose telehealth as an alternative to in-person visits, total visits at the start of the pandemic decreased by 9% among a national sample of 16.7 million individuals with commercial or Medicare insurance. Total visits, comprised of in-person visits and telehealth visits, declined in every state, revealing how COVID-19 led to deferred care across the country at the start of the pandemic [3]. Policy changes such as the CARES Act strived to provide a seamless transition for those who wanted care without endangering themselves and others. The CARES Act encouraged providers to serve more patients by providing higher payments, including telehealth in Medicaid benefits, and authorizing a wide variety of providers to utilize telehealth [1]. Although some physical interactions between provider and patients cannot be replaced by telehealth, patients have benefitted from telehealth’s safety and convenience during these unique times.

References

1. Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1595–1599. DOI: 10.15585/mmwr.mm6943a3

2. Lonergan PE, Washington SL III, Branagan L, Gleason N, Pruthi RS, Carroll PR, Odisho AY. Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19: Cross-Sectional Analysis. J Med Internet Res 2020;22(7):e19322. DOI: 10.2196/19322

3. Patel SY, Mehrotra A, Huskamp HA, Uscher-Pines L, Ganguli I, Barnett ML. Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US. JAMA Intern Med. Published online November 16, 2020. DOI: 10.1001/jamainternmed.2020.5928

High-frequency oscillatory ventilation (HFOV) is a lung-protective method of mechanical ventilation that utilizes nonconventional gas exchange mechanisms to provide lung ventilation at very low tidal volumes and high frequencies [1]. It can maintain high end-expiratory lung volume without inducing overdistension, minimizing the risk of ventilator-induced lung injury (VILI) [7]. HFOV provides an alternative to conventional mechanical ventilation, which is associated with a higher risk of VILI occurrence [2,7]. It is often used as a rescue strategy when conventional mechanical ventilation has failed [2]. HFOV is a safe and effective ventilation strategy in the full spectrum of patient populations but has most frequently been used in the treatment of patients with acute respiratory distress syndrome (ARDS), those at risk for developing VILI, and neonates with respiratory failure [2,3].

High-frequency oscillatory ventilation has been associated with improved clinical outcomes when compared to conventional mechanical ventilation for patients with ARDS [3]. ARDS is characterized by acute lung inflammation, reducing the lungs’ ability to adequately oxygenate blood [3]. Patients typically require an artificial respirator in order to prevent death [3]. HFOV assists with the opening of collapsed lung tissue by providing constant positive pressure in the airway [3]. It can substantially reduce the mechanical stress and strain applied during each tidal breath, preventing further trauma to the lungs [1].  

VILI results from two primary mechanisms: volutrauma and atelectotrauma [2]. It is characterized by an application of mechanical forces to the pulmonary epithelium lining the distal airways and alveoli, leading to the production of an inflammatory response within the lung that can spread through the blood to distal organs [1]. VILI can result in multisystem organ failure [1]. HFOV helps prevent VILI by reducing the risk of volutrauma [2]. By maintaining alveolar inflation at a constant airway pressure, HFOV prevents the lung “inflate-deflate” cycle while providing improved oxygenation to high-risk patients [2]. 

In the last two decades, high-frequency oscillatory ventilation has become an established method of treating neonates with respiratory failure [4]. Premature infants have structurally and functionally immature lungs that are predisposed to hypoxia [5]. Critically ill neonates often experience oxygen toxicity and barotrauma due to low lung volumes and ventilation-perfusion mismatch [5]. HFOV has become a widely used lung-protective strategy in neonatal respiratory failure since it is associated with improved respiratory status compared with conventional ventilation [5]. In a clinical trial that examined 500 neonates either on HFOV or a conventional ventilation strategy, infants in the HFOV treatment group were successfully extubated at an earlier age and were more likely to be alive and independently breathing by 36 weeks [5]. 

Lastly, here are some potential adverse effects that physicians should be aware of [2]. HFOV is not recommended in patients with intracranial hypertension and severe airflow limitation [1]. HFOV is less effective in disease processes with increased airway resistance, which can lead to air trapping and hyperinflation and result in barotrauma [2]. Cardiovascular function must be closely monitored as there is risk of decreased venous return, reduced cardiac output, intraventricular hemorrhage, and increased intrathoracic pressure [2]. Patients on HFOV should also be monitored for sepsis since intubation increases the likelihood of bacterial infection in the bloodstream [6]. 

References 

1. Sklar, M., Fan, E., & Goligher, E. (2017). High-Frequency Oscillatory Ventilation in Adults With ARDS. Chest, 152(6), 1306-1317. doi:10.1016/j.chest.2017.06.025 

2. Meyers, M., Rodrigues, N., & Ari, A. (2019). High-frequency oscillatory ventilation: A narrative review. Canadian Journal of Respiratory Therapy, 55, 40-46. doi:10.29390/cjrt-2019-004 

3. Sud, S., Sud, M., Friedrich, J. et al. (2016). High-frequency oscillatory ventilation versus conventional ventilation for acute respiratory distress syndrome. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd004085.pub4 

4. Keszler, M., & Durand, D. (2001). Neonatal High-Frequency Ventilation. Clinics in Perinatology, 28(3), 579-607. doi:10.1016/s0095-5108(05)70108-1 

5. Bouchut, J., Godard, J., Claris, O., & Weiskopf, R. (2004). High-frequency Oscillatory Ventilation. Anesthesiology, 100(4), 1007-1012. doi:10.1097/00000542-200404000-00035 

6. Briggs, S., Goettler, C., Schenarts, P. et al. (2009). High-Frequency Oscillatory Ventilation as a Rescue Therapy for Adult Trauma Patients. American Journal of Critical Care, 18(2), 144-148. doi:10.4037/ajcc2009303 

7. Imai, Y., & Slutsky, A. (2005). High-frequency oscillatory ventilation and ventilator-induced lung injury. Critical Care Medicine, 33, 129-134. doi:10.1097/01.ccm.0000156793.05936.81 

Medical tourism is the process of traveling to a different country for medical care. Tens of thousands of U.S. residents travel abroad each year for medical services, and the total number of medical tourists to all countries in 2017 alone was estimated at 14-16 million (Dalen, 2018). Medical tourism is becoming increasingly popular due to the lower cost of various health services abroad, the availability of procedures or therapies not offered in one’s current location, and preferences of immigrants to return to their country of origin for medical care. The most common procedures sought by medical tourists include cosmetic surgery, dentistry, and heart surgery (HHS).  

Medical tourism was initially fueled by citizens of developing countries traveling to the United States and other developed countries for the expertise and advanced technology of leading medical centers not available in their homeland. Though this practice continues today, there has been a recent trend in which citizens of highly developed nations seek medical services in less-developed areas due to the relative low cost of treatments, inexpensive flights, and increase of online marketing (Meštrović 2018). For instance, the cost of insurance in the United States is much higher than that of many other countries, making it difficult for a number of Americans to afford the medical services they need or desire domestically (Faulkner 2018). As a result, many Americans travel abroad to where a variety of medical services are offered at a lower cost. 

Popular destinations for medical tourists vary depending on the medical procedure or treatment sought. Countries in Central and South America have become popular for cosmetic and plastic surgery, bariatric procedures, and dental care. A number of highly developed nations including Belgium, Canada, Germany, Israel, and Italy also attract foreign patients because of their sophisticated modern care that prioritizes patient preferences and satisfaction. Countries in Asia, including India, Malaysia, Singapore, and Thailand, are popular destinations for medical tourists seeking cardiac surgery and orthopedic surgery. India in particular is known for its very affordable medical services, with costs as low as 10% of those in the United States. In 2004, approximately 1.2 million medical tourists traveled to India for health care (Horowitz et al. 2007). 

Medical tourism presents potential opportunities but also significant concerns and challenges for the patient as well as the healthcare landscape in developing countries around the world. Though economists Mattoo and Rathindran suggest that the quality of care available to citizens of developing countries can be improved through the revenue generated by medical services offered to foreign patients, others have indicated that “medical tourism may seriously undermine the care of local residents by adversely impacting workforce distribution” (Horowitz et al. 2007). Concerns surrounding patient safety and quality of medical care have also been raised, depending on the area visited and the medical services sought. For instance, medications in lower-income settings of care may be counterfeit, outdated, or of poor quality (AMA). Other potential risks for medical tourists include substandard surgical care and poor infection control compared to that in the patient’s home country. 

Communication and travel-related risks are additional challenges for medical tourists. In particular, undergoing a procedure by a medical professional who does not speak one’s language fluently poses a higher risk of misunderstandings (HHS). Furthermore, patients may develop complications from procedures received abroad and may face difficulties seeking help from the foreign professionals who provided the services or receiving proper follow-up care upon returning home, as they often do not have detailed records of the procedures they underwent and the medications they were given. It is important for patients to understand the various risks that arise when seeking health care services in a foreign country before deciding whether to travel abroad for medical purposes. 

References 

American Medical Association (AMA). Medical Tourism. American Medical Association.  https://www.ama-assn.org/delivering-care/ethics/medical-tourism

Dalen JE (2018, July 15). Medical Tourists: Incoming and Outgoing. The American Journal of  Medicine. DOI: 10.1016/j.amjmed.2018.06.022. 

Faulkner, B. (2018, October 31). The Rise of Medical Tourism and What It Means for Healthcare. Healthcare in America. https://healthcareinamerica.us/the-rise-of-medical-tourism-and-what-it-means-for-healthcare-767f228d3727. 

Horowitz MD, Rosensweig JA, Jones CA (2007, November 13). Medical Tourism: Globalization of the Healthcare Marketplace. Medscape General Medicine. 2007;9(4):33.  

Meštrović, T. (2018, August 23). What is Medical Tourism? News Medical Life Sciences. https://www.news-medical.net/health/What-is-Medical-Tourism.aspx. 

U.S. Department of Health & Human Services (HHS). Medical Tourism: Getting Medical Care in Another Country. Travelers’ Health. https://wwwnc.cdc.gov/travel/page/medical-tourism. 

Preoperative anemia is associated with an increased chance of perioperative morbidity and mortality [1]. This is true across a variety of surgeries: anemia can jeopardize the long-term outcome of patients undergoing cardiovascular or non-cardiovascular operations [2, 3]. Of the various conditions that cause perioperative anemia, iron deficiency is very common [1]. If diagnosed about a month before surgery, iron deficiency can be treated successfully [4]. Unfortunately, iron deficiency is frequently undiagnosed, with potentially fatal implications for this patient [1]. This article discusses two means of diagnosing iron deficiency anemia, as well as the steps medical professionals can take after diagnosis to improve surgical outcomes. 

The most common technique of diagnosing iron deficiency anemia is by obtaining the patient’s complete blood count [1]. Following a diagnosis of anemia, a patient must return to the laboratory to give further blood samples and be tested for various metrics, including thyroid function, iron studies, and reticulocyte count [1]. With these tests, physicians will be able to diagnose the type of anemia that patients suffer from [1]. Although these tests can help diagnose some iron deficiency anemia cases, their accuracy can be limited [1]. 

In response to the limitations of the traditional method, researchers offered an alternative approach, consisting of a complete blood count followed by reflex anemia testing in patients with a hemoglobin concentration less than or equal to 12 g/dl [1]. Reflex testing is an automated process that can diagnose iron deficiency anemia and the most common medical conditions that cause anemia [1]. The process would only require a single patient visit and can be more cost-effective [1]. Compared to the traditional method, which diagnosed 1.2 and 3.3% of patients at two different stages, this two-step process diagnosed 26.1% of patients with anemia during the study, suggesting that it can diagnose iron-deficiency anemia more efficiently and effectively [1]. 

If a timely diagnosis of iron deficiency anemia can be achieved, patients can be treated before surgery to prevent complications. Effective treatment can prevent patients from needing perioperative red cell transfusions, which run the risk of perioperative and postoperative complications [4, 5]. One means of treating anemia is iron infusion therapy (IVI), which should occur 22 to 28 days before surgery to maximize efficacy [1]. Studies have shown IVI to be of minimal risk and successful in preventing perioperative anemia-related complications when treating colorectal cancer, gynecology, and obstetric patients [4, 6]. Even if a medical team decides against IVI, research suggests that referring patients to a structured preoperative anemia management clinic lowers the chance that they will need a blood transfusion later on [5]. 

Even if the alternatives to traditional complete blood counting are not extensive, it is clear that physicians must take the steps to diagnose their patients’ iron deficiency anemia before surgery. Given the independent predictive power of anemia in determining several surgical outcomes, this is a condition that cannot be taken lightly, especially given the potential benefit of preoperative testing and proactive treatment [2]. 

References 

[1] O. Okocha et al., “An Effective and Efficient Testing Protocol for Diagnosing Iron-deficiency Anemia Preoperatively,” Anesthesiology, vol. 133, no. 1, p. 109-118, July 2020. [Online]. Available: https://doi.org/10.1097/ALN.0000000000003263. 

[2] M. Dunkelgrun et al., “Anemia as an Independent Predictor of Perioperative and Long-Term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery,” The American Journal of Cardiology, vol. 101, no. 8, p. 1196-1200, April 2008. [Online]. Available: https://doi.org/10.1016/j.amjcard.2007.11.072. 

[3] K. M. Musallam et al., “Preoperative Anaemia and Postoperative Outcomes in Non-Cardiac Surgery: A Retrospective Cohort Study,” The Lancet, vol. 378, no. 9800, p. 1396-1407, October 2011. [Online]. Available: https://doi.org/10.1016/S0140-6736(11)61381-0. 

[4] I. Ellermann et al., “Treating Anemia in the Preanesthesia Assessment Clinic: Results of a Retrospective Evaluation,” Anesthesia & Analgesia, vol. 127, no. 5, p. 1202-1210, November 2018. [Online]. Available: https://doi.org/10.1213/ANE.0000000000003583. 

[5] U. S. Perepu, A. M. Leitch, and S. Reddy, “Implementation of a Preoperative Anemia Management Clinic in a Tertiary Academic Medical Center,” Blood, vol. 128, no. 22, p. 1004, December 2016. [Online]. Available: https://doi.org/10.1182/blood.V128.22.1004.1004. 

[6] M. Muñoz et al., “Perioperative Anemia Management in Colorectal Cancer Patients: A Pragmatic Approach,” The World Journal of Gastroenterology, vol. 20, no. 8, p. 1972-1985, February 2014. [Online]. Available: https://doi.org/10.3748/wjg.v20.i8.1972. 

Insomnia is the most prevalent sleep disorder in America, with 6-10% of Americans meeting the criteria for an insomnia disorder and a third of the population experiencing transient, acute or chronic insomnia annually.¹ While insomnia and persistent sleep loss are significant risk factors for cardiovascular morbidity, mental illness, substance abuse and impaired functioning, there are also significant side effects and risks associated with the sedatives commonly prescribed to treat insomnia.² Surveys conducted by the NCHS estimate that about 4% of the American population uses prescription sleep aids and the majority of those prescriptions are written for three sedative classes: benzodiazepines, “Z-hypnotics” (nonbenzodiazepines) and antidepressants.³ 

The two most prevalent classes of sedatives are benzodiazepines (nitrazepam, temazepam, diazepam, lorazepam) and Z-hypnotics (zopiclone, zaleplon, zolpidem) which both function as g-aminobutyric acid (GABA) agonists. Both classes of drugs have comparable adverse side effects which include headaches, confusion, cognitive impairment, and blurred vision.⁴ However, meta-analyses of several major randomized control trials have found that these side effects are less severe and occur at a lower rate in Z-hypnotics than in benzodiazepines.⁵  

Both benzodiazepines and Z-hypnotics present an elevated risk for elderly patients, whose reduced renal and hepatic capacity may prolong drug metabolism and elimination. Both drugs have been shown to greatly increase the likelihood of injuries or falls.⁴ Additionally, it should be noted that the myorelaxant effects of benzodiazepines are known to be up to forty times more powerful than those of Z-hypnotics which may leave elderly patients with respiratory pathologies at risk of respiratory depression.⁶   

In terms of potential for abuse, it is estimated that approximately 20% of patients taking benzodiazepines develop a physical dependency on the drug and over 30% have difficulty stopping or reducing their dosage.^4,7 In contrast, it has been demonstrated in several studies that, although there is still a risk of dependence on Z-hypnotics, the risk is far lower. As a result of the potential for addiction and abuse in both drugs, it is recommended that the course of use of either class of sedative for sleep disorders be limited to a maximum of four weeks.⁵ 

Finally, the third class of sedatives is antidepressants. Tricyclic antidepressants (TCAs) are often used to treat insomnia, both for their mild sedative effects as well as for their ability to treat depression, a common underlying cause of insomnia.⁸ Although TCAs are considered to carry low risk of addiction, their side effects can include anticholinergic effects, some daytime impairment and the risk of serotonin syndrome if taken above the prescribed dosage.⁹ 

Due to the side effects and risks associated with each class of sedative, non-pharmacological behavioral treatments generally remain the first preference of physicians treating sleeping problems. Long-term use of any sleep medication is associated with less restorative sleep and dependency on the sedative agent to induce sleep or to stay asleep. As acute cases of insomnia often resolve themselves upon the elimination of the causal stressor, physicians generally encourage patients to first attempt relaxation training, improvement of sleep hygiene and cognitive therapies.⁸ Non-pharmacological treatment has been found to improve symptoms of insomnia in 70-80% of patients.¹⁰  

If nonpharmacological treatments fail, or the patient is experiencing significant distress or daytime dysfunction as a result of their sleeping problems, treatment with sedatives may be necessary.⁸  The current literature suggests that benzodiazepines are more risky than Z-hypnotics. Antidepressants present still lower risk but are generally only effective in cases of insomnia concomitant with depressive symptoms. In conclusion, sedatives remain a necessary tool in the treatment of sleep disorders, however, due to their associated risk factors, the dosage and duration of sedative use should be minimized.¹¹ 

References 

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association; 2013. 

2. Medic G, Wille M, Hemels ME. Short- and long-term health consequences of sleep disruption. Nat Sci Sleep. 2017;9:151-161. doi:10.2147/NSS.S134864 

3. Products – Data Briefs – Number 127 – August 2013. www.cdc.gov. Published June 7, 2019. Accessed October 26, 2020. https://www.cdc.gov/nchs/products/databriefs/db127.htm 

4. Taylor D, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. Wiley; 2019. 

5. ‌Wilson SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24(11):1577-1601. doi:10.1177/0269881110379307 

6. Montplaisir J, Hawa R, Moller H, et al. Zopiclone and zaleplon vs benzodiazepines in the treatment of insomnia: Canadian consensus statement. Hum Psychopharmacol. 2003;18(1):29-38. doi:10.1002/hup.445 

7. National Institute for Health and Care Excellence (NICE). Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. Technology appraisal guidance (TA77). London: NICE, 2004. https://www.nice.org.uk/guidance/ta77/resources/guidance-on-the-use-of-zaleplon-zolpidem-and-zopiclone-for-the-shortterm-management-of-insomnia-pdf-2294763557317 

8. Pagel JF, Parnes BL. Medications for the Treatment of Sleep Disorders: An Overview. Prim Care Companion J Clin Psychiatry. 2001;3(3):118-125. doi:10.4088/pcc.v03n0303 

9. ‌Signs & Symptoms of Trazodone Overdose. American Addiction Centers. Published February 4, 2020. Accessed October 26, 2020. https://americanaddictioncenters.org/trazodone-abuse/trazodone-overdose-signs-symptoms 

10. ‌McCall WV. Diagnosis and management of insomnia in older people. J Am Geriatr Soc. 2005;53:S272-S277. doi:10.1111/j.1532-5415.2005.53393.x 

11. Agravat A. ‘Z’-hypnotics versus benzodiazepines for the treatment of insomnia. Progress in Neurology and Psychiatry. 2018;22(2):26-29. doi:10.1002/pnp.502 

Several vaccines for Covid-19 are currently in development and will likely be approved in the coming months. However, after a vaccine is developed, it must be quickly scaled up and deployed in order to be effective. Effective vaccine deployment will have wide coverage, a short release time and an efficient deployment method [1]. However, vaccines formulated during a pandemic can face constraints on the supply chain and limitations on delivery, both of which ultimately complicate deployment. 

Deployment efforts begin before a pandemic occurs. An existing reserve of vaccine-related supplies and modern infrastructure are crucial to ensuring fast deployment during a pandemic. Robust seasonal vaccine capacity is a particularly successful way to ensure the supply chain can handle unexpected events. A study by Porter et al. in the wake of the 2009 H1N1 pandemic examined 97 countries that received vaccines from the WHO. Countries that submitted national deployment and vaccination plans received the vaccine before countries that did not submit these plans [2]. The authors found that countries were twice as likely to submit national deployment and vaccination plans if they already had a seasonal influenza vaccine program. 

After a vaccine is developed, manufacturers will churn out millions of doses, which must be stored quickly and safely to ensure smooth deployment. In an assessment of the U.S.’s vaccine distribution infrastructure, Jacobson et al. noted that computer models can help vaccine producers estimate the amount of storage needed and the optimal locations for storage facilities. The study’s authors suggest dispersing production and storage facilities, as well as working with humanitarian aid organizations to determine where vaccines should be sent and stored. The study also notes that successful vaccine deployment depends on having an adequate stockpile of relevant delivery methods, which can be prepared in the ramp-up period [3]. 

Unlike seasonal vaccines, pandemic vaccines must be quickly rolled out to a large swath of the population. As a result, it’s essential to establish protocols for allocating vaccines and to determine which groups should be targeted. The problem of allocating vaccines has both a strategic and a moral component. The CDC has established guidelines for allocation, including a five-tier system for prioritizing vaccines and identifying target groups. The tiers prioritize healthcare and national security and suggest that initial rounds of vaccination should target disadvantaged populations like pregnant women and the elderly and disabled [4]. A recent philosophical study in Science proposes a Fair Priority Model, which uses overall benefit, priority for the disadvantaged and equal moral concern as its grounding principles. The model prioritizes avoiding premature death by instituting Standard Expected Years of Life Lost (SEYLL) as a formula for determining which groups receive a vaccine first [5]. 

Hessel warns of potential security risks while deploying a vaccine during a pandemic. Most notably, governments should be prepared for an influx of counterfeit vaccines and should have a plan to remove these from market quickly [6]. A recent study by Henson et al. examined a 2018 case where a hospital in the Philippines saw its supply of rabies vaccines infiltrated by counterfeits. After testing the existing stockpile to determine which batches were counterfeit, the hospital determined that 1,711 patients received the counterfeit vaccine. Of the 1,397 patients they were able to contact, 734 patients were given another vaccine [7]. The gap between the number of patients vaccinated in the second round and those given a counterfeit illustrates the importance of quickly removing counterfeit vaccines from circulation, ideally before they come into contact with patients. As with many of the strategies related to vaccine deployment, early identification and preparedness is crucial in ensuring a smooth and unencumbered roll out. 

References 

[1] Liu, Jiming, and Shang Xia. “Toward Effective Vaccine Deployment: A Systematic Study.” Journal of Medical Systems, vol. 35, no. 5, 2011, pp. 1153–1164., doi:10.1007/s10916-011-9734-x. 

[2] Porter, Rachael M., et al. “Does Having a Seasonal Influenza Program Facilitate Pandemic Preparedness? An Analysis of Vaccine Deployment during the 2009 Pandemic.” Vaccine, vol. 38, no. 5, 2020, pp. 1152–1159., doi:10.1016/j.vaccine.2019.11.025. 

[3] Jacobson, Sheldon H., et al. “Survey of Vaccine Distribution and Delivery Issues in the USA: from Pediatrics to Pandemics.” Expert Review of Vaccines, vol. 6, no. 6, 2007, pp. 981–990., doi:10.1586/14760584.6.6.981. 

[4] “Allocating and Targeting Pandemic Influenza Vaccine During an Influenza Pandemic.” Pandemic Vaccine Targeting Guidance, Centers for Disease Control, 2 June 2020, www.cdc.gov/flu/pandemic-resources/pdf/2018-Influenza-Guidance.pdf. 

[5] Emanuel, Ezekiel J., et al. “An Ethical Framework for Global Vaccine Allocation.” Science, vol. 369, no. 6509, 2020, pp. 1309–1312., doi:10.1126/science.abe2803. 

[6] Hessel, Luc. “Pandemic Influenza Vaccines: Meeting the Supply, Distribution and Deployment Challenges.” Influenza and Other Respiratory Viruses, vol. 3, no. 4, 2009, pp. 165–170., doi:10.1111/j.1750-2659.2009.00085.x. 

[7] Henson, Karl Evans R, et al. “Counterfeit Rabies Vaccines: The Philippine Experience.” Open Forum Infectious Diseases, vol. 7, no. 8, 2020, doi:10.1093/ofid/ofaa313. 

Scientists have recently identified a chemical analog of acetaminophen (ApAP) that appears to have decreased liver and kidney toxicity. The peer-reviewed publication, “A novel pipeline of 2-(benzenesulfonamide)-N-(4-hydroxyphenyl) acetamide analgesics that lack hepatotoxicity and retain antipyresis,” by Bazan et al. will be released in the European Journal of Medicinal Chemistry on September 15, 2020. The researchers represented the LSUHS School of Medicine in New Orleans, as well as the Department of Organic Chemistry at the University of Alcala in Madrid.ⁱ  Though the drug remains in the earlier stages of testing and approval, it could have immense implications as a potential acetaminophen alternative. Research has shown that an estimated 100 million Americans in the U.S. suffer from chronic pain and that the resulting healthcare expense is upwards of 560 billion USD.ⁱⁱ  

Referred to in the paper as “3,” 2-(benzenesulfonamide)-N-(4-hydroxyphenyl) acetamide was produced via several steps, the first introducing a 1,1-dioxo-1,2-benzothiazol-3-one moiety onto an existing methyl group of ApAP. The resulting compound, denoted “1,” was found to have a similar analgesic profile to ApAP, but metabolized too rapidly in vivo. 1 was then reacted with a variety of different amines, resulting in an N-substituted amide. The addition of an amine nucleophile to the carbonyl with the sulfonamide leaving group finally resulted in the production of 3, the candidate acetaminophen alternative. The chemical reactions took place in relatively cheap polar solvents, such as water or ethanol, and were carried out at room temperature until thin-layer chromatography indicated the depletion of reagent 1. A detailed visual of this reaction is available online for open access in the European Journal of Medicinal Chemistry. 

ApAP, though considered safe in most industrialized countries, is the number one cause for acute fulminant hepatic failure.ⁱⁱⁱ For this reason, researchers have long sought to identify the source of this toxicity and identify a less volatile acetaminophen alternative. Bazan et. al performed in vitro hepatotoxicity assays on 3 by measuring relative LDH and GSH production, as well as in vivo assays using a dosage of 600mg/kg, with liver function tests as an indicator. Serum creatinine and cytochrome P450 enzyme metabolism assays were also performed to indicate renal function and potential drug-drug interactions, respectively. 3 outperformed ApAP in each assay in terms of cell damage, serum creatinine levels, and cytochrome isoenzyme interaction. Researchers further identified that the oxidation of ApAP to N-acetyl-p-benzoquinone imine (NAPQI) was responsible for heightened markers of free radical formation, loss of hepatic tight junctions, and increased number of apoptotic nuclei in liver cells resulting from ApAP exposure. 

Importantly, 3 showed overall promise as a pain-reducing medication. Two methodologically distinct analgesic assays found that compared to ApAP, 3 similarly resulted in a significant reduction of visceral and inflammatory pain. Furthermore, a Baker’s yeast-induced hyperthermia model showed that both compounds had significant fever-reducing abilities. 

The researchers at LSU have given the rights for further research and marketing of 3 to South Rampart Pharma, LLC, a Louisiana-based company which focuses on the development of opioid alternatives and non-addictive pain medications. Hernan Bazan, the founder of the startup, reports, “We currently working to finalize the preclinical data package necessary to submit our lead molecule for the first Investigation New Drug application by the third quarter of 2020, followed by the rapid initiation of Phase 1 clinical trials to evaluate safety. Ongoing preclinical studies have reproduced these extensive proof of concept studies confirming that our lead compound shows pain reduction with absent liver and kidney toxicity.”^iv 

References

^[i] Louisiana State University. Researchers discover new class of safer analgesics. Medical Xpress. https://medicalxpress.com/news/2020-07-class-safer-analgesics.html. Published July 6, 2020. Accessed August 7, 2020.

^[ii] Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: National Academies Press; 2011.

^[iii] Brune K, Renner B, Tiegs G. Acetaminophen/paracetamol: A history of errors, failures and false decisions. European Journal of Pain. 2014;19(7):953-965. doi:10.1002/ejp.621.

^[iv] BioSpace. South Rampart Pharma Identifies New Class of Non-Opioid Pain Medicines in European Journal of Medicinal Chemistry Publication. BioSpace. https://www.biospace.com/article/releases/south-rampart-pharma-identifies-new-class-of-non-opioid-pain-medicines-in-european-journal-of-medicinal-chemistry-publication/. Published July 14, 2020. Accessed August 7, 2020.