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George Tewfik, Dennis Grech, Linda Laham, Faraz Chaudhry, Rotem Naftalovich Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USACorrespondence: George Tewfik, Rutgers New Jersey Medical School, Department of Anesthesiology, 185 South Orange Ave, Newark, NJ, 07103, USA, Tel +1-973 972-5007, Email glt31@njms.rutgers.eduAbstract: The objective of this narrative review was to assess current literature regarding acquisition and consolidation of physician practices in the United States (US). The acquisition and consolidation of physician practices is a trend affecting patient care, quality of services, healthcare economics and the daily practice of physicians. As practices are acquired by fellow physician groups, private equity investors and entities such as hospitals or large healthcare systems, it is important to better understand the underlying forces driving these transactions and their effects. This is a narrative review of peer-reviewed publications to determine what current literature has covered regarding the acquisition and consolidation of physician practices in the US regarding risks and benefits of this trend. Sources included the SCOPUS, Medline- PUBMED and Web of Science databases. Peer reviewed publications from 2009 to 2022 were included for initial review and curation for relevance using the search terms “physician” and “practice” with either “acquisition” or “consolidation”. Synthesis conducted after narrowing down of relevant articles did not use quantitative measurements, but instead examined overall trends, as well as risk and benefits of ongoing acquisition and consolidation in a narrative format. Journal articles focused on physician consolidation in the US often reported increases in physician numbers with decreases in numbers of individual practices. Private equity quantitative analyses reported rapidly accelerating acquisitions driven by these investors, and vertical integration scholarly work reported frequent geographic consolidation of nearby practitioners. Risks associated with these transactions included such items as decreased physician autonomy and higher cost of care. Benefits included practice stability, improved negotiation with insurers and improved access to resources.Keywords: healthcare economics, physician practice, physician practice acquisition, systematic review

Background: Mallampati scoring is a common exam method for evaluating the oropharynx as a part of the airway assessment and for anticipation of difficult intubation. It partitions the oropharynx into 4 categories with scores of 1, 2, 3, and 4. Even though its reliability is known to be limited by confounding factors such as patient positioning, patient phonation, tongue protrusion, and examiner variability, the effect of respiration, i.e., inspiration and expiration, has not yet been formally studied., Methods: Mallampati scores were collected from 100 surgical patients during both inspiration and expiration and later compared to the score obtained in the medical record, determined by a board certified anesthesiologist., Results: Score deviations from the medical record reference were compared for both inspiration and expiration showing that respiration affects Mallampati scores; for some patients, the scores improved (i.e., decreased), while in others they worsened (i.e., increased). The respiratory change effect was quantified and visualized by plotting the area under the curve of the histogram of the deviations. 42% of the patients had a worsening of scores by 1 or 2 points with inspiration while 36% of the patients had a worsening of scores by 1 or 2 points with expiration., Conclusions: Mallampati scoring is commonly used in evaluating the oropharynx as a part of the airway assessment and as a screening tool for difficult intubations. However, as this study points out, the respiratory cycle substantially affects the Mallampati scoring system, with significant deviations of 1 or 2 points. In a scoring system of 4 score categories, these deviations are remarkable., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2023 Rotem Naftalovich et al.)

Background: The American Society of Anesthesiologists (ASA) has an impressive array of professional perioperative guidelines but has not issued a guideline specific to perioperative blood glucose management and does not delve into the topic in their other guidelines., Case Report: We experienced a perioperative case that highlights the potential difficulty of glucose management in this setting. During anesthetic induction for an orthopedic foot surgery, as the medication was infusing, an IDDM 1 (insulin dependent diabetes mellitus type 1) patient expressed feeling that her blood sugar level was low. Her finger stick after induction showed severe hypoglycemia with a blood glucose of 34 mg/dL. The hypoglycemia was treated with intravenous glucose and further closely monitored., Conclusions: This case led us to revisit the different perioperative guidelines and recommendations for diabetic patients and this manuscript aims to highlight the similarities and discrepancies among the different published recommendations. This case highlights the value of utilizing insulin pump infusions in the perioperative setting when available., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Learning in the operating room (OR) for residents in anesthesiology is difficult but essential for successful resident education. Numerous approaches have been attempted in the past to varying degrees of success, with efficacy often judged afterward using surveys distributed to participants. The OR presents a particularly complex set of challenges for academic faculty due to the pressures required by concurrent patient care, production pressures, and a noisy environment. Often, educational reviews in ORs are personnel specific, and instruction may or may not take place in this setting, as it is left to the discretion of the parties without regular direction., Objective: This study aims to determine if a structured intraoperative keyword training program could be used to implement a curriculum to improve teaching in the OR and to facilitate impactful discussion between residents and faculty. A structured curriculum was chosen to allow for the standardization of the educational material to be studied and reviewed by faculty and trainees. Given the reality that educational reviews in the OR tend to be personnel specific and are often focused on the clinical cases of the day, this initiative sought to increase both the time and efficiency of learning interactions between learners and teachers in the stressful environment of the OR., Methods: The American Board of Anesthesiology keywords from the Open Anesthesia website were used to construct a weekly intraoperative didactic curriculum, which was distributed by email to all residents and faculty. A weekly worksheet from this curriculum included 5 keywords with associated questions for discussion. The residents and faculty were instructed to complete these questions on a weekly basis. After 2 years, an electronic survey was distributed to the residents to evaluate the efficacy of the keyword program., Results: A total of 19 teaching descriptors were polled for participants prior to and following the use of the intraoperative keyword program to assess the efficacy of the structured curriculum. The survey results showed no improvement in intraoperative teaching based on respondent perception, despite a slight improvement in teaching time, though this was statistically insignificant. The respondents reported some favorable aspects of the program, including the use of a set curriculum, suggesting that greater structure may be beneficial to facilitate more effective intraoperative teaching in anesthesiology., Conclusions: Although learning is difficult in the OR for residents, the use of a formalized didactic curriculum, centered on daily keywords, does not appear to be a useful solution for residents and faculty. Further efforts are required to improve intraoperative teaching, which is well known to be a difficult endeavor for both teachers and trainees. A structured curriculum may be used to augment other educational modalities to improve the overall intraoperative teaching for anesthesia residents., (©George Tewfik, Rotem Naftalovich, Carlos Rodriguez-Aponte, Bishoy Ezzat. Originally published in the Interactive Journal of Medical Research (https://www.i-jmr.org/), 18.05.2023.)

Fluid-warming systems are crucial in surgical and trauma settings because of their key role in preventing or treating hypothermia and enabling proper resuscitation of blood products that are stored cold. Recently, several manufacturers have issued warnings of the possibility of aluminum leaching from their fluid warmers and cautioned about the potential for aluminum toxicity in patients who underwent fluid resuscitation with these devices. Studies suggest that one of the main factors affecting aluminum leaching in this setting is the coating of the aluminum plate itself. Coating, often with a biocompatible material, appears to reduce aluminum leaching by 100- to 200-fold compared with an uncoated plate. Nonetheless, leaching with the coating is still at a level exceeding U.S. regulations. A few aluminum-free warming systems are available on the market, but these are not carried by all providers and some clinicians may be less familiar with their use. Medical device manufacturers will likely design future warming systems with less potential for aluminum blood contact. In the meantime, the risk of inadequate resuscitation, consequent to the proper fluid warmer no longer being available, is contrasted with the risk of potential toxicity. In the situation described here, the regulators deferred the ultimate decision of which fluid warmer to use in a given situation to the risk-benefit decision of the clinician., (© Copyright AAMI 2022 Copying, networking, and distribution prohibited.)

Surgical airway approaches are, at times, last resort options in difficult airway management. In Special Operations these interventions confront distorted anatomy from combat trauma, extreme conditions, and may be performed by non-medically trained personnel. Under these circumstances, needle cricothyroidotomy using a large bore intravenous catheter can be considered. A small syringe connected to the needle can confirm transtracheal placement through air aspiration before passing the angiocatheter over the needle. Button activated retracting needles should be avoided for this when possible. We recommend a 3-mL Luer-lock syringe because a small syringe is better suited for generating pressure and once the catheter is in the trachea, this same syringe can be connected to bag valve ventilation by replacing its plunger with a connector from a 6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and light high-yield items to the Tactical Combat Casualty Care medic inventory should be considered in future revisions., (2022.)

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach that uses a combination of evidence-based methods to improve patient care. Different ERAS protocols are used in various surgical fields but for spine surgery there is no widely used standard ERAS protocol. We compiled and examined the multiple available publications on ERAS protocols for spine surgery. Some general commonalities exist between ERAS protocols; however, a great deal of variety is observed in the granularity of important details such as differing drug choices or specific dosing. To assess and relate the different available ERAS protocols, we conducted a comprehensive narrative literature review focused on comparing commonalities and differences among the following aspects of ERAS protocols: mechanisms of action, post-surgery pain levels, opioid consumption, utilization of muscle relaxants, use of anti-inflammation drugs, and ambulation after surgery. Our goal in this project was to simplify the search process for institutions who review the literature. In this review, certain ERAS elements such as early ambulation, blood loss, pain management, and patient positioning are further explored in more depth.

Mechanical respirators typically use a plastic circuit apparatus to pass gases from the ventilator to the patient. Structural integrity of these circuits is crucial for maintaining oxygenation. Anesthesiologists, respiratory therapists, and other critical care professionals rely on the circuit to be free of defects. The American Society for Testing and Materials maintains standards of medical devices and had a standard (titled Standard Specification for Anesthesia Breathing Tubes) that included circuits. This standard, which was last updated in 2008, has since been withdrawn. Lack of a defined standard can invite quality fade-the phenomenon whereby manufacturers deliberately but surreptitiously reduce material quality to widen profit margins. With plastics, this is often in the form of thinner material. A minimum thickness delineated in the breathing circuit standard would help ensure product quality, maintain tolerance to mechanical insults, and avert leaks. Our impression is that over the recent years, the plastic in many of the commercially available breathing circuits has gotten thinner. We experienced a circuit leak in the middle of a laminectomy due to compromised plastic tubing in a location that evaded the safety circuit leak check that is performed prior to surgery. This compromised ventilation and oxygenation in the middle of a surgery in which the patient is positioned prone and hence with a minimally accessible airway; it could have resulted in anoxic brain injury or death. The incident led us to reflect on the degree of thinness of the circuit's plastic., (© Copyright AAMI 2021. Copying, networking, and distribution prohibited.)

Background and Aims: to quantify the scalp-cortex distance and determine its variation among patients. We hypothesized that in a significant number of patients, this distance is greater than the maximum penetration depth of current cerebral oximeters., Material and Methods: A retrospective anatomic study using transverse head CT images selected randomly from 102 patients over the age of 18 years without brain swelling, intracranial mass effect, or brain hemorrhage. Scalp-cortex distances were determined at two separate locations along the craniocaudal axis; most cephalad to the frontal sinus (I 0 ) and also 2 cm cephalad to that location (I 2 ). Multiple measurements were obtained bilaterally at 1, 3, 5, 7, and 9 cm from midline., Results: The average scalp-cortex distance was 14.3 mm and 15 mm at I 0 and I 2 respectively. Distances varied more in I 2 than in I 0 ; from the measurements, 12.8% vs . 6.8% were over 20 mm, 4.4% vs . 2.2% over 25 mm, 1.1% vs . 0.6% over 35 mm and 0.6% vs . none over 40 mm at I 2 and I 0, respectively. 1.5% of the measurements at I 2 were over 30 mm., Conclusion: Cerebral oximetry manufacturers all claim to measure cerebral tissue up to a depth of 20-25 mm; 20 mm with the EQUANOX and INVOS compared with 25 mm with the FORE-SIGHT. Scalp-cortex distance is within 25 mm in more than 95% of patients. However, even with the probe placed as per the manufacturer's recommendations, in a small but significant subset of patients, this distance is greater than the maximum penetration depth of current cerebral oximeters and hence may not reflect actual brain tissue oxygen saturation., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

The ability to adequately ventilate a patient is critical and sometimes a challenge in the emergency, intensive care, and anesthesiology settings. Commonly, initial ventilation is achieved through the use of a face mask in conjunction with a bag that is manually squeezed by the clinician to generate positive pressure and flow of air or oxygen through the patient's airway. Large or small erroneous openings in the breathing circuit can lead to leaks that compromise ventilation ability. Standard procedure in anesthesiology is to check the circuit apparatus and oxygen delivery system prior to every case. Because the face mask itself is not a piece of equipment that is associated with a source of leak, some common anesthesia machine designs are constructed such that the circuit is tested without the mask component. We present an example of a leak that resulted from complete failure of the face mask due to a tiny tear in its cuff by the patient's sharp teeth edges. This subsequently prevented formation of a seal between the face mask and the patient's face and rendered the device incapable of generating the positive pressure it is designed to deliver. This instance depicts the broader lesson that deviation from clinical routines can reveal unappreciated sources of vulnerability in device design., (© Copyright AAMI 2021. Copying, networking, and distribution prohibited.)

The association between blood viscosity and pathological conditions involving a number of organ systems is well known. However, how the body measures and maintains appropriate blood viscosity is not well-described. The literature endorsing the function of the carotid sinus as a site of baroreception can be traced back to some of the earliest descriptions of digital pressure on the neck producing a drop in blood delivery to the brain. For the last 30 years, improved computational fluid dynamic (CFD) simulations of blood flow within the carotid sinus have demonstrated a more nuanced understanding of the changes in the region as it relates to changes in conventional metrics of cardiovascular function, including blood pressure. We suggest that the unique flow patterns within the carotid sinus may make it an ideal site to transduce flow data that can, in turn, enable real-time measurement of blood viscosity . The recent characterization of the PIEZO receptor family in the sinus vessel wall may provide a biological basis for this characterization. When coupled with other biomarkers of cardiovascular performance and descriptions of the blood rheology unique to the sinus region, this represents a novel venue for bioinspired design that may enable end-users to manipulate and optimize blood flow., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Iskander, Bilgi, Naftalovich, Hacihaliloglu, Berkman, Naftalovich and Pahlevan.)

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice., (© Copyright AAMI 2021. Copying, networking, and distribution prohibited.)

The progressive increase in lifespan over the past century carries with it some adversity related to the accompanying burden of debilitating diseases prevalent in the older population. This review focuses on oxidative stress as a major mechanism limiting longevity in general, and healthful aging, in particular. Accordingly, the first goal of this review is to discuss the role of oxidative stress in limiting longevity, and compare healthful aging and its mechanisms in different longevity models. Secondly, we discuss common signaling pathways involved in protection against oxidative stress in aging and in the associated diseases of aging, e.g., neurological, cardiovascular and metabolic diseases, and cancer. Much of the literature has focused on murine models of longevity, which will be discussed first, followed by a comparison with human models of longevity and their relationship to oxidative stress protection. Finally, we discuss the extent to which the different longevity models exhibit the healthful aging features through physiological protective mechanisms related to exercise tolerance and increased β-adrenergic signaling and also protection against diabetes and other metabolic diseases, obesity, cancer, neurological diseases, aging-induced cardiomyopathy, cardiac stress and osteoporosis., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Our group thought the study by Lee and Kim entitled "Hemodynamic Changes in the Carotid Artery after Infusion of Normal Saline Using Computational Fluid Dynamics" was a very elegant method to discern the changes in blood rheology within the carotid sinus after administration of crystalloid [...].

The carotid sinus is a dilated area at the base of the internal carotid artery of humans and is located immediately superior to the bifurcation of the internal and external carotid arteries. It is widely accepted, in the fields of medicine and physiology, to function as a baroreceptor in its central control role. This paper presents a hypothesis challenging this paradigm - that the carotid sinus functions by detecting oscillations at the vessel wall which result from shear stress due to vortical flow. This is contrary to conventional thinking which presumes that the carotid sinus responds to blood pressure or wall pressure. Our hypothesis is based on anatomy, physiology and physical properties of fluid which make the sinus the area of highest vorticity. Utilizing magnetic resonance angiograms of undiseased carotid vessels, we computed the oscillatory shear index (OSI) via a computational fluid dynamics simulation of flow. This region of highest OSI coincides with the area where the nerve to the carotid sinus lies within the vessel wall. Accordingly, the hypothesis is that the carotid sinus acts as a mechanotransducer of wall shear stress oscillation and not as a baroreceptor., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Since satiety is largely due to stretch of the stomach and people tend to eat a consistent weight of food, increasing food volume and mass increases satiety. This can be achieved without increasing the calories of food by mixing food with a material that cannot be metabolized. Such a material should be inert, safe, resistant to stomach acid, lack taste, available in powder form, smooth, resistant to heat, and cost effective. Polytetrafluoroethylene (PTFE) is an ideal substance for this purpose. It is a soft plastic that is widely considered to be the most inert material known and is extremely stable. Animal feeding trials showed that rats fed a diet of 25% PTFE for 90 days had no signs of toxicity and that the rats lost weight. This article publishes the data from these subchronic animal feeding trials, reviews the relevant available literature, and hypothesizes that increasing the volume of food by mixing the food with PTFE powder at a ratio of 3 parts food to 1 part PTFE by volume will substantially improve satiety and reduce caloric consumption in people., (© 2016 Diabetes Technology Society.)

Monitoring of cerebral perfusion by near-infrared spectroscopy estimates regional cerebral oxygen saturation (rSO2). We present a case in which, before clamping the left carotid artery during an endarterectomy, the right and left rSO2 measurements were 72% and 74%, respectively. Within 15 seconds of clamping the external carotid artery, the left rSO2 decreased by 8%, yielding right and left rSO2 measurements of 70% and 66%, respectively. No electroencephalogram changes ensued. The internal carotid artery was clamped 1 minute later, whereas the external carotid remained clamped. No electroencephalogram changes were observed. The rSO2 measurements demonstrate that the value of this cerebral oximetry is not determined solely from internal carotid blood flow and can be significantly affected by the external carotid.

Background and Aims: We aimed to determine the ropivacaine concentration that provided adequate analgesia with early ambulation and minimal urinary retention or other side-effects when used with fentanyl and epinephrine for patient-controlled epidural analgesia (PCEA) after elective cesarean section., Material and Methods: Forty-eight patients were randomized to four groups in a double-blinded fashion. All groups received an initial 10 ml/h of epidural study solution for 24 h. The solution contained: 0.2, 0.1, 0.05, or 0.025% ropivacaine for Groups I-IV, respectively, with fentanyl 3.0 μg/ml and epinephrine 0.5 μg/ml. Patients could administer additional PCEA doses of 4 ml of their study solution with a lock-out time of 10 min. Overall satisfaction, side-effects, motor block, neurologic function, and pain using Visual Analog Scale were assessed., Results: Patients in all groups showed no difference in sedation, pruritus, nausea, vomiting, and uterine cramps. Pain scores at rest were lower for Group IV than Groups I-III (P < 0.001). Twelve, five, one, and zero patients could not ambulate in Groups I-IV, respectively. Nine, nine, two, and zero (III