Guest Editorial

Death on the table: preparing for the inevitabl

Ultrasound for the Anesthesiologists: Present and Future

Ultrasound is a safe, portable, relatively inexpensive, and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine. Anesthesiologists encounter a variety of emergent situations and may benefit from the application of such a rapid and accurate diagnostic tool in their routine practice. This paper reviews current and potential applications of ultrasound in anesthesiology in order to encourage anesthesiologists to learn and use this useful tool as an adjunct to physical examination. Ultrasound-guided peripheral nerve blockade and vascular access represent the most popular ultrasound applications in anesthesiology. Ultrasound has recently started to substitute for CT scans and fluoroscopy in many pain treatment procedures. Although the application of airway ultrasound is still limited, it has a promising future. Lung ultrasound is a well-established field in point-of-care medicine, and it could have a great impact if utilized in our ORs, as it may help in rapid and accurate diagnosis in many emergent situations. Optic nerve sheath diameter (ONSD) measurement and transcranial color coded duplex (TCCD) are relatively new neuroimaging modalities, which assess intracranial pressure and cerebral blood flow. Gastric ultrasound can be used for assessment of gastric content and diagnosis of full stomach. Focused transthoracic (TTE) and transesophageal (TEE) echocardiography facilitate the assessment of left and right ventricular function, cardiac valve abnormalities, and volume status as well as guiding cardiac resuscitation. Thus, there are multiple potential areas where ultrasound can play a significant role in guiding otherwise blind and invasive interventions, diagnosing critical conditions, and assessing for possible anatomic variations that may lead to plan modification. We suggest that ultrasound training should be part of any anesthesiology training program curriculum

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

Abstract Background: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. Methods: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. Results: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. Conclusion: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals

Inflammatory responses after surgery

The inflammatory response after major surgery is of great importance for patients, physicians and perioperative medicine in general. This article, although not intended to be comprehensive, provides an overview of present knowledge about inflammatory mechanisms, predictive parameters and therapeutic approache

and serotonin (Sanna et al., 1994) receptors, G-protein-coupled receptors

ABSTRACT Since volatile anesthetics inhibited high voltage-gated calcium channels and G-protein-coupled M 1 muscarinic signaling, their effects upon M 1 receptor-induced modulation of L-type (␣1C) calcium channel was investigated. Voltage-clamped Ba 2ϩ currents (I Ba ) were measured in Xenopus oocytes coexpressed with L-type channels and M 1 muscarinic receptors. M 1 receptor agonist, acetyl-␤-methylcholine (MCh) inhibited the peak and late components of I Ba in a dose-dependent manner. Analysis of I Ba after the treatment with MCh or volatile anesthetics revealed that the inactivating component, its time constant, and the noninactivating current were all decreased by these agents. MCh-induced inhibition followed a second messenger pathway that included G-proteins, phospholipase C, inositol-1,4,5-trisphosphate, and intracellular calcium [Ca 2ϩ ] i . Although halothane or isoflurane inhibited I Ba, their effect was not mediated through these intracellular second messengers. By using volatile anesthetics and MCh sequentially, and in various combinations, the susceptibility of L-type currents and their modulation by M 1 receptors to volatile anesthetics were investigated. When MCh and volatile anesthetics were administered together simultaneously, a pronounced inhibition that was approximately equal to the sum of their individual effects was seen. Halothane or isoflurane further inhibited the I Ba when either volatile anesthetic was administered following the inhibition produced by prior administration of MCh. However, when MCh was administered following either volatile anesthetic, its effect was significantly reduced. Thus, whereas volatile anesthetics appear to directly inhibit L-type channels, they also interfere with channel modulation by G-protein-coupled receptors, which may have functional implications for both neuronal and cardiovascular tissues. In addition to ligand-gated channels, such as GABA A (Mihic et a

Receptors, G proteins, and their interactions

Membrane receptors coupling to intracellular G proteins (G protein-coupled receptors) form one of the major classes of membrane signaling proteins. They are of great importance to the practice of anesthesiology because they are involved in many systems of relevance to the specialty (cardiovascular and respiratory control, pain transmission, and others) and many drugs target these systems. In recent years, understanding of these signaling systems has grown. The structure of receptors and G proteins has been elucidated in more detail, their regulation is better understood, and the complexity of interactions between the various parts of the system (receptors, G proteins, effectors, and regulatory molecules) has become clear. These findings may help explain both actions and side effects of drugs. In addition, these newly discovered targets are likely to play important roles in disease states of relevance to anesthesiologist