Adam Kay was a doctor in the UK National Health Service (NHS). As becomes clear early in his memoire, This is Going to Hurt, he no longer is. After this early revelation, readers receive almost 300 rollicking pages of “What was it like? Why did I quit?” Kay divides the book into sections that correspond to post medical school training (ie, house officer, senior house officer, registrar, senior registrar) and his various postings. Each of these sections contain several dozen short—approximately 250–500 word—diary entries. He then ends with an open letter to the UK Minister of Health. This book can be consumed like snacks: a few diary entries during your own busy day or, as I did, in a single “can’t-put-this-down” feast. This is an easy read and is written as first-person narrative at the end of each shift. It is very funny, but that does not mean it is trivial. Kay is candid, insightful, emotional, and shocking. He exposes the health care system’s underbelly and his own trials and tragedies. A book that includes 90-hour workweeks, some ungrateful patients, and unforgiving administrators could have been maudlin or meanspirited; instead, it is recognizable, relatable, and riotous. Accordingly, the paperback edition was a UK number-one bestseller for over a year—selling over a million copies—and received the 2018 National Book Award. Kay is now an award-winning comedy writer for the British Broadcasting Corporation (BBC) (and was a former member of the medical musical duo, the Amateur Transplants). Regardless, this book generated widespread sympathy for doctors. It is important for anyone believing our system needs an overhaul or greater focus on practitioner wellbeing. Kay’s work is now available in North American bookshops. This initial relative lack of exposure is a shame given that doctors of all jurisdictions share a bond based on what we went through and often still do. This book is also no less useful for those who live with health care professionals. After all, my wife, family, and friends have endured my absences and moods but may not have understood them. This book is similarly informative for those joining our profession or for patients and politicians wanting to understand the medical mind. It even offers schadenfreude for anyone enduring exasperating jobs or mindless bureaucracy, that is, virtually all of us. Accordingly, I bought several copies to distribute to trainees, colleagues, and friends. Kay subsequently produced a 144-page 2019 sequel entitled Twas the nightshift before Christmas (Pan Macmillan/Picador, London, ISBN 978-1-529-01858-5) not yet available in the United States. This sophomore publication points out that, during the holidays while others look to rest, approximately 1.4 million NHS staff head into work. After all, births do not wait, pneumonia does not care, and—to give an example of his edgy prose—“elderly patients will go full jenga on the ice, shattering their hips like bags of biscuits.” Kay uses the same diary format but divides this book into his 6 NHS Christmases (2004–2009). A pocket-sized book likely designed for Christmas stockings could have been contrived and inferior. Regardless, I still found it insightful and amusing including his suggestion that anesthesia is like Santa: “he sees you when you’re sleeping, he knows when you’re awake.” If Kay attracts criticism, it will not be from me but might be from those who do not care to mix medicine and humor especially when it contains expletives and a plethora of impaled foreign objects. It is also UK-centric. Fortunately, there are doctor memoires to suit all tastes. Readers may even feel inspired, as I did after reading Kay, to revisit the book that kick-started the dystopian medical memoire genre: Dr Stephen Bergman’s House of God (Berkley Publishing, 432 pages, ISBN-10: 0425238091). Because Bergman’s 1978 book has stood the test of time, I think Kay’s will too. In the 1970s, Bergman released his book under a pseudonym: Dr Samuel Shem. Nowadays, doctors like Kay are happy to own their experiences and shortcomings, and we are still the beneficiaries. I heartily recommend any medical memoire that helps you reflect and rejuvenate. In my case, even if he has quit the profession, the erstwhile Dr Kay still dispenses much-needed medicine. Peter G. Brindley, MD, FRCPC, FRCP (Edin), FRCP (Lond)Departments of Critical Care Medicine and Anesthesiology and Pain MedicineDosseter Ethics CentreUniversity of AlbertaEdmonton, Alberta, Canada[email protected]

Milk of Paradise offers a global history of opium and its synthetic descendants. This clinician and ethicist believes it warrants the attention of this Journal’s readers, not only because we prescribe these products daily or because newspapers are clogged with stories of opiate-related tragedies and law. This 336-page book comes from the historian, novelist, and presenter, Lucy Inglis. Published in 2019, it is divided into 3 iterative sections: opium, morphine, and heroin. This is buttressed by over 30 pages of bibliography which speaks to her scholarship and allows the reader to go deeper still. In one volume, Inglis covers cultivation and crime, pharmacology and profiteering, addiction and abstinence, trade and trafficking. In so doing, she makes the case for the central role of analgesics and intoxicants throughout 5000 years of human history. This is a nonmedical text, but, clearly, opiates need to be understood as more than just receptor agonists and antagonists. This book offers “Big History,” namely it covers myriad forces acting over a long timeframe and involving many disciplines. It is also an engaging read from an author who has pivoted from her previous focus on Georgian History. Inglis challenges us to realize that “since Neolithic times, opium has made life if not perfect then tolerable” and reminds us that “many of us will end our lives dependent.” Her tight prose covers the war on drugs (and why countries such as China have zero tolerance, whereas countries such as Portugal opt for decriminalization), the wars because of drugs (Hong Kong, Mexico, Afghanistan, Philippines, Thailand), and the drugs that became widespread because of wars (the American Civil War, First World War, Vietnam). She includes logical segues into “narcomania,” the codependency between drugs and artistic creativity, the creation of the hypodermic syringe, the rise of human immunodeficiency virus (HIV), and the imperfect results of methadone in abstinence and chemical parole. Bestselling books have viewed human history through the prism of commercial products such as salt1 and coal.2 Inglis offers a similarly well-crafted work but via an even more profitable pervasive product. The book’s title is apposite given that “Milk of paradise” is one of many sobriquets for the latex of the papaver somniferum plant. It is also the last line of Coleridge’s poem, Kubla Khan, which can be seen as a product of opium’s chimeric role in reality, creativity, pain, and paradise. Regardless, there are more than 400 species, and the opium poppy was never fully wild. Accordingly, Inglis’s treatise begins in the Fertile Crescent and traces cultivation during the Bronze Age and in Greek and Roman civilizations. This continues through the Renaissance and the West’s collusion during the Opium Wars. In the second part, she addresses the creation of morphine, and how myriad offshoot products offered temporary relief from pain, insomnia, dyspnea, and dysentery, albeit alongside addiction, despair, prostitution, and crime. The third part incorporates the present day: the easy availability of synthetic opiates, the exuberance of Big Pharma and some prescribers, and the resultant “Generation Oxy.” Inglis concludes that the war on drugs will be endless and futile because no product is as easy to produce, as profitable, as necessary, or as temporarily comforting. Moreover, no other commercial product touches more lives: from pipe to prescription, syrup to blister-pack, intravenous drip to burnt spoon, birth to palliation. To quote Inglis, “Within these parameters, economies are built, legal and illegal, petty, and international. Whether sidewalk dope dealers or pharmaceutical giants, merchants know no country, just as the search for a glimpse of paradise is constant.” Inglis does not overglamorize opium or opiates, but the book does contain colorful, intriguing quotes. These include the poet, Jean Cocteau, who argued that “everything one does in life, occurs in an express train racing toward death. To smoke opium is to get out of the train while it is still moving.” This reviewer also has no wish to romanticize drug use/abuse, but this book helped me better understand why opium, morphine, heroin, fentanyl, and myriad other agents are about more than seeking oblivion. Hyperbole aside, Inglis’s work helps explain humanity: its desires and frailty. These are important lessons for those trusted with prescribing substances that have an extraordinary power to both help and harm. Peter G. Brindley, MD, FRCPC, FRCP Edin, FRCP LondDossetor Ethics CentreAnesthesiology and Pain MedicineIntensive Care MedicineUniversity of Alberta HospitalEdmonton, Alberta, Canada[email protected]

Jointly edited by 2 anesthesiologists that are widely published in the subspecialty of neuroanesthesia, the first edition of Neuroanesthesia: A Problem-Based Learning Approach is an essential textbook for the general anesthesiologist. The book provides an up-to-date review for the day-to-day practice of neuroanesthesia. This book includes 48 contributors and presents a problem-based approach to neuroanesthesia in 8 sections, with multiple chapters covering 29 separate topics. The main sections encompass a wide array of topics including oncological, vascular and spine procedures, pediatrics, functional neurosurgery, neuroanesthesia complications, and neuroanesthesia concepts which are all presented in considerable detail. Each chapter is designed to mirror the oral board examination format. It begins with a short stem case that describes a real-life scenario, followed by selected case-based questions and answers which highlight the fundamentals of the topic. This approach is effective to review core knowledge in neuroanesthesia including pharmacology of anesthetic agents, neurophysiology, neuromonitoring techniques, and background to the case with some basic information about surgical goals and aims of treatment. This is followed by an in-depth discussion section with specific focus on details related to various anesthetic concerns for that topic. At the end of each chapter, there are 10 multiple choice questions that are aimed at summarizing and reviewing key learning points with answers provided. In addition to basic introductory knowledge, there are some useful chapters in new emerging procedures in neuroanesthesia that are of interest to the experienced practitioner. Of note, there is up-to-date evidence presented for acute endovascular thrombectomy in acute stroke, which provides the reader with the latest indications for general versus sedation-based anesthetic techniques. Contrasting arguments are given for each technique, with the literature in well-organized summary tables that identify all the latest pertinent studies. Highly specialized procedures such as deep brain stimulator insertion and epilepsy surgery are discussed, including functional testing using electroencephalography and electrocorticograph. In addition, dedicated chapters on less-known topics such as extracranial–intracranial bypass, awake craniotomy, and neurosurgery in pregnancy may be of interest to the subspecialist. Information presented in these chapters is given in an easy-to-digest format targeted for an audience that needs to know the nuances of these procedures for their day-to-day practice. The layout of this book presents the reader with an easy-to-read text complimented with multiple tables and full-color diagrams to illustrate important points. At the end of each chapter, citations predominantly from the last decade of the anesthesiology literature are available for the convenience of the reader who wants to explore further knowledge on a certain subject. This print edition does have a valuable supplementary digital content available online through Oxford Medicine including all questions in the 29 chapters prepared as a practice examination. This is also aimed for those wanting to practice for board certification examinations as well as an aid to reinforce the most important learning points in the text. One of the criticisms of this book include the multiple-choice review questions written at the end of each chapter. In fact, each answer is written directly underneath the question making it difficult for the reader to self-test without seeing the correct answer. This is a point for improvement in later editions of this textbook. As the textbook is a compilation of chapters from different international contributors, the text is occasionally repetitive; however, this is a good indicator of the significant effort invested in this book by the 2 editors with expertise in neuroanesthesia. The authors succeeded in creating an engaging and problem-oriented approach to the most pertinent topics in neuroanesthesia. Overall, Neuroanaesthesia: A Problem-Based Approach is a valiant effort for giving an updated and easy-to-digest synopsis of current anesthesia concerns in the subspecialty. It is a recommended supplement to any anesthesiology trainee as part of their board examination preparation because it will cover most topics in the field of neuroanesthesia that is relevant to their everyday practice. In addition, this well-thought-out text will provide supplementary knowledge to those who want to pursue a subspecialty career in neuroanesthesiology. The book is highly recommended as a valuable reference for all the latest evidence on a wide variety of commonly performed procedure and niche topics. Anday Altas, MDMarco M. Garavaglia, MDDepartment of AnesthesiaUniversity of TorontoToronto, Ontario, Canada[email protected]

No other journal can match Anesthesia & Analgesia for its original and significant contributions to the anesthesiology field. Each monthly issue features peer-reviewed articles reporting on the latest advances in drugs, preoperative preparation, patient monitoring, pain management, pathophysiology, and many other timely topics. Backed by internationally-known authorities who serve on the Editorial Board and as Section Editors, Anesthesia &Analgesia is your gateway to everything that is happening in anesthesia and 14 related subspecialties: Analgesia; Ambulatory Anesthesia; Anesthetic Pharmacology; Cardiovascular Anesthesia; Critical Care and Trauma; Economics, Education, and Policy; Neurosurgical Anesthesia; Obstetric Anesthesia; Pain Mechanisms; Pain Medicine; Pediatric Anesthesia; Regional Anesthesia; Patient Safety; and Technology, Computing and Simulation.

No other journal can match Anesthesia & Analgesia for its original and significant contributions to the anesthesiology field. Each monthly issue features peer-reviewed articles reporting on the latest advances in drugs, preoperative preparation, patient monitoring, pain management, pathophysiology, and many other timely topics. Backed by internationally-known authorities who serve on the Editorial Board and as Section Editors, Anesthesia &Analgesia is your gateway to everything that is happening in anesthesia and 14 related subspecialties: Analgesia; Ambulatory Anesthesia; Anesthetic Pharmacology; Cardiovascular Anesthesia; Critical Care and Trauma; Economics, Education, and Policy; Neurosurgical Anesthesia; Obstetric Anesthesia; Pain Mechanisms; Pain Medicine; Pediatric Anesthesia; Regional Anesthesia; Patient Safety; and Technology, Computing and Simulation.

The second edition of An Introduction to Pharmacovigilance describes the pharmacovigilance organization of health systems worldwide and, in particular, in the United States and Europe. The authors of the second edition of this guide have considerable experience in the field of pharmacovigilance. Patrick Waller was an Honorary Professor at the London School of Hygiene and Tropical Medicine and Chairman of the EU Pharmacovigilance Working Party. He then worked in the field of pharmacovigilance for the Medicines Control Agency in London and from 2002 to 2011 as an independent consultant in pharmacovigilance and pharmacoepidemiology. Mira Harrison-Woolrych is an honorary research associate professor of the Dunedin School of Medicine. She has >20 years’ experience in pharmacovigilance, pharmacoepidemiology, and medicines regulation in both the United Kingdom and New Zealand. She is currently Secretary of the International Society of Pharmacovigilance. These authors, who are among the world’s leading experts in the field of pharmacovigilance, have traced its history from the first adverse effects that led to the thalidomide tragedy up to the current systems used worldwide. The term pharmacovigilance was coined by the World Health Organization as “The science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems.” After a historical introduction, this book is divided into 9 chapters. The authors describe the concept and classification of adverse drug reactions, the scales used for causality assessment in individual cases, the types and sources of data used in pharmacovigilance from the first pharmaco-epidemiological system, registries and the systematic review and meta-analysis of studies. They then describe the pharmacovigilance process, the procedure for reporting adverse effects followed by the impact of pharmacovigilance on drug safety regulations and the Summary of Product Characteristics (European Commission) or the US Package Insert prepared by pharmaceutical companies. Differences between regulations implemented in the United States, Europe, and other countries are well documented, and the authors emphasize the need for international collaboration. In the last chapters, the authors address the ethical and societal considerations in relation to the patient-informed consent process. They conclude their guide by giving us a glimpse of the future directions of pharmacovigilance and how newcomers can expand their knowledge and improve their literacy in pharmacovigilance. They also give references for further reading, including larger textbooks and texts covering specific populations, as well as information about key websites, training courses, and professional societies relevant to the field of pharmacovigilance. The chapters are concisely written, although the information becomes more detailed as the reader advances in this guide. This well-structured and documented book is extremely useful for all practitioners, including anesthetists. Younger professionals can learn the rules of pharmacovigilance, whereas experienced physicians and writers have a reference text and checklist for regulatory pharmacovigilance documentation requirements. This guide is essential to improve knowledge in pharmacovigilance. Jean-Marc Malinovsky, MD, PhDService d’anesthésie réanimationPôle URADCentre Hospitalier Universitaire de ReimsReims Cedex, France[email protected]

This concise book is intended to be a comprehensive, easy-to-read text aimed both at anesthesiology trainees preparing for examinations and experienced practitioners needing a succinct reference guide. Authored by a number of experienced practitioners in the field of anesthesiology from across the United States, the editors have structured this textbook to describe common challenges in clinical anesthesia in a question–answer format. The book comprises 12 main, specialty-specific sections and a total of 60 chapters. Each chapter starts with a hypothetical clinical scenario relevant to a particular subspecialty in anesthesiology. A large number of chapters address the cardiovascular system and anesthetic considerations, for example, ischemic heart disease, valvular abnormalities, or uncommon conditions such as care of a patient with a transplanted heart presenting for noncardiac surgery. In every chapter, the starting clinical scenarios are well structured and provide a comprehensive account of the clinical issue, including relevant investigations. The main content of each chapter is in a format of a series of simple questions and succinct answers. Wherever indicated, basic understanding of anatomy and physiology is discussed, such as applied anatomy of coronary circulation, the denervated heart or nomenclature, and classification of pacemakers. The anesthetic implications in each of these situations are covered explicitly and referenced appropriately. The style of presentation is one of the main strengths of this book. Using a problem-based approach, the authors immediately direct readers to the matter at hand, that is, the clinical situation and how to safely provide anesthesia care while facilitating critical thinking and problem-solving skills. The questions guide readers through the logical steps in safe anesthetic management of various elective and emergency cases in great detail. Current evidence and guidelines are cited wherever necessary, such as the 2014 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery,1 or the Universal Definition of Myocardial infarction.2 Chapters on intraoperative coagulopathies, difficult airway management, and obstetric anesthesia also cover the applied pathophysiology and anesthetic implications quite well. The section on pediatric anesthesiology topics is comprehensive, and particularly, neonatal resuscitation and premature infant are described. Because this is the first edition of this book, it can be appraised using Yao and Artusio’s Anesthesiology: Problem-Oriented Patient Management,3 a core textbook, now in its 8th edition. Both books are laid out in a problem-based format using clinically relevant case scenarios. The table of contents is similar; both books deal with the topics in a well-organized questionanswer format. The Yao and Artusio book is a major reference text and covers each topic in extensive detail, with preoperative, intraoperative, and postoperative phases clearly yet compactly presented, referenced, and well illustrated where appropriate. The Anesthesiology case reviews book touches on the most relevant topics; however, the level of detail is not as extensive as that of the Yao and Artusio book. Some important and current practices in anesthesiology have been overlooked in this book, such as important considerations for use of newer reversal agents for nondepolarizing neuromuscular blockers (sugammadex) or use of gastric ultrasound for patients with a full stomach. Moreover, obstructive sleep apnea is not described as a condition in its own right, but as an association with obesity. The recent updated STOP-Bang questionnaire4 and the 2016 Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients with Obstructive Sleep Apnea5 are also missing. In the regional anesthesia chapters, brachial plexus anatomy illustrations are presented in color; however, there is limited mention of the use of ultrasound for nerve blocks, a standard of care practiced in many institutions worldwide. The addition of colorful illustrations, graphs, and figures could make this book more readable. Some integral anesthesia topics such as acute and chronic pain management are mentioned very superficially, and some readers may find this an important exclusion of a significant knowledge area. Overall, this is a good book, serving as a handy resource for both trainees and clinicians who like to review high-yield topics in a case-based format. This book finds its place somewhere between being a useful concise pocket handbook for bedside reference, such as Oxford Handbook for Anesthesia,6 and a case-based reference book with more detail, such as the Yao and Artusio book.3 In the end, if a reader would like to use a textbook that touches on most of the relevant clinical topics in anesthesia or prepare for examinations, this book will serve as an important addition to their collection of useful resources. Najia Hasan, MBBS, FRCADepartment of Anaesthesia and Intensive CarePrince Charles HospitalCwm Taf University Health BoardWales, United Kingdom Mandeep Singh, MBBS, MD, MSc, FRCPCDepartment of Anesthesiology and Pain ManagementToronto Western HospitalUniversity Health NetworkUniversity of TorontoToronto, Ontario, CanadaDepartment of Anaesthesiology and Pain ManagementWomen’s College HospitalToronto, Ontario, CanadaToronto Sleep and Pulmonary CentreToronto, Ontario, Canada[email protected]

Background & Objectives: Postoperative cognitive dysfunction (POCD) can complicate a patient’s postoperative recovery in several ways. Optimised doses of anaesthetics as guided by processed electroencephalogram indices may minimise POCD. This preliminary report is based on a review (1)which is under development and has not been published to address whether optimised anaesthesia guided by processed EEG indices can reduce the risk of POCD in non-cardiac surgical or non-neurosurgical patients undergoing general anaesthesia compared with standard practice where only clinical signs are used. Materials & Methods: The methods and analysis were done in accordance with our recent published protocol (1).We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (issue4 2015), MEDLINE OvidSP (1990 to October 2015), EMBASE OvidSP (1990 to October 2015). Two authors independently examined all studies to select those which met the inclusion criteria for assessing methodological quality. We resolved disagreements by a consensus meeting between the three authors. If considered appropriate, we pooled the results of comparable groups of trials by a meta-analysis. Results: From the initial search of 4068 abstracts, only five studies fulfilled the inclusion criteria. Three studies (2,3,4) used Mini Mental State Exam (MMSE) and battery of neuropsychological tests and defined POCD as a decline in the POCD Z score of greater than 1.96 SD in at least two domains. By using a fixed effect model, we found a significant effect of anaesthesia guided by processed EEG indices on reducing risk of POCD at 12 weeks ((2047 participants; risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.96)) (see figure) but failed to demonstrate this effect on POCD at one week ((1985 participants; risk ratio (RR) 0.63, 95% confidence interval (CI) 0.69 to 1.01)).Conclusion: Optimised doses of anaesthetics as guided by processed EEG indices may reduce risk of POCD at 12 weeks. More studies are needed to elucidate the effect on early POCD (1 week) and late POCD (52 weeks).