AnesthesiaAnesthesia

Anesthesia, edited by Miller, first published in 1981, has become the standard textbook in anesthesiology. The fifth edition has six sections: "Introduction," "Scientific Principles," "Anesthesia Management," "Subspecialty Management," Critical Care Medicine," and "Ancillary Responsibilities and Problems." In addition, there is an appendix on the different American Society of Anesthesiologists practice guidelines, including those for such practices as pulmonary artery catheterization, difficult airway management, transesophageal electrocardiography (TEE), and sedation and analgesia by nonanesthesiologists. New chapters on TEE and finding professional information on the Internet have been added. For the first time, the textbook comes with a CD-ROM, which provides verbal and visual description of the more difficult technical problems in anesthesiology.

The chapters are well written and up-to-date. For example, the chapter on uptake and distribution, an old subject, has references as late as 1998. The chapter on monitoring the depth of anesthesia includes a discussion on bispectral electroencephalographic monitoring, a very recent addition to the anesthesia armamentarium. The manual infusion schemes outlined in the chapter on intravenous drug delivery systems are very practical. In the chapter on preoperative evaluation, the author critically analyzes the results of significant studies on the subject, providing the clinician with a better understanding. In the same chapter, the protocols for the evaluation of cardiovascular, respiratory, and liver problems are extremely helpful.

The chapters in the book are well referenced, some extensively so. For example, three chapters have 742, 892, and 1216 references. The figures are either in color or black and white, the latter unbelievably clear. The color plates and the figures in the chapter on TEE and the atlas of peripheral nerve block procedures are very nicely done. The CD-ROM is extremely helpful in understanding difficult technical procedures such as TEE and double lumen endotracheal intubation. Finally, chapters are included that one does not expect in an anesthesiology text, on subjects such as brain death, the anesthesiologist's work environment and teaching with simulators, information on the Internet, quality assurance, and teaching anesthesia.

This book is not without deficiencies. In the chapter on basic principles of pharmacology, the references are not listed in the text, making it difficult for someone to follow up on a subject. In the chapter on metabolism and toxic effects of inhaled anesthetics, the authors state that "sevoflurane is currently used in Japan" when this anesthetic agent has been used clinically in the United States for 2 to 3 years. There is no discussion of popliteal sciatic nerve block in the chapter on nerve blocks. The chapter on trauma has no discussion of trauma as it applies to a specific organ system, eg, chest trauma, nor a discussion of regional anesthesia for trauma. In the chapter on postoperative pain, there is no discussion of the role of peripheral nerve blocks, no comparison of epidural opioids with intravenous opioids, and no analysis of the outcome studies done after epidural opioid analgesia. Because of the format of the book, several topics are repeated. For example, three chapters discuss renal physiology. Since the topics are discussed first in the physiology section and then in the clinical section, repetition cannot be avoided, but it could have been minimized if the physiology had been discussed more succinctly in the clinical section.

There are now two other general textbooks in anesthesiology, one of which has become a worthy competitor, but Miller's is the most comprehensive. There is something for everyone: residents at all levels, fellows, clinicians, researchers, and administrators. Although the text is massive, readers can easily find what they seek—for example, the clinician can go straight to the section on subspecialty management—and each chapter can stand on its own. Finally, the inclusion of the American Society of Anesthesiologists practice guidelines and the CD-ROM make this book invaluable.

Essentials of Complementary and Alternative Medicine is a much needed and very enlightening soft cover companion to a forthcoming and presumably comprehensive Textbook of Complementary and Alternative Medicine. As a succinct introduction to the field, it does not attempt to cover all forms of complementary and alternative medicine (CAM) but does discuss a surprisingly large number.

It is coedited by Wayne B. Jonas, the former director of the Office of Alternative Medicine at the National Institutes of Health (now the National Center for Complementary and Alternative Medicine). Dr Jonas has brought his insight to bear on both the commonalties and differences of allopathic medicine and CAM. It is humbling to think that practitioners of the CAM healing arts were healing and probably curing patients long before allopathic medicine was even contemplated.

The book has three parts. The first covers social and scientific foundations, the second, safety. The third is an overview of 20 different disciplines of CAM with the chapters "Ayurvedic Medicine," "Traditional Chinese Medicine," "Native American Medicine," "Tibetan Medicine," "Chiropractic Medicine," "Osteopathy," "Naturopathic Medicine," "Holistic Nursing," "Medical Acupuncture," "Phytomedicine," "Spiritual Healing," "Massage Therapy," "Qigong," "Biofeedback Therapy," "Hypnotherapy," "Behavioral Medicine," "Orthomolecular Medicine and Megavitamin Therapy," "Homeopathy," "Nutritional Biotherapy," and "Meditation and Mindfulness." This final portion, which comprises about two thirds of the book, is written by 24 different authors and thus is subject to variation in the thoroughness with which each discipline is discussed and in the number and quality of pertinent references cited.

Nevertheless, the text is most illuminating and provocative, as it forces one to realize how little knowledge of the field has been included in medical education in the past. The authors do point out that more than 75 medical schools now have courses on CAM.

In 1997, 42% of all patients visiting medical doctors' offices used CAM therapy on their own, the majority of whom chose not to inform their physicians.¹ If 32% of French physicians, 20% of German physicians, and 42% of British physicians employ homeopathy in their practices, how can US physicians remain completely ignorant of this and other CAM disciplines? The book also causes one to consider the possible utilization of CAM therapies in one's own practice.

Consequently, readers are strongly urged to take the time to personally review the pertinent references for the use of the variety of widely employed and presumably effective CAM therapies cited. An excellent chapter, "How to Practice Evidence-Based Complementary and Alternative Medicine," facilitates this process.

This text directs the reader to both conventional and electronic resources, which can convey a fundamental grasp of each type of CAM discussed as well as the benefits and risks associated with the therapy. A plea is also made for physicians to conduct well-controlled studies to determine the effectiveness or ineffectiveness of CAM therapies before either accepting or rejecting them out of hand.

There is a very useful collation of herbal and nonherbal products used by CAM practitioners and an index of both indications and precautions for CAM therapies, a useful discussion of a unifying concept for CAM therapies, and a consideration of the historic evolution of both CAM therapies and allopathic medicine. Also valuable are chapters on the adverse effects of acupuncture and spinal manipulation.

A minor quibble is with the binding. The book does not retain the pages well once they have been spread widely apart to facilitate easier reading. As a consequence, an occasional page comes loose and is subject to loss.

Essentials of Complementary and Alternative Medicine is a well thought out collection of essays on a variety of healing disciplines not covered by conventional medical education in the past. This book should serve well as a preliminary and relatively inexpensive introduction to the field.

Clinician's Complete Reference to Complementary and Alternative Medicine is intended to be a convenient reference for the clinician to the various disciplines in complementary and alternative medicine (CAM). Ninety authors have contributed chapters on 64 fields of practice.

The text is organized into sections covering "Mind-Body Interventions," "Bioelectromagnetic Applications," "Alternative Systems of Medical Practice," "Community-Based Health Care Practices," "Manual Healing Methods," "Pharmacologic and Biologic Treatments," "Diet and Nutritional Treatments," and "Unclassified Diagnostic and Treatment Methods."

Topics discussed include the more familiar practices such as biofeedback, hypnotherapy, meditation, spiritual healing and prayer, yoga, acupuncture, traditional Chinese medicine, homeopathy, chiropractic, and orthomolecular medicine. Also included are less familiar practices, such as poetry therapy, magnetic field therapy, craniosacral therapy, polarity therapy, reiki, antineoplaston therapy, chelation therapy, enzyme therapy, flower essence therapy, nutritional oncology and integrative cancer care, applied kinesiology, aromatherapy, colon hydrotherapy, color therapy, detoxification therapy, fasting, juice therapy, iridology, quartz crystal therapy, and reflexology, among others.

Each chapter is subdivided into sections that include a discussion of the origins and history of the therapy, mechanisms of action of the therapy according to its own theory, the biologic mechanism of action, forms of the therapy, applications, and an evidence-based analysis of the therapy. Also included are the indications and reasons for referral, a description of a typical patient encounter, a discussion of credentialing and training necessary to properly practice the discipline being discussed, and a section describing what to look for in a provider. Most chapters have suggested readings, limited bibliographies, and references for studies being cited.

Since multiple authors contribute individual chapters, there is considerable variability in the comprehensiveness with which the topics are discussed as well as the extent of the discussion of the scientific basis explaining and evaluating the therapy in question. Some chapters are written by practitioners of certain disciplines who admit that no research is available to substantiate their practices but who simultaneously assure the reader of high rates of effectiveness based on their personal experience. The authors of other chapters cite papers published in referenced journals and give Internet citations to Web pages dealing with the subject that are very helpful. Also included at the end of the text is a listing of various illnesses with specific recommendations as to which CAM therapy would be most effective for the particular illness in question.

As might be expected in an undertaking with such a large number of contributors, there are some significant errors and omissions. Among these are such items as the omission of references 25 to 34 from the chapter on light therapy and faulty Internet citations for translations of Chinese research articles on Qigong therapy.

Novey's book discusses more CAM practices but in less depth and detail than does the Jonas and Levin text. The latter also has much more detail on potential complications of CAM therapies and more substantive discussion of the background and philosophies of the various cultural related medical practices such as Ayurveda, Native American Medicine, and Shamanism. The Jonas and Levin text places a greater emphasis on those therapies established to be effective by the National Institute of Alternative Medicine.

Clinician's Complete Reference to Complementary and Alternative Medicine is an inexpensive introductory survey type reference to many of the therapies employed in CAM treatment. It contains numerous Internet citations to CAM therapy that are not readily found elsewhere. There is considerable variation in the depth and quality of the discussion of the various therapies. In general, this text is a useful addition to the library of any clinician wishing to have access to a convenient introduction to many of the various CAM therapies and is a reasonable place to go to find beginning references for a more detailed discussion of any specific topic.

The fetus has gained considerable moral status in our society. In a parallel manner, the stature of fetal medicine has increased, as intense basic and applied research has been translated into novel approaches to the clinical evaluation of management of the fetus in utero.

Fetal Medicine, edited by Charles H. Rodeck and Martin J. Whittle, is a comprehensive text devoted to the challenges of this growing multidisciplinary field. The editors have tapped the knowledge of numerous international contributors whose expertise encompasses several different clinical disciplines and research backgrounds. Ten years in the making, the text is nevertheless current in both scope and detail.

The book has 10 sections encompassing a broad range of topics related to the fetus. The topics illustrate the scientific principles underlying fetal development and offer clinically relevant insights into the care of the fetus. The initial chapters focus on the cellular and molecular biology of human fetal development and fetal and placental physiology. Interesting chapters on homeobox genes, fetal growth and its regulation, and development of the central nervous system, cardiovascular system, and respiratory system highlight the first two sections.

The bulk of the text is devoted to prenatal screening and diagnosis. These sections include chapters on nuances and challenges of effective genetic counseling and recent developments in the termination of pregnancy. A section on bereavement and reaction to fetal loss is an important contribution, often missing in similar texts. Chapters on biochemical surveillance for neural tube defects, Down syndrome, and new developments in cytogenetics, DNA analysis (including TaqMan and oligonucleotide assays), and ultrasound screening for fetal abnormalities are part of this section. Similarly, there is a wealth of information on the diagnosis of fetal genetic disease, eg, hemoglobinopathies, cystic fibrosis, muscular dystrophy, and inborn errors of metabolism; fetal malformations, eg, cardiac disease, renal disorders, and hydrops fetalis; and other fetal conditions, eg, intrauterine growth restriction, red blood cell alloimmunization, twin and higher order multiple gestations, and fetal gene therapy. The final two sections address issues of fetal monitoring and the neonate. The appendix includes several charts of normal fetal measurements.

The book also includes a short section on ethical issues in maternal-fetal medicine, which contains an insightful discussion of the philosophical framework of the fetus as patient. Given the broad range of ethical dilemmas facing fetal medicine, this well-written section is a valuable contribution that hopefully will be expanded in future editions. An important section on epidemiology, containing chapters on the prevention of neural tube defects and the adult consequences of fetal disease, adds to the comprehensive nature of the text.

The book presents a wide range of topics on normative and abnormal fetal development in a scholarly and comprehensive fashion. There are some overlapping passages, but they tend to be complementary and supportive, rather than redundant. Chapters tend to be short, concise, extremely focused, and well referenced. The book contains 600 illustrations and numerous color plates.

In summary, Fetal Medicine is one of at least two new texts in this emerging field of medicine. It is a well-written, balanced book, which includes both the relevant basic science and clinical perspectives. The text's major strength is its comprehensiveness. I would recommend Fetal Medicine to my obstetric, genetic, perinatal, and neonatal colleagues as an accessible resource for insights into the challenging issues faced by practitioners in this field.

In The Endangered Medical Record the authors propose a solution to a significant problem facing health care: current coding systems such as the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), Medicare's diagnosis-related groups, and the Health Care Financing Administration's Common Procedure Coding System are a blight on the health care system in the United States.

The authors provide significant evidence that such coding systems fail on several levels. First, the systems were often not designed for the purposes to which they are being put. The ICD-9's primary purpose is the collection and reporting of international causes of morbidity and mortality. It does not even do that well, so it is no surprise that it is wholly inadequate for use in electronic medical records, clinical research, epidemiological research, and administrative tasks such as billing, reimbursement, and single-hospital statistics and trends. Second, these coding systems are really classifications, putting patient cases into broad categories. Once a code is assigned, significant clinical detail is lost and cannot be recovered without a return to the original, paper-based patient record—an expensive and time-consuming task. Third, these coding systems encourage distortion and hiding of the truth because of the manner in which they are used. Certain codes are "forbidden" by third party payers, thus they are avoided even if they would accurately describe what was wrong with the patient or what services were really provided to patients. Fourth, the rules are so complicated that even coding professionals do not consistently code patient cases. Both intracoder and intercoder variability is high.

The authors convincingly argue that the result of these shortcomings is a wealth of inaccurate, distorted data that threaten the health-care information infrastructure in this country. If clinicians are to document their care in an electronic medical record in a structured, machine-readable format, the use of existing coding systems will eliminate the clinical detail that we at least have in paper-based format now. A better way is necessary, both to remedy current problems in health information and to prevent a worsening of the situation with the advent of electronic recording, storage, and transmission of health care data.

The authors propose a solution called entity coding, which allows for the capture of clinical detail, yet supports classification of the data for such purposes as research, statistics, and billing and reimbursement. The authors even outline how the transition to entity coding should occur and recommend that the wholesale adoption of International Classification of Diseases, 10th Revision (ICD-10) in the United States be delayed until entity coding can be implemented nationwide. Once implemented, entity codes could then be mapped algorithmically to classifications such as ICD-10, preventing the need for any direct, human classification of patient cases. The advantage of this approach is the elimination of variability in classification, the subsequent inaccuracy and variability of data, and the consequent ill-informed policy, funding, and reimbursement decisions.

The fact that the first author helped the government develop the clinical modifications to ICD-9 lends credibility to the description of the problem and its consequences for the health care industry and to the solution that is set forth. The argument for entity coding is logical and clearly stated—the book is comprehensible to the average reader; one need not be a clinician or a coder. However, entity coding is unproven —at least the authors present no evidence of its success in health care—thus an argument against the wholesale adoption of such a system nationwide all at once, as the authors propose, can be made. Perhaps a trial of entity coding and an evaluation of its benefits would be a more rational step.

Furthermore, there is a large body of medical informatics literature about medical terminologies and coding systems, and a different solution is proposed in this literature: concept-based reference terminologies with a rich set of hierarchical and semantic relationships among them. The authors do not even address this literature, let alone ponder whether the two solutions—entity coding and reference terminologies—are compatible or incompatible. The danger is that too many proposed solutions will prolong the status quo, while bureaucrats and committees examine, study, and debate the various alternatives. Furthermore, both camps could learn from one another to create a solution that draws on the strengths of both approaches, providing an even better solution. A unified front, with the proponents of both entity coding and reference terminologies advocating a single solution, is the ideal approach to addressing a problem that continues to deteriorate the quality of health care information, and the decisions based on it, in the United States.