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author:("bet, S.")
1.  The aging anesthesiologist: a narrative review and suggested strategies 
Canadian Journal of Anaesthesia  2014;61(9):865-875.
To address an aging anesthesia workforce, we review the relevant changes and implications associated with age in order to stimulate discussion at the individual, local, and national levels regarding appropriate changes in practice aimed at protecting patient safety.
Principal findings
In a 2013 survey of Canadian Anesthesiologists, 22% were aged 55-64 yr, 7% were aged 65-74 yr, and 3% were older than 74 yr. Clinical abilities decline with age, making older anesthesiologists more likely than their younger colleagues to be associated with adverse patient events. Anesthesiologists older than 65 yr in Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury compared with anesthesiologists younger than 51 yr of age. In the absence of overt deterioration in skills, decisions about reducing activities and retirement are left largely to individuals despite their limited ability to self-assess competence. This state of affairs may contribute to the increased incidence of adverse events and poor patient outcomes.
Provincial regulatory bodies have peer assessment programs to evaluate physicians at random, following a complaint, and at certain ages, but all have limitations. Simulation has been used widely for training and assessment in the aviation industry as well as in automobile driving exams. Simulation can assess crisis recognition and management, which is crucial in anesthesiology and not well assessed by other methods, and could assist elderly anesthesiologists during the pre-retirement phase of their careers. A standardized schedule for winding down would have advantages for physicians, their department, and their patients. A suggested schedule might include no further on-call duties for those aged 60 yr and older, no further high-acuity cases for those aged 65 yr and older, and retirement from operating room (OR) clinical practice (with possible continuation of non-OR clinical or other non-clinical activities, if desired) at age 70 yr. These timelines could be extended with satisfactory performance in annual simulation sessions involving assessment and practice in crisis management.
PMCID: PMC4160565  PMID: 24985937
2.  Transfer of learning and patient outcome in simulated crisis resource management: a systematic review 
Canadian Journal of Anaesthesia  2014;61(6):571-582.
Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes.
Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE®, EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners’ reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility.
Principal findings
Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality.
Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality.
Electronic supplementary material
The online version of this article (doi:10.1007/s12630-014-0143-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4028539  PMID: 24664414
3.  Increased paired box transcription factor 8 has a survival function in Glioma 
BMC Cancer  2014;14:159.
The molecular basis to overcome therapeutic resistance to treat glioblastoma remains unclear. The anti-apoptotic b cell lymphoma 2 (BCL2) gene is associated with treatment resistance, and is transactivated by the paired box transcription factor 8 (PAX8). In earlier studies, we demonstrated that increased PAX8 expression in glioma cell lines was associated with the expression of telomerase. In this current study, we more extensively explored a role for PAX8 in gliomagenesis.
PAX8 expression was measured in 156 gliomas including telomerase-negative tumours, those with the alternative lengthening of telomeres (ALT) mechanism or with a non-defined telomere maintenance mechanism (NDTMM), using immunohistochemistry and quantitative PCR. We also tested the affect of PAX8 knockdown using siRNA in cell lines on cell survival and BCL2 expression.
Seventy-two percent of glioblastomas were PAX8-positive (80% telomerase, 73% NDTMM, and 44% ALT). The majority of the low-grade gliomas and normal brain cells were PAX8-negative. The suppression of PAX8 was associated with a reduction in both cell growth and BCL2, suggesting that a reduction in PAX8 expression would sensitise tumours to cell death.
PAX8 is increased in the majority of glioblastomas and promoted cell survival. Because PAX8 is absent in normal brain tissue, it may be a promising therapeutic target pathway for treating aggressive gliomas.
PMCID: PMC4015841  PMID: 24602166
PAX8; Glioblastoma; Glioma; Telomere maintenance mechanism; Telomerase; ALT; BCL2; Cell survival
4.  A Novel Complex, RUNX1-MYEF2, Represses Hematopoietic Genes in Erythroid Cells 
Molecular and Cellular Biology  2012;32(19):3814-3822.
RUNX1 is known to be an essential transcription factor for generating hematopoietic stem cells (HSC), but much less is known about its role in the downstream process of hematopoietic differentiation. RUNX1 has been shown to be part of a large transcription factor complex, together with LDB1, GATA1, TAL1, and ETO2 (N. Meier et al., Development 133:4913–4923, 2006) in erythroid cells. We used a tagging strategy to show that RUNX1 interacts with two novel protein partners, LSD1 and MYEF2, in erythroid cells. MYEF2 is bound in undifferentiated cells and is lost upon differentiation, whereas LSD1 is bound in differentiated cells. Chromatin immunoprecipitation followed by sequencing (ChIP-seq) and microarray expression analysis were used to show that RUNX1 binds approximately 9,000 target sites in erythroid cells and is primarily active in the undifferentiated state. Functional analysis shows that a subset of the target genes is suppressed by RUNX1 via the newly identified partner MYEF2. Knockdown of Myef2 expression in developing zebrafish results in a reduced number of HSC.
PMCID: PMC3457535  PMID: 22801375
5.  Do technical skills correlate with non-technical skills in crisis resource management: a simulation study 
BJA: British Journal of Anaesthesia  2012;109(5):723-728.
Both technical skills (TS) and non-technical skills (NTS) are key to ensuring patient safety in acute care practice and effective crisis management. These skills are often taught and assessed separately. We hypothesized that TS and NTS are not independent of each other, and we aimed to evaluate the relationship between TS and NTS during a simulated intraoperative crisis scenario.
This study was a retrospective analysis of performances from a previously published work. After institutional ethics approval, 50 anaesthesiology residents managed a simulated crisis scenario of an intraoperative cardiac arrest secondary to a malignant arrhythmia. We used a modified Delphi approach to design a TS checklist, specific for the management of a malignant arrhythmia requiring defibrillation. All scenarios were recorded. Each performance was analysed by four independent experts. For each performance, two experts independently rated the technical performance using the TS checklist, and two other experts independently rated NTS using the Anaesthetists' Non-Technical Skills score.
TS and NTS were significantly correlated to each other (r=0.45, P<0.05).
During a simulated 5 min resuscitation requiring crisis resource management, our results indicate that TS and NTS are related to one another. This research provides the basis for future studies evaluating the nature of this relationship, the influence of NTS training on the performance of TS, and to determine whether NTS are generic and transferrable between crises that require different TS.
PMCID: PMC3470444  PMID: 22850221
cardiopulmonary resuscitation; clinical competence; medical education; patient simulation
7.  LMA with positive pressure ventilation is safe! 
PMCID: PMC3155144  PMID: 21860758
8.  Combined rigid videolaryngoscopy-flexible bronchoscopy for intubation 
Korean Journal of Anesthesiology  2011;60(5):381-382.
PMCID: PMC3110301  PMID: 21716571
9.  Intravenous magnesium sulphate for aneurysmal subarachnoid hemorrhage: an updated systemic review and meta-analysis 
Critical Care  2011;15(1):R52.
Previous meta-analyses of magnesium sulphate infusion in the treatment of aneurysmal subarachnoid hemorrhage (SAH) have become outdated due to recently published clinical trials. Our aim was thus to perform an up-to-date systemic review and meta-analysis of published data on the use of magnesium sulphate infusion in aneurysmal SAH patients.
A systemic review and meta-analysis of the literature was carried out on published randomized controlled clinical trials that investigated the efficacy of magnesium sulphate infusion in aneurysmal SAH patients. The results were analyzed with regard to delayed cerebral ischemia (DCI), delayed cerebral infarction, and favorable neurological outcomes at three and six months. The risks of bias were assessed using the Jadad criteria, with a Jadad score >3 indicating a lower such risk. Meta-analyses are presented in terms of relative risk (RR) with 95% confidence intervals (CIs).
Six eligible studies with 875 patients were reviewed. The pooled RR for DCI was 0.87 (95% CI, 0.36 to 2.09; P = 0.75). That for delayed cerebral infarction was 0.58 (95% CI, 0.35 to 0.97; P = 0.04), although this result did not persist if only randomized clinical trials with a lower risk of bias were included (RR 0.61, 95% CI, 0.31 to 1.22; P = 0.17). The pooled RR for a favorable outcome at three months was 1.14 (95% CI, 0.99 to 1.31; P = 0.07), and that for a favorable outcome at six months was 1.08 (95% CI, 0.94 to 1.24; P = 0.29).
The present findings do not lend support to a beneficial effect of magnesium sulphate infusion on delayed cerebral infarction. The reduction in DCI and improvement in the clinical outcomes of aneurysmal SAH patients following magnesium sulphate infusion observed in previous pilot studies are not confirmed, although a beneficial effect cannot be ruled out because of sample size limitation.
PMCID: PMC3221982  PMID: 21299874
10.  Analysis of Fungal Diversity in the Wheat Rhizosphere by Sequencing of Cloned PCR-Amplified Genes Encoding 18S rRNA and Temperature Gradient Gel Electrophoresis 
Like bacteria, fungi play an important role in the soil ecosystem. As only a small fraction of the fungi present in soil can be cultured, conventional microbiological techniques yield only limited information on the composition and dynamics of fungal communities in soil. DNA-based methods do not depend on the culturability of microorganisms, and therefore they offer an attractive alternative for the study of complex fungal community structures. For this purpose, we designed various PCR primers that allow the specific amplification of fungal 18S-ribosomal-DNA (rDNA) sequences, even in the presence of nonfungal 18S rDNA. DNA was extracted from the wheat rhizosphere, and 18S rDNA gene banks were constructed in Escherichia coli by cloning PCR products generated with primer pairs EF4-EF3 (1.4 kb) and EF4-fung5 (0.5 kb). Fragments of 0.5 kb from the cloned inserts were sequenced and compared to known rDNA sequences. Sequences from all major fungal taxa were amplified by using both primer pairs. As predicted by computer analysis, primer pair EF4-EF3 appeared slightly biased to amplify Basidiomycota and Zygomycota, whereas EF4-fung5 amplified mainly Ascomycota. The 61 clones that were sequenced matched the sequences of 24 different species in the Ribosomal Database Project (RDP) database. Similarity values ranged from 0.676 to 1. Temperature gradient gel electrophoresis (TGGE) analysis of the fungal community in the wheat rhizosphere of a microcosm experiment was carried out after amplification of total DNA with both primer pairs. This resulted in reproducible, distinctive fingerprints, confirming the difference in amplification specificity. Clear banding patterns were obtained with soil and rhizosphere samples by using both primer sets in combination. By comparing the electrophoretic mobility of community fingerprint bands to that of the bands obtained with separate clones, some could be tentatively identified. While 18S-rDNA sequences do not always provide the taxonomic resolution to identify fungal species and strains, they do provide information on the diversity and dynamics of groups of related species in environmental samples with sufficient resolution to produce discrete bands which can be separated by TGGE. This combination of 18S-rDNA PCR amplification and TGGE community analysis should allow study of the diversity, composition, and dynamics of the fungal community in bulk soil and in the rhizosphere.
PMCID: PMC91386  PMID: 10347051
11.  References that anyone can edit: review of Wikipedia citations in peer reviewed health science literature 
Objectives To examine indexed health science journals to evaluate the prevalence of Wikipedia citations, identify the journals that publish articles with Wikipedia citations, and determine how Wikipedia is being cited.
Design Bibliometric analysis.
Study selection Publications in the English language that included citations to Wikipedia were retrieved using the online databases Scopus and Web of Science.
Data sources To identify health science journals, results were refined using Ulrich’s database, selecting for citations from journals indexed in Medline, PubMed, or Embase. Using Thomson Reuters Journal Citation Reports, 2011 impact factors were collected for all journals included in the search.
Data extraction Resulting citations were thematically coded, and descriptive statistics were calculated.
Results 1433 full text articles from 1008 journals indexed in Medline, PubMed, or Embase with 2049 Wikipedia citations were accessed. The frequency of Wikipedia citations has increased over time; most citations occurred after December 2010. More than half of the citations were coded as definitions (n=648; 31.6%) or descriptions (n=482; 23.5%). Citations were not limited to journals with a low or no impact factor; the search found Wikipedia citations in many journals with high impact factors.
Conclusions Many publications are citing information from a tertiary source that can be edited by anyone, although permanent, evidence based sources are available. We encourage journal editors and reviewers to use caution when publishing articles that cite Wikipedia.
PMCID: PMC3944683  PMID: 24603564
12.  Twelve tips for a successful interprofessional team-based high-fidelity simulation education session 
Medical Teacher  2014;36(10):853-857.
Simulation-based education allows experiential learning without risk to patients. Interprofessional education aims to provide opportunities to different professions for learning how to work effectively together. Interprofessional simulation-based education presents many challenges, including the logistics of setting up the session and providing effective feedback to participants with different backgrounds and mental models. This paper aims to provide educators with a series of practical and pedagogical tips for designing, implementing, assessing, and evaluating a successful interprofessional team-based simulation session. The paper is organized in the sequence that an educator might use in developing an interprofessional simulation-based education session. Collectively, this paper provides guidance from determining interprofessional learning objectives and curricular design to program evaluation. With a better understanding of the concepts and pedagogical methods underlying interprofessional education and simulation, educators will be able to create conditions for a unique educational experience where individuals learn with and from other specialties and professions in a controlled, safe environment.
PMCID: PMC4245993  PMID: 25023765

Results 1-12 (12)