Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce.

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

Defining rural teaching hospitals in Canada: Developing and testing a new definition.

INTRODUCTION: The current definition of 'teaching hospital' provided by Canadian Institute of Health Information (CIHI) focuses on large academic teaching hospitals. High-quality rural training experiences have been identified as a key component of training the future rural medical workforce. Identifying communities and hospitals where this training is currently available and taking place is important in understanding the current landscape of available rural training but is hampered by the lack of an agreed upon definition of 'rural teaching hospital'. This limits the understanding of current rural training landscapes, comparison across regions and research in this area. We propose a definition of a 'rural teaching hospital'. METHODS: Using the CIHI definition of rural as an initial reference point, we used accessible data from the University of Calgary and University of Alberta Distributed Medical Education (DME) programs to develop a definition of a 'rural teaching hospital'. We then identified rural Alberta hospitals to show how this definition would work in practice. RESULTS: Our definition of a rural teaching hospital is a hospital situated in a town of <30,000 people, teaching occurs at least 36 h a week and that teaching includes at least Family Medicine clerkship OR Family Medicine residency rotations. We identified 104 Alberta rural hospitals. The University of Calgary and University of Alberta DME programs included 70 communities and 44 of these communities met all three proposed criteria for rural teaching hospitals. CONCLUSION: Creating a working definition of a 'rural teaching hospital' is of high importance for both research and for day-to-day operations of rural educational units.

Résumé Introduction: La définition du terme "hôpital d'enseignement " selon l'Institut canadien d'information sur la santé (ICIS) désigne surtout les grands hôpitaux universitaires. L'expérience de formation de bonne qualité en milieu rural est un élément essentiel de la formation du futur personnel médical en milieu rural. Il importe de déterminer quels sont les communautés et les hôpitaux où cette formation a lieu pour comprendre le contexte actuel de la formation rurale offerte, mais l'on se bute à une définition du terme " hôpital d'enseignement rural " qui ne fait pas consensus. Cela limite la compréhension des contextes actuels de formation en milieu rural, la comparaison entre régions et la recherche sur cette question. Nous proposons donc une définition du terme " hôpital d'enseignement rural ". Méthodologie: Avec la définition de l'ICIS de l'adjectif rural comme point de départ, nous avons utilisé les données accessibles des programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta pour formuler une définition du terme " hôpital d'enseignement rural ". Nous avons ensuite identifié les hôpitaux de l'Alberta pour illustrer comment la définition s'insère dans la pratique. Résultats: Selon nous, un hôpital d'enseignement rural désigne un hôpital situé dans une ville de < 30 000 personnes, l'enseignement y a lieu pendant au moins 36 h par semaine et il inclut au moins un stage en médecine familiale OU des rotations de résidence en médecine familiale. Au total, 104 hôpitaux ruraux de l'Alberta répondaient à cette définition. Les programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta comptaient 70 communautés et 44 d'entre elles remplissaient les trois critères proposés pour être reconnues avoir un hôpital d'enseignement rural. Conclusion: Il est très important de formuler une définition de travail du terme " hôpital d'enseignement rural " tant pour la recherche que pour les activités quotidiennes des unités d'éducation en milieu rural. Mots-clés: Définitions, éducation médicale satellite, éducation médicale, hôpitaux ruraux.

Exploring anesthesiologists' understanding of situational awareness: a qualitative study.

PURPOSE: This study explored how anesthesiologists understand situational awareness (SA) and how they think SA is learned, taught, and assessed. METHODS: Semi-structured interviews were performed with practicing anesthesiologists involved in teaching. This qualitative study was conducted using constructivist grounded theory techniques (i.e., line-by-line coding, memoing, and constant comparison) in a thematic analysis of interview transcripts. Group meetings were held to develop and review themes emerging from the data. RESULTS: Eighteen anesthesiologists were interviewed. Respondents displayed an understanding of SA using a mixture of examples from clinical experience and everyday life. Despite agreeing on the importance of SA, formal definitions of SA were lacking, and the participants did not explicate the topic of SA in either their practice or their teaching activities. Situational awareness had been learned informally through increasing independence in the clinical context, role modelling, reflection on errors, and formally through simulation. Respondents taught SA through modelling and discussing scanning behaviour, checklists, verbalization of thought processes, and debriefings. Although trainees' understanding of SA was assessed as part of the decision-making process for granting clinical independence, respondents found it difficult to give meaningful feedback on SA to their trainees. CONCLUSION: Although SA is an essential concept in anesthesiology, its use remains rather tacit, primarily due to the lack of a common operational definition of the term. Faculty development is required to help anesthesiologists teach and assess SA more explicitly in the clinical environment.

Immunopathogenesis of hypersensitivity syndrome reactions to sulfonamides.

Cytokines play a role in the immunopathological and molecular mechanisms of sulfonamide-induced hypersensitivity reactions (HSRs). The objective of this study was to analyze the reliability and correlation between the clinical symptoms observed in affected patients (n = 86) because of a sulfonamide-induced HSR and their lymphocyte toxicity assay (LTA) values. Another goal was to determine the cytokine secretion in the patient's sera and their expression in the peripheral blood mononuclear cells (PBMCs) and to explore whether a correlation exists among positive LTA score, cytokine levels, and HSR occurrence. The final goal is to determine whether these measures could be used to predict the likelihood of a patient to experience an HSR during sulfonamide treatment. Such a predictive ability would be valuable to the clinician to know whether the patient would tolerate sulfonamides or whether an alternative antibiotic should be prescribed. The LTA showed a good correlation with the clinical involvement of patients with hypersensitivity syndromes. In addition, the pro-inflammatory cytokines presented significant differences in patients that had rash, fever, and organ involvement than in control patients or any of the other patient groups. Expression of tumor necrosis factor alpha (TNF-alpha) is significantly higher in patients presenting rash, fever, and organ involvement versus all other groups. It is concluded that a positive LTA is a predictor for sulfonamide-induced true HSR. In addition, T-helper cell 1 cytokines [TNF-alpha, interleukins (ILs) 1 and 2] as well as the chemokine regulated upon activation, normal T-cell expressed and secreted (RANTES) control the pathogenesis of sulfonamide-induced HSR and may be used in early diagnosis of the syndrome.

Late outcomes in adult survivors of toxic epidermal necrolysis after treatment in a burn center.

Despite improved survival after burn center treatment for patients with toxic epidermal necrolysis (TEN), little is known about the overall long-term outcomes in these patients. In this work we sought to analyze late outcomes in survivors of TEN who were treated in our burn center. Subjects completed a questionnaire that included the RAND 36-Item Health Survey (SF-36) and the Dermatology Life Quality Index. Subjects were examined, when possible, and completed the Functional Independence Measure. Scores on the SF-36 were compared with age- and sex-matched National normative data. All results are presented as the mean +/- SD. Of 35 adults admitted with TEN between January 1, 1995, and January 6, 2003, 10 have died in hospital, 4 have died since discharge, and 8 have been lost to follow-up, leaving a study population of 13 subjects (age 45 +/- 18 years with initial %TBSA involvement 65 +/- 29). Follow-up occurred at 38 +/- 27 months after discharge. The most common ophthalmic problems were chronic photosensitivity (54%) and dry eyes (31%). The Dermatology Life Quality Index (maximum-worst score = 30) was 9 +/- 10. SF-36 scores were significantly lower than in the age- and sex-matched normal population across all domains except mental health. The Functional Independence Measure score (maximum-best score = 126) was 123 +/- 4. Survivors of TEN demonstrate a high level of independent function in activities of daily living, but numerous complications of TEN significantly impair their overall quality of life, emphasizing the need for long-term follow-up.

An electron microscopic and morphometric study of ursodeoxycholic effect in primary biliary cirrhosis.

BACKGROUND/AIMS: Primary biliary cirrhosis (PBC) is a chronic liver disease that results in cholestasis and bile duct loss. Ursodeoxycholic acid (UDCA) has been shown to reduce hepatocellular damage in PBC. The study attempted to quantify perisinusoidal collagenization and the number of apoptotic bodies in PBC liver biopsies from patients in a randomized control trial treated with UDCA compared to those who received placebo. METHODS: Twenty-eight patients with PBC (10 cirrhotic, 18 non-cirrhotic; 13 treated with UDCA, 15 treated with placebo) were compared with 32 controls with normal hepatic histology on light microscopy. Liver biopsies were examined for degree of perisinusoidal fibrosis and apoptotic activity using electron microscopy. RESULTS: The degree of perisinusoidal fibrosis and apoptotic activity was similar in pretreatment biopsies of UDCA and placebo-treated patients. After two years of placebo, patients showed a significant increase in fibrosis (P < 0.001). In contrast, there were no changes in non-cirrhotic and a decrease in fibrosis in cirrhotic patients given UDCA. At baseline, PBC patients had higher numbers (apoptotic cells/100 hepatocytes +/- SE) of apoptotic cells (7 +/- 3), than controls (2 +/- 0.5) (P < 0.05), with no difference between cirrhotic and non-cirrhotic patients in the two groups of patients. After two years, the numbers of apoptotic cells in UDCA-treated patients decreased significantly compared to baseline (3 +/- 2) (P < 0.05); with placebo patients the number of apoptotic cells increased (12 +/- 5) (P < 0.05). CONCLUSION: Treatment with UDCA prevents the deposition of perisinusoidal collagen and reduces the apoptotic activity in PBC patients after 2 years of therapy.

Ethanol signals for apoptosis in cultured skin cells.

Ethanol is commonly used in cosmetic and pharmaceutical preparations. To test whether ethanol may cause apoptosis in skin cells, we treated A431 epidermoid skin cells and neonatal human primary skin cells with different concentrations of ethanol, for different time periods. Ethanol was toxic to cells in both a dose- and time-dependent manner and increased the percentage of cells undergoing apoptosis. Treatment of cells with 40 and 100 mM ethanol increased release of the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) into culture medium and increased its expression in cells. The TNF-alpha was toxic to A431 epidermoid skin cells at concentrations similar to those released by cells on exposure to ethanol. Ethanol-treated cells examined by electron microscopy showed organelle damage, condensed chromatin, and apoptotic bodies. Therefore, even at low concentrations, ethanol may induce apoptosis in skin cells by enhancing the effects of TNF-alpha.

Tumor necrosis factor-alpha and transforming growth factor-beta reflect severity of liver damage in primary biliary cirrhosis.

BACKGROUND AND AIMS: The pathogenesis of primary biliary cirrhosis (PBC) is unknown. The role of cytokines such as tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta (TGF-beta), and the effect of ursodeoxycholic acid (UDCA) in modifying the cytokine environment in patients with PBC has remained largely unstudied. Our aims were to determine: (i) the relationship between serum levels of TNF-alpha and TGF-beta and the severity of PBC; and (ii) the effects of UDCA therapy on TNF-alpha and TGF-beta levels in patients with PBC. METHODS: We studied 90 patients who had been treated with UDCA (53 patients) or placebo (37 patients) for 2 years as part of a randomized, double-blind, controlled trial. Patients were divided into histological stage I/II or stage III/IV disease. Serum TNF-alpha and TGF-beta levels were quantified by enzyme-linked immunoabsorbent assay. RESULTS: Baseline levels of TNF-alpha were significantly greater in patients with stage III/IV compared to stage I/II disease. After 2 years of treatment with UDCA, patients showed a significantly greater decrease in TNF-alpha levels and progression risk score compared to placebo-treated patients. TNF-alpha and TGF-beta levels were significantly reduced compared to baseline levels in the UDCA-treated group after 2 years, while there was no significant change in the levels of placebo-treated patients. CONCLUSIONS: Serum TNF-alpha and TGF-beta levels may reflect severity of disease in patients with PBC. The beneficial effects of UDCA therapy may be explained by lowering serum levels of these two cytokines.