Caring for the invisible and forgotten: a qualitative document analysis and experience-based co-design project to improve the care of families experiencing out-of-hospital cardiac arrest.

OBJECTIVES: The objectives of this project were to collect and analyze clinical governance documents related to family-centred care and cardiac arrest care in Canadian EMS organizations; and to improve the family-centredness of out-of-hospital cardiac arrest care through experience-based co-design. METHODS: We conducted qualitative document analysis of Canadian EMS clinical governance documents related to family-centred and cardiac arrest care, combining elements of content and thematic analysis methods. We then used experience-based co-design to develop a family-centred out-of-hospital cardiac arrest care policy and procedure template. RESULTS: Thirty-five Canadian EMS organizations responded to our requests, representing service area coverage for 80% of the Canadian population. Twenty documents were obtained for review and six overarching themes were identified: addressing family in event of in-home death, importance of family, family member escort, provider discretion and family presence discouraged. Informed by our qualitative analysis we then co-designed a policy and procedure template was created that prioritizes patient care while promotes family-centredness. CONCLUSIONS: There were few directives to support family-centred care by Canadian EMS organizations. A family-centred out-of-hospital cardiac arrest care policy and procedure template was developed using experience-based co-design to assist EMS organizations improve the family-centredness of out-of-hospital cardiac arrest care.

RéSUMé: OBJECTIFS: Les objectifs de ce projet étaient de recueillir et d'analyser des documents de gouvernance clinique liés aux soins centrés sur la famille et aux soins de l'arrêt cardiaque dans les organisations canadiennes de SMU; et d'améliorer le caractère centré sur la famille des soins en cas d'arrêt cardiaque à l'extérieur de l'hôpital grâce à une co-conception fondée sur l'expérience. MéTHODES: Nous avons effectué une analyse qualitative des documents de gouvernance clinique des SMU canadiens liés aux soins axés sur la famille et aux arrêts cardiaques, en combinant des éléments de contenu et des méthodes d'analyse thématique. Nous avons ensuite utilisé la co-conception fondée sur l'expérience pour élaborer un modèle de politique et de procédure de soins en cas d'arrêt cardiaque centrés sur la famille en dehors de l'hôpital. RéSULTATS: Trente-cinq organisations Canadiennes de SMU ont répondu à nos demandes, ce qui représente une couverture de zone de service pour 80 % de la population canadienne. Vingt documents ont été obtenus aux fins d'examen et six thèmes principaux ont été cernés: s'adresser à la famille en cas de décès à domicile, l'importance de la famille, accompagnement d'un membre de la famille, la discrétion du fournisseur et la présence de la famille découragée. Éclairés par notre analyse qualitative, nous avons ensuite co-conçu un modèle de politique et de procédure qui priorise les soins aux patients tout en favorisant l'orientation familial. CONCLUSIONS: Il y avait peu de directives pour soutenir les soins axés sur la famille par les organisations canadiennes de SMU. Un modèle de politique de soins d'arrêt cardiaque centré sur la famille a été élaboré à l'aide d'une co-conception basée sur l'expérience pour aider les organisations de SMU à améliorer l'orientation familiale des soins en cas d'arrêt cardiaque hors hôpital.

Near-zero-index ultra-fast pulse characterization.

Transparent conducting oxides exhibit giant optical nonlinearities in the near-infrared window where their linear index approaches zero. Despite the magnitude and speed of these nonlinearities, a "killer" optical application for these compounds has yet to be found. Because of the absorptive nature of the typically used intraband transitions, out-of-plane configurations with short optical paths should be considered. In this direction, we propose an alternative frequency-resolved optical gating scheme for the characterization of ultra-fast optical pulses that exploits near-zero-index aluminium zinc oxide thin films. Besides the technological advantages in terms of manufacturability and cost, our system outperforms commercial modules in key metrics, such as operational bandwidth, sensitivity, and robustness. The performance enhancement comes with the additional benefit of simultaneous self-phase-matched second and third harmonic generation. Because of the fundamental importance of novel methodologies to characterise ultra-fast events, our solution could be of fundamental use for numerous research labs and industries.

Adolescent perspectives of bedtime social media use: A qualitative systematic review and thematic synthesis.

Adolescence is often characterised by changes in sleep patterns, with reports that the average adolescent does not get the recommended sleep time. Recent qualitative research has identified the use of electronics at bedtime and engagement with social media platforms as barriers to gaining sufficient time and quality of sleep during adolescence. A systematic review and thematic synthesis was undertaken following the three-step thematic synthesis framework. Four databases were searched, and full texts were screened based on pre-existing inclusion/exclusion criteria. Fourteen studies were included, encompassing 967 participants. Three analytical themes were developed: 1) social motivations; 2) habitual smartphone use and 3) recognition of a problem. Findings confirmed how bedtime social media use requires a new framework for recognising the importance of peer relations, where increased frequency and immediacy of communication lays the foundation for social accountability to meet communicative norms and fear of missing out. In the review, adolescents commonly express a lack of control in relation to their social media use which triggered discussion of the habitual aspects of bedtime social media use. The importance of intervention strategies which recognise the wider peer-to-peer social implications of bedtime social media use is discussed with some practical insights offered.

Ultrafast photochemistry produces superbright short-wave infrared dots for low-dose in vivo imaging.

Optical probes operating in the second near-infrared window (NIR-II, 1,000-1,700 nm), where tissues are highly transparent, have expanded the applicability of fluorescence in the biomedical field. NIR-II fluorescence enables deep-tissue imaging with micrometric resolution in animal models, but is limited by the low brightness of NIR-II probes, which prevents imaging at low excitation intensities and fluorophore concentrations. Here, we present a new generation of probes (Ag2S superdots) derived from chemically synthesized Ag2S dots, on which a protective shell is grown by femtosecond laser irradiation. This shell reduces the structural defects, causing an 80-fold enhancement of the quantum yield. PEGylated Ag2S superdots enable deep-tissue in vivo imaging at low excitation intensities (<10 mW cm-2) and doses (<0.5 mg kg-1), emerging as unrivaled contrast agents for NIR-II preclinical bioimaging. These results establish an approach for developing superbright NIR-II contrast agents based on the synergy between chemical synthesis and ultrafast laser processing.

Publisher Correction: Femtosecond laser fabrication of silver nanostructures on glass for surface enhanced Raman spectroscopy.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A Randomized Crossover Trial of Conventional versus Modified "Koch" Chest Compressions in a Height-Restricted Aeromedical Helicopter.

Aim: Low overhead height can negatively affect chest compression performance. An adapted compression technique has been proposed by paramedic H. Koch (pron. "Cook"). This study compares conventional to Koch technique in a height-restricted aeromedical helicopter. Methods: Eighteen clinicians were randomized to 2 minutes of conventional or Koch compressions, then crossed-over. Koch technique uses a forearm/elbow instead of overlapping hands. Compression quality was assessed with a Skill Reporting Laerdal Resusci-Anne manikin. Quality variables were: the number and rate of compressions, compression depth, release, land marking, and overall aggregate quality score. Participant feedback was collected using the Borg Scale of Perceived Exertion, and compression difficulty using a zero-to-ten scale. Furthermore, we solicited open-ended descriptive responses. Results: The average overall quality score was 63% for conventional compressions versus 79% for Koch compressions (p = 0.04). On average, the Koch compression method increased compression depth by 5 mm (95% CI 4.3 to 5.7) and the proportion of compressions at the correct depth by 17% (95% CI 7.55 to 26.45), although these were not statistically significant. Correct release and land marking showed no statistically significant difference between techniques. Koch compressions resulted in statistically significant reductions in physical exertion and difficulty (p < 0.001). Qualitative feedback described modified compressions as easier and more sustainable. Conclusions: In a height-restricted aeromedical helicopter, the average overall quality score improved using Koch compressions, although the mean rate, mean depth, correct release and land marking were found to be similar between techniques. Qualitative feedback described Koch compressions as easier and more sustainable. In settings where the compressor is affected by reduced overhead working height, Koch compressions may be an advisable alternative.

Femtosecond laser fabrication of silver nanostructures on glass for surface enhanced Raman spectroscopy.

We report on an optimized fabrication protocol for obtaining silver nanoparticles on fused silica substrates via laser photoreduction of a silver salt solution. We find that multiple scans of the laser over the surface leads to a more uniform coverage of densely packed silver nanoparticles of approximately 50 nm diameter on the fused silica surface. Our substrates yield Raman enhancement factors of the order of 1011 of the signal detected from crystal violet. We use a theoretical model based on scanning electron microscope (SEM) images of our substrates to explain our experimental results. We also demonstrate how our technique can be extended to embedding silver nanoparticles in buried microfluidic channels in glass. The in situ laser inscription of silver nanoparticles on a laser machined, sub-surface, microfluidic channel wall within bulk glass paves the way for developing 3D, monolithic, fused silica surface enhance Raman spectroscopy (SERS) microfluidic sensing devices.

Rapid Laser Manufacturing of Microfluidic Devices from Glass Substrates.

Conventional manufacturing of microfluidic devices from glass substrates is a complex, multi-step process that involves different fabrication techniques and tools. Hence, it is time-consuming and expensive, in particular for the prototyping of microfluidic devices in low quantities. This article describes a laser-based process that enables the rapid manufacturing of enclosed micro-structures by laser micromachining and microwelding of two 1.1-mm-thick borosilicate glass plates. The fabrication process was carried out only with a picosecond laser (Trumpf TruMicro 5×50) that was used for: (a) the generation of microfluidic patterns on glass, (b) the drilling of inlet/outlet ports into the material, and (c) the bonding of two glass plates together in order to enclose the laser-generated microstructures. Using this manufacturing approach, a fully-functional microfluidic device can be fabricated in less than two hours. Initial fluid flow experiments proved that the laser-generated microstructures are completely sealed; thus, they show a potential use in many industrial and scientific areas. This includes geological and petroleum engineering research, where such microfluidic devices can be used to investigate single-phase and multi-phase flow of various fluids (such as brine, oil, and CO2) in porous media.

Professional Competencies ToolKit: Using Flash Cards to Teach Reflective Practice to Medical Students in Clinical Clerkship.

Introduction: Early clinical experiences can be overwhelming to medical students. The Professional Competencies ToolKit (ProComp ToolKit) gives medical students a framework on which to build these early experiences and reflect on issues related to professionalism as each patient encounter unfolds. Methods: The ProComp ToolKit is a set of 28 flash cards, grouped within six domains of professional competency. Each flash card is a tool for learning, defining a topic in a catchy title and laying out a specific set of skills to be acquired within the clinical setting. Tasks and tips on each flash card guide students through the process of clinical observation, self-observation, and patient interactions. Students meet in small groups with facilitators every 2 weeks throughout the year to discuss these experiences. At the end of the year, students write a narrative based on the flash card that was most meaningful to their professional identity development. Results: We demonstrated how the student narratives that emerged from using the flash cards, exchanged in a small-group setting, led to group problem solving and validation of students' experiences and values. In the narratives, students discussed the origin of negative behaviors and attitudes that can become normalized in patient care while asserting the primacy of patient-centered care and devising self-awareness strategies. Discussion: Our experience using the ProComp ToolKit shows that teaching reflective practice can successfully be integrated into students' clinical experiences. Professionalism skills can be reflected upon such that they become habitual and integral to students' developing professional identities.

Learning From Patients: Why Continuity Matters.

PURPOSE: Patient continuity, described as the student participating in the provision of comprehensive care of patients over time, may offer particular opportunities for student learning. The aim of this study was to describe how students experience patient continuity and what they learn from it. METHOD: An interpretive phenomenological study was conducted between 2015 and 2016. Seventeen fourth-year medical students were interviewed following a longitudinal clinical placement and asked to describe their experiences of patient continuity and what they learned from each experience. Transcripts were analyzed by iteratively refining and testing codes, using health system definitions of patient continuity as sensitizing concepts to develop descriptive themes. RESULTS: Students described three different forms of patient continuity. Continuity of care, or relational continuity, enabled students to build trusting and professional relationships with their patients. Geographical continuity allowed students to access information about patients from electronic records and their preceptors which allowed students to achieve diagnostic closure and learn to reevaluate their decisions. Students valued the learning that accrued from following challenging patients and addressing challenging decisions over time. Although difficult, these patient continuity experiences led students to critical reflection that was both iterative and deep, leading to intentions for future behavior. CONCLUSIONS: Patient continuity in medical education does not depend solely on face-to-face continuity. Within various patient continuity experiences, following challenging patients and experiencing unanticipated diagnostic and management outcomes trigger critical reflection in students, leading to deep learning.

Utilization Criteria for Prehospital Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service: Determining Who Might Benefit.

Introduction Prehospital ultrasound (PHUS) assessments by physicians and non-physicians are performed on medical and trauma patients with increasing frequency. Prehospital ultrasound has been shown to be of benefit by supporting interventions. Problem Which patients may benefit from PHUS has not been clearly identified. METHODS: A multi-variable logistic regression analysis was performed on a previously created retrospective dataset of five years of physician- and non-physician-performed ultrasound scans in a Canadian critical care Helicopter Emergency Medical Service (HEMS). For separate medical and trauma patient groups, the a-priori outcome assessed was patient characteristics associated with the outcome variable of "PHUS-supported intervention." RESULTS: Both models were assessed (Likelihood Ratio, Score, and Wald) as a good fit. For medical patients, the characteristics of heart rate (HR) and shock index (SI) were found to be most significant for an intervention being supported by PHUS. An extremely low HR was found to be the most significant (OR=15.86 [95% confidence interval (CI), 1.46-171.73]; P=.02). The higher the SI, the more likely that an intervention was supported by PHUS (SI 0.9 to<1.3: OR=9.15 [95% CI, 1.36-61.69]; P=.02; and SI 1.3+: OR=8.37 [95% CI, 0.69-101.66]; P=.09). For trauma patients, the characteristics of Prehospital Index (PHI) and SI were found to be most significant for PHUS support. The greatest effect was PHI, where increasing ORs were seen with increasing PHI (PHI 14-19: OR=13.36 [95% CI, 1.92-92.81]; P=.008; and PHI 20-24: OR=53.10 [95% CI, 4.83-583.86]; P=.001). Shock index was found to be similar, though, with lower impact and significance (SI 0.9 to<1.3: OR=9.11 [95% CI, 1.31-63.32]; P=.025; and SI 1.3+: OR=35.75 [95% CI, 2.51-509.81]; P=.008). CONCLUSIONS: In a critical care HEMS, markers of higher patient acuity in both medical and trauma patients were associated with occurrences when an intervention was supported by PHUS. Prospective study with in-hospital follow-up is required to confirm these hypothesis-generating results. O'Dochartaigh D , Douma M , Alexiu C , Ryan S , MacKenzie M . Utilization criteria for prehospital ultrasound in a Canadian critical care Helicopter Emergency Medical Service: determining who might benefit. Prehosp Disaster Med. 2017;32(5):536-540.

Five-year Retrospective Review of Physician and Non-physician Performed Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service.

OBJECTIVE: To describe the use of prehospital ultrasonography (PHUS) to support interventions, when used by physician and non-physician air medical crew (AMC), in a Canadian helicopter emergency medical service (HEMS). METHODS: A retrospective review was conducted of consecutive patients who underwent ultrasound examination during HEMS care from January 1, 2009 through March 10, 2014. An a priori created data form was used to record patient demographics, type of ultrasound scan performed, ultrasound findings, location of scan, type of interventions supported by PHUS, factors that affected PHUS completion, and quality indicator(s). Data analysis was performed through descriptive statistics, Student's t-test for continuous variables, Z-test for proportions, and Mann-Whitney U Test for nonparametric data. Outcomes included interventions supported by PHUS, factors associated with incomplete scans, and quality indicators associated with PHUS use. Differences between physician and AMC groups were also assessed. RESULTS: PHUS was used in 455 missions, 318 by AMC and 137 by physicians. In combined trauma and medical patients, in the AMC group interventions were supported by PHUS in 26% of cases (95% CI 18-34). For transport physicians the percentage support was found to be significantly greater at 45% of cases (95% CI 34-56) p = < 0.006. Incomplete PHUS scans were common and reasons included patient obesity, lack of time, patient access, and clinical reasons. Quality indicators associated with PHUS were rarely identified. CONCLUSIONS: The use of PHUS by both physicians and non-physicians was found to support interventions in select trauma and medical patients. Key words: emergency medical services; aircraft; helicopter; air ambulance; ultrasonography; emergency care, prehospital; prehospital emergency care.

Slanted channel microfluidic chip for 3D fluorescence imaging of cells in flow.

Three-dimensional cellular imaging techniques have become indispensable tools in biological research and medical diagnostics. Conventional 3D imaging approaches employ focal stack collection to image different planes of the cell. In this work, we present the design and fabrication of a slanted channel microfluidic chip for 3D fluorescence imaging of cells in flow. The approach employs slanted microfluidic channels fabricated in glass using ultrafast laser inscription. The slanted nature of the microfluidic channels ensures that samples come into and go out of focus, as they pass through the microscope imaging field of view. This novel approach enables the collection of focal stacks in a straight-forward and automated manner, even with off-the-shelf microscopes that are not equipped with any motorized translation/rotation sample stages. The presented approach not only simplifies conventional focal stack collection, but also enhances the capabilities of a regular widefield fluorescence microscope to match the features of a sophisticated confocal microscope. We demonstrate the retrieval of sectioned slices of microspheres and cells, with the use of computational algorithms to enhance the signal-to-noise ratio (SNR) in the collected raw images. The retrieved sectioned images have been used to visualize fluorescent microspheres and bovine sperm cell nucleus in 3D while using a regular widefield fluorescence microscope. We have been able to achieve sectioning of approximately 200 slices per cell, which corresponds to a spatial translation of ∼ 15 nm per slice along the optical axis of the microscope.

Determining the 3D orientation of optically trapped upconverting nanorods by in situ single-particle polarized spectroscopy.

An approach to unequivocally determine the three-dimensional orientation of optically manipulated NaYF4:Er(3+),Yb(3+) upconverting nanorods (UCNRs) is demonstrated. Long-term immobilization of individual UCNRs inside single and multiple resonant optical traps allow for stable single UCNR spectroscopy studies. Based on the strong polarization dependent upconverted luminescence of UCNRs it is possible to unequivocally determine, in real time, their three-dimensional orientation when optically trapped. In single-beam traps, polarized single particle spectroscopy has concluded that UCNRs orientate parallel to the propagation axis of the trapping beam. On the other hand, when multiple-beam optical tweezers are used, single particle polarization spectroscopy demonstrated how full spatial control over UCNR orientation can be achieved by changing the trap-to-trap distance as well as the relative orientation between optical traps. All these results show the possibility of real time three-dimensional manipulation and tracking of anisotropic nanoparticles with wide potential application in modern nanobiophotonics.

Mannitol dosing error during interfacility transfer for intracranial emergencies.

OBJECT: Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury. METHODS: The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status. RESULTS: A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3-13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (<0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (>1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (>1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%). CONCLUSIONS: Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.

Cattle-derived microbial input to source water catchments: An experimental assessment of stream crossing modification.

The provision of safe drinking water is a global issue, and animal production is recognized as a significant potential origin of human infectious pathogenic microorganisms within source water catchments. On-farm management can be used to mitigate livestock-derived microbial pollution in source water catchments to reduce the risk of contamination to potable water supplies. We applied a modified Before-After Control Impact (BACI) design to test if restricting the access of livestock to direct contact with streams prevented longitudinal increases in the concentrations of faecal indicator bacteria and suspended solids. Significant longitudinal increases in pollutant concentrations were detected between upstream and downstream reaches of the control crossing, whereas such increases were not detected at the treatment crossing. Therefore, while the crossing upgrade was effective in preventing cattle-derived point source pollution by between 112 and 158%, diffuse source pollution to water supplies from livestock is not ameliorated by this intervention alone. Our findings indicate that stream crossings that prevent direct contact between livestock and waterways provide a simple method for reducing pollutant loads in source water catchments, which ultimately minimises the likelihood of pathogenic microorganisms passing through source water catchments and the drinking water supply system. The efficacy of the catchment as a primary barrier to pathogenic risks to drinking water supplies would be improved with the integration of management interventions that minimise direct contact between livestock and waterways, combined with the mitigation of diffuse sources of livestock-derived faecal matter from farmland runoff to the aquatic environment.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

INTRODUCTION: Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. HYPOTHESIS/PROBLEM: The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. METHODS: A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. RESULTS: From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). CONCLUSION: Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

Developing interprofessional health competencies in a virtual world.

BACKGROUND: Virtual worlds provide a promising means of delivering simulations for developing interprofessional health skills. However, developing and implementing a virtual world simulation is a challenging process, in part because of the novelty of virtual worlds as a simulation platform and also because of the degree of collaboration required among technical and subject experts. Thus, it can be difficult to ensure that the simulation is both technically satisfactory and educationally appropriate. METHODS: To address this challenge, we propose the use of de Freitas and Oliver's four-dimensional framework as a means of guiding the development process. We give an overview of the framework and describe how its principles can be applied to the development of virtual world simulations. RESULTS: We present two virtual world simulation pilot projects that adopted this approach, and describe our development experience in these projects. We directly connect this experience to the four-dimensional framework, thus validating the framework's applicability to the projects and to the context of virtual world simulations in general. CONCLUSIONS: We present a series of recommendations for developing virtual world simulations for interprofessional health education. These recommendations are based on the four-dimensional framework and are also informed by our experience with the pilot projects.

Twelve tips for teaching in a provincially distributed medical education program.

BACKGROUND: As distributed undergraduate and postgraduate medical education becomes more common, the challenges with the teaching and learning process also increase. AIM: To collaboratively engage front line teachers in improving teaching in a distributed medical program. METHOD: We recently conducted a contest on teaching tips in a provincially distributed medical education program and received entries from faculty and resident teachers. RESULTS: Tips that are helpful for teaching around clinical cases at distributed teaching sites include: ask "what if" questions to maximize clinical teaching opportunities, try the 5-min short snapper, multitask to allow direct observation, create dedicated time for feedback, there are really no stupid questions, and work with heterogeneous group of learners. Tips that are helpful for multi-site classroom teaching include: promote teacher-learner connectivity, optimize the long distance working relationship, use the reality television show model to maximize retention and captivate learners, include less teaching content if possible, tell learners what you are teaching and make it relevant and turn on the technology tap to fill the knowledge gap. CONCLUSION: Overall, the above-mentioned tips offered by front line teachers can be helpful in distributed medical education.

Physical stability and resistance to peroxidation of a range of liquid-fill hard gelatin capsule products on extreme long-term storage.

BACKGROUND: The industrial take-up of liquid-fill hard capsule technology is limited in part by lack of published long-term physical and chemical stability data which demonstrate the robustness of the system. OBJECTIVE: To assess the effects of extreme long-term storage on liquid-fill capsule product quality and integrity, with respect to both the capsules per se and a standard blister-pack type (foil-film blister). MATERIALS AND METHODS: Fourteen sets of stored peroxidation-sensitive liquid-fill hard gelatin capsule product samples, originating ~20 years from the current study, were examined with respect to physical and selected chemical properties, together with microbiological evaluation. RESULTS AND DISCUSSION: All sets retained physical integrity of capsules and blister-packs. Capsules were free of leaks, gelatin cross-linking, and microbiological growth. Eight samples met a limit (anisidine value, 20) commonly used as an index of peroxidation for lipid-based products with shelf lives of 2-3 years. Foil-film blister-packs using PVC or PVC-PVdC as the thermoforming film were well-suited packaging components for the liquid-fill capsule format. CONCLUSION: The study confirms the long-term physical robustness of the liquid-fill hard capsule format, together with its manufacturing and banding processes. It also indicates that various peroxidation-sensitive products using the capsule format may be maintained satisfactorily over very prolonged storage periods.