Workload of Team Leaders and Team Members During a Simulated Sepsis Scenario.

OBJECTIVES: Crisis resource management principles dictate appropriate distribution of mental and/or physical workload so as not to overwhelm any one team member. Workload during pediatric emergencies is not well studied. The National Aeronautics and Space Administration-Task Load Index is a multidimensional tool designed to assess workload validated in multiple settings. Low workload is defined as less than 40, moderate 40-60, and greater than 60 signify high workloads. Our hypothesis is that workload among both team leaders and team members is moderate to high during a simulated pediatric sepsis scenario and that team leaders would have a higher workload than team members. DESIGN: Multicenter observational study. SETTING: Nine pediatric simulation centers (five United States, three Canada, and one United Kingdom). PATIENTS: Team leaders and team members during a 12-minute pediatric sepsis scenario. INTERVENTIONS: National Aeronautics and Space Administration-Task Load Index. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-seven teams were recruited from nine sites. One hundred twenty-seven team leaders and 253 team members completed the National Aeronautics and Space Administration-Task Load Index. Team leader had significantly higher overall workload than team member (51 ± 11 vs 44 ± 13; p < 0.01). Team leader had higher workloads in all subcategories except in performance where the values were equal and in physical demand where team members were higher than team leaders (29 ± 22 vs 18 ± 16; p < 0.01). The highest category for each group was mental 73 ± 13 for team leader and 60 ± 20 for team member. For team leader, two categories, mental (73 ± 17) and effort (66 ± 16), were high workload, most domains for team member were moderate workload levels. CONCLUSIONS: Team leader and team member are under moderate workloads during a pediatric sepsis scenario with team leader under high workloads (> 60) in the mental demand and effort subscales. Team leader average significantly higher workloads. Consideration of decreasing team leader responsibilities may improve team workload distribution.

Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial.

IMPORTANCE: The quality of cardiopulmonary resuscitation (CPR) affects hemodynamics, survival, and neurological outcomes following pediatric cardiopulmonary arrest (CPA). Most health care professionals fail to perform CPR within established American Heart Association guidelines. OBJECTIVE: To determine whether "just-in-time" (JIT) CPR training with visual feedback (VisF) before CPA or real-time VisF during CPA improves the quality of chest compressions (CCs) during simulated CPA. DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized, 2 × 2 factorial-design trial with explicit methods (July 1, 2012, to April 15, 2014) at 10 International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) institutions running a standardized simulated CPA scenario, including 324 CPR-certified health care professionals assigned to 3-person resuscitation teams (108 teams). INTERVENTIONS: Each team was randomized to 1 of 4 permutations, including JIT training vs no JIT training before CPA and real-time VisF vs no real-time VisF during simulated CPA. MAIN OUTCOMES AND MEASURES: The proportion of CCs with depth exceeding 50 mm, the proportion of CPR time with a CC rate of 100 to 120 per minute, and CC fraction (percentage CPR time) during simulated CPA. RESULTS: The quality of CPR was poor in the control group, with 12.7% (95% CI, 5.2%-20.1%) mean depth compliance and 27.1% (95% CI, 14.2%-40.1%) mean rate compliance. JIT training compared with no JIT training improved depth compliance by 19.9% (95% CI, 11.1%-28.7%; P < .001) and rate compliance by 12.0% (95% CI, 0.8%-23.2%; P = .037). Visual feedback compared with no VisF improved depth compliance by 15.4% (95% CI, 6.6%-24.2%; P = .001) and rate compliance by 40.1% (95% CI, 28.8%-51.3%; P < .001). Neither intervention had a statistically significant effect on CC fraction, which was excellent (>89.0%) in all groups. Combining both interventions showed the highest compliance with American Heart Association guidelines but was not significantly better than either intervention in isolation. CONCLUSIONS AND RELEVANCE: The quality of CPR provided by health care professionals is poor. Using novel and practical technology, JIT training before CPA or real-time VisF during CPA, alone or in combination, improves compliance with American Heart Association guidelines for CPR that are associated with better outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02075450.

Training using medical simulation.

As the time available for medical education is shortened by reductions in training hours and the demands of modern healthcare delivery, educators are increasingly looking towards simulation as a means of providing safe and reproducible situations for clinical skills teaching, decision-making and team training. The tools available for simulation-based training have developed rapidly over the past 15 years. There is an increasing range of manikins and part-task trainers - devices that permit selected elements of a skill or task to be practised independently of a whole-body manikin. Those interested in simulation have also focused significantly on adult learning theory to ensure that the training offered through simulation is appropriate, effective and complementary to other educational approaches. By mapping simulated scenarios to the Royal College of Paediatrics and Child Health Curriculum for General Paediatric Training at Level 1, the authors have developed two complementary courses aimed at preparing the general paediatric trainee for progression to the middle grade role. It is hoped that such approaches will become integral to paediatric training in the future.

Development of the orpheus perfusion simulator for use in high-fidelity extracorporeal membrane oxygenation simulation.

Despite its life-sustaining potential, extracorporeal membrane oxygenation (ECMO) remains a complex treatment modality for which close teamwork is imperative with a high risk of adverse events leading to significant morbidity and mortality. The provision of adequate training and continuing education is key in mitigating these risks. Traditional training for ECMO has relied predominantly on didactic education and hands-on water drills. These methods may overemphasize cognitive skills while underemphasizing technical skills and completely ignoring team and human factor skills. These water drills are often static, lacking the time pressure, typical alarms, and a sense of urgency inherent to actual critical ECMO scenarios. Simulation-based training provides an opportunity for staff to develop and maintain technical proficiency in high-risk, infrequent events without fear of harming patients. In addition, it provides opportunities for interdisciplinary training and improved communication and teamwork among team members (1). Although simulation has become widely accepted for training of practitioners from many disciplines, there are currently, to our knowledge, no commercially available dedicated high-fidelity ECMO simulators. Our article describes the modification of the Orpheus Perfusion Simulator and its incorporation into a fully immersive, high-fidelity, point-of-care ECMO simulation model.

Thermodynamics, molecular mobility and crystallization kinetics of amorphous griseofulvin.

Griseofulvin is a small rigid molecule that shows relatively high molecular mobility and small configurational entropy in the amorphous phase and tends to readily crystallize from both rubbery and glassy states. This work examines the crystallization kinetics and mechanism of amorphous griseofulvin and the quantitative correlation between the rate of crystallization and molecular mobility above and below Tg. Amorphous griseofulvin was prepared by rapidly quenching the melt in liquid N2. The thermodynamics and dynamics of amorphous phase were then characterized using a combination of thermal analysis techniques. After characterization of the amorphous phase, crystallization kinetics above Tg were monitored by isothermal differential scanning calorimetry (DSC). Transformation curves for crystallization fit a second-order John-Mehl-Avrami (JMA) model. Crystallization kinetics below Tg were monitored by powder X-ray diffraction and fit to the second-order JMA model. Activation energies for crystallization were markedly different above and below Tg suggesting a change in mechanism. In both cases molecular mobility appeared to be partially involved in the rate-limiting step for crystallization, but the extent of correlation between the rate of crystallization and molecular mobility was different above and below Tg. A lower extent of correlation below Tg was observed which does not appear to be explained by the molecular mobility alone and the diminishing activation energy for crystallization suggests a change in the mechanism of crystallization.

Stable-form screening: overcoming trace impurities that inhibit solution-mediated phase transformation to the stable polymorph of sulfamerazine.

Solution-mediated phase transformation (SMPT) has been used as a focused technique to rapidly identify the stable polymorph of a given substance. Despite ample precedence for acetonitrile being a good solvent for SMPT of sulfamerazine (SMZ), samples from specific lots of SMZ failed to convert from Form I to Form II after suspension for 2 weeks in acetonitrile. In these lots, an acetyl derivative of SMZ was identified and shown to impede transformation to the stable polymorph. The inhibitory effect of this impurity on polymorphic conversion was overcome with practical adjustments to experimental procedure, which hastened the kinetics of SMPT. The critical factors considered were (1) modifying the solvent to increase solubility, (2) minimizing the level of impurity in the slurries, (3) pre-treatment of the solid to quickly reach maximum supersaturation, and (4) temperatures that optimized kinetics as well as the free energy difference between enantiotropically related polymorphs.

Influence of crystal structure on the tableting properties of n-alkyl 4-hydroxybenzoate esters (parabens).

Certain crystallographic features, such as the existence of slip planes, can greatly facilitate the ability of crystals to deform plastically. An investigation of the relationship between the slip planes and the tableting performance of the crystals of methyl, ethyl, n-propyl, and n-butyl 4-hydroxybenzoate (parabens) was conducted. The absence of slip planes in methyl paraben crystal structure results in significantly poorer tableting performance than the other three parabens. While slip planes are present in the crystal structures of ethyl, propyl, and butyl parabens, they exhibited different plasticity as confirmed by crystal free volume analysis, crystal nano-indentation hardness, and Heckel analysis. Sieved fraction, 150-250 microm, of each paraben powder was compressed into tablets under different conditions. Tablet tensile strength, porosity, and Indices of tableting performance (ITP) were obtained. Under the same compaction pressure, tablet tensile strength was higher for crystals with higher plasticity. Tableting performance, assessed using the ITP, also improved with increasing crystal plasticity. The results confirm that high levels of plasticity, which can result from the presence of slip planes in crystal lattice, plays a critical role in the formation of strong and intact tablets by means of powder compaction.

A calorimetric investigation of thermodynamic and molecular mobility contributions to the physical stability of two pharmaceutical glasses.

The purpose of this work was to investigate the contribution of thermodynamics and mobility to the physical stability of two pharmaceutical glasses with similar glass transition temperatures (Tg), by comparing configurational thermodynamic quantities and molecular relaxation time constants (tau) at temperatures below Tg. Ritonavir and nifedipine were chosen as model glasses because they show excellent and poor physical stability, respectively. Although ritonavir and nifedipine have similar Tg values (50 and 46 degrees C, respectively), amorphous ritonavir is quite stable while nifedipine has been reported to crystallize at temperatures as low as 40 degrees C below Tg. Modulated temperature differential scanning calorimetry (MTDSC) was used to characterize both crystalline phases and freshly prepared glasses. The glasses were then annealed at Tg-Ta = 25 degrees C while monitoring the extent of relaxation and heat capacity change as a function of time via MTDSC. Configurational thermodynamic quantities (Gc, Hc, and Sc) and molecular relaxation time constants, tau, were calculated from the calorimetric data. Interestingly, the Gibbs free energy driving force for crystallization was nearly identical for the two compounds. The largest differences were found in the configurational entropy (Sc) values for the fresh glasses and in the Sc values over time. Configurational entropy values were approximately 50% higher for ritonavir. The tau values of freshly prepared glasses indicated that both materials had similar initial mobility at the annealing temperatures and the temperature dependence of tau was approximately Arrhenius, regardless of age. Although initial tau values were similar, the tau values after 3 days annealing were approximately sixfold greater for ritonavir. The relatively poor physical stability of nifedipine compared to ritonavir is attributed to both the lower entropic barrier to crystallization for fresh and annealed glass, and higher molecular mobility in aged glasses of nifedipine. These observations below Tg are consistent with the previous work on physical stability of amorphous pharmaceuticals performed above Tg.

Influence of crystal structure on the compaction properties of n-alkyl 4-hydroxybenzoate esters (parabens).

PURPOSE: The aim of the study is to examine the influence of slip planes on the nanoindentation hardness and compaction properties of methyl, ethyl, n-propyl, and n-butyl 4-hydroxybenzoate (parabens). METHODS: Molecular modeling calculations, embodying the attachment energy concept, were performed to predict the slip planes in the crystal lattices, whereas the nanoindentation hardness of the crystals and the tensile strength of directly compressed compacts were measured. RESULTS: Unlike the other three parabens, methyl paraben has no slip planes in its crystal lattice, and its crystals showed greater nanoindentation hardness, corresponding to lower plasticity, whereas its tablets exhibited substantially lower tensile strength than those of ethyl, propyl, or butyl paraben. CONCLUSIONS: The nanoindentation hardness of the crystals and the tensile strength of directly compressed tablets were each found to correlate directly with the absence or presence of slip planes in the crystal structures of the parabens because slip planes confer greater plasticity. This work presents a molecular insight into the influence of crystal structural features on the tableting performance of molecular crystals in general and of crystalline pharmaceuticals in particular.

Quantitation of crystalline and amorphous forms of anhydrous neotame using 13C CPMAS NMR spectroscopy.

Although most drugs are formulated in the crystalline state, amorphous or other crystalline forms are often generated during the formulation process. The presence of other forms can dramatically affect the physical and chemical stability of the drug. The identification and quantitation of different forms of a drug is a significant analytical challenge, especially in a formulated product. The ability of solid-state 13C NMR spectroscopy with cross polarization (CP) and magic-angle spinning (MAS) to quantify the amounts of three of the multiple crystalline and amorphous forms of the artificial sweetener neotame is described. It was possible to quantify, in a mixture of two anhydrous polymorphic forms of neotame, the amount of each polymorph within 1-2%. In mixtures of amorphous and crystalline forms of neotame, the amorphous content could be determined within 5%. It was found that the crystalline standards that were used to prepare the mixtures were not pure crystalline forms, but rather a mixture of crystalline and amorphous forms. The effect of amorphous content in the crystalline standards on the overall quantitation of the two crystalline polymorphic forms is discussed. The importance of differences in relaxation parameters and CP efficiencies on quantifying mixtures of different forms using solid-state NMR spectroscopy is also addressed.

Similarity in structures of racemic and enantiomeric ibuprofen sodium dihydrates.

The crystal structures of two ibuprofen sodium dihydrates, racemic sodium (RS)-2-(4-isobutylphenyl)propanoate dihydrate or (RS)-NaIBDH, Na+.C13H17O2-.2H2O, and enantiomeric sodium (S)-2-(4-isobutylphenyl)propanoate dihydrate or (S)-NaIBDH, Na+.C13H17O2-.2H2O, have been determined in the space groups P-1 and P1, respectively. The unit cells of the two triclinic structures have similar lattice parameters and cell volumes. The constituent ions have similar coordination environments, but differ slightly in their hydrogen-bonding interactions. The dominance of the interactions between the O atoms and the Na+ cations explains the structural similarity of these two structures, despite the fact that one is heterochiral while the other is homochiral.

Identifying the stable polymorph early in the drug discovery-development process.

The thermodynamically most stable polymorph under ambient conditions is almost without exception the most desirable crystalline form for development by a pharmaceutical company. It is, therefore, beneficial to discover and to characterize this polymorph at the earliest possible stage of development. A screen for discovering the stable polymorph of a pharmaceutical compound early in the drug discovery-development process is developed and described. In this screen, a small amount of compound is suspended in a diverse group of solvents for two weeks in an effort to crystallize the most stable polymorph. The solubility of the compound in each solvent utilized in the stable polymorph screen is also simultaneously determined using a simple gravimetric method. Ritonavir and an early development candidate (Pfizer compound A) are used as model compounds to demonstrate the utility of the screen for finding the stable polymorph early in the drug discovery-development process.

Mechanochromism of piroxicam accompanied by intermolecular proton transfer probed by spectroscopic methods and solid-phase changes.

Structural and solid-state changes of piroxicam in its crystalline form under mechanical stress were investigated using cryogenic grinding, powder X-ray diffractometry, diffuse-reflectance solid-state ultraviolet-visible spectroscopy, variable-temperature solid-state (13)C nuclear magnetic resonance spectroscopy, and solid-state diffuse-reflectance infrared Fourier transform spectroscopy. Crystalline piroxicam anhydrate exists as colorless single crystals irrespective of the polymorphic form and contains neutral piroxicam molecules. Under mechanical stress, these crystals become yellow amorphous piroxicam, which has a strong propensity to recrystallize to a colorless crystalline phase. The yellow color of amorphous piroxicam is attributed to charged piroxicam molecules. Variable-temperature solid-state (13)C NMR spectroscopy indicates that most of the amorphous piroxicam consists of neutral piroxicam molecules; the charged species comprise only about 8% of the amorphous phase. This ability to quantify the fractions of charged and neutral molecules of piroxicam in the amorphous phase highlights the unique capability of solid-state NMR to quantify mixtures in the absence of standards. Other compounds of piroxicam, which are yellow, are known to contain zwitterionic piroxicam molecules. The present work describes a system in which proton transfer accompanies both solid-state disorder and a change in color induced by mechanical stress, a phenomenon which may be termed mechanochromism of piroxicam.

Dehydration kinetics of piroxicam monohydrate and relationship to lattice energy and structure.

The dehydration kinetics of piroxicam monohydrate (PM) is analyzed by both model-free and model-fitting approaches. The conventional model-fitting approach assuming a fixed mechanism throughout the reaction is found to be too simplistic. The model-free approach allows for a change of mechanism and activation energy, Ea, during the course of a reaction and is therefore more realistic. The complexity of the dehydration of PM is illustrated by the dependence of Ea on both the heating conditions, isothermal or nonisothermal, and on the fraction of conversion, alpha (0 < or = alpha < or = 1). Under both isothermal and nonisothermal conditions, Ea increases with alpha for 0 < or = alpha < or = 0.25, followed by an approximately constant value of Ea during further dehydration. In the constant-Ea region, isothermal dehydration follows the two-dimensional phase boundary model (R2), whereas nonisothermal dehydration follows a mechanism intermediate between two- and three-dimensional diffusion that cannot be described by any of the common models. Structural studies suggest that the complex hydrogen-bond pattern in PM is responsible for the observed dehydration behavior. Ab initio calculations provide an explanation for the changes in the molecular and crystal structures accompanying the reversible change in hydration state between anhydrous piroxicam Form I and PM. This work also demonstrates the utility of model-free analysis in describing complex dehydration kinetics.

Solid-state properties of warfarin sodium 2-propanol solvate.

The goal of the present work was to understand the effect of relative humidity (RH) and temperature on the molecular structure, crystal structure, and physical properties of warfarin sodium 2-propanol solvate (W). After previous determination of the crystal structure of W, which corresponds to a 1:1 2-propanol solvate, the present work shows that W has a critical RH (60% < RH(0) < or = 68%), below which minimal uptake of water occurs, due to surface adsorption, but above which gradual and continuous uptake of water occurs, due to deliquescence. Deliquescence begins at the surface and proceeds inward into the bulk of the crystal. Single crystal X-ray diffractometry indicates no change in the crystal and molecular structure of W during the initial stages of deliquescence. Studies of the unit cell and volume computations of W show that water can neither find space to enter the crystal lattice, nor can replace 2-propanol. Thus, water does not exchange with 2-propanol within the lattice, contrary to previous reports. Storage of single crystals of W at 120 degrees C for 23 h produces shrinkage cracks along the needle (b) axis, which are interpreted as a reduction in d-spacing of the 00l planes. Thus, under thermal stress, W crystals undergo amorphization with concurrent loss of 2-propanol, which may proceed via an intermediate crystalline phase. The phase changes of W, which depend on RH and temperature, are explained at the molecular level.

Improved tableting properties of p-hydroxybenzoic acid by water of crystallization: a molecular insight.

PURPOSE: To understand the influence of water in the crystal structure on the compaction properties of otherwise structurally similar crystals, p-hydroxybenzoic acid anhydrate (HA) and the monohydrate (HM) were used as model compounds. METHODS: Bulk powder of HM was prepared by exposing HA powder to 97% relative humidity at 23 degrees C. Each powder, HA or HM, was uniaxially compressed and triaxially decompressed under various pressures to form square-faced tablets. The tensile strength and porosity of the tablets were measured. RESULTS: Incorporation of water into the crystal lattice results in greater tablet strength and larger reduction in volume for HM crystals than for HA crystals. Both HA and HM crystals contain hydrogen-bonded, zigzag-shaped layers that lie parallel to the (401) plane. When HA crystals are compressed, the zigzag-shaped layers mechanically interlock, inhibiting slip and reducing plasticity. However, water molecules in the HM crystals assume a space-filling role, which increases the separation of the layers. This effect allows easier slip between layers and provides greater plasticity of HM crystals, which increases the interparticulate bonding area under the same compaction pressure. However, the water molecules in the HM crystals increase their lattice energy by forming a three-dimensional hydrogen-bonding network. The greater bonding strength that results is reflected in greater tensile strength of HM compacts at zero porosity. CONCLUSIONS: The presence of water molecules in the crystal structure of p-hydroxybenzoic acid facilitates plastic deformation of HM crystals, thereby enhancing their bonding strength and giving much stronger tablets than of HA crystals.

Crystallization kinetics of amorphous nifedipine studied by model-fitting and model-free approaches.

The crystallization of amorphous nifedipine was studied using hot-stage microscopy (HSM), powder X-ray diffractometry (PXRD), and differential scanning calorimetry (DSC). The kinetic data obtained from DSC studies under isothermal and nonisothermal conditions were examined using both model-fitting and model-free approaches. Evaluation of 16 different models showed that model A4 (Avrami-Erofeev, n = 4) to be most appropriate for crystallization in the conversion range 0.05-0.80. This choice was based on the goodness of fit, the residual plots, and the guidance provided by the model-free approach. The model-free approach indicated that the activation energy decreases slightly as the crystallization proceeds. This variation of the activation energy with the extent of conversion determines the range of conversion over which a model can be fit, and the magnitude of the activation energy helps in the selection of the best model. The model-free approach gives much better predictions than the model of best fit and allows the experimental kinetic function to be numerically evaluated. At the early stage (alpha = 0-0.6), the numerically reconstructed model is almost identical to A4, but gradually approaches A3 (Avrami-Erofeev, n = 3) as the crystallization progresses (alpha = 0.6-0.8) and deviates from both models near the end of the reaction. This behavior may be explained by the relative contributions of nucleation and crystal growth at different stages of the reaction.

Racemic species of sodium ibuprofen: characterization and polymorphic relationships.

Racemic and homochiral sodium ibuprofen were characterized by thermal analysis and powder X-ray diffractometry. The melting point phase diagram was constructed and thermodynamic calculation was performed. In contrast to racemic ibuprofen, which is a racemic compound, racemic sodium ibuprofen forms both a racemic conglomerate (termed the gamma-form) as well as two polymorphic racemic compounds, alpha and beta, which are less stable monotropes. From the supercooled liquid, alpha and beta crystallized along with the original gamma-form. Forms alpha and beta are "enantiotropically related" with a transition temperature between 75 degrees and 113 degrees C, but can be considered to be metastable monotropes of the racemic conglomerate, the stable gamma-form.