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Constantinos Kallis,1– 3 Amit Kaura,1,3 Nathan A Samuel,4 Abdulrahim Mulla,3 Ben Glampson,3 Kevin O’Gallagher,5 Jim Davies,4 Dimitri Papadimitriou,3 Kerrie J Woods,4 Anoop D Shah,6,7 Bryan Williams,6,7 Folkert W Asselbergs,6,7 Erik K Mayer,3,8 Richard W Lee,1,9 Christopher Herbert,10 Stuart W Grant,11 Nick Curzen,12 Iain B Squire,13 Thomas Johnson,14 Ajay M Shah,15 Divaka Perera,5 Rajesh K Kharbanda,4 Riyaz S Patel,6 Keith M Channon,4 Jamil Mayet,1,3 Jennifer K Quint1– 3 1National Heart and Lung Institute, Imperial College London, London, UK; 2School of Public Health, Imperial College London, London, UK; 3NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK; 4NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK; 5NIHR King’s Biomedical Research Centre, King’s College London and King’s College Hospital NHS Foundation Trust, London, UK; 6NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK; 7Institute of Health Informatics, University College London, London, UK; 8Imperial Clinical Analytics, Research & Evaluation (iCARE) and Department of Surgery & Cancer, Imperial College London, London, UK; 9Early Diagnosis and Detection Centre, NIHR BRC at The Royal Marsden and Institute of Cancer Research, London, UK; 10NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK; 11NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust and the University of Manchester, Manchester, UK; 12NIHR Southampton Clinical Research Facility and Biomedical Research Centre, Faculty of Medicine, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; 13NIHR Leicester Biomedical Research Centre, Glenfield Hospital, and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 14NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; 15NIHR Guys & St Thomas’ Hospital Clinical Research Facility, King’s College Hospital, and King’s College London British Heart Foundation Centre of Excellence, London, UKCorrespondence: Jennifer K Quint, School of Public Health, Imperial College London, Floor 9, Sir Michael Uren Building, 86 Wood Ln, London, W12 0BZ, United Kingdom, Email j.quint@imperial.ac.ukBackground: No single biomarker currently risk stratifies chronic obstructive pulmonary disease (COPD) patients at the time of an exacerbation, though previous studies have suggested that patients with elevated troponin at exacerbation have worse outcomes. This study evaluated the relationship between peak cardiac troponin and subsequent major adverse cardiac events (MACE) including all-cause mortality and COPD hospital readmission, among patients admitted with COPD exacerbation.Methods: Data from five cross-regional hospitals in England were analysed using the National Institute of Health Research Health Informatics Collaborative (NIHR-HIC) acute coronary syndrome database (2008– 2017). People hospitalised with a COPD exacerbation were included, and peak troponin levels were standardised relative to the 99th percentile (upper limit of normal). We used Cox Proportional Hazard models adjusting for age, sex, laboratory results and clinical risk factors, and implemented logarithmic transformation (base-10 logarithm). The primary outcome was risk of MACE within 90 days from peak troponin measurement. Secondary outcome was risk of COPD readmission within 90 days from peak troponin measurement.Results: There were 2487 patients included. Of these, 377 (15.2%) patients had a MACE event and 203 (8.2%) were readmitted within 90 days from peak troponin measurement. A total of 1107 (44.5%) patients had an elevated troponin level. Of 1107 patients with elevated troponin at exacerbation, 256 (22.8%) had a MACE event and 101 (9.0%) a COPD readmission within 90 days from peak troponin measurement. Patients with troponin above the upper limit of normal had a higher risk of MACE (adjusted HR 2.20, 95% CI 1.75– 2.77) and COPD hospital readmission (adjusted HR 1.37, 95% CI 1.02– 1.83) when compared with patients without elevated troponin.Conclusion: An elevated troponin level at the time of COPD exacerbation may be a useful tool for predicting MACE in COPD patients. The relationship between degree of troponin elevation and risk of future events is complex and requires further investigation.Keywords: COPD, CVD, exacerbation

Abdullah Mohammed Alobaid,1,2 Abdulmajeed Mobrad,3 Cameron Gosling,2 Lisa McKenna,4 Brett Williams2 1Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 2Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences Monash University, Melbourne, Victoria, Australia; 3Department of Emergency Medical Services, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 4La Trobe University, School of Nursing and Midwifery, Melbourne, Victoria, AustraliaCorrespondence: Abdullah Mohammed AlobaidPrince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia, Tel +966533336396, Email a.alobaid33@gmail.comIntroduction: Although emergency medical services (EMS) stakeholders acknowledge the need for both male and female paramedics in the EMS field, the Saudi EMS system is currently only staffed by male paramedics and emergency medical technicians (EMTs) working in EMS organisations.Aim: To understand and explore the Saudi Arabian community’s perceptions on engaging Saudi female paramedics in the EMS workforce.Material and Methods: This was a cross-sectional survey design using convenience sampling of the public in Riyadh city by self-administered English and Arabic language questionnaires. Questionnaire validity was assessed by face and content validity.Results: Of the 3603 surveys distributed, 3132 were returned (87% completion response rate). Most respondents were aged between 18 and 29 years (n = 1308, 41%), and the sex distribution was (n = 1646, 52.6%) male and (n = 1486, 47.4%) female. Overall, 77% (n = 2412) of the respondents supported the need for female paramedics in Saudi Arabian ambulance services, and 74.8% (n = 2343) preferred that female paramedics treated female patients.Conclusion: This is the first public study to explore Saudi public perceptions about female paramedics in EMS in the Riyadh region, Saudi Arabia. The Saudi public is supportive of female paramedics being employed as paramedics in the country. Moreover, significant differences in perceptions were evidenced in the sex groups over any other factors.Keywords: emergency medical services, female, paramedic, public perception, Saudi Arabia

Brett Williams, Bronwyn Beovich, Alexander Olaussen Department of Paramedicine, Monash University, Melbourne, Victoria, AustraliaCorrespondence: Brett WilliamsDepartment of Paramedicine, Monash University, Peninsula Campus, PO Box 527, McMahons Road, Frankston, Victoria, 3199, AustraliaTel +61 3 9904 4283Email brett.williams@monash.eduIntroduction: Although paramedicine is an integral element of healthcare systems, there is a lack of universal consensus on its definition. This study aimed to derive a global consensus definition of paramedicine.Methods: Key attributes pertaining to paramedicine were identified from existing definitions within the literature. Utilising text analysis, common attribute themes were identified and six initial domains were developed. These domains formed the basis for a four-round Delphi study with a panel of 58 global experts within paramedicine to develop an international consensus definition.Results: Response rates across the study varied from 96.6% (round 1) to 63.8% (round 4). Participant feedback on appropriate attributes to include in the definition reflected the high level of specialized clinical care inherent within paramedicine, and its status as an essential element of healthcare systems. In addition, the results highlighted the extensive range of paramedicine capabilities and roles, and the diverse environments within which paramedics work.Conclusion: Delphi methodology was utilized to develop a global consensus definition of paramedicine. This definition is as follows: paramedicine is a domain of practice and health profession that specialises across a range of settings including, but not limited to, emergency and primary care. Paramedics work in a variety of clinical settings such as emergency medical services, ambulance services, hospitals and clinics as well as non-clinical roles, such as education, leadership, public health and research. Paramedics possess complex knowledge and skills, a broad scope of practice and are an essential part of the healthcare system. Depending on location, paramedics may practice under medical direction or independently, often in unscheduled, unpredictable or dynamic settings. We believe that the generation and provision of this consensus definition is essential to enable the further development and maturation of the discipline of paramedicine.Keywords: allied health personnel, consensus, Delphi study, paramedicine

Alaa O Oteir,1,2 Saddam F Kanaan,3 Mahmoud T Alwidyan,1 Khader A Almhdawi,3 Brett Williams2 1Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan; 2Department of Paramedicine, Monash University, Melbourne, Victoria, Australia; 3Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, JordanCorrespondence: Alaa O OteirDepartment of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technolgy, P.O. Box 3030, Irbid, 22110, JordanEmail aooteir@just.edu.joAim: To investigate the structural validity and internal consistency of a cardiopulmonary resuscitation attitudes questionnaire among Allied Health Professions (AHP) university students.Methods: Structural validity of a 17-item questionnaire was tested using principal component analysis. A group of AHP university students completed the questionnaire. Internal consistency of the questionnaire was measured by Cronbach’s α.Results: A total of 856 AHP students completed the questionnaire (mean age= 20.8 (± 1.1) years, 74.0% were females). The analysis reduced a 17-item questionnaire to an 11-item questionnaire. The final questionnaire had three distinct factors; (1) attitudes towards mouth-to-mouth ventilation (MMV), (2) attitudes towards chest compressions (CC), and (3) the importance of cardiopulmonary resuscitation (CPR). It had factor loadings ranging from 0.629 to 0.878 and could explain 66% of the variance in the attitude. The questionnaire had acceptable internal consistency (Cronbach α=0.83; 95% CI=81.5) and was feasible with no floor or ceiling effect.Conclusion: The 11-item CPR attitude questionnaire had acceptable structural validity and internal consistency and good parsimony and unidimensionality. The questionnaire can be used to measure the university students’ attitude and assess the effectiveness of CPR training activities. Future studies are required to measure the responsiveness and applicability to other cohorts.Keywords: cardiopulmonary resuscitation, attitude, questionnaire psychometric properties, allied health professions

Adel S Bashatah,1 Khalid A Al-Ahmary,2 Mohamed Al Arifi,3 Yousif A Asiri,3 Yazed AlRuthia,3 Ahmed Sayed Metwally,4 Christine A King,5 Brett Williams5 1Department of Nursing Administration & Education, College of Nursing, King Saud University, Riyadh, Saudi Arabia; 2College of Public Health, King Saud Bin Abdul-Aziz University for Health Science, Jeddah, Saudi Arabia; 3Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 4Department of Mathematics, College of Science, King Saud University, Riyadh, Saudi Arabia; 5Department of Paramedicine, Monash University, Frankston, VIC, AustraliaCorrespondence: Adel S BashatahDepartment of Nursing Education & Administration, College of Nursing, King Saud University, Riyadh, Saudi ArabiaEmail abashatah@ksu.edu.saBackground: Collaborative interprofessional practice improves health outcomes. Interprofessional education (IPE) is essential in improving this collaboration and the quality of care. Although the majority of IPE research focuses on students, the delivery of IPE requires multiple levels of support within educational institutions, particularly teaching staff that are positive about and advocate for IPE. This study explored the attitudes of teaching staff towards interprofessional collaboration across a range of professions in Health at King Saud University, Saudi Arabia.Methods: A pre-test post-test design was used with 53 teaching staff from the Health Colleges, King Saud University, before and after an interprofessional development workshop. A 12-item, 3-subscale version of the IEPS was used to evaluate changes in the 3-subscales “competency and autonomy”, “perceived need for cooperation” and “perception of actual cooperation”.Results: This study involved teaching staff from medicine, nursing, pharmacy, dentistry, applied medical science and emergency medical services. Results showed positive attitudes towards IPE, including competency and autonomy, the need for cooperation, and the perception of actual cooperation. The analysis also showed a statistically significant effect of subscale 1 (competency and autonomy) was produced between the pre- and post-workshop training.Conclusion: Interprofessional collaboration across the Health Colleges is an essential component of IPE, just as IPE is an integral component of interprofessional collaborative practice. The findings provided a baseline, as well as an incentive, for further development in IPE, from policy through to practice, across the Health Colleges. Findings also showed teaching staff having a positive attitude towards interprofessional collaboration. Further research is needed on tools for measuring IPC across university hierarchies and disciplines, as well as on enablers of IPE (and not just barriers).Keywords: interdisciplinary communication, interprofessional collaboration, interprofessional education, health occupations, Saudi Arabia

Eihab Khasawneh,1,2 Cameron Gosling,1 Brett Williams1 1Department of Paramedicine, Monash University, Frankston, Victoria, Australia; 2Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, JordanCorrespondence: Eihab Khasawneh Department of ParamedicineMonash University, 47 – 49 Moorooduc Highway, Frankston, VIC 3199, AustraliaTel +61 03 9904536Email eihab.khasawneh@monash.eduIntroduction: Numeracy is the ability to reason and to apply simple numerical concepts. Numerical and drug calculation skills are essential for patient safety. Health-care providers who perform drug calculation in their work required good math skills, especially numerical ability. The aims of this study were to explore the relationship between numerical ability, math anxiety and drug calculation performance and to explore the factors that contribute to drug calculation ability among paramedic students.Methods: A sequential explanatory mixed-method approach that included a paper-based questionnaire followed by face-to-face interviews was used in this study. The participants completed a 30-minute survey that is composed of demographics, the 10-item Mathematics Anxiety Rating Scale (MARS), a 12-question numerical ability test (NAT) and a 9-question drug calculation ability test (DCAT) and then were invited for a structured interview.Results: The mean MARS scores were higher for the second-year students than the third students. The NAT and DCAT scores for the third-year students were higher than the second-year students. There was a significant difference in the mean drug calculation ability test scores (DCAT) (t (106) = 2.13, p = 0.035 and Cohen’s d = 0.43 between males (5.05 (2.32)) and females (4.03 (2.43))). Math education prior joining the university (beta = 0.862, p = 0.030) made the strongest unique contribution when controlling for the other variables followed by numerical ability (beta =0.25, p < 0.001). The themes that emerged from the interviews included the impact of technology, classmates’ impact, mathematics competence and the mental block.Conclusion: Drug calculation is fundamental in paramedic practice. It is affected by the numerical ability of the students and is negatively and indirectly impacted by mathematics anxiety. Modifications of a paramedic program curriculum can improve student’s ability to think critically and to overcome medication dosage problems.Keywords: drug dosage calculation, allied health personnel, paramedics, anxiety, gender

Abdullah Mohammed ALobaid,1,2 Cameron McR Gosling,1 Eihab Khasawneh,1,3 Lisa McKenna,4 Brett Williams1 1Department of Paramedicine, Monash University, Melbourne, Victoria, Australia; 2Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 3Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan; 4La Trobe University, School of Nursing and Midwifery, Melbourne, Victoria, AustraliaCorrespondence: Abdullah Mohammed ALobaidDepartment of Community Emergency Health & Paramedic Practice, Monash University, Monash University-Peninsula Campus, McMahons Road, Frankston, Melbourne, Victoria, AustraliaTel +61 411112042Email a.alobaid33@gmail.comBackground: The number of women entering the medical and healthcare workforce globally has increased in the past several decades. Women have many roles and positions in healthcare organizations, hospitals and healthcare education settings. Although there has been an increase in the number of women, female workers continue to face many workplace challenges. This scoping review aimed to explore the challenges female healthcare professionals face in the workforce.Methods: A scoping review utilizing Arksey and O’Malley’s six-step framework was undertaken to identify and map available literature addressing challenges faced by female healthcare professionals in the workforce. The databases searched included Embase, EmCare, Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Business Source Complete (BSC). Additional searches were performed using Google Scholar, Trove and grey literature.Results: The initial search yielded 2455 publications (Medline n=369; EmCare n=276; Embase n=612; CINAHL n=1088; Business Source Complete n=109; mixed grey literature n=1). After removal of duplicates, 1782 citations remained. Abstract and title screening reduced the field to 36 publications, following which full-text reviews were conducted. Consensus was reached on 16 publications for final review. After analyzing the articles, three themes were identified: i) family responsibilities, ii) workplace environment and iii) stereotyping.Conclusion: Findings confirm that female healthcare professionals face circumstances that may affect their family lives, as well as factors relating to the workplace environment and stereotypes. Implementing strategies such as reduced work hours, flexible timing and part-time work can support women in the workplace, which then enhances and supports gender equality in healthcare organizations.Keywords: female, healthcare providers, family responsibilities, workplace, stereotype

Christine King, 1 Tanya Edlington, 2 Brett Williams 1 1Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, VIC, Australia; 2The Conversation Clinic Pty Ltd, Melbourne, VIC, AustraliaCorrespondence: Brett WilliamsDepartment of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, VIC, AustraliaTel +61 49 904 4283Email brett.williams@monash.eduBackground: The importance of effective clinical supervision for emerging clinicians is well recognised, not only for practice preparation, but also for reducing future attrition rates. Also recognised are the challenges faced by both students and supervisors during the supervision experience. This study aimed to identify the qualities of the “ideal” clinical supervision environment from the perspective of clinical supervisors from both nursing and allied health.Design: A qualitative study using an interview method based on action research.Methods: The convergent interview method was used with 20 clinical supervisors and educators from nursing and allied health across Victoria. Interviews were recorded and data analysis occurred at the end of each pair of interviews to develop deeper questions in line with the method.Results: 12 major themes emerged as “ideal” qualities with a range of suggestions on how these can be achieved.Conclusion: The “ideal” qualities can be used in assessing and improving current contexts, as well as designing new clinical supervision processes, models, programs and guidelines or policies. The convergent interview method allowed for deeper level analysis than previous research.Keywords: clinical supervision, clinical placement, health educators, nursing, allied health personnel

L Michael Bowen, Brett Williams Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, AustraliaCorrespondence: Brett WilliamsDepartment of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, AustraliaEmail brett.williams@monash.eduIntroduction: Professionalism is an essential behavior for paramedic students to demonstrate. In the United States, paramedic accreditation standards require educators to evaluate and document summative affective evaluation on each paramedic student before graduation. The 2009 Emergency Medical Services Education Standards identified the affective behaviors as one of the three learning domains and published a grading tool to help educators recognize professional behaviors. However, little attention was given to the validity or reliability of this tool. Therefore, the aim of this study was to evaluate the psychometric properties of the 5-point Paramedic Affective Domain Tool.Methods: This was a retrospective study with educators that completed evaluations on paramedic students from May 2013 to January 2017. A total of 707 cases met inclusion criteria and 131 unique evaluators from 27 different paramedic programs. A Rasch Partial Credit Model was used to analyze the data.Results: Almost 97% of the paramedic students received passing scores and 28.1% (n=199) received perfect scores. Only 3.5% (n=25) failed the evaluation. Scores ranged from 11 to 55 (M = 46, SD = 9.02) and α = 0.97. Evidence suggests that the tool is not valid and the clustering of scores suggests minimal information can be gleaned from the results.Conclusion: Serious consideration should be made in the continued use of this tool and future research should focus on developing a new tool that is both valid and reliable.Keywords: allied health personnel, paramedic, professionalism

Osama A Samarkandi,1 Adel S Bashatah,2 Anas A Khan,3 Abdulmajeed M Almobrad,4 Bronwyn Beovich,5 Brett Williams5,6 1Basic Science Department, eLearning and IT Unit, Prince Sultan College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia; 2College of Nursing, King Saud University, Riyadh, Saudi Arabia; 3Emergency Medicine Department, College of Medicine, University Medical City, King Saud University, Riyadh, Saudi Arabia; 4EMS Department, Prince Sultan College for EMS, King Saud University, Riyadh, Saudi Arabia; 5Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; 6Division of Paramedicine, School of Medicine, University of Tasmania, Hobart, TAS, Australia Introduction: Translation of research findings into clinical practice has potential to improve health care procedures, increase patient safety, and improve patient outcomes. However, low levels of evidence utilization in clinical practice have been widely reported. Anecdotal evidence suggests that this is also the case for emergency medical technicians (EMTs) in Saudi Arabia. This study aimed to examine the barriers to the utilization of research findings within this cohort. Methods: The BARRIERS scale was used to gather data from a convenience sample of EMTs in Saudi Arabia. Results: The barriers most commonly rated as “great” or “moderate” were “Implications for practice are not made clear”, “The relevant literature is not compiled in one place”, and “The EMT feels the benefits of changing practice will be minimal”. However, when responses were examined at a subscale level, reliability, as measured by Cronbach’s α, was suboptimal (range 0.20–0.62). Discussion: No similar study has been conducted within paramedicine to enable direct comparison of our results; however, the top barriers identified in the present study are also highly rated in some previous studies of nurse cohorts. The low reliability measures of the subscales may demonstrate the importance of context specificity when utilizing this scale and that further research is required to develop a reliable and valid tool for use within this cohort. Conclusion: The top 2 barriers identified indicate that there may be a need for improvement regarding communication of research evidence to Saudi EMTs. For future studies, translation of the BARRIERS scale may be useful. However, as these EMT courses are taught in English, careful consideration of cultural suitability and more subtle interpretation issues could also be appropriate. Once context-specific barriers are identified and examined, they may inform the development of effective strategies to increase the uptake of research evidence into Saudi EMT practice. Keywords: emergency medical technician, paramedic, Saudi Arabia, research utilization, evidence-based practice

Yu-Tung Chang,1,2 Kuang-Chau Tsai,2 Brett Williams1,3 1Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia; 2Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; 3Division of Paramedicine, University of Tasmania, Hobart, TAS, Australia Objectives: Core competencies are considered the foundation for establishing Emergency Medical Technician (EMT) and paramedic curricula, and for ensuring performance standards in the delivery of prehospital care. This study surveyed EMT instructors and medical directors to identify the most desirable core competencies for all levels of EMTs in Taiwan. Methods: A principal components analysis with Varimax rotation was conducted. An online questionnaire was distributed to obtain perspectives of EMT instructors and medical directors on the most desirable core competencies for EMTs. The target population was EMT training-course instructors and medical directors of fire departments in Taiwan. The questionnaire comprised 61 competency items, and multiple-choice and open-ended questions were used to obtain respondents’ perspectives of the Taiwanese EMT training and education system. Results: The results identified three factors at EMT-1 and EMT-2 levels and five factors at the EMT-Paramedic level. The factors for EMT-1 and EMT-2 were similar, and those for EMT-Paramedics identified further comprehensive competence perspectives. The key factors that appear to influence the development of the Taiwanese Emergency Medical Services (EMS) education system are the attitude of authorities, the licensure system, and legislation. Conclusion: The findings present new core competencies for the Taiwanese EMT system and provide capacity to redesign curricula and reconsider roles for EMT-1 and EMT-2 technicians. At the EMT-Paramedic level, the findings demonstrate the importance of incorporating competency standards in the current skills-based curriculum. Moreover, the core-competencies gap that exists between Taiwanese EMT-1s, EMT-2s, and EMT-Paramedics and internationally recognized core competencies needs to be addressed. By identifying the key factors that potentially impact the development of the EMS education system, such as the attitude of authorities, the licensure system, and legislation, these findings will inform future curricula design in Taiwan. Keywords: EMT, paramedics, core competencies, curriculum standards

Brett Williams,1 Rosalind Lau,1 Emma Thornton,1 Lauren S Olney2 1Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia; 2Clinical and Community Services Division, Ambulance Victoria, Melbourne, VIC, Australia Background: The concepts of empathy and burnout are critical for practicing paramedics and the profession. While there has been an increasing body of research on the relationship between empathy and burnout with physicians and nurses, surprisingly, no research has been undertaken with paramedics. The aim of this scoping review was to explore the relationship between empathy and burnout. Method: A scoping review was performed based on Arskey and O’Malley’s framework. Five databases were searched: CINAHL plus, EMBASE, MEDLINE, PsycINFO, and Scopus. Google Scholar was searched for gray literature. Two reviewers independently assessed eligibility and extracted the data.Results: The initial search produced a yield of 1270 articles after removal of duplicates. All abstracts were screened for relevance, and 30 articles were selected for further screening. Twenty six articles were deemed relevant, of which there were 23 cross-sectional studies, two editorials, and one description article on the multidimensional aspect of burnout and empathy. The studies were conducted in Europe, USA, North America, and Asia. In most studies, there was an inverse correlation between empathy and emotional exhaustion and depersonalization but a positive correlation with personal accomplishment. Conclusion: Although there seems to be a real relationship between empathy and burnout in physicians and nurses, the strength of the relationship differs to some extent depending on the samples and settings. Due to similarities between health professions, the relationship between empathy and burnout may also be relevant to the paramedic profession. Future paramedic research should focus on longitudinal studies to determine the factors that might influence empathy and burnout levels to provide a better understanding of these two key factors. Keywords: burnout, empathy, nurse, physician, paramedic

L Michael Bowen, Brett Williams, Luke Stanke Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia Background: Professionalism is a pillar of paramedicine. Internationally paramedic curricula emphasize valid assessment of three domains: cognitive, psychomotor, and affective domains (professionalism). Little is reported on competency measures for professionalism specific to paramedicine. Literature suggests that paramedic students, paramedic practitioners, medical directors, and patients believe that professional attributes should have an increased focus.Objective: The objective of this scoping review is to outline valid and reliable assessments that evaluate professional behaviors.Method: This review used Arksey and O’Malley’s six-stage scoping methodology. In September 2016, five databases were searched for articles of relevance; these were MEDLINE, Scopus, Google Scholar, PsycINFO/APA, and EMBASE.Results: A total of 1587 articles were identified after removal of 468 duplicates. Five articles met the inclusion criteria, two of the articles were from the US and three from UK. The studies range from 2004 to 2014. Three different scales were identified but only two were recommended for use. A US-based scale is composed of 11 items and one generic form of professionalism. The UK scale has 77 items and identified 11 factors within 68 items.Conclusions: This scoping review serves to describe valid and reliable measures for professionalism among paramedicine by outlining the quantity of instruments evident in the literature. The scoping review aimed to report the scales supporting evidence of validity and reliability. Three scales were identified in a total of five different studies that specifically measured professional attributes in paramedicine. Currently, two scales are available: an evaluation with 11 items and a self-reported questionnaire with 77 items. Keywords: paramedicine, EMS, measurement, professional behavior, affective domain, emergency medical technician, ambulance

Yu-Tung Chang,1,2 Kuang-Chau Tsai,2 Brett Williams1 1Department of Community Emergency Health and Paramedic Practice, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia; 2Emergency Medicine Department, Far Eastern Memorial Hospital, New Taipei City, Taiwan Purpose: The development of emergency medical services (EMS) training in Taiwan is in a transitional phase because of increasing demand for, and advancements in, clinical skill sets. The aim of this study is to review the current literature to compare the key factors of EMS training and education development in different countries in order to provide a new curricula blueprint for the Taiwanese EMS training system.Method: The method follows Arksey and O’Malley’s six stages of scoping review.Results: Five databases were searched for relevant articles: MEDLINE, EMBASE, Allied and Complementary Medicine Database; Education Resources Information Center, and Google Scholar. The initial search of five databases produced 1,230 articles, of which title and abstract screening excluded 1,156 articles. The 74 remaining articles underwent a full-text screening process, which further reduced the number of articles to 22. Researching references and citations produced an additional 23 articles, national curriculum standards produced a further six documents, and one article derived from emergency medical technician (EMT) regulation in Taiwan. In total, 52 articles were included in the study, categorized by competency and standards, EMT education and learning environment, curriculum design, and teaching and learning method.Conclusion: This study reviewed international EMS training and education literature and documents to summarize the essential elements for developing an EMS education system: for example, core competencies and standards, education environment, curriculum design, and teaching and learning method. By connecting the essential elements for developing an EMS education system, a blueprint for the Taiwanese EMS education system can be identified. Analysis and study of the essential elements will provide educators with clear direction in developing the EMS education system in Taiwan. Keywords: EMT, EMS, curriculum, education standards, teaching methods

Brett Williams,1 Adiva Sifris,2 Marty Lynch1 1Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, 2Faculty of Law, Monash University, Frankston, VIC, Australia Background: A growing body of literature indicates that empathic behaviors are positively linked, in several ways, with the professional performance and mental well-being of lawyers and law students. It is therefore important to assess empathy levels among law students using psychometrically sound tools that are suitable for this cohort.Participants and methods: The 20-item Jefferson Scale of Empathy – Health Profession Students Version was adapted for a law context (eg, the word “health care” became “legal”), and the new Jefferson Scale of Empathy – Law Students (JSE-L-S) version was completed by 275 students at Monash University, Melbourne, Australia. Data were subjected to principal component analysis.Results: Four factors emerged from the principal component analysis (“understanding the client’s perspective”, “responding to clients’ experiences and emotions”, “responding to clients’ cues and behaviors”, and “standing in clients’ shoes”), which accounted for 46.7% of the total variance. The reliability of the factors varied, but the overall 18-item JSE-L-S yielded a Cronbach’s alpha coefficient of 0.80. Several patterns among the item loadings were similar to those reported in studies using other versions of the Jefferson Scale of Empathy.Conclusion: The JSE-L-S appears to be a reliable measure of empathy among undergraduate law students, which could help provide insights into law student welfare and future performance as legal practitioners. Additional evaluation of the JSE-L-S is required to disambiguate some of the minor findings explored. Adjustments may improve the psychometric properties. Keywords: empathy, law, student, Jefferson, sympathy

Marija Spasenoska,1 Shane Costello,1 Brett Williams2 1Faculty of Education, 2Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, VIC, Australia Objective: The purpose of this present study was to investigate the psychometric properties of the Jefferson Scale of Physician Empathy – student version (JSPE-S). Subjects and methods: This study recruited 193 Malaysian medical students enrolled in year one and year two studies. A principal-component analysis with Varimax rotation was conducted. Procrustes rotation was used to confirm the item to model fit, which allows for a comparison of actual structure against an ideal hypothesized structure. Items were systematically removed based on low communalities of < 0.3 and poor loading of items onto components. Results: A two-component solution was found, comprised of “perspective taking” and “compassionate care”. Following item removal, eleven items remained. A Procrustes analysis revealed that this eleven-item measure demonstrated an excellent model fit. A possible third component was identified, though is not recommended for use, due to construct underrepresentation. Conclusion: This study found the Jefferson Scale of Physician Empathy fitted best to a two-component model using eleven items. Item, component, and overall congruence were very high, and scale reliabilities were adequate. The results of this study suggest that the eleven-item, two-component solution demonstrates excellent psychometric properties and structural validity in a Malaysian medical student population. Future research could consider using the short eleven-item measure in both student and health care profession samples to investigate the role of empathy in health care. Keywords: empathy, medical students, psychometrics

Brett Williams,1 Christine King,1 Tanya Edlington,21Department of Community Emergency Health and Paramedic Practice, Monash University, Franskton, VIC, 2The Conversation Clinic Pty Ltd, Melbourne, VIC, Australia Background: Clinical supervisors are responsible for managing many facets of clinical learning and face a range of challenges when the need for "difficult" conversations arises, including the need to manage conflict and relationships. Methods: Spotlight on Conversations Workshop was developed to improve the capacity of clinical supervisors to engage in difficult conversations. They were designed to challenge the mindset of clinical supervisors about difficult conversations with students, the consequences of avoiding difficult conversations, and to offer activities for practicing difficult conversations. Preworkshop, postworkshop, and 4-month follow-up evaluations assessed improvements in knowledge, intent to improve, and confidence along with workshop satisfaction. Results: Nine workshops were delivered in a range of locations across Victoria, Australia, involving a total of 117 clinical supervisors. Preworkshop evaluations illustrated that more than half of the participants had avoided up to two difficult conversations in the last month in their workplace. Postworkshop evaluation at 4 months showed very high levels of satisfaction with the workshop's relevancy, content, and training, as well as participants' intention to apply knowledge and skills. Also shown were significant changes in participants' confidence to have difficult conversations not only with students but also with other peers and colleagues. In follow-up in-depth interviews with 20 of the 117 participants, 75% said they had made definite changes in their practice because of what they learned in the workshop and another 10% said they would make changes to their practice, but had not had the opportunity yet to do so. Conclusion: We conclude that the Spotlight on Conversations Workshop can improve the clinical supervisor–student relationship as well as build general difficult conversation capacity for a range of stakeholders in clinical settings. Keywords: clinical, education, supervision, communication

Brett Williams,1 Chloe Abel,1 Eihab Khasawneh,2 Linda Ross,1 Tracy Levett-Jones31Department of Community Emergency Health & Paramedic Practice, Monash University, Frankston, Victoria, Australia; 2Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan; 3School of Nursing and Midwifery, The University of Newcastle, Callaghan, New South Wales, AustraliaBackground: Simulation-based education is an important part of paramedic education and ­training. While accessing clinical placements that are adequate in quality and quantity continues to be challenging, simulation is being recognized by paramedic academics as a potential alternative. Examining students’ satisfaction of simulation, particularly cross-culturally is therefore important in providing feedback to academic teaching staff and the international paramedic community.Objective: This study aimed to compare simulation satisfaction among paramedic students from universities in Australia and Jordan.Methods: A cross-sectional study using a paper-based English version of the Satisfaction with Simulation Experience Scale was administered to paramedic students from all year levels.Results: A total of 511 students participated in this study; 306 students (60%) from Australia (Monash University) and 205 students (40%) from Jordan (Jordan University of Science and Technology). There were statistically significant differences with large effect size noted in all three original factors between Australian and Jordanian students: debrief and feedback (mean =38.66 vs mean =34.15; P

Nicola Hogan,1 Shane Costello,1 Malcolm Boyle,2 Brett Williams2 1Faculty of Education, Monash University, Clayton, VIC, Australia; 2Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, VIC, Australia Introduction: Investigation into the psychological effects of violence toward health care workers and its associated trauma is increasing. The Impact of Event Scale (IES) provides a measure of current, subjective, emotional distress symptomatic of a specific traumatic event. However, its validity among paramedics is largely unknown. Problem: The purpose of this study was to investigate the psychometric properties and factor structure of the IES with a sample of Australian paramedics. Methods: The study aimed to investigate the psychometric properties and factor structure of the 15-item IES with a sample of Australian paramedics using Exploratory Factor Analysis with model fit statistics as found in confirmatory analysis. Results: Maximum Likelihood Factor Analysis with Varimax rotation supported the hypothesis that a two-factor solution would provide the best fit of the data. Procrustes rotation provided further support for this hypothesis indicating that the factors, labeled “Intrusion” and “Avoidance”, as well as the individual items of the 12-item final model, were a good fit to an ideal solution. Conclusion: The revision of the scale has improved its validity for use in the general population of paramedics, improving the potential for its use in trauma-related research. Keywords: impact of event scale, psychometrics, paramedics, occupational violence, PTSD

Laura F Sandoval,1 Brooke Williams,1 Steven R Feldman1–3 1Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine, Winston-Salem, NC, USA; 2Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA; 3Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA Abstract: Brodalumab is an anti-IL-17 receptor monoclonal antibody currently in development for the treatment of moderate-to-severe plaque psoriasis. With many systemic psoriasis therapies to choose from, and several newer agents in development, physicians need up to date evidence for the use of these drugs. A PubMed search was conducted through August 1, 2014 to identify randomized controlled trials and systematic reviews of brodalumab for the treatment of psoriasis. Results of Phase I and II trials, as well as a few smaller studies, have provided promising data on efficacy, safety, health-related quality of life, pharmacokinetics, and changes in lesional skin. Early Phase III data continue to support the use of brodalumab as a potentially valuable option for the treatment of psoriasis. Keywords: anti-interleukin-17, psoriasis, biologic agents, efficacy, safety, systemic therapy

David Campbell,1 Irwyn Shepherd,2 Matthew McGrail,3 Lisa Kassell,4 Marnie Connolly,1,5 Brett Williams,6 Debra Nestel7 1East Gippsland Regional Clinical School, School of Rural Health, Monash University, Melbourne, VIC, 2Simconhealth Healthcare Simulation Consultancy Group, Linsfield, NSW, 3School of Rural Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, 4Southern General Practice Training, Churchill, 5Central Gippsland Health Service, Sale, 6Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, 7School of Rural Health and HealthPEER, Monash University, Melbourne, VIC, Australia Introduction: Procedural skills are a significant component of clinical practice. Doctors, nurses, midwives and paramedics are trained to use a variety of procedural skills. Rural clinicians in particular are often required to maintain competence in some procedural skills that are used infrequently, and which may require regular and repeated rehearsal. This paper reports on a research project conducted in Gippsland, Victoria, to ascertain the frequency of use, and relevance to clinical practice, of a range of skills in the fields of medicine, nursing, midwifery, and paramedic practice. The project also gathered data on the attitudes of clinicians regarding how frequently and by what means they thought they needed to practice these skills with a particular focus on the use of simulation as an educational method. Methods: The research was conducted following identification of a specific set of procedural skills for each professional group. Skills were identified by an expert steering committee. We developed online questionnaires that consisted of two parts: 1) demographic and professional characteristics, and 2) experience of procedural skills and perceived training needs. We sought to invite all practicing clinicians (doctors, nurses, midwives, paramedics) working in Gippsland. Online surveys were distributed between November 2011 and April 2012 with three follow-up attempts. The Monash University Human Research Ethics Committee approved the study. Results: Valid responses were received from 58 doctors, 94 nurses, 46 midwives, and 30 paramedics, whom we estimate to represent not more than 20% of current clinicians within these professions. This response rate reflected some of the difficulties experienced in the conduct of the research. Results were tabulated for each professional group across the range of skills. There was significant correlation between the frequency of certain skills and confidence with maintenance of these skills. This did not necessarily correlate with perceptions of respondents as to how often they need to practice each skill to maintain mastery. The more complex the skill, the more likely the respondents were to report a need for frequent rehearsal of the skill. There was variation between the professional groups as to how to retain mastery; for some skills, professional groups reported skill maintenance through clinical observation and clinical practice; for other skills, simulation was seen to be more appropriate. Conclusion: This project provided insight into the clinical application of procedural skills for clinicians comprising a relatively large professional population within a defined geographical region in rural Victoria, as well as attitudes to skills maintenance and competency. Although not the focus of the study, an unexpected outcome was the design of questionnaires on procedural skills. We believe that the questionnaires may have value in other rural settings. We acknowledge the limitations of the study in the text. The project provides some information on which to base planning for procedural skills education, including simulation-based training, and directions for further research. Keywords: procedural skills, simulation, rural health education, skills maintenance

Brett Williams,1 Ted Brown,2 Malcolm Boyle,1 Lisa McKenna,3 Claire Palermo,4 Jamie Etherington1 1Department of Community Emergency Health and Paramedic Practice, 2Department of Occupational Therapy, 3School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University–Peninsula Campus, Frankston, 4Department of Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences, Monash University–Berwick Campus, Berwick, Vic, Australia Purpose: This research examines the extent and nature of empathy among emergency health (paramedic), nursing, and midwifery students at one Australian university and investigates the longitudinal changes in empathy levels across the course of study. Methods: First-, second-, and third-year students at Monash University completed the Jefferson Scale of Empathy–Health Professional (JSE-HP) in 2008, 2009, and 2010, and the resulting mean empathy scores were analyzed by course, year of course, year of study, age, and sex. Results: Midwifery students were found to have higher empathy levels than nursing and emergency health students. Second- and third-year students scored higher than their counterparts in the first year. Empathy levels dipped in 2009 and rose in 2010. Students aged 26–30 years and 31–35 years recorded higher scores than their younger colleagues, and female students were found to be more empathic than their male counterparts. Conclusion: The finding that empathy levels are relatively stable over the term of study contributes to the understanding of how empathy evolves over the course of study and offers insights into the importance of incorporating and promoting empathy in health care curricula. Keywords: empathy, nursing, paramedics, midwifery, undergraduates

Brett Williams,1 Sivalal Sadasivan,2 Amudha Kadirvelu,2 Alexander Olaussen11Department of Community Emergency Health and Paramedic Practice, Melbourne, Australia; 2Jeffrey Cheah School of Medicine and Health Sciences, Sunway Campus, Selangor, MalaysiaBackground: The literature indicates that medical practitioners experience declining empathy levels in clinical practice. This highlights the need to educate medical students about empathy as an attribute early in the academic curriculum. The objective of this study was to evaluate year one students' self-reported empathy levels following a 2-hour empathy workshop at a large medical school in Malaysia.Methods: Changes in empathy scores were examined using a paired repeated-measures t-test in this prospective before and after study.Results: Analyzing the matched data, there was a statistically significant difference and moderate effect size between mean empathy scores before and 5 weeks after the workshop (112.08±10.67 versus 117.93±13.13, P

Brett Williams,1 Ted Brown,2 Lisa McKenna,3 Malcolm J Boyle,1 Claire Palermo,4 Debra Nestel,5 Richard Brightwell,6 Louise McCall,7 Verity Russo11Department of Community Emergency Health and Paramedic Practice, 2Department of Occupational Therapy, 3School of Nursing and Midwifery, 4Department of Nutrition and Dietetics, 5School of Rural Medicine, Monash University, Melbourne, VIC, 6School of Medical Sciences, Edith Cowan University, Perth, WA, 7Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, AustraliaBackground: Empathy is paramount in the health care setting, optimizing communication and rapport with patients. Recent empirical evidence suggests that empathy is associated with improved clinical outcomes. Therefore, given the importance of empathy in the health care setting, gaining a better understanding of students' attitudes and self-reported empathy is important. The objective of this study was to examine self-reported empathy levels of students enrolled in different health disciplines from two large Australian universities.Materials and methods: A total of 1,111 students from two different universities enrolled in eight different health professions were administered the Jefferson Scale of Physician Empathy – Health Profession Students version, a 20-item 7-point Likert scale questionnaire to evaluate self-reported empathy levels.Results: A total of 1,111 students participated in this study. The majority of participants were from Monash University (n=771), with 340 students from Edith Cowan University. No statistically significant differences were found between universities: Monash University (mean 110.1, standard deviation [SD] 11.8); Edith Cowan University (mean 109.2, SD 13.3, P=0.306). The mean female empathy score (mean 110.8, SD 11.7) was significantly higher than the mean male score (mean 105.3, SD 13.5; P

Brett Williams, Paul A Jennings, Chris Fielder, Amanda Ghirardello Department of Community Emergency Health and Paramedic Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, VIC, Australia Background: Knowledge translation involves the dissemination and application of scientific research findings into clinical practice. In the health care arena, uptake of evidence-based assessment and intervention strategies is aimed at reducing inefficiencies and ultimately improving patient outcomes. However, numerous studies have purported gaps in knowledge translation in the health care professions. The objective of this study was to classify the traits of undergraduate paramedic students from Monash Univeristy, Australia, using the practice style inventory (PSI). Methods: A cross-sectional study of students across all undergraduate years from Emergency Health and Emergency Health/Nursing was completed. Student knowledge translation levels were measured using the 17-item paper-based PSI. Results: A total of 266 students participated in the study, of which 68.4% were females. The majority of participants were

Brett Williams,1 Andrew Quested,1 Simon Cooper21Department of Community Emergency Health and Paramedic Practice, 2School of Nursing and Midwifery, Berwick, Monash University, Frankston, VIC, AustraliaAbstract: Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one's surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.Keywords: eye-tracking, paramedic, situational awareness, medical error, pre hospital

The influence of low-temperature closed-die forging on the quasi-static and cyclic behaviour of as-cast ZK60 magnesium alloy was investigated. As-cast ZK60 billets were forged at a ram speed of 20 mm/sec and a temperature of 250 °C. While the yield strength of the starting alloy was 139 MPa, the forging process improved the yield strength significantly by ~68% to 234 MPa. Moreover, the stresscontrolled push-pull fatigue tests at the stress amplitudes of 140 MPa to 180 MPa revealed that the fatigue life was enhanced by an order of magnitude. Microstructural analyses besides the texture measurements at different locations of the forged part manifested partial grain refinement and texture modification strengthening mechanisms. It is believed that the fatigue life improvement is achieved in the wake of the grain refinement and the subsequent material strengthening.

BackgroundAssociations of socioenvironmental features like urbanicity and neighborhood deprivation with psychosis are well-established. An enduring question, however, is whether these associations are causal. Genetic confounding could occur due to downward mobility of individuals at high genetic risk for psychiatric problems into disadvantaged environments.MethodsWe examined correlations of five indices of genetic risk [polygenic risk scores (PRS) for schizophrenia and depression, maternal psychotic symptoms, family psychiatric history, and zygosity-based latent genetic risk] with multiple area-, neighborhood-, and family-level risks during upbringing. Data were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins born in 1994-1995 and followed to age 18 (93% retention). Socioenvironmental risks included urbanicity, air pollution, neighborhood deprivation, neighborhood crime, neighborhood disorder, social cohesion, residential mobility, family poverty, and a cumulative environmental risk scale. At age 18, participants were privately interviewed about psychotic experiences.ResultsHigher genetic risk on all indices was associated with riskier environments during upbringing. For example, participants with higher schizophrenia PRS (OR = 1.19, 95% CI = 1.06-1.33), depression PRS (OR = 1.20, 95% CI = 1.08-1.34), family history (OR = 1.25, 95% CI = 1.11-1.40), and latent genetic risk (OR = 1.21, 95% CI = 1.07-1.38) had accumulated more socioenvironmental risks for schizophrenia by age 18. However, associations between socioenvironmental risks and psychotic experiences mostly remained significant after covariate adjustment for genetic risk.ConclusionGenetic risk is correlated with socioenvironmental risk for schizophrenia during upbringing, but the associations between socioenvironmental risk and adolescent psychotic experiences appear, at present, to exist above and beyond this gene-environment correlation.

30 patients with epiphora and related complaints were investigated by Radionuclide Dacrocystography. It was possible to do this procedure easily in all age groups. The site of block in the lacrimal system could be accurately determined by this non-invasive technique.