Interactive PDF Research Articles

Using the CSCP Classic Tales resources to improve literacy in Year 9

Abstract Over the past decade, the literacy rate of the pupils I teach has been declining. This has led to some problems with GCSE Classical Civilisation, where pupils are not strong enough readers to fully access the prescribed sources. To counter this, one of my former colleagues suggested that we use the Classic Tales resources as the basis for our Year 9 course (students aged 13). The aim is to teach the pupils as much mythology as possible, which is an excellent foundation for the myth and religion unit, and to get them to read as much as we can, using the interactive reader, pdf transcripts, and recordings of the stories to engage all pupils in the class. The aim of this paper is to discuss the successes and failures of this strategy.

SGLT2 Inhibitors- The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review.

A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.

A randomised controlled evaluation of an online perfectionism intervention for people with disordered eating – how perfect does it need to be?

ABSTRACT Less help-seeking for an eating disorder is predicted by higher levels of denial of, and failure to perceive, illness severity. This research evaluates a “backdoor” approach to early intervention by investigating whether internet cognitive behaviour therapy for perfectionism can significantly improve disordered eating. Additionally, we investigated whether a more interactive intervention impacted outcomes. Participants were recruited worldwide online; 368 were screened, 172 (46.7%) met inclusion criteria (endorsed high shape, weight, or eating concerns) and randomised to an interactive (Focused Minds Program; FMP) or static PDF intervention (Centre for Clinical Intervention; CCI-P) or waitlisted (control condition). Participants completed assessments on disordered eating, perfectionism, and a range of secondary variables at the end of treatment, and 1- and 3-month follow-up. Intent-to-treat analyses indicated that, compared to control, FMP resulted in significantly lower levels of disordered eating at each assessment and CCI-P at the 1- and 3-month follow-up (respective 3-month follow-up between group effect sizes of 0.78 and 0.54). There were no significant differences between the two active interventions on any measure except depression and hated self. Results suggest an alternative approach to directly tackling disordered eating that is low-cost is effective, with a more interactive intervention producing a more rapid effect. Trials Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) Trial Number: ACTRN12621001448831

"I Wish This Tool Was Available to Me Sooner": Piloting a Workplace Autism Disclosure Decision-Aid Tool for Autistic Youth and Young Adults.

For autistic youth and young adults, deciding whether to disclose their autism at work may be complex since they are newly entering the workforce and are at an impressionable developmental period. Decision-aid tools can help someone make a choice regarding a topic/situation. We developed a workplace autism disclosure decision-aid tool called DISCLOSURE (Do I Start the Conversation and Let On, Speak Up, and REveal?) to support autistic youth and young adults navigate disclosure decision-making. In this study, we aimed to assess the DISCLOSURE tool's (1) impact on decision-making and self-determination capabilities and (2) usability, feasibility, and acceptability. This was a single-arm pre-post pilot study. The DISCLOSURE tool comprises three interactive PDF documents and videos. Thirty participants (mean age of 23.5 years) completed online surveys before and after interacting with the DISCLOSURE tool. We used descriptive statistics for usability, feasibility, and acceptability. We calculated the Wilcoxon signed rank and paired t-tests to determine pre-post changes in decision-making and self-determination capabilities (Decisional Conflict Scale-Low Literacy Version [DCS-LL]; adapted Arc's Self-Determination Scale). We analyzed open-ended data using conventional (inductive) content analysis. There were significant decreases in DCS-LL total and subscale scores (p < 0.0001) and a significant increase in Arc's total score (p = 0.01), suggesting important improvements. There were no significant increases for Arc's psychological empowerment and self-realization subscales (p = 0.05; p = 0.09). Median scores (4.0/5.0) indicate that participants agreed that the DISCLOSURE tool is acceptable, feasible, and meets the usability criteria. We developed four categories to describe the open-ended data: (1) disclosure capabilities, (2) the role of others, (3) positive tool impact and feedback, and (4) minimal tool impact and constructive feedback. Findings are suggestive of the DISCLOSURE tool's ability to support workplace autism disclosure decision-making. Future studies should ascertain the DISCLOSURE tool's effectiveness, explore others' feedback (e.g., employers), and how to incorporate the tool into relevant employment and vocational programs.

A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making.

A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure. A Delphi design was utilised. An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study. Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential. The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements. In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes. Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population. The CREDES guidance on conducting and reporting Delphi studies. None.

How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool

BackgroundDecision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care.MethodsThe study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care.ResultsCare providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions.DiscussionDeveloping an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.

Interactive PDF Forms to Conduct Online Examinations in University Education: Practical Experience and Lessons Learned

Due to the Corona Pandemic, paper-based examinations had to be transferred to an online format on short notice. At the Lucerne University of Applied Sciences and Arts we conducted three online examinations with a total of 816 students using an interactive PDF form. We faced two major challenges redesigning our examinations: 1) avoiding unnecessary stress to students' working memory by choosing a simple examination design and 2) minimizing the possibility of cheating. In our paper we explain how we addressed these challenges working with an interactive PDF form in combination with the learning management system Ilias. Our results show that using an interactive PDF form lowers the extraneous cognitive load on our students, increases our efficiency in correcting, reduces error rates in grading and further allows for faster feedback to our students.

Signaling Context in Topic-Based Writing

In topic-based writing delivered as web help or interactive PDF, readers are able to access topics non-linearly, reading only those topics they feel a need to read. Consequently, readers can easily lose a sense of a topic's broader context of related topics and concepts, which is knowledge presumed of a "qualified reader."&lt;br/&gt; Purpose: This paper investigates how relative "that" and "which" clauses are used to signal context in writing that is intended to be free of obligatory contextual connections to other topics in a documentation set.&lt;br/&gt; Method: This analysis relies on a computer-assisted, descriptive analysis of relative pronoun use in a corpus of published, topic-based documentation. The analysis focuses on "that" and "which," typically used in English to refer to and add information (e.g., a context) about an antecedent noun.&lt;br/&gt; Results: Relative "that" and "which" clauses are shown to be used in a variety of ways in topic-based writing to signal associations between topics, making it easier for readers who need context to find it.&lt;br/&gt; Conclusions: The author offers implications for writing practice that include deliberate, strategic use of "that" and "which" and complementary documentation design that enables readers to locate contextual information signaled by those pronouns.

Interactive PDF Forms to Conduct Online Examinations in University Education

Interactive PDF Forms to Conduct Online Examinations in University Education

Collaborative Online Professional Development Design

COVID-19 has impacted not only higher education teaching practice, but also professional development (PD) such as F2F workshop sessions for supervisor training have had to pivot to online modes. This presentation overviews the process of designing an academic supervision training workshop as an online module that can be used as a design framework for other professional development and training contexts. We used a design-based research methodology (McKenney &amp; Reeves, 2019) encompassing three stages.&#x0D; Stage 1 Evaluation and Analysis&#x0D; We formed a collaborative design team of two academics and a professional staff member and met regularly over Zoom as due to COVID-19 we were all working from home, and across countries (Australia and New Zealand). We began with an evaluation of the existing introductory supervision online module to identify key design elements and refinements that we could integrate into the new refresher module. This was followed by a collaborative definition of the scope of the new PD module that was focused upon providing a ‘Refresher Course’ for experienced higher degree research supervisors. We decided to focus the content of the module upon authentic user-generated scenarios from highly experienced academics across the university. User reflection was designed through an optional link to contribute to an institutional Wiki page to provide tips and comments from user experiences in supervision. The analysis of users needing an informative but short time investment in the refresher module highlighted the need for collating resources that would be referenced throughout the module to be made available at the end of the module as a downloadable interactive PDF resource for users.&#x0D; Stage 2 Collaborative Prototype Design&#x0D; An initial storyboard module prototype based upon learning object and instructional design principles (Boyle, 2003; Author1, 2007; Reigeluth et al., 2016) was created. While we began with big ideas based upon the rapid prototype of how to make the new module interactive and appealing to the users there were significant design restraints imposed by the institutional Course Builder online development platform, that provides a basic Web 1.0 approach to online module design and delivery. This meant that user interaction options were limited, file size uploads were small, and display dimensions fixed. Therefore, Vimeo was used to host and embed the video vignettes in the module pages through an institutional license providing a range of privacy and customisation options. We were able to negotiate these technical design hurdles, albeit with downgraded expectations of user interaction within our new module design.&#x0D; Stage 3 Evaluation and Redesign&#x0D; User feedback on the initial prototype was very positive and the user-generated video vignettes and funky iPad created graphics were highlights. Feedback also highlighted the need for additional user instructions, a more unified design across the module and implementation of accessibility features such as closed captioning for the video vignettes. This was achieved through maintaining a consistent font and paragraphing style and creating a new embedded player style format for the Vimeo video host platform. Closed captions were added by manually transcribing and timecoding the videos on Vimeo.

An empirical study of how the Dutch healthcare regulator first formulates the concept of trust and then puts it into practice

BackgroundResponsive regulation assumes that the parties being regulated are trustworthy and motivated by social responsibility. This assumes that regulation based upon trust will improve the regulated organization more effectively than other regulation models. The purpose of our qualitative study was to unravel the most important elements of trust in the inspectee which can support the inspector’s work and to develop a model and a framework of trust that can be used by the inspectors to legitimize their trust in the inspectee.MethodsWe conducted an empirical study on trust regarding the regulation of care services to reveal how trust in the inspectee is conceptualized and assessed. Based on literature and empirical research, we synthesized the concept of trust into six elements, five regarding behavior, and a sixth looking at information about its context. We developed a practical framework for the concept to reduce the conceptual ambiguity, strengthen regulatory assessment, and support appropriate tailoring of the regulatory response.ResultsSix elements with respect to trust emerged from the data: showing integrity; transparency; ability to learn; accepting feedback; showing actual change in behavior; context information. These five behavioral elements, plus the context information were merged into a Framework of Trust and designed into an interactive PDF document.ConclusionsThis study has sought to address a gap in the empirical knowledge regarding the assessment of trust in the inspectee. The results aim to inform and clarify the regulatory conceptualization and understanding of trust in the inspectee. Other inspectorates may learn from these results for their own practice and explore whether operational deployment of our Framework of Trust effects their assessment and enforcement strategies.

Communicating 3D data-interactive 3D PDF documents for expert reports and scientific publications in the field of forensic medicine.

Modern forensic investigations increasingly revert to 3D imaging techniques, such as computed tomography, magnetic resonance imaging, and 3D surface imaging. Findings are therefore often based on 3D data sets; however, this information is commonly reported and communicated within 2D imagery. The use of interactive 3D PDFs is already established in the scientific community but has yet to be implemented in the field of forensic medicine. Three example cases were chosen to serve as exemplary data for the most commonly applied imaging techniques in postmortem imaging. 3D surface models were created from postmortem magnetic resonance imaging (PMMR), postmortem computed tomography (PMCT), and 3D surface imaging data sets. PMMR revealed a space-occupying subdural hemorrhage that led to ipsilateral compression of the brain tissue of the right hemisphere. PMCT displayed a defect in the skull on the left side of the temporal bone. 3D surface imaging data displayed a patterned discoloration on the inside of the left forearm. Interactive 3D PDFs offer the possibility to communicate 3D information to the reader while maintaining all the benefits of a regular 2D PDF. With Adobe Acrobat, the reader can interactively navigate through 3D data sets and create sufficient depth cues to generate a realistic 3D perception of the data. The interactive 3D PDF is a useful extension of standard 2D PDFs and has the potential to communicate 3D data to the reader in a more complete, more comprehensible, and less subjective manner than 2D PDFs.

Traktat Parkosza. Eksperymentalna edycja elektroniczna

The fifteenth-century Latin manuscript presenting the proposal of Polish spelling formulated by Jakub Parkosz is an interesting challenge to the editors primarily because it introduces special characters that were not used later. The text of the treatise was presented and discussed in a book by Marian Kucała (available under open licence) which was used as the basis for an experimental electronic edition of the treatise in the form of an interactive PDF file, also available as a LuaLaTeX source. For transliteration, the electronic edition uses the existing Unicode letters with some additions from the private use area of the Medieval Unicode Font Initiative. This paper presents the rationale for the transliteration and discusses some possible alternative forms of electronic editions.

Development of an evaluation tool for geriatric rehabilitation care

BackgroundGeriatric rehabilitation care (GRC) is short-term and multidisciplinary rehabilitation care for older vulnerable clients. Studies were conducted about its effects. However, elements that influence the quality of GRC have not been studied previously.MethodsIn this study realist evaluation is used to find out which are the mechanisms and outcomes and which (groups of) persons are the context for GRC, according to GRC professionals. The mechanisms, outcomes and context of GRC were explored in three consecutive phases of qualitative data gathering, i.e. individual interviews, expert meeting, and focus groups.ResultsEight mechanisms — client centeredness, client satisfaction during rehabilitation, therapeutic climate, information provision to client and informal care givers, consultation about the rehabilitation (process), cooperation within the MultiDisciplinary Team (MDT), professionalism of GRC professionals, and organizational aspects — were found. Four context groups—the client, his family and/or informal care giver(s), the individual GRC professional, and the MDT—were mentioned by the respondents. Last, two outcome factors were determined, i.e. client satisfaction at discharge and rehabilitation goals accomplished.ConclusionsIn order to translate these insights into a practical tool that can be used by MDTs in the practice of GRC, identified mechanisms, contexts, and outcomes were visualized in a GRC evaluation tool. A graphic designer developed an interactive PDF which is the GRC evaluation tool. This tool may enable MDTs to discuss, prioritize, evaluate, and improve the quality of their GRC practice.

Focus on lasers, imaging, and microscopy

Focus on lasers, imaging, and microscopy

Interactive 3D Reconstruction of Pulmonary Anatomy for Preoperative Planning, Virtual Simulation, and Intraoperative Guiding in Video-Assisted Thoracoscopic Lung Surgery.

Routine imaging modalities combined with state-of-the-art reconstruction software can substantially improve preoperative planning and simplify complex procedure by enhancing the surgeon's knowledge of the patient's specific anatomy. The aim of the current study was to demonstrate the feasibility of interactive three-dimensional (3D) computed tomography (CT) reconstructions for preoperative planning and intraoperative guiding in video-assisted thoracoscopic lung surgery (VATS) with 3D vision. Twenty-five consecutive patients referred for an anatomic pulmonary resection by a single surgeon were included. Data were collected prospectively. All patients underwent a CT angiography in the diagnostic pathway prior to referral. 3D reconstruction of the pulmonary anatomy was obtained from CT scans with dedicated software. An interactive PDF file of the 3D reconstruction with virtual resection was created, in which all the pulmonary structures could be individually selected. Furthermore, the reconstructions were used for intraoperative guiding on double monitor during VATS with 3D vision. In total, 26 procedures were performed for 5 benign and 21 malignant conditions. Lobectomy and segmentectomy were performed in 20 (76.9 %) and 6 (23.1%) cases, respectively. In all patients, preoperative 3D reconstruction of pulmonary vessels corresponded with the intraoperative findings. Reconstructions revealed anatomic variations in 4 (15.4%) patients. No conversion to thoracotomy or in-hospital mortality occurred. Preoperative planning with interactive 3D CT reconstruction is a useful method to enhance the surgeon's knowledge of the patient's specific anatomy and to reveal anatomic variations. Intraoperative 3D guiding in VATS with 3D vision is feasible and could contribute to the safety and accuracy of anatomic resection.

Interactive 3D Digital Models for Anatomy and Medical Education.

This chapter explores the creation and use of interactive, three-dimensional (3D), digital models for anatomy and medical education. Firstly, it looks back over the history and development of virtual 3D anatomy resources before outlining some of the current means of their creation; including photogrammetry, CT and surface scanning, and digital modelling, outlining advantages and disadvantages for each. Various means of distribution are explored, including; virtual learning environments, websites, interactive PDF's, virtual and augmented reality, bespoke applications, and 3D printing, with a particular focus on the level of interactivity each method offers. Finally, and perhaps most importantly, the use of such models for education is discussed. Questions addressed include; How can such models best be used to enhance student learning? How can they be used in the classroom? How can they be used for self-directed study? As well as exploring if they could oneday replace human specimens, and how they complement the rise of online and e-learning.

Implementation of a clinical tool to assess and address pain management requests in the pharmacy.

Morbidity and mortality associated with inappropriate use of over-the-counter combination analgesics containing codeine (OTC CACC) in Australia resulted in it being upscheduled in 2010 from "Pharmacy Only" (Schedule 2) to "Pharmacist Only" (Schedule 3), and further to "Prescription Only" (Schedule 4) in February 2018. There have been a number of concerns and challenges identified by community pharmacists in the provision of OTC CACC. In practice, sub-optimal management of patients accessing these medications has been demonstrated. To assist the management of patients using OTC CACC, the development of a management and referral pathway would be advantageous. To evaluate the use of an online interactive clinical tool and/or clinical information via an online PDF-based platform for managing OTC CACC requests and codeine dependence. Two interactive online clinical tools to aid management of patients who presented requesting OTC CACC were developed. Evaluation of these tools was undertaken using responses to multiple choice questions and feedback from pharmacist surveys. Of the 904 pharmacists who responded to the evaluation survey, 66.7% had not used the tool in the preceding 12 months. The most common reason why pharmacists did not access either the online interactive, or online PDF clinical tools was that they had no knowledge of them. Older age of the pharmacist (50 years or older compared to younger than 30) predicted tool access (adjusted proportional odds ratio = 3.16, 95% CI 1.72-5.80, p < 0.001). The access of the tool was positively associated with it being perceived as useful (adjusted odds ratio = 14.7, 95% CI 6.7-32.5, p < 0.001). A number of pharmacists participating in the evaluation had never accessed either the online interactive or online PDF clinical tool, as they were not aware of them. Further research needs to be conducted into how to best promote and increase awareness of online clinical tools to pharmacists, especially younger pharmacists, and determine the best way to integrate online clinical tools effectively and efficiently into current practice.

Animal use in pharmacy tertiary educational laboratories: students’ perceptions and need assessments

Morbidity and mortality associated with inappropriate use of over-the-counter combination analgesics containing codeine (OTC CACC) in Australia resulted in it being upscheduled in 2010 from “Pharmacy Only” (Schedule 2) to “Pharmacist Only” (Schedule 3), and further to “Prescription Only” (Schedule 4) in February 2018. There have been a number of concerns and challenges identified by community pharmacists in the provision of OTC CACC. In practice, sub-optimal management of patients accessing these medications has been demonstrated. To assist the management of patients using OTC CACC, the development of a management and referral pathway would be advantageous.To evaluate the use of an online interactive clinical tool and/or clinical information via an online PDF-based platform for managing OTC CACC requests and codeine dependence.Two interactive online clinical tools to aid management of patients who presented requesting OTC CACC were developed. Evaluation of these tools was undertaken using responses to multiple choice questions and feedback from pharmacist surveys.Of the 904 pharmacists who responded to the evaluation survey, 66.7% had not used the tool in the preceding 12 months. The most common reason why pharmacists did not access either the online interactive, or online PDF clinical tools was that they had no knowledge of them. Older age of the pharmacist (50 years or older compared to younger than 30) predicted tool access (adjusted proportional odds ratio = 3.16, 95% CI 1.72–5.80, p < 0.001). The access of the tool was positively associated with it being perceived as useful (adjusted odds ratio = 14.7, 95% CI 6.7–32.5, p < 0.001).A number of pharmacists participating in the evaluation had never accessed either the online interactive or online PDF clinical tool, as they were not aware of them. Further research needs to be conducted into how to best promote and increase awareness of online clinical tools to pharmacists, especially younger pharmacists, and determine the best way to integrate online clinical tools effectively and efficiently into current practice.

Revisiting 'Effectiveness of problem-based learning curricula: theory, practice and paper darts'.

Revisiting 'Effectiveness of problem-based learning curricula: theory, practice and paper darts'.