Introducing a new collaborative prenatal clinic model

OBJECTIVE

To measure quality of care-planning for women in a new collaborative prenatal model of care.

METHODS

A collaborative patient-centered (CPC) model was introduced into a tertiary prenatal clinic, replacing the traditional model. A retrospective analysis was conducted of women with a first documented hospital doctor contact between February 1, 2015, and October 1, 2016. Quality of care-planning before and after introduction of the model was compared by measuring the number and size of documented care plans and amount of doctor contact. Categorical data were compared using χ² or Fisher exact tests; continuous data were analyzed using the student t test.

RESULTS

Quality of care was measured for 3606 women before, and 3511 after, introduction of the CPC model. Under the model, more women had clinical risks identified and care plans documented (2224 [63.3%] vs 1883 [52.2%]; P<0.001), and more clinical risks were identified (1.07 vs 0.74; P<0.001). Doctors documented more in each care plan (P<0.001) and had more subsequent clinical contact with women (0.69 ± 1.23 vs 0.88 ± 1.34; P<0.001) in the model.

CONCLUSION

Introduction of a collaborative model in a tertiary prenatal clinic improved identification of clinical risks and documentation of care plans, and increased doctor contacts.

Simplifying the language of fetal monitoring

BACKGROUND

Health professionals in Australia and New Zealand have used various intrapartum fetal surveillance (IFS) guidelines, with clear differences in how these guidelines present information. Based on clinician feedback, the 2015 Queensland Clinical Guideline on IFS structured the prose-based Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) IFS Guidelines as a traffic-light matrix and represented the categorical terms of unlikely, maybe, possible and likely fetal compromise, as the colours GREEN, BLUE, AMBER, and RED, respectively.

AIMS

To determine whether the interpretation of the RANZCOG IFS Guidelines in Table Format is more accurate and quicker compared to the current presentation of the RANZCOG Guideline in prose format.

MATERIALS AND METHOD

Twenty-nine clinicians, naïve to the use of the RANZCOG IFS Guidelines, interpreted ten cardiotocographs (CTGs) using one format and then the alternative format (totalling 580 CTG interpretations). Accuracy and time to decision were recorded as well as a participant questionnaire. A repeated measures analysis of variance was used to compare differences.

RESULTS

Compared to prose format, clinicians interpreted CTGs quicker using the table format (P < 0.01), especially CTGs representative of unlikely and maybe fetal compromise. There was a trend toward more accurate interpretation for table format for all clinicians, with significance among medical officers (P = 0.02). Participants responded more favourably to the table format regarding questions about ease of use, determining actions required, and desire to use the system in the future (P < 0.01).

CONCLUSIONS

Presenting the RANZCOG IFS Guideline in table format as opposed to prose format improved the speed and accuracy of CTG interpretation and is preferred by clinicians.

The Art of Scientific Performance

Humanity builds upon scientific findings, but the credibility of science might be at risk in a 'postfactual' era of advanced information technologies. Here we propose a systemic change for science, to turn away from a growth paradigm and to refocus on quality, characterized by curiosity, surprise, discovery, and societal relevance.

Improved laparoscopic skills in gynaecology trainees following a simulation-training program using take-home box trainers

BACKGROUND

Lack of time and access to equipment are recognised barriers to simulation training.

AIM

To investigate the effect of a take-home laparoscopic simulator training program on the laparoscopic skills of gynaecology trainees.

METHOD

Participants (n = 17 in 2015, n = 16 in 2016) were supplied with a box trainer, associated equipment and instructions on self-directed training. A program was designed and implemented in 2015 comprising of ten weekly laparoscopic skills tasks and modified in 2016 to eight monthly tasks. Half of the participants were randomly allocated a supervisor. Participants performed baseline and post-training assessments of laparoscopic skills in a box trainer task (thread transfer) and virtual reality simulator tasks (laparoscopic tubal ligation and bilateral oophorectomy).

RESULTS

Trainees in 2015 demonstrated an improvement in the median time to complete the laparoscopic tubal ligation task (baseline 124 s vs post-training 91 s, P = 0.041). There was no difference in the number of tubal ligation bleeding incidents, or in the time taken to complete the box trainer thread transfer task. In 2016 trainees demonstrated improvement in tubal ligation time (baseline 251 vs 71 post-training, P = 0.021) and bilateral oophorectomy time (baseline 891 s vs 504 post-training, P = 0.025). There was no significant difference in other outcome measures. There was no difference found in performance when groups were compared by supervisor allocation.

CONCLUSION

A take-home box trainer simulation-training program was associated with improvement in laparoscopic skills. This type of program may improve trainee access to simulation training.

Effects of UV-B radiation on leaf hair traits of invasive plants-Combining historical herbarium records with novel remote sensing data

Ultraviolet-B (UV-B) radiation is a key but under-researched environmental factor that initiates diverse responses in plants, potentially affecting their distribution. To date, only a few macroecological studies have examined adaptations of plant species to different levels of UV-B. Here, we combined herbarium specimens of Hieracium pilosella L. and Echium vulgare L. with a novel UV-B dataset to examine differences in leaf hair traits between the plants' native and alien ranges. We analysed scans of 336 herbarium specimens using standardized measurements of leaf area, hair density (both species) and hair length (H. pilosella only). While accounting for other bioclimatic variables (i.e. temperature, precipitation) and effects of herbivory, we examined whether UV-B exposure explains the variability and geographical distribution of these traits in the native (Northern Hemisphere) vs. the alien (Southern Hemisphere) range. UV-B explained the largest proportion of the variability and geographical distribution of hair length in H. pilosella (relative influence 67.1%), and hair density in E. vulgare (66.2%). Corresponding with higher UV-B, foliar hairs were 25% longer for H. pilosella and 25% denser for E. vulgare in records from the Southern as compared to those from the Northern Hemisphere. However, focusing on each hemisphere separately or controlling for its effect in a regression analysis, we found no apparent influence of UV-B radiation on hair traits. Thus, our findings did not confirm previous experimental studies which suggested that foliar hairs may respond to higher UV-B intensities, presumably offering protection against detrimental levels of radiation. We cannot rule out UV-B radiation as a possible driver because UV-B radiation was the only considered variable that differed substantially between the hemispheres, while bioclimatic conditions (e.g. temperature, precipitation) and other considered variables (herbivory damage, collection date) were at similar levels. However, given that either non-significant or inconclusive relationships were detected within hemispheres, alternative explanations of the differences in foliar hairs are more likely, including the effects of environment, genotypes or herbivory.

Predictors of mode of birth and duration of labour following induction using prostaglandin vaginal gel

BACKGROUND AND AIMS

Using data from a randomised controlled trial (RCT) comparing two policies of prostaglandin (PGE2) vaginal gel induction of labour (IOL) at term, this study aimed to determine: (i) demographic/clinical factors that predict IOL outcomes; and (ii) clinical characteristic(s) of women who would benefit from a policy of amniotomy once technically possible as opposed to giving more PGE2.

MATERIAL AND METHODS

Following an initial PGE2 dose, women were randomised to amniotomy or repeat-PGE2. Using RCT data, two multivariate models were developed, assessing the relationship between demographic/clinical characteristics and the outcomes of caesarean section (CS), and vaginal delivery within 24 h (VD < 24 h). Regression-equations were used to predict the likelihood of CS and VD < 24 h, varying independent predictors from the multivariate analyses.

RESULTS

Of 245 term women undergoing IOL, 90 had a CS, 155 delivered vaginally and 79 had a VD < 24 h. Controlling for confounders, nulliparity [adjusted odds ratio (aOR) = 3.71 (1.55, 8.88)] and modified Bishop's score (MBS) at first review [aOR = 0.78 (0.66, 0.92)] were independently associated with CS. Nulliparity [aOR = 0.06 (0.02, 0.15)], MBS at first review [aOR = 1.66 (1.35, 2.05)], and a policy of early amniotomy [aOR = 2.28 (1.04, 5.00)] were associated with VD < 24 h. Modelling using regression equations, and varying both MBS at first review and parity, there was no scenario where repeat PGE2 was predicted to be superior to an earlier amniotomy.

CONCLUSIONS

Following IOL using PGE2 vaginal gel at term, both parity and cervical favourability at first review are associated with CS and VD < 24 h. All combinations of parity and MBS at first review predicted fewer CS and greater likelihood of VD < 24 h with a policy of amniotomy once technically possible.

Water Quality Is a Poor Predictor of Recreational Hotspots in England

Maintaining and improving water quality is key to the protection and restoration of aquatic ecosystems, which provide important benefits to society. In Europe, the Water Framework Directive (WFD) defines water quality based on a set of biological, hydro-morphological and chemical targets, and aims to reach good quality conditions in all river bodies by the year 2027. While recently it has been argued that achieving these goals will deliver and enhance ecosystem services, in particular recreational services, there is little empirical evidence demonstrating so. Here we test the hypothesis that good water quality is associated with increased utilization of recreational services, combining four surveys covering walking, boating, fishing and swimming visits, together with water quality data for all water bodies in eight River Basin Districts (RBDs) in England. We compared the percentage of visits in areas of good water quality to a set of null models accounting for population density, income, age distribution, travel distance, public access, and substitutability. We expect such association to be positive, at least for fishing (which relies on fish stocks) and swimming (with direct contact to water). We also test if these services have stronger association with water quality relative to boating and walking alongside rivers, canals or lakeshores. In only two of eight RBDs (Northumbria and Anglian) were both criteria met (positive association, strongest for fishing and swimming) when comparing to at least one of the null models. This conclusion is robust to variations in dataset size. Our study suggests that achieving the WFD water quality goals may not enhance recreational ecosystem services, and calls for further empirical research on the connection between water quality and ecosystem services.