Biodiversity-production feedback effects lead to intensification traps in agricultural landscapes

Intensive agriculture with high reliance on pesticides and fertilizers constitutes a major strategy for 'feeding the world'. However, such conventional intensification is linked to diminishing returns and can result in 'intensification traps'-production declines triggered by the negative feedback of biodiversity loss at high input levels. Here we developed a novel framework that accounts for biodiversity feedback on crop yields to evaluate the risk and magnitude of intensification traps. Simulations grounded in systematic literature reviews showed that intensification traps emerge in most landscape types, but to a lesser extent in major cereal production systems. Furthermore, small reductions in maximal production (5-10%) could be frequently transmitted into substantial biodiversity gains, resulting in small-loss large-gain trade-offs prevailing across landscape types. However, sensitivity analyses revealed a strong context dependence of trap emergence, inducing substantial uncertainty in the identification of optimal management at the field scale. Hence, we recommend the development of case-specific safety margins for intensification preventing double losses in biodiversity and food security associated with intensification traps.

An open-access global database of meta-analyses investigating yield and biodiversity responses to different management practices

We here present a database of evidence on the impact of agricultural management practices on biodiversity and yield. This database is the result of a systematic literature review, that aimed to identify meta-analyses that use as their response variables any measure of biodiversity and yield. After screening more than 1,086 titles and abstracts, we identified 33 relevant meta-analyses, from which we extracted the overall estimates, the subgroup estimates as well as all information related to them (effect size metric, taxonomic group, crop type etc.). We also extracted information relative to the empirical studies used for each meta-analysis and recorded the countries in which they took place and assessed the quality of each meta-analysis. Our dataset is publicly accessible and can be used for conducting second-order meta-analyses on the effect of management measures on species richness, taxon abundance, biomass and yields. It can also be used to create evidence maps on agriculture-related questions.

Effectiveness and cost-effectiveness of an electronic mindfulness-based intervention to improve maternal mental health in the peripartum: study protocol for a randomised controlled trial

BACKGROUND

Perinatal women are highly vulnerable to developing mental health issues and particularly susceptible to a recurrence of psychiatric illness. Poor mental health during the perinatal period can have long-term impacts on the physical and psychiatric health of both mother and child. A potentially useful strategy to improve women's mental health is through a mobile application teaching mindfulness, an evidence-based technique helping individuals focus on the present moment.

METHODS

A mixed method, prospective randomised controlled trial. The study group comprise women aged 18 years and over, who are attending the public and private maternity clinics at Mater Mothers' Hospital. A sample of 360 prenatal women will be randomised into the intervention group (with the use of the mindfulness app) or usual care. Participants will remain in the study for 11 months and will be assessed at four timepoints for changes in postnatal depression, mother-infant bonding, and quality of life. A cost-effectiveness evaluation will also be conducted using quality-adjusted life year (QALY) calculations. A random selection of intervention participants will be invited to attend focus groups to give feedback on the mindfulness app.

DISCUSSION

Previous studies have found mindfulness interventions can reduce stress, anxiety, depression, and sleep disturbances in a prenatal population. The risks of the intervention are low, but could be of significant benefit for women who are unable to attend face-to-face appointments due to geographical, financial, or time barriers; during endemic or pandemic scenarios; or due to health or mobility issues.

TRIAL REGISTRATION

This study was approved by the Mater Misericordiae Human Research Ethics Committee (83,589). Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622001581752 ( https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385107&isReview=true ). Registered on 22 Dec. 2022.

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation

OBJECTIVE

This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies.

METHODS

A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest.

RESULTS

There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit.

CONCLUSIONS

A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Surface Energy and Wetting Behavior of Dolomite in the Presence of Carboxylic Acid-Based Deep Eutectic Solvents

This study endeavors to apply experimental and theoretical analyses to assess the viability of wettability alteration for two carboxylic acid-based deep eutectic solvents (DESs). To prepare these chemicals, oxalic acid and citric acid were used as hydrogen bond donors mixed with choline chloride as the hydrogen bond acceptor in an equimolar ratio. In the theoretical part, dolomite and crude oil were characterized using a three-phase setup. Then, the adhesion propensity of brines/crude oil toward dolomite was evaluated by calculating the work of adhesion. Contact angle and interfacial tension measurements were conducted in the experimental part to investigate the impact of chemicals on brine-crude oil and brine-rock interactions. Results revealed that the oxalic acid-based DES outperformed the citric acid-based DES in terms of interfacial tension reduction. In addition, choline chloride/oxalic acid (1:1) could effectively restore the wettability of the dolomite sample to its original state with a wettability alteration index of 82%. Theoretical calculations also confirmed the wettability alteration potential of DESs. Finally, a correlation was proposed to predict the contact angle of brine on the dolomite surface in the presence of crude oil using surface-energy components of brine, crude oil, and dolomite.

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study

BACKGROUND

The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort).

METHODS

We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage.

RESULTS

1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage.

CONCLUSIONS

A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials

BACKGROUND

Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods.

METHODS

We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924).

FINDINGS

Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I²=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I²=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I²=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I²=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I²=0%).

INTERPRETATION

In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events.

FUNDING

Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Metabolomic changes in lactating multiparous naturally MAP-infected Holstein-Friesian dairy cows suggest changes in mitochondrial energy pathways

Mycobacterium avium subspecies paratuberculosis (MAP) is the causative organism of Johne's Disease, a chronic intestinal infection of ruminants. Infected cows begin shedding MAP within the asymptomatic, subclinical stage of infection before clinical signs, such as weight loss, diarrhoea and reduced milk yields develop within the clinical stages of disease. Herein, we examine the milk metabolomic profiles of naturally MAP-infected Holstein-Friesian cows. The study used biobanked milk samples which were collected 73.4 ± 3.79 (early lactation) and 143 ± 3.79 (mean ± SE) (mid-lactation) days post-calving from 5 MAP-infected and 5 control multiparous cows. The milk metabolome was assessed using flow infusion electrospray high-resolution mass spectrometry (FIE-HRMS) for sensitive, non-targeted metabolite fingerprinting. Metabolite fingerprinting assessments using partial least squares discriminate analyses (PLS-DA) indicated that lactation stage was a larger source of variation than MAP status. Examining each lactation stage separately for changes associated to MAP-infection status identified 45 metabolites, 33 in early lactation and 12 in mid-lactation, but only 6 metabolites were targeted in both stages of lactation. Pathway enrichment analysis suggested that MAP affected the malate-aspartate shuffle during early lactation. Pearson's correlation analysis indicated relationships between milk lactose concentrations in mid-lactation and 6 metabolites that were tentatively linked to MAP-infection status. The targeted metabolites were suggestive of wider changes in the bioenergetic metabolism that appear to be an acceleration of the effects of progressing lactation in healthy cows. Additionally, milk lactose concentrations suggest that MAP reduces the availability of lactose derivatives.

Clinicians' attitudes towards a co-leadership structure for maternity emergency teams: An interview study

Shared leadership improves team performance in many domains and is present in some interprofessional healthcare teams. Despite the dominant paradigm of a singular obstetrician leader in maternity emergencies, co-leadership, a specific form of shared leadership, has been identified as a potentially beneficial to clinical care. This qualitative interview study addresses the gaps in knowledge regarding clinician attitudes toward co-leadership and how a co-leadership structure might be implemented within a maternity care setting. Twenty-five clinicians (midwives, obstetricians and anaesthetists) working in the birthing units of two tertiary maternity units were interviewed and a conventional content analysis conducted. Clinicians viewed co-leadership as potentially beneficial to patient care through improved leadership performance and co-leader back up behavior. Implementation of co-leadership was thought to require a supportive organizational culture, agreed patient management protocols and the participation in simulation training. Enacting co-leadership required adaptable leadership sharing practices, effective communication, and high levels of trust between the co-leaders. These findings inform the future implementation strategies for co-leadership in interprofessional healthcare teams.

Induction of labour involving an amniotomy: Waiting compared to immediate oxytocin

During induction of labour (IOL), the optimal timing of oxytocin following amniotomy is unknown, with limited data to guide decision-making. This study aimed to see whether a 2-h delay after amniotomy before starting oxytocin during IOL reduced the use of oxytocin as well as other positive or negative impact. A propensity-score-matched cohort study assessed the maternal, neonatal and process outcomes of 1168 women (584 per group) comparing immediate oxytocin to a 2-h delay ('wait') after amniotomy. Women who waited were significantly less likely to receive oxytocin (61.2 vs 100%, P < 0.001) but more likely to receive antibiotics (14.7 vs 10.3%, P = 0.021), to be delivered by caesarean section (20.0 vs 14.6%, P = 0.013) and to be exclusively breastfeeding during discharge (77.2 vs 71.2%, P = 0.019). These findings provide further information for women and caregivers regarding the risks and benefits of a short delay before starting oxytocin.

Thermal treatment of carbon-fibre-reinforced polymers (Part 2: Energy recovery and feedstock recycling)

The use of carbon fibre (CF)-reinforced plastics has grown significantly in recent years, and new areas of application have been and are being developed. As a result, the amount of non-recyclable waste containing CF is also rising. There are currently no treatment methods for this type of waste. Within this project different approaches for the treatment of waste containing CF were investigated. Main subject of the research project were large-scale investigations on treatment possibilities and limits of waste containing CF in high temperature processes, with focus on the investigation of process-specific residues and possible fibre emission. The results showed that the two conventional thermal waste treatment concepts with grate and rotary kiln firing systems are not suitable for a complete oxidation of CFs due to the insufficient process conditions (temperature and dwell time). The CFs were mainly discharged via the bottom ash/slag. Due to the partial decomposition during thermal treatment, World Health Organization (WHO) fibres occurred in low concentrations. The tests run in the cement kiln plant have shown the necessity of comminution for waste containing CF. With respect to the short testing times and moderate quantities of inserted CF, a final evaluation of the suitability of this disposal path was not possible. The use of specially processed waste containing CF (carbon-fibre-reinforced plastic (CFRP) pellets) as a carbon substitute in calcium carbide production led to high carbon conversion rates. In the unburned furnace dust, which is marketed as a by-product of the process, CFs in relevant quantities could be detected.

The utility of routine screening for anaemia at 36 weeks gestation

Anaemia is a global disease, affecting over 1 billion people worldwide; 12% of Australian women experience anaemia in pregnancy. Professional bodies/institutions recommend screening for and treating anaemia in pregnancy but there is inconsistency in recommendations for when to screen. A ten-year retrospective analysis was undertaken of 10 518 pregnancies where there was not a specific indication for repeat blood tests. Using a 28-week haemoglobin (Hb) threshold of ≥110 g/L, seven out of ten could safely forego a routine 36-week full blood count. Less than 2.5% would then be anaemic at 36 weeks, none of whom would have had a Hb < 90 g/L.

Shared Leadership in Healthcare Action Teams: A Systematic Review

OBJECTIVES

The aims of this review were to consolidate the reported literature describing shared leadership in healthcare action teams (HCATs) and to review the reported outcomes related to leadership sharing in healthcare emergencies.

METHODS

A systematic search of the English language literature before November 2017 was performed using PsycINFO, MEDLINE, PubMed, CINAHL, and EMBASE. Articles describing sharing of leadership functions in HCATs were included. Healthcare teams performing routine work were excluded. Studies were reviewed for type of leadership sharing and sharing-related outcomes.

RESULTS

Thirty-three articles met the inclusion criteria. A variety of shared leadership models were described across the following three categories: spontaneous collaboration, intuitive working relations, and institutionalized practices. While leadership sharing has the potential for both positive and negative influences on team performance, only six articles reported outcomes potentially attributable to shared leadership.

CONCLUSIONS

Despite strong evidence for a positive relationship between shared leadership and team performance in other domains, there is limited literature describing shared leadership models in HCATs. The association between shared leadership and team performance in HCATs is a rich area for further investigation.

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital

BACKGROUND

Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR).

METHOD

Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation.

RESULTS

This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital.

CONCLUSION

This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.

388Investigating the utility of the customised fetal growth chart: a pragmatic randomised controlled trial

Background

To determine if the routine use of a customised fetal growth chart, when compared to a standard growth chart, reduces the risk of adverse pregnancy outcome through increased detection of adverse growth.

Methods

A double-blind, single centre, randomised controlled trial was conducted. All women with a singleton pregnancy receiving routine antenatal care through hospital clinics were included and randomised to either a standard growth chart (SC) or a customised growth chart (CC). Serial measurements of symphyseal fundal height (SFH) were plotted onto the chart in the electronic clinical record; pre-programmed alerts notified the clinician when growth or size required review. The primary outcome measure was a composite perinatal morbidity/mortality outcome.

Results

3993 women were recruited; 45.4% nulliparous; 50.0% Caucasian, 17.8% Asian; 34.9% were overweight/obese prior to pregnancy; average 30 (SD 5.5) years old. The median (IQR) number of growth alerts was 2 (0-3) for both groups (p = 0.378); there was no difference in the total number of ultrasounds per pregnancy (median [IQR] 3 [2-4] for both groups, p = 0.266). There was no significant difference in primary composite outcome (CC 6.4%, SC 7.5%, p = 0.171) or individual components, apart from stillbirth (CC n = 1 0.05%, SC n = 8 0.4%, p = 0.039).

Conclusions

Use of a CC resulted in no difference in primary outcome, number of growth alerts or number of ultrasounds.

Key messages

In a large, pragmatic RCT use of a CC in conjunction with serial SFH measurements may infer some benefit over a SC, particularly in relation to stillbirth.

Do drivers of nature visitation vary spatially? The importance of context for understanding visitation of nature areas in Europe and North America

Nature visitation is important, both culturally and economically. Given the contribution of nature recreation to multiple societal goals, comprehending determinants of nature visitation is essential to understand the drivers associated with the popularity of nature areas, for example, to inform land-use planning or site management strategies to maximise benefits. Understanding the factors related to nature, tourism and recreation can support the management of nature areas and thereby, also conservation efforts and biodiversity protection. This study applied a Multiscale Geographically Weighted Regression (MGWR) to quantify the spatially varying influence of different factors associated with nature visitation in Europe and North America. Results indicated that some explanatory variables were stationary for all sites (age 15 to 65, population density (within 25 km), GDP, area, built-up areas, plateaus, and mountains). In contrast, others exhibited significant spatial non-stationarity (locally variable): needle-leaf trees (conifers), trails, travel time, roads, and Red List birds and amphibians. Needle-leaf trees and travel time were found to be negatively significant in Europe. Roads were found to have a significant positive effect in North America. Trails and Red List bird species were found to have a positive effect in both North America and North Europe, with a greater effect in Europe. Red List amphibians was the only spatially variable predictor to have both a positive and negative impact, with selected sites in North America and northern Europe being positive, whereas Iceland and central and southern Europe were negative. The scale of the response-predictor relationship (bandwidth) of these locally variable predictors was smallest for Red List amphibians at 1033 km, with all other spatially variable predictors between 9558 and 12,285 km. The study demonstrates the contribution that MGWR, a spatially explicit model, can make to support a deeper understanding of processes associated with nature visitation in different geographic contexts.

Measuring the impact of cardiotocograph decision support software on neonatal outcomes: A propensity score-matched observational study

BACKGROUND

This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46 000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique.

AIMS

This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour.

MATERIALS AND METHODS

The study cohort was divided into two equivalent 18-month epochs, before and after the introduction of INFANT-Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre- and post-implementation groups by baseline covariates. The matched cohort included 11 154 public-funded women between November 2016 and 2019, with a singleton live fetus ≥34 + 0 weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48 h, Apgar <4 at 5 min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death.

RESULTS

The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37-0.88; P = 0.01). A significant reduction in nursery admission >48 h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05-0.60; P = 0.002).

CONCLUSIONS

INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery.

Adherence to best practice: Preventing surgical site infection following caesarean section in Australia

BACKGROUND

Surgical site infection (SSI) following caesarean section is a serious but underreported problem with an estimated incidence of 5-9%. It is essential to identify adherence to established prevention strategies to reduce the incidence rate.

AIMS

The aims of this study were to quantify unwarranted variation from evidence-based practice on the prevention of SSI at caesarean section in Australia; and to identify predictors of not implementing an existing infection prevention bundle: pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal.

MATERIALS AND METHODS

An online cross-sectional survey of obstetricians and obstetric Diplomates was conducted in 2016. The primary outcome was adherence to an existing infection prevention bundle, with demographic and clinical variables predicting adherence through multivariable binary logistic regression.

RESULTS

Forty-nine percent of respondents (response rate 39.6%) reported implementing zero or only one element of the infection prevention bundle. The types of respondents most likely to have poor adherence were Diplomates (adjusted odds ratio (aOR) 2.58), obstetricians practising in private hospitals (aOR 3.34), those usually practising in public and private hospitals (aOR 2.23), and those not usually implementing a surgical safety checklist (aOR 3.77).

CONCLUSIONS

Adherence to best practice at caesarean section is low among many Australian obstetricians. Infection control practitioners and obstetricians need to collaboratively implement surgical safety checklists at caesarean section, and monitor implementation using process key performance indicators, and audit and feedback. These strategies will reduce unwarranted variation from evidence-based infection control practice.

Changes in fatigue, barriers, and predictors towards physical activity in advanced cancer patients over a period of 12 months-a comparative study

Purpose

Physical activity (PA) is recommended to improve advanced cancer patients’ (ACP) physical functioning, fatigue, and quality of life. Yet, little is known about ACPs’ attitude towards PA and its influence on fatigue and depressiveness over a longer period. This prospective, non-interventional cohort study examined ACPs’ fatigue, depression, motivation, and barriers towards PA before and after 12 months of treatment among ACP

Methods

Outpatients with incurable cancer receiving treatment at a German Comprehensive Cancer Center reporting moderate/severe weakness/tiredness during self-assessment via MIDOS II were enrolled. Fatigue (FACT-F), depression (PHQ-8), cancer-related parameters, self-assessed PA behavior, motivation for and barriers against PA were evaluated (T0). Follow-up data was acquired after 12 months (T1) using the same questionnaire.

Results

At follow-up, fatigue (p=0.017) and depressiveness (p=0.015) had increased in clinical relevant extent. Physically active ACP did not show significant progress of FACT-F (p=0.836) or PHQ-8 (p=0.799). Patient-reported barriers towards PA remained stable. Logistic regression analyses identified motivation as a positive predictor for PA at both time points (T0, β=2.152, p=0.017; T1, β =2.264, p=0.009). Clinically relevant depression was a negative predictor for PA at T0 and T1 (T0, β=−3.187, p=0.044; T1, β=−3.521, p=0.041).

Conclusion

Our findings emphasize the importance of psychological conditions in physical activity behavior of ACP. Since psychological conditions seem to worsen over time, early integration of treatment is necessary. By combining therapy approaches of cognitive behavioral therapy and exercise in interdisciplinary care programs, the two treatment options might reinforce each other and sustainably improve ACPs’ fatigue, physical functioning, and QoL.

Trial registration

German Register of Clinical Trials, DRKS00012514, registration date: 30.05.2017

Assumptions in ecosystem service assessments: Increasing transparency for conservation

Conservation efforts are increasingly supported by ecosystem service assessments. These assessments depend on complex multi-disciplinary methods, and rely on a number of assumptions which reduce complexity. If assumptions are ambiguous or inadequate, misconceptions and misinterpretations may arise when interpreting results of assessments. An interdisciplinary understanding of assumptions in ecosystem service science is needed to provide consistent conservation recommendations. Here, we synthesise and elaborate on 12 prevalent types of assumptions in ecosystem service assessments. These comprise conceptual and ethical foundations of the ecosystem service concept, assumptions on data collection, indication, mapping, and modelling, on socio-economic valuation and value aggregation, as well as about using assessment results for decision-making. We recommend future assessments to increase transparency about assumptions, and to test and validate them and their potential consequences on assessment reliability. This will support the taking up of assessment results in conservation science, policy and practice.

Implications of scale dependence for cross-study syntheses of biodiversity differences

Biodiversity studies are sensitive to well-recognised temporal and spatial scale dependencies. Cross-study syntheses may inflate these influences by collating studies that vary widely in the numbers and sizes of sampling plots. Here we evaluate sources of inaccuracy and imprecision in study-level and cross-study estimates of biodiversity differences, caused by within-study grain and sample sizes, biodiversity measure, and choice of effect-size metric. Samples from simulated communities of old-growth and secondary forests demonstrated influences of all these parameters on the accuracy and precision of cross-study effect sizes. In cross-study synthesis by formal meta-analysis, the metric of log response ratio applied to measures of species richness yielded better accuracy than the commonly used Hedges' g metric on species density, which dangerously combined higher precision with persistent bias. Full-data analyses of the raw plot-scale data using multilevel models were also susceptible to scale-dependent bias. We demonstrate the challenge of detecting scale dependence in cross-study synthesis, due to ubiquitous covariation between replication, variance and plot size. We propose solutions for diagnosing and minimising bias. We urge that empirical studies publish raw data to allow evaluation of covariation in cross-study syntheses, and we recommend against using Hedges' g in biodiversity meta-analyses.

Incremental prognostic value of tricuspid annular dilatation over the STS score

Background

Transcatheter aortic valve replacement (TAVR) is the treatment of choice in most patients with severe aortic stenosis. The Society of Thoracic Surgeons (STS) score is a well established risk score to estimate morbidity, mortality and procedural risk of patients undergoing TAVR. However, tricuspid annular Dilatation (TAD), which is an increasingly recognized pathology associated with increased mortality, is not implemented in the STS Score.

Purpose

The purpose of this analysis was to investigate the incremental prognoctic value of TAD over the STS score.

Methods

Maximal septo-lateral diameter of the tricuspid annulus was measured in 923 patients on 3-dimensional MDCT datasets. A cut-off of 23 mm/m2 body-surface area was revealed by receiver-operating curve statistics and used to define TAD. Incremental prognostic Information was tested with c-index statistics and continuous net reclassification improvement (NRI). Patients were followed for 2 years and all-cause mortality was defined as study endpoint.

Results

Of 923 patients included in this analyis, TAD was found in 370 patients (40%). Patients with TAD had a significantly higher mortality (hazard ratio 2.18 with 95% CI 1.71 and 2.78, p&lt;0.001). The mean STS score in the investigated patient cohort was 5.6±5.0. TAD provided incremental prognostic Information over the STS score when assessed with c-index statistics (rise from 0.63 to 0.66, p&lt;0.01) or continuous NRI (0.209 with 95% CI 0.127 and 0.292, p&lt;0.001). Estimated survival rates at 2 years were 88.2% (95% CI 84.5 and 92.1) in patients with a low STS score (&lt;4) and no TAD and 57.5% (95% CI 51.1 and 64.7) in patients with a high STS score (&gt;4) and TAD. Estimated survival rates in patients with a low STS score and TAD and patients with a high STS score and no TAD were similiar (75.8% with 95% CI 68.9 and 83.5 and 74.8% with 95% CI 69.2 and 80.7, respectively). Kaplan-Meier curves are shown in Figure 1.

Conclusion

TAD is a common entity in patients undergoing TAVR for severe aortic stenosis. It is associated with significantly higher mortality and provides incremental prognostic Information over the STS score.

Funding Acknowledgement

Type of funding source: None

Identifying Agricultural Frontiers for Modeling Global Cropland Expansion

The increasing expansion of cropland is major driver of global carbon emissions and biodiversity loss. However, predicting plausible future global distributions of croplands remains challenging. Here, we show that, in general, existing global data aligned with classical economic theories of expansion explain the current (1992) global extent of cropland reasonably well, but not recent expansion (1992-2015). Deviations from models of cropland extent in 1992 ("frontierness") can be used to improve global models of recent expansion, most likely as these deviations are a proxy for cropland expansion under frontier conditions where classical economic theories of expansion are less applicable. Frontierness is insensitive to the land cover dataset used and is particularly effective in improving models that include mosaic land cover classes and the largely smallholder-driven frontier expansion occurring in such areas. Our findings have important implications as the frontierness approach offers a straightforward way to improve global land use change models.

Consequences of multiple imputation of missing standard deviations and sample sizes in meta-analysis

Meta-analyses often encounter studies with incompletely reported variance measures (e.g., standard deviation values) or sample sizes, both needed to conduct weighted meta-analyses. Here, we first present a systematic literature survey on the frequency and treatment of missing data in published ecological meta-analyses showing that the majority of meta-analyses encountered incompletely reported studies. We then simulated meta-analysis data sets to investigate the performance of 14 options to treat or impute missing SDs and/or SSs. Performance was thereby assessed using results from fully informed weighted analyses on (hypothetically) complete data sets. We show that the omission of incompletely reported studies is not a viable solution. Unweighted and sample size-based variance approximation can yield unbiased grand means if effect sizes are independent of their corresponding SDs and SSs. The performance of different imputation methods depends on the structure of the meta-analysis data set, especially in the case of correlated effect sizes and standard deviations or sample sizes. In a best-case scenario, which assumes that SDs and/or SSs are both missing at random and are unrelated to effect sizes, our simulations show that the imputation of up to 90% of missing data still yields grand means and confidence intervals that are similar to those obtained with fully informed weighted analyses. We conclude that multiple imputation of missing variance measures and sample sizes could help overcome the problem of incompletely reported primary studies, not only in the field of ecological meta-analyses. Still, caution must be exercised in consideration of potential correlations and pattern of missingness.

Deciphering the Biodiversity-Production Mutualism in the Global Food Security Debate

Without changes in consumption, along with sharp reductions in food waste and postharvest losses, agricultural production must grow to meet future food demands. The variety of concepts and policies relating to yield increases fail to integrate an important constituent of production and human nutrition - biodiversity. We develop an analytical framework to unpack this biodiversity-production mutualism (BPM), which bridges the research fields of ecology and agroeconomics and makes the trade-off between food security and protection of biodiversity explicit. By applying the framework, the incorporation of agroecological principles in global food systems are quantifiable, informed assessments of green total factor productivity (TFP) are supported, and possible lock-ins of the global food system through overintensification and associated biodiversity loss can be avoided.

Maximizing HBr/Br2 in the flue gas and prevention of secondary pollution during the oxy-combustion of brominated waste electrical and electronic equipment part 1- thermodynamic considerations

Organobromine compounds comprise between 3 and 8% by weight of WEEE and mainly converted to HBr and Br₂ in the incinerator. However, these compounds, during the cooling of the flue gases, can form the PBDD/Fs in the post-combustion area of the furnace. Due to the many benefits of Oxy-combustion process, our group has developed a fluidised bed incinerator for burning the WEEE and plan to maximise HBr/Br₂ in the flue gas. Experimental results presented in the recent papers show that the combustion of the WEEE particles attains quickly to thermodynamic equilibrium. Thermodynamic modelling can, therefore, predict the concentration of brominated pollutants, particularly HBr, Br₂, HgBr₂, and Br˙ in the flue gas. In this paper, the effect of various parameters for increasing the HBr/Br₂ ratio in the flue gas has been investigated. The model shows that the addition of very small amounts of hydrogen in the post-combustion area can convert Br₂ and Br˙ into HBr.

Fatigue, barriers to physical activity and predictors for motivation to exercise in advanced Cancer patients

Background

In order to counteract fatigue, physical activity (PA) is recommended for all stages of cancer. However, only few advanced cancer patients (ACP) are physically active. Quantitative data with high numbers of ACP reporting barriers to PA are missing. This study aimed to identify barriers to PA in ACP with tiredness/weakness and investigate their motivation towards it.

Methods

Outpatients with metastatic cancer receiving cancer care at a German Cancer Center reporting moderate/severe tiredness/weakness during self-assessment (MIDOS II) were enrolled. We assessed Fatigue-(FACF-F) and Depression (PHQ8) Scores, demographics, cancer-specific parameters, motivation for PA, physical, psychological and social barriers.

Results

141 of 440 eligible patients (32.0%) with different diagnoses agreed to participate. Patients frequently reported “I feel weakened due to my tumor therapy” (n = 108; 76.6%), physical symptoms (tiredness, weakness, dyspnea, joint-problems, pain, nausea [n = 107; 75.9%]) and fatigue (n = 99; 70.2%) as barriers to PA. However, no significant group differences regarding these barriers were found between physically active and inactive patients. Social barriers were rarely chosen. Motivated patients were 5.6 times more likely to be physically active (p < 0.001), also motivation turned out to be the strongest predictor for a physically active behavior (β = 1.044; p = 0.005). Motivated attitude towards PA was predicted by fatigue (β = − 2.301; p = 0.008), clinically relevant depression (β = − 1.390, p = 0.039), knowledge about PA and quality of life (QoL) (β = 0.929; p = 0.002), PA before diagnosis (β = 0.688; p = 0.005 and Interest in exercise program (β = 0.635; p = 0.008).

Conclusion

“I feel weakened due to my tumor therapy” is the most reported barrier to PA among both, physically and inactive patients. Motivation for PA is the strongest predictor of performing PA. Interest in PA, knowledge about PA/QoL and PA before diagnosis are main predictors of a motivated attitude. Absence/presence of social barriers did not associate with motivation, fatigue and depression proved to be a negative predictor. Programs including information, motivational counseling and individualized training should be offered for ACP to overcome barriers and reduce fatigue.

Trial registration

German Register of Clinical Trials DRKS00012514, registration date: 30.5.2017.

BESTMAP: behavioural, Ecological and Socio-economic Tools for Modelling Agricultural Policy

Half of the European Union (EU) land and the livelihood of 10 million farmers is threatened by unsustainable land-use intensification, land abandonment and climate change. Policy instruments, including the EU Common Agricultural Policy (CAP) have so far failed to stop this environmental degradation. BESTMAP will: 1) Develop a behavioural theoretical modelling framework to take into account complexity of farmers’ decision-making; 2) Develop, adapt and customize a suite of opensource, flexible, interoperable and customisable computer models linked to existing data e.g. LPIS/IACS and remote sensing e.g. Sentinel-2; 3) Link economic, individual-farm agent-based, biophysical ecosystem services and biodiversity and geostatistical socio-economic models; 4) Produce a simple-to-use dashboard to compare scenarios of Agri-Environmental Schemes adoption; 5) Improve the effectiveness of future EU rural policies’ design, monitoring and implementation.

TRY plant trait database - enhanced coverage and open access

Plant traits-the morphological, anatomical, physiological, biochemical and phenological characteristics of plants-determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait-based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits-almost complete coverage for 'plant growth form'. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait-environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives.

Midwifery leadership in maternity emergencies: a video analysis

Maternity emergencies require effective leadership due to their time-critical high stakes nature, and like many emergency teams are recommended to have a singular leader. Midwives possess many of the skills required for leadership, but the extent to which they contribute to leadership in emergencies is unknown. In this video analysis study of 16 interprofessional teams responding to a simulated post-partum hemorrhage, a functional view of leadership was applied to determine midwifery contribution to leadership. The number and type of leadership utterances by team members during an emergency response was assessed, and midwifery and doctor leadership utterances compared. Midwives contributed just over 40% of all leadership utterances, indicating the occurrence of interprofessional shared leadership, despite the recommendation for a singular leadership. While the number of leadership utterances per scenario was similar for midwives and doctors, midwives contributed less to utterances of a clinical nature compared to doctors but a similar amount of non-clinical leadership. Further exploration of the factors which influence midwifery leadership in emergencies and the impact it may have on patient care is warranted.

1336Outcome analysis of systolic or diastolic CT acquisition prior to transcatheter aortic valve replacement to estimate prothesis size

Background

Computed tomography (CT) imaging is considered as standard of care for transcatheter aortic valve replacement (TAVR) prothesis sizing. ECG-triggered high-pitch helical CT data acquisition on dual-source CT systems is associated with less contrast volumes, but CT image reconstruction of the aortic valve is limited to a single time point within the cardiac cycle. Although systolic CT imaging of the aortic valve is recommended due to the changes in aortic annulus area during the cardiac cycle, this recommendation is not supported by clinical outcome data.

Purpose

The study aimed to assess the impact of systolic vs. diastolic CT imaging of the aortic annulus for TAVR sizing on patient outcomes in a large series of patients.

Methods

In the study CT images of 1346 patients undergoing TAVR at our centre from 2013–2016 were re-evaluated. Patients were stratified into two groups with 0–35% and 36–99% of the RR-interval as systolic and diastolic CT imaging. Outcomes according to VARC2-criteria at 30 days and long-term survival were analysed.

Results

CTs of 1135 out of 1346 patients were analysed retrospectively, 278 (24.5%) of which were acquired during systole and 859 (75.5%) during diastole. Mean age was 80.6±7.6 years and 52.2% were female. Mean follow-up, available for 83.4% of patients, was 2.1±0.8 years. No significant difference in baseline characteristics was observed across both groups.

Aortic annular area measurements were significantly larger in systole (mean aortic anulus area: systole: 4.8±1.0 cm2; diastole: 4.5±1.0 cm2, p<0.01), resulting in larger implanted valves. Balloon-expandable valves were used in 69.4% of patients; the need for post-dilation did not differ between both groups (systole 4.7%, and diastole 7.5%; p=0.13).

There was no difference between groups concerning the combined endpoints for device success or early safety according to VARC2-criteria. Overall 30-day mortality was 3.4% (systole: 4.2% and diastole: 3.1%, p=0.35). Device failure occurred in 2.7% (systole: 2.9% and diastole: 2.7%, p=0.83). Permanent pacemaker implantation was required in 20.1% (systole: 18.7%, and diastole: 20.5%; p=0.55). Stroke rate at 30 days was 2.9%, n=33 and was similar in the two groups. The landmark analysis demonstrates the 30-day and 1-year mortality rates for both groups (Figure).

Figure 1. Landmark analysis mortality

Conclusion

The current analysis does not suggest that systolic CT imaging for TAVR sizing is associated with improved early or late outcomes. Accordingly, full-cycle CT imaging which usually is associated with higher contrast volumes, should be avoided in this elderly population, which often presents with reduced kidney function.

1335Tricuspid anular dilatation is associated with higher mortality in patients undergoing TAVR

Background

Tricuspid annular dilatation is an increasingly recognized entity associated with poor outcomes in patients with valvular heart disease, which led to upvaluation of tricuspid annuloplasty in current European and U.S. guidelines on valvular heart disease.

Purpose

To investigate the prognostic role of tricuspid annular dilatation measured in multi-slice CT (MDCT) datasets in patients undergoing transfemoral aortic valve replacement (TAVR).

Methods

All consecutive patients with available MDCT data undergoing TAVR at our institution between 2013 und 2016 were included. Maximal septal-lateral diameter was obtained from 3-dimensional MDCT datasets. Receiver-operating curves (ROC) analysis was performed to obtain an ideal cut-off for septal-lateral dilatation in systolic and diastolic heart phase. All-cause mortality served as endpoint.

Results

The study included 1137 patients, of whom 299 died within a mean follow-up period of 1.8±1 years. Mean patient's age was 80.6 years and 51.5% were women. TAVR was performed via transfemoral approach in all patients and balloon-expandable prosthesis were used in 69.4% of patients. ROC analysis revealed a cut-off of 45.7 mm for diastolic MDCT scans (n=859) and 36.1 mm for systolic MDCT scans (n=278). Patients above this threshold experienced a significantly higher mortality within the follow-up period (s. attached Figure, hazard ratio 1.63 with 95% CI 1.39 and 1.92, p<0.001). Tricuspid annular dilatation had no impact on procedural outcomes including device failure (2.4 vs. 2.9%, p=0.7), need for permanent pacemaker implantation (17.6 vs. 21.3%, 0.16, acute myocardial infarction (0.3 vs. 1.2%, p=0.18) and acute stroke (1.8 vs. 1.1%, p=0.28) defined according to Valve Academic Research Consortium-2 (VARC-2) criteria.

Conclusion

Tricuspid annular dilatation assessed with MDCT in patients undergoing TAVR is associated with 63% higher all-cause mortality. Future studies will have to determine whether interventional tricuspid annuloplasty techniques can reduce mortality in this group of patients.

Predicting the duration of induction of labour in nulliparous women

This study examined if the modified Bishops score (MBS) at the start of an induction of labour (IOL) (VE-1) or if the MBS after pharmacological/mechanical ripening (VE-2) was the better predictor of the duration of induced labour and whether there was one component of the score that was most predictive of time to delivery.The measures at VE-2 were correlated more strongly with the time to birth, than VE-1 measures. At both VE-1 and VE-2, component measures (especially position of the cervix) showed weak correlation compared to composite measures. Omitting position from the composite score resulted in a simplified modified Bishops score (sMBS) that had the highest correlation coefficients. A model comprising sMBS and 5 clinical variables explained ∼73% of the variance.The vaginal examination findings prior to an IOL do not impact how long the labour may take. A more favourable cervix ∼12 h later (measured using a 4-item composite of dilatation, length, consistency and station) predicts a quicker induced labour.Impact statementWhat is already known? Induction of labour (IOL) is a common obstetric intervention in Australia. The IOL process can be a protracted and sometimes frustrating experience for women, and it may not result in a vaginal birth. A 'failed induction' or 'failure to progress' are relatively common indications for caesarean section (CS) in this setting where, despite many hours of an oxytocin infusion, the woman does not establish or progress in the active phase of labour.What does this study add? The measures at VE-2 were correlated more strongly with the time to birth, than VE-1 measures. At both VE-1 and VE-2, component measures (especially position of the cervix) showed weak correlation compared to composite measures. Omitting position from the composite score resulted in a simplified modified Bishops score (sMBS) that had the highest correlation coefficients. A model comprising sMBS and 5 clinical variables explained ∼73% of the variance.What are the implications of these findings? It is not the initial VE that is most predictive of the duration of labour but rather the VE after cervical ripening (mechanical or pharmacological). Simplified MBS (without the component of position of cervix) is most predictive of labour duration.

Conventional land-use intensification reduces species richness and increases production: A global meta-analysis

Most current research on land-use intensification addresses its potential to either threaten biodiversity or to boost agricultural production. However, little is known about the simultaneous effects of intensification on biodiversity and yield. To determine the responses of species richness and yield to conventional intensification, we conducted a global meta-analysis synthesizing 115 studies which collected data for both variables at the same locations. We extracted 449 cases that cover a variety of areas used for agricultural (crops, fodder) and silvicultural (wood) production. We found that, across all production systems and species groups, conventional intensification is successful in increasing yield (grand mean + 20.3%), but it also results in a loss of species richness (-8.9%). However, analysis of sub-groups revealed inconsistent results. For example, small intensification steps within low intensity systems did not affect yield or species richness. Within high-intensity systems species losses were non-significant but yield gains were substantial (+15.2%). Conventional intensification within medium intensity systems revealed the highest yield increase (+84.9%) and showed the largest loss in species richness (-22.9%). Production systems differed in their magnitude of richness response, with insignificant changes in silvicultural systems and substantial losses in crop systems (-21.2%). In addition, this meta-analysis identifies a lack of studies that collect robust biodiversity (i.e. beyond species richness) and yield data at the same sites and that provide quantitative information on land-use intensity. Our findings suggest that, in many cases, conventional land-use intensification drives a trade-off between species richness and production. However, species richness losses were often not significantly different from zero, suggesting even conventional intensification can result in yield increases without coming at the expense of biodiversity loss. These results should guide future research to close existing research gaps and to understand the circumstances required to achieve such win-win or win-no-harm situations in conventional agriculture.

Addressing the pitfalls when designing intervention studies to discover and validate biomarkers of habitual dietary intake

INTRODUCTION

Dietary exposure monitoring within populations is reliant on self-reported measures such as Food Frequency Questionnaires and diet diaries. These methods often contain inaccurate information due to participant misreporting, non-compliance and bias. Urinary metabolites derived from individual foods could provide additional objective indicators of dietary exposure. For biomarker approaches to have utility it is essential that they cover a wide-range of commonly consumed foods and the methodology works in a real-world environment.

OBJECTIVES

To test that the methodology works in a real-world environment and to consider the impact of the major sources of likely variance; particularly complex meals, different food formulations, processing and cooking methods, as well as the dynamics of biomarker duration in the body.

METHODS

We designed and tested a dietary exposure biomarker discovery and validation strategy based on a food intervention study involving free-living individuals preparing meals and collecting urine samples at home. Two experimental periods were built around three consecutive day menu plans where all foods and drinks were provided (n = 15 and n = 36).

RESULTS

The experimental design was validated by confirming known consumption biomarkers in urinary samples after the first menu plan. We tested biomarker performance with different food formulations and processing methods involving meat, wholegrain, fruits and vegetables.

CONCLUSION

It was demonstrated that spot urine samples, together with robust dietary biomarkers, despite major sources of variance, could be used successfully for dietary exposure monitoring in large epidemiological studies.

Implementation of gestational weight gain guidelines - what's more effective for ensuring weight recording in pregnancy?

Background

Pregnant women who gain weight in accordance with guidelines have the lowest risk of pregnancy and birth-related complications. However, evidence-practice gaps often exist. To address pregnancy weight management barriers, a stepped implementation science approach was used, comprising targeted in-services, provision of scales for clinic rooms, and changes to routine weight recording in a hospital electronic medical record. The aim of this study was to assess the cumulative influence of evidence-based interventions on staff’s compliance to recording of antenatal weights.

Methods

Retrospective data analysis of weight recording over three 15-month cohorts across April 2014–December 2017. Variables calculated from data included: proportion of women with weight recorded at booking and proportion of women who had a weight recorded at each visit. Generalised estimating equation modelling was used to examine differences in weight recording compliance rates between cohorts, pre-pregnancy body mass index categories, model of care and clinicians.

Results

There were approximately 13,000 pregnancies in each cohort. The proportion of women who had a weight recorded at each visit per cohort differed significantly between cohorts from 4.2% (baseline), 18.9% (scales and in-services) to 61.8% (medical record prompts), p < 0.001.

Conclusion

Significant improvements were achieved through systematic barrier analysis and subsequent mapping and implementation of appropriate and effective interventions. Improvements were observed across the entire service, in all models of care with all professional groups demonstrating increased recording of weights.

Leadership sharing in maternity emergency teams: a retrospective cohort study in simulation

Background

Shared leadership is associated with improved team performance in many domains, but little is understood about how leadership is shared spontaneously in maternity emergency teams, and if it is associated with improved team performance.

Methods

A video analysis study of multidisciplinary teams attending a maternity emergency management course was performed at a simulation centre colocated with a tertiary maternity hospital. Sixteen teams responding to a simulated postpartum haemorrhage were analysed between November 2016 and November 2017. Videos were transcribed, and utterances coded for leadership type using a coding system developed a priori. Distribution of leadership utterances between team members was calculated using the Gini coefficient. Teamwork was assessed using validated tools and clinical performance was assessed by time to perform a critical intervention and a checklist of required tasks.

Results

There was a significant sharing of leadership functions across the team despite the traditional recommendation for a singular leader, with the dominant leader only accounting for 58% of leadership utterances. There was no significant difference in Auckland Team Assessment Tool scores between high and low leadership sharing teams (5.02 vs 4.96, p=0.574). Time to critical intervention was shorter in low leadership sharing teams (193 s vs 312 s, p=0.018) but checklist completion did not differ significantly. Teams with better clinical performance had fewer leadership utterances beyond the dominant two leaders compared with poorer performing teams.

Conclusions

Leadership is spontaneously shared in maternity emergency teams despite the recommendation for singular leadership. Spontaneous leadership emerging from multiple team members does not appear to be associated with the improvements in team performance seen in other domains.

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.