Audit and feedback : effects on professional obstetrical practice and health care outcomes

Orientadores: Jose Guilherme Cecatti, Helaine Maria Besteti Pires MilanezDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Introdução: Auditoria e Feedback, estratégia de intervenção na prática médica, sendo um resumo da atuação durante certo período, com posterior formulação de recomendações para a melhoria do serviço estudado. Sua efetividade ainda é incerta em Obstetrícia. Objetivo: Estudar o processo de Auditoria e Feedback em Obstetrícia e implementar o uso do material da Reproductive Health Library. Avaliar o possível efeito da intervenção sobre as taxas de parto por cesárea, com a utilização da classificação de Robson. Métodos: coleta prospectiva de dados sobre os seis parâmetros obstétricos selecionados segundo publicações baseadas em evidência, antes e depois de um período de intervenção, preparado após análise dos índices de prevalência de cada prática: episiotomia seletiva, cardiotocografia contínua durante o trabalho de parto em gestações de baixo risco, antibioticoprofilaxia no parto por cesárea, uterotônico no terceiro período do parto, indução de parto às 41 semanas em gestações de baixo risco e suporte contínuo durante o trabalho de parto. Realizado agrupamento de todos os partos segundo a classificação de Robson, em 10 grupos, levando em conta o antecedente obstétrico, tipo de gestação, curso do trabalho de parto e idade gestacional. Resultados: os dois períodos foram similares quanto às características obstétricas gerais. Com relação aos parâmetros selecionados, foi observada redução significativa do uso de episiotomia seletiva (RR 0.84 IC95% 0.73-0.97), embora o mesmo não tenha ocorrido entre as primigestas (p=0,315), aumento na presença de acompanhante durante o trabalho de parto (RR 1.42; 1.24-1.63) e adequação de uso de uterotônico (ocitocina 10UI) no terceiro período (p<0,0001). Segundo a classificação de Robson, não ocorreu alteração no índice global de partos cesárea nos dois períodos estudados (respectivamente 45.5% e 43.3%). Houve predomínio do Grupo 3 (multipara sem cesárea anterior, feto único, cefálico, de termo, trabalho de parto espontâneo) com índices de 28.5 e 26.8% respectivamente. O segundo mais prevalente foi o Grupo 1 (nulípara, feto único, cefálico, termo e trabalho de parto espontâneo), com 25.5 e 22.6% do total de partos, seguido pelo Grupo 5 (multípara com cesárea prévia, feto único, cefálico, gestação de termo), com taxas de 22.9 e 21.3% respectivamente. O Grupo 5 foi também responsável pela maior contribuição ao número total de cesáreas (36.4 e 34.6% nos dois períodos). Os Grupos 2 (nulípara, feto único, cefálico, de termo, em trabalho de parto induzido ou cesárea antes de trabalho de parto) e 4 (multípara, feto único, cefálico, de termo, em trabalho de parto induzido ou cesárea antes de trabalho de parto), embora tenham pouca contribuição ao número total de partos, demonstraram altos índices de cesárea dentro do seus grupos. O grupo 10, composto por prematuros, foi o quarto mais prevalente, também com altos índices de cesárea no seu grupo, porém com redução significativa entre os períodos pré e pós-intervenção (p=0.0058). Conclusão: o processo de Auditoria e feedback pode ser utilizado como mecanismo de implementação em obstetrícia, sobretudo quando a equipe é receptiva a mudanças.Abstract: Background: Audit and feedback is a widely used strategy to improve professional practice and can be defined as any summary of clinical performance of health care over a period of time, which may include recommendations for clinical action. Its effectiveness is still uncertain in Obstetrics. Objectives: to assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to implement the use of RHL material as a routine in medical practice; to evaluate the effect of the intervention over the incidence of caesarean sections, according to the Robson's classification, in 10 groups. Methods: The study proposed has an audit and feedback design and was conducted in the obstetric Unit of the University of Campinas, Brazil, between the years 2007- 2008. It started by providing up to date estimates of prevalence rates of six audit standards underwritten by evidence-based recommendations: selective episiotomy; continuous electronic fetal monitoring during uncomplicated labour of low risk pregnant women; antibiotic prophylaxis for women undergoing caesarean section; use of oxytocin after delivery as one of the procedures of active management of third stage of labour; routine induction of labour at 41 weeks for uncomplicated pregnancies and continuous support for women during childbirth. The results were then analyzed and presented as feedback to clinical practice. Active information based on the WHO Reproductive Health Library (RHL) was prepared to remind important and reliable health care interventions during meetings with the whole maternity staff. After four months, the same practices were again measured and analyzed to compare data and assess if the intervention was effective. All caesarean sections were evaluated according to Robson's Classification to study a possible effect of the intervention on caesarean rates. Results: both periods studied showed equivalency in the total number of deliveries, vaginal and caesarean births, forceps and deliveries in nulliparous. Considering the obstetric practices evaluated, there was a significant reduction in selective episiotomy (RR 0.84 95%CI 0.73-0.97), but not in nulliparous (p=0.315); an increase in continuous support for women during childbirth (RR 1.42; 1.24-1.63). There was also a change in the institution protocol for the use of uterotonic (oxitocyn) during third stage of labor, with a shift to the WHO recommended dosage of 10UI (p<0.0001). There was no change observed in the use of continuous electronic fetal monitoring, routine induction of labour at 41 weeks for uncomplicated pregnancies and antibiotic prophylaxis in caesarean sections. Considering caesarean sections, there was no prevalence change after intervention. Robson's classification was applied and Group 3 (multiparous excluding previous CS, single, cephalic, =37 weeks, spontaneous labour) accounted for the largest proportion of deliveries, 28.5% and 26.8% in both periods. Group 1 (nulliparous, single, cephalic, =37 weeks, spontaneous labour) was the second largest one, with 25.5% and 22.6% respectively, while Group 5 (previous caesarean section, single, cephalic, =37 weeks) was the third, with percentages of 22.9% and 21.3% respectively. Group 5 also represented the most prevalent when considering only caesarean sections, accounting for 36.4% and 34.6% in both periods. Groups 2 (nulliparous, single, cephalic, =37 weeks, induction or CS before labour) and 4 (multiparous excluding previous CS, single, cephalic, =37 weeks, induction or CS before labour) had low contribution for the total number of deliveries, however they had higher rates of caesarean sections within each group. Group 10 (all single, cephalic, = 36 weeks, including previous CS) represented the fourth largest among all deliveries, with respectively 6.6% and 8.6%. Within its group, the rate of caesarean section was high, with a significant decrease from 70.5% to 42.6%, from pre to post intervention period (p=0.0058). Conclusion: Audit and feedback can be used as a successful implementation tool in obstetrics, especially when the medical staff is open and receptive to change.MestradoTocoginecologiaMestre em Tocoginecologi

Host and viral mechanisms of congenital Zika syndrome

In 2015-2016, in the Americas, and especially in northeast Brazil, a significant number of cases of microcephaly and other congenital brain abnormalities were linked with an outbreak of Zika virus (ZIKV) infection in pregnant women. While maternal symptoms of ZIKV are generally mild and self-limiting, clinical presentation in fetuses and newborns infected is extensive and includes microcephaly, decreased cortical development, atrophy and hypoplasia of the cerebellum and cerebellar vermis, arthrogryposis, and polyhydramnios. The term congenital ZIKV syndrome (CZS) was introduced to describe the range of findings associated with maternal-fetal ZIKV transmission. ZIKV is primarily transmitted b

Fake News on the Covid-19 outbreak: a new metadata-based dataset for the analysis of Brazilian and British Twitter posts

Abstract. The dissemination of fake news is a problem that has already been ad-dressed but by no means is solved. After the manipulation made by Cambridge Analytica which was based on classifying users by their political views and tar-geting specific political propaganda on the Brexit campaign, the Trump election and the Bolsonaro election, there is no doubt this issue can have a real impact on society. During a pandemic, any type of fake news can be the difference between life and death when the data shared can directly hurt the people who are believing in it. Moreover, there is also a new trend of using artificial robots to disseminate such news with a special target on Twitter which can be linked with political campaigns. Thus, it is essential that we identify and understand what kind of news is selected to be dressed as fake and how it is disseminated. This paper aims to investigate the dissemination of fake news related withCovid-19 in the UK and Brazil in order to understand the impact of fake news on public sector actions, social isolation and quarantine imposition. Those two case studies are well versed on the fake news dissemination. Our initial dataset of Twitter posts has focused on posts from four different cities (Natal, Sao Paulo, Sheffield and London) and has shown interesting pointers that will be discussed

PREVALENCE OF HYPERTENSION AND DIABETES MELLITUS AMONG INDIGENOUS PEOPLES

Objective: to analyze the prevalence of systemic hypertension and diabetes mellitus among indigenous villagers associated with ethnicity and describe the frequency of care/diagnosis according to professional category.Method: epidemiological and descriptive study, carried out with data on Systemic Hypertension and Diabetes Mellitus produced in the Distritos Sanitários Especiais Indígenas (Special Indigenous Health Districts of Pará), between 2013-2017, obtained from the Sistema de Informações da Atenção à Saúde Indígena (Indigenous Health Care Information System). For analysis, the morbidities weregrouped, and Pearson’s Chi-square was used, p≤0.05.Results: 624 cases of Systemic Arterial Hypertension and 108 cases of Diabetes mellitus were studied, identifying a greater involvement of women. The Munduruku ethnic group showed a higher prevalence of systemic hypertension (35.0%; n=219) and diabetes mellitus (23.1%; n=25). It was observed expressive participation of the nursing team in the care of indigenous peoples.Conclusion: The identified prevalence can be attributed to the accelerated nutritional transition and changes in lifestyle habits. Such findings are important for qualified and culturally meaningful nursing care.Objetivo: analisar prevalência de Hipertensão Arterial Sistêmica e Diabetes mellitus nos indígenas aldeados associadas à etnia e descrever a frequência de atendimento/diagnóstico segundo categoria profissional.Método: estudo epidemiológico, descritivo, realizado com dados de Hipertensão Arterial Sistêmica e Diabetes mellitus produzidos nos Distritos Sanitários Especiais Indígenas, do Pará, entre 2013-2017, obtidos do Sistema de Informações da Atenção à Saúde Indígena. Para análise, agrupou-se as morbidades e utilizou-se o Qui-quadrado de Pearson, p≤0,05.Resultados: foram estudados 624 casos de Hipertensão Arterial Sistêmica e 108 casos de Diabetes mellitus, identificando-se maior acometimento de mulheres. A etnia Munduruku apresentou maior prevalência de Hipertensão Arterial Sistêmica (35,0%; n=219) e Diabetes mellitus (23,1%; n=25). Observou-se participação expressiva da equipe de enfermagem no atendimento aos indígenas.Conclusão: A prevalência identificada pode ser atribuída à acelerada transição nutricional e mudanças nos hábitos de vida. Tais achados são importantes para assistência de enfermagem qualificada e culturalmente significada.Objetivo: analizar la prevalencia de Hipertensión Arterial Sistémica y de la Diabetes mellitus en pobladores indígenas asociada a la etnia y describir la frecuencia de atención/diagnóstico según la categoría profesional. Método: estudio epidemiológico y descriptivo, realizado con datos de hipertensión arterial sistémica y diabetes mellitus producidos en los Distritos Especiales de Salud Indígena del Estado de Pará, entre 2013-2017, obtenidos del Sistema de Información de Atención a la Salud Indígena. Para el análisis, se agruparon las morbilidades y se utilizó la prueba de chi-cuadradode Pearson, p≤0,05. Resultados: Se estudiaron 624 casos de Hipertensión Arterial Sistémica y 108 casos de Diabetes mellitus, identificando una mayor afectación de las mujeres. El grupo étnico Munduruku mostró una mayor prevalencia de hipertensión sistémica (35,0%; n=219) y de diabetes mellitus (23,1%; n=25). Se observó la participación expresiva del equipo de enfermería en el cuidado de los indígenas. Conclusión: La prevalencia identificada puede atribuirse a la transición nutricional acelerada y a los cambios en los hábitos de vida. Estos resultados son importantes para una atención de enfermería cualificada y culturalmente significativa

Metabolomics applied to maternal and perinatal health : a review of new frontiers with a translation potential

The prediction or early diagnosis of maternal complications is challenging mostly because the main conditions, such as preeclampsia, preterm birth, fetal growth restriction, and gestational diabetes mellitus, are complex syndromes with multiple underlying mechanisms related to their occurrence. Limited advances in maternal and perinatal health in recent decades with respect to preventing these disorders have led to new approaches, and “omics” sciences have emerged as a potential field to be explored. Metabolomics is the study of a set of metabolites in a given sample and can represent the metabolic functioning of a cell, tissue or organism. Metabolomics has some advantages over genomics, transcriptomics, and proteomics, as metabolites are the final result of the interactions of genes, RNAs and proteins. Considering the recent “boom” in metabolomic studies and their importance in the research agenda, we here review the topic, explaining the rationale and theory of the metabolomic approach in different areas of maternal and perinatal health research for clinical practitioners. We also demonstrate the main exploratory studies of these maternal complications, commenting on their promising findings. The potential translational application of metabolomic studies, especially for the identification of predictive biomarkers, is supported by the current findings, although they require external validation in larger datasets and with alternative methodologies

ADESÃO AO TRATAMENTO FISIOTERAPÊUTICO EM ADOLESCENTES COM FIBROSE CÍSTICA

Objetivo: Avaliar o grau de adesão ao tratamento fisioterapêutico em adolescentes com Fibrose Cística (FC) acompanhados em um programa multidisciplinar. Método: Estudo observacional de corte transversal com 14 pacientes do ambulatório multidisciplinar de FC no período de maio de 2016 a outubro de 2016. Foi aplicado um questionário próprio para determinar a adesão da fisioterapia; conjuntamente com a adesão do medicamento alfadornase, analisada através do Teste de Morisky-Green e a gravidade da doença, foi avaliada pela aplicação do Escore de Shwachman-Kulczycki. Resultados: A idade média dos pacientes foi de 15 anos, sendo 8 (57,1%) do sexo masculino. De acordo com o grau de adesão, 5 (35,7%) foram classificados com baixa adesão, 4 (28,6%) com moderada adesão e 5 (35,7%) com alta adesão. O escore de Shwachman-Kulczycki foi classificado em excelente 6 (48,8%), bom 4 (28,5%), leve 3 (21,4%), moderado 1 (7,1%). No presente estudo não foi observada correlação da adesão da fisioterapia com o escore de gravidade, e também com o uso da medicação alfadornase. Conclusão: Foi observada adesão satisfatória (moderada a alta) para fisioterapia respiratória em 64,3% dos adolescentes com FC investigados. No entanto, notou-se um equilíbrio entre baixa adesão e alta adesão (35,7%) para esse tratamento

The global EPTO database: Worldwide occurrences of aquatic insects

Motivation: Aquatic insects comprise 64% of freshwater animal diversity and are widely used as bioindicators to assess water quality impairment and freshwater eco-system health, as well as to test ecological hypotheses. Despite their importance, a comprehensive, global database of aquatic insect occurrences for mapping freshwater biodiversity in macroecological studies and applied freshwater research is missing. We aim to fill this gap and present the Global EPTO Database, which includes world-wide geo- referenced aquatic insect occurrence records for four major taxa groups: Ephemeroptera, Plecoptera, Trichoptera and Odonata (EPTO).Main type of variables contained: A total of 8,368,467 occurrence records globally, of which 8,319,689 (99%) are publicly available. The records are attributed to the cor-responding drainage basin and sub-catchment based on the Hydrography90m dataset and are accompanied by the elevation value, the freshwater ecoregion and the pro-tection status of their location. Spatial location and grain: The database covers the global extent, with 86% of the observation records having coordinates with at least four decimal digits (11.1 m preci-sion at the equator) in the World Geodetic System 1984 (WGS84) coordinate refer-ence system.Time period and grain: Sampling years span from 1951 to 2021. Ninety- nine percent of the records have information on the year of the observation, 95% on the year and month, while 94% have a complete date. In the case of seven sub-datasets, exact dates can be retrieved upon communication with the data contributors. Major taxa and level of measurement: Ephemeroptera, Plecoptera, Trichoptera and Odonata, standardized at the genus taxonomic level. We provide species names for 7,727,980 (93%) records without further taxonomic verification.Software format: The entire tab-separated value (.csv) database can be downloaded and visualized at https://glowabio.org/project/epto_database/ . Fifty individual data-sets are also available at https://fred.igb-berlin.de, while six datasets have restricted access. For the latter, we share metadata and the contact details of the authors

Manifesto à cidade de Ponta Delgada dos arquitetos e estudantes de arquitetura micaelense

Os micaelenses sabem-no já: o importante conjunto da nova praça lado-sul da matriz, está projectado e vai erguer-se em moldes pombalinos!... A incongruência e o absurdo de uma tal proposição sente-o todo e qualquer leigo; basta para tanto boa fé e um pouco de bom senso