gEYEded: Subtle and Challenging Gaze-Based Player Guidance in Exploration Games

This paper investigates the effects of gaze-based player guidance on the perceived game experience, performance, and challenge in a first-person exploration game. In contrast to existing research, the proposed approach takes the game context into account by providing players not only with guidance but also granting them an engaging game experience with a focus on exploration. This is achieved by incorporating gaze-sensitive areas that indicate the location of relevant game objects. A comparative study was carried out to validate our concept and to examine if a game supported with a gaze guidance feature triggers a more immersive game experience in comparison to a crosshair guidance version and a solution without any guidance support. In general, our study findings reveal a more positive impact of the gaze-based guidance approach on the experience and performance in comparison to the other two conditions. However, subjects had a similar impression concerning the game challenge in all conditions

Gerinnungsdiagnostik bei der postpartalen Hämorrhagie

Die postnatale Hämorrahagie (PPH), gemäss WHO definiert als Blutverlust von mindestens 500 ml innerhalb von 24 Stunden nach der Entbindung, ist eine der Hauptusachen für schwere mütterliche Morbidität und Mortalität, sowohl in ressourcenschwachen Ländern als auch in industrialisierten Ländern

Gerinnungsmanagement bei der postpartalen Hämorrhagie

Jede schwere postpartale Hämorrhagie (PPH) wird aufgrund der Pathophysiologie und der Behandlung in eine erworbene Gerinnungsstörung münden. Deshalb ist es unumgänglich, dass auch Geburtshelfer/innen die Grundzüge des Gerinnungsmanagements bei der PPH beherrschen. In einem ersten Schritt gilt es, die postpartal häufig anzutreffende gesteigerte Fibrinolyse zu durchbrechen durch die Gabe von Tranexamsäure. Die weiteren Schritte dienen der Aufrechterhaltung funktionierender Rahmenbedingungen für die Gerinnung: Volumenersatz durch kristalloide Infusionslösungen (keine Kolloide), Achten auf Körpertemperatur sowie Korrektur von Kalzium- und pH-Werten. Im Falle einer anhaltenden schweren PPH mit entsprechend hohem Blutverlust gilt es, die Gerinnung durch Gabe von Einzelfaktoren zu stützen (Faktor XIII, Fibrinogen) sowie ggf. Thrombozyten und Erythrozyten zu ersetzen. Bei massivem Blutverlust ist auf adäquaten Ersatz des Plasmavolumens zu achten; bei gleichzeitiger Koagulopathie bietet sich die Verabreichung von gefrorenem Frischplasma (FFP) an. Nach überstandener PPH besteht postpartal ein erhöhtes Thromboembolierisiko mit entsprechender Notwendigkeit zur Thromboseprophylaxe. = Virtually all cases of severe postpartum hemorrhage (PPH) lead to a coagulation disorder. Thus, it is essential that obstetricians are also familiar with the main features of coagulation management during PPH. The first step is to reduce increased fibrinolysis, which regularly occurs during PPH, by administering tranexamic acid. Further steps aim at establishing a functioning setting for the coagulation system: fluid resuscitation with isotonic crystalloids (avoid colloids), maintaining normothermia, correcting pH and preserving normocalcaemia. In the case of severe PPH with ongoing bleeding it is essential to replace coagulation factors (factor XIII, fibrinogen) and, if necessary, to transfuse platelets and erythrocytes. In the case of heavy blood loss and existing coagulopathy, it may become necessary to replace plasma volume through the administration of fresh frozen plasma (FFP). After successful treatment of PPH, patients are at increased risk for thrombotic events and should receive antithrombotic prophylaxis

Morbiditäts- und Mortalitätskonferenz

Die Morbiditäts- und Mortalitätskonferenz (MuM-Konferenz) definiert sich als regelmäßige interdisziplinäre Fallkonferenz von vermeidbaren und/oder unerwünschten Ereignissen. Ziel ist die Sicherstellung eines zeitnahen und kontinuierlichen Verbesserungsprozesses von Behandlungsqualität und Patientensicherheit sowie der Stärkung der Zusammenarbeit und Sicherheitskultur. Dieser Beitrag bietet praktische Tipps und Tricks für die Vorbereitung, Durchführung und Nachbereitung einer MuM-Konferenz anhand unserer Erfahrungen in der Klinik für Geburtshilfe des UniversitätsSpitals Zürich. Die MuM-Konferenz reiht sich in eine Reihe von Maßnahmen ein, welche maßgebend zur Verbesserung von Zusammenarbeit, Behandlungsqualität, Patientensicherheit und Sicherheitskultur sowie der Erweiterung relevanter Wissens- und Handlungskompetenzen beitragen

Success Rate and Long-Term Effects of Embolization of Pelvic Arteries for the Treatment of Postpartum Hemorrhage

Introduction: Postpartum hemorrhage (PPH) is the leading cause of peripartal maternal mortality and accounts for 25% of all maternal deaths worldwide. The most common reasons of PPH are uterine atony, retained placenta, or placenta accreta spectrum. Treatment of PPH depends on the etiology and corresponds to a stepwise approach, which follows the German, Austrian and Swiss guideline for the diagnosis and therapy of PPH in Switzerland. In severe ongoing PPH, hysterectomy has been the ultima ratio for many decades. Nowadays, interventional embolization of the pelvic arteries (PAE) has become a popular alternative. Besides being a highly effective minimally invasive method, PAE avoids hysterectomy with consecutively reduced morbidity and mortality. However, data on the long-term effects of PAE on fertility and menstrual cycle are scarce. Methods: We performed a monocentric study consisting of a retro- and a prospective part including all women who had undergone a PAE between 2012 and 2016 at University Hospital Zurich. Descriptive characteristics of patients and efficacy of PAE defined as cessation of bleeding were analyzed retrospectively. In the prospective part, all patients were contacted for a follow-up questionnaire regarding menstruation and fertility after embolization. Results: Twenty patients with PAE were evaluated. Our data showed a success rate of PAE in 95% of patients with PPH; only 1 patient needed a second, then successful, PAE. No patient needed a hysterectomy or any other surgical intervention. In our study, an association between mode of delivery and identified etiology of PPH is observed. After spontaneous delivery (n = 6), the main reason of severe PPH was retained placenta (n = 4), while after cesarean section (n = 14), uterine atony was identified in most cases (n = 8). Regarding menstruation after embolization, all women reported regular menstruation after the breastfeeding period (100%). The majority reported a regular pattern with a shorter or similar duration (73%) and lower or similar intensity (64%). Dysmenorrhea decreased in 67% of patients. Four patients planned another pregnancy, of whom only one had become pregnant with assisted reproductive technology and ended up in a miscarriage. Discussion: Our study confirms the efficacy of PAE in PPH, thus obviating complex surgical interventions and associated morbidity. The success of PAE does not depend on the primary cause of PPH. Our results may encourage the prompt decision to perform PAE in the management of severe PPH in case of failure of conservative management and help physicians in the post-interventional counseling regarding menstruation patterns and fertility

Postpartum Blood Loss in Women Treated for Intrahepatic Cholestasis of Pregnancy

OBJECTIVE To evaluate postpartum blood loss in women with treated intrahepatic cholestasis of pregnancy. METHODS In a retrospective case-control study, 15,083 deliveries including 348 women with intrahepatic cholestasis of pregnancy (2.3%) were analyzed from 2004 to 2014. To adjust for differences in baseline characteristics, a propensity analysis was performed and women in the control group were matched to the women in the intrahepatic cholestasis of pregnancy group in a 5:1 ratio. Blood loss was analyzed by estimated blood loss and Δ hemoglobin (Hb, difference between prepartum and postpartum Hb). A subgroup analysis regarding severity of intrahepatic cholestasis of pregnancy based on maximum bile acid level (mild [less than 40 micromoles/L], moderate [40-99 micromoles/L], and severe intrahepatic cholestasis of pregnancy [100 micromoles/L or greater]) was performed. Differences in estimated blood loss, ΔHb, and meconium staining between subgroups were analyzed. A Spearman rank correlation was performed to evaluate the association of bile acid levels and blood loss within subgroups. RESULTS Estimated blood loss (median 400 [300-600] mL compared with 400 [300-600] mL, P=.22), ΔHb (14.0 [5.0-22.0] compared with 12.0 [4.0-21.0] g/L, P=.09), meconium staining (14.5% compared with 11.4%, P=.12), and number of stillbirths after 26 weeks of gestation (0.6% compared with 1.8%, P=.10) were not significantly different in the study compared with the control group. In moderate and severe intrahepatic cholestasis of pregnancy, meconium staining was observed significantly more often compared with that in a control group (23.0% and 32.3% compared with 11.4%, P<.01). There was no correlation between estimated blood loss or ΔHb and severity of intrahepatic cholestasis of pregnancy. CONCLUSIONS In our cohort of women with intrahepatic cholestasis of pregnancy who are treated with ursodeoxycholic acid and have planned delivery (induction of labor or planned cesarean delivery) at 38 weeks of gestation, no differences in postpartum blood loss were seen

Postponed pregnancies and risks of very advanced maternal age

QUESTIONS UNDER STUDY To evaluate pregnancy outcome in pregnant women aged ≥45 years, termed very advanced maternal age (VAMA). METHODS We retrospectively compared the outcome of pregnancies in VAMA patients with controls aged 30 years at time of delivery. Subgroups of singleton and multiple pregnancies were also analysed. Incidences of maternal and fetal adverse outcomes were measured. Statistical significance was set at p 7 days (37.8% vs 15.1%; OR 3.42) was found. Infant complications such as prematurity (44.9% vs 16.2%; OR 4.2) and low birthweight <5th percentile (11.0% vs 5.6%; OR 2.1) were also increased. CONCLUSION Pregnant women of very advanced maternal age (≥45 years) have significantly increased maternal and fetal risks. Women postponing pregnancy or planning a pregnancy in very advanced age should be informed about these risks, in particular before artificial reproductive technologies are applied or "social freezing"