The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

<p>Abstract</p> <p>Background</p> <p>The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.</p> <p>Methods</p> <p>A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009</p> <p>Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.</p> <p>Results</p> <p>A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0<abbrgrp><abbr bid="B1">1</abbr><abbr bid="B2">2</abbr><abbr bid="B3">3</abbr><abbr bid="B4">4</abbr></abbrgrp>. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.</p> <p>Conclusions</p> <p>Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.</p

Educators' Perceptions of the Importance of Selected Competencies for Teachers of Students with Emotional and Behavioral Disorders and their Perceptions of Personal Proficiency

This study investigated educators' perceptions of the importance of competencies for teachers of students with emotional and behavioral disorders and their own proficiency in the competencies. Participants included educators who had completed university-based coursework on emotional and behavioral disorders. Competencies from the Qualification and Preparation of Teachers of Exceptional Children study were correlated with CEC's content standards and knowledge skill sets for special education teachers of individuals with emotional and behavioral disorders. Participants ranked 88 competencies on importance and proficiency. Results revealed that educators' proficiency in competencies, their years of experience, and level of education contribute a significant percentage of variance in their ratings of the importance of competencies. Implications for further research are provided

Factors influencing migrant fisher access to fishing grounds

Fisher migration plays a critical role in artisanal fisheries in the Western Indian Ocean. The present study uses a multiple method approach to evaluate fishing behaviour of migrant fishers at four destinations in Kenya, and focuses on fishing grounds used by migrant fishers to illustrate spatial characteristics that attract or determine access and fishing behaviour. Migrant fisher knowledge of natural trends, cycles and oceanographic processes that influence the abundance of target resources largely determines access to fishing grounds. Calm winds and a fairly high Chl-a concentration make favourable conditions at fishing grounds on the north coast during the northeast monsoon. Fishing grounds on the south coast include sheltered areas that remain accessible during the southeast monsoon. Increased fisheries productivity is experienced during the rainy season due to sediment loading and increased supplies of particulate matter. The main catch landed on the north coast included octopus, grouper and tripletail that were found within the reefs and on the deep slopes, while on the south coast it included needlefish, tunas and mackerels, barracuda and sardine, among other highly migratory pelagic species. Besides natural conditions, local regulations at the destination, including gear and licence restrictions, were also found to be important determinants of access by migrant fishers.

Liver toxicity of Crude extract of Ficus natalensis traditionally used in South Western Uganda

Background: Traditional healers have used medicinal plants to treat infectious diseases since time immemorial. These natural products have not only played a vital role in healing, but have also contributed to the discovery of many pharmaceutically active agents. Objectives: This research was aimed at assessing the effects of crude extract of Ficus natalensis on the liver. Methodology: Test and control Wistar albino rats were fed on either Water or Ethanolic extract of Ficus natalensis and water-only (control) respectively and their serum harvested. Biochemical analysis of liver function tests was performed and Human Diagnostic Test Kits were used to assay for the enzymes ALT (alanine aminotransferase), (AST (serum aspartate aminotransferase) and γ-GT (gamma glutamyl transpeptidase).The organ body weight ratio was also recorded. Results: The cold water decoction once administered to the rats showed adverse effects leading to death of the experimental animals by day 3. The ethanolic extract results showed that there was a dose-dependent alteration in the indices of liver function as well as enlargement of the liver following feeding on the ethanolic extract of Ficus natalensis. All the serum enzyme activity of ALT, AST and GGT were increased in a dose-dependent manner and the groups of animals being fed on the ethanolic extract, showed a reduction in weight. Discussion: The cold water extraction might have extracted all the active ingredients including some that were toxic to the laboratory animals leading to their death. The ethanolic extracts exhibited alterations in the indices of liver function as well as enlargement of the liver in a dose-specific manner. All the serum enzyme activity of ALT, AST and GGT was increased in a dose-dependent manner. This could possibly be due to hepatotoxicity resulting from the metabolites of the Ficus natalensis. Key words: Ficus natalensis, Ethanolic extract, Liver toxicit

Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research

Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Aim: The aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers. Methods: An operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: “No Skill Mix”, “Minimal Direct Access”, “More Prevention” and “Maximum Delegation”. The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England. Results: The operational research model suggested that 73% of clinical time in England’s state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:“No Skill Mix”, the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: “Minimal Direct Access”, where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. “No Skill Mix”. Scenario 3: “More Prevention”, that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. “No Skill Mix”. Scenario 4 “Maximum Delegation” where all care within dental therapists’ jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. “No Skill Mix”. Conclusion: Alternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce

Generalisability of deep learning models in low-resource imaging settings: A fetal ultrasound study in 5 African countries

Most artificial intelligence (AI) research have concentrated in high-income countries, where imaging data, IT infrastructures and clinical expertise are plentiful. However, slower progress has been made in limited-resource environments where medical imaging is needed. For example, in Sub-Saharan Africa the rate of perinatal mortality is very high due to limited access to antenatal screening. In these countries, AI models could be implemented to help clinicians acquire fetal ultrasound planes for diagnosis of fetal abnormalities. So far, deep learning models have been proposed to identify standard fetal planes, but there is no evidence of their ability to generalise in centres with limited access to high-end ultrasound equipment and data. This work investigates different strategies to reduce the domain-shift effect for a fetal plane classification model trained on a high-resource clinical centre and transferred to a new low-resource centre. To that end, a classifier trained with 1,792 patients from Spain is first evaluated on a new centre in Denmark in optimal conditions with 1,008 patients and is later optimised to reach the same performance in five African centres (Egypt, Algeria, Uganda, Ghana and Malawi) with 25 patients each. The results show that a transfer learning approach can be a solution to integrate small-size African samples with existing large-scale databases in developed countries. In particular, the model can be re-aligned and optimised to boost the performance on African populations by increasing the recall to $0.92 \pm 0.04$ and at the same time maintaining a high precision across centres. This framework shows promise for building new AI models generalisable across clinical centres with limited data acquired in challenging and heterogeneous conditions and calls for further research to develop new solutions for usability of AI in countries with less resources

Dental therapists in general dental practice. A literature review and case study analysis to determine what works, why, how and in what circumstances

Introduction In the United Kingdom, policy and guidance changes regarding the role of Dental Therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive‐focussed, teamwork approach. However, success in the adoption of this model of working has been varied. Aims Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances. Materials and Methods The research comprised two stages. (i) A structured literature search, dual‐coding papers for high‐level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill‐mix operates in the general dental service. (ii) Six case studies of general dental practices (three with a Dental Therapist/three without a Dental Therapist) employing a range of skill‐mix models incorporating semi‐structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature. Results Eighty‐four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider, and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories. Conclusion Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice

Dental Treatment in a State-Funded Primary Dental Care Facility: Contextual and Individual Predictors of Treatment Need?

OBJECTIVE:This study examined individual and contextual factors which predict the dental care received by patients in a state-funded primary dental care training facility in England. METHODS:Routine clinical and demographic data were extracted from a live dental patient management system in a state-funded facility using novel methods. The data, spanning a four-year period [2008-2012] were cleaned, validated, linked by means of postcode to deprivation status, and analysed to identify factors which predict dental treatment need. The predictive relationship between patients' individual characteristics (demography, smoking, payment status) and contextual experience (deprivation based on area of residence), with common dental treatments received was examined using unadjusted analysis and adjusted logistic regression. Additionally, multilevel modelling was used to establish the isolated influence of area of residence on treatments. RESULTS:Data on 6,351 dental patients extracted comprised of 147,417 treatment procedures delivered across 10,371 courses of care. Individual level factors associated with the treatments were age, sex, payment exemption and smoking status and deprivation associated with area of residence was a contextual predictor of treatment. More than 50% of children (<18 years) and older adults (≥65 years) received preventive care in the form of 'instruction and advice', compared with 46% of working age adults (18-64 years); p = 0.001. The odds of receiving treatment increased with each increasing year of age amongst adults (p = 0.001): 'partial dentures' (7%); 'scale and polish' (3.7%); 'tooth extraction' (3%; p = 0.001), and 'instruction and advice' (3%; p = 0.001). Smokers had a higher likelihood of receiving all treatments; and were notably over four times more likely to receive 'instruction and advice' than non-smokers (OR 4.124; 95% CI: 3.088-5.508; p = 0.01). A further new finding from the multilevel models was a significant difference in treatment related to area of residence; adults from the most deprived quintile were more likely to receive 'tooth extraction' when compared with least deprived, and less likely to receive preventive 'instruction and advice' (p = 0.01). CONCLUSION:This is the first study to model patient management data from a state-funded dental service and show that individual and contextual factors predict common treatments received. Implications of this research include the importance of making provision for our aging population and ensuring that preventative care is available to all. Further research is required to explain the interaction of organisational and system policies, practitioner and patient perspectives on care and, thus, inform effective commissioning and provision of dental services

Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England

BACKGROUND: Research suggests that health professionals who have trained together have a better understanding of one another’s scope of practice and are thus equipped for teamwork during their professional careers. Dental hygiene-therapists (DHTs) are mid-level providers that can deliver routine care working alongside dentists. This study examines patterns of delegation (selected tasks and patients) by dental students to DHT students training together in an integrated team. METHODS: A retrospective sample of patient data (n = 2,063) was extracted from a patient management system showing the treatment activities of two student cohorts (dental and DHT) involved in team training in a primary care setting in the South of England over two academic years. The data extracted included key procedures delegated by dental students to DHT students coded by skill-mix of operator (e.g., fissure sealants, restorations, paediatric extractions) and patient demography. χ(2) tests were conducted to investigate the relationship between delegation and patient age group, gender, smoking status, payment-exemption status, and social deprivation. RESULTS: A total of 2,063 patients managed during this period received treatments that could be undertaken by either student type; in total, they received 14,996 treatment procedures. The treatments most commonly delegated were fissure sealants (90%) and restorations (51%); whilst the least delegated were paediatric extractions (2%). Over half of these patients (55%) had at least one instance of delegation from a dental to a DHT student. Associations were found between delegation and patient age group and smoking status (P <0.001). Children under 18 years old had a higher level of delegation (86%) compared with adults of working age (50%) and patients aged 65 years and over (56%). A higher proportion of smokers had been delegated compared with non-smokers (45% cf. 26%; P <0.001). CONCLUSIONS: The findings suggest that delegation of care to DHT students training as a team with dental students, involved significantly greater experience in treating children and adult smokers, and providing preventive rather than invasive care in this integrated educational and primary care setting. The implications for their contribution to dentistry and the dental team are discussed, along with recommendations for primary care data recording