A model-based cost-utility analysis of multi-professional simulation training in obstetric emergencies

ObjectiveTo determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies-Practical Obstetric Multi-Professional Training (PROMPT)-with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs).DesignA model-based cost-utility analysis.SettingMaternity units in England.PopulationSimulated cohorts of individuals affected by permanent OBPIs.MethodsA decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters.Main outcome measuresOutcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained.ResultsNationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings.ConclusionIn this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs

Laparoscopic simulation training in gynaecology:Current provision and staff attitudes - a cross-sectional survey

<p>The objectives of this study were to explore current provision of laparoscopic simulation training, and to determine attitudes of trainers and trainees to the role of simulators in surgical training across the UK. An anonymous cross-sectional survey with cluster sampling was developed and circulated. All Royal College of Obstetricians and Gynaecologists (RCOG) Training Programme Directors (TPD), College Tutors (RCT) and Trainee representatives (TR) across the UK were invited to participate. One hundred and ninety-six obstetricians and gynaecologists participated. Sixty-three percent of hospitals had at least one box trainer, and 14.6% had least one virtual-reality simulator. Only 9.3% and 3.6% stated that trainees used a structured curriculum on box and virtual-reality simulators, respectively. Respondents working in a Large/Teaching hospital (<i>p</i> = 0.008) were more likely to agree that simulators enhance surgical training. Eighty-nine percent agreed that simulators improve the quality of training, and should be mandatory or desirable for junior trainees. Consultants (<i>p</i> = 0.003) and respondents over 40 years (<i>p</i> = 0.011) were more likely to hold that a simulation test should be undertaken before live operation. Our data demonstrated, therefore, that availability of laparoscopic simulators is inconsistent, with limited use of mandatory structured curricula. In contrast, both trainers and trainees recognise a need for greater use of laparoscopic simulation for surgical training.</p

Temporal trends in stillbirth over eight decades in England and Wales:A longitudinal analysis of over 56 million births and lives saved by improvements in maternity care

BACKGROUND: Considering the public health importance of stillbirth, this study quantified the trends in stillbirths over eight decades in England and Wales. METHODS: This longitudinal study utilized the publicly available aggregated data from the Office for National Statistics that captured maternity information for babies delivered in England and Wales from 1940 to 2019. We computed the trends in stillbirth with the associated incidence risk difference, incidence risk ratio, and extra lives saved per decade. RESULTS: From 1940-2019, 56 906 273 births were reported. The stillbirth rate declined (85%) drastically up to the early 1980s. In the initial five decades, the estimated number of deaths per decade further decreased by 67 765 (9.49/1000 births) in 1940-1949, 2569 (0.08/1000 births) in 1950-1959, 9121 (3.50/1000 births) in 1960-1969, 15 262 (2.31/1000 births) in 1970-1979, and 10 284 (1.57/1000 births) in 1980-1989. However, the stillbirth rate increased by an additional 3850 (0.58/1000 births) stillbirths in 1990-1999 and 693 (0.11/1000 births) stillbirths in 2000-2009. The stillbirth rate declined again during 2010-2019, with 3714 fewer stillbirths (0.54/1000 births). The incidence of maternal age 35 years) increased. CONCLUSIONS: The stillbirth rate declined drastically, but the rate of decline slowed in the last three decades. Though teenage pregnancy (<20 years) had reduced, the prevalence of women with a higher risk of stillbirth may have risen due to an increase in advanced maternal age. Improved, more personalised care is required to reduce the stillbirth rate further

Effects of Supplementary Feeding on the Breeding Ecology of the Buff-Throated Partridge in a Tibetan Sacred Site, China

Our goal was to document effects of year-round supplemental feeding on breeding ecology of the Buff-throated Partridge, Tetraophasis szechenyii, within a Tibetan sacred site. We evaluated effects of supplemental feeding used as religious/cultural practices which could potentially aid conservation of endangered phasianids. We compared fed breeding groups to neighboring nonfed groups. Fed groups initiated first clutches significantly earlier than nonfed groups. Earlier laying groups within fed and nonfed groups showed significantly lower hatching rates than later groups; however, fed groups showed significantly higher hatching rates than nonfed groups laying in the same period. Earlier laying increased opportunities to renest. All six fed groups with clutch failures renested compared to only one of five nonfed groups with clutch failures. Fed female breeders showed significantly greater investment in their young with larger clutches and larger eggs, which likely increased survivability of early hatchlings. We observed no predation on birds at feeding sites and recorded only four cases of predation on incubating females, which showed no detectable difference between fed and nonfed groups. Ground-nesting birds typically face high risks of predation. Ten of the 48 groups nested in trees, which occurs in few phasianid species. Tree nests showed significantly higher hatching rates compared to ground nests; however, we found no significant difference in tree nesting between fed and nonfed groups. This partridge is one of four gallinaceous species with cooperative breeding. Breeding groups with helpers had significantly greater reproductive success than single pairs, and fed female breeders with helpers laid bigger eggs than single pairs. Comparing annual reproductive output per group, fed groups not only produced significantly more independent young (≥150 days post-hatching), their young hatched significantly earlier, which likely have greater reproductive value over later hatched young of nonfed groups. Supplemental feeding year-round is likely what enabled the successes of the fed partridges

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Curriculum development for basic gynaecological laparoscopy with comparison of expert trainee opinions; Prospective cross-sectional observational study

OBJECTIVE: To develop content for a basic laparoscopic curriculum in gynaecology.STUDY DESIGN: Prospective cross-sectional observational study. Modified Delphi method with three iterations undertaken by an invited group of national experts across the United Kingdom (UK). Two anonymous online surveys and a final physical group meeting were undertaken. Junior trainees in gynaecology undertook a parallel iteration of the Delphi process for external validation. Population included: expert panel - certified specialists in minimal-access gynaecological surgery, RCOG national senior trainee representatives, and medical educationalists, junior trainees group - regional trainees in gynaecology in first and second year of speciality training.RESULTS: Experts (n=37) reached fair to almost complete significant agreement (κ=0.100-0.8159; p&lt;0.05) on eight out of nine questions by the second iteration. Trainees (n=19) agreed with the experts on 89% (51/57) of categories to be included in the curriculum. Findings indicated that 39 categories should be included in the curriculum. Port placement, laparoscopic equipment and patient selection were ranked the most important theoretical categories. Hand-eye co-ordination, camera navigation and entry techniques were deemed the most valuable skills. Diagnostic laparoscopy, laparoscopic sterilisation, and laparoscopic salpingectomy were the operations agreed to be most important for inclusion. Simulation training was agreed as the method of skill development. The expert panel favoured box trainers, whereas the junior trainee group preferred virtual reality simulators. A basic simulation laparoscopic hand-eye co-ordination test was proposed as a final assessment of competence in the curriculum.CONCLUSION: Consensus was achieved on the content of a basic laparoscopic curriculum in gynaecology, in a cost- and time-effective, scientific process. The Delphi method provided a simple, structured consumer approach to curriculum development that combined views of trainers and trainees that could be used to develop curricula in other areas of post-graduate education.</p

Improving team training in acute health care: critical synthesis of seven mixed methods studies.

Background: Research had previously shown that practical team rehearsals in acute health care are beneficial, but subsequent work suggested that further improvement is possible. We critically synthesised seven studies aiming to identify the characteristics of effective teams and inform and guide better team training. Methods: Two studies aimed to identify successes and challenges in a unit with improvements in outcome after the introduction of team training. The studies were a staff safety attitudes survey and an interrupted time-series of the effect of training on the management and outcome of an emergency. Mixed-methods research was used in five further studies to identify the characteristics of effective maternity teams in simulation and experiences of real life. Findings: The introduction of team training improved the management and outcome in the index emergency, but there remained persistent variation in team performance managing an emergency. The staff survey demonstrated a positive safety culture yet identified a perceived need for improved senior presence. Analysis of simulation established that some teams were significantly better than others in managing the emergency, and this variation was correlated with their teamwork, not their individual knowledge, skills, or attitudes. Declaring the emergency early, structured handover, and closed-loop communication were associated with significantly better team performance. Better teamwork, including the clear verbalisation of crucial information, was also associated with better patient perception of care. The focus groups corroborated these findings and agreed that the behaviours of a leader are more important than seniority rank. Simple practical methods for teaching those behaviours were explored and agreed. Triangulation of focus group and simulation data using an established framework revealed similarities (convergence and complementarity), differences (dissonance), and issues requiring further research to corroborate or refute findings. Interpretation: The effectiveness of acute health-care teams is related to simple behaviours that can be taught, with methods appropriate for different learners

Validation of virtual-reality simulation for obstetric ultrasonography: A prospective cross-sectional study

In bagged and unbagged shoot experiments, we investigated the survival and growth rate of first instar larvae of Chrysophtharta bimaculata on 9 families of a natural host, Eucalyptus regnans. Families used had been previously assessed as being either of low or high susceptibility to C. bimaculata damage. In conjunction with larval experiments, we measured 24 tree and leaf characteristics (including foliar elemental concentrations, foliar terpenes, leaf toughness and tree growth rates) and attempted to correlate the plant characters measured with differences in larval performance and previous scorings of E. regnans family susceptibility.\ud \ud First instar larval growth and survival did not differ significantly across families or between low and high susceptibility family groups (=susceptibility classes), although survival was significantly greater in bagged than unbagged treatments. As predators were in low abundance at the study site, we attribute higher survival rates of larvae in bagged treatments to increased protection from adverse weather conditions. Only one plant character measured, an unidentified foliar phlorglucinol, was significantly negatively correlated with larval survival. Of the 24 plant characters measured, 11 were significantly different between families and 10 were significantly different between susceptibility classes. Only 4 plant characters were significantly different at both the family and susceptibility class levels; viz. proportion red leaves, tree height at end of season, trunk volume at end of season and relative growth rate based on tree height. Principle Component Analysis using all plant characters measured, or subsets of them, could not separate individual families or susceptibility classes. Our results suggest that herbivore resistance mechanisms in E. regnans do not affect C. bimaculata larvae, but may influence adult feeding and/or oviposition