Mf Lobo

An intrauterine pressure generator for educational simulation of labour and delivery

Simulation provides a risk free and controllable environment for training of healthcare providers. The limited realism of available simulators and training programs impedes immersive training in obstetric emergencies. In developed countries, intrapartum monitoring in high-risk cases involves continuous evaluation of foetal heart rate and uterine contractions signals. We present an essential component of a high-fidelity simulator for normal and critical situations in labour and delivery, namely an intrauterine pressure generator. The signal model behind the generator consists of a truncated Gaussian curve with the programmable features: amplitude, frequency, duration, and resting tone. Through analysis of 44h of physiological data, we demonstrate that the natural variability of these features and of the baseline pressure can be approximated by deterministic trends and stationary stochastic processes. Signal parameters can be controlled by simulation instructors, scripts, or other models to reflect different patients, pathologies, and evolving clinical situations. Twelve 40-min tracings reflecting three different patients in labour were presented to three clinical experts, who attributed similar realism scores to simulated and to real tracings.

Self-perceived impact of simulation-based training on the management of real-life obstetrical emergencies

OBJECTIVE To evaluate the self-perceived impact of attending a simulation-based training course on the management of real-life obstetrical emergencies. STUDY DESIGN A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n=54) from a tertiary care university hospital participated in a simulation-based training course for the management of four obstetric emergencies. One year after the last session of the course, participants were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge, technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading scale was used. The χ(2) test with one degree of freedom or the Fishers exact test were used to compare groups of participants. The t-test for independent samples was used to compare mean scores between groups. RESULTS A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19 obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills during real emergencies. Obstetric nurses expressed a significantly higher improvement than obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p=0.002), in their technical skills (p=0.024), and in their ability to deal with teamwork related issues (p=0.005). Participants who had experienced in real-life situations all four simulated scenarios rated the impact of training significantly higher than others (p=0.049), and also reported a better improvement in their knowledge of management guidelines (p=0.006). CONCLUSIONS Healthcare professionals who participated in a simulation-based training course in obstetrical emergencies perceived a substantial improvement in their knowledge and skills when witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and for those who witness all trained obstetrical emergencies.

The Atlantic divide in coronary heart disease : epidemiology and patient care in the US and Portugal

INTRODUCTION AND OBJECTIVES We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available. METHODS We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries. RESULTS Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries. CONCLUSIONS Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.

A model for educational simulation of the effect of oxytocin on uterine contractions

Fetal oxygenation is sometimes compromised due to hyperstimulation of uterine contractions (UC) following labor augmentation with oxytocin. We present a model for educational simulation that incorporates the pharmacokinetic-pharmacodynamic properties of oxytocin, reproducing the effect of this drug on UC features. Six UC tracings were generated, reflecting different relevant situations. Three independent experts identified correctly the simulated situations in all tracings and attributed an average realism score of 9.4 (0-10). The model presented for simulation of the effect of oxytocin on UC provides sufficiently realistic results to be used in healthcare education and can easily be adapted to different patients and educational scenarios.

A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000–2010

Objective To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. Design Repeated cross-sectional retrospective cohort study. Setting Acute care hospitals in Portugal and USA during 2000-2010. Participants Adults discharged with AMI. Interventions Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). Main Outcome Measures In-hospital mortality and length of stay. Results We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. Conclusions Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.

Picturing inequities for health impact assessment: linked electronic records, mortality and regional disparities in Portugal

Abstract Health impact assessment (HIA) focuses on minimizing inequities when studying the effects of a policy on the population’s health. Nevertheless, it is seldom simultaneously quantified, multivariate, and visually graphically comprehensible for non-statisticians. This paper aims to address that gap, assessing a policy promoting the quality of Electronic Health Records, linking hospital and primary health care data (Blood Pressure, Cholesterol, Triglycerides, Waist Circumference, Body Mass Index) to mortality outcomes and regional inequities. Acute Myocardial Infarction patients admitted in the hospital are then followed regularly in Portuguese NHS Primary Care. Regional disparities regarding recorded information are observed and different association patterns with mortality identified, ranked, and visualized through adjusted ORs for sex, age, and indicators of severity of hospital admission, complemented with multivariate correspondence analysis. A pathway to handling equity within quantitative HIA shows that complexity in data and methods may generate simplicity and clarity through visual graphical aids. Tackling Big Data with Data Science in HIA may even be at the center of future health reforms, assessing impacts of health promotion and chronic disease policies.

Comparing Comorbidity Adjustment Scores for Predicting in-Hospital Mortality Using Administrative Data

The Charlson Comorbidity Index (CCI) is a method for classifying comorbidities as a single measure on a scale, based on ICD-9-CM codes over administrative databases. This study aims to compare different variants of the CCI and their relation with in-hospital mortality, using different weights associated to each comorbidity. Within the 9,613,563 hospitalizations in the 15-year studied period, the area under the ROC curve was higher considering the original Charlson weights, when compared to other more recent proposals. Also, all the indexes had an increased association with in-hospital mortality throughout time. For recent years this association is stronger, demonstrating an increased applicability of the Charlson index in administrative databases. The validity of the coding algorithms strongly depends on the completeness and accuracy of diagnostic coding, particularly considering secondary diagnoses. The Charlson index can be a valuable tool for longitudinal studies, but important differences among weights, through years, and for different main diagnoses, should be considered and discussed.