Developing and evaluating an online learning tool to improve midwives' accuracy of visual estimation of blood loss during waterbirth: An experimental study.

OBJECTIVE: The principal objective was to test the effectiveness of an online learning tool to improve midwives' accuracy of blood loss estimations in a birthing pool environment. The secondary objective was to assess the acceptability of the online learning tool to the midwives using it. DESIGN: A one group pre-test, post-test experiment with immediate and six weeks follow-up to test ability together with an online questionnaire to assess perceived usefulness of an online learning tool. SETTING: A large NHS maternity hospital comprising an acute care obstetric unit, a small district unit labour ward, one alongside midwifery-led unit and three freestanding midwifery-led units. PARTICIPANTS: Volunteer NHS employed midwives who had experience in caring for women labouring and giving birth in water (n = 24). INTERVENTION: An online learning tool comprising six randomly ordered short video simulations of blood loss in a birthing pool in real time, and a tutorial giving verbal and pictorial guidance on making accurate blood loss estimations in water was developed then piloted. Midwives' accuracy scores for estimating blood loss in each of the videos were calculated at three timepoints; pre and immediately post the learning component, and six weeks later. The estimated blood loss volume was subtracted from the actual blood loss volume, to give the difference between estimated and real blood loss in millilitres (ml) which was then converted to percentage difference to standardise comparison across the six volumes. The differences between pre- and post-learning for each of the six blood volumes was analysed using a repeated measures ANOVA. Statistical significance was set at p < 0.05. An online questionnaire incorporated questions using Likert scales to gauge confidence and competence and free text. Free text responses were analysed using a modified form of inductive content analysis. FINDINGS: Twenty-two midwives completed the online learning and immediate post-test, 14 completed a post-test after six weeks, and 15 responded to the online questionnaire. Pre-test results showed under-estimation of all blood loss volumes and particularly for the two largest volumes (1000 and 1100 ml). Across all volumes, accuracy of estimation was significantly improved at post-test 1. Accuracy diminished slightly, but overall improvement remained, at post-test 2. Participants rated the online tool positively and made suggestions for refining it. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This is the first study measuring the accuracy of midwives' blood loss estimations in a birthing pool using real-time simulations and testing the effectiveness of an online learning tool to improve this important skill. Our findings indicate a need to develop interventions to improve midwives' accuracy at visually estimating blood loss in water, and the potential of an online approach. Most women who labour and/or give birth in water do so in midwifery-led settings without immediate access to medical support. Accuracy in blood loss estimations is an essential core skill.

Do estimates of blood loss differ between student midwives and midwives? A multicenter cross-sectional study.

OBJECTIVE: the principal objective of this study was to assess the quality of blood loss estimates by midwives and student midwives. The secondary objectives were: to assess the intraobserver agreement of visual blood estimates and the rate of underestimation of blood loss by participants, and to estimate the sensitivity, specificity, and negative likelihood ratio of these estimates for clinically pertinent blood losses (≥ 500mL and ≥ 1000mL). DESIGN: multicenter cross-sectional study. SETTING: thirty-three French maternity units and 35 French midwifery schools participated in this study. PARTICIPANTS: volunteer French midwifery students (n = 463) and practicing midwives (n = 578). INTERVENTION: an online survey showed 16 randomly ordered photographs of 8 different simulated blood quantities (100, 150, 200, 300, 500, 850, 1000, and 1500mL) with a reference 50-mL image in each photo and asked participants to estimate the blood loss. The visual blood loss estimates were compared with Fisher's exact test. Intraobserver agreement for these estimates was assessed with a weighted kappa coefficient, and the negative predictive values (probability of no hemorrhage when visual estimate was negative) were calculated from prevalence rates in the literature. FINDINGS: of the 16,656 estimates obtained, 34.1% were accurate, 37.2% underestimated the quantity presented, and 28.7% overestimated it. Analyses of the intraobserver reproducibility between the two estimates of the same photograph showed that agreement was highest (weighted kappa ≥ 0.8) for the highest values (1000mL, 1500mL). For each volume considered, students underestimated blood loss more frequently than midwives. In both groups, the negative predictive values regarding postpartum hemorrhage (PPH) diagnosis (severe or not) were greater than 98%. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: student midwives tended to underestimate the quantity of blood loss more frequently than the midwives. Postpartum hemorrhage (≥ 500mL) was always identified, but severe postpartum hemorrhage (≥ 1000mL) was identified in fewer than half the cases. These results should be taken into account in training both student midwives and practicing professionals.

Methodologic Quality and Statistical Reporting of Physical Therapy Randomized Controlled Trials Relevant to Musculoskeletal Conditions.

OBJECTIVES: To investigate the methodologic quality and statistical reporting of reports of trials indexed on the Physiotherapy Evidence Database (PEDro) classified in the musculoskeletal subdiscipline, and to analyze the characteristics of the trials that can predict trial report quality. DESIGN: Cross-sectional study based on a collection of randomized controlled trials. We randomly selected 19% of trials coded as musculoskeletal from PEDro. Methodologic quality was assessed using the PEDro scale. We assessed aspects of the trial using 9 items from the Consolidated Standards of Reporting Trials (CONSORT) statement. We performed multivariate linear regression analysis models to predict the total PEDro score. SETTING: Not applicable. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: A total of 1404 articles were included in the analysis. The mean total PEDro scale score was 5.27±1.63 points, which reflects low methodologic quality. There was a slight improvement in the quality of articles over time. The characteristics that predicted the total PEDro scale score were endorsement of the CONSORT statement, sample size calculation, lower number of primary outcomes, evaluation of electrotherapy as intervention, if the trial reported the research design in the title, reporting of participant flow diagram, years since publication (most recent trials), and trials published in English. CONCLUSIONS: The quality of the trials in musculoskeletal physical therapy is suboptimal. The use of reporting checklists (eg, CONSORT statement) should be mandatory in all journals. Journal reviewers and journal editors should also use the CONSORT statement during the review process.

Characterizing phenotypes and outcomes of drug-associated liver injury using electronic medical record data.

PURPOSE: To evaluate the incidence, phenotypes, and outcomes of drug-associated liver injury identified in electronic medical record (EMR) data using standardized criteria for drug-induced liver injury (DILI). METHODS: This retrospective cohort study used EMR data from a large integrated healthcare system. Study inclusion required 18 years of age or older, ≥1 prescription fill for any of 14 medications associated with hepatotoxicity between 1 January 2003 and 30 June 2009, and ≥12 months of membership prior to the drug exposure. Patients with underlying non-drug causes of liver injury were excluded to minimize capture of liver injury events unrelated to drugs. Drug-associated liver injuries were identified by liver chemistry elevations temporally associated with drug use based on standardized criteria for DILI. Cases were classified by clinical pattern and severity. Outcomes of liver transplant and all-cause and liver-related death were examined. RESULTS: A total of 1 053 979 drug exposures were identified in 601 125 patients. We identified 265 drug-associated liver injuries (32.8 per 100 000 persons) occurring in 250 patients. Isoniazid exhibited the highest incidence rate of 606 per 100 000 persons. Of the 265 cases, 41% were mild; 12% exhibited moderate drug-associated liver injury (with concomitant ALT ≥ 5× ULN and bilirubin ≥2× ULN); and 17% exhibited coagulopathy, ascites, encephalopathy, or other organ failure. Last, seven cases (3%) were associated with death, and there were no liver transplants. CONCLUSIONS: Study results align with earlier prospective studies, supporting the value of standardized methodology to identify drug-associated liver injury in the EMR. These methods can potentially enhance safety and clinical outcomes.

Efficient coding and statistically optimal weighting of covariance among acoustic attributes in novel sounds.

To the extent that sensorineural systems are efficient, redundancy should be extracted to optimize transmission of information, but perceptual evidence for this has been limited. Stilp and colleagues recently reported efficient coding of robust correlation (r = .97) among complex acoustic attributes (attack/decay, spectral shape) in novel sounds. Discrimination of sounds orthogonal to the correlation was initially inferior but later comparable to that of sounds obeying the correlation. These effects were attenuated for less-correlated stimuli (r = .54) for reasons that are unclear. Here, statistical properties of correlation among acoustic attributes essential for perceptual organization are investigated. Overall, simple strength of the principal correlation is inadequate to predict listener performance. Initial superiority of discrimination for statistically consistent sound pairs was relatively insensitive to decreased physical acoustic/psychoacoustic range of evidence supporting the correlation, and to more frequent presentations of the same orthogonal test pairs. However, increased range supporting an orthogonal dimension has substantial effects upon perceptual organization. Connectionist simulations and Eigenvalues from closed-form calculations of principal components analysis (PCA) reveal that perceptual organization is near-optimally weighted to shared versus unshared covariance in experienced sound distributions. Implications of reduced perceptual dimensionality for speech perception and plausible neural substrates are discussed.

Analysis on the distinguishing features of traditional Chinese therapeutics and related statistical issues.

Traditional Chinese medicine (TCM) is one of the rarely existing ancient traditional medicines that hold systematic theories as well as preventative and therapeutic methods for diseases in practice. From the 1950s, such research methods as mathematics, statistics, and data mining (DM) have been gradually introduced to TCM studies, making it more scientific. Meanwhile, the distinct features of TCM theories and diagnostic-model have constantly challenged the methodology of statistics. This paper introduces the following scientific features of traditional Chinese therapeutics: 1) its goal is to balance the functions and conditions of human body; 2) it emphasizes on holism and individualization; 3) it stresses the longitudinal regulation and evaluation mode, which is a circle of syndrome diagnosis, treatment and evaluation; 4) the interventions of TCM are abundant, compound and natural; and 5) humanistic thought is everywhere. Some statistical problems are raised based on these features. First, complex statistical methods that can analyze subjective indexes and latent variables, multidimensional and multistage data, non-equilibrium designed studies, and longitudinal data are required. Second, comprehensive evaluation on multiple-target mechanism has been brought in by combination treatment. Third, there is a need to analyze how humanity and related cultural factors may influence the effect of interventions. Thus, promoting implemented studies of statistics as well as carrying out the TCM scientific propositions have become the common expectations of both TCM and modern medicine.

Evaluating real-life high-throughput screening data.

High-throughput screening (HTS) is the result of a concerted effort of chemistry, biology, information technology, and engineering. Many factors beyond the biology of the assay influence the quality and outcome of the screening process, yet data analysis and quality control are often focused on the analysis of a limited set of control wells and the calculated values derived from these wells. Taking into account the large number of variables and the amount of data generated, multiple views of the screening data are necessary to guarantee quality and validity of HTS results. This article does not aim to give an exhaustive outlook on HTS data analysis but tries to illustrate the shortfalls of a reductionist approach focused on control wells and give examples for further analysis.

Good pharmacovigilance practices: technology enabled.

The assessment of spontaneous reports is most effective it is conducted within a defined and rigorous process. The framework for good pharmacovigilance process (GPVP) is proposed as a subset of good postmarketing surveillance process (GPMSP), a functional structure for both a public health and corporate risk management strategy. GPVP has good practices that implement each step within a defined process. These practices are designed to efficiently and effectively detect and alert the drug safety professional to new and potentially important information on drug-associated adverse reactions. These practices are enabled by applied technology designed specifically for the review and assessment of spontaneous reports. Specific practices include rules-based triage, active query prompts for severe organ insults, contextual single case evaluation, statistical proportionality and correlational checks, case-series analyses, and templates for signal work-up and interpretation. These practices and the overall GPVP are supported by state-of-the-art web-based systems with powerful analytical engines, workflow and audit trials to allow validated systems support for valid drug safety signalling efforts. It is also important to understand that a process has a defined set of steps and any one cannot stand independently. Specifically, advanced use of technical alerting methods in isolation can mislead and allow one to misunderstand priorities and relative value. In the end, pharmacovigilance is a clinical art and a component process to the science of pharmacoepidemiology and risk management.