The effect of non-pharmacological prenatal interventions on fear of childbirth: an overview of systematic reviews and meta-analysis.

BACKGROUND: During pregnancy and childbirth, alongside positive feelings, women undergo feelings such as fear of childbirth (FoC) and worry about its consequences, which could leave negative effects on the mother and her child during pregnancy, delivery, and postpartum. The study was carried out to determine the effectiveness of prenatal non-pharmacological interventions on reducing the FoC. METHODS: The protocol of the study was registered in PROSPERO (ID: CRD42023468547). PubMed, Web of Science, Cochrane, Scopus, SID (Scientific Information Database) and Google Scholar search engine databases were systematically searched until July 27, 2023 with no limitation of time and limited to Persian and English studies in order to perform this overview. Certainty of evidence was assessed using GRADE, methodological quality using AMSTAR 2 and reporting quality using PRISMA score. Meta-analysis was performed on the data extracted from the original trials to evaluate the effect of different interventions on reducing the FoC. Sub-group analysis and meta-regression models were used to examine high heterogeneity, and sensitivity analysis was used to eliminate the effect of high risk of bias studies on the study findings. RESULTS: Overall, 15 systematic reviews (SRs) were included in the overview, among which meta-analysis was performed in 9 studies. Considering methodological quality, these SRs were in low to critically low status and had relatively complete reports regarding reporting quality. Meta-analysis findings indicated that psychological interventions (SMD -2.02, 95% CI -2.69 to -1.36, 16 trials, 1057 participants, I2 = 95%) and prenatal educations (SMD -0.88, 95% CI -1.16 to -0.61, 4 trials, 432 participants, I2 = 72.8%) cause a significant reduction in FoC relative to prenatal usual cares with low certainty of evidence. Distraction techniques lead to a significant reduction in FoC relative to prenatal usual care with high certainty of evidence (SMD -0.75, 95% CI -1.18 to -0.33, 4 trials, 329 participants, I2 = 69%), but enhanced cares do not result in a significant decrease FoC relative to prenatal usual care with very low certainty of evidence (SMD -1.14, 95% CI -2.85 to 0.58, 3 trials, 232 participants, I2 = 97%). CONCLUSIONS: Distraction techniques are effective in reducing FoC. Regarding the effect of psychological interventions and prenatal educations on the reduction of FoC, the findings indicated that the interventions may result in the reduction of FoC. Very uncertain evidence showed that enhanced cares are not effective in reducing the FoC.

Chain of Thought Utilization in Large Language Models and Application in Nephrology.

Chain-of-thought prompting enhances the abilities of large language models (LLMs) significantly. It not only makes these models more specific and context-aware but also impacts the wider field of artificial intelligence (AI). This approach broadens the usability of AI, increases its efficiency, and aligns it more closely with human thinking and decision-making processes. As we improve this method, it is set to become a key element in the future of AI, adding more purpose, precision, and ethical consideration to these technologies. In medicine, the chain-of-thought prompting is especially beneficial. Its capacity to handle complex information, its logical and sequential reasoning, and its suitability for ethically and context-sensitive situations make it an invaluable tool for healthcare professionals. Its role in enhancing medical care and research is expected to grow as we further develop and use this technique. Chain-of-thought prompting bridges the gap between AI's traditionally obscure decision-making process and the clear, accountable standards required in healthcare. It does this by emulating a reasoning style familiar to medical professionals, fitting well into their existing practices and ethical codes. While solving AI transparency is a complex challenge, the chain-of-thought approach is a significant step toward making AI more comprehensible and trustworthy in medicine. This review focuses on understanding the workings of LLMs, particularly how chain-of-thought prompting can be adapted for nephrology's unique requirements. It also aims to thoroughly examine the ethical aspects, clarity, and future possibilities, offering an in-depth view of the exciting convergence of these areas.

Current perspectives on maternity critical care.

Maternal critical care is a developing area of clinical practice. Looking after a critically ill woman requires a multidisciplinary team that must endeavour to maintain the relative normality of pregnancy. Whilst consideration of the fetus should be taken when making clinical decisions regarding maternal care, unfounded concerns for the fetus can contribute to therapeutic inertia such that potentially life-saving therapies are denied to pregnant women. The management of a critically ill obstetric patient must reflect, as closely as possible, the management of critical illness outside pregnancy. We will discuss some of the current evidence and concepts around this emerging area in obstetrics, including enhanced maternity care, maternal medicine networks and clinical care.

Perceptions of UK clinicians towards postoperative critical care.

Postoperative critical care is a finite resource that is recommended for high-risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk-stratified in practice; elucidate clinicians' opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri-operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real-world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk-averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure-specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri-operative critical care services, such as an overall lack of capacity, competition for beds with non-surgical cases and poor flow through the hospital leading to bed 'blockages'. Critical care is perceived to provide benefit to high-risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating 'enhanced care' units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals.

What do women in Medicaid say about enhanced prenatal care? Findings from the national Strong Start evaluation.

BACKGROUND: Medicaid pays for approximately half of United States births, yet little research has explored Medicaid beneficiaries' perspectives on their maternity care. Typical maternity care in the United States has been criticized as too medically focused while insufficiently addressing psychosocial risks and patient education. Enhanced care strives for a more holistic approach. METHODS: The perspectives of participants in the Strong Start for Mothers and Newborns II initiative, which provided enhanced prenatal care to women covered by Medicaid or the Children's Health Insurance Program (CHIP) during pregnancy through Birth Centers, Group Prenatal Care, and Maternity Care Homes, are evaluated. Strong Start intended to improve care quality and birth outcomes while lowering costs. We analyzed data from 133 focus groups with 951 pregnant or postpartum women who participated in Strong Start from 2013 to 2017. RESULTS: The majority of focus group participants said that Strong Start's enhanced care offered numerous important benefits over typical maternity care, including considerably more focus on women's psychosocial risk factors and need for education. They praised increased support; nutrition, breastfeeding, and family planning education; community referrals; longer time with practitioners; and involvement of partners in their care. Maternity Care Home participants, however, occasionally voiced concerns over lack of practitioner continuity and short clinical appointments, whereas Group Prenatal Care participants sometimes said they could not attend visits because of lack of childcare. CONCLUSIONS: Medicaid and CHIP beneficiaries reported positive experiences with Strong Start care. If more Medicaid practitioners could adopt aspects of the prenatal care approaches that women praised most, it is likely that women's risk factors could be more effectively addressed and their overall care experiences could be improved.

Implementing enhanced recovery pathways to improve surgical outcomes.

An enhanced recovery pathway is a structured perioperative healthcare program that incorporates evidence-based interventions including protocols and guidelines with the aim of providing standardized care. Enhanced recovery pathways can help maintain operating room safety and efficiency, improve postoperative recovery and a variety of important patient outcomes, and reduce overall costs of patient care following major surgery. Postoperative complications are minimized, which, in part, are attributed to adjustments in fasting and postoperative nutrition, interventions aimed at improving early mobilization, and careful selection of pharmacological agents for anesthesia and analgesia. Major surgery can lead to a variety of physiological stressors including organ dysfunction, and hormonal and neurological disturbances. The current notion of fast-tracking (bypassing phase I recovery level of care) differs from enhanced recovery pathways as the principles of enhanced recovery pathways are often applied to inpatient and complex procedures and span the entire spectrum of patient care. Also, enhanced recovery pathways programs are being used for pediatric patients especially with the hope of minimizing opioid exposure and the quality of recovery. A PubMed literature search was performed for articles that included the terms enhanced recovery pathways to improve surgical outcomes. In this article, we summarized the clinical application of enhanced recovery pathways and highlighted the key elements that characterize implementing an enhanced recovery pathway in surgery.

Quantifying the economic value of earlier and enhanced management of anorexia nervosa for adults in England, Germany and Spain: improving the care pathway.

BACKGROUND: Anorexia nervosa (AN) is a serious mental illness. One-third of people develop severe, enduring, illness, adversely impacting quality of life with high health system costs. This study assessed the economic case for enhanced care for adults newly diagnosed with AN. METHODS: A five-state 312-month-cycle Markov model assessed the economic impact of four enhanced care pathways for adults newly diagnosed with AN in England, Germany, and Spain. Enhancements were halving wait times for any outpatient care, receiving specialist outpatient treatment post-referral, additional transitional support post-referral, and all enhancements combined. Care pathways, estimates of impact, resource use, and costs were drawn from literature. Net monetary benefits (NMBs), impacts on health system costs, and disability-adjusted life years (DALYs) averted were estimated. Parameter uncertainty was addressed in multi-way sensitivity analyses. Costs are presented in 2020 purchasing power parity adjusted Euros. RESULTS: All four enhanced care pathways were superior to usual care, with the combined intervention scenario having the greatest NMBs of €248,575, €259,909, and €258,167 per adult in England, Germany, and Spain, respectively. This represented maximum NMB gains of 9.38% (€21,316), 4.3% (€10,722), and 4.66% (€11,491) in England, Germany and Spain compared to current care. Healthcare costs would reduce by more than 50%. CONCLUSIONS: Early and effective treatment can change the trajectory of AN. Reducing the untreated duration of the disorder is crucial. There is a good economic case in different country contexts for measures to reduce waiting times between diagnosis and treatment and increase access to enhanced outpatient treatment.

Characteristics and outcomes of surgical patients admitted to an overnight intensive recovery unit: A retrospective observational study.

Postoperative 'enhanced care' models that sit between critical care and ward-based care may allow for more cost-effective and efficient utilisation of resources for high-risk surgical patients. In this retrospective observational study, we describe an overnight intensive recovery model in a tertiary hospital, termed 'recovery high dependency unit', and the characteristics, treatment, disposition at discharge and in-hospital outcomes of patients admitted to this unit. We included all adult patients (≥18 years) admitted to the recovery high dependency unit for at least one hour between July 2017 and June 2020. Over this three-year period, 1257 patients were included in the study. The median length of stay in the recovery high dependency unit was 12.6 (interquartile range 9.1-15.9) hours and the median length of hospital stay was 8.3 (interquartile range 5.0-17.3) days. Hospital discharge data showed that 1027 (81.7%) patients were discharged home and that 37 (2.9%) patients died. Non-invasive ventilation was delivered to 59 (4.7%) patients and 290 (23.1%) required vasopressor support. A total of 164 patients (13.0%) were admitted to the intensive care unit following their recovery high dependency unit admission. Of the 1093 patients who were discharged to the ward, 70 patients (6.4%) had a medical emergency team call within 24 hours of discharge from the recovery high dependency unit. In this study of a recovery high dependency unit patient cohort, there was a relatively low need for intensive care unit admission postoperatively and a very low incidence of medical emergency team calls post-discharge to the ward. Other institutions may consider the introduction and evaluation of this model in the care of their higher risk surgical patients.

Family communication and the efficacy of family focused therapy in individuals at clinical high risk for psychosis with comorbid anxiety.

AIM: Comorbid anxiety disorder is related to greater illness severity among individuals at clinical high risk (CHR) for psychosis, but its potential role in moderating response to Family Focused Therapy (FFT) for CHR is unexamined. We investigated whether comorbid anxiety disorder in CHR individuals is associated with less constructive communication during family problem-solving interactions, whether their communication skills differentially improve after FFT, and whether FFT is effective in reducing anxiety in this population. METHODS: Individuals recruited into the second phase of the 8-site North American Prodrome Longitudinal Study (NAPLS2) participated (N = 129). They were randomly assigned to 18-sessions of FFT-CHR or three-sessions of Enhanced Care (EC). Participants completed a diagnostic interview at pre-treatment, a family interaction task at pre-treatment and 6-months, and a self-report anxiety measure at pretreatment, 6 and 12-months. RESULTS: Individuals at CHR with comorbid anxiety engaged in more negative and fewer positive behaviours during family problem-solving interactions at pre-treatment than did those without comorbid anxiety. There was a significant interaction between anxiety diagnosis and time on interactional behaviour scores, such that individuals at CHR with an anxiety diagnosis showed a greater decrease in negative behaviours and increase in positive behaviours from baseline to 6-months than those without anxiety disorder(s) regardless of treatment condition. However, individuals' self-reported anxiety symptoms decreased more in FFT-CHR than in EC from pre-treatment to 12-month follow-up, regardless of anxiety diagnoses. CONCLUSIONS: Individuals at CHR with symptoms of anxiety benefit from family interventions in showing reductions in anxiety and improvements in family communication.

A protocol for a type 1 effectiveness-implementation randomized controlled trial of the WHO digital mental health intervention Step-by-Step to address depression among Chinese young adults in Macao (SAR), China.

Background: Among Chinese college students, the burden of depression is considerably high, affecting up to 30 % of the population. Despite this burden, few Chinese students seek mental health treatment. In addition, depression is highly comorbid with other mental health disorders, such as anxiety. Scalable, transdiagnostic, evidence-based interventions are needed for this population. Objective: The study will evaluate the effectiveness of a World Health Organization transdiagnostic digital mental health intervention, Step-by-Step, to reduce depressive and anxiety symptoms and improve well-being compared with enhanced care as usual and its implementation in a Chinese university community. Methods: A type 1 effectiveness-implementation two-arm, parallel, randomized controlled trial will be conducted. The two conditions are 1) the 5-session Step-by-Step program with minimal guidance by trained peer-helpers and 2) psychoeducational information on depression and anxiety and referrals to local community services. A total of 334 Chinese university students will be randomized with a 1:1 ratio to either of the two groups. Depression, anxiety, wellbeing, and client defined problems will be assessed at pre-intervention, post-intervention, and 3-month follow-up. Endline qualitative interviews and focus group discussions will be conducted to explore SbS implementation among service users, university staff, and stakeholders. Data will be analysed based on the intent-to-treat principle. Discussion: Step-by-Step is an innovative approach to address common mental health problems in populations with sufficient digital literacy. It is a promising intervention that can be embedded to scale mental health services within a university setting. It is anticipated that after successful evaluation of the program and its implementation in the type 1 hybrid design RCT study, Step-by-Step can be scaled and maintained as a low-intensity treatment in universities, and potentially extended to other populations within the Chinese community. Trial registration: ChiCTR2100050214.

The Effect of Physician-Led Enhanced Care Teams in Prehospital Trauma Resuscitation.

Trauma is the leading cause of morbidity and mortality for those under 45 years of age in the United States with half of the deaths in trauma being attributed to hemorrhagic shock. The use of enhanced care teams (ECTs) that include physicians in selective prehospital settings has allowed the delivery of advanced critical care interventions in the field. We present a unique case where a young driver involved in a motor vehicle accident was trapped under the weight of his vehicle, causing extended extrication time. An ECT from the closest trauma center was able to deliver massive transfusion and definitive airway care while the patient was being extricated. While previous literature regarding the benefit of ECTs has been debated, this case suggests a unique niche where rapid deployment of an ECT to the scene made a pronounced difference in survival of the patient.

Randomized controlled trial evaluating a collaborative model of care for transitioning children with medical complexity from hospital to home healthcare: Study protocol.

This article describes the study protocol for an evaluation of an innovative model of care that supports home health nurses (HHN) who serve children with medical complexity (CMC). CMC constitute a small proportion of children, but have very high need for health services, are hospitalized frequently, and account for significant proportion of pediatric healthcare expenditures. High-quality home health nursing services are important for CMC, but models of care of home healthcare, after discharge of CMC from the hospital, have not been tested. Our project aims are to develop, implement, and test a model of care, called ICollab, to improve home healthcare delivery for CMC. The ICollab model consists of collaboration between HHN, primary-care physicians and clinicians of the complex care program of a tertiary-care children's hospital in the care of CMC. In this randomized clinical trial, we will recruit 110 CMC discharged home on home health nursing services. The intervention group (n = 55) will receive the ICollab intervention for 6 months post-discharge from the hospital, in addition to usual care. Children in the control group (n = 55) will receive only usual care. Outcome measures will include healthcare utilization metrics (hospitalization rates, emergency room visit rates, and days to readmission), caregiver burden and caregiver satisfaction with home healthcare, HHN retention, and HHN collaboration with other healthcare providers. We hypothesize that ICollab will reduce healthcare utilization and caregiver burden, and improve caregiver satisfaction with home healthcare, increase HHN retention, and increase HHN collaboration with other healthcare providers. Results of this study have the potential to provide a critically needed evidence-base for interventions to improve the quality of healthcare delivery for CMC. This study is registered on clinicaltrials.gov (NCT03978468) and is ongoing.

Enhanced care team response to incidents involving major trauma at night: are helicopters the answer?

INTRODUCTION: Challenges exist in how to deliver enhanced care to patients suffering severe injury in geographically remote areas within regionalised trauma networks at night. The physician led Enhanced Care Teams (ECTs) in the West Midlands region of England do not currently utilise helicopters to respond to incidents at night. This study describes this remote trauma workload at night within the regional network in terms of incident location; injury profile and patient care needs and discusses various solutions to the delivery of ECTs to such incidents, including the need for helicopter based platforms. METHODS: We present a retrospective analysis of incidents involving Major Trauma occurring in the West Midlands Regional Trauma Network in England over a one year period (1st April 2012 until the 31st March 2013). Anonymised patient records from the Trauma Audit and Research Network (TARN) for patients that had been conveyed to hospital by ambulance/air ambulance were cross-referenced with the West Midlands Ambulance Service NHS Foundation Trust (WMAS) Computer Assisted Dispatch (CAD) archive for the same period. Data were abstracted from the combined dataset relating to injury severity (ISS/ICU admission/death at scene or as inpatient); ECT resource activations/scene attendances; incident location and the need for enhanced level care. RESULTS: A total of 603 incidents involving Major Trauma were identified during night time hours. Enhanced Care Team resources attended scene in 167 cases (27.7%). Of the incidents not attended by an ECT 179 (41.1%) were due to falls and 91 (20.9%) involved a 'Road Traffic Collision'. A total of 36 incidents (6.0% of total at night) occurred in locations identified as being greater than 45min by road from the nearest major trauma centre. In these cases 13 patients had enhanced care needs that could not be addressed at scene by the attending ambulance service personnel. CONCLUSIONS: There is limited evidence to support the need for night HEMS operations in the West Midlands regional trauma network. The potential role of night HEMS in other regional trauma networks in England requires further evaluation with specific reference to the incidence of Major Trauma and efficiency of existing road based systems.

Does the use of dedicated dispatch criteria by Emergency Medical Services optimise appropriate allocation of advanced care resources in cases of high severity trauma? A systematic review.

BACKGROUND AND OBJECTIVES: The deployment of Enhanced Care Teams (ECTs) capable of delivering advanced clinical interventions for patients at the scene of incidents is commonplace by Emergency Medical Services in most developed countries. It is unclear whether primary dispatch models for ECT resources are more efficient at targeting deployment to patients with severe trauma than secondary dispatch, following requests from EMS personnel at scene. The objective of this study was to review the evidence for primary and secondary models in the targeted dispatch of ECT resources to patients with severe traumatic injury. METHODS: This review was completed in accordance with a protocol developed using the PRISMA guidelines. We conducted a search of the MEDLINE, EmBase, Web of Knowledge/Science databases and the Cochrane library, focussed on subject headings and keywords involving the dispatch of ECT resources by Emergency Medical Services. Design and results of each study were described. Heterogeneity in the design of the included studies precluded the completion of a meta-analysis. A narrative synthesis of the results therefore was performed. RESULTS: Five hundred and forty-eight articles were screened, and 16 were included. Only one study compared the performance of the different models of dispatch. A non-statistically significant reduction in the length of time for HEMS resources to reach incident scenes of 4min was found when primary dispatch protocols were utilised compared to requests from EMS personnel at scene. No effect on mortality; severity of injury or proportion of patients admitted to intensive care was observed. The remaining studies examined the processes utilised within current primary dispatch models but did not perform any comparative analysis with existing secondary dispatch models. CONCLUSIONS: This review identifies a lack of evidence supporting the role of primary dispatch models in targeting the deployment of Enhanced Care Teams to patients with severe injuries. It is therefore not possible to identify a model for ECT dispatch within pre-hospital systems that optimises resource utilisation. Further studies are required to assess the efficiency of systems utilised at each stage of the process used to dispatch Enhanced Care Team resources to incidents within regionalised pre-hospital trauma systems.