Work and workload of Dutch primary care midwives in 2010

Objective

to re-assess the work and workload of primary care midwives in the Netherlands.

Background

in the Netherlands most midwives work in primary care as independent practitioners in a midwifery practice with two or more colleagues. Each practice provides 24/7 care coverage through office hours and on-call hours of the midwives. In 2006 the results of a time registration project of primary care midwives were published as part of a 4-year monitor study. This time the registration project was repeated, albeit on a smaller scale, in 2010.

Method

as part of a larger study (the Deliver study) all midwives working in 20 midwifery practices kept a time register 24 hours a day, for one week. They also filled out questionnaires about their background, work schedules and experiences of workload. A second component of this study collected data from all midwifery practices in the Netherlands and included questions about practice size (number of midwives and number of clients in the previous year).

Findings

in 2010, primary care midwives actually worked on an average 32.6 hours per week and approximately 67% of their working time (almost 22 hours per week) was spent on client-related activities. On an average a midwife was on-call for 39 hours a week and almost 13 of the 32.6 hours of work took place during on-call-hours. This means that the total hours that an average midwife was involved in her work (either actually working or on-call) was almost 59 hours a week. Compared to 2004 the number of hours an average midwife was actually working increased by 4 hours (from 29 to 32.6 hours) whereas the total number of hours an average midwife was involved with her work decreased by 6 hours (from 65 to 59 hours). In 2010, compared to 2001–2004, the midwives spent proportionally less time on direct client care (67% versus 73%), although in actual number of hours this did not change much (22 versus 21). In 2009 the average workload of a midwife was 99 clients at booking, 56 at the start of labour, 33 at childbirth, and 90 clients in post partum care.

Conclusion

the midwives worked on an average more hours in 2010 than they did in 2004 or 2001, but spent these extra hours increasingly on non-client-related activities.     

Optimal surgical management of pulmonary metastases: VATS versus thoracotomy

Survival benefit after pulmonary metastasectomy is under question and knowledge of functional recovery after pulmonary metastasectomy by thoracotomy and video‐assisted thoracoscopic surgery (VATS) is of great importance. We analysed prospective data of 100 patients operated for pulmonary metastasis by either VATS or thoracotomy. VATS yielded a better physical performance 1 month postoperative, shorter hospital stay, a shorter duration of chest tube drainage and epidural analgesia. We concluded that VATS is the preferable approach due to superior functional outcome.     

De novo 16p13.11 microdeletion identified by high-resolution array CGH in a fetus with increased nuchal translucency

Objective  We investigated the application of high-resolution microarray-based comparative genomic hybridisation (array CGH) on a fetus showing increased nuchal translucency (NT).
Design  Case study.
Setting  Tertiary referral obstetrics unit.
Sample  Pregnant woman attended the antenatal clinic.
Methods  Conventional karyotyping and genetic test was carried out for the alpha-globin gene. High-resolution array CGH using the high-density 244K Agilent microarray was performed on fetal blood sample by cordocentesis to investigate the possibility of any genomic imbalance.
Main outcome measures  Detection of chromosomal abnormality.
Results  Karyotyping analysis showed 46,XY. Molecular genetic diagnosis confirms the fetus has Hb-H constant spring disease but cannot explain the increased NT to 3.2 mm. Array CGH analysis discovered a 1.32-Mb microdeletion on chromosome 16p13.11. Deletion at 16p13.11 has been implicated to predispose to autism and/or mental retardation. Baby was delivered at 40 weeks of gestation, and follow up was carried out at 3 months of age without sign of mental retardation/developmental delay.
Conclusions  This case study demonstrated that array CGH can accurately calibrate the size and identify de novo interstitial chromosome imbalances. However, the presence of chromosome copy variants with unknown clinical significance currently limits its wider scale application in prenatal diagnosis and needs further investigations.     

Pushing functional MRI spatial and temporal resolution further: High‐density receive arrays combined with shot‐selective 2D CAIPIRINHA for 3D echo‐planar imaging at 7 T

To be able to examine dynamic and detailed brain functions, the spatial and temporal resolution of 7 T MRI needs to improve. In this study, it was investigated whether submillimeter multishot 3D EPI fMRI scans, acquired with high‐density receive arrays, can benefit from a 2D CAIPIRINHA sampling pattern, in terms of noise amplification (g‐factor), temporal SNR and fMRI sensitivity. High‐density receive arrays were combined with a shot‐selective 2D CAIPIRINHA implementation for multishot 3D EPI sequences at 7 T. In this implementation, in contrast to conventional inclusion of extra k_z gradient blips, specific EPI shots are left out to create a CAIPIRINHA shift and reduction of scan time. First, the implementation of the CAIPIRINHA sequence was evaluated with a standard receive setup by acquiring submillimeter whole brain T₂*‐weighted anatomy images. Second, the CAIPIRINHA sequence was combined with high‐density receive arrays to push the temporal resolution of submillimeter 3D EPI fMRI scans of the visual cortex. Results show that the shot‐selective 2D CAIPIRINHA sequence enables a reduction in scan time for 0.5 mm isotropic 3D EPI T₂*‐weighted anatomy scans by a factor of 4 compared with earlier reports. The use of the 2D CAIPIRINHA implementation in combination with high‐density receive arrays, enhances the image quality of submillimeter 3D EPI scans of the visual cortex at high acceleration as compared to conventional SENSE. Both the g‐factor and temporal SNR improved, resulting in a method that is more sensitive to the fMRI signal. Using this method, it is possible to acquire submillimeter single volume 3D EPI scans of the visual cortex in a subsecond timeframe. Overall, high‐density receive arrays in combination with shot‐selective 2D CAIPIRINHA for 3D EPI scans prove to be valuable for reducing the scan time of submillimeter MRI acquisitions.     

Post-operative discomfort after ring or clip tubal ligation--is there any difference and do indomethacin suppositories help?

One-hundred patients undergoing Falope ring or clip laparoscopic tubal ligation were given either a placebo or a 100 mg indomethacin rectal suppository one hour pre-operatively. Treatment was randomised and double-blind. Post-operative analgesic requirements and side effects were monitored. Forty-seven patients receiving indomethacin and 48 patients receiving placebo were available for analysis. Thirty-five patients in the indomethacin group required Meperidine (pethidine) analgesia (mean dose 58 mg) compared to 41 patients (mean dose 65 mg) in the placebo group. These differences were not significant. There were no significant differences in the non-narcotic analgesia given to each group, the side effects or the number requiring to stay overnight in the hospital. Analysis of the analgesic requirements of the 53 patients having clip sterilization and the 42 patients sterilized with Falope rings showed no statistical differences. This trial suggests that the immediate post-operative discomfort rates between ring and clip tubal occlusion are not different and that there is no significant benefit from the use of an indomethacin suppository pre-operatively.     

Spinal cord stimulation is not cost-effective for non-surgical management of critical limb ischaemia.

OBJECTIVE: To quantify the costs of treatment in critical limb ischaemia (CLI) and to compare costs and effectiveness of two treatment strategies: spinal cord stimulation (SCS) and best medical treatment. METHODS: One hundred and twenty patients with CLI not suitable for vascular reconstruction were randomised to either SCS in addition to best medical treatment or best medical treatment alone. Primary outcomes were mortality, amputation and cost. Cost analysis was based on resources used by patients for 2 years after randomisation. Both medical and non-medical costs were included. RESULTS: Patient and limb survival were similar in the two treatment groups. Costs of in-hospital-stay and institutional rehabilitation constituted the predominant part (+/-70%) of the total costs of medical care in CLI. Cost of SCS-implantation and complications (7950 euro per patient) exceeded by far cost due to amputation procedures (410 euro per patient). The total costs of treatment were 36,600 euro per patient over 2 years for the SCS-group vs. 28,700 euro for best medical treatment alone (28% higher for SCS-group, p=0.009). CONCLUSIONS: Total costs of treatment in CLI are high. Major components are hospital and rehabilitation costs. In contrast to recent reviews, there were no long-term benefits of SCS-treatment. Therefore, cost-effectiveness is reduced to cost-minimisation and SCS-treatment is considerably more expensive than best medical treatment.