1,720,965 research outputs found
Training in occupational medicine: Jurisprudential malfunctions in the Italian system and European perspectives
No full textBackground. To practice occupational health in Europe, a medical doctor must qualify in occupational medicine. This requires a period of postgraduate specialist medical training lasting a minimum of four years, in conformity with European regulations, to obtain a certificate of completion of training which is then mutually recognized within the entire European Union. Discussion. In 2002 an Italian law allowed doctors specialized in public health medicine and legal/forensic medicine to also practice as consultants in occupational medicine in the country. However a subsequent law in 2008 determined that only physicians specialized in occupational medicine could freely practice as consultants in this discipline. The other two categories (consultants in public health medicine and consultants in legal/forensic medicine) were required to undertake additional training (a Master course) to qualify as consultants in occupational medicine. Conclusions. Doctors who entered postgraduate training in public health or legal/forensic medicine before 2008, with the option to practice also as consultants in occupational medicine upon completion of their training, suffered an unprecedented and legally questionable retroactive application of this new law which stripped them of previously acquired rights. Moreover, even after qualifying by undertaking this extra training in occupational medicine, the latter two categories of doctors do not have their training recognized in other member states of the European Union. To disallow the rights of doctors qualified in occupational medicine to work as consultants in the latter medical discipline elsewhere within the European Union seems a clear violation of professional rights and, as such, legal action could be taken to submit this issue to European attention
Jellyfish stings and their management: A review
No full textJellyfish (cnidarians) have a worldwide distribution. Despite most being harmless, some species may cause local and also systemic reactions. Treatment of jellyfish envenomation is directed at: alleviating the local effects of venom, preventing further nematocyst discharges and controlling systemic reactions, including shock. In severe cases, the most important step is stabilizing and maintaining vital functions. With some differences between species, there seems to be evidence and consensus on oral/topical analgesics, hot water and ice packs as effective painkillers and on 30 s application of domestic vinegar (4%-6% acetic acid) to prevent further discharge of unfired nematocysts remaining on the skin. Conversely, alcohol, methylated spirits and fresh water should be carefully avoided, since they could massively discharge nematocysts; pressure immobilization bandaging should also be avoided, as laboratory studies show that it stimulates additional venom discharge from nematocysts. Most treatment approaches are presently founded on relatively weak evidence; therefore, further research (especially randomized clinical trials) is strongly recommended. Dissemination of appropriate treatment modalities should be deployed to better inform and educate those at risk. Adequate signage should be placed at beaches to notify tourists of the jellyfish risk. Swimmers in risky areas should wear protective equipment. © 2013 by the authors
A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005–2015
Get PDFCesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005–15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005–2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age 40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33–36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005–15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit
Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005–2015
Get PDFSince Italy has the highest cesarean section (CS) rate (38.1%) among all European countries, the containment of health care costs associated with CS is needed, along with control of length of hospital stay (LOS) following CS. This population based cross-sectional study aims to investigate LoS post CS (overall CS, OCS; planned CS, PCS; urgent/emergency CS, UCS), in Friuli Venezia Giulia (a region of North-Eastern Italy) during 2005–2015, adjusting for a considerable number factors, including various obstetric conditions/complications. Maternal and newborn characteristics (health care setting and timeframe; maternal health factors; child’s size factors; child’s fragility factors; socio-demographic background; obstetric history; obstetric conditions) were used as independent variables. LoS (post OCS, PCS, UCS) was the outcome measure. The statistical analysis was conducted with multivariable linear (LoS expressed as adjusted mean, in days) as well as logistic (adjusted proportion of LoS > 4 days vs. LoS ≤ 4 days, using a 4 day cutoff for early discharge, ED) regression. An important decreasing trend over time in mean LoS and LoS > ED was observed for both PCS and UCS. LoS post CS was shorter with parity and history of CS, whereas it was longer among non-EU mothers. Several obstetric conditions/complications were associated with extended LoS. Whilst eclampsia/pre-eclampsia and preterm gestations (33–36 weeks) were predominantly associated with longer LoS post UCS, for PCS LoS was significantly longer with birthweight 2.0–2.5 kg, multiple birth and increasing maternal age. Strong significant inter-hospital variation remained after adjustment for the major clinical conditions. This study shows that routinely collected administrative data provide useful information for health planning and monitoring, identifying inter-hospital differences that could be targeted by policy interventions aimed at improving the efficiency of obstetric care. The important decreasing trend over time of LoS post CS, coupled with the impact of some socio-demographic and obstetric history factors on LoS, seemingly suggests a positive approach of health care providers of FVG in decision making on hospitalization length post CS. However, the significant role of several obstetric conditions did not influence hospital variation. Inter-hospital variations of LoS could depend on a number of factors, including the capacity to discharge patients into the surrounding non-acute facilities. Further studies are warranted to ascertain whether LoS can be attributed to hospital efficiency rather than the characteristics of the hospital catchment area
Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005–2015
Get PDFAlthough length of stay (LoS) after childbirth has been diminishing in several high-income countries in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG) during 2005–2015, to investigate the mean LoS and the percentage of LoS longer than our proposed ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe, maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression coefficients (RC) with 95% confidence interval (95%CI). The adjusted mean LoS was calculated by level of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH p-value for the respective estimates. During 2005–2015, the average LoS in FVG was 2.9 and 3.3 days after SVD and IVD respectively, and the pooled regional proportion of LoS > ED was 64.4% for SVD and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS > ED and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted figures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS were 2.3 and 3.4 days respectively, among “low risk” pregnancies. The corresponding figures for “high risk” pregnancies were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from “low” to “high” risk pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days. By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS post SVD (hospital B vs. A/G) was 1.1 days both among “low risk” (1.1 = 3.4–2.3 days) and “high risk” (1.1 = 3.6–2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models confirmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM. Therefore, health and clinical factors were less influential than practice patterns in determining LoS after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS > ED) should be reviewed and audited if need be. Primary care services within the catchment areas of the maternity centres of FVG should be improved to implement the follow up of puerperae undergoing ED after VD
Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (NorthEastern Italy), 2005–2015
Get PDFAlthough length of stay (LoS) after childbirth has been diminishing in several high-income countries
in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term
newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics
of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG)
during 2005–2015, to investigate the mean LoS and the percentage of LoS longer than our proposed
ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post
instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression
model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe,
maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic
background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression
coefcients (RC) with 95% confdence interval (95%CI). The adjusted mean LoS was calculated by level
of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed
the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH
p-value for the respective estimates. During 2005–2015, the average LoS in FVG was 2.9 and 3.3 days
after SVD and IVD respectively, and the pooled regional proportion of LoS>ED was 64.4% for SVD
and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery
modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS> ED
and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean
LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted
fgures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS were 2.3 and 3.4
days respectively, among “low risk” pregnancies. The corresponding fgures for “high risk” pregnancies
were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from “low” to “high” risk
pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days.
By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS
post SVD (hospital B vs. A/G) was 1.1 days both among “low risk” (1.1 = 3.4–2.3 days) and “high risk”
(1.1 = 3.6–2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models
confrmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM.
Therefore, health and clinical factors were less infuential than practice patterns in determining LoS
after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized
guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS> ED) should be reviewed
and audited if need be. Primary care services within the catchment areas of the maternity centres
of FVG should be improved to implement the follow up of puerperae undergoing ED after VD.
At the beginning of the 20th century home births were the norm and hospital deliveries very rare. Women started to deliver in hospital during World War 2 (WW2), in facilities near the military areas where their respective partners were training. Tis trend continued in the decades following WW2, with standard length of stay afer childbirth (LoS) increasing up to 10 days.
In the 70 ies some USA hospitals started to assess the health of mothers and newborn for eligibility to returnhome within 12–24 hours afer childbirth, with a midwife on call for domiciliary care up to 3 days for 2 weekspost discharge.
In 1992 the American Academy of Pediatrics (AAP) and the American College of Obstetricians and
Gynecologists (ACOG) formalized the most frequently shared defnition of early discharge (ED) afer childbirth worldwide as a LoS less than 48 h post spontaneous vaginal deliveries (SVD) and less than 96 h post cesarean section (CS). Tereafer the reduction of LoS expanded to other high-income countries, with increasing applications of ED.
LoS afer childbirth remained however a controversial aspect of obstetric care, creating an open debate not
only on its impact on the health of mothers and babies but also on health policies, state legislations and functioning of the respective health care systems. Nevertheless, ED of mothers and newborn has in fact increased dramatically in several high-income countries over the past 10–15 years. However, the evidence on the impact of ED on healthy mothers and term newborns (≥37 weeks) afer a vaginal delivery (VD) is still inconclusive and little is known of the characteristics of those discharged early.
Since LoS has become a critical indicator of efciency of health care delivery, understanding its associated
factors could provide information helpful in the reduction of health care costs, improvement in the delivery
of obstetric care, containment of untoward events associated with comorbidities and complications requiring readmission. For instance, in Canada (excluding Quebec) from 2003 to 2010, neonatal readmission rates were lowest for LoS of 1–2 days following VD and 2–4 days afer CS.
Several factors are reportedly associated with LoS in the open literature, including readiness for discharge
(clinical and perceived) of the mother8,17–19. However, information on the impact of medical/obstetrical conditions associated with pregnancies is scarce or totally lacking.
Using a comprehensive database with information on a considerable number of factors, we previously
reviewed the case mix of hospital performance by LoS post SVD as well as instrumental vaginal deliveries (IVD) during 2005–2015 in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy.
In this study we present the impact of the outstanding determinants on LoS following SVD and IVD, with the aim of inforing health care policy makers
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