Correction to: Implementing a Blood Pressure Measurement Curriculum for First-Year Medical Students.

[This corrects the article DOI: 10.1007/s40670-023-01825-9.].

A Comparison of Patient Characteristics and Outcomes Between Patients Receiving Flexor Digitorum Superficialis Slip Excision or Isolated A1 Pulley Release for Trigger Finger.

PURPOSE: Resection of the radial or ulnar slip of the flexor digitorum superficialis (FDS) tendon is a known treatment option for persistent trigger finger. Risk factors for undergoing FDS slip excision are unclear. We hypothesized that patients who underwent A1 pulley release with FDS slip excision secondary to persistent triggering would have a higher comorbidity burden compared to those receiving A1 pulley release alone. METHODS: We identified all adult patients who underwent A1 pulley release with FDS slip excision because of persistent triggering either intraoperatively or postoperatively from 2018 to 2023. We selected a 3:1 age- and sex-matched control group who underwent isolated A1 pulley release. Charts were retrospectively reviewed for demographics, selected comorbidities, trigger finger history, and postoperative course. We performed multivariable logistic regression to assess the probability of FDS slip excision after adjusting for several variables that were significant in bivariate comparisons. RESULTS: We identified 48 patients who underwent A1 pulley release with FDS slip excision and 144 controls. Our multivariable model showed that patients with additional trigger fingers and a preoperative proximal interphalangeal (PIP) joint contracture were significantly more likely to undergo FDS slip excision. CONCLUSIONS: Patients who underwent A1 pulley release with FDS slip excision were significantly more likely to have multiple trigger fingers or a preoperative PIP joint contracture. Clinicians should counsel patients with these risk factors regarding the potential for FDS slip excision in addition to A1 pulley release to alleviate triggering of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Implementing a Blood Pressure Measurement Curriculum for First-Year Medical Students.

A core clinical skill medical students need to learn is obtaining an accurate blood pressure (BP) reading. We developed a standardized BP curriculum for first-year medical students. Medical students completed online modules and a hands-on skills session to learn BP skills. Pre- and post-surveys and an observed structured clinical encounter (OSCE) assessed student confidence and ability to accurately measure BP. Student confidence and mean OSCE scores (pre = 2.63, post = 6.51; p < 0.001) improved upon completion of the curriculum. The curriculum was feasible, well received, and improved student's skills for taking an accurate BP.

A survey of gastrointestinal parasites in dogs illegally entering the UK (2015-2017).

Background: This study involving non-compliant, seized dogs entering the UK surveyed endoparasites detected in faecal samples. A focus was placed on taeniid infection as the detection of these tapeworms acts as a marker for failure of effective tapeworm treatment. Methods: Individual faecal samples taken from 65 dogs over a 24-month period were examined for helminth eggs, for protozoal oocysts and cysts, using a centrifugal flotation technique. Any sample presenting positive results for taeniid eggs had residual faeces examined using polymerase chain reaction to aid speciation of the tapeworm eggs. Additionally, a Baermann technique was used to assess faeces for lungworm larvae. Results: Patent endoparasite infection was detected in 27.7% of dog faecal samples. No sample was positive for lungworm larvae. Five dogs were co-infected with Isospora spp. and Toxocara canis. One dog sample was detected with taeniid eggs, identified as Taenia serialis. Conclusions: The taeniid-positive dog indicated that appropriate tapeworm treatment may not have occurred, reinforcing the risk to the UK of illegally imported dogs potentially introducing Echinococcus multilocularis infection.

Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: a systematic review and meta-analysis.

OBJECTIVE: Reduced fetal movement, defined as a decrease in the frequency or strength of fetal movements as perceived by the mother, is a common reason for presentation to maternity care. Observational studies have demonstrated an association between reduced fetal movement and stillbirth and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aimed at encouraging awareness of reduced fetal movement and/or improving its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes. DATA SOURCES: Searches were conducted in MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, and Google Scholar. Guidelines, trial registries, and gray literature were also searched. Databases were searched from inception to January 20, 2022. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials and controlled nonrandomized studies were eligible if they assessed interventions aimed at encouraging awareness of fetal movement or fetal movement counting and/or improving the subsequent clinical management of reduced fetal movement. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review. METHODS: Risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies I tools for randomized controlled trials and nonrandomized studies, respectively. Variation caused by heterogeneity was assessed using I2. Data from studies employing similar interventions were combined using random effects meta-analysis. RESULTS: A total of 1609 citations were identified; 190 full-text articles were evaluated against the inclusion criteria, 18 studies (16 randomized controlled trials and 2 nonrandomized studies) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth when compared with standard care (2 studies, n=330,084) with a pooled adjusted odds ratio of 1.19 (95% confidence interval, 0.96-1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in neonatal intensive care unit admissions and Apgar scores of <7 at 5 minutes of age and may not be associated with increases in cesarean deliveries or induction of labor. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth when compared with standard care with a pooled odds ratio of 0.69 (95% confidence interval, 0.18-2.65) based on data from 3 randomized controlled trials (n=70,584). Counting fetal movements may increase maternal-fetal attachment and decrease anxiety when compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (1 study, n=393,857), the evidence is uncertain about the effect on stillbirth (adjusted odds ratio, 0.86; 95% confidence interval, 0.70-1.05). CONCLUSION: The effect of interventions for encouraging awareness of reduced fetal movement alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labor. The meta-analysis was hampered by variations in interventions, outcome reporting, and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.

Safety of Antimicrobials for Postexposure Prophylaxis and Treatment of Anthrax: A Review.

BACKGROUND: Bacillus anthracis, the causative agent for anthrax, poses a potential bioterrorism threat and is capable of causing mass morbidity and mortality. Antimicrobials are the mainstay of postexposure prophylaxis (PEP) and treatment of anthrax. We conducted this safety review of 24 select antimicrobials to identify any new or emerging serious or severe adverse events (AEs) to help inform their risk-benefit evaluation for anthrax. METHODS: Twenty-four antimicrobials were included in this review. Tertiary data sources (e.g. Lactmed, Micromedex, REPROTOX) were reviewed for safety information and summarized to evaluate the known risks of these antimicrobials. PubMed was also searched for published safety information on serious or severe AEs with these antimicrobials; AEs that met inclusion criteria were abstracted and reviewed. RESULTS: A total of 1316 articles were reviewed. No consistent observations or patterns were observed among the abstracted AEs for a given antimicrobial; therefore, the literature review did not reveal evidence of new or emerging AEs that would add to the risk-benefit profiles already known from tertiary data sources. CONCLUSIONS: The reviewed antimicrobials have known and/or potential serious or severe risks that may influence selection when recommending an antimicrobial for PEP or treatment of anthrax. Given the high fatality rate of anthrax, the risk-benefit evaluation favors use of these antimicrobials for anthrax. The potential risks of antimicrobials should not preclude these reviewed antimicrobials from clinical consideration for anthrax but rather guide appropriate antimicrobial selection and prioritization across different patient populations with risk mitigation measures as warranted.

Supervision and assessment in midwifery practice during a global pandemic: A cohort survey.

AIM: To evaluate new practice assessment processes in midwifery placements linked to a United Kingdom university during COVID-19. BACKGROUND: The new regulatory body standards for supervising and assessing practice of student nurses and midwives replaced the former mentorship model. Locally, these were implemented in conjunction with the Practice Assessment Toolkit - a resource developed from the national project exploring grading in midwifery practice. Emergency regulatory standards in response to the global pandemic impacted on student placements and temporarily created greater flexibility in assessing practice. DESIGN: A cohort survey using mixed methods. METHODS: Online questionnaires comprising qualitative and quantitative components targeted each of the four stakeholder groups: second and third-year student midwives, practice supervisors, practice assessors, midwifery academics. Aspects of the assessment process were explored including whether changes in the assessment process had influenced reliability, views of the Practice Assessment Toolkit and grading versus a binary pass/fail approach. RESULTS: Views were mixed about whether the new practice assessment process improved reliability, but the context of the global pandemic was acknowledged. Some clinicians embraced the changes more readily than others, and organisational approaches varied. There was a reliance on students' knowledge and understanding of requirements. Inconsistencies could have a detrimental effect on student learning and the reliability of assessment. Practice assessors relied on a range of practice supervisors' comments to make their decisions. Some participants considered that the separation of these roles enhanced reliability of assessment while others found it challenging. Detachment of students from the assessment process appeared to promote objectivity and honesty, potentially reducing grade inflation. The Practice Assessment Toolkit was useful and assisted reliability, however issues around individual expectations, application and relationships persisted. Most participants were in favour of retaining grading of practice in at least the final year of the midwifery programme. Qualitative themes comprised: Impetus for change; Reliance and reliability; Benefits of detachment; Mind the gap; To grade or not to grade. CONCLUSIONS: This first evaluation of the new practice assessment process suggested it has potential to increase reliability, however this is dependent on individual and institutional understanding and adherence. The context of the global pandemic also influenced implementation and findings. The benefits of using consistent terminology were demonstrated through application of the Practice Assessment Toolkit. Further evidence is presented of the advantages and challenges of grading practice or using the binary approach. Recommendations are made to promote concepts identified in the findings and for future research. TWEETABLE ABSTRACT: The first evaluation of the new NMC practice supervision and assessment process demonstrated its potential to increase reliability but depended on understanding and application. Concurrent use of the Practice Assessment Toolkit enhanced consistency in midwifery student assessment.

The 'Reality of Revalidation in Practice' (RRiP) project - Experiences of registrants and preparation of students in nursing and midwifery in the United Kingdom: A descriptive exploratory survey.

BACKGROUND: Renewal of healthcare registration or license to practise is becomingly increasingly common, worldwide. Evidence regarding the experience of nursing and midwifery revalidation in the United Kingdom is limited. Preparation of students for the process has not yet been considered in the literature. OBJECTIVES: To explore registrants' experiences of undertaking or supporting colleagues through revalidation. To consider preparation of pre-registration students for this future professional requirement. DESIGN: A descriptive exploratory study comprising an on-line survey. SETTING: A university in the southwest of England and associated clinical placements. PARTICIPANTS: Nursing and Midwifery Council registrants, comprising 40 university staff and 40 clinicians; 36 pre-registration nursing and midwifery students. METHODS: Participation in an anonymous on-line survey was invited via university databases. Descriptive statistical analysis of quantitative data used a combination of software and manual methods. Qualitative data were manually coded and categorised into themes through inductive reasoning. FINDINGS: Most experiences of revalidation were positive. Reflective discussions resulted in mutual learning, particularly if partners were chosen by the registrant. External scrutiny was welcomed. Some registrants questioned involvement of line managers and alignment with performance review, seeking to avoid a 'tick-box exercise' and conflicts of interest. University staff felt better prepared and more positive than clinicians. Pre-registration curriculum activities preparing students included writing reflections, maintaining portfolios, practice assessment and discussions about the revalidation process. Midwifery students seemed better prepared than nursing peers. Key themes of 'Professional values', 'Preparation', 'Process' and 'Purpose' and a range of positive influences and potential hazards informed development of a conceptual model. CONCLUSIONS: The purpose and process of revalidation is enhanced if confirmation is undertaken by a registered nurse or midwife of the individual's choice. Preparation of students for future revalidation is facilitated by role-modelling of positive attitudes and explicitly linking relevant pre-registration curriculum activities to this process and purpose.

Debriefing for Professional Practice Placements in Nursing: A Concept Analysis.

AIM: The aim of the study was to provide an in-depth analysis on the concept of debriefing for professional practice placements within baccalaureate nursing education. BACKGROUND: When conducted properly, debriefing leads to positive outcomes on undergraduate nursing students' learning. However, if debriefing is conducted poorly, it can inhibit students' learning. Clarification of debriefing as a concept in professional practice placements is integral to its development and successful use within undergraduate nursing education. METHOD: The Walker and Avant concept analysis model was used in this study. RESULTS: The analysis identified four defining attributes (description, emotion, analytical reflection, application), three antecedents (an experience, a supportive and respectful environment, and a competent and knowledgeable debrief facilitator), and three consequences (increased knowledge, increased confidence in knowledge, and increased clinical judgment/clinical decision making). CONCLUSION: Knowledge of the defining attributes, antecedents, consequences of debriefing, and empiric referents assists educators in developing successful debriefing frameworks and instrument evaluation criteria for use in professional practice placements.

National survey: Developing a common approach to grading of practice in pre-registration midwifery.

This paper presents the final phase of a national project exploring grading of practice in programmes leading to registration as a midwife in the United Kingdom. The aim was to develop a generic framework for grading practice, enhancing standardisation while enabling flexibility in application of current and new educational standards. A mixed method on-line survey considered existing practice assessment tools, factors contributing to robust and reliable assessment and perceptions of two assessment tools developed by the research team: a 'Lexicon Framework' and 'Rubric', which were tested through scenarios. Participants included 170 midwifery and nursing academics, clinicians and students, representing 20 universities in the UK. Seven key themes emerged, from which an 'Evidence Based Model for Professional Practice Assessment' was developed. The proposed tools were overall positively evaluated and demonstrated a good level of reliability. A national tool to standardise midwifery practice assessment is recommended, and scope for transferability of our tools to all midwifery programmes and to nursing was identified. Other recommendations include engagement of key stakeholders in development of practice assessment documentation, and maintaining the professional purpose of grading practice as central to the process. A set of key principles for assessing practice is presented.

Hospital-Acquired Hyponatremia in Children Following Hypotonic versus Isotonic Intravenous Fluids Infusion.

Hypotonic solutions have been used in pediatrics for maintenance of intravenous (IV) hydration. However, recent randomized control trials and cohort studies have raised significant concerns for association with hospital-acquired hyponatremia (HAH). The study aimed to assess whether the use of hypotonic parenteral solutions (PS) compared with isotonic PS is associated with increased HAH risk in children with common pediatric conditions. Retrospective chart review of 472 patients aged 2 months to 18 years who received either isotonic or hypotonic PS as maintenance fluids. Administration of hypotonic PS was associated with a four-fold increase in risk of developing HAH in the univariate analysis, (unadjusted odds ratio (OR) = 3.99; 95% confidence interval (CI): 1.36⁻11.69, p = 0.01). Hypotonic PS were associated with HAH (p = 0.04) when adjusted for the level of admission serum CO2. There was a mean decrease of serum sodium of 0.53 mEq/L in the hypotonic group compared to the mean increase of 4.88 mEq/L in the isotonic group. These data suggest that hypotonic PS are associated with HAH in children admitted for common pediatric conditions. Isotonic PS should be considered as a safer choice for maintenance fluid hydration.

Difficulty in the Clinical Diagnosis of Tularemia: Highlighting the Importance of a Physical Exam.

We report an 18-month-old male who presented with fever and nonspecific symptoms. He was evaluated for multiple differential diagnoses including Kawasaki disease and JIA and received treatment for them. After he was readmitted, tularemia was considered based on the physical exam finding of an ulcer on the scalp and enlarged lymph nodes. Tularemia titers were positive, and the patient was given the appropriate antibiotic and was discharged home. Follow-up of the patient showed complete resolution of symptoms. This is a case that demonstrates the importance of physical exam in identifying rare diseases presenting with common signs and symptoms.

Peer mentoring: Enhancing the transition from student to professional.

OBJECTIVE: to share the experience of a model of peer mentoring in a pre-qualification midwifery programme DESIGN: description of the framework and benefits of the model SETTING: University and practice PARTICIPANTS: third year midwifery students INTERVENTIONS: practical activities meeting regulatory body requirements in a pre-qualification mentorship module MEASUREMENTS AND FINDINGS: informal evaluations by students of key activities undertaken during peer mentoring demonstrated a range of positive outcomes. These included enhanced confidence, self-awareness, interpersonal and teaching skills, team-working and leadership - factors also associated with emotional intelligence. Students developed an appreciation of the accountability of the mentor including making practice assessment decisions. They stated that the learning achieved had aided their professional development and enhanced employability. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this module equips students with skills for their future role in facilitating learners and contributes to development of a 'professional persona', enhancing their transition to qualified midwives. The Peer Mentoring Model would be easily adapted to other programmes and professional contexts.

Core principles to reduce current variations that exist in grading of midwifery practice in the United Kingdom.

AIM: To reduce variations in grading of midwifery practice and enhance reliability of assessment. BACKGROUND: The first phase of a national project showed there to be widely ranging interpretation and application of professional educational standards in relation to grading of practice in midwifery. This raised concerns about reliability and equity of professional assessment. The second phase therefore sought to achieve consensus on a set of core principles. METHODS: A participatory action research process in two stages, using a Mini-Delphi approach. Educational leads from all 55 institutions delivering midwifery programmes nationally were invited to participate. Stage one: Questionnaire comprising 12 statements drawn from the findings of the initial phase of the project. Stage two: Face-to-face discussion. FINDINGS: Statements were categorised based on questionnaire responses: 1) Consensus, 2) Staged consensus, 2) Minor modifications, 4) Controversial. Consensus was achieved on 11 core principles through group discussion; only one was omitted from the final set. RECOMMENDATIONS: All midwifery programmes nationally to incorporate the agreed core principles. Findings should be disseminated to the regulatory body to help inform changes to midwifery and nursing educational standards. The core principles may also contribute to curriculum development in midwifery and other professions internationally.

A scoping study to explore the application and impact of grading practice in pre-registration midwifery programmes across the United Kingdom.

Grading of practice is a mandatory element of programmes leading to registration as a midwife in the United Kingdom, required by the Nursing and Midwifery Council. This validates the importance of practice by placing it on an equal level with academic work, contributing to degree classification. This paper discusses a scoping project undertaken by the Lead Midwives for Education group across the 55 Higher Education Institutions in the United Kingdom which deliver pre-registration midwifery programmes. A questionnaire was circulated and practice tools shared, enabling exploration of the application of the standards and collation of the views of the Lead Midwives. Timing and individuals involved in practice assessment varied as did the components and the credit weighting applied to practice modules. Sign-off mentor confidence in awarding a range of grades had increased over time, and mentors seemed positive about the value given to practice and their role as professional gatekeepers. Grading was generally felt to be more robust and meaningful than pass/refer. It also appeared that practice grading may contribute to an enhanced student academic profile. A set of guiding principles is being developed with the purpose of enhancing consistency of the application of the professional standards across the United Kingdom.

Infantile Tubercular Meningitis With Brain Infarct.

A previously healthy 6-month-old Asian girl presented to the emergency department (ED) after 7 to 10 days of fever of 101 to 102°F, cough, and intermittent vomiting. Pneumonia was diagnosed and successfully treated, and the patient was discharged. She returned to the ED after her mother noticed mild facial asymmetry, left upper extremity weakness, and an episode of jerkiness. The mother then revealed that both she and the child's maternal grandmother, who also lived with the patient, had suffered chronic coughs in recent months. The mother's previous chest radiograph showed pulmonary tuberculosis. The patient's magnetic resonance imaging findings were consistent with a cerebrovascular event. Positive results on cerebrospinal fluid analysis, the mother's suspicious tuberculosis-like history, and the patient's clinical symptoms pointed heavily toward a diagnosis of tuberculous meningitis. A 4-drug antituberculosis regimen with dexamethasone was instituted and scheduled to continue for 12 months. However, the patient returned to the ED 2 months later after developing an obstructive hydrocephalus.

Clinical guidance for smallpox vaccine use in a postevent vaccination program.

This report outlines recommendations for the clinical use of the three smallpox vaccines stored in the U.S. Strategic National Stockpile for persons who are exposed to smallpox virus or at high risk for smallpox infection during a postevent vaccination program following an intentional or accidental release of the virus. No absolute contraindications exist for smallpox vaccination in a postevent setting. However, several relative contraindications exist among persons with certain medical conditions. CDC recommendations for smallpox vaccine use were developed in consideration of the risk for smallpox infection, risk for an adverse event following vaccination, and benefit from vaccination. Smallpox vaccines are made from live vaccinia viruses that protect against smallpox disease. They do not contain variola virus, the causative agent of smallpox. The three smallpox vaccines stockpiled are ACAM2000, Aventis Pasteur Smallpox Vaccine (APSV), and Imvamune. Surveillance and containment activities including vaccination with replication-competent smallpox vaccine (i.e., vaccine viruses capable of replicating in mammalian cells such as ACAM2000 and APSV) will be the primary response strategy for achieving epidemic control. Persons exposed to smallpox virus are at high risk for developing and transmitting smallpox and should be vaccinated with a replication-competent smallpox vaccine unless severely immunodeficient. Because of a high likelihood of a poor immune response and an increased risk for adverse events, smallpox vaccination should be avoided in persons with severe immunodeficiency who are not expected to benefit from vaccine, including bone marrow transplant recipients within 4 months of transplantation, persons infected with HIV with CD4 cell counts <50 cells/mm3, and persons with severe combined immunodeficiency, complete DiGeorge syndrome, and other severely immunocompromised states requiring isolation. If antivirals are not immediately available, it is reasonable to consider the use of Imvamune in the setting of a smallpox virus exposure in persons with severe immunodeficiency. Persons without a known smallpox virus exposure might still be at high risk for developing smallpox infection depending on the magnitude of the outbreak and the effectiveness of the public health response. Such persons will be defined by public health authorities and should be screened for relative contraindications to smallpox vaccination. Relative contraindications include atopic dermatitis (eczema), HIV infection (CD4 cell counts of 50-199 cells/mm3), other immunocompromised states, and vaccine or vaccine-component allergies. Persons with relative contraindications should be vaccinated with Imvamune when available and authorized for use by the Food and Drug Administration. These recommendations will be updated as new data on smallpox vaccines become available and further clinical guidance for other medical countermeasures including antivirals is developed.

Strongyloidiasis in a healthy 8-year-old girl in north-eastern USA.

A previously healthy, white 8-year-old girl presented with a 1-week history of abdominal pain and vomiting after a trip to a lake in Pennsylvania, north-eastern USA. There was marked dehydration. A raised blood eosinophilic count prompted microscopy for ova and parasites which demonstrated a heavy load of larvae of Strongyloides stercoralis. Charcot-Leyden crystals were also detected. The child received oral ivermectin and made a complete recovery.

Septic bursitis in an 8-year-old boy.

Background. The prepatellar bursa can become inflamed owing to repeated trauma. Prepatellar bursitis is extremely rare in children. Methods. We report the case of an 8-year-old boy who was treated for an erythematous, swollen, and severely painful right knee, fever, inability to bear weight on the leg, and purulent material draining from a puncture wound. We describe the differential diagnosis for tender swollen knee, including infection, gout, rheumatoid arthritis, and osteoarthritis. If untreated, prepatellar bursitis can progress to patellar osteomyelitis. Results. Wound cultures grew Streptococcus pyogenes, with the infection resolving with amoxicillin. Conclusions. A high index of suspicion is necessary in children presenting with prepatellar bursitis to prevent potentially devastating sequelae of infection of the septic joint.