Portfolios in practice: Developing advancing practice within a musculoskeletal competency-based model.

INTRODUCTION: The development of professional portfolios and the relevance of this within professional practice, competency and capability is gaining significant credibility in line with professional requirements. Nursing and medicine in terms of historical perspectives have long held the need for clinicians to maintain a portfolio for professional validation, whilst in other professional groups it is a requirement of registration. The allied health professionals, physiotherapy and ultimately musculoskeletal practice within this context are rapidly developing advancing and consultant practice. This professional development further requires appropriate verification and validation of practice, and achieving this can be through formal and non-formal routes. PURPOSE: This paper looks to explore this and give direction to professionals developing portfolios whilst placing the requirements in context to contemporary practice in the U.K. Universities, professional bodies and special interest groups are now aligning in the need to support practice in a multi-format way, that moves away from traditional methods of evaluation into more diverse models of competency-based assessment. IMPLICATIONS: With improvement in technology, the development of national frameworks and standards, portfolios in practice although commonly considered as standard practice will be a requirement not only of registration but as a criteria of maintaining status, career development and expansion of roles. BACKGROUND: Musculoskeletal (MSK) physiotherapy in the U.K. has moved forward significantly in the last 20 years. Sitting within a clinical reasoned framework, the introduction of additional skills such is image requesting, injection therapies, and non-medical prescribing has further underpinned the advanced practice agenda (Langridge et al., 2015). While these advancements in practice are driving the profession forward, challenges remain in providing the workforce with a clear process of career development. Alongside developing professional pathways methods of evidencing advanced knowledge and skills acquired outside formal routes are required to support practitioners' career pathway into advancing practice.

Patient characteristics in tardive COVID-19 pseudoperniosis: a case series of 16 patients.

BACKGROUND: Acute pseudoperniosis (PP) has a recognized association with COVID-19 and tends to occur without cold precipitation in young, healthy patients, often without a clear history of COVID-19. These lesions usually resolve within 2 weeks and without long-term sequelae. In the early months of 2021, patients with delayed and protracted PP began to emerge. We have called this presentation 'tardive COVID-19 PP (TCPP)'. AIM: To consolidate and expand knowledge on TCPP, we describe the clinical characteristics, treatments and outcomes of 16 patients with TCPP who were reviewed by our outpatient dermatology service. RESULTS: The initial clinical manifestations were erythema, swelling and PP of the fingers in 56.2%, and of the toes in 31.2%, desquamation in 56.2% and acrocyanosis in 12.5%. Ten patients had eventual involvement of all acral sites. The median duration of symptoms was 191 days. Six patients reported close contact with a confirmed or suspected case of COVID-19, but only two had positive COVID-19 tests. Four patients experienced complete or almost complete resolution of symptoms, while the rest remain under active treatment. CONCLUSION: Unlike acute PP, TCPP has a protracted and delayed presentation that is typically associated with profound acrocyanosis. Patients with TCPP represent a new phenomenon that is part of the post-COVID-19 syndrome, with risk factors and pathophysiology that are not yet fully understood. Our data indicate that likely predisposing factors for developing TCPP include young age, a preceding history of cold intolerance and an arachnodactyloid phenotype. Anorexia, connective tissue disorders or sickle cell trait may also predispose to TCPP. In addition, low titre antinuclear antibody positivity, the presence of cryoglobulins, or low complement levels may represent further risk factors. Finally, prolonged low temperatures are also likely to be contributing to the symptoms.

Telemedicine for medical abortion: a systematic review.

BACKGROUND: Telemedicine is increasingly being used to access abortion services. OBJECTIVE: To assess the success rate, safety, and acceptability for women and providers of medical abortion using telemedicine. SEARCH STRATEGY: We searched PubMed, EMBASE, ClinicalTrials.gov, and Web of Science up until 10 November 2017. STUDY CRITERIA: We selected studies where telemedicine was used for comprehensive medical abortion services, i.e. assessment/counselling, treatment, and follow up, reporting on success rate (continuing pregnancy, complete abortion, and surgical evacuation), safety (rate of blood transfusion and hospitalisation) or acceptability (satisfaction, dissatisfaction, and recommendation of the service). DATA COLLECTION AND ANALYSIS: Quantitative outcomes were summarised as a range of median rates. Qualitative data were summarised in a narrative synthesis. MAIN RESULTS: Rates relevant to success rate, safety, and acceptability outcomes for women ≤10+0 weeks' gestation (GW) ranged from 0 to 1.9% for continuing pregnancy, 93.8 to 96.4% for complete abortion, 0.9 to 19.3% for surgical evacuation, 0 to 0.7% for blood transfusion, 0.07 to 2.8% for hospitalisation, 64 to 100% for satisfaction, 0.2 to 2.3% for dissatisfaction, and 90 to 98% for recommendation of the service. Rates in studies also including women >10+0 GW ranged from 1.3 to 2.3% for continuing pregnancy, 8.5 to 20.9% for surgical evacuation, and 90 to 100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers. CONCLUSION: Based on a synthesis of mainly self-reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in-person abortion care, and surgical evacuation rates are higher. TWEETABLE ABSTRACT: A systematic review of medical abortion through telemedicine shows outcome rates similar to in-person care.

Effectiveness, safety, and acceptability of first-trimester medical termination of pregnancy performed by non-doctor providers: a systematic review.

BACKGROUND: Previous systematic reviews have concluded that medical termination of pregnancy (TOP) performed by non-doctor providers may be as effective and safe as when provided by doctors. Medical treatment of incomplete miscarriage by non-doctor providers and the treated women's acceptance of non-doctor providers of TOP has not previously been reviewed. OBJECTIVES: To review the effectiveness, safety, and acceptability of first-trimester medical TOP, including medical treatment for incomplete miscarriage, by trained non-doctor providers. SEARCH STRATEGY AND SELECTION CRITERIA: A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials.gov) were searched from inception through April 2016. Randomised controlled trials and comparative observational studies were included. DATA COLLECTION AND ANALYSIS: Meta-analyses were performed for included randomised controlled trials regarding the outcomes of effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias. MAIN RESULTS: Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective when performed by non-doctor providers as when performed by doctors (RR 1.00; 95% CI 0.99-1.01). Women's acceptance, reported as overall satisfaction with the allocated provider, is probably equally high between groups (RR 1.00; 95% CI 1.00-1.01). CONCLUSION: Medical TOP and medical treatment of incomplete miscarriage provided by trained non-doctor providers is probably equally as effective and acceptable to women as when provided by doctors. TWEETABLE ABSTRACT: Medical termination of pregnancy performed by doctors and non-doctors can be equally effective and acceptable.

Self-administration of injectable contraceptives: a systematic review.

BACKGROUND: The contraceptive injectable is a safe and effective method that is used worldwide. With the variety of injectable delivery systems, there is potential for administration by the woman herself. Self-administration of the contraceptive injectable is the subject of this systematic review. OBJECTIVES: To assess how effective and safe the contraceptive injectable method is when women themselves perform/administer it, compared with when the usual healthcare providers administer it. SEARCH STRATEGY: We searched PubMed, Popline, Cochrane, CINAHL, and Embase for articles with subject headings or text words related to 'self-administration' and 'contraception'. SELECTION CRITERIA: Studies that compared the administration of the contraceptive injectable by the woman herself versus administration by the healthcare provider were included. Outcomes of interest were continuation rates, safety, and the women's overall satisfaction with the contraceptive provider and method. DATA COLLECTION AND ANALYSIS: We undertook data extraction, descriptive analysis, and assessment of risk of bias. MAIN RESULTS: Three studies met the inclusion criteria. The best available evidence shows that there may be little or no difference in continuation rates when women self-administer contraceptive injections (326 per 1000 women; 95% CI 192-554 per 1000 women) compared with administration by healthcare providers (304 per 1000 women). Safety was not estimable as no serious adverse events were reported in any of the studies. With regards to overall satisfaction towards the provider and the method, the effect of the intervention was uncertain. AUTHORS' CONCLUSIONS: Findings suggest that with appropriate information and training the provision of contraceptive injectables for the woman to self-administer at home can be an option in some contexts. TWEETABLE ABSTRACT: This review assessed the continuation rates and safety of self-administration of the contraceptive injection.

Overview of abortion cases with severe maternal outcomes in the WHO Multicountry Survey on Maternal and Newborn Health: a descriptive analysis.

OBJECTIVE: To summarise individual and institutional characteristics of abortion-related severe maternal outcomes reported at health facilities. DESIGN: Secondary analysis of data from the WHO Multicountry Survey on Maternal and Newborn Health. SETTING: 85 health facilities in 23 countries. SAMPLE: 322 women with abortion-related severe maternal outcomes. METHODS: Frequency distributions and comparisons of differences in characteristics between cases of maternal near miss and death using Fisher's exact tests of association. MAIN OUTCOME MEASURES: Individual and institutional characteristics and frequencies of potentially life-threatening conditions, and interventions provided to women with severe maternal outcomes, maternal near miss, and maternal death. RESULTS: Most women with abortion-related severe maternal outcomes (SMOs) were 20-34 years old (65.2%), married or cohabitating (92.3%), parous (84.2%), and presented with abortions resulting from pregnancies at less than 14 weeks of gestation (67.1%). The women who died were younger, more frequently without a partner, and had abortions at ≥14 weeks of gestation, compared with women with maternal near miss (MNM). Curettage was the most common mode of uterine evacuation. The provision of blood products and therapeutic antibiotics were the most common other interventions recorded for all women with abortion-related SMOs; those who died more frequently had antibiotics, laparotomy, and hysterectomy, compared with women with MNM. Although haemorrhage was the most common cause of abortion-related SMO, infection (alone and in combination with haemorrhage) was the most common cause of death. CONCLUSION: This analysis affirms a number of previously observed characteristics of women with abortion-related severe morbidity and mortality, despite the fact that facility-based data on abortion-related SMO suffers a number of limitations.

Understanding women's experiences with medical abortion: In-depth interviews with women in two Indian clinics.

We explored women's perspectives on using medical abortion, including their reasons for selecting the method, their experiences with it and their thoughts regarding demedicalisation of part or all of the process. Sixty-three women from two urban clinics in India were interviewed within four weeks of abortion completion using a semi-structured in-depth interview guide. While women appreciated the non-invasiveness of medical abortion, other factors influencing method selection were family support and distance from the facility. The degree of medicalisation that women wanted or felt was necessary also depended on the way expectations were set by their providers. Confirmation of abortion completion was a source of anxiety for many women and led to unnecessary interventions in a few cases. Ultimately, experiences depended more on women's expectations about the method, and on the level of emotional and logistic support they received rather than on inherent characteristics of the method. These findings emphasise the circumstances under which women make reproductive choices and underscore the need to tailor service delivery to meet women's needs. Women-centred counselling and care that takes into consideration individual circumstances are needed.

Ultrastaging of colorectal cancer by sentinel lymph node mapping technique--a multicenter trial.

Sentinel lymph node (SLN) mapping accurately diagnoses the status of nodal basin with >95% accuracy in melanoma and breast cancer. A multicenter trial for SLN mapping was performed on 203 patients with colorectal cancer to determine accuracy, upstaging, skip metastasis, and aberrant drainage. Lymphazurin 1% was injected subserosally around the tumor and 1-4 blue staining nodes were marked as SLNs for detailed histological analysis. SLN mapping was successful in 98% of patients with an average of 1.7 SLNs per patient. SLNs were negative in 63% of the patients and positive in 37% of the patients. Skip metastasis was seen in 8 of the patients. Occult micrometastasis was found in 14% of patients. In 5% of the patients, unusual lymphatic drainage lead to an alteration of the extent of lymphadenectomy. This multicenter trial proved that SLN mapping in patients with colorectal cancer is simple, cost effective, and upstages at least 14% of patients from AJCC stage I/II to stage III. These patients may then benefit from adjuvant chemotherapy.

Technical details of sentinel lymph node mapping in colorectal cancer and its impact on staging.

BACKGROUND: Sentinel lymph node (SLN) mapping for melanoma and breast cancer has greatly enhanced the identification of micrometastases in many patients, thereby upstaging a subset of these patients. The purpose of this study was to see if SLN mapping technique could be used to identify SLNs in colorectal cancer and to assess its impact on pathological staging and treatment. METHODS: At the time of surgery, 1 ml of Lymphazurin 1% was injected subserosally around the tumor without injecting into the lumen. The first to fourth blue nodes identified were considered the SLNs, which have the highest probability to contain metastases. A standard oncological resection of the bowel was then performed. Multilevel microsections of the SLNs, including a detailed pathological examination of the entire specimen, was performed. RESULTS: SLN was successfully identified in 85 (98.8%) of 86 patients. In 85 patients, there were 1,367 (16 per patient) lymph nodes examined, of which 140 (1.6 per patient) were identified as SLNs. In 53 (95%) of 56, of whom the SLNs were without metastases (negative), all other non-SLNs also were negative. In 29 (34% of 85) patients, SLNs were positive for metastases; in 14 of the 29 patients, other non-SLNs also were positive in addition to the SLNs. In the other 15 of the 29 patients (18% of 85 patients), SLNs were the only site of metastases, and all other non-SLNs were negative. In 7 patients (8.2% of 85 patients), micrometastases were identified only in 1 or 2 of the 10 sections of a single SLN. In five of seven patients, such micrometastases were detected by hematoxylin and eosin staining and immunohistochemistry; in the other two patients, it was detected only by immunohistochemistry. In patients with negative SLNs, the rate of occurrence of micrometastases in non-SLNs was 5 (0.4%) of 1,184 lymph nodes. CONCLUSIONS: SLN mapping can be performed easily in colorectal cancer patients, with an accuracy of more than 95%. The identification of submicroscopic lymph node metastases by this technique may have upstaged these patients (18%) from stage I/II to stage III disease, who may then benefit from further adjuvant chemotherapy.

Too far, too little, too late: a community-based case-control study of maternal mortality in rural west Maharashtra, India.

A total of 121 maternal deaths, identified through multiple-source surveillance in 400 villages in Maharashtra, were prospectively enrolled during 1993-95 in a population-based case-control study, which compared deaths with the survivors of similar pregnancy complications. The cases took significantly longer to seek care and to make the first health contact after the decision to seek care was taken. They also travelled significantly greater distances through a greater number of health facilities before appropriate treatment was started. Multivariate analysis showed the negative effect of excessive referrals and the protective effect of the following: residing in and not away from the village; presence of a resident nurse in the village; having an educated husband and a trained attendant at delivery; and being at the woman's parents' home at the time of illness. Other significant findings showed that deaths due to domestic violence were the second-largest cause of deaths in pregnancy, that more than two-thirds of maternal deaths were underreported in official records, and that liveborn infants of maternal deaths had a markedly higher risk of dying in the first year of life. This study points to the need for information-education-communication (IEC) efforts to increase family (especially male) preparedness for emergencies, decentralized obstetric management with effective triage, and a restructuring of the referral system.

PIP: Maternal deaths account for 13% of all deaths among reproductive-aged women in India. 121 maternal deaths, identified through multiple-source surveillance in 400 villages in Maharashtra, were prospectively enrolled during 1993-95 in a population-based case-control study comparing deaths with the survivors of similar pregnancy complications. Mothers who died took significantly longer to seek care and to make the first health contact after deciding to seek care. They also travelled significantly farther through more health facilities before appropriate treatment was started. Multivariate analysis showed the negative effect of excessive referrals and the protective effect of living in rather than away from villages, having a resident nurse in the village, having an educated husband and a trained attendant at delivery, and being at the woman's parents' home at the time of illness. Domestic violence was the second largest cause of deaths in pregnancy, more than two-thirds of maternal deaths were underreported in official records, and liveborn infants of maternal deaths had a significantly higher risk of dying during the first year of life. Information-education-communication efforts to increase family preparedness for emergencies, decentralized obstetric management with effective triage, and a restructuring of the referral system are needed.

A prospective cohort study on the survival experience of under five children in rural western India.

OBJECTIVE: To study the role of birth weight, nutrition, immunization and other medical as well as social factors in determining child survival. DESIGN: A prospective cohort study. SETTING: 45 villages in Shirur Development Block in Pune District in Maharashtra. METHODS: A cohort of 4129 children were followed from birth till 5 years of age. Weight and length/height of the child was measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status and other bio-medical factors. Cause of death was ascertained by verbal autopsy. RESULTS: The neonatal, infant and underfive mortality was rates were estimated to be 37, 60 and 79 per 1000 live births, respectively. Diarrhea and ARI contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline in the post-neonatal period followed by a marginal fall in the post-infancy period till 5 years age. Girls had a better survival in the early neonatal period but the trend reversed in the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis revealed that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under five mortality. CONCLUSION: Birth weight continues to exert its influence not only on survival/mortality in early life but even as late as 5 years of age. Strategies to improve child survival should include immunization and breastfeeding.

PIP: Findings are presented from a prospective study conducted in 45 villages in Shirur Development Block in Pune District, Maharashtra, to gain insight into the role of birth weight, nutrition, immunization, and other medical and social factors in determining child survival. 4129 children were followed from birth until age 5 years, with child weight and length/height measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status, and other biomedical factors, and the cause of death was ascertained through verbal autopsy. The neonatal, infant, and under-five mortality rates were estimated to be 37, 60, and 79 per 1000 live births, respectively. Diarrhea and acute respiratory infections (ARI) contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline during the post-neonatal period, followed by a marginal fall in the post-infancy period until age 5 years. Girls had a better survival during the early neonatal period, but the trend reversed during the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis found that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under-five mortality. Since birth weight continues to influence survival and mortality even up to age 5 years, strategies to improve child survival should include immunization and breast-feeding.

Unsafe motherhood: the determinants of maternal mortality.

PIP: Maternal mortality is a three-step process (pregnancy, pregnancy-related complications, and death). Close birth spacing, early pregnancy, unwanted pregnancy, and access to family planning are determinants of maternal mortality. World Fertility Survey figures show that 35% of maternal deaths in Asia could be prevented if all women who did not want children had access to contraceptives. The status of women affects health during pregnancy. Many years of physical neglect and inequitable distribution of food, health care, and other resources effect stunting, an inadequately formed pelvis, low pre-pregnancy weight, anemia, and chronic illnesses such as malaria. Conditions such as aseptic abortion can be prevented. Clean delivery practices, proper management of the third stage of labor, and tetanus immunization are other preventive measures. Many complications are difficult to prevent and to predict; some studies have estimated that up to 50% of maternal deaths were to "low risk" women. The timing of detection of complication and the effectiveness and speed of treatment impact on survival. Intervention means preventing delays in seeking care, delays in reaching an appropriate facility (substantial numbers of deaths occur en route), and delays in receiving treatment, even after reaching the appropriate facility. The timing between the occurrence of the emergency and death involves sociocultural, logistic, and health services factors. When safe motherhood efforts become part of child survival efforts, maternal health will improve.^ieng

Determinants of low birth weight: a community based prospective cohort study.

The study aimed at identifying and quantifying determinants of low birth weight (LBW) by following a community based prospective cohort of pregnant women in 45 villages in Pune district. In the 1922 live births born to mothers without a chronic illness, in whom birth weight was available within 24 hours, the cumulative incidence of LBW (< 2500 g) was 29%. The unadjusted relative risks for LBW were significantly higher for lower socio-economic status (RR = 1.71), maternal age less than 20 years (RR = 1.27), primiparity (RR = 1.32), last pregnancy interval less than 6 months (RR = 1.48), non-pregnant weight less than 40 kg (RR = 1.3), height below 145 cm (RR = 1.51), hemoglobin less than 9 g/dl (RR = 1.53) and third trimester bleeding (RR = 1.87). Multivariate logistic regression analysis showed that the adjusted odds ratio for LBW decreased with increasing gestational duration, non-pregnant weight, parity and rising education level of the mother. Socio-economic status, non-pregnant weight, maternal height, and severe anemia in pregnancy had substantial attributable risk per cent for LBW (41.4%, 22.9%, 29.5% and 34.5%, respectively). The findings suggest that selectively targetted interventions such as improving maternal education and nutrition, specifically anemia, wider availability of contraception to delay the first pregnancy and to increase pregnancy intervals may help in identifying and ensuring adequate care for those women at greatest risk of LBW.

PIP: In India, medical social workers followed a cohort of 1922 pregnant women in 45 contiguous villages in Pune District at monthly intervals so researchers could identify and quantify risk factors of low birth weight (LBW: 2500 g). 29% of the infants were LBW infants. LBW infants were significantly more likely to be born to mothers of very low socioeconomic status (unadjusted relative risk [RR] = 1.71), aged less than 20 (RR = 1.27), pregnant for the first time (RR = 1.32), whose last pregnancy interval was shorter than 6 months (RR = 1.48), whose nonpregnant weight was less than 40 kg (RR = 1.3), whose height was less than 145 cm (RR = 1.51), whose hemoglobin was less than 9 g/dl (RR = 1.53), who bled during the third trimester (RR = 1.87), and who delivered the infant prematurely (i.e., 32 weeks) (RR = 3.84). Mothers with 8-10 years of formal schooling were less likely to have an LBW infant than illiterate mothers (RR = 0.78). Boys were less likely to be LBW infants than girls (RR = 0.78). The multivariate logistic regression analysis revealed that the adjusted odds ratio for LBW fell as gestational age (0.207), nonpregnant weight (0.711), parity (0.835), and maternal educational status (0.869) increased. The attributable risk percentages for risk factors were 73.9% for premature birth, 46.6% for third trimester bleeding, 41.4% for very low socioeconomic status, 34.5% for hemoglobin less than 9 g/dl, 32.5% for last pregnancy interval shorter than 6 months, 29.5% for height less than 145 cm, 24.4% for primiparity, 22.9% for nonpregnant weight less than 40 kg, 21.3% for adolescent mother, and 21.5% (preventive fraction) for high maternal educational status. These findings suggest that health professionals should target limited resources to improving maternal education and nutrition status (i.e., reducing anemia), to providing wider availability of contraception to delay age at first pregnancy and to increase intervals between births, and to making sure that mothers at greatest risk of delivering a LBW infant receive appropriate care.

Male bias in health care utilization for under-fives in a rural community in western India.

A cross-sectional survey, in 1991, of 3100 families in 45 contiguous villages in the Pune district of Maharashtra state showed that 456 under-5-year-olds had suffered an acute respiratory infection and/or diarrhoea during the previous 7 days. Significantly more boys (88.9%) than girls (76.5%) were treated by a registered private medical practitioner (odds ratio (OR) = 2.51). Referrals for further treatment were followed by parents significantly more often in the case of their sons (69.2%) than daughters (25%) (OR = 6.75). An average of Rs 35 (US$1 1.16) was spent on the treatment of a son, compared with Rs 23 (US$ 0.76) for a daughter. In general, parents were willing to travel a greater distance (> 2 km) to seek medical treatment for their sons. These differences persisted even after adjusting for severity of illness, parent's income, occupation and education, and the birth order of the child. Intervention programmes directed at under-fives would need to correct the bias against girls if equitable access to health care is to be achieved.