Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion-BMI randomized controlled trial.

AIMS: Obesity is associated with higher electrical cardioversion (ECV) failure in persistent atrial fibrillation (PeAF). For ease-of-use, many centers prefer patches over paddles. We assessed the optimum modality and shock vector, as well as the safety and efficacy of the Manual Pressure Augmentation (MPA) technique. METHODS: Patients with obesity (BMI ≥ 30) and PeAF undergoing ECV using a biphasic defibrillator were randomized into one of four arms by modality (adhesive patches or handheld paddles) and shock vector (anteroposterior [AP] or anteroapical [AA]). If the first two shocks (100 and 200 J) failed, then patients received a 200-J shock using the alternative modality (patch or paddle). Shock vector remained unchanged. In an observational substudy, 20 patients with BMI of 35 or more, and who failed ECV at 200 J using both patches/paddles underwent a trial of MPA. RESULTS: In total, 125 patients were randomized between July 2016 and March 2018. First or second shock success was 43 of 63 (68.2%) for patches and 56 of 62 (90.3%) for paddles (P = 0.002). There were 20 crossovers from patches to paddles (12 of 20 third shock success with paddles) and six crossovers from paddles to patches (three of six third shock success with patches). Paddles successfully cardioverted 68 of 82 patients compared with 46 of 69 using patches (82.9% vs 66.7%; P = 0.02). Shock vector did not influence first or second shock success rates (82.0% AP vs 76.6% AA; P = 0.46). MPA was successful in 16 of 20 (80%) who failed in both (patches/paddles), with 360 J required in six of seven cases. CONCLUSION: Routine use of adhesive patches at 200 J is inadequate in obesity. Strategies that improve success include the use of paddles, MPA, and escalation to 360 J.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant-led virtual fracture clinic in an Australian level 1 trauma centre.

BACKGROUND: In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting. METHODS: A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates. RESULTS: A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P = 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P < 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P < 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P < 0.01). No complications or adverse events were reported. CONCLUSION: This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.

A comparison of early versus delayed elective electrical cardioversion for recurrent episodes of persistent atrial fibrillation: A multi-center study.

BACKGROUND: Due to barriers to accessing timely elective electrical cardioversion (CV) for persistent AF (PeAF), we adopted a policy of instructing patients to present directly to the Emergency Department (ED) for CV. OBJECTIVE: We compare a strategy of Emergency CV (ED-CV) versus Elective CV (EL-CV) for treatment of symptomatic PeAF. METHODS: Between 2014 and 7, we evaluated 150 patients undergoing CV for PeAF. ED-CV patients were provided an AF action plan for recurrent symptoms and advised to present to ED within 36 h. EL-CV patients followed standard care, including cardiologist referral and placement on an elective hospital waiting list. Follow-up was 12 months. RESULTS: We included 75 consecutive ED-CV patients and 75 consecutive EL-CV patients. ED-CV patients had a significantly shorter median AF duration prior to CV (1 day vs 3 months; p < 0.01) and less overall AF-related symptoms at 12 months (modified EHRA symptom score ≥ 2a in 44% vs 72%; p = 0.005). Time to next AF recurrence was longer in the ED-CV group (295 ±â€¯15 vs 245 ±â€¯15 days; logrank p = 0.001), as was time to AF ablation referral (314 ±â€¯13 vs 276 ±â€¯15 days; logrank p = 0.01). Baseline LA area was similar (ED-CV 27 ±â€¯4 cm2 vs EL-CV 28 ±â€¯11 cm2; p = 0.67), however EL-CV had larger atria at follow-up (31 ±â€¯8 vs 26 ±â€¯6 cm2; p = 0.01). There were no complications in either group. CONCLUSION: ED-CV is an acceptable strategy for symptomatic PeAF. In addition to reduced time spent in AF and improved symptom scores, this strategy may also slow progression of atrial substrate & delay onset of next AF episode.

A sedge plant as the source of Kangaroo Island propolis rich in prenylated p-coumarate ester and stilbenes.

Propolis samples from Kangaroo Island, South Australia, were investigated for chemical constituents using high-field nuclear magnetic resonance spectral profiling. A type of propolis was found containing a high proportion of prenylated hydroxystilbenes. Subsequently, the botanical origin of this type of propolis was identified using a beehive propolis depletion method and analysis of flora. Ligurian honey bees, Apis mellifera ligustica Spinola, were found to produce propolis from resin exuded by the Australian native sedge plant Lepidosperma sp. Montebello (Cyperaceae). The plants, commonly known as sword sedge, were found to have resin that matched with the propolis samples identified as the most abundant propolis type on the island containing C- and O-prenylated tetrahydroxystilbenes (pTHOS) in addition to a small amount of prenylated p-coumarate. The isolation of five pTHOS not previously characterized are reported: (E)-4-(3-methyl-2-buten-1-yl)-3,4',5-trihydroxy-3'-methoxystilbene, (E)-2,4-bis(3-methyl-2-buten-1-yl)-3,3',4',5-tetrahydroxystilbene, (E)-2-(3-methyl-2-buten-1-yl)-3-(3-methyl-2-butenyloxy)-3',4',5-trihydroxystilbene, (E)-2,6-bis(3-methyl-2-buten-1-yl)-3,3',5,5'-tetrahydroxystilbene and (E)-2,6-bis(3-methyl-2-buten-1-yl)-3,4',5-trihydroxy-3'-methoxystilbene. A National Cancer Institute 60 human cell line anticancer screen of three of these compounds showed growth inhibitory activity. The large Australasian genus Lepidosperma is identified as a valuable resource for the isolation of substances with medicinal potential.

Sedges in the mist: A new species of Lepidosperma (Cyperaceae, Schoeneae) from the mountains of Tasmania.

The status of a putative new species of Lepidosperma from the mountains of south-western Tasmania, Australia, was investigated. Phenetic analysis (Flexible UPGMA Agglomerative Hierarchical Fusion and semi-strong hybrid multidimensional scaling) was conducted on a database derived from morphological and anatomical characters scored from herbarium material, culm anatomy slides and scanning electron micrographs of fruit. The results of the analysis support the recognition of a new species, here described as Lepidosperma monticola G.T.Plunkett & J.J.Bruhl. The distribution, habitat and conservation status are discussed.