In-person peer support for critical care survivors: The ICU REcovery Solutions cO-Led through surVivor Engagement (ICURESOLVE) pilot randomised controlled trial.

BACKGROUND: Peer support is a promising intervention to mitigate post-ICU disability, however there is a paucity of rigorously designed studies. OBJECTIVES: The objective of this study was to establish feasibility of an in-person, co-designed, peer-support model. METHODS: Prospective, randomised, adaptive, single-centre pilot trial with blinded outcome assessment, conducted at a university-affiliated hospital in Melbourne, Australia. Intensive care unit survivors (and their nominated caregiver, where survivor and caregiver are referred to as a dyad), >18 years of age, able to speak and understand English and participate in phone surveys, were eligible. Participants were randomised to the peer-support model (six sessions, fortnightly) or usual care (no follow-up or targeted information). Two sequential models were piloted: 1. Early (2-3 weeks post hospital discharge) 2. Later (4-6 weeks post hospital discharge). Primary outcome was feasibility of implementation measured by recruitment, intervention attendance, and outcome completion. Secondary outcomes included post-traumatic stress and social support. RESULTS: Of the 231 eligible patients, 80 participants were recruited. In the early model we recruited 38 participants (28 patients, 10 carers; 18 singles, 10 dyads), with an average (standard deviation) age of 60 (18) years; 55 % were female. Twenty-two participants (58 %) were randomised to intervention. Participants in the early intervention model attended a median (interquartile range) of 0 (0-1) sessions (total 24 sessions), with 53% (n = 20) completing the main secondary outcome of interest (Impact of Event Scale) at the baseline and 37 % (n = 14) at the follow-up. For the later model we recruited 42 participants (32 patients, 10 carers; 22 singles, 10 dyads), with an average (standard deviation) age of 60.4 (15.4) years; 50 % were female. Twenty-one participants (50 %) were randomised to intervention. The later intervention model attended a median (interquartile range) of 1 (0-5) sessions (total: 44 sessions), with the main secondary outcome impact of events scale (IES-R) completed by 41 (98 %) participants at baseline and 29 (69 %) at follow-up. CONCLUSIONS: In this pilot trial, a peer-support model that required in-person attendance delivered in a later posthospital phase of recovery appeared more feasible than an early model. Further research should investigate alternative modes of intervention delivery to improve feasibility (ACTRN12621000737831).

UK-Wide Multicenter Evaluation of Second-line Therapies in Primary Biliary Cholangitis.

BACKGROUND & AIMS: Thirty-to-forty percent of patients with primary biliary cholangitis inadequately respond to ursodeoxycholic acid. Our aim was to assemble national, real-world data on the effectiveness of obeticholic acid (OCA) as a second-line treatment, alongside non-licensed therapy with fibric acid derivatives (bezafibrate or fenofibrate). METHODS: This was a nationwide observational cohort study conducted from August 2017 until June 2021. RESULTS: We accrued data from 457 patients; 349 treated with OCA and 108 with fibric acid derivatives. At baseline/pre-treatment, individuals in the OCA group manifest higher risk features compared with those taking fibric acid derivatives, evidenced by more elevated alkaline phosphatase values, and a larger proportion of individuals with cirrhosis, abnormal bilirubin, prior non-response to ursodeoxycholic acid, and elastography readings >9.6kPa (P < .05 for all). Overall, 259 patients (OCA) and 80 patients (fibric acid derivatives) completed 12 months of second-line therapy, yielding a dropout rate of 25.7% and 25.9%, respectively. At 12 months, the magnitude of alkaline phosphatase reduction was 29.5% and 56.7% in OCA and fibric acid groups (P < .001). Conversely, 55.9% and 36.4% of patients normalized serum alanine transaminase and bilirubin in the OCA group (P < .001). The proportion with normal alanine transaminase or bilirubin values in the fibric acid group was no different at 12 months compared with baseline. Twelve-month biochemical response rates were 70.6% with OCA and 80% under fibric acid treatment (P = .121). Response rates between treatment groups were no different on propensity-score matching or on sub-analysis of high-risk groups defined at baseline. CONCLUSION: Across the population of patients with primary biliary cholangitis in the United Kingdom, rates of biochemical response and drug discontinuation appear similar under fibric acid and OCA treatment.

Persistent Hepatitis E virus infection across England and Wales 2009-2017: Demography, virology and outcomes.

The first clinical case of persistent HEV infection in England was reported in 2009. We describe the demography, virology and outcomes of patients identified with persistent HEV infection in England and Wales between 2009 and 2017. A series of 94 patients with persistent HEV infection, defined by HEV viraemia of more than 12 weeks, was identified through routine reference laboratory testing. Virology, serology and clinical data were recorded through an approved PHE Enhanced Surveillance System. Sixty-six cases (70.2%) were transplant recipients, 16 (17.0%) had an underlying haematological malignancy without stem cell transplantation, six (6.4%) had advanced HIV infection, five (5.3%) were otherwise immunosuppressed, and one patient (1.1%) had no identified immunosuppression. Retrospective analysis of 46 patients demonstrated a median 38 weeks of viraemia before diagnostic HEV testing. At initial diagnosis, 16 patients (17.0%) had no detectable anti-HEV serological response. Of 65 patients treated with ribavirin monotherapy, 11 (16.9%) suffered virological relapse despite undetectable RNA in plasma or stool at treatment cessation. Persistent HEV infection remains a rare diagnosis, but we demonstrate that a broad range of immunocompromised patients are susceptible. Both lack of awareness and the pauci-symptomatic nature of persistent HEV infection likely contribute to significant delays in diagnosis. Diagnosis should rely on molecular testing since anti-HEV serology is insufficient to exclude persistent HEV infection. Finally, despite treatment with ribavirin, relapses occur even after cessation of detectable faecal shedding of HEV RNA, further emphasising the requirement to demonstrate sustained virological responses to treatment.

The risks and benefits of using social media to engage consumers in service design and quality improvement in Australian public hospitals: findings from an interview study of key stakeholders.

BACKGROUND: Engaging consumers - patients, families, carers and community members who are current or potential service users - in the planning, design, delivery, and improvement of health services is a requirement of public hospital accreditation in Australia. There is evidence of social media being used for consumer engagement in hospitals internationally, but in Australia this use is uncommon and stakeholders' experiences have not been investigated. The aim of the study was to explore the experiences and beliefs of key Australian public hospital stakeholders around using social media as a consumer engagement tool. This article focuses on the study findings relating to methods, risks, and benefits of social media use. METHODS: Semi-structured interviews were conducted with Australian public hospital stakeholders in consumer representative, consumer engagement/patient experience, communications or quality improvement roles. Qualitative data were analysed using a deductive content analysis method. An advisory committee of consumer and service provider stakeholders provided input into the design and conduct of this study. RESULTS: Twenty-six Australian public hospital service providers and consumers were interviewed. Participants described social media being used to: recruit consumers for service design and quality improvement activities; as an online space to conduct consultations or co-design; and, to gather feedback and patient experience data. The risks and benefits discussed by interview participants were grouped into five themes: 1) overcoming barriers to engagement, 2) consumer-initiated engagement; 3) breadth vs depth of engagement, 4) organisational transparency vs control and 5) users causing harm. CONCLUSIONS: Social media can be used to facilitate consumer engagement in hospital service design and quality improvement. However, social media alone is unlikely to solve broader issues commonly experienced within health consumer engagement activities, such as tokenistic engagement methods, and lack of clear processes for integrating consumer and patient feedback into quality improvement activities.

From policy to practice: prioritizing person-centred healthcare actions in the state of Victoria.

BACKGROUND: Meaningful involvement of consumers in healthcare is a high priority worldwide. In Victoria, Australia, a Partnering in Healthcare (PiH) policy framework was developed to guide health services in addressing consumer-focused healthcare improvements. The aim of this project was to identify priorities for improvement relating to the framework from the perspective of Victorian healthcare consumers and those who work in the healthcare sector. METHODS: A survey of Victorians representing key stakeholder groups was used to identify a "long list" of potential priorities, followed by a day-long summit to reduce this to a "short list" using explicit prioritization criteria. The survey was piloted prior to implementation, and diverse consumer groups and key health service providers were purposefully sampled for the summit. RESULTS: The survey (n = 680 respondents) generated 14-20 thematic categories across the proposed framework's five domains. The summit (n = 31 participants, including n = 21 consumer representatives) prioritized the following five areas based on the survey findings: communication, shared decision-making, (shared) care planning, health (system) literacy and people (not) around the patient. These priorities were underpinned by three cross-cutting principles: care/compassion/respect, accountability and diversity. CONCLUSION: Few studies have explicitly sought consumer input on health policy implementation. Adopting a codesign approach enabled the framework to be a shared foundation of healthcare improvement. The framework was subsequently launched in 2019. All Victorian health services are required to commit annually to improvement priorities against at least two framework domains.

A Playtime and Handicap Analysis of 143 Regular Golfers After Total Knee Arthroplasty at Minimum 2-Year Follow-Up.

BACKGROUND: Regular and competitive golfers are concerned by the ability to recover their previous activity golfing after total knee arthroplasty (TKA). The purpose of this study was to conduct targeted analysis of the effect of unilateral total knee replacement on the playtime and golf level in a population of experienced golfers, with a minimum follow-up of two years. METHODS: Questionnaires were distributed to the French Golf Federation's golfing members. Those who were older than 50 years and had undergone a unilateral primary TKA provided information on the timing of return to play, mode of movement on the course, pain during golfing, physical activity via University of California Los Angeles scale, level of golf and weekly playing time, before and after surgery. In addition, surgeons' recommendations and level of arthroplasty satisfaction were collected. RESULTS: Questionnaires were completed by 290 competitive golfers, of which 143 were eligible for inclusion. The average time to return to the 18-hole course was 3.7 months. Participants surveyed at a minimum 2 years after TKA played at a higher level than before surgery with a handicap improvement of 0.85 and increased their average weekly playtime from 8.9 to 10.2 hours. Knee pain while playing golf decreased after surgery (6.13 to 1.27 on the visual analog scale) and the University of California Los Angeles score improved (7.02 to 7.85). CONCLUSION: This study demonstrated the ability of regular golfers to return to golf within six months after unilateral total knee replacement, with increasing level of golf and weekly playtime and better golfing comfort.

Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative.

OBJECTIVES: Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN: We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING: Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS: Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS: A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

How did Ebola information spread on twitter: broadcasting or viral spreading?

BACKGROUND: Information and emotions towards public health issues could spread widely through online social networks. Although aggregate metrics on the volume of information diffusion are available, we know little about how information spreads on online social networks. Health information could be transmitted from one to many (i.e. broadcasting) or from a chain of individual to individual (i.e. viral spreading). The aim of this study is to examine the spreading pattern of Ebola information on Twitter and identify influential users regarding Ebola messages. METHODS: Our data was purchased from GNIP. We obtained all Ebola-related tweets posted globally from March 23, 2014 to May 31, 2015. We reconstructed Ebola-related retweeting paths based on Twitter content and the follower-followee relationships. Social network analysis was performed to investigate retweeting patterns. In addition to describing the diffusion structures, we classify users in the network into four categories (i.e., influential user, hidden influential user, disseminator, common user) based on following and retweeting patterns. RESULTS: On average, 91% of the retweets were directly retweeted from the initial message. Moreover, 47.5% of the retweeting paths of the original tweets had a depth of 1 (i.e., from the seed user to its immediate followers). These observations suggested that the broadcasting was more pervasive than viral spreading. We found that influential users and hidden influential users triggered more retweets than disseminators and common users. Disseminators and common users relied more on the viral model for spreading information beyond their immediate followers via influential and hidden influential users. CONCLUSIONS: Broadcasting was the dominant mechanism of information diffusion of a major health event on Twitter. It suggests that public health communicators can work beneficially with influential and hidden influential users to get the message across, because influential and hidden influential users can reach more people that are not following the public health Twitter accounts. Although both influential users and hidden influential users can trigger many retweets, recognizing and using the hidden influential users as the source of information could potentially be a cost-effective communication strategy for public health promotion. However, challenges remain due to uncertain credibility of these hidden influential users.

The Effect of Extensor Tendon Adhesions on Finger Motion.

PURPOSE: To quantify the amount and pattern of finger range of motion loss at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints with a simulated extensor tendon adhesion at the level of the proximal phalanx or metacarpal. METHODS: In 10 cadaveric specimens, traction sutures were placed in the forearm extensor digitorum communis and flexor digitorum profundus tendons of the middle and ring fingers. Active motion was simulated by suspending weights from the traction sutures via pulleys. The angles of the MCP, PIP, and DIP joints were measured at the position of maximum flexion and extension. Extensor tendon adhesions were simulated alternately at the proximal phalanx and metacarpal levels of the middle and ring fingers, using suture anchors. Repeat measurements were taken using the same amount of force. RESULTS: There was an average total loss of flexion of 38° and of extension of 6° with a proximal phalanx adhesion, with a greater contribution of flexion loss at the PIP joint. The loss of flexion was 17° and of extension was 50° with a metacarpal adhesion, with a loss of extension mostly at the MCP joint. CONCLUSIONS: The results of this study identified clear patterns of motion loss that are associated with isolated simulated adhesions in different locations along the extensor mechanism. The greatest motion loss occurred at the joint immediately distal to the simulated adhesion. CLINICAL RELEVANCE: Although extrapolation of these findings to clinical relevance remains unclear, the ability to predict the level of adhesion by the pattern of motion restriction may allow for a targeted tenolysis procedure. This would reduce the amount of soft tissue dissection required, which in turn, could be expected to reduce the degree of repeat adhesion formation.

Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable Angina.

BACKGROUND: Non-ST-segment elevation acute coronary syndromes include unstable angina and non-ST-segment elevation myocardial infarction. Most randomized controlled trials of routine versus selective invasive coronary angiography have high rates of crossover from control to intervention groups and do not include subgroup analysis for unstable angina. Consequently, no clear, specific recommendations exist regarding the use of angiography in unstable angina. OBJECTIVE: To assess the effect of angiography on mortality in unstable angina, incorporating the results of additional cardiac procedures and events. DESIGN: Longitudinal study using hospital discharge data, discrete-time survival analysis with propensity score adjustment, and sensitivity analysis. SETTING: Victoria, Australia, 2001 to 2011. PARTICIPANTS: All residents, all ages. INTERVENTION: Routine invasive coronary angiography. MEASUREMENTS: 12-month all-cause mortality. RESULTS: Emergently admitted patients with unstable angina (n = 33 901) who did or did not receive angiography during their first hospitalization were balanced on 44 covariates of propensity score. Routine angiography was associated with a 52% decrease in 12-month mortality (hazard ratio, 0.48 [95% CI, 0.38 to 0.61]); revascularization offered no additional statistical mortality benefit compared with diagnostic angiography alone. The predicted cumulative probability of death at 12 months was 0.024 (CI, 0.021 to 0.027) for patients receiving angiography within 2 months of their index unstable angina versus 0.097 (CI, 0.090 to 0.105) for those not receiving it. Sensitivity analysis demonstrated that to negate the observed effect size, an unmeasured confounder must independently decrease mortality by 90% and have a prevalence gap of 15% or greater between the angiographic groups. LIMITATION: Nonrandom allocation of angiography. CONCLUSION: Patients with unstable angina benefit from an invasive management pathway initiated by invasive coronary angiography during their hospitalization and up to 2 months after discharge. PRIMARY FUNDING SOURCES: National Health and Medical Research Council, Australia and BUPA Health Foundation.

Musculoskeletal injury profiles in professional Women's Tennis Association players.

OBJECTIVE: The physical demands of professional tennis combined with high training/match loads can contribute to musculoskeletal injury. The objectives of this study were to (1) describe the type, location and severity of injuries sustained during a 12-month tennis season in a cohort of professional female tennis players on the Women's Tennis Association (WTA) tour and (2) prospectively investigate associations between training/match loads and injury. METHODS: 52 WTA players competing at the Australian Open (2015) consented to participate. Injuries reported to WTA medical staff were classified using tennis-specific guidelines. Individual match exposure data were collected for all matches played at international level in 2015 and expressed per 1000 hours of WTA competition matchplay (MP) and 1000 match exposures (MEs). Variables associated with the number of injuries in the season and loss of time from competition were identified with regression analysis. RESULTS: The injury incidence rate (IR) was 56.6 (95% CI: 49.5 to 64.6) per 1000 hours of MP or 62.7 (95% CI: 54.8 to 71.6) per 1000 MEs, although the IR of injuries resulting in loss of time from competition was lower (12.8 per 1000 hours of MP, 92 injuries/100 players). Lower limb (51%) and muscle/tendon (50%) injuries were the most common site and type of injury. Common specific injury site subcategories were the thigh, shoulder/clavicle, ankle and knee in order of frequency. Various measures of match load were significantly associated with injury. CONCLUSION: This study prospectively analysed injury profiles, including severity across an entire season of professional tennis, and investigated the relationship between training/match loads and injury. These data may help medical professionals develop injury risk identification and prevention programmes.

Mechanics of Metacarpophalangeal Joint Extension.

PURPOSE: It is a common belief that extension of the metacarpophalangeal (MCP) joint of the finger is achieved via the sagittal bands acting as a sling or lasso to attach the extensor tendon to the base of the proximal phalanx. The aim of this study was to test the hypotheses that (1) division of the sagittal bands reduces extension force or torque of the MCP joint, and (2) division of the extensor tendon distal to the sagittal band will not affect the extension force or torque of the MCP joint. METHODS: Ten cadaver limbs were secured to a jig to allow for testing of the extension force of the MCP joints of the index, middle, and ring fingers. A 1-kg load was applied to the forearm extensor digitorum communis tendon and the extension force was measured with the MCP joint positioned at 0° (neutral extension) and again at 45° flexion. These measurements were repeated after the sagittal bands were divided in 15 specimens; in the other 15 specimens, the extensor tendon was divided just distal to the sagittal bands. RESULTS: After sagittal band division, extension force was similar in the 2 groups (0.11 N reduction after division with the MCP joints in neutral and 0.14 N in 45° flexion). There was significantly less extension force after division of the extensor tendon in both joint positions (0.95 N reduction after division in neutral extension and 0.66 N in 45° flexion). CONCLUSIONS: The sagittal bands do not primarily extend the MCP as a sling or lasso. The extensor tendon continuation to the extensor hood and middle phalanx is the major extension motor. The MCP joint is extended by the torque generated by the extensor tendon passing the joint carrying a force and possessing an extension moment arm. CLINICAL RELEVANCE: This principle should be correctly understood in the literature to ensure that clinical decisions related to injury and/or repair of the extensor tendon and sagittal bands are based on a sound understanding of their mechanics.

Neutrophilic Dermatosis of the Hands: A Review of 17 Cases.

PURPOSE: Neutrophilic dermatosis of the hands is an inflammatory skin condition related to Sweet syndrome that responds to corticosteroids. It commonly affects the dorsum of the hand and often mimics infection, with violaceous inflammatory papules and plaques that may ulcerate. The aim of this study was to review the clinical presentation of neutrophilic dermatosis of the hands. METHODS: A retrospective review was undertaken of all cases of neutrophilic dermatosis of the hands seen at a tertiary hospital in New South Wales, Australia, over a 5-year period. RESULTS: Seventeen cases were identified. The mean time to diagnosis was 9 days after lesion onset. Most cases were older adults (mean age, 71 years). The most common referral diagnoses were infection or a nonhealing wound and 65% of cases reported a history of trauma. The dorsal index finger was the site of involvement in 41% of cases. One case involved the palm. Histopathology reports were available for skin punch biopsy for 14 of 17 cases, which showed dermal neutrophilic infiltrate (93%) and epidermal involvement with necrosis, ulceration, or pustulation (64%). Six cases were treated surgically prior to the correct diagnosis and management being introduced. CONCLUSIONS: Neutrophilic dermatosis of the hands was often misdiagnosed as infection. A history of trauma is common and may be misleading. Dermatological consultation and skin punch biopsy are useful in confirming the diagnosis, ideally prior to surgical management. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Effects of Removal and Reinsertion of Headless Compression Screws.

PURPOSE: This study investigates the loss of compression when 3 commonly used headless compression screws are backed out (reversed), and assesses the ability to re-establish compression with screws of greater diameter. METHODS: Two investigators tested 3 screw designs (Acutrak 2, Synthes HCS, Medartis SpeedTip CCS) in 2 diameters and lengths. Each design had 10 test cycles in a polyurethane foam bone model with compression recorded using a washer load cell. A 28-mm screw of the narrower diameter was inserted until 2 mm recessed and then reversed 30°, 60°, 90°, 180°, 270°, 360°, and 720°. After this the screw was removed completely and a 24-mm screw of greater diameter inserted until recessed 2 mm with the compressive force again recorded. RESULTS: All screws showed an immediate, statistically significant loss of compression at 30° of reversing. The Acutrak 2 Micro screw demonstrated not only the greatest mean compressive force, but also the fastest compressive loss. Insertion of the shorter screw of greater diameter was associated with re-establishment of compression to levels comparable with the original screw. CONCLUSIONS: This study reaffirms the importance of establishing the correct screw length before insertion due to the immediate loss of compression with reversal of these devices. CLINICAL RELEVANCE: If a headless compression screw penetrates the far joint surface, the screw should be completely removed and replaced with a shorter screw of greater diameter.

OBTAIN A: Outcome Benefits of Tranexamic Acid in Hip Arthroplasty. A Randomized Double-Blinded Controlled Trial.

BACKGROUND: We examined whether the blood conserving effect of tranexamic acid (TXA) in total hip arthroplasty using the direct anterior approach, translates to an effect on functional outcomes in the perioperative period. METHODS: We conducted a single-center, randomized, double-blinded, placebo-controlled trial. One hundred one patients were randomized to receive either TXA or an equivalent volume of normal saline. The primary outcome measure was thigh swelling. Secondary outcome measures included, visual analogue pain score, timed up and go test, a 10 meter walk test, and length of stay. Blood loss and the incidence of blood transfusions were also recorded. RESULTS: There were no statistically significant differences between the primary outcome of thigh swelling or the secondary outcome measures of postoperative pain nor mobility. There was a significant reduction in length of stay for those that received TXA 3.58 days (0.84) compared with the control group 4.27 days (0.98) (P < .001). There was significantly less intraoperative blood loss observed in the TXA group (0.460L SD 0.228) compared with the control group (0.687L SD 0.283L) (P < .001). The estimated blood loss was also significantly less in the TXA group (1.084L SD 0.440) compared with the control group (1.394 L SD 0.426). CONCLUSION: TXA is an effective agent in reducing blood loss in total hip arthroplasty using the anterior approach. The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility. Administration of TXA may have a positive effect on reducing the duration of inpatient stays.

An assessment of 2 objective measurements of web space position.

PURPOSE: To describe 2 simple objective clinical methods of measuring the web position between fingers and to determine their intra-observer and inter-observer reliabilities. METHODS: Two observers examined the second, third, and fourth web spaces on both hands of 30 adult healthy volunteers. The web index measured the web height as a relative ratio to constant anatomical landmarks on both fingers subtending the web. The dorsal web index took reference from the distance between the metacarpophalangeal and proximal interphalangeal joints, whereas the palmar web index was measured in relation to the distance between the most proximal basal digital and proximal interphalangeal joint creases. The intraclass correlation coefficient was used to determine intra-observer and inter-observer reliability. RESULTS: Intraclass correlation coefficient values for intra-observer and inter-observer reliability were greater than 0.80, indicating excellent agreement. There was no statistically significant difference between the dorsal or palmar measurement methods in terms of reliability. CONCLUSIONS: The dorsal or palmar measurement method may be reliably used in healthy adults to establish a web index that describes the web position. The palmar method is considered easier to perform. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Severe cholestatic jaundice after a single administration of ajmaline; a case report and review of the literature.

BACKGROUND: Ajmaline is a pharmaceutical agent now administered globally for a variety of indications, particularly investigation of suspected Brugada syndrome. There have been previous reports suggesting that repetitive use of this agent may cause severe liver injury, but little evidence exists demonstrating the same effect after only a single administration. CASE PRESENTATION: A 33-year-old man of Libyan origin with no significant past medical history underwent an ajmaline provocation test for investigation of suspected Brugada syndrome. Three weeks later, he presented with painless cholestatic jaundice which peaked in severity at eleven weeks after the test. Blood tests confirmed no evidence of autoimmune or viral liver disease, whilst imaging confirmed the absence of biliary tract obstruction. A liver biopsy demonstrated centrilobular cholestasis and focal rosetting of hepatocytes, consistent with a cholestatic drug reaction. Over the course of the next few months, he began to improve clinically and biochemically, with complete resolution by one year post-exposure. CONCLUSION: Whilst ajmaline-related hepatotoxicity was well-recognised in the era in which the drug was administered as a regular medication, clinicians should be aware that ajmaline may induce severe cholestatic jaundice even after a single dose administration.

Evaluating a novel model of hepatitis B care, Hep B PAST, in the Northern Territory of Australia: results from a prospective, population-based study.

Background: The Northern Territory (NT) has the highest prevalence of chronic hepatitis B (CHB) in Australia. The Hep B PAST program aims to improve health outcomes for people living with CHB. Methods: This mixed methods study involves First Nations peoples living in the NT. We used participatory action research principles across three steps: 1. Foundation step: establishing hepatitis B virus (HBV) status and linkage to care; 2. Capacity building: training the health workforce; 3. Supported transition to primary healthcare: implementation of the "Hub and Spoke" model and in-language resources. Analysis occurred at three time points: 1. Pre-Hep B PAST (2018); 2. Foundation step (2020); and 3. Completion of Hep B PAST (2023). Evaluation focuses on four key indicators, the number of people: 1) with documented HBV status; 2) diagnosed with CHB; 3) receiving care; and 4) receiving treatment. Findings: Hep B PAST (2018-23) reached 40,555 people. HBV status was documented in 11% (1192/10,853), 79.2% (26,075/32,915) and 90.8% (28,675/31,588) of people at pre-Hep B PAST, foundation step, and completion respectively. An estimated 99.9% (821/822) of people were diagnosed, 86.3% (709/822) engaged in care, and 24.1% (198/822) on antiviral treatment at completion. CHB prevalence in the study population is 2.6%, decreasing from 6.1% to 0.4% in the pre- and post-vaccination cohorts. Interpretation: Hep B PAST is an effective model of care. Partner health services are exceeding elimination targets. This model could enable other countries to enhance the cascade of care and work towards eliminating HBV. Funding: National Health and Medical Research Council.

Mobile garbage bins and hand injuries in older people.

OBJECTIVES: To conduct a database search, chart and literature review of open extensor tendon and proximal interphalangeal joint injuries incurred while handling mobile garbage bins. DESIGN, SETTING AND PARTICIPANTS: A review of medical records at a Sydney tertiary referral hospital and a NSW rural Level 2 trauma hospital from 1 January 2006 to 31 December 2010, identified through database searches of appropriate medical record codes and followed by a chart review. RESULTS: We identified 11 patients with finger injuries from handling mobile garbage bins that necessitated hospital-based treatments. Their average age was 75 years. Eight patients required surgery. Patients typically fell while maintaining their grip on mobile garbage bin handles, causing abrasive injury to the dorsal aspect of the proximal interphalangeal joint. CONCLUSIONS: Older patients are at risk of significant injuries to the dorsal side of their fingers when manoeuvring mobile garbage bins. This risk could be reduced by providing older members of the community with help to move their bins, or by modifying the design of bin handles. We propose a simple modification to the design of bin handles.