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.

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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.

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