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A significant lesson for those assessing the work of others stems from the necessity to review what has been written before. It remains a common but human error to misinterpret or misrepresent the words of others and indeed, for inconsistencies in these to become apparent. This is certainly so in the field of congenital hand surgery and especially so with discussion of thumb duplication/polydactyly. Many of the presentations in this journal issue deal with the subject of thumb duplication. All involve a consideration of classification despite an emphasis on investigative measures and techniques in some. For ease of reading, I will place my comments on these articles within the categories of classification, investigations assisting management decisions and alternative techniques, though the contents of each article are not necessarily restricted to these categories.

We describe how COVID-19-related policy decisions and guidelines impacted healthcare workers (HCWs) during the UK’s first COVID-19 pandemic phase. Guidelines in healthcare aim to streamline processes, improve quality and manage risk. However, we argue that during this time the guidelines we studied often fell short of these goals in practice. We analysed 74 remote interviews with 14 UK HCWs over 6 months (February–August 2020). Reframing guidelines through Mol’s lens of ‘enactment’, we reveal embodied, relational and material impacts that some guidelines had for HCWs. Beyond guideline ‘adherence’, we show that enacting guidelines is an ongoing, complex process of negotiating and balancing multilevel tensions. Overall, guidelines: (1) were inconsistently communicated; (2) did not sufficiently accommodate contextual considerations; and (3) were at times in tension with HCWs’ values. Healthcare policymakers should produce more agile, acceptable guidelines that frontline HCWs can enact in ways which make sense and are effective in their contexts.

Background: De Quervain syndrome is the second most common compressive tendinopathy. Although the length of the first extensor compartment (FEC) has been studied previously, there is no documented reported comparison study of short-axis and long-axis sonographic measurements. The thread technique, or Guo Technique, has been applied to carpal tunnel syndrome, trigger finger, and superficial peroneal compressive neuropathy. To perform this procedure, it is critically important to accurately identify the boundaries for transection. Methods: Twenty-one fresh frozen cadaver upper extremities were examined under ultrasound to determine the length of the extensor retinaculum (ER) over the FEC. Using the sonographic landmarks, the ERs were measured in short axis and long axis over their proximal to distal margins and from the distal margins to the distal edges of the radial styloids. These sonographic measurements were then compared with gross anatomical measurements. Results: The short-axis sonographic measurement of the ER on average was 22.53 mm (95% confidence interval [CI] = 20.79-24.05 mm). The long-axis sonographic measurement of the ER on average was 15.65 mm (95% CI = 13.70-17.78 mm). The average length of the ER by gross anatomical dissection was 22.40 mm (95% CI = 21.15-23.51 mm). Conclusions: The short axis is not significantly different from the gross anatomical measurement; however, the long axis is significantly lower than the gross anatomical measurement. The results support the idea that the short axis is more accurate than the long axis.

This cadaveric study tested the feasibility of decompressing the ulnar nerve across the elbow percutaneously with a commercially available surgical dissection thread, a guiding needle, hydrodissection and ultrasound guidance. We performed the procedure in 19 fresh-frozen cadaveric upper extremities. Subsequently, we did an anatomical dissection of the specimens to visualize the extent of ulnar nerve decompression and the extent of damage to surrounding structures. The cubital tunnel and deep across the medial elbow were completely transected leaving the ulnar nerve fully decompressed in all cases. There was no evidence of direct injury to the ulnar nerve or adjacent neurovascular structures. A prerequisite knowledge of sonographic anatomy and experience with interventional ultrasound is essential. Future clinical studies should evaluate this technique’s safety and efficacy compared with conventional ones.

There is growing interest in an occupational perspective when working with people experiencing chronic pain. The Activity Card Sort Australia (18-64) is a client-centered and occupation-centered tool that has not been explored with this population. The aim of this study was to explore the process and experience of completing the ACS-Aus (18-64) with people experiencing chronic pain. This observational multiple-case study included video and audio-recordings of three participants (one male, one female, one nonbinary) completing the ACS-Aus (18-64) and semi-structured interviews at 1-week follow-up. Findings The findings for the process included two themes: the interaction (understanding engagement, therapeutic relationship and rapport, motivational interviewing) and the card sort (storytelling and reminiscing, identifying gaps and possibilities, categorizing and grouping cards). Occupational narratives of participants were developed from the experience. The ACS-Aus (18-64) supported participants to re-engage with their occupational selves and imagine future occupational engagement. Longitudinal studies are required to explore outcomes.

Reactive infectious mucocutaneous eruption is a recently distinguished mucosal-predominant blistering eruption triggered by respiratory infections. We describe a previously healthy 11-year-old Black female with rapidly progressive mucocutaneous blistering after prodromal respiratory infection symptoms. Reactive infectious mucocutaneous eruption was suspected and treated with systemic corticosteroids followed by etanercept. Twenty-four hours after etanercept, the diagnosis of multisystem inflammatory syndrome in children was raised and intravenous immunoglobulin was given. Rapidly worsening mucocutaneous disease ensued but was controlled by a second dose of etanercept. Our case highlights the following: (1) the novel observation of possible interaction/neutralization of etanercept by intravenous immunoglobulin, (2) the challenging differential diagnosis of multisystem inflammatory syndrome in children for reactive infectious mucocutaneous eruption patients in the Coronavirus disease 2019 (COVID-19) pandemic, and (3) the role of early treatment to prevent dyspigmentation.

The reconstruction of a congenital hypoplastic thumb usually involves release of a tight first web space, metacarpophalangeal joint stabilization, reconstruction of intrinsic muscle function, and extrinsic tendon reconstruction, as appropriate. Numerous surgical options and combinations are available, but the approaches vary among surgeons who work in the field of congenital hand surgery and the empirical evidence that allows for evaluation of the results of techniques is scarce. Both the pre-operative assessment and intra-operative findings of all thumb elements – bone, joints, and soft tissues – should be considered in the surgical decision-making and eventually define the methods of reconstruction. This article summarizes the different reconstructive options.

Background: After the thread transecting technique was successfully applied for the thread carpal tunnel release, we researched using the same technique in the thread trigger finger release (TTFR). This study was designed to test the operational feasibility of the TTFR on cadavers and verify the limits of division on the first annular (A1) pulley to ensure a complete trigger finger release with minimal iatrogenic injuries. Methods: The procedure of TTFR was performed on 14 fingers and 4 thumbs of 4 unembalmed cadaveric hands. After the procedures, all fingers and thumbs were dissected and visually assessed. Results: All of the digits and thumbs demonstrated a complete A1 pulley release. There was no injury to the neurovascular bundle (radial digital nerve in case of thumb), flexor tendon, or A2 pulley for each case. Conclusions: The cadaveric study showed that the technique of TTFR was safe and effective, and the future clinical study is necessary to verify the findings of this study.

Social climate is a term used to describe the environment of a particular setting which may influence the moods and behaviors of the people inhabiting that setting. This review explores perceptions of social climate in secure forensic services and the associations with aggression. Article searches were conducted using electronic databases, hand-searching reference lists, and contacting experts. Inclusion/exclusion criteria were applied to each study, and quality screens conducted on the remaining articles to establish those for inclusion. A total of seven studies were identified. Factors which were found to have an association with aggression included patients’ perceptions of safety, the level of cohesion between patients, the atmosphere of the environment, and an open group climate. It is argued that services which create positive social climates for both staff and patients are more likely to observe lower levels of aggression.

A systematic review of the reasons why detained adult offenders fail to attend or successfully complete treatment programme(s) was conducted. An initial search of the literature identified 2,827 articles, which following evaluation against explicit inclusion/exclusion criteria and a quality assessment was reduced to 13 studies. Extracted data from the 13 studies were synthesised using a qualitative approach. Despite the 13 studies being heterogeneous in design, there was consensus on the reasons offenders gave for completion/noncompletion of treatment. The majority were consistent with the factors outlined in the Multifactor Offender Readiness Model (MORM) and included a perceived lack of self-efficacy, negative perceptions of treatment, staff and peers, an inability to regulate emotions, and a lack of perceived choice and control. A lack of opportunity to engage in established, professionally run, groups, as well as perceived inadequate support from members of staff, was also associated with poor engagement and noncompletion of treatment.

A 75-year-old female presented with a 1 year history of a firm, diffusely swollen, and erythematous facial plaque. She had preceding unsuccessful investigations and treatment for angioedema. Full-skin examination revealed multiple prominent varicosities on the chest and abdomen. Superior vena cava syndrome was suspected. Solid facial edema (Morbihan’s syndrome) and various infiltrates included in the differential diagnosis were ruled out with a skin biopsy. Chest computed tomography confirmed a complete superior vena cava thrombosis. Extensive workup for associated malignancy has to date been unremarkable, and as yet an underlying cause remains to be found.

In 2004, eight formerly communist East Central European states acceded to the European Union, an event which was celebrated as the final overcoming of the post-war division of Europe into East and West and the ‘return to Europe’ of those states which had been ‘kidnapped’ by the Soviet Union. To mark the accession, an Austrian film production company commissioned five East Central European directors to make short documentary films under the collective title Über die Grenze: Fünf Ansichten von Nachbarn ( Across the Border: Five Views From Neighbours). Drawing on geopolitical analysis of the dichotomy of Europe and Eastern Europe which underpinned the European Union enlargement discourse, this paper examines the Czech episode České Velenice Evropské as a film which explores the ways in which borders have been conceptualized and identities (re)framed in the context of European Union enlargement. At the moment when the Central European states’ symbolic ‘return to Europe’ is being realized, director Jan Gogola reflects on the meaning of European Union accession for Central Europeans, on shifting borders and their implications for the construction and understanding of identities of self and other, and on the dynamics of openness and closure in Europe.

Significant time and resources are devoted to the monitoring of social climate in secure settings. However, if these efforts are to help (rather than hinder) attempts to improve the functioning of such units, the monitoring of social climate must be based on sound psychometric methods. The aim of this review was to determine what questionnaires exist to measure the social climate in secure settings and what evidence exists regarding their psychometric properties. Twelve questionnaire-based measures of social climate were identified. The Essen Climate Evaluation Schema has received the most consistent empirical support, but this questionnaire does not provide as much of an in-depth, detailed insight into social climate as that provided by other social climate questionnaires. Although more extensive measures of climate exist, they have not yet received sufficient validation to justify their routine use in practice. Nevertheless, there is growing evidence that some questionnaire-based measures can provide a reliable and valid assessment of the social climate in secure settings, which has important clinical and theoretical implications.

Background. Dietary habits are known to influence cardiovascular disease (CVD) risk factors, which even in childhood are a predictor of future morbidity. Our objective was determining the impact of a school-based intervention of providing fruit daily in the classroom and its effects on risk factors for CVD, and dietary habits. Methods. The study was a randomized controlled trial involving 2 public and 2 private schools, one of each in an intervention and control group. Measurements at both the start and end of 8 weeks were aimed to identify any changes in physiological measures, and child food choices. Results. The intervention had minimal impact on physiological variables but was effective in improving the amount of fruit and vegetables consumed and preferences toward fruit intake. Parent activity and dietary choices were poor at baseline, but significantly improved in the intervention group compared to the control group over the 8 weeks. Conclusion. This intervention was effective in improving the amount of fruit consumed and attitudes toward fruit intake over just 2 months. It has also shown the importance of not just the school environment but also the home environment in influencing children developing good dietary choice habits and lifestyle.

Background. Participation in occupations is vital for learning and development. Children with disabilities are at risk for decreased participation. Purpose. The purpose of this study is to examine peer-reviewed literature about the participation-based experiences of children and youth with disabilities in activities outside of formal preschool and school academics. Method. A scoping review was conducted to examine research studies published between 1990 and 2012. Studies included participants from 2 to 18 years who had at least one physical or intellectual/cognitive disability. Findings. Forty-nine articles discussing 32 studies and three systematic reviews met the inclusion criteria. Perceptions of and influences on participation were important emerging themes about direct impacts on patterns of participation. A child or youth’s level of functioning, activity level, level of enjoyment, and contextual factors were found to influence their level of successful participation. Implications. Occupational therapists can use the findings from this review to consider supports and barriers within interventions to enhance participation in meaningful life situations.

In 1937, Müller introduced the concept of a teratological sequence of thumb hypoplasia with increasing severity from mild deficiency, through severe deficiency, to thumb absence. Blauth subsequently detailed five specific grades. In 1992, Manske and McCarroll altered Blauth’s classification such that Grade 3 was sub-divided into Grades 3A and 3B, according to a presence or absence of the proximal metacarpal. Buck-Gramcko added a Grade 3C in which there was only a remnant metacarpal head. This article investigates their publications and those of others to identify ‘who said what’ and clarify the definitions of grades of thumb hypoplasia. A modification of Blauth’s classification is proposed, which retains the integrity of the concept of Müller and the skeletal and soft tissue grading of Blauth, but which also incorporates the disparate anomalies that may present in Grades 2 and 3 hypoplastic thumbs.

As Andrew Barker has observed (2010), Joseph Roth’s Tarabas: Ein Gast auf dieser Erde (1934) ‘appears to support the traditional view of Roth as a writer who, when confronted by a cruel present, retreats into a comforting fiction’ about the past. Against this view I argue that this tale of sin and penance is a parable of Germany in 1933. Tarabas’s redemption suggests the possibility of an end to the history of anti-Semitism and Jewish persecution, of which the Third Reich’s nascent reign of terror is but the latest instalment. And yet, in the final chapter of the novel, written from the perspective of 1933, it is the cyclical view of history as eternal return which predominates. In the end, as much as it is a parable of redemption, Tarabas is also simultaneously a novel of warning.

The rapid increase in gene-disease discoveries offers real promise of clinical applications for people and families affected by genetic conditions but for which health professionals are not prepared because of lack of training. The availability of clinically relevant education resources is critical to enabling nurses to develop the appropriate genetics-genomics knowledge and skills to provide optimum care for individuals and families. The Internet is a core resource to support teaching and learning in nurse education. Evaluating such resources is important to maximise the education experience, particularly for subjects traditionally perceived by nurses as being difficult. Telling Stories, Understanding Real Life Genetics is a web-based educational resource. It uses real accounts from individuals and professionals to promote understanding of the impact of genetics-genomics on the lives of people and their families. Google Analytics™ Web analytics service provides time series data for analysing web usage to optimise website effectiveness. We present data of visitor activity and behaviour from 123 countries over three years from 2009–2011 and consider how the application of the web analytics informs approaches to enhancing visibility of the website, provides an indicator of engagement with genetics-genomics both nationally and globally, and informs future expansion of the site as a global resource for health professional education. Telling Stories is an accessible, broad-reaching resource that is of global relevance for health professionals, attracting over 33,500 visitors between 2009–2011, with steadily increasing numbers of returning visitors. The United Kingdom, United States, Canada and the Netherlands are the largest site users. Returning visitors spend significantly more time on site and view more pages than new visitors. Most referring sites are education establishments. More needs to be done now to enhance the site’s accessibility for people of other languages and cultures.

Cardiovascular risk factors in childhood are known to be a pre- dictor of morbidity. The objective here was to determine the feasibility of a school-based intervention of provid- ing fruit daily in the classroom and its effects on risk factors of cardiovascu- lar disease and dietary behavior. The authors designed a pilot study (23 chil- dren, 9-11 years old) for a random- ized controlled trial with fruit served daily in the classroom over a period of 5 weeks as a readily available healthy dietary alternative and follow-up over 16 weeks. The main outcome included acceptability and impact on class time in addition to BMI, waist to hip ratio, body fat percentage, bench test, blood pressure, blood glucose and choles- terol levels, food habits, and attitudes toward dietary fruit intake. The pilot study showed that the intervention (a) was well received by children, par- ents, and teachers; (b) created mini- mal disruption to daily activity; and (c) may have the potential to influence physiological parameters and attitudes toward dietary intake in children. Improvements were seen in physiologi- cal measures such as body fat percent- age and cardiovascular endurance tests, with improvements also seen in blood high-density lipoprotein choles- terol. Questionnaire data suggested that both dietary choices and can- teen choices of the children improved over the intervention period. This pilot study provides the proof of concept for conducting a randomized controlled trial of daily provision of fruit within the school environment to evaluate the impact on cardiovascular risk factors at an early age.

In the absence of forensic evidence (such as DNA or fingerprints), offender behavior can be used to identify crimes that have been committed by the same person (referred to as behavioral case linkage). The current study presents the first empirical test of whether it is possible to link different types of crime using simple aspects of offender behavior. The discrimination accuracy of the kilometer distance between offense locations (the intercrime distance) and the number of days between offenses (temporal proximity) was examined across a range of crimes, including violent, sexual, and property-related offenses. Both the intercrime distance and temporal proximity were able to achieve statistically significant levels of discrimination accuracy that were comparable across and within crime types and categories. The theoretical and practical implications of these findings are discussed and recommendations made for future research.

This study evaluates the outcome of axillary nerve injuries treated with nerve grafting. Thirty-six patients were retrospectively reviewed after a mean of 53 months (minimum 12 months). The mean interval from injury to surgery was 6.5 months. Recovery of deltoid function was assessed by the power of both abduction and retropulsion, the deltoid bulk and extension lag. The deltoid bulk was almost symmetrical in nine of 34 cases, good in 22 and wasted in three. Grade M4 or M5* was achieved in 30 of 35 for abduction and in 32 of 35 for retropulsion. There was an extension lag in four patients. Deltoid bulk continued to improve with a longer follow-up following surgery. Nerve grafting to the axillary nerve is a reliable method of regaining deltoid function when the lesion is distal to its origin from the posterior cord.

Background Analysis of recurrent event data is frequently needed in clinical and epidemiological studies. An important issue in such analysis is how to account for the dependence of the events in an individual and any unobserved heterogeneity of the event propensity across individuals. Methods We applied a number of conditional frailty and nonfrailty models in an analysis involving recurrent myocardial infarction events in the Long-Term Intervention with Pravastatin in Ischaemic Disease study. A multiple variable risk prediction model was developed for both males and females. Results A Weibull model with a gamma frailty term fitted the data better than other frailty models for each gender. Among nonfrailty models the stratified survival model fitted the data best for each gender. The relative risk estimated by the elapsed time model was close to that estimated by the gap time model. We found that a cholesterol-lowering drug, pravastatin (the intervention being tested in the trial) had significant protective effect against the occurrence of myocardial infarction in men (HR = 0.71, 95% CI 0.60—0.83). However, the treatment effect was not significant in women due to smaller sample size (HR = 0.75, 95% CI 0.51—1.10). There were no significant interactions between the treatment effect and each recurrent MI event (p = 0.24 for men and p = 0.55 for women). The risk of developing an MI event for a male who had an MI event during follow-up was about 3.4 (95% CI 2.6—4.4) times the risk compared with those who did not have an MI event. The corresponding relative risk for a female was about 7.8 (95% CI 4.4—13.6). Limitations The number of female patients was relatively small compared with their male counterparts, which may result in low statistical power to find real differences in the effect of treatment and other potential risk factors. Conclusions The conditional frailty model suggested that after accounting for all the risk factors in the model, there was still unmeasured heterogeneity of the risk for myocardial infarction, indicating the effect of subject-specific risk factors. These risk prediction models can be used to classify cardiovascular disease patients into different risk categories and may be useful for the most effective targeting of preventive therapies for cardiovascular disease.

Portacaths™ (Bard Medical Division, Georgia, USA) are routinely used for central venous access in patients with poor peripheral veins who require regular long-term venous access. Complications associated with central venous access devices, including infection and thrombosis, are well described in the literature; however, to our knowledge there have been few case reports of right atrial thrombi and pulmonary emboli related to implanted ports. This paper discusses the case of a patient who developed an atrial thrombosis 4 months after port placement and subsequent pulmonary emboli.