Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study.

BACKGROUND: Proximal hamstring complex injury (PHCI) is a common injury among professional athletes, particularly those participating in pivot contact sports. Previous studies have suggested that surgery can be effective in restoring function and allowing athletes to return to sport (RTS), but the factors influencing successful RTS have been less clear. PURPOSE: To assess RTS capabilities after surgical treatment of PHCI in professional athletes and to identify favorable predictors of RTS. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study (2002-2022) was conducted on professional athletes who underwent surgical treatment for PHCI at a sports surgery center. The primary outcome of the study was the RTS capability, evaluated based on the rate of athletes' return to their preinjury level of competition, time delay to RTS, and quality of RTS as measured using their level of performance and progression of scores on activity scales such as the Tegner Activity Scale (TAS) and University of California, Los Angeles (UCLA), scale. "Maintained performance" was defined as athletes returning to the same preinjury activity level (per the TAS and UCLA scale) and perceiving themselves to have maintained their performance. Secondary outcomes covered the potential RTS predictors and complication rate. The study distinguished 2 types of PHCI: proximal hamstring tendon avulsion injury (proximal rupture with empty footprint, or having a "positive dropped ice cream sign") and complete proximal hamstring free tendon rupture (PHTR; proximal rupture without empty footprint, or having a "negative dropped ice cream sign"). RESULTS: The study examined 64 professional athletes (mean age, 27.3 years; 82.8% male) undergoing surgery for PHCI. The RTS rate was 98.4%, with 78.1% of the athletes returning to their preinjury level of competition at 6.2 months (SD, 2.5 months). Twelve (19%) patients had returned to sport at an inferior level of competition, and 2 (3.1%) were unable to continue in their preinjury sport. Subgroup analysis revealed variation in RTS based on sport type, with the highest rate of return to preinjury performance found in athletes in handball and sports with splits (fencing, squash, and escalade; 100%) and soccer (95.2%). In the univariate analysis, male sex (hazard ratio [HR], 4.05; 95% CI, 1.45-11.3; P = .008), higher preinjury TAS score (HR, 1.27; 95% CI, 1.06-1.52; P = .011), injury involving the semimembranosus (HR, 4.84; 95% CI, 2.31-10.2; P < .001) or conjoint tendon (HR, 3.12; 95% CI, 1.55-6.25; P = .001), and PHTR (HR, 7.77; 95% CI, 3.54-17.0; P < .001) were significantly associated with a better postoperative level of competition. Multivariate analysis identified 3 favorable predictors of RTS with HRs of 2.91 (95% CI, 1.01-8.35; P = .047) for male sex, 3.86 (95% CI, 1.78-8.37; P < .001) for isolated semimembranosus injury, and 5.18 (95% CI, 2.24-12.0; P < .001) for PHTR. The complication rate was 4.7%. CONCLUSION: Favorable predictors of early RTS were male sex, isolated semimembranosus injury, and PHTR injuries. REGISTRATION: NCT02906865 (ClinicalTrials.gov identifier).

Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion.

BACKGROUND: No validated score is available for the prediction of return to sport (RTS) after proximal hamstring avulsion (PHA) surgery. PURPOSE: To validate a new assessment tool for patients after PHA surgery: the Parisian Hamstring Avulsion Score (PHAS). STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: All patients at our clinic who had surgery for PHA between January 2015 and March 2018 were included in this study. A suspected clinical diagnosis of PHA was confirmed by magnetic resonance imaging. PHA was repaired by surgical reinsertion with suture anchors. Minimum postoperative follow-up was 2 years, and the PHAS, University of California, Los Angeles (UCLA), score, and Tegner score were used. The PHAS is a patient-reported outcome measure, evaluating the effect of PHA injury with 9 items. It was validated by calculating its psychometric properties, and then correlation analysis was performed to determine the relationship between the PHAS, UCLA score, and Tegner score. Cutoff values for the prediction of RTS were determined. RESULTS: A prospective case series study was performed. A total of 156 patients were included. Median age (first quartile; third quartile) was 54.2 years (44.7 years; 61.3 years), and the mean ± SD time of the final follow-up was 69 ± 11.6 months. Two years after surgery, 66.7% (n = 104) of patients were able to RTS. A strong correlation was noted between all 3 scores at 1 year postoperatively. Overall internal consistency was high, with a Cronbach alpha coefficient of 0.86. The intraclass correlation coefficient was 0.96, showing excellent reliability. The minimal detectable change was 12.9. No patients reached the maximum score at 2 years. Analysis of the receiver operating characteristic curves of the 3 scores at postoperative 9 months in relation to the RTS at 1 and 2 years showed area under the curve values of >0.7, indicating significant discriminant capacity for the RTS. A PHAS cutoff value of 86 at 9 months for the prediction of RTS at postoperative 1 year had a sensitivity of 65.6% (95% CI, 53.7%-77.5%) and a specificity of 81.4% (95% CI, 69.8%-93%). CONCLUSION: PHAS is a valid and reliable tool for follow-up after PHA surgery. It also offers a simple way to predict RTS.

French Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Development and Validation.

Background: The 12-item Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity. Purpose/Hypothesis: We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed. Results: Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version (r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version (r = 0.94). Conclusion: The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.

Comparison of the retear rate 2years after ACL reconstruction with the Tape Locking Screw short graft system and the STG technique: A case control study with propensity score matching.

PURPOSE: Theoretically, short semitendinosus grafts result in less pain and morbidity while providing greater knee flexion strength and sparing the gracilis tendon. They often require the use of blind bone tunnels as well as fixation at both ends of the graft with suspensory cortical buttons. The "Tape Locking Screw" (TLS) system is another option. There are few studies comparing ACL reconstruction with a short graft using the 4-strand semitendinosus graft (ST4-TLS) technique with that of the semitendinosus-gracilis (STG) procedure. This study was designed: (1) to compare the retear rate following these two technics after 2years of follow-up, (2) to compare the clinical scores, complications and return to sport times between the two procedures Q1, Q2. HYPOTHESIS: Our hypothesis was that there would be no differences in retear rates between the two techniques. METHODS: This single center case control study included 290 patients who underwent STG reconstruction that were paired by propensity score matching to 299 patients who underwent ST4-TLS reconstruction. The main evaluation criterion was the retear rate 2years after surgery. Secondary criteria were the two-year postoperative complication rate, the time to return to sport, to pivot sports and to running, as well as the complication rates and clinical scores 6months, 1year and 2years after surgery. RESULTS: At the final follow-up, the overall retear rate in our series of ACL ligament reconstruction was 6.0% (36/596). There was no difference in retear rates between the groups 2years after ligament reconstruction [ST4-TLS: 6.7% (20/299) vs. STG: 5.4% (16/297); p=0.47]. The postoperative KOOS symptom score and the Tegner score were found to be better in the STG group at 1year (81 vs. 78, p=0.008) and 2years (5.64 vs. 5.10, p=0.016), respectively, representing the minimally clinically important difference (MCID) for the latter. No difference was found in the other clinical scores 6months, 1year or 2years after surgery. There was no significant difference in the return to sport [TLS: 93.0% (164/299) vs. STG: 93.0% (158/297) p=0.99] or the complication rate [TLS: 8.7% (26/299) vs. STG: 7.4% (22/297) p=0.89] between the groups. DISCUSSION: The ST4-TLS ACL ligament reconstruction technique was found to be as reliable as the standard STG procedure 2years after surgery for the retear rate and the return to sport, although the results of certain postoperative clinical scores seem to be lower. LEVEL OF EVIDENCE: III; case control study.

Mapping competency in public health training - experience of the Europubhealth consortium.

BACKGROUND: Public health education aims at producing a competent workforce. The WHO-ASPHER framework proposes a set of relevant public health competencies organised in 10 sections (e.g. science practice, leadership, law policies and ethics etc). As part of the Europubhealth (EPH) consortium, eight universities collaborate for the delivery of a 2-year international public health master course. The training pathway includes a first "foundation" year, with a choice of four options (components), and a second "specialisation" year with a choice of seven components. In 2020, EPH consortium decided to use the WHO-ASPHER framework in order to map the competencies addressed and the level of proficiency targeted by each component of its master course. METHODS: An 84-item questionnaire covering the whole WHO-ASPHER framework was sent to the 11 EPH component coordinators, asking them to rate the proficiency levels targeted at the end of their courses. Answers from each coordinator were summarised by calculating mean proficiency levels for each of the 10 competency sections. We used Bland & Altman plots to explore heterogeneity of answers and then calculated transformed scores to account for rating heterogeneity. We use tabulation and a heat map to explore patterns of proficiency levels across components. RESULTS: There were differences in overall proficiency levels between years with, as expected, higher scores in year two. Year one components reached medium to high proficiency scores for the sections "science practice", "health promotion" and "communication" with scores ranging from 2.6 to 3 (on a 1-low to 4-high scale). When compared with year one on a heat-map, year two components displayed more contrasted profiles, typically aiming for high proficiency level (i.e. scores above 3.5) on 3 out of the 10 sections of competencies. Except for the "collaborations and partnership" section, the training pathways offered by the EPH master course seem to offer opportunities for a high proficiency level in all domains of competencies. CONCLUSIONS: The mapping proved a useful exercise to identify strengths and complementarities among the EPH consortium. The results suggest that the EPH master course is coherent and offers students opportunities to gain proficiency in most competencies relevant to public health practice.

Sustainability studies in orthopaedic surgery: The carbon footprint of anterior cruciate ligament reconstruction depends on graft choice.

PURPOSE: Environmental sustainability in medicine is a growing concern. Determining the carbon footprint of medical procedures may aid in selecting a less impactful technique moving forward. The purpose of this study was to understand the environmental impact of different anterior cruciate ligament reconstruction techniques, for which there is no consensus in terms of optimal graft. METHODS: A life cycle analysis of different anterior cruciate ligament reconstruction techniques was performed. These included quadrupled semitendinosus graft, bone-patellar tendon-bone graft, iliotibial band augmented with gracilis graft, doubled semitendinosus and doubled gracilis graft, and quadriceps tendon graft. All procedures were systematically paired with a lateral extra-articular procedure. The study was conducted in a specialised centre using surgeon preference cards, with the help of a dedicated organisation for calculation according to the ISO 14044 standard. The primary outcome measure was the carbon footprint of each of the five techniques. Secondary outcomes included other environmental impact indicators, including human carcinogenic toxicity and mineral resource scarcity, among others, based on the ReCiPe 2016 midpoint guideline. The analysis had three scopes, each encompassing varying numbers of processes: graft implantation, full procedure, and entire environmental impact, from medical prescription to patient discharge. Results were reported as percentage increases compared to the graft technique with the lowest environmental impact. RESULTS: It was demonstrated that the surgical procedure itself accounted for <40% of the life cycle, with arthroscopy being 88% of surgery's GHG emissions, and scrubbing and draping contributing 39% to the carbon footprint. The iliotibial band augmented with gracilis tendon technique had the lowest carbon footprint (0.199 Kg Co2 eq), and the least impact in most categories at all scopes of the life cycle analysis. Using this technique as a reference, in terms of graft implantation, it was determined that extensor mechanism grafts had the highest carbon footprint (300% higher than the reference). Greater scopes showed a similar trend, with percentage differences decreasing significantly, reaching 1-3% when considering the entire environmental impact for most categories. Nevertheless, among the aforementioned factors of the ReCiPe 2016 guidelines, the semitendinosus graft paried with a lateral extra-articular procedure displayed greater difference in human carcinogenic toxicity and mineral resource scarcity (6% and 10% respectively) compared to the reference. The individual processes with the highest impact were also highlighted. CONCLUSIONS: In the institution where the study was conducted, the studied iliotibial band graft option was found to have the lowest environmental impact. Such analyses of standardised procedures can be replicated in individual institutions in order to determine their environmental impact. Identification of procedures with comparable results and differing environmental consequences may influence the future decision-making process. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Comparison of Revision ACL Reconstruction Using Iliotibial Band Augmented With Allograft Versus Bone-Patellar Tendon-Bone Autograft With Lateral Extra-articular Tenodesis.

Background: Bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction (ACLR) is one of the conventional techniques in the revision setting especially after a primary hamstring tendon graft. The use of the iliotibial band (ITB) augmented with allograft (AG) is an encouraging graft alternative for ACLR in terms of clinical and biomechanical data in the literature. Purpose: To compare the clinical outcomes of BTB graft with lateral extra-articular tenodesis, modified Lemaire (BTB-LET), and an ITB graft augmented with hamstring AG (ITB-AG) in the setting of revision ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with either the BTB-LET or ITB-AG technique between 2012 and 2020 and who had a minimum follow-up of 2 years. The clinical outcomes were assessed by the Lysholm, Tegner, Anterior Cruciate Ligament-Return to Sport after Injury, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Return to sports, complications, and revisions were also analyzed. Results: A total of 167 patients were included, with 106 patients in the BTB-LET group and 61 patients in the ITB-AG group. There were no significant group differences in sociodemographic characteristics; however, the mean follow-up was significantly longer in the BTB-LET compared with the ITB-AG group (52.0 vs 38.8 months, respectively; P = .0001). There were no significant differences in postoperative outcome scores; however, patients in the ITB-AG group had a higher rate of return to competitive pivoting sports (32.8% vs 17.9%; P = .0288) and a higher overall rate of return to preinjury sport (63.9% vs 47.2%; P = .0365). Complications, including revisions for meniscal or chondral lesions and retears (8 [8.3%] in the BTB-LET group and 2 [4.0%] in the ITB-AG group), were not significantly different. All retears were due to sports-related accidents. Conclusion: In this study, ITB-AG was not different from BTB-LET in terms of functional outcomes scores but allowed better return to sport rate. Performing ITB-AG reconstruction in the setting of revision ACLR appears to be safe, effective, and associated with a satisfying return-to-sports rate.

Customized-individually-made origin® implants in total knee arthroplasty allow a reliable solution for accurate reproduction of planned implant positioning.

PURPOSE: To evaluate the accuracy and reproducibility of a patient-specific, customized individually made (CIM) total knee replacement (TKR) using the ORIGIN® prosthesis. METHODS: This was a prospective study conducted at a University Hospital from January 15, 2019, to April 30, 2021. The study included patients planned for an ORIGIN® CIM TKR procedure. Exclusion criteria included revision surgery, severe deformity, stiffness, or laxity. Evaluations were carried out using computed tomography scans performed 8 weeks preoperatively and 6 weeks postoperatively. The primary outcome measurements were the preoperative, planned, and postoperative CT scan alignment measurements including the Hip-Knee-Ankle (HKA) angle, mechanical Medial Distal Femoral articular surface Angle (mMDFA, distal alpha angle), Posterior Distal femoral articular surface angle (PDFA, posterior alpha angle), mechanical Medial Proximal Tibial articular surface Angle (mMPTA, beta angle) and posterior proximal tibial angle (PPTA). Secondary outcomes included the accuracy of implant positioning with percentage of outliers at 2° and 3° RESULTS: The study encompassed 51 knees from 50 patients with mean age of 68.1 (SD = 8.89). The overall HKA angle deviated by -0.93° [95% CI: -1.45; -0.43], and the PDFA angle by -0.61° [95% CI: -1.07; -0.15], while the mMPTA exceeded planned values by 1.00° [95% CI: 0.57; 1.43]. The 3° outliers rate ranged from 3.9% for the mMPTA to 7.8% for the HKA alignment, with no outliers in mMDFA and PPTA. Similarly, the 2° outliers rate ranged from 15.7% for both the PDFA angle and mMPTA to 19.6% for the HKA alignment. The Bland-Altman plots further emphasized the precision of planned and post-operative angles across all measurements. CONCLUSION: The CIM TKR showed high accuracy and reproducibility, closely matching preoperative planning. The weakest accuracy at 3°-outliers is in the reproduction of the HKA alignment at 92.2% (range for all angle: 92.2-100%). Similarly, the weakest accuracy at 2°-outliers is in the reproduction of the HKA alignment at 80.4% (range for all angles: 80.4-92.2%).

Dynamic intermittent compression cryotherapy with intravenous nefopam results in faster pain recovery than static compression cryotherapy with oral nefopam: post-anterior cruciate ligament reconstruction.

PURPOSE: To evaluate the effectiveness of dynamic intermittent compression cryotherapy (DICC) (CryoNov®) with an intravenous nefopam-based pain management protocol (DCIVNPP) in reducing post-operative pain following anterior cruciate ligament reconstruction (ACLR) compared to static compression cryotherapy (SCC) (Igloo®) and oral Nefopam. METHODS: This was a retrospective analysis of prospectively collected data including 676 patients who underwent primary ACLR in 2022. Patients were either in the DCIVNPP group or in the SCC (control group), and were matched for age, sex, and Lysholm and Tegner scores (338 per arm). The primary outcome was pain on the visual analogue scale (VAS), analyzed in relation to the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds for VAS. The secondary outcome was side effects. RESULTS: Postoperative pain in the DCIVNPP group was less severe on the VAS than in the control group (p < 0.05). The maximum difference in the VAS between groups was 0.57, which is less than the MCID threshold for VAS. The DCIVNPP group crossed the PASS threshold for VAS on Day 3, sooner than the control group. The side effect profiles were similar in both groups except for higher rates of dizziness and malaise in the DCIVNPP group, and higher rates of abdominal pain in the control group. Most of the side effects decreased over time in both groups, with no significant side effects after Day 3. CONCLUSION: DCIVNPP effectively allows for faster pain recovery than in the control group. The difference in side effects between the protocols may be due to mode of administration of nefopam. LEVEL OF EVIDENCE: III.

Pregabalin does not reduce postoperative pain after outpatient ACL surgery: A case-control study.

INTRODUCTION: In France, prescribing pregabalin requires a secure prescription valid for 6 months since the decree of 12 February 2021, based on recommendations of the French Centre for Evaluation and Information on Pharmacodependence and Addiction vigilance (CEIP-A). This led to discontinuation of this treatment as a postoperative analgesic in the French ACL Study (FAST) cohort. We aimed to evaluate the impact of this change on early postoperative pain. HYPOTHESIS: Pregabalin is an important analgesic for reducing early postoperative pain after anterior cruciate ligament (ACL) repair. METHODS: At our healthcare facility, 584 patients from the FAST cohort who underwent primary isolated ACL reconstruction were included: 292 patients operated before June 1, 2021 who received pregabalin postoperatively and 292 patients operated after June 1, 2021 who did not receive pregabalin. The patients were matched based on age, sex, preoperative Lysholm and Tegner scores. Pain was evaluated on a visual analog scale (VAS) on D0 in the evening, D0 at night, D1, D2 and D3. RESULTS: The patients who did not receive pregabalin had more severe pain at night on D0: 5.21 vs 5.68 (p=.048). There was no difference between groups in the postoperative pain at rest during the evening of D0 (p=.89), D1 (p=.33), D2 (p=.37) and D3 (p=.21). CONCLUSION: In the context of outpatient arthroscopic ACL reconstruction, pregabalin does not reduce early postoperative pain in a clinically significant manner. LEVEL OF EVIDENCE: IV; case-control study.

Experiences of Inter-Hospital Transfers (IHT) by Patients and Relatives during the COVID-19 Pandemic in France: A Qualitative Study.

BACKGROUND: The first wave of the COVID-19 epidemic led to a rapid and unexpected saturation of the French ICU, forcing the health care system to adapt. Among other emergency measures, inter-hospital transfers were carried out. OBJECTIVE: To assess the psychological experience of patients and their relatives regarding inter-hospital transfers. METHODS: Semi-structured interviews were conducted with transferred patients and their relatives. A phenomenological study design was used to examine subjective experiences and their meanings for the participants. RESULTS: The analysis found nine axes pertaining to the experiences of IHT (inter-hospital transfers), grouped in three super-ordinate themes: Information about inter-hospital transfers, differences in patients' and relatives' experiences, and host hospital experience. It appears that patients felt little impacted by the transfers, unlike relatives who experienced intense anxiety when the transfer was announced. Good communications between patients and their relatives resulted in a good level of satisfaction regarding their host hospitals. COVID-19 and its somatic consequences seem to have had more psychological impact on the participants than the transfers by themselves. CONCLUSION: Our results suggest that there are limited current psychological consequences of the IHT implemented during the first wave of COVID-19, although the involvement of patients and their relatives in the organization of the IHT at the time of transfer could further limit them.

Return to Sport After Revision ACL Reconstruction: A Comparative Cohort Study of Outcomes After Single- Versus Multiple-Revision Surgeries.

Background: The return-to-sport rate at 2 years after multiple-revision anterior cruciate ligament (ACL) reconstructions has not been evaluated. Hypothesis: It was hypothesized that patients who undergo multiple-revision ACL reconstructions would have a lower return-to-sport rate at 2 years after surgery than those who undergo a single-revision reconstruction. Furthermore, it was hypothesized that the multiple-revision group would have lower functional scores. Study Design: Cohort study; Level of evidence, 3. Methods: A single-center cohort study in patients who underwent revision ACL reconstruction was begun in 2012. This study included 2 groups: Patients who underwent a single revision, and those who underwent multiple revisions. The main evaluation criterion was the return to sport at the 2-year follow-up. The secondary criteria were the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and ACL-Return to Sport after Injury (ACL-RSI) functional knee scores at the 1- and 2-year follow-ups. Results: A total of 322 patients (single-revision group: n = 302; multiple-revision group: n = 20) were included. A significant difference in the percentage of patients who stopped all sports activity was found between the 2 groups at 2 years (single-revision group: 19.4%; multiple-revision group: 50%). The return-to-sport rate at the same or lower level of performance was higher in the single-revision group as well (17% vs 14.3% for return at the same level; 45.6% vs 14.3% for return at a lower level; P = .03). At the 2-year follow-up, the functional scores of the single-revision group were significantly higher those than in the multiple-revision group: IKDC (77.7 ± 13.82 vs 64.79 ± 15.22; P < .001), KOOS (72.66 ± 17.63 vs 52.5 ± 15.64; P < .001), Lysholm (84.05 ± 11.88 vs 72.5 ± 13.49; P < .001), and ACL-RSI (52.34 ± 21.83 vs 46.43 ± 14.8; P = .0036). Conclusion: Only a small percentage of patients returned to the same level of sport after single- revision and multiple-revision ACL reconstruction, yet significantly more in the former. More patients who underwent multiple revisions gave up their sport. Functional scores were higher for single-revision than multiple-revision surgeries.

Hospitalization and Death in the First 30 days After Outpatient Lower Extremity Arterial Stenting.

PURPOSE: To compare the safety of outpatient versus inpatient endovascular treatment of lower extremity arterial disease (LEAD) using real-life data. MATERIALS AND METHODS: This retrospective observational study used real-life data from the French national health data information system on adult patients who underwent stenting for LEAD between 2013 and 2016. The outcomes of interest were all-cause mortality, all-cause hospitalization, planned hospitalization, and unplanned hospitalization at day 3 and day 30 after the index endovascular intervention for LEAD revascularization. A propensity score was used to control for indication bias. Outcome rates in outpatient and inpatient settings were compared with the Poisson regression model. Sensitivity analyses were performed by varying the definition of the outcomes of interest. RESULTS: During the study period, 26,715 interventions were performed among which 2819 (10.6%) were in outpatient settings. Outpatients were slightly younger than inpatients (64.73 ± 10.68 vs. 68.10 ± 11.50, respectively). The percentage of women patients was similar: 19.8% in the outpatient group and 27.2% in the inpatient group. Within 30 days after discharge, 73 patients (.31%) and 2 (.07%) patients (p = .02) died in the inpatient group and outpatient group, respectively. The death and rehospitalization rate were similar: 3.8 and 3.5 per 1000 person-months for inpatients and outpatients, respectively. No difference was observed after adjusting for patients' case-mix in the regression model (RR = .99; 95% CI [.82-1.19]). CONCLUSIONS: Outpatient stenting for LEAD did not present any additional risk of early postoperative rehospitalization or death compared with inpatient stenting.

Surgical technique of anterior cruciate ligament ligamentoplasty with pedicular hamstrings via an inside-out approach: BIOFAST hamstring tendons graft.

This surgical technique of anterior cruciate ligament (ACL) reconstruction uses a 4-stranded hamstring tendons graft (HG), via an inside-out approach with a femoral cortical button and a tibial screw. It offers preservation of the tibial attachment of the hamstrings and enables double tibial fixation: biological and mechanical. This technique, "BIOFAST HG", does not require any calculation of the length of the tunnels, nor the use of different sized, or adjustable, buttons. If the sliding in the femoral tunnel fails, it is possible to easily convert to a so-called "classic technique". The first 60 cases were reviewed with a conversion rate of 3%. This technique allows the benefits of a pedicled graft over the classic HG technique in a simple way, with minimal conversions to the classic technique.

Impact of recommendations on sodium valproate prescription among women with epilepsy: An interrupted time-series study.

BACKGROUND: The European Medicines Agency (EMA) has developed risk minimization measures (RMMs) to reduce the use of the teratogenic drug, sodium valproate (VPA). The objective was to assess the impact of these RMMs among females with epilepsy in France. METHODS: We used data from the French National Health Insurance Database (SNDS), including 114,936 females aged under 50, with a reimbursement claim for an antiepileptic drug from January 2011 to December 2017, and identified as people with epilepsy. We used a controlled interrupted time series stratifying on age: girls (0-14 years old) and women of childbearing age (15-49 years), and with 129,917 males as controls. RESULTS: VPA prevalent use among girls and women of childbearing age with epilepsy decreased significantly after the issue of the RMMs (trend changes of, respectively, -5 and -4 users per 1000 females at-risk per quarter in comparison to the control group). We did not detect any significant change in VPA incident use. CONCLUSIONS: VPA use decreased over the study period among females with epilepsy but there were still 317 women and 206 girls started on VPA therapy VPA in 2017 (8 per 1000 at-risk and 18 per 1000, respectively). This suggests that either the measures should be strengthened or that the lowest level of VPA use has been reached. In this context, the introduction of a new RMM (in 2018) needs to be evaluated.

TRANSCOV cohort protocol: an epidemiological study assessing the impact of critically ill COVID-19 patients long distance transfers between intensive care units.

INTRODUCTION: During spring 2020, four regions of France faced a surge of severe COVID-19 patients which threatened to overflow local intensive care units (ICU) capacities. As an emergency response, between 13 March 2020 and 10 April 2020, an estimated 661 patients were transferred from overcrowded ICUs to eight other French regions and four neighbouring countries. The intensity, geographical spread and the diversity of vectors used are unprecedented. The study aims at assessing the impact of these inter-ICU transfers on the short-term and medium-term physical and psychological outcomes in this population of severe COVID-19 patients. METHODS AND ANALYSIS: The TRANSCOV cohort is a multicentre observational retrospective study. All transferred patients between ICUs outside the origin region will be invited to take part. For each transfer, up to four control patients will be selected among those admitted in the same ICU during the same period (±4 days of transfer date). Clinical data will be extracted from medical records and will include haemodynamic and respiratory parameters, as well as clinical severity scores before, during and after transfer. Data linkage with medicoadministrative data will enrich the clinical database and allow follow-up up to 1 year after initial admission. ETHICS AND DISSEMINATION: The study has been approved by the French Ethics and Scientific Committee on the 16 July 2020 (file no. 2046524). The results will be disseminated via publication of scientific articles and communications in national and international conferences. TRIAL REGISTRATION NUMBER: 20 CO 015 CZ.

Impact of ICU transfers on the mortality rate of patients with COVID-19: insights from comprehensive national database in France.

BACKGROUND: The first wave of the COVID-19 pandemic confronted healthcare systems around the world with unprecedented organizational challenges, particularly regarding the availability of intensive care unit (ICU) beds. One strategy implemented in France to alleviate healthcare pressure during the first COVID-19 wave was inter-hospital transfers of selected ICU patients from overwhelmed areas towards less saturated ones. At the time, the impact of this transfer strategy on patient mortality was unknown. We aimed to compare in-hospital mortality rates among ICU patients with COVID-19 who were transferred to another healthcare facility and those who remained in the hospital where they were initially admitted to. METHOD: A prospective observational study was performed from 1 March to 21 June 2020. Data regarding hospitalized patients with COVID-19 were collected from the Ministry of Health-affiliated national SI-VIC registry. The primary endpoint was in-hospital mortality. RESULTS: In total, 93,351 hospital admissions of COVID-19 patients were registered, of which 18,348 (19.6%) were ICU admissions. Transferred patients (n = 2228) had a lower mortality rate than their non-transferred counterparts (n = 15,303), and the risk decreased with increasing transfer distance (odds ratio (OR) 0.7, 95% CI: 0.6-0.9, p = 0.001 for transfers between 10 and 50 km, and OR 0.3, 95% CI: 0.2-0.4, p < 0.0001 for transfer distance > 200 km). Mortality decreased overall over the 3-month study period. CONCLUSIONS: Our study shows that the mortality rates were lower for patients with severe COVID-19 who were transferred between ICUs across regions, or internationally, during the first pandemic wave in France. However, the global mortality rate declined overall during the study. Transferring selected patients with COVID-19 from overwhelmed regions to areas with greater capacity may have improved patient access to ICU care, without compounding the short-term mortality risk of transferred patients.

Socioeconomic disparities and risk of hypertension among older Americans: the Health and Retirement Study.

BACKGROUND: Reducing hypertension represents a critical point of intervention to lower the burden of cardiovascular disease worldwide. Although the relationship between lower socioeconomic status and higher rates of hypertension is well documented, most of the evidence comes from prevalence studies involving young adult population. AIM: To investigate the independent association of wealth, education and income with incident hypertension among older adults living in the United States. METHODS: This cohort study included 16 587 individuals aged 50 years and older, free of hypertension and cardiovascular disease at baseline from the Health and Retirement Study over the period 1992-2014. We used Cox proportional hazards models to examine longitudinal associations between wealth, education, and income at baseline and self-reported diagnosis of incident hypertension. RESULTS: During a median follow-up of 7.8 years, 6817 participants declared an occurrence of hypertension (incidence rate: 45.3 [95% confidence interval (CI) = 44.2-46.4] per 1000 person-years). Overall, those in low as compared with high socioeconomic status groups had a higher risk of developing hypertension in late life. In particular, adjusted hazard ratios [95% CI] across decreasing wealth quartiles were 1.0 (reference), 0.97 [0.88-1.08], 1.17 [1.05-1.30], and 1.20 [1.07-1.35] in men, and 1.0 (reference), 1.28 [1.17-1.41], 1.21 [1.09-1.33], and 1.28 [1.16-1.42] in women. In multivariate analyses, wealth remained strongly associated with incident hypertension among women after accounting for other socioeconomic, behavioral and anthropometric risk factors. CONCLUSIONS: Socioeconomic status, especially wealth, is a strong independent predictor of incident hypertension in older adults. Our findings support population-based interventions tailored to those in disadvantaged socioeconomic groups to reduce the risk of hypertension.

Gender difference of geographic distribution of the stroke incidence affected by socioeconomic, clinical and urban-rural factors: an ecological study based on data from the Brest stroke registry in France.

BACKGROUND: Mapping the spatial distribution of disease occurrence is a strategy to identify contextual factors that could be useful for public health policies. The purpose of this ecological study was to examine to which extent the socioeconomic deprivation and the urbanization level can explain gender difference of geographic distribution in stroke incidence in Pays de Brest, France between 2008 and 2013. METHODS: Stroke cases aged 60 years or more were extracted from the Brest stroke registry and combined at the census block level. Contextual socioeconomic, demographic, and geographic variables at the census block level come from the 2013 national census. We used spatial and non-spatial regression models to study the geographic correlation between socioeconomic deprivation, degree or urbanization and stroke incidence. We generated maps using spatial geographically weighted models, after longitude and latitude smoothing and adjustment for covariates. RESULTS: Stroke incidence was comparable in women and men (6.26 ± 3.5 vs 6.91 ± 3.3 per 1000 inhabitants-year, respectively). Results showed different patterns of the distribution of stroke risk and its association with deprivation or urbanisation across gender. For women, stroke incidence was spatially homogeneous over the entire study area, but was associated with deprivation level in urban census blocks: age adjusted risk ratio of high versus low deprivation = 1.24, [95%CI 1.04-1.46]. For men, three geographic clusters were identified. One located in the northern rural and deprived census blocks with a 9-14% increase in the risk of stroke. Two others clusters located in the south-eastern (mostly urban part) and south-western (suburban and rural part) with low deprivation level and associated with higher risk of stroke incidence between (3 and 8%) and (8.5 and 19%) respectively. There were no differences in profile of cardiovascular risk factors, stroke type and stroke severity between clusters, or when comparing clusters cases to the rest of the study population. CONCLUSIONS: Understanding whether and how neighborhood and patient's characteristics influence stroke risk may be useful for both epidemiological research and healthcare service planning.