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International audience; 12 The primary role of the shoulder joint in tennis forehand drive is at the expense of the 13 loadings undergone by this joint. Nevertheless, few studies investigated glenohumeral (GH) 14 contact forces during forehand drives. The aim of this study was to investigate GH 15 compressive and shearing forces during the flat and topspin forehand drives in advanced 16 tennis players. 3D kinematics of flat and topspin forehand drives of 11 advanced tennis 17 players were recorded. The Delft Shoulder and Elbow musculoskeletal model was 18 implemented to assess the magnitude and orientation of GH contact forces during the 19 forehand drives. The results showed no differences in magnitude and orientation of GH 20 contact forces between the flat and topspin forehand drives. The estimated maximal GH 21 contact force during the forward swing phase was 3573 ± 1383 N, which was on average 1.25 22 time greater than during the follow-through phase, and 5.8 times greater than during the 23 backswing phase. Regardless the phase of the forehand drive, GH contact forces pointed 24 toward the anterior-superior part of the glenoid therefore standing for shearing forces. 25 Knowledge of GH contact forces during real sport tasks performed at high velocity may 26 improve the understanding of various sport-specific adaptations and causative factors for 27 shoulder problems. 28 2 29

International audience; Smoking only partly explains the higher lung cancer incidence observed among socially deprived people. Occupational exposures may account for part of these inequalities, but this issue has been little investigated. We investigated the extent to which smoking and occupational exposures to asbestos, silica and diesel motor exhaust mediated the association between education and lung cancer incidence in men. We analyzed data from a large French population-based case–control study (1976 lung cancers, 2648 controls). Detailed information on lifelong tobacco consumption and occupational exposures to various carcinogens was collected. We conducted inverse probability-weighted marginal structural models. A strong association was observed between education and lung cancer. The indirect effect through smoking varied by educational level, with the strongest indirect effect observed for those with the lowest education (OR = 1.34 (1.14–1.57)). The indirect effect through occupational exposures was substantial among men with primary (OR = 1.22 (1.15–1.30) for asbestos and silica) or vocational secondary education (OR = 1.18 (1.12–1.25)). The contribution of smoking to educational differences in lung cancer incidence ranged from 22 % (10–34) for men with primary education to 31 % (−3 to 84) for men with a high school degree. The contribution of occupational exposures to asbestos and silica ranged from 15 % (10–20) for men with a high school degree to 20 % (13–28) for men with vocational secondary education. Our results highlight the urgent need for public health policies that aim at decreasing exposure to carcinogens at work, in addition to tobacco control policies, if we want to reduce socioeconomic inequalities in the cancer field.

International audience; OBJECTIVES: We investigated the relationship between lung cancer and occupational exposure to welding activity in ICARE, a population-based case-control study. METHODS: Analyses were restricted to men (2276 cases, 2780 controls). Welding exposure was assessed through detailed questionnaires, including lifelong occupational history. ORs were computed using unconditional logistic regression, adjusted for lifelong cigarette smoking and occupational exposure to asbestos. RESULTS: Among the regular welders, welding was associated with a risk of lung cancer (OR=1.7, 95% CI 1.1 to 2.5), which increased with the duration (OR=2.0, 95% CI 1.0 to 3.9 when duration \textgreater10 years), and was maximum 10-20 years since last welding. The risk was more pronounced in case of gas welding (OR=2.0, 95% CI 1.2 to 3.3), when the workpiece was covered by paint, grease, or other substances (OR=2.0, 95% CI 1.2 to 3.4) and when it was cleaned with chemical substances before welding. No statistically significant increase in lung cancer risk was observed among occasional welders. CONCLUSIONS: Although these results should be confirmed, we showed that type of welding and mode of workpiece preparation are important determinants of the lung cancer risk in regular welders

Postpartum hemorrhage affects 5% of parturients. Its prevention relies mainly on the administration of oxytocin derivatives. Carbetocin is a newly available analogue of oxytocin but has a considerable incidence of side effects.; L'hémorragie du post-partum affecte 5 % des parturientes. Sa prévention repose entre autres, sur l'administration de dérivés ocytociques. La carbétocine est une molécule analogue de l'ocytocine, récemment disponible mais qui présente une fréquence d'évènements secondaires importante.

International audience; OBJECTIVES: The aim of the study was to determine whether self-reported occupational exposure to cleaning/disinfecting agents in hospital workers is accurate, in comparison to expert assessment, taken to be the gold standard. METHODS: In the Epidemiological Study of the Genetics and Environment of Asthma (EGEA), participants were interviewed on occupation with a specific questionnaire for hospital workers regarding tasks and cleaning/disinfecting agents. Two estimates of exposure were available: self-report and expert assessment. The expert assessment involved a standardised procedure to estimate intensity, frequency and probability of exposure for each job. The present analysis focused on eight exposures: formaldehyde, glutaraldehyde, bleach/chlorine, alcohol, quaternary ammonium components, ammonia, sprays and latex gloves. Agreement and differences between self-reported and expert estimates were studied by kappa and phi coefficients and McNemar tests, respectively. RESULTS: In the survey of 1571 adults, 176 ever hospital workers (327 occupations) with both self-reported and expert exposure assessments were studied. An underestimation of self-reported exposure was observed especially for formaldehyde (26.5% vs 32.7%, p=0.01), ammonia (7.4% vs 18.8%, p

39ème Congrès de la Société de Biomécanique, Valenciennes, France, 27-/08/2014 - 29/08/2014; Previous study showed that kinematic patterns reveal very little variability over repeated tennis strokes for individual player (Knudson 1990). Sport media, however, regularly show difficulties encountered by elite athletes in being accustomed to new equipment, especially in tennis activity. The stability of the pattern would thus be altered by changes in racket specifications. During overhead motion, the shoulder complex has a predominant function as it funnels the energy generated by the lower limbs and trunk to the upper limb and then to the racket, through the so-called kinetic chain (Sciascia et al. 2012). The variability of shoulder kinematic patterns could thus be a key point in habituation to a new equipment. The aim of this study was to explore the variability of the humerothoracic joint kinematic pattern in a highly skilled player when serving with his own racket and with another one. It was hypothesised that the kinematic pattern would be more variable when serving with another racket than with the regular one

Background Revision total hip arthroplasty (rTHA) is a challenging surgery with a higher rate of complications than primary arthroplasty, particularly instability and aseptic loosening. The purpose of this study is to compare dual mobility cup (DMC) and standard mobility cup (SMC) in all rTHAs performed at our institution over a decade with a 1 year minimum follow-up. Methods Two hundred ninety-five rTHAs (acetabular only and bipolar revisions) between 2006 and 2016 were retrospectively reviewed. These were divided into those with a DMC (184 revisions) or SMC (111 revisions). Dislocation and complications requiring re-revision were reported. Results The rTHA mean age was 69 years ± 13.9 (19-92) and the mean follow-up was 2.3 years. Dislocation risk was statistically lower (P = .01) with a DMC (3.8%; 7/184) than with an SMC (13.5%; 15/111). DMC required re-rTHA in 24/184 (13%) for any reason compared to SMC in 19/111 (17.1%) (P = .34). There was no significant difference in early aseptic loosening (P = .28) between the 2 groups. For young patients (≤55 years), results were similar with a lower dislocation rate in the DMC group (P = .24) and no increased risk of early aseptic loosening (P = .49). Conclusion This study demonstrates that for all rTHA indications DMC compared to SMC has a significantly decreased risk of postoperative dislocation without risk of early aseptic loosening at medium term follow-up. The use of DMC in rTHA is an important consideration particularly with the predicted increased incidence of both primary and revision THA globally.

Introduction Variations in the length of lateral extra-articular reconstruction (LER) have been widely investigated during knee flexion but there is no information about length changes during pivot shift. This study sought to assess the changes in LER tension during weightbearing knee flexion in a normal knee and in a computer-simulated pivot-shift scenario. Hypothesis Placing the femoral tunnel posterior and proximal to the lateral femoral epicondyle allows the LER to tighten early in the flexion range during weightbearing (squatting motion) and simulated pivot-shift. Material and methods A computer model was used to simulate weightbearing knee flexion and pivot shift scenarios. Changes in LER tension were calculated in both scenarios by estimating the distance between six femoral attachment sites (posterior and proximal to the lateral femoral epicondyle) and two tibial tunnel locations: Gerdy's tubercle (GT) and the anterolateral ligament (ALL) anatomic attachment site. Results Independent of the location of the femoral and tibial tunnels, the LER tightened by up to 22% of its resting length during the early portion of weightbearing knee flexion and then relaxed from 40° to 60° of knee flexion. The ALL tibial tunnel position allowed complete LER relaxation at 60° flexion whereas LER using the GT tibial tunnel position remained tighter. In the simulated pivot-shift test, and for all femoral tunnel locations, the LER tightened by 20% to 34% of its resting value for the GT tibial tunnel position and by 11% to 26% for the ALL tibial tunnel position. Discussion During weightbearing knee flexion, placing the femoral tunnel proximal and posterior to the femoral epicondyle was associated with LER tightening in the early degrees of flexion and LER relaxation between 40 and 60° flexion. LER tightening occurred during a simulated pivot-shift test supporting the concept that a posterior and proximal femoral LER tunnel position is most effective during weightbearing knee flexion and altered knee kinematics.

Background Although cements are widely used during arthroplasty procedures, few recommendations exist regarding their optimal usage modalities, which, nevertheless, govern the long-term surgical outcomes. No detailed information is available on how cements are used in French hospitals. The objectives of this questionnaire survey among surgeons working at a multi-site university hospital in France were to describe practices, determine whether these varied with surgeon experience, and look for differences compared to recommendations. Hypothesis Cementing techniques vary widely among surgeons at a university hospital. Material and methods A questionnaire was sent to the five orthopaedic departments of our university hospital to collect data on the surgeons (age, sex, years of experience), their practice (type of implants used, annual number of arthroplasties with each arthroplasty type and each indication, and proportion of cemented arthroplasties), the type of cement used, and the cementing technique. Results Of the 34 surgeons, 21 completed the questionnaire, 20 males and 1 female with a mean age of 41 years (range, 31–59 years) and a mean of 11 years (range, 1–29 years) of experience. High-viscosity antibiotic-loaded cement was preferred by 20 (95%) surgeons, notably for knee arthroplasties, of which the median annual numbers were 55 (range, 0–218) and 8 (range, 1–40) for primary and revision cemented procedures, respectively. Various cementing techniques in ambient air were used: 12/21 (57%) surgeons used pulsed lavage to prepare the bone before cementation and 18/21 (86%) applied the cement to both the bone cuts and the implant. Of the 18 surgeons who performed knee arthroplasties, 12 used pulsed lavage, including 9 of the 11 surgeons with more than 5 years of experience and only 3 of the 7 less experienced surgeons. Similarly, of the 12 surgeons who used pulsed lavage for cemented arthroplasties, 11 were among the 12 surgeons who performed more than 15 cemented arthroplasties annually and 1 was among the 6 who performed fewer cemented arthroplasties. Discussion Cementing techniques varied widely, reflecting the dearth of recommendations and controversial results of published studies. In our centre, the use of pulsed lavage to improve bone preparation and cement application to both the bone and the implant should be promoted, as both techniques are universally advocated. Our study demonstrates the need to provide surgeons with opportunities to exchange their experiences about the other aspects of cementing in order to harmonise practices and to optimise the use of cement. Level of evidence IV, questionnaire survey.

Background Excessive Knee Flexion Gait Pattern (KFGP) is a common gait deviation in many pathological conditions. The contractures of the muscles that have been identified as being responsible of KFGP are: iliopsoas, hamstring and gastrocnemius. Research question How do isolated contractures of the iliopsoas, hamstrings and gastrocnemius impact knee flexion during gait? Methods Three levels of contracture (mild, moderate and severe) were simulated bilaterally using an exoskeleton on 10 healthy participants for iliopsoas, hamstring and gastrocnemius muscles. A gait analysis session was performed to evaluate the joint kinematics according to the different simulated contractures. Thirty one parameters were chosen to analyze the kinematics of the thorax, pelvis, hip, knee and ankle. A principal component analysis (PCA) was used to determine the kinematic parameters influenced by contractures. Results In addition to a permanent knee flexion observed for the three muscles with contracture: the contracture of the iliopsoas induces a large hip flexion with pronounced anterior pelvis tilt; the contracture of the hamstrings induces an ankle dorsiflexion during the support phase with a posterior pelvis tilt; the contracture of the gastrocnemius induces an absence of first and second rocker of the ankle with a slight flexion of hip and a slight anterior pelvis tilt. Significance These results support the identification of the muscles responsible for a KFGP. A better knowledge of the interactions between contractures and associated joint kinematics of the same and adjacent joints will support the interpretation of gait analyses by more precisely and faster targeting the concerned muscle.

Background: Noise in the vicinity of airports is a crucial public health issue. Exposure to aircraft noise has been shown to have adverse effects on health and particularly on sleep. Many studies support the hypothesis that noise at night can affect subjective sleep quality. Fewer studies, however, have performed objective measurements of sleep. Objectives: The aim of the present study was to investigate the relationship between aircraft noise exposure and objective parameters assessed by actigraphy of sleep quality in the population living near two French airports. Methods: This study includes 112 participants living in the vicinity of Paris-Charles de Gaulle and Toulouse-Blagnac airports. Wrist actigraphy measurements were performed during eight nights to evaluate objective parameters of sleep quality such as sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), time in bed (TB) and sleep efficiency (SE). Acoustic measurements were made simultaneously both inside the participants' bedrooms and outside (at the exterior frontage) in order to estimate aircraft noise levels. Energy indicators related to the sound energetic average for a given period of time, as well as indicators related to noise events (such as the number of events that exceed a given threshold for example) were estimated. Logistic and linear regression models were used, taking into account potential confounders: age; gender; marital status; education; and body mass index (BMI). Results: Energy indicators, and more particularly indicators related to noise events, were significantly associated with objective parameters of sleep quality. Increased levels of aircraft noise and increased numbers of aircraft noise events increased the time required for sleep onset (SOL) and the total wake time after sleep onset (WASO), and decreased sleep efficiency (SE). An association was also observed between aircraft noise exposure and an increase in total sleep time (TST) and time in bed (TB). Conclusion: The findings of the present study contribute to the overall evidence suggesting that nocturnal aircraft noise exposure may decrease objective quality of sleep. Aircraft noise exposure affects objective parameters of sleep quality, not only in terms of noise levels but also in terms of number of events. Mechanisms for adapting to sleep deprivation could be observed.

The objective of this prospective study was to assess the effect of CPAP therapy on job productivity and work quality for patients with severe obstructive sleep apnea (OSA). A convenience sample of patients diagnosed with severe OSA using polysomnography or polygraphy and with a therapeutic indication for CPAP was enrolled in our study. Patients completed two self-administered questionnaires: the first before CPAP therapy and the second during the first 6 months after CPAP treatment. OSA symptoms were evaluated through self-administered questionnaires assessing potential effects on occupational activity: excessive daytime sleepiness was rated by the Epworth Sleepiness Scale (ESS), emotional status was rated by the Hospital Anxiety and Depression (HAD) scale, work quality was rated by the Work Role Functioning Questionnaire (WRFQ). Forty patients (30 men, mean age 47.3 ± 8.3, mean BMI 31.6 ± 7.4, mean apnea-hypopnea index 51.8 ± 16.3) showed a beneficial effect of CPAP therapy on ESS score (mean 11.6 to 8.2, p

Context and objective Among the different products and protective gear used by riders of two-wheeled motorized vehicles, back protectors that are designed to prevent damage to the spinal column are widely used today compared other protections. However, few studies measure their effectiveness. Can their effectiveness be measured? How do they help decrease or change the nature of thoracolumbar traumas that occur? To address these questions and remedy the lack of objective data regarding these products, an epidemiological, clinical, and biomechanical analysis of motorcycle riders who were admitted to a French trauma center after an accident was performed. So, this study investigates the effectiveness of back protectors, including their ability to prevent specific mechanisms of thoracic and lumbar spinal injuries related to TWMV accidents. Method A questionnaire was administered to victims of accidents involving two-wheeled motorized vehicles who were admitted to the trauma room at the Marseille trauma center over the course of 2016. Collect data are related to the victim, the accident scenario, and a detailed description of the observed injuries using AIS (Abbreviated Injury Scale) coding and Magerl classification. Univariate analyses and Fisher tests were performed for victims who were or were not wearing back protectors. Results This study collected data from 124 victims. Almost half of the victims were wearing a back protector at the time of the accident (53 victims, thus 43% of riders). Collectively, twenty-nine victims who were wearing back protectors had 57 thoracolumbar injuries, and twenty eight victims who were not wearing back protectors had 75 thoracolumbar lesions. The results from this study show that there is no significant difference in the nature and mechanism of thoracolumbar injuries as a function of back protection. The majority of the thoracolumbar injuries were not severe. They were primarily bone injuries, essentially compression fractures, regardless of whether a back protector was worn. Conclusion This study shows that the use of back protection does not decrease the number, type, or mechanism of thoracolumbar injuries associated with accidents involving two-wheeled motorized vehicles. However, it suggests that lumbar vertebral injuries are deflected towards the thoracic vertebrae when back protectors are worn. Finally, it suggests that the design of back protectors should be reconsidered to better protect riders from what are referred to as compression fractures (craniocaudal force), which remain the primary form of fracture regardless of the rider’s characteristics, based on the data analyzed.

The aim of this systematic review with meta-analysis was to determine the change in gait biomechanics after total ankle replacement and ankle arthrodesis for end-stage osteoarthritis. Methods Electronic databases were searched up until May 2019. Peer-reviewed journal studies including adult participants suffering from end-stage ankle osteoarthritis and reporting pre- and post-operative kinematics, kinetics and spatio-temporal effects of total ankle replacement and ankle arthrodesis during walking were included with a minimum of 12months follow-up. Seventeen suitable studies were identified and assessed according to methodological and biomechanical qualities. Meta-analysis was performed by calculating the effect size using standard mean differences between pre- and post-operative gait status. Findings Seventeen studies with a total of 883 patients were included. Meta-analysis revealed moderate evidence of an improvement in lower limb kinematics, kinetics and spatio-temporal parameters after total ankle replacement. Moderate evidence indicated an increase in ankle moment, hip range of motion and walking speed after ankle arthrodesis. Interpretation The currently available evidence base of research papers evaluating changes in gait biomechanics after total ankle replacement and ankle arthrodesis is limited by a lack of prospective research, low sample sizes and heterogeneity in the patho-etiology of ankle osteoarthritis. Following total ankle replacement, improvements were demonstrated for spatio-temporal, kinematic and kinetic gait patterns compared to the pre-operative measures. Improvements in gait mechanics after ankle arthrodesis were limited to walking speed and ankle moment. Increased hip range of motion after ankle arthrodesis could represent a sign of compensation for the lack of ankle motion.

Successive implementation of seven-valent then 13-valent pneumococcal conjugate vaccines (PCVs) led to a marked decrease in pneumococcal disease burden, including pneumococcal meningitis. We assessed the long-term effect of implementation of PCVs on incidence of pneumococcal meningitis in children in France over a 16-year period.We did a quasi-experimental, population-based interrupted time-series analysis with a nationwide prospective survey over 16 years in France, recruiting children aged younger than 15 years from 227 paediatric wards from January, 2001, to December, 2016. The main outcome by the time-series model was the estimated incidence of pneumococcal meningitis per 100 000 children (of a population of 12·6 million children in 2017) before and after PCV7 and PCV13 implementation. The time-series model was based on segmented regression with autoregressive error.We enrolled 1778 children with pneumococcal meningitis. PCV13 implementation led to a significant reduction in monthly incidence of pneumococcal meningitis from 0·12 per 100 000 children before PCV13 to a nadir of 0·07 in December, 2014 (-38%, 95% CI -56·1 to -20·4; p0·0001). A sharp increase occurred during 2015 and 2016, (+2·3% per month, incidence of 0·13 per 100 000 children at the end of the study period, p=0·0002), mainly related to an increase of serotype 24F, which was frequently penicillin resistant.The early effect of PCV13 implementation greatly reduced the incidence of pneumococcal meningitis in children less than 15 years old. However, a sharp rebound in incidence linked to the emergence of serotype 24F compromised the long-term PCV efficacy. If confirmed in future studies and in other countries, pneumococcal meningitis incidence rebound and 24F emergence should be considered when developing next-generation PCVs.The French Pediatric Infectious Diseases Group, Association Clinique et Thérapeutique Infantile du Val de Marne, Pfizer, and for the National Reference Centre for Pneumococci, the French National Health Agency.

PURPOSE: Surgeons mainly consider the anterior anatomy of the distal femur in the treatment of patellar instability (PI) with trochlear dysplasia (TD). Through this research, the idea was to analyse the posterior femoral condyle length in TD. The research team posited the presence of morphological differences in the posterior part of the femoral epiphysis in TD compared to a control group. They also postulated that the posterior bicondylar angle (PCA), in the axial plane, was increased in TD. METHODS: This is a single-centre morphological study of 100 patients who had a computed tomography (CT) using the same protocol. 50 patients with PI (25 dysplasias A and 25 B-C-D according to the Dejour classification), and 50 controls were included. All patients presenting a clinical PI were considered for the study. None of these patients had undergone a surgical treatment prior to imaging. Demographic characteristics, BMI, and laterality were comparable in all patients. 20 pilot CT scans were used to establish the methodology. The following measurements were performed: anterior bicondylar angle, PCA, and condylar lengths with respect to the surgical transepicondylar axis. Ratios were calculated in relation to the femoral width. TD was classified according to the Dejour classification in grade A or grades B-C-D. An analysis of variance and a linear model were performed within some groups to investigate which parameters correlated with the classification's grade. RESULTS: This study showed a link between TD and the PCA: control group (1.4?±?0.2°), type A group (1.6?±?0.3°), and types B, C, D group (2.6?±?0.3°) (p?=?0.01). The difference between the control group and types B, C, D TD group was significant (p?=?0.002). In groups B, C, D, the PCA was more important, which proves that in these groups the posterior part of the lateral condyle was relatively shorter compared to the medial condyle. The greater the dysplasia, the longer the medial condyle was in the anterior posterior (p?=?0.02). CONCLUSIONS: This study shows not only an anterior but also a posterior anomaly in PI with TD. There is a correlation between the severity of the anterior deformation and the PCA: in other words, the knee is placed in valgus in flexure which promotes the external dislocation of the patella. This anatomical study could open a field of research on the development of surgical treatments based on the correction of posterior condylar femoral anomalies in PI. LEVEL OF EVIDENCE: III.

Hospitalizations for anaphylaxis have been increasing steadily in many countries, whereas the anaphylaxis mortality rate has remained low and stable over the past 20 years.1-3 A small proportion of patients experiencing anaphylactic reactions are hospitalized in an intensive care unit (ICU). In the United States, this proportion was 5% of the patients seen in the emergency department for anaphylaxis.4 In the United Kingdom, 81 pediatric anaphylaxis cases were collected between 2005 and 2009, with a steady yearonyear increase.

BACKGROUND: Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V-VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient's survival. METHODS: A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector. RESULTS: Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50-53%), followed by ventro-dorsal (23-26%), trifurcation (13-20%), and quadrifurcation types (5-11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85-100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ??III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0-3%), and results were comparable to "classic" liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml. CONCLUSION: Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

Objectives The etiology of male breast cancer (MBC) is largely unknown but a causal role of exposure to organic solvents has been suggested. Previous studies on occupational risk factors of breast cancer were often restricted to women who are frequently exposed to lower levels and at a lower frequency than men. We investigated the association between MBC and occupational exposure to petroleum and oxygenated and chlorinated solvents in a multicenter case-control study of rare cancers in Europe. Methods The study included 104 MBC cases and 1901 controls. Detailed lifetime work history was obtained during interviews, together with sociodemographic characteristics, medical history and lifestyle factors. Occupational exposures to solvents were estimated from a job-exposure matrix. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated using unconditional logistic regression models. Results Lifetime cumulative exposure to trichloroethylene >23.9 ppm years was associated with an increased MBC risk, compared to non-exposure [OR (95% CI): 2.1 (1.2-4.0); P trend

Road traffic accidents (RTAs) are the first cause of abdominopelvic injuries (APIs). The objective of this study was to describe the characteristics and severity of APIs due to traffic accidents in a large French trauma registry and to identify risk factors for API.All victims from the French Rhône registry of victims of RTAs were analyzed from 1996 to 2013. This registry contained data that were issued over a 20-year period from 245 medical departments, from prehospital care until re-adaptation, and forensic medicine departments. All APIs, defined as an injury between the diaphragm and the pelvic bone, were extracted and studied.Among 162,695 victims, 10,165 had an API (6.7%). Accidents frequently involved young men and 2 cars. Mean Injury Severity Score (ISS) was 8.7. Mortality rate was 5.6%. Soft tissue injuries largely predominated (n = 6,388; 54.4% of patients). Overall, 2,322 victims had a pelvic bone injury. Internal abdominal organs were involved in 2,425 patients; the most frequent were the spleen, liver, and kidney. Wearing of the seat belt appeared to be a significant protective factor in API, including serious injuries. A partial analysis over the past 2 years among the most severe patients hospitalized in the intensive care unit indicated that nonoperative management was carried out in two thirds of the wounded. In uni- or multivariate analysis, sex, age, type of user, antagonist, time of occurrence, associated severe lesions, or wearing of the seat belt were statistically associated with the occurrence of API, highlighting a more dangerous user profile.Abdominopelvic injuries concern a minority of road traffic injuries, but they are responsible for significant mortality. Large solid organs are the most frequently affected. Women drivers wearing a seat belt and driving in town during the day appear to be more protected against API.

Objective The effects of seat height and anthropometric dimensions on drivers’ preferred postures were investigated using a multiadjustable vehicle mock-up with a large number of adjustments and extended ranges. Background Many studies have been conducted on preferred driving posture under different test conditions showing mixed and even contradictory findings. No studies thus far have considered the clutch and compared Chinese and European drivers. Method Four seat height conditions were tested: free and three imposed heights (250, 300, and 350 mm). Sixty-one subjects (40 French-born and 21 Chinese-born) participated in the experiment, covering a large range of stature and sitting height–to–stature ratio. The RAMSIS kinematic model was used to reconstruct postures, and main intersegmental angles were extracted for characterizing posture. Results Under the free seat height condition, no significant differences in preferred intersegmental angles were observed between different participant groups. Seat height mainly affected trunk–thigh angle, whereas it had almost no effect on trunk orientation and other intersegmental angles. Chinese participants sat more forward in the seat, leading to a more opened trunk–thigh angle and a more reclined trunk. Conclusions Results suggest that intersegmental angles of preferred posture are not dependent on anthropometric dimensions, although shorter drivers prefer a slightly less reclined trunk. Self-selected driving posture results from a compromise between maintaining the intersegmental angles in one’s preferred range and a preferred trunk orientation in space. Applications The findings contribute to a better understanding of preferred driving postures and would be helpful for improving vehicle interior design.

Previous research has demonstrated that women have a higher risk of anterior cruciate ligament (ACL) injury than men. Tibiofemoral articular geometry may play a role in the occurrence of ACL tears. The purpose of this study was to analyze the gender-specific geometric characteristics differences in tibiofemoral morphology in ACL-deficient patients. Medial tibial slope (MTS), lateral tibial slope (LTS), medial tibial plateau concavity, medial and lateral femoral condyle convexity, and lateral plateau convexity were analyzed in 276 patients with complete ACL injuries (138 females and 138 males). Two blinded observers measured the anatomical parameters of tibiofemoral geometry with use of multiplanar CT scans. Intra- and inter-rater reliabilities were assessed and comparisons between anatomic measures were made between male and female patients. The average ICC for all measurements was 0.90 (range 0.83–0.97) indicating good reliability. Male ACL injured patients demonstrated significantly greater LTS (10.5° ± 2.8) than female patients (9.6° ± 3.5°; p

Introduction Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors. Hypothesis Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study. Patients and methods A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup). Results The patients with unstable THAs were 67 ± 12 [37–73] years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5 years after in 20 cases (16%), 5 to 10 years after in 17 cases (13%) and more than 10 years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4–2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15–7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0–3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3–7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2–15.9), and cup inclination outside Lewinnek's safe zone (30°–50°) with OR of 2.4 (95% CI: 1.4–4.0). Discussion This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation. Level of evidence Level III; case-control study.

International audience; Ten to 29% of lung cancers might be linked to occupational factors but 60% of them are not compensated. The PROPOUMON project aimed to improve the identification, recognition and compensation of occupational lung cancer as occupational disease using a self-administered questionnaire (AQREP). One objective was to assess the AQREP, comparing it with the questionnaire drawn up by the French Language Pneumology Society (Q-SPLF). From March 2014 to September 2015, 90 lung cancer patients treated at the Centre Léon-Bérard responded to the AQREP and Q-SPLF. The two physicians in charge of the consultation assessed independently whether or not a consultation was indicated. A certificate for the compensation process was proposed when a suspicion of high or average imputability was identified. Analysis of the questionnaires was concordant for 73% of the patients. The AQREP has a sensitivity of 72% and a specificity of 73%. Its positive and negative predictive values were 62 and 82%. The information provided by 24 patients were discordant between questionnaires. In two patients with discordant evaluation (AQREP+/Q-SPLF-; AQREP-/Q-SPLF+), one Initial Medical Certificate (IMC) was written. This study made it possible to conclude that AQREP is relevant for the identification of potentially occupational lung cancers. Collegial discussion of complex cases might be considered. The project is currently been extended to other centers and to lymphoma.; Dix à 29 % des cancers bronchopulmonaires seraient d’origine professionnelle dont 60 % ne seraient pas indemnisés. Le projet Propoumon vise à améliorer le repérage, la reconnaissance et l’indemnisation des cancers bronchopulmonaires d’origine professionnelle en maladie professionnelle à partir d’un auto-questionnaire (AQREP). Un des objectifs était d’évaluer sa capacité à détecter les patients pouvant bénéficier d’une consultation « cancers professionnels », en le comparant avec le questionnaire de la Société de pneumologie de langue française (Q-SPLF). De mars 2014 à septembre 2015, 90 patients suivis au centre Léon-Bérard pour un cancer bronchopulmonaire ont répondu aux deux questionnaires. Les deux médecins responsables de la consultation évaluaient de façon indépendante, sur la base de l’AQREP ou du Q-SPLF, l’indication d’une consultation. Si à l’issue de la consultation des arguments en faveur d’une origine professionnelle étaient réunis, une démarche de déclaration était proposée. L’analyse des questionnaires par les médecins était concordante à 73 %. L’AQREP a une sensibilité de 72 % et une spécificité de 73 %. Ses valeurs prédictives positive et négative sont de 62 et 82 %. Les informations renseignées par 24 patients étaient discordantes entre les questionnaires. Pour deux patients ayant une évaluation discordante (AQREP+/Q-SPLF- ; AQREP-/Q-SPLF+), un « Certificat médical initial » a été rédigé. Le premier a été refusé par l’Assurance maladie, le second est en cours d’instruction. Cette étude a permis de conclure en la capacité de l’AQREP à repérer les cancers bronchopulmonaires potentiellement d’origine professionnelle. Une réunion de concertation pour discuter des cas complexes pourrait être envisagée. Le projet s’élargit actuellement à d’autres centres et aux lymphomes.

Background Saliva cortisol is a possible marker of noise-induced stress and could then mediate the relation observed between exposure to aircraft or road traffic noise and cardiovascular diseases. However, the association between transportation noise and cortisol levels is still unclear. The objective of the study was to investigate the variability of saliva cortisol concentration as an indicator of disturbed hypothalamus-pituitary-adrenal (HPA) axis regulation in relation to long-term aircraft noise exposure. Methods Saliva samples were taken when awakening and before going to bed for 1244 participants older than 18 years of age. Information about health, socioeconomic and lifestyle factors was also collected by means of a face-to-face questionnaire performed at home by an interviewer. Aircraft noise exposure was assessed for each participant’s home address using noise maps. Linear regression models were used to evaluate the effects of aircraft noise exposure on the morning and evening cortisol levels and on the daily variation of cortisol per hour. Results This study suggests a modification of the cortisol circadian rhythm in relation to aircraft noise exposure. This exposure was associated with a smaller variation of cortisol levels over the day, with unchanged morning cortisol levels, but higher cortisol levels in the evening. Conclusions These findings provide some support for a psychological stress induced by aircraft noise exposure, resulting in HPA dysregulation and a flattened cortisol rhythm, thus contributing to cardiovascular diseases.

© 2017 International Society of Blood Transfusion Background and Objectives: Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to > 5% of their patients, whereas another 25% transfused plasma to < 1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. Materials and Methods: Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients’ case-mix in each unit, unit’s characteristics, and local blood product transfusion policies and processes. Results: The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case-mix, centre characteristics or local transfusion services were not identified as significant relevant factors. Conclusion: Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research.

International audience; This longitudinal study aimed at exploring the direct and indirect relationships between organizational, psychosocial, biomechanical, and personal factors and carpal tunnel syndrome (CTS) in French workers. Between 2002 and 2005, 3710 workers were included in the Cosali cohort. Between 2007 and 2010, 1611 workers were re-examined using the same standardized clinical protocol. Subjects free from CTS at baseline were studied (804 men and 563 women). We used structural equation models to examine the relationships between incident CTS cases and organizational (machine-paced work or work pace dependent on customers' demand), psychosocial (job strain model), biomechanical (Borg's rating perceived exertion, wrist bending, pinching, and hand-transmitted vibrations), and personal factors at baseline. Symptomatic CTS risk was directly increased by biomechanical factors (standardized coefficient = 0.19, P = 0.011), female gender (0.25, P < 0.001), and age (0.15, P = 0.042). No psychosocial factors had a direct impact on CTS, but decision authority and skill discretion had an indirect impact by influencing biomechanical exposure. Exposure to machine-paced work had an indirect impact on increasing CTS, either by raising biomechanical exposure (0.19, P < 0.001) or by lowering decision authority (-0.18, P < 0.001) and skill discretion (-0.20, P < 0.001), which in turn increased biomechanical exposure. Similar complex relationships were observed between risk factors and CTS defined by a more strict case definition. Biomechanical exposure had a direct impact on CTS, while organizational factors and psychosocial factors had an indirect impact on CTS. The findings support conceptual models linking work organization to CTS.

Background: Social participation is a modifiable health determinant influenced by physical and social aspects of the environment. Little is known about aging women's and men's community activities and barriers according to region and population size. This study compared social participation, desire to participate more, and perceived barriers of aging women and men by Canadian region and population size. Methods: A secondary analysis of the 2008-2009 cross-sectional Canadian Community Health Survey - Healthy Aging was done with 16,274 respondents aged 65+. Respondents were grouped into five regions [Atlantic, Quebec, Ontario, Prairies and British Columbia] and five population size groups [rural (< 1000 inhabitants); small urban (1000-29,999); medium urban (30,000-99,999); large urban (100,000-499,999); and metropolitan (e500,000) areas]. Social participation was estimated by monthly frequencies of engagement in community activities. If they desired to participate more, respondents were asked to identify barriers to their participation from a list of 13 reasons. Results: There were no differences in total social participation between regions but Prairies and Quebec respondents had the highest and lowest frequency, respectively, of activities with family and friends (5.4 and 4.3 activities/month; p = 0.01). Medium urban centers had the highest participation and metropolises, the lowest (17.4 vs 14.3 activities/month; p < 0.01). About one fourth of all respondents wanted to participate more, regardless of region or population size. Overall, women wanted to participate more than men (26.6 vs 20.7%; p < 0.001), especially in Ontario (28.3 vs 21.1%; p < 0.001) and British Columbia (30.1 vs 22.9%; p < 0.001). Men in Quebec were less likely than men in other regions to report 'personal responsibilities' as a barrier to participation (p < 0.001). Men were more likely than women to report being 'too busy', especially in rural areas (27.1 vs 6.5%; p < 0.001). Rural women were more likely than rural men to be constrained by transportation problems (15.1 vs 1.2%, p < 0.001). Unavailability of activities was more of a constraint in rural areas than metropolises (13.6 vs 6.0%, p < 0.001). Conclusions: Overall, there were no practical differences between women's and men's social participation. However, unavailability of activities and transportation problems suggest that local initiatives and further research on environmental characteristics are required to foster aging Canadians' participation.; Contexte : La participation sociale est un déterminant de la santé qui est modifiable et influencé par les aspects physiques et sociaux de l'environnement. On sait peu de choses sur les activités communautaires des femmes et des hommes vieillissants et sur les obstacles selon la région et la taille de la population. Cette étude a comparé la participation sociale, le désir de participer davantage et les obstacles perçus par les femmes et les hommes vieillissants selon la région et la taille de la population canadienne. Méthodes : Une analyse secondaire de l'Enquête transversale sur la santé dans les collectivités canadiennes - Vieillissement en santé 2008-2009 a été effectuée auprès de 16 274 répondants âgés de 65 ans et plus. Les répondants ont été regroupés en cinq régions [Atlantique, Québec, Ontario, Prairies et Colombie-Britannique] et cinq groupes de population [régions rurales (< 1000 habitants) ; petites villes (1000-29 999) ; villes moyennes (30 000 à 99 999) ; grandes villes (100 000 à 499 999) ; et régions métropolitaines (e500 000)]. La participation sociale a été estimée en fonction de la fréquence mensuelle de la participation aux activités communautaires. S'ils souhaitaient participer davantage, on a demandé aux répondants d'identifier les obstacles à leur participation à partir d'une liste de 13 raisons. Résultats : Il n'y avait aucune différence entre les régions pour la participation sociale totale, mais les répondants des Prairies et du Québec avaient respectivement la fréquence la plus élevée et la plus faible d'activités avec la famille et les amis (5,4 et 4,3 activités/mois ; p = 0,01). Les centres urbains moyens avaient la plus forte participation et les métropoles, la plus faible (17,4 vs 14,3 activités/mois ; p < 0,01). Environ un quart de tous les répondants voulaient participer davantage, indépendamment de la région ou de la taille de la population. Dans l'ensemble, les femmes voulaient participer davantage que les hommes (26,6 % vs 20,7 % ; p < 0,001), surtout en Ontario (28,3 % vs 21,1 % ; p < 0,001) et en Colombie-Britannique (30,1 vs 22,9 % ; p < 0,001). Les hommes du Québec étaient moins susceptibles que les hommes des autres régions de déclarer que les " responsabilités personnelles " constituaient un obstacle à leur participation (p < 0,001). Les hommes étaient plus susceptibles que les femmes de déclarer être " trop occupés ", surtout en milieu rural (27,1 vs 6,5 % ; p < 0,001). En milieu rural les femmes étaient plus susceptibles que les hommes d'être limitées par des problèmes de transport (15,1 % contre 1,2 %, p < 0,001). L'indisponibilité des activités était plus une contrainte dans les zones rurales que dans les métropoles (13,6 vs 6,0%, p < 0,001). Conclusions : Dans l'ensemble, il n'y avait pas de différences pratiques entre la participation sociale des femmes et celle des hommes. Cependant, l'absence d'activités et les problèmes de transport semblent indiquer que des initiatives locales et d'autres recherches sur les caractéristiques environnementales sont nécessaires pour favoriser la participation des Canadiens vieillissants.

PURPOSE: Reconstruction of the medial patellofemoral ligament (MPFL) has become the gold standard for the treatment of the recurrent patellar dislocation (RPD). Lateral retinacular release can be performed in association with MPFL reconstruction, but the effect on outcomes is not clear. To evaluate the effect of lateral release on outcomes following MPFL reconstruction is the aim of this study. It is hypothesized that isolated MPFL reconstruction was not inferior to MPFL reconstruction and lateral retinacular release in terms of IKDC subjective score and patellar tilt (PT). METHODS: Patients between ages 18 and 45 scheduled to undergo MPFL reconstruction without an associated bony procedure (tibial tubercle osteotomy or trochleoplasty) were randomized to isolated MPFL reconstruction or MPFL reconstruction (no LRR group) and arthroscopic LRR (LRR group). Evaluation criteria were subjective IKDC score as the primary outcome and PT evaluated with a CT-scan. PT was evaluated with the quadriceps relaxed (PTQR) and contracted (PTQC). RESULTS: Of 43 patients included in the trial, 7 were lost of follow-up, 3 were not able to complete evaluation because of medical reasons, and 33 patients were evaluated with a minimum of 12 months and a median follow-up of 24 (12-60) months. The average subjective IKDC score was at 86?±?20 (29-94) in the LRR group and 82?±?15 (39-95) in the no LRR group (p?=?0.45). The PTQR was at 22°?±?7° (13-37) in the LRR group and 21?±?10 (4-37) in the no LRR group (n.s.). The PTQC was at 27°?±?9° (12-40) in the LRR group and 25?±?12 (5-45) in the no LRR group (n.s.). No complications were noted in either group. CONCLUSIONS: No significant differences were found in subjective IKDC score or patellar tilt based on the addition of an arthroscopic LRR to an MPFL reconstruction in patients with RPD not undergoing associated bony procedures. There is no indication to a systematic lateral retinacular release in association with MPFL reconstruction in the treatment of RPD. LEVEL OF EVIDENCE: II.

A literature review was conducted to develop more realistic medical simulators that better prepare aspiring health professionals to perform a medical procedure in vivo. Thus, this review proposes an approach that might assist researchers design improved medical simulators, particularly new materials that would enhance the sensation of touch for skin substitutes. By targeting the current needs in the field of simulation learning, we concluded that peripheral venous catheter insertion simulators lack realistic haptic feedback. Enhanced peripheral venous catheter insertion simulators will accelerate the mastery of the medical procedure, thus decreasing the number of failures in patients and costs related to this procedure.

INTRODUCTION: Due to inconsistent results and high failure rates, total knee arthroplasty (TKA) is more often used to treat isolated patellofemoral osteoarthritis (PFOA) despite the theoretical advantage of patellofemoral arthroplasty (PFA). It is perceived that second-generation PFA may have improved the outcomes of surgery. In this systematic review, the primary aim was to compare outcomes of second-generation PFA and TKA by assessment of patient-reported outcome measures (PROMs). METHODS: A systematic search was made in PubMed, Medline, Embase, Cinahl, Web of Science, Cochrane Library and MeSH to identify studies using second-generation PFA implants or TKA for treatment of PFOA. Only studies using The American Knee Society (AKSS), The Oxford Knee Score (OKS) or The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to report on PROMs were included. RESULTS: The postoperative weighted mean AKSS knee scores were 88.6 in the second-generation PFA group and 91.8 in the TKA group. The postoperative weighted mean AKSS function score was 79.5 in the second-generation PFA group and 86.4 in the TKA group. There was no significant difference in the mean AKSS knee or function scores between the second-generation PFA group and the TKA group. The postoperative weighted mean OKS score was 36.7 and the postoperative weighted mean WOMAC score was 24.4. The revision rate was higher in the second-generation PFA group (113 revisions [8.4%]) than in the TKA group (3 revisions [1.3%]). Progression of OA was most commonly noted as the reason for revision of PFA, and it was noted in 60 cases [53.1%]; this was followed by pain in 33 cases [29.2%]. CONCLUSION: Excellent postoperative weighted mean AKSS knee scores were found in both the second-generation PFA group and in the TKA group, suggesting that both surgical options can result in a satisfying patient-reported outcome. Higher revision rates in the second-generation PFA studies may in part be due to challenges related to patient selection. Based on evaluation of PROMs, the use of second-generation PFA seems to be an equal option to TKA for treatment of isolated PFOA in appropriately selected patients. Hopefully, this can be considered by physicians in their daily clinical work. LEVEL OF EVIDENCE: IV.

Musculoskeletal models generally solve the muscular redundancy by numerical optimisation. They have been extensively validated using instrumented implants. Conversely, a reduction approach considers only one flexor or extensor muscle group at the time to equilibrate the inter-segmental joint moment. It is not clear if such models can still predict reliable joint contact and musculo-tendon forces during gait. Tibiofemoral contact force and gastrocnemii, quadriceps, and hamstrings musculo-tendon forces were estimated using a reduction approach for five subjects walking with an instrumented prosthesis. The errors in the proximal-distal tibiofemoral contact force fell in the range (0.3-0.9 body weight) reported in the literature for musculoskeletal models using numerical optimisation. The musculo-tendon forces were in agreement with the EMG envelops and appeared comparable to the ones reported in the literature with generic musculoskeletal models. Although evident simplifications and limitations, it seems that the reduction approach can provided quite reliable results. It can be a useful pedagogical tool in biomechanics, e.g. to illustrate the theoretical differences between inter-segmental and contact forces, and can provide a first estimate of the joint loadings in subjects with limited musculoskeletal deformities and neurological disorders.

Though neurally adjusted ventilatory assist (NAVA) is known to improve patient-ventilator interactions in infants with bronchiolitis [1, 2], its impact on respiratory muscles unloading has not previously been studied.

International audience; Objective - To examine the association between occupational exposure to petroleum-based and oxygenated solvents and the risk of oral and oropharyngeal cancer.Methods - The ICARE study is a large population-based case-control study conducted in France between 2001 and 2007. This present analysis was restricted to men and included 350 and 543 cases of squamous cell-carcinoma of the oral cavity and oropharynx, respectively, and 2780 controls. Lifetime tobacco, alcohol consumption and complete occupational history were assessed through detailed questionnaires. Job-exposure matrices allowed us to assess occupational exposure to five petroleum-based solvents (white spirits; diesel/fuel oils/kerosene; gasoline; benzene; special petroleum products) and five oxygenated solvents (diethyl ether; tetrahydrofuran; ketones and esters; alcohols; ethylene glycol). Odds-ratios (ORs), adjusted for age, smoking, alcohol consumption and socioeconomic status, and 95% confidence intervals (CI) were estimated using unconditional logistic models.Results - Associations between oral cancer risk and exposure to white spirits and diesel/fuel oils/kerosene were suggested, but there was no exposure-response trend. Concerning exposure to oxygenated solvents, participants with the highest levels of cumulative exposure to diethyl ether had a significant excess risk of oropharyngeal cancer (OR = 7.78, 95%CI 1.42 to 42.59; p for trend = 0.04). Ever exposure to tetrahydrofuran was associated with a borderline significant increased risk of oral cancer (OR = 1.87, 95%CI 0.97 to 3.61), but no exposure-response trend was observed. Additional adjustments for exposure to other solvents did not substantially change the results.Conclusion - Our results do not provide evidence for a major role of petroleum-based and oxygenated solvents in the occurrence of oral and oropharyngeal cancers in men.

Objective: This study assesses the effectiveness of protective clothing (motorcycle jacket, trousers, gloves, knee-high or ankle boots, back protection) for motorized 2-wheeler (MTW) riders. Methods: This retrospective observational study used injury data from the Rhône Registry of Road Accident Victims, plus a postal survey conducted in 2016. Seven thousand one hundred forty-eight MTW riders involved in accidents between 2010 and 2014 were identified from the Registry and were invited to complete a questionnaire. Nine hundred seventy-nine individuals returned the questionnaire with relevant information; 951 with complete injury descriptions and clothing information were included in the study. The impact of protective clothing on injury risk was estimated using Poisson regression, with weighting for nonrespondents. Results: Sixty-seven percent of MTW riders sustained upper limb injuries and 47% sustained lower limb injuries. Gloves were the most frequent gear worn (76%), followed by jackets (59%) and knee-high or ankle boots (37%). Only 23% had back protection and 0.3% had an airbag. Wearing protective clothing was associated with a lower risk of soft tissue injury to upper and lower limbs: For upper limbs, the risk was lower when one of 2 items (a motorcycle jacket or gloves) was worn (relative risk [RR]=0.36; 95% confidence interval [CI], 0.18-0.75) and was lowest when both were worn (RR = 0.28; 95% CI, 0.12-0.69); for lower limbs, risk was reduced by wearing both motorcycle trousers and boots (RR = 0.60; 95% CI, 0.40-0.91) but was not significantly reduced when only one of these items was worn (RR = 0.90; 95% CI, 0.67-1.21). This protective effect was mainly due to a reduction in abrasions/lacerations rather than contusions. However, protective clothing did not reduce the risk of fracture, dislocation, or sprain, except for knee-high or ankle boots, which were associated with lower risk of ankle or foot fracture (RR = 0.43; 95% CI, 0.24-0.75). No effect of back protectors was shown. Conclusions: This study confirms the potential for motorcycle clothing to protect users from injury, in particular abrasions and lacerations. However, it did not show any significant protective effect against more serious injuries, such as fracture, dislocation, or sprain, except for knee-high or ankle boots, which reduced foot and ankle fracture risk. Our results argue for more widespread use of protective clothing by MTW users.

ObjectivesIn a previous analysis of data from a French population-based case–control study (the Investigation of occupational and environmental CAuses of REspiratory cancers (ICARE) study), ‘having ever worked’ in wood-related occupations was associated with excess lung cancer risk after adjusting for smoking but not for occupational factors. The present study aimed to investigate the relationship between lung cancer risk and wood dust exposure after adjusting for occupational exposures.MethodsData were obtained from 2276 cases and 2780 controls on smoking habits and lifelong occupational history, using a standardised questionnaire with a job-specific questionnaire for wood dust exposure. Logistic regression models were used to calculate ORs and 95% CIs adjusted for age, area of residence, tobacco smoking, the number of job periods and exposure to silica, asbestos and diesel motor exhaust (DME).ResultsNo significant association was found between lung cancer and wood dust exposure after adjustment for smoking, asbestos, silica and DME exposures. The risk of lung cancer was slightly increased among those who were exposed to wood dust more than 10 years, and had over 40 years since the first exposure.ConclusionOur findings do not provide a strong support to the hypothesis that wood dust exposure is a risk factor for lung cancer. This study showed the importance of taking into account smoking and occupational coexposures in studies on lung cancer and wood dust exposure. Further studies evaluating the level and frequency of exposure during various tasks in woodwork are needed.

The benefit of belatacept on antibody-mediated rejection (ABMR) incidence after kidney transplant with preformed donor-specific antibodies (DSAs) has never been assessed. Between 2014 and 2016, we conducted a multicenter prospective clinical trial with 49 patients to determine kidney allograft outcome in recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000) treated with belatacept (BELACOR trial). Immunosuppressive strategy included antithymocyte globulin, belatacept, mycophenolate mofetil, and steroids. An ancillary control group was designed retrospectively, including patients fulfilling the same inclusion criteria treated with calcineurin inhibitors. In BELACOR group, no patient exhibited acute ABMR, patient and allograft survival at 1 year was 100% and 95.4%, respectively, and the estimated glomerular filtration rate was 53.2 mL/min/1.73 m2 . However, the 12-month incidence of acute T cell-mediated rejection was 25.4% (14.5% to 42.4%). Comparison with the control group showed significantly higher T cell-mediated rejection incidence only in the BELACOR group (P = .003). Considering the DSAs, the outcome was similar in the 2 groups except a significantly higher number of patients displayed a complete disappearance of class II DSAs in the BELACOR group (P = .001). Belatacept was not associated with an acute ABMR increased risk and may be considered as immunosuppressive strategy in transplant recipients with preformed DSAs (maximal mean fluorescence intensity 500 to 3000). Prospective randomized trials are needed to confirm these results.

Objectives: Thirty percent of the general population are Staphylococcus aureus nasal carriers. It has been shown that this increases with repeated contact with patients, but it is not known whether all categories of healthcare workers are at equal risk of carriage. We aimed to explore S. aureus nasal carriage among healthcare professionals.Methods: Prospective study conducted in two French university hospitals in 2014 and 2016. Volunteers were screened for S. aureus nasal carriage. Profession and hygiene habits were collected. Based on the results of this initial study, a second study focused on semi-skilled workers and biomedical equipment technicians (BETs) only; participants were given education on the basic rules of hygiene, then re-screened three months later.Results: In the initial study, 38.8% of the 436 participants were detected as nasal carriers. There was a significant difference in nasal carriage according to professional category (p

The importance of occupational exposures in patients with head and neck squamous cell carcinomas (HNSCC) has received little attention. In a single-center study, we prospectively characterized occupational exposures in 154 HNSCC cancer patients in a systematic occupational consultation and examined the association between most frequent exposures, HNSCC stage and localization. Patients occupied a mean of 3.3 different positions during their working life. The prevalence of asbestos, the most frequent exposure (46 patients; 29.9%) was higher than in the French population > 50 years. Other frequent exposures were solvents (n = 26; 16.9%) and silica (n = 19; 12.3%). For 37 patients (24%) a possible link was identified between occupational exposures and HNSCC. Duration of asbestos exposure was significantly higher (p = 0.04) in patients with hypopharyngeal and laryngeal cancer compared to other localizations. Occupational exposures are frequent in patients with HNSCC and should receive increased attention by physicians.

Whole-body vibration (WBV) is a training method that exposes the entire body to mechanical oscillations while standing erect or seated on a vibrating platform. This method is nowadays commonly used by clinicians to improve specific motor outcomes in various sub-populations such as elderly and young healthy adults, either sedentary or well-trained. The present study investigated the effects of acute WBV application on the balance control mechanisms during gait initiation (GI) in young healthy adults and elderly. It was hypothesized that the balance control mechanisms at play during gait initiation may compensate each other in case one or several components are perturbed following acute WBV application, so that postural stability and/or motor performance can be maintained or even improved. It is further hypothesized that this capacity of adaptation is altered with aging. Main results showed that the effects of acute WBV application on the GI postural organization depended on the age of participants. Specifically, a positive effect was observed on dynamic stability in the young adults, while no effect was observed in the elderly. An increased stance leg stiffness was also observed in the young adults only. The positive effect of WBV on dynamic stability was ascribed to an increase in the mediolateral amplitude of “anticipatory postural adjustments” following WBV application, which did overcompensate the potentially destabilizing effect of the increased stance leg stiffness. In elderly, no such anticipatory (nor corrective) postural adaptation was required since acute WBV application did not elicit any change in the stance leg stiffness. These results suggest that WBV application may be effective in improving dynamic stability but at the condition that participants are able to develop adaptive changes in balance control mechanisms, as did the young adults. Globally, these findings are thus in agreement with the hypothesis that balance control mechanisms are interdependent within the postural system, i.e., they may compensate each other in case one component (here the leg stiffness) is perturbed.

A 28-year-old man with history of hypertension sustained trauma in 2017, with closed right proximal tibial fracture. Internal fixation achieved consolidation, but was associated with varus malpositioning of the medial tibial plateau and iterative patellar luxation ([figure 1A][1]). The patient

Purposes Intervention mapping (IM) is a protocol for developing effective behavior change interventions. It has been used for 10 years to develop work disability prevention (WDP) interventions, but it is not known to what extent and with what success. The main objective of this study was to review the effectiveness of these interventions. Secondary objectives were to review their fidelity to the IM protocol, their theoretical frameworks and their content. Methods A search strategy was conducted in MEDLINE, Web of Science, PsycINFO, Pascal, Francis, and BDSP. All titles and abstracts were reviewed. A standardized extraction form was developed. All included studies were reviewed by two reviewers blinded to each other. Results Eight WDP interventions were identified aimed at return to work (RTW; n = 6) and self-management at work (n = 2). RTW interventions targeted workers with stress-related mental disorders (n = 1), low back pain (n = 1), musculoskeletal disorders (n = 1), cancer (n = 2) and gynecological surgery (n = 1). The fidelity to the IM protocol was weaker for the participatory planning group. Matrices of change, change methods, and applications were systematically reported. The main theoretical frameworks used were the attitude-social influence-self efficacy model (n = 4) and the theory of planned behavior (n = 2). Half of the interventions included a workplace component (n = 4). Two interventions were reported as effective, and one partially effective. Conclusion The IM protocol is used in WDP since 2007. The participative dimension appears underused. Few theoretical frameworks were used. Implications are to better consider the stakeholders involvement, and mobilize theoretical frameworks with greater attempts to intervene on the work environment.

PURPOSE: Psychosocial consequences of road accidents are a major clinical problem that incurs significant social, occupational, and economic costs. The purpose of our study was to assess medical and socio-occupational factors of psychological distress in the severely injured 5 years after a road accident. METHODS: A total of 691 of the 1168 subjects enrolled in a prospective cohort of road accident casualties (ESPARR cohort) responded to both standardized follow-up questionnaires at 1 and 5 years, assessing socio-occupational characteristics, physical and psychological sequelae, pain and perceived quality of life. RESULTS: One quarter of participants exhibited psychological distress 5 years after the road accident; most of whom are women, with low educational level,and suffering from spinal lesions. After adjusting for several factors, psychological distress at 5 years was predicted by female gender and low educational level, and by several other factors observed 1 year after the road accident: poor self-reported quality of life, attention deficit and symptoms of anxiety. CONCLUSIONS: Early-stage improvement in the screening and care of mental disorders in road accident casualties should help to reduce long-term psychological distress. Language: en

Purpose:The aim of the current study was to determine whether the anaerobic performance assessed by a modified Wingate test could account for the 1,500-m rowing ergometer performance in young competitive rowers.Methods:Fourteen national-level adolescent rowers performed on a rowing ergometer i) a 30-s allout exercise (i.e., modified Wingate test) and ii) a 1,500-m all-out exercise (i.e., rowing performance). For each of these two exercises, the mean power output was considered as the main performance criterion (PWIN and P1500, respectively).Results:PWIN was correlated to P1500 (r2 = .83, p < .0001, β = 100%). Furthermore, the estimated total muscle mass was correlated to PWIN and P1500 (r2 = .72 and r2 = .83, p < .0001, β = 100%, respectively). The allometric scaling also indicated that total muscle mass accounts 62% for the relationship between PWIN and P1500.Conclusion:Our results highlight the importance of considering the contribution of total muscle mass and anaerobic energy pathways to 1,500-m rowing performance in competitive adolescent rowers. Therefore, the modified Wingate test could be used by rowing coaches to potentially identify talented young rowers.

Introduction The best fixation method for an anterior cruciate ligament (ACL) graft is debated. The tibial fixation of tendon grafts is the principal weak point for mechanical and anatomical reasons. Preserving the tibial insertion for hamstring grafts during ACL reconstruction make provide a mechanical benefit. The aim of this study was to compare the strength at the tibial tunnel of a hamstring graft with intact tibial insertion without a screw, to that of a graft with intact tibial insertion and screw fixation, and to that of a free graft with screw fixation. We hypothesized that preserving the graft's tibial insertion increases the maximum resistance of the tibial fixation relative to a free graft. Materials and methods Five pairs of knees (10 specimens) from frozen human donors were used. The tendons of the semitendinosus and gracilis were prepared as a four-strand graft while preserving their tibial insertion. The graft was passed through the tibial tunnel using standard instrumentation and the usual landmarks. Three conditions were tested: group 1 – graft with intact tibial insertion without interference screw; group 2 – graft with intact tibial insertion and interference screw; group 3 – knees from group 1 in which the tendons were detached (free graft) after the first test and fixed with an interference screw in the tibial tunnel. The screw diameter was chosen based on the graft diameter. The specimens were tested in traction using a materials testing system (Instron® 8500 PLUS) in the axis of the tunnel. The main outcome measure was the maximum load at failure (N). The secondary outcome measure was the stiffness. The groups were compared using the Friedman test and the Nemenyi post-hoc test with a 5% threshold. Results The load at failure was 33% higher in group 1 than group 3 (89.2 N vs. 67.2 N, p > 0.05). The load at failure of group 2 was 25% higher than group 1 (111.2 N vs. 89.2 N, p > 0.05) and 65% higher than group 3 (111.2 N vs. 67.2 N p = 0.005). There were no differences in stiffness between groups 1 and 2 (p = 1). Discussion Our hypothesis was confirmed–preserving the tibial insertion of hamstring tendons intended for ACL reconstruction increases the maximum load to failure at the tibial tunnel. Under these experimental conditions it seems that adding a screw increases the pullout strength of the graft by +25% in absolute terms; however this difference was not statistically significant. Level of evidence III, controlled laboratory study.

Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. LEVEL OF EVIDENCE: V.

Background: Whole-body vibration is commonly used in physical medicine and neuro-rehabilitation as a clinical prevention and rehabilitation tool. The goal of this systematic review is to assess the long-term effects of whole-body vibration training on gait in different populations of patients. Methods: We conducted a literature search in PubMed, Science Direct, Springer, Sage and in study references for articles published prior to 7 December 2018. We used the keywords “vibration,” “gait” and “walk” in combination with their Medical Subject Headings (MeSH) terms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used. Only randomized controlled trials (RCT) published in English peer-reviewed journals were included. All patient categories were selected. The duration of Whole-Body Vibration (WBV) training had to be at least 4 weeks. The outcomes accepted could be clinical or biomechanical analysis. The selection procedure was conducted by two rehabilitation experts and disagreements were resolved by a third expert. Descriptive data regarding subjects, interventions, types of vibration, training parameters and main results on gait variables were collected and summarized in a descriptive table. The quality of selected studies was assessed using the PEDro scale. Statistical analysis was conducted to evaluate intergroup differences and changes after the WBV intervention compared to the pre-intervention status. The level of evidence was determined based on the results of meta-analysis (effect size), statistical heterogeneity (I2) and methodological quality (PEDro scale). Results: A total of 859 studies were initially identified through databases with 46 articles meeting all of the inclusion criteria and thus selected for qualitative assessment. Twenty-five studies were included in meta-analysis for quantitative synthesis. In elderly subjects, small but significant improvements in the TUG test (SMD = −0.18; 95% CI: −0.32, −0.04) and the 10MWT (SMD = −0.28; 95% CI: −0.56, −0.01) were found in the WBV groups with a strong level of evidence (I2 = 7%, p = 0.38 and I2 = 22%, p = 0.28, respectively; PEDro scores ≥5/10). However, WBV failed to improve the 6MWT (SMD = 0.37; 95% CI: −0.03, 0.78) and the Tinetti gait scores (SMD = 0.04; 95% CI: −0.23, 0.31) in older adults. In stroke patients, significant improvement in the 6MWT (SMD = 0.33; 95% CI: 0.06, 0.59) was found after WBV interventions, with a strong level of evidence (I2 = 0%, p = 0.58; PEDro score ≥5/10). On the other hand, there was no significant change in the TUG test despite a tendency toward improvement (SMD = −0.29; 95% CI: −0.60, 0.01). Results were inconsistent in COPD patients (I2 = 66%, p = 0.03), leading to a conflicting level of evidence despite a significant improvement with a large effect size (SMD = 0.92; 95% CI: 0.32, 1.51) after WBV treatment. Similarly, the heterogeneous results in the TUG test (I2 = 97%, p < 0.00001) in patients with knee osteoarthrosis make it impossible to draw a conclusion. Still, adding WBV treatment was effective in significantly improving the 6 MWT (SMD = 1.28; 95% CI: 0.57, 1.99), with a strong level of evidence (I2 = 64%, p = 0.06; PEDro score ≥5/10). As in stroke, WBV failed to improve the results of the TUG test in multiple sclerosis patients (SMD = −0.11; 95% CI: −0.64, 0.43). Other outcomes presented moderate or even limited levels of evidence due to the lack of data in some studies or because only one RCT was identified in the review. Conclusions: WBV training can be effective for improving balance and gait speed in the elderly. The intervention is also effective in improving walking performance following stroke and in patients with knee osteoarthrosis. However, no effect was found on gait quality in the elderly or on balance in stroke and multiple sclerosis patients. The results are too heterogenous in COPD to conclude on the effect of the treatment. The results must be taken with caution due to the lack of data in some studies and the methodological heterogeneity in the interventions. Further research is needed to explore the possibility of establishing a standardized protocol targeting gait ability in a wide range of populations.

Purpose: Soft tissue balancing is of central importance to outcome following total knee arthroplasty (TKA). However, there are lack of data analysing the effect of tibial bone cut thickness on valgus laxity. A cadaveric study was undertaken to assess the biomechanical consequences of tibial resection depth on through range knee joint valgus stability. We aimed to establish a maximum tibial resection depth, beyond which medial collateral ligament balancing becomes challenging, and a constrained implant should be considered.Methods: Eleven cadaveric specimens were included for analysis. The biomechanical effects of increasing tibial resection were studied, with bone cuts made at 6, 10, 14, 18 and 24 mm from the lateral tibial articular surface. A computer navigation system was used to perform the tibial resection and to measure the valgus laxity resulting from a torque of 10 Nm. Measurements were taken in four knee positions: 0° or extension, 30°, 60° and 90° of flexion. Intra-observer reliability was assessed. A minimum sample size of eight cadavers was necessary. Statistical analysis was performed using a nonparametric Spearman's ranking correlation matrix at the different stages: in extension, at 30°, 60° and 90° of knee flexion. Significance was set at p?Results: There was no macroscopic injury to the dMCL or sMCL in any of the specimens during tibial resection. There was no significant correlation found between the degree of valgus laxity and the thickness of the tibial cut with the knee in extension. There was a statistically significant correlation between valgus laxity and the thickness of the tibial cut in all other knee flexion positions: 30° (p

Le maintien en emploi (MEE) est une priorité de santé publique qui a conduit à demander à la Haute Autorité de Santé d'élaborer des recommandations de bonne pratique «Santé et maintien en emploi: prévention de la désinsertion professionnelle des travailleurs». L'objectif de cet article est de présenter la revue de la littérature concernant le MEE des patients atteints de cancer. Les études sur les effets à moyen et long terme du cancer chez les survivants sont relativement peu nombreuses mais suggèrent des effets durables sur le MEE. Les facteurs favorisant le MEE sont liés à la personne, à la maladie et ses traitements, au poste de travail mais également à l'accompagnement mis en oeuvre pour favoriser ce maintien en emploi. Un plan spécifique de MEE comprenant 3phases (compréhension de la situation, identification des freins et leviers au MEE, mise en oeuvre de mesures ciblant l'individu, le milieu de travail et la coordination des intervenants) devrait être établi en concertation avec le travailleur, le médecin du travail, l'employeur, le médecin traitant et les médecins du parcours de soins. Summary Return to work is a public health priority which led the French Health Authority to publish recommendations about ?return to work and health: prevention of exclusion from work?. The aim of this article is to present a literature review of return to work after cancer. Studies about medium-term and long-term effects of cancer are sparse. They suggest worker durable effects. Factors associated with return to work are linked to the patient characteristics, to characteristics of the illness and the treatment, to the workplace and to the help provided to the patient during the return to work process. A specific plan for returning to work in 3 phases (situation comprehension, identification of negative and positive factors for returning to work, implementation of measures concerning the patient, the workplace and the coordination between return to work actors) should be built for each patient, involving the worker, the occupational practitioner, the general and specialist practitioners.

Objective Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject. Design A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Societe Francaise d’Anesthesie et de Reanimation; SFAR) and the French Society of Emergency Medicine (Societe Francaise de Medecine d’Urgence; SFMU) in collaboration with the French Society of Radiology (Societe Francaise de Radiologie; SFR), French Defence Health Service (Service de Sante des Armees; SSA), French Society of Urology (Association Francaise d’Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Societe Francaise de Chirurgie Orthopedique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Societe Francaise de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. Results The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ). Conclusions Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.