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Background: Evidence-based clinical practice guidelines define initial management of acute pulmonary embolism (PE) according to risk stratification for early death., Aims: The aims of the present study were to investigate patterns of non-compliance with guidelines for the acute PE treatment, and the associated risk of adverse events., Methods: We performed an observational, multicentre, cohort study of acute PE. Inclusion criteria were all patients with pulmonary embolism admitted to the participating centres between January 2011 and April 2017. The measure of 100% compliance was used to allocate patients in the compliant or non-compliant groups. The primary outcome was all-cause death at 6 months. Secondary outcomes included recurrent venous thromboembolism and major bleeding., Results: In total, 1285 patients were included. Treatment was not in compliance with the guidelines in 172 patients (13.4%). Four factors were identified to be related to non-compliance with the guidelines: shock or hypotension (relative risk [RR] 5.23, 95% confidence interval [CI] 2.64-10.30; P<0.001), renal insufficiency (RR 1.80, 95% CI 1.41-2.28; P<0.001), active cancer (RR 1.35, 95% CI 1.24-1.48; P<0.001) and right ventricular dysfunction at admission (RR 1.06, 95% CI 1.01-1.11; P=0.01). The primary endpoint of all-cause death at 6 months occurred in 62 of 172 patients (36.0%) in the non-compliant group and in 131 of 1113 patients (11.8%) in the compliant group (hazard ratio 2.02, 95% CI 1.45-2.81; P<0.001). The rates of recurrent venous thromboembolism (8.7% vs 1.1%; P<0.001) and major bleeding (13.4% vs 4.9%, P=0.04) from admission to 6-month follow-up were higher in the non-compliant group., Conclusion: Non-compliance with guidelines was independently associated with worse outcomes, including death, recurrent venous thromboembolism and bleeding., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Burnout is a pathology that can affect care-giving professionals. It associates emotional exhaustion (EE), depersonalization (DP) and impaired personal accomplishment (PA). Surgery entails great responsibility and frequently heavy workloads, incurring risk of burnout. Data, however, are not available for French orthopedic and trauma surgeons. We therefore conducted a prospective survey to 1) assess burnout prevalence in French orthopedic surgeons, and 2) investigate risk factors and protective factors., Hypothesis: Burnout prevalence is at least as high in French orthopedic surgeons as in other medical and surgical specialties., Materials and Methods: A nationwide survey was conducted in France between February and April 2017, using a digitized questionnaire sent out by e-mail. Burnout was assessed on the MBI (Maslach Burnout Inventory), and depressive symptoms on the GHQ-12 (General Health Questionnaire-12). Demographic and occupational data were also collected., Results: Out of 1,900 surgeons contacted, 441 (23%) responded. Mean age was 50.2±10.1 years; 413 (93.7%) were male. Sixty one (14%) reported elevated EE, 100 (23%) elevated DP, and 82 (19%) impaired AP. One hundred and seventy two (39%) showed burnout symptomatology (e.g., pathologic score on one MBI scale), while 47 (10%) had pathologic scores on 2 or 3 scales, indicating severe burnout. One hundred and ninety three (43%) would not advise their children to take up orthopedic surgery. Thirty eight (8%) expressed suicidal ideation. Statistical analysis identified public-sector practice (OR=4.6; 95% CI: 2.1-10.7; p=0.0002) and pathologic GHQ-12 score (OR=6.3; 95% CI: 2.2-17.8; p=0.0006) as risk factors for burnout. Outside activity (OR=0.39; 95% CI: 0.1-0.9; p=0.0406) and male gender (OR=0.2; 95% CI: 0.05-0.7; p=0.0160) emerged as protective factors., Discussion: Despite a response rate of only 23% (n=441/1,900), the present study sheds light on burnout rates in French orthopedic surgeons, with 39% burnout symptoms and 10% severe burnout. Burnout impacts personal and occupational life, with increased suicidal ideation and impaired quality of life. The present results confirm the importance of screening and treatment in care-providers., Type of Study: Level IV, prospective descriptive transverse study without control group., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Data regarding the use of direct oral anticoagulants (DOACs) for the treatment of acute pulmonary embolism (PE) are sparse. We conducted a prospective multicentre registry study to describe patterns of DOAC prescription for the treatment of acute PE, and the associated risk of 6-month adverse events in daily practice., Methods: We included all PE patients discharged since the availability of DOACs for the dedicated indication of acute PE treatment. Clinical data and 6-month outcomes, including death, recurrent venous thromboembolism (VTE), bleeding, and chronic thromboembolic pulmonary hypertension (CTEPH) were recorded prospectively. Temporal trends in DOAC prescription were tested., Results: Between 09/2012 and 04/2017, 1082 patients were included: 60.6% (n = 656) were treated with DOACs and 39.4% (n = 426) with another anticoagulant. The prescription rate of DOACs increased sharply just after their release on the market to reach a plateau over time, between 56% and 72% of the total prescription per year in PE patients (p for trend = 0.33). Active malignancy and renal function impairment were factors independently associated with non-prescription of DOACs. Overall, prescription of DOACs was appropriate in 95.3% of patients. The rate of use of non-recommended DOAC doses was 4.2% (n = 28). The rate of death, recurrent VTE, bleeding and CTEPH were 2.4%, 1.2%, 7.2%, and 1.9%, respectively in the DOAC group., Conclusion: The choice to prescribe DOACs or not is related to patient characteristics. The overall appropriateness of prescription is high, while the rate of adverse events observed in patients treated with DOAC is low in our registry., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Burnout syndrome is one of the manifestations of distress in healthcare workers and is characterised by emotional exhaustion (EE), depersonalisation (DP), and a sense of low personal accomplishment (PA). The surgical residency is a period of intense training that imposes major challenges on future surgeons, who may therefore be at high risk for burnout syndrome. Nevertheless, no data on burnout syndrome in orthopaedic and trauma surgery (OTS) residents in France is available. Therefore we performed a prospective survey to: (1) evaluate the prevalence of burnout syndrome among OTS residents in France, (2) and to look for factors associated with a higher or lower risk of burnout syndrome in the survey respondents., Hypothesis: Burnout syndrome is at least as prevalent among OTS residents in France as among residents in other medical and surgical specialities., Material and Methods: A nationwide prospective survey was conducted in France between February and April 2017 via a digital questionnaire sent by email. Burnout syndrome was evaluated using the Maslach Burnout Inventory (MBI) and symptoms of depression using the General Health Questionnaire (GHQ-12). Demographic data and information on relationships with partners and working modalities were collected., Results: Of 480 OTS residents, 107 (22%) completed the questionnaire. Mean age was 27 years and 65% (n=70) were male. High EE was reported by 26% (n=28), high DP by 63% (n=68), and low PA by 33% (n=36) of respondents. The scores on two or all three of the MBI sub-scales were abnormal, indicating severe burnout syndrome, in 40% (n=43) of respondents. The GHQ-12 scores indicated symptoms of depression in 40% (n=43) of respondents. Furthermore, 61% (n=66) of respondents stated that they would not recommend OTS or any other area of medicine to their children as a career and 10% (n=11) reported suicidal ideation during the past year. The statistical analysis identified three risk factors for burnout syndrome: medical errors (odds ratio [OR], 8.8; 95% confidence interval [95%CI], 1.7-58.7; p=0.0121), symptoms of depression (OR, 19.3; 95%CI, 2.9-196.0; p=0.0048), and living single (OR, 4.7; 95%CI, 1.4-18.9; p=0.0173)., Discussion: Despite the 22% response rate, this study provides useful information on the prevalence of burnout syndrome among OTS residents in France, with severe burnout in 40% and suicidal ideation in 10%. These prevalences may be overestimations, however, as residents who felt under stress may have been more likely to respond to the survey. In published studies, burnout syndrome was associated with higher risks of medical error and suicidal behaviour. These data emphasise the importance of detecting and managing burnout syndrome in healthcare staff., Level of Evidence Iv: Prospective descriptive cross-sectional survey with no control group., (Copyright © 2018. Published by Elsevier Masson SAS.)

Exposure to ionizing radiation in the operating room is governed by practical prevention and protection measures on the international, national and local levels. We evaluated the equivalent dose to the hand of an orthopedic surgeon over 13 months. An orthopedic surgeon wore a ring dosimeter on the ring finger of his right hand for all surgical procedures requiring intraoperative fluoroscopy between March 2014 and April 2015. Monthly doses were evaluated by the IRSN over the study period. The number and type of procedures were compiled as well as the type of fluoroscopy unit used. Four hundred procedures were performed during this period, including 182 with fluoroscopy. The equivalent cumulative dose at the hand was 4,75 mSv. No correlation was found with the type of procedure or type of fluoroscopy unit (conventional or mini C-arm). Equivalent doses were below the annual regulatory limit in France of 500 mSv. These results are consistent with those reported in the literature. However, recent studies have noted that both younger surgeons in training and more experienced surgeons must remember to use radiation protection measures., (Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.)