Moderators, Mediators, and Prognostic Indicators of Treatment With Hip Arthroscopy or Physical Therapy for Femoroacetabular Impingement Syndrome: Secondary Analyses From the Australian FASHIoN Trial.

BACKGROUND Although randomized controlled trials comparing hip arthroscopy with physical therapy for the treatment of femoroacetabular impingement (FAI) syndrome have emerged, no studies have investigated potential moderators or mediators of change in hip-related quality of life. PURPOSE To explore potential moderators, mediators, and prognostic indicators of the effect of hip arthroscopy and physical therapy on change in 33-item international Hip Outcome Tool (iHOT-33) score for FAI syndrome. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Overall, 99 participants were recruited from the clinics of orthopaedic surgeons and randomly allocated to treatment with hip arthroscopy or physical therapy. Change in iHOT-33 score from baseline to 12 months was the dependent outcome for analyses of moderators, mediators, and prognostic indicators. Variables investigated as potential moderators/prognostic indicators were demographic variables, symptom duration, alpha angle, lateral center-edge angle (LCEA), Hip Osteoarthritis MRI Scoring System (HOAMS) for selected magnetic resonance imaging (MRI) features, and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) score. Potential mediators investigated were change in chosen bony morphology measures, HOAMS, and dGEMRIC score from baseline to 12 months. For hip arthroscopy, intraoperative procedures performed (femoral ostectomy ± acetabular ostectomy ± labral repair ± ligamentum teres debridement) and quality of surgery graded by a blinded surgical review panel were investigated for potential association with iHOT-33 change. For physical therapy, fidelity to the physical therapy program was investigated for potential association with iHOT-33 change. RESULTS A total of 81 participants were included in the final moderator/prognostic indicator analysis and 85 participants in the final mediator analysis after exclusion of those with missing data. No significant moderators or mediators of change in iHOT-33 score from baseline to 12 months were identified. Patients with smaller baseline LCEA (β = -0.82; P = .034), access to private health care (β = 12.91; P = .013), and worse baseline iHOT-33 score (β = -0.48; P < .001) had greater iHOT-33 improvement from baseline to 12 months, irrespective of treatment allocation, and thus were prognostic indicators of treatment response. Unsatisfactory treatment fidelity was associated with worse treatment response (β = -24.27; P = .013) for physical therapy. The quality of surgery and procedures performed were not associated with iHOT-33 change for hip arthroscopy (P = .460-.665 and P = .096-.824, respectively). CONCLUSION No moderators or mediators of change in hip-related quality of life were identified for treatment of FAI syndrome with hip arthroscopy or physical therapy in these exploratory analyses. Patients who accessed the Australian private health care system, had smaller LCEAs, and had worse baseline iHOT-33 scores, experienced greater iHOT-33 improvement, irrespective of treatment allocation

Hyponatrémie en hospitalisation : facteurs favorisants, prise en charge et pronostic

Introduction : l’hyponatrémie est un trouble fréquent en hospitalisation relevant de prises en charge variées et souvent complexes. La survenue de ce trouble, souvent évitable, est associée à une surmortalité en hospitalisation. La prévention et la prise en charge rapide de toute hyponatrémie sont donc des éléments fondamentaux, qui nécessitent d’identifier les terrains et les situations à risque. Nous avons cherché dans notre travail à décrire, au sein des demandes d’avis spécialisés, les caractéristiques cliniques et biologiques, les différents facteurs favorisants, les prises en charge avant et après avis, ainsi que le pronostic global des patients présentant une hyponatrémie en hospitalisation. Matériels et méthodes : au sein du service de néphrologie du CHU de Marseille, nous avons recueilli toutes les demandes d’avis spécialisé concernant la prise en charge d’une hyponatrémie entre le 03 mai 2018 et le 03 juin 2020. Nous avons colligé de façon rétrospective les données relatives à chaque patient, aux différents temps de l’hospitalisation. Nous avons également recueilli les données de survie en hospitalisation et à long terme.Résultats : nous avons analysé 324 demandes d’avis initiales pour hyponatrémie. Il s’agissait d’une population aux nombreuses comorbidités, avec un index moyen de Charlson à 8. La mortalité en hospitalisation était de 17%, et de 50% durant le suivi global. 71,9% des patients présentaient cette hyponatrémie dès l’admission, et 53,7% conservaient ce trouble à la sortie ou au décès. 75,9% des patients présentaient au moins un facteur favorisant. Les patients décédés en fin de suivi présentaient une natrémie à l’admission significativement plus basse (128,6 mmol/L vs 130,5 mmol/L, p=0,04). De même, on retrouvait chez les patients décédés en fin de suivi plus d’hyponatrémie à l’admission (78,4% vs 65,4%, p=0,009), et plus d’hyponatrémie non corrigée (42,6% vs 29%, p = 0,01). Après analyse multivariée, l’absence de correction de l’hyponatrémie en hospitalisation était corrélée à un excès de mortalité globale (HR 1,819 [IC 95% 1,13-2,9], p=0,013).Conclusions : l’apparition d’une hyponatrémie en hospitalisation est associée à une forte mortalité. Elle survient chez une population polypathologique. La surmortalité propre à l’hyponatrémie peut être évitée par sa prévention et sa prise en charge rapide, à l’aide de mesures et d’outils adaptés

Trunk, pelvis and lower limb walking biomechanics are similarly altered in those with femoroacetabular impingement syndrome regardless of cam morphology size

Background: Studies of walking in those with femoroacetabular impingement syndrome have found altered pelvis and hip biomechanics. But a whole body, time-contiuous, assessment of biomechanical parameters has not been reported. Additionally, larger cam morphology has been associated with more pain, faster progression to end-stage osteoarthritis and increased cartilage damage but differences in walking biomechanics between large compared to small cam morphologies have not been assessed. Research question: Are trunk, pelvis and lower limb biomechanics different between healthy pain-free controls and individuals with FAI syndrome and are those biomechanics different between those with larger, compared to smaller, cam morphologies? Methods: Twenty four pain-free controls were compared against 41 participants with FAI syndrome who were stratified into two groups according to their maximum alpha angle. Participants underwent three-dimensional motion capture during walking. Trunk, pelvis, and lower limb biomechanics were compared between groups using statistical parametric mapping corrected for walking speed and pain. Results: Compared to pain-free controls, participants with FAI syndrome walked with more trunk anterior tilt (mean difference 7.6°, p < 0.001) as well as less pelvic rise (3°, p < 0.001), hip abduction (-4.6°, p < 0.05) and external rotation (-6.5°, p < 0.05). They also had lower hip flexion (-0.06Nm⋅kg, p < 0.05), abduction (-0.07Nm⋅kg, p < 0.05) and ankle plantarflexion moments (-0.19Nm⋅kg, p < 0.001). These biomechanical differences occurred throughout the gait cycle. There were no differences in walking biomechanics according to cam morphology size. Significance: Results do not support the hypothesis that larger cam morphology is associated with larger differences in walking biomechanics but did demonstrate general differences in trunk, pelvis and lower limb biomechanics between those with FAI sydrome and pain-free controls. Altered external biomechanics are likely the result of complex sensory-motor strategy resulting from pain inhibition or impingement avoidance. Future studies should examine internal loading in those with FAI sydnrome

Specificities of Meningitis and Meningo-Encephalitis After Kidney Transplantation: A French Retrospective Cohort Study

International audienceKidney transplant recipients develop atypical infections in their epidemiology, presentation and outcome. Among these, meningitis and meningoencephalitis require urgent and adapted anti-infectious therapy, but published data is scarce in KTRs. The aim of this study was to describe their epidemiology, presentation and outcome, in order to improve their diagnostic and management. We performed a retrospective, multicentric cohort study in 15 French hospitals that included all 199 cases of M/ME in KTRs between 2007 and 2018 (0.9 case per 1,000 KTRs annually). Epidemiology was different from that in the general population: 20% were due to Cryptococcus neoformans, 13.5% to varicella-zoster virus, 5.5% to Mycobacterium tuberculosis, and 4.5% to Enterobacteria (half of which producedextended spectrum beta-lactamases), and 5% were Post Transplant Lymphoproliferative Disorders. Microorganisms causingM/ME in the general population were infrequent (2%, forStreptococcus pneumoniae) or absent (Neisseria meningitidis). M/ME caused by Enterobacteria, Staphylococci or filamentous fungi were associated with high and early mortality (50%–70% at 1 year). Graft survival was not associated with the etiology of M/ME, nor was impacted by immunosuppression reduction. Based on these results, we suggest international studies to adapt guidelines in order to improve the diagnosis and theprobabilistic treatment of M/ME in SOTRs

Multi-centre randomised controlled trial comparing arthroscopic hip surgery to physiotherapist-led care for femoroacetabular impingement (FAI) syndrome on hip cartilage metabolism: the Australian FASHIoN trial

Background Arthroscopic surgery for femoroacetabular impingement syndrome (FAI) is known to lead to self-reported symptom improvement. In the context of surgical interventions with known contextual effects and no true sham comparator trials, it is important to ascertain outcomes that are less susceptible to placebo effects. The primary aim of this trial was to determine if study participants with FAI who have hip arthroscopy demonstrate greater improvements in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to participants who undergo physiotherapist-led management. Methods Multi-centre, pragmatic, two-arm superiority randomised controlled trial comparing physiotherapist-led management to hip arthroscopy for FAI. FAI participants were recruited from participating orthopaedic surgeons clinics, and randomly allocated to receive either physiotherapist-led conservative care or surgery. The surgical intervention was arthroscopic FAI surgery. The physiotherapist-led conservative management was an individualised physiotherapy program, named Personalised Hip Therapy (PHT). The primary outcome measure was change in dGEMRIC score between baseline and 12 months. Secondary outcomes included a range of patient-reported outcomes and structural measures relevant to FAI pathoanatomy and hip osteoarthritis development. Interventions were compared by intention-to-treat analysis. Results Ninety-nine participants were recruited, of mean age 33 years and 58% male. Primary outcome data were available for 53 participants (27 in surgical group, 26 in PHT). The adjusted group difference in change at 12 months in dGEMRIC was -59 ms (95%CI − 137.9 to - 19.6) (p = 0.14) favouring PHT. Hip-related quality of life (iHOT-33) showed improvements in both groups with the adjusted between-group difference at 12 months showing a statistically and clinically important improvement in arthroscopy of 14 units (95% CI 5.6 to 23.9) (p = 0.003). Conclusion The primary outcome of dGEMRIC showed no statistically significant difference between PHT and arthroscopic hip surgery at 12 months of follow-up. Patients treated with surgery reported greater benefits in symptoms at 12 months compared to PHT, but these benefits are not explained by better hip cartilage metabolism.Medicine, Faculty ofNon UBCOrthopaedic Surgery, Department ofReviewedFacultyResearche