Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty.

BACKGROUND: Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury. METHODS: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at one institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean BMI was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than one year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21). RESULTS: Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < 0.001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < 0.001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < 0.001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = 0.88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < 0.001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = 0.08). CONCLUSIONS: Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like non-arthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures.

Racial and Gender Differences in Medical Student Burnout: A 2021 National Survey.

OBJECTIVE: To measure racial and gender differences in medical student burnout and identify possible contributing factors. PATIENTS AND METHODS: Electronic surveys were distributed to medical students at 9 US medical schools from December 27, 2020, through January 17, 2021. Questions covered demographic characteristics, stressors contributing to burnout, and the 2-item Maslach Burnout Inventory. RESULTS: Of 5500 invited students, 1178 (21%) responded (mean age, 25.3 years; 61% identified as female). Fifty-seven percent of respondents identified as White, 26% as Asian, and 5% as Black. Overall, 75.6% of students met the criteria for burnout. Women reported more burnout (78% vs 72%; P=.049). There were no differences in burnout prevalence by race. Students commonly reported that lack of sleep (42%), decreased engagement in hobbies or self-care (41%), stress about grades (37%), feeling socially disconnected (36%), and lack of exercise (35%) contributed to burnout. Compared with students of other races, Black students reported that their feelings of burnout were affected significantly more by lack of sleep and poor diet, and Asian students more by stress about grades, residency, and publishing pressure (all P<.05). Female students were more affected than male students by stress about grades, poor diet, and feelings of social disconnectedness and inadequacy (all P<.05). CONCLUSION: Burnout (75.6%) was higher than historical norms, and female students reported higher burnout than male students. There was no difference in burnout prevalence by race. There were racial and gender differences in self-identified contributors of burnout. Additional research is needed to confirm whether stressors were contributors to or consequences of burnout, as well as how to address them.

Combatting Burnout by Maximizing Medical Student Participation in Exercise Events.

Physicians have a higher risk of burnout than many other professions, and burnout is associated with less altruistic professional values, worse patient-doctor relationships, and increased medical errors. Burnout begins in medical school, such that institutions should intervene early to facilitate increased engagement in forms of self-care, including but not limited to exercise. Exercise is negatively associated with burnout, but there is limited research on what motivates students to participate in exercise events and how events could be optimally designed to maximize attendance. Students from nine medical schools across the United States were invited to complete an online survey assessing the effectiveness of various factors at increasing participation in exercise events. Of 5500 invited students, 1182 (21%) responded. Mean age was 25 years, 61% were female, and 38% male. Fifty-seven percent identified as White, 26% Asian, and 5% Black. Students reported financial discounts (56%), having all logistics planned by event organizers (46%), and opportunities to find informal mentors (40%) as most likely to increase participation. To increase student participation in wellness events, institutions should prioritize available funding toward strategies that save students time and money while building community across levels of training and departments.

Medicine in Motion: Addressing Physician Burnout Through Fitness, Philanthropy, and Interdisciplinary Community Building.

Physician burnout is a public health crisis. Although recent studies underscore its prevalence, there are few rigorous studies examining its prevention, especially among medical students and residents. Prior interventions have centered on mindfulness techniques and flexible workload scheduling, yielding limited success. However, interventions that combine fitness with philanthropy and community building may be more effective. The purpose of this report is 2-fold: first, to provide a review of physician burnout and potential prevention mechanisms and, second, to present a case study of how Medicine in Motion (MiM) addresses these issues. MiM facilitates various athletic workouts, competitions, and other events for students and professionals in medicine, dentistry, nursing, and physical therapy to support wellness and charitable initiatives. This analysis identifies 4 barriers to physicians and those in the health care profession from participating in wellness activities: (1) insufficient awareness, (2) logistical challenges, (3) lack of purpose, and (4) absence of perceived support. To overcome these barriers, MiM provides a model toolkit for starting a grassroots movement against physician burnout that other health care institutions may emulate. Institutions should provide financial support for these wellness programs. Future research is needed to evaluate these combined exercise, philanthropic, and community building efforts.

Obesity, preoperative weight loss, and telemedicine before total joint arthroplasty: a review.

The preoperative period prior to elective total joint arthroplasty (TJA) is a critical time for lifestyle interventions since a scheduled surgery may help motivate patients to lose weight. Weight loss may reduce complications associated with obesity following TJA and enable patients with severe obesity (body mass index [BMI] > 40 kg/m2) to become eligible for TJA, as many institutions use a 40 kg/m2 cut-off for offering surgery. A comprehensive review was conducted to (1) provide background on complications associated with obesity following TJA, (2) synthesize prior research on the success rate of patients losing weight after being denied TJA for severe obesity, (3) discuss bariatric surgery before TJA, and (4) propose mobile health telemedicine weight loss interventions as potential weight loss methods for patients preoperatively. It is well established that obesity increases complications associated with TJA. In total knee arthroplasty (TKA), obesity increases operative time, length of stay, and hospitalization costs as well as the risk of deep infection, revision, and component malpositioning. Obesity may have an even larger impact on complications associated with total hip arthroplasty (THA), including wound complications and deep infection. Obesity also increases the risk of hip dislocation, aseptic loosening, and venous thromboembolism after THA. Synthesis of the only two studies (n = 417), to our knowledge, that followed patients denied TJA for severe obesity demonstrated that only 7% successfully reduced their BMI below 40 kg/m2 via lifestyle modifications and ultimately underwent TJA. Unfortunately, bariatric surgery may only increase certain post-TKA complications including death, pneumonia, and implant failure, and there is limited research on preoperative weight loss via lifestyle modification. A review of short-term mobile health weight loss interventions that combined personalized counseling with self-monitoring via a smartphone app found about 5 kg of weight loss over 3-6 months. Patients with severe obesity have more weight to lose and may have additional motivation to do so before TJA, so weight loss results may differ by patient population. Research is needed to determine whether preoperative mobile health interventions can help patients become eligible for TJA and produce clinically significant weight loss sufficient to improve postoperative outcomes.

Preoperative Nonsurgical Weight Loss Interventions Before Total Hip and Knee Arthroplasty: A Systematic Review.

BACKGROUND: An upcoming total joint arthroplasty (TJA) may motivate patients with severe obesity (body mass index [BMI] > 40 kg/m2) to lose weight. Weight loss can optimize outcomes following TJA, and many surgeons use a 40 kg/m2 cut-off for undergoing TJA to reduce the risk of complications. However, few patients who are denied TJA for severe obesity successfully lose weight. This is the first systematic review of nonsurgical weight loss interventions before TJA. METHODS: Five electronic databases were searched for articles on January 11, 2021. Studies that utilized preoperative nonsurgical weight loss interventions for patients with obesity (BMI ≥ 30 kg/m2) scheduled for or awaiting TJA of the hip or knee were included. Two reviewers independently screened articles, assessed methodological quality, and extracted data. RESULTS: We retrieved 1943 unique records, of which 7 met inclusion criteria including 2 randomized clinical trials and 5 single-arm case series. Overall, weight loss ranged from 5.0 to 32.5 kg. Four interventions reduced BMI by 3 kg/m2 at 3-5 months, while 1 reduced BMI by 12.7 kg/m2. Other weight outcomes and those related to pain, function, complications, and adverse events were inconsistently reported. CONCLUSION: Although larger trials are needed, particularly randomized controlled trials that measure preoperative weight loss in a control group, nutritional status, and postoperative complications, the available evidence indicates that short-term, nonsurgical, preoperative weight loss interventions before TJA produce both statistically significant weight loss and reduced BMI before surgery. It remains unknown if the amount of weight loss from these interventions is clinically significant and sufficient to improve outcomes after TJA.

Weight loss before total joint arthroplasty using a remote dietitian and mobile app: study protocol for a multicenter randomized, controlled trial.

BACKGROUND: The months prior to elective surgery may present an opportunity for patients to initiate behavior changes that will simultaneously ready them for surgery and improve their overall health status. An upcoming elective total joint arthroplasty (TJA) may serve as motivation for patients with severe obesity (body mass index [BMI]> 40 kg/m2) to lose weight, as it may optimize clinical outcomes following TJA and help them become eligible for TJA since some surgeons use a BMI of 40 kg/m2 as a cut-off for offering surgery in an effort to optimize outcomes. METHODS: The purpose of this multicenter randomized, controlled trial is to assess the feasibility and efficacy of a 12-week remote dietitian (RD) supervised dietary and physical activity weight loss intervention and mobile app for 60 patients with severe obesity prior to undergoing TJA. Intervention participants will receive access to a smartphone app and connect with an RD who will contact these participants weekly or bi-weekly via video calls for up to nine video calls. Together, participants and RDs will set goals for lifestyle modifications, and RDs will check on progress towards achieving these goals using in-app tools such as food logs and text messages between video calls. All patients will be encouraged to lose at least 20 pounds with a goal BMI < 40 kg/m2 after 12 weeks. Individuals randomized to the control group will receive clinical standard of care, such as nutritionist and/or physical therapy referrals. Outcome and demographic data will be collected from blood serology, chart review, mobile app user data, pre- and postintervention surveys, and phone interviews. The primary outcome measure will be weight change from baseline. Secondary outcome measures will include percentage of patients eligible to undergo TJA, number of sessions completed with dietitians, self-reported global health status (PROMIS Global Health scale), self-reported joint-specific pain and function (Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS)), and serologies such as hemoglobin A1c, total lymphocyte count, albumin, and transferrin. Qualitative responses transcribed from phone interviews about the intervention will also be analyzed. DISCUSSION: This will be the first study to assess pre-operative weight loss in patients with severe obesity anticipating orthopaedic surgery using an RD and mobile app intervention aimed at helping patients become eligible for TJA. TRIAL REGISTRATION: Registered on 1 April 2020 at Clincialtrials.gov. Trial number is NCT04330391 .

BWHealthy Weight Pilot Study: A randomized controlled trial to improve weight-loss maintenance using deposit contracts in the workplace.

OBJECTIVE: Deposit contracts, where participants "bet" on achieving a goal and get their money back only if successful, have been shown to be effective for short-term weight-loss. This pilot study examined their effect on weight-loss maintenance. METHODS: From 2016 to 2018, we conducted a pilot, 50-week randomized controlled trial among 42 hospital employees (19 intervention and 23 control), in Boston, Massachusetts, who lost ≥10 lb (4.5 kg) in the two years prior to enrollment. Participants were recruited primarily in-person. Both control and intervention participants were asked to attend a weigh in weekly and received weekly email communication. Intervention participants also entered into a deposit contract to maintain baseline weight within ≤2 lb (0.9 kg). We examined weight change from baseline to 50 weeks (primary outcome) and maintenance of baseline weight at 50 weeks (secondary outcome; binary - yes v. no). Participants completed baseline and follow-up surveys and received incentives for completion. RESULTS: At baseline, mean (SD) weight was 83.2 (15.5 kg) among intervention and 80.7 (14.5 kg) among control participants. After 50 weeks, intervention participants had slightly less but non-significant weight gain (adjusted ß -1.12 kg; 95% CI -5.28, 3.05) than control participants; 73.7% of intervention v. 39.1% of control participants met their weight-loss maintenance goal by study end (adjusted OR 4.78; 95% CI 1.01, 22.71). CONCLUSIONS: A deposit contract was not associated with differences in weight but led to more participants meeting their weight-loss maintenance goals; a deposit contract for weight-loss maintenance should be tested in a full-scale intervention. Most intervention participants viewed the deposit contract as acceptable.

Unintended consequences in traffic-light food labeling: A call for mixed methods in public health research.

Nudge theory describes how indirect suggestions and positive reinforcement can influence decision-making. We used nudge theory to implement a traffic-light labeling and choice architecture (modifying product placement) intervention at Harvard University cafeterias, but found no significant change in sales. Survey and focus group data showed that some students thought the labeling may exacerbate eating disorders, however, there is extremely limited research on potential negative consequences of labeling. One way to describe these findings is through 20th century philosopher Michel Foucault's concept of biopower. Biopower manipulates cultural norms and nudges individuals to engage in self-surveillance and self-discipline, de facto subjugating themselves to certain ways of being. Biopower may lead to the creation of an in-group and an out-group based on who can adopt the new behaviors, such as healthy eating. Those in the out-group may face additional unintended consequences, highlighting the need for mixed-methods research to better evaluate public health interventions.

Showers, Culture, and Conflict Resolution: A Qualitative Study of Employees' Perceptions of Workplace Wellness Opportunities.

OBJECTIVE: Research on employee opinions of workplace wellness programs is limited. METHODS: At a large academic medical center in Boston, we conducted 12 focus groups on employee perceptions of wellness programs. We analyzed data using the immersion-crystallization approach. Participant mean age (N = 109) was 41 years; 89% were female; 54% were white. RESULTS: Employees cited prominent barriers to program participation: limited availability; time and marketing; disparities in access; and workplace culture. Encouraging supportive, interpersonal relationships among employees and perceived institutional support for wellness may improve workplace culture and improve participation. Employees suggested changes to physical space, including onsite showers and recommended that a centralized wellness program could create and market initiatives such as competitions and incentives. CONCLUSION: Employees sought measures to address serious constraints on time and space, sometimes toxic interpersonal relationships, and poor communication, aspects of workplaces not typically addressed by wellness efforts.

Supporting healthful lifestyles during pregnancy: a health coach intervention pilot study.

BACKGROUND: Excessive gestational weight gain (GWG) is associated with adverse health outcomes in both the mother and child. Many previous lifestyle interventions in women with excess weight during pregnancy encouraging appropriate GWG have been unsuccessful, and there remains no consensus about the content, format, or theoretical framework of GWG interventions. We assessed the feasibility and acceptability of a remote health coach intervention to promote healthful lifestyle behaviors and appropriate GWG among overweight pregnant women. METHODS: At one northeastern US clinic, we enrolled 30 overweight (pre-pregnancy BMI ≥ 25 kg/m2) pregnant women at a median gestation of 12.5 weeks (IQR: 11-15) into a one-arm trial. We connected participants with a health coach to provide behavioral support to help participants adopt healthful lifestyles during pregnancy. Health coaches contacted participants by phone every 2-3 weeks to monitor goals, and sent emails and text messages between calls. Participants completed baseline (N = 30) and follow-up (N = 26) surveys at the end of the intervention (36 weeks gestation), as well as follow-up phone interviews (N = 18). RESULTS: Among 30 participants, median age was 32 years (IQR: 28-33), median self-reported pre-pregnancy BMI was 27.3 kg/m2 (IQR: 25.7-31.1), and 17/30 were white, 9/30 African-American, and 3/30 Asian. Three-quarters (22/29) of participants completed at least a college degree. Although 25/30 participants reported in baseline surveys that they worried about being able to lose the weight postpartum that they expected to gain during pregnancy, just 12/26 participants reported the same at follow-up (P < 0.001). In follow-up surveys, 21/26 participants reported that health coaches were helpful in keeping them motivated, and 22/26 thought the phone conversations helped them face problems and find solutions. Based on qualitative assessment, several themes emerged in follow-up interviews about the quality of the intervention including accountability and support from health coaches. Participants also expressed desire for more visual resources and integration with standard clinical care to improve the intervention. CONCLUSIONS: We demonstrated feasibility and high participant satisfaction with our remote health coach intervention during pregnancy. We identified areas in which we could refine the intervention for inclusion in a full-scale RCT, such as integration with clinical care and additional visual resources. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov ( NCT03080064 , 3/14/2017).

Changes in the food environment over time: examining 40 years of data in the Framingham Heart Study.

BACKGROUND: Research has explored associations between diet, body weight, and the food environment; however, few studies have examined historical trends in food environments. METHODS: In the Framingham Heart Study Offspring (N = 3321) and Omni (N = 447) cohorts, we created food environment metrics in four Massachusetts towns utilizing geocoded residential, workplace, and food establishment addresses from 1971 to 2008. We created multilevel models adjusted for age, sex, education, and census tract poverty to examine trends in home, workplace, and commuting food environments. RESULTS: Proximity to and density of supermarkets, fast-food, full service restaurants, convenience stores, and bakeries increased over time for residential, workplace, and commuting environments; exposure to grocery stores decreased. The greatest increase in access was for supermarkets, with residential distance to the closest supermarket 1406 m closer (95% CI 1303 m, 1508 m) by 2005-2008 than in 1971-1975. Although poorer census tracts had higher access to fast-food restaurants consistently across follow-up, this disparity dissipated over time, due to larger increases in proximity to fast-food in wealthier neighborhoods. CONCLUSIONS: Access to most food establishment types increased over time, with similar trends across home, workplace, and commuter environments.

A Traffic-Light Label Intervention and Dietary Choices in College Cafeterias.

OBJECTIVES: To examine whether traffic-light labeling and choice architecture interventions improved dietary choices among students at a northeastern US university. METHODS: In 6 cafeterias at Harvard University, in Cambridge, Massachusetts, we implemented a 7-week intervention including traffic-light labeling (red: least nutrient rich; yellow: nutrient neutral; green: most nutrient rich), choice architecture (how choices are presented to consumers), and "healthy-plate" tray stickers. During the 2014-2015 academic year, 2 cafeterias received all interventions, 2 received choice architecture only, and 2 were controls. We analyzed sales for 6 weeks before and 7 weeks during interventions. Using interrupted time-series analyses, we measured changes in red, yellow, and green items served. We collected 1329 surveys to capture perceptions of labeling. RESULTS: Among 2.6 million portions served throughout the study, we found no significant changes in red (-0.8% change/week; P = .2) or green (+1.1% change/week; P = .4) items served at intervention sites compared with controls. In surveys, 58% of students reported using traffic-light labels at least a few times per week, and 73% wanted them to continue. CONCLUSIONS: Although many students reported using traffic-light labels regularly and wanted interventions to continue, cafeteria interventions did not demonstrate clear improvements in dietary quality.

Dectin-1 Controls TLR9 Trafficking to Phagosomes Containing ß-1,3 Glucan.

Dectin-1 and TLR9 play distinct roles in the recognition and induction of innate immune responses to Aspergillus fumigatus and Candida albicans. Dectin-1 is a receptor for the major fungal cell wall carbohydrate ß-1,3 glucan that induces inflammatory cytokines and controls phagosomal maturation through spleen tyrosine kinase activation. TLR9 is an endosomal TLR that also modulates the inflammatory cytokine response to fungal pathogens. In this study, we demonstrate that ß-1,3 glucan beads are sufficient to induce dynamic redistribution and accumulation of cleaved TLR9 to phagosomes. Trafficking of TLR9 to A. fumigatus and C. albicans phagosomes requires Dectin-1 recognition. Inhibition of phagosomal acidification blocks TLR9 accumulation on phagosomes containing ß-1,3 glucan beads. Dectin-1-mediated spleen tyrosine kinase activation is required for TLR9 trafficking to ß-1,3 glucan-, A. fumigatus-, and C. albicans-containing phagosomes. In addition, Dectin-1 regulates TLR9-dependent gene expression. Collectively, our study demonstrates that recognition of ß-1,3 glucan by Dectin-1 triggers TLR9 trafficking to ß-1,3 glucan-containing phagosomes, which may be critical in coordinating innate antifungal defense.