BACKGROUND: Ethnic minority adults have disproportionately higher rates of obesity than Caucasians but are less likely to undergo bariatric surgery. Recent data suggest that minorities might be less likely to seek surgery. Whether minorities who seek surgery are also less likely to proceed with surgery is unclear.
METHODS: We interviewed 651 patients who sought bariatric surgery at two academic medical centers to examine whether ethnic minorities are less likely to proceed with surgery than Caucasians and whether minorities who do proceed with surgery have higher illness burden than their counterparts. We collected patient demographics and abstracted clinical data from the medical records. We then conducted multivariable analyses to examine the association between race and the likelihood of proceeding with bariatric surgery within 1 year of initial interview and to compare the illness burden by race and ethnicity among those who underwent surgery.
RESULTS: Of our study sample, 66% were Caucasian, 18% were African-American, and 12% were Hispanics. After adjustment for socioeconomic factors, there were no racial differences in who proceeded with bariatric surgery. Among those who proceeded with surgery, illness burden was comparable between minorities and Caucasian patients with the exception that African-Americans were underrepresented among those with reflux disease (0.4, 95% CI 0.2-0.7) and depression (0.4, 0.2-0.7), and overrepresented among those with anemia (4.8, 2.4-9.6) than Caucasian patients.
CONCLUSIONS: Race and ethnicity were not independently associated with likelihood of proceeding with bariatric surgery. Minorities who proceeded with surgery did not clearly have higher illness burden than Caucasian patients.
Less than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians' and medical students' confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students' patient populations.
In 2009, Massachusetts (MA) Department of Public Health (DPH) implemented new regulations that required public schools in the state to measure height and weight, determine body mass index (BMI), and notify parents of children in grades 1, 4, 7, and 10 of their child's weight status. After 3 years of implementation, MA DPH recently abandoned parental notification of school-based BMI screening results citing several concerns including flaws in the ability to monitor the way that the BMI screening results were communicated from the schools to parents/guardians and some reports of breaches in confidentiality of students' measurements. In this article, we review implementation issues that could have impacted the success of the MA DPH regulation as well as lessons to be learned and potentially applied to future childhood obesity efforts.
OBJECTIVE: This study was developed as a pilot study to determine if targeted interventions regarding increasing physical activity level through the use of pedometers and fitness DVDs would result in a decrease in BMI in overweight or obese children.
METHODS: 24 children aged 4-17 taking part in "Moving and Losing" were randomized to (1) Control Group; (2) Pedometer Group; (3) DVD Group; (4) Pedometer + DVD Group and asked to complete self-report physical activity logs at visit one and two. Baseline, midpoint, and endpoint weight, height, Body Mass Index (BMI) were measured for outcome variables.
RESULTS: Almost half (42%) of participants turned in their activity logs and pedometers at midpoint, but at endpoint less than a quarter of participants turned in their pedometers and/or activity logs. BMI increased by 4.1% in the Control Group, 8.7% in the Pedometer Group, and 6.7% in the DVD Group. BMI decreased by 0.3% in the Pedometer + DVD Group.
CONCLUSION: The use of pedometers and fitness DVDs may not be culturally acceptable in African-American female children and adolescents from South Carolina who are overweight or obese. Further studies should look into in-depth needs assessments and planning processes that include participants as stakeholders.
OBJECTIVE: Physicians who are physically fit have a higher likelihood of counseling their patients about physical activity. We sought to determine if the amount of physical activity in physicians and medical students differs from the general adult population of the United States and if geographic differences in physical activity levels exist.
METHODS: A cross-sectional survey was distributed to physicians and medical students throughout the United States to determine their level of physical activity according to US Department of Health and Human Services (DHHS) 2008 guidelines; data were collected from participants from June 2009 through January 2010. Our data set was compared with physical activity data from the Centers for Disease Control and Prevention (CDC) and we used geographic regions defined by the US Census Bureau.
RESULTS: Our survey respondents contained 631 attending physicians, 159 fellow physicians, 897 resident physicians, and 262 medical students. Only 64.5% of the general US adult population meets DHHS guidelines for physical activity, but 78% of the survey participants fulfilled the guidelines. The percentage of US adults who do not engage in leisure-time physical activity is 25.4% compared with 5.8% of survey participants. Survey respondents in the southern region had the lowest physical activity levels and participants in the western region had the highest levels.
CONCLUSION: Physicians and medical students engage in more physical activity than the general US adult population. Regional differences in the general population's physical activity also persisted in physicians and medical students. Therefore, physicians who complete less physical activity may be less likely to encourage patients to engage in physical activity in geographic areas where the adult population is less active.
OBJECTIVE: Evidence suggests that the level of physical activity of physicians can be correlated directly with physician counselling patterns about this behaviour. Our objective was to determine if medical students, resident and fellow physicians and attending physicians meet the physical activity guidelines set forth by the US Department of Health and Human Services.
METHODS: A representative cross-sectional web-based survey was conducted in June 2009-January 2010 throughout the USA (N=1949). Using the short form of the International Physical Activity Questionnaire, the authors gathered demographical data and information related to physical activity, the level of training, the number of work hours per week, body mass index (BMI), confidence about counselling about physical activity and frequency with which the physical activity is encouraged to his/her patients.
RESULTS: Based on the 1949 respondents, attending physicians (84.8%) and medical students (84%) were more likely than resident (73.2%) and fellow physicians (67.9%) to meet physical activity guidelines.
CONCLUSION: Physicians and medical students engage in more physical activity and tend to have a lower BMI than the general population. Resident and fellow physicians engage in less physical activity than attending physicians and medical students.
BACKGROUND: The combined associations of changes in cardiorespiratory fitness and body mass index (BMI) with mortality remain controversial and uncertain.
METHODS AND RESULTS: We examined the independent and combined associations of changes in fitness and BMI with all-cause and cardiovascular disease (CVD) mortality in 14 345 men (mean age 44 years) with at least 2 medical examinations. Fitness, in metabolic equivalents (METs), was estimated from a maximal treadmill test. BMI was calculated using measured weight and height. Changes in fitness and BMI between the baseline and last examinations over 6.3 years were classified into loss, stable, or gain groups. During 11.4 years of follow-up after the last examination, 914 all-cause and 300 CVD deaths occurred. The hazard ratios (95% confidence intervals) of all-cause and CVD mortality were 0.70 (0.59-0.83) and 0.73 (0.54-0.98) for stable fitness, and 0.61 (0.51-0.73) and 0.58 (0.42-0.80) for fitness gain, respectively, compared with fitness loss in multivariable analyses including BMI change. Every 1-MET improvement was associated with 15% and 19% lower risk of all-cause and CVD mortality, respectively. BMI change was not associated with all-cause or CVD mortality after adjusting for possible confounders and fitness change. In the combined analyses, men who lost fitness had higher all-cause and CVD mortality risks regardless of BMI change.
CONCLUSIONS: Maintaining or improving fitness is associated with a lower risk of all-cause and CVD mortality in men. Preventing age-associated fitness loss is important for longevity regardless of BMI change.
BACKGROUND: The goal of anterior cruciate ligament reconstruction is to attain a graft that closely resembles the native anterior cruciate ligament anatomy. By reconstructing the original anatomy, one hopes to eliminate issues related to graft elongation, impingement, and excessive tension while achieving ideal knee kinematics.
HYPOTHESIS: Clinical grafts placed using the transtibial technique will differ in the sagittal and coronal planes when compared with obliquity of the anatomic anterior cruciate ligament.
STUDY DESIGN: Controlled laboratory study/case series; Level of evidence, 4.
METHODS: With the assistance of computer navigation, our study compared the anterior cruciate ligament orientation of 5 cadaver knees with 12 clinical anterior cruciate ligament-reconstructed knees using the transtibial technique.
RESULTS: Clinical graft obliquity differed from the anatomic anterior cruciate ligament in all flexion angles: 0 degrees, 30 degrees, 60 degrees, and 90 degrees. In the sagittal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 13.6 degrees, 12.7 degrees, 16.7 degrees, and 17 degrees, respectively. In the coronal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 4.9 degrees, 7.6 degrees, 8.9 degrees, and 12.7 degrees, respectively. Paired t tests demonstrated that the difference between the clinical and anatomic anterior cruciate ligament was significant (P <.05), except in the coronal plane at 0 degrees of flexion. In spite of this, all patients demonstrated a negative pivot shift and Lachman at the conclusion of their reconstructions and at 6-month follow-up.
CONCLUSION: The sagittal and coronal plane obliquity of well-functioning grafts placed using the transtibial technique were more vertical than anatomic fibers.
CLINICAL RELEVANCE: Graft obliquity, in both the coronal and sagittal plane, may be an important means to target appropriate anterior cruciate ligament graft position and can be monitored using surgical navigation systems.
BACKGROUND: The native anterior cruciate ligament (ACL) does not behave as a simple bundle of fibers with constant tension but as a continuum of ligament fibers with differential length change during knee flexion/extension. Computer-assisted navigation can be used to assess length change in different fibers within the native ACL and to evaluate how different reconstruction grafts replicate the range of native ligament fiber length change behavior.
HYPOTHESIS: Anterior cruciate ligament reconstruction graft size and configuration (single-vs double-bundle) are deciding factors as to how much of the native ACL fiber length change behavior is replicated.
STUDY DESIGN: Controlled laboratory study.
METHODS: The fiber length change behavior of the entire native ACL was assessed by measuring the length change pattern of representative anteromedial (AM) and posterolateral (PL) bundle fibers (1 at the center and 4 at the periphery of each bundle). The tibial and femoral ACL attachment areas in 5 fresh-frozen cadaveric knees were digitized, and the length change of each representative fiber was recorded during knee flexion/extension using an image-free, optical navigation system. Subsequently, single-bundle ACL reconstructions of different diameters (6, 9, and 12 mm) positioned at the center of the overall native femoral and tibial attachment sites were modeled to assess how much of the range of ligament fiber length change of the native ligament was captured. This was compared with a double-bundle graft using 6-mm-diameter AM and PL grafts positioned at the centers of the femoral and tibial attachment sites of each separate bundle.
RESULTS: The 6-, 9-, and 12-mm single-bundle grafts simulated 32%, 51%, and 66% of the ligament fiber length change behavior of the native ACL, respectively. The length change patterns in these grafts were similar to the central fibers of the native ACL: the PL fibers of the AM bundle and AM fibers of the PL bundle. However, even a 12-mm graft did not represent the most AM and PL native fibers. The 6-mm AM and PL bundle grafts (equivalent in cross-sectional area to a 9-mm single-bundle graft) simulated 71% of the native ACL and better captured the extremes of the range of native ligament fiber length change.
CONCLUSION: Increasing single-bundle graft size appears to capture more of the range of native ACL fiber length change. However, for a similar graft cross-sectional area, a 2-bundle graft simulates the length change behavior of the native ligament more precisely and thus may better emulate the synergistic actions of anisometric and isometric fibers of the native ligament in restraining knee laxity throughout the range of flexion.
CLINICAL RELEVANCE: The range of native ACL fiber length change behavior is better replicated by larger diameter grafts but may be best reproduced by double-bundle reconstruction.
ACL insufficiency can be documented clinically with the pivot shift maneuver, but the specific pathologic kinematics of the pivot shift is difficult to quantify. Navigation provides an opportunity to analyze in vivo the motions that comprise the pivot shift and the kinematic changes that are inherent after ACL reconstruction. We hypothesized that tibial rotation, anterior tibial translation (ATT), acceleration of posterior translation (APT) and the newly described angle of P, quantified during navigated pivot shift examination, correlate with clinical grading of the pivot shift phenomena. Navigation data from 12 patients who underwent navigated ACL surgery were retrospectively reviewed. A characteristic P-shaped track of motion is recorded by the navigation software during the pivot-shift examination. The "angle of P" was developed as a means characterizing this track of motion and was measured in all cases. The tibial rotation, maximum anterior tibial translation and acceleration of posterior translation during the pivot shift were also measured. The charts of these patients were reviewed to obtain information on the clinical grading of the pivot-shift before and after ACL reconstruction. Spearman correlation analysis was then used to identify significant correlations between clinical grade of the pivot shift and the angle of p measured with computer navigation. After reconstruction, the clinical grade of the pivot shift was zero in all patients. The tibial rotation, maximum ATT, APT and the angle of p also decreased. On analysis of 24 EUAs, 12 before reconstruction and 12 after, there was excellent and significant correlation between the clinical grade of pivot shift examination and the angle of P (R2 = 0.97, p < 0.001). Only good correlation was noted between the clinical pivot shift and the rotation (R2 = 0.77, p < 0.0001), maximum ATT (R2 = 0.87, p < 0.0001) and APT (R2 = 0.81, p < 0.0001). There was a stepwise increase of 6-7 mm of translation and 5-6 degrees of rotation for each increasing grade of pivot shift. There were also increases in the angle of P and APT for each increasing grade of pivot. A decrease in tibial rotation, maximum ATT, APT and angle ofp is detected by computer navigation with ACL reconstruction, correlating with clinical grading. Clinical quantification of the distinct elements of the pivot shift may allow for more accurate evaluation of different ACL reconstruction constructs. There is also potential for these variables to be measured intraoperatively and guide ACL reconstruction when computer navigation is employed.