The Effect of Social Isolation on 1-Year Outcomes After Surgical Repair of Low-Energy Hip Fracture

OBJECTIVES

To evaluate whether social isolation or loneliness is associated with outcomes 1 year after low-energy hip fracture.

METHODS

DESIGN

Prospective inception cohort study.

SETTING

Academic level I trauma center.

PATIENT SELECTION CRITERIA

Participants were 65 years or older and enrolled 2-4 days after surgery for a first low-energy hip fracture. Exclusion criteria were bilateral or periprosthetic hip fracture, previous hip fracture, non-English speaking, international address, active cancer, stage 4 cancer in the past 5 years, radiation to the hip region, and cognitive impairment. Participants were followed longitudinally for 1 year.

OUTCOME MEASURES AND COMPARISONS

The patient-reported outcomes measurement information system (PROMIS)-29 was elicited 2-4 days postoperatively and 1 year later. Patient-reported risk factors included the Lubben Social Networks Scale and the University of California, Los Angeles Loneliness Scale, which were compared with the lower extremity activity scale and PROMIS-29 domains.

RESULTS

Three hundred and twenty-five patients were enrolled. Participants had a median age of 81.7 years, were 70.9% female, and were 85.9% White. In total, 31.6% of patients were socially isolated at the time of fracture. At 1 year, 222 of the 291 subjects who were confirmed alive at 1 year provided data. Multivariable linear models were performed separately for each outcome, including lower extremity activity scale and PROMIS-29 domains. Controlling for age, sex, education, and body mass index, those who were socially isolated at the time of fracture had worse PROMIS-29 function (β = -3.83; P = 0.02) and ability to participate in social roles (β = -4.17; P = 0.01) at 1 year. Secondary analyses found that prefracture loneliness was associated with clinically meaningfully worse function, anxiety, depression, fatigue, sleep, pain, and ability to participate in social roles at 1 year (all P < 0.01).

CONCLUSIONS

Prefracture social isolation was associated with worse outcomes 1 year after surgical repair of low-energy hip fracture. These data suggest loneliness may be more strongly associated with important patient-centric metrics than prefracture social isolation. Given the dearth of modifiable risk factors in this population, future studies are needed to evaluate whether improving social connections could affect outcomes in this rapidly growing demographic.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes

BACKGROUND

Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.

RESULTS

A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.

DISCUSSION

In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

Clinical integration of patient-reported outcome measures to enhance the care of patients with SLE: a multi-centre prospective cohort study

OBJECTIVE

To assess the feasibility and impact of integrating electronic patient-reported outcome measures (PROMs) into the routine outpatient care of patients with SLE.

METHODS

We conducted a prospective cohort study, utilizing a mixed-methods sequential explanatory design, of SLE outpatients receiving rheumatology care at two academic medical centres. Participants completed electronic PROMs at enrolment and then prior to their next two routine rheumatology visits. PROM score reports were shared with patients and rheumatologists before visits. Patients and rheumatologists completed post-visit surveys evaluating the utility of PROMs in the clinical encounters. Focus groups of patients and interviews with treating rheumatologists were conducted to further explore their experience utilizing PROMs.

RESULTS

A total of 105 SLE patients and 17 rheumatologists participated in the study. Patients completed PROMs in 159 of 184 encounters (86%), with 93% of surveys completed remotely. Patients reported that PROMs were 'quite a bit' or 'very' useful (55% of encounters) and beneficial to communication (55% of encounters). In contrast, physicians found PROMs useful (20%) and beneficial to communication (17%) less frequently. There was no significant change in visit length, health-related quality of life or disease activity after implementation of PROMs; however, patient satisfaction improved slightly. Qualitative analyses revealed that patients felt PROMs provided utility primarily by facilitating communication, particularly when physicians discussed the surveys.

CONCLUSION

The remote capture and integration of electronic PROMs into clinical care was feasible in a diverse cohort of SLE outpatients. PROMs were useful to patients and enhanced their clinical experience primarily by facilitating communication.

Effect of Seasonality on Variation Among Patients Presenting With Rib Fractures in the United States

BACKGROUND

A prior single-site study from the Midwest exploring seasonality of traumatic rib fractures found injuries are more common during summer months and lower in winter months. There have been no modern studies evaluating seasonality of these common injuries nationally. Our aim was to describe temporal and spatial distribution of rib fractures in the United States. We hypothesized presentations for traumatic rib fractures follow a seasonal pattern, with greater frequency of rib fractures in the summer and lower levels in the winter.

METHODS

We obtained hospital emergency department (ED) encounter data from Nationwide Emergency Department Sample (NEDS) from January 1, 2018 to December 31, 2018. We used ICD-10 codes to identify all patients with diagnostic codes specific to rib fractures. To examine seasonal patterns, we constructed negative binomial regression models using seasons as covariates to predict incidence of rib fracture encounters across regions.

RESULTS

Of 15,439,004 trauma-related ED encounters in 2018, 384 431 (2%) encounters included a diagnosis of rib fracture(s). The percentage of ED trauma encounters with rib fractures was similar across the 4 regions. Rib fractures were more common in the summer in the Midwest, South, and West as compared to winter [22% (95% CI = 10-34%, P = .007), 12% (95% CI = 5-20%, P = 0.02), and 11% (95% CI = 5-17%, P = .008), respectively].

DISCUSSION

Our hypothesis was generally supported by our evaluation of NEDS. However, while seasonal variation in rib fractures does appear to exist in the Midwest, South, and West, this variation is not ubiquitous across the United States.

Prospective study of long-term quality-of-life after rib fractures

BACKGROUND

Long-term quality-of-life after rib fractures remains understudied. We aimed to evaluate quality-of-life of patients who had rib fractures 1 year after discharge. We hypothesized that patients with rib fractures, even as an isolated injury, have suboptimal long-term quality-of-life.

METHODS

We prospectively enrolled adults admitted to our level 1 trauma center with acute rib fractures. Primary outcome was quality-of-life at 1 year after discharge, characterized using the revised trauma-specific quality-of-life questionnaire and a supplemental survey. Secondary analysis evaluated association between baseline frailty (measured using the Rib Fracture Frailty Index) and quality-of-life. Patients with low versus moderate frailty risk underwent full matching and linear mixed model analysis.

RESULTS

We enrolled 139 patients, among whom 72 (52%) completed 1-year surveys. Patients reported excellent emotional well-being (median [interquartile range]: 4.8 [3.7-5.0]) and functional engagement (median [interquartile range]: 5.0 [4.3-5.0]) but poor physical well-being and recovery (median [interquartile range]: 3.2 [2.8-3.6]). Nearly 40% of patients reported some degree of rib pain, and 29% had not returned to preinjury working capacity. Patients with and without isolated rib fractures reported similar median revised trauma-specific quality-of-life scores. We did not find statistically significant association between low versus moderate frailty and any quality-of-life domain, but no patients in our cohort had high frailty risk and our study was underpowered to detect this association.

CONCLUSION

Rib fractures are associated with suboptimal quality-of-life 1 year after discharge, even after isolated injury. Our sample size was limited, but our findings highlight persistent long-term consequences of rib fractures despite advances in inpatient management. Patients should be counseled on the potential for prolonged convalescence.

Transarterial Embolization for the Treatment of Chronic Musculoskeletal Pain: A Systematic Review of Indications, Safety, and Efficacy

Objective

The study objective was to evaluate the safety and efficacy of transcatheter arterial “embolization” (TAE) in the treatment of chronic “musculoskeletal pain” refractory to standard therapy.

Methods

PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for original research articles evaluating TAE in patients with musculoskeletal conditions from database inception to January 21, 2020. Search terms employed were as follows: “embolization”, “pain”, “knee osteoarthritis”, joint replacement, epicondylitis, tenderness, inflammation, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), microspheres, Embozene, geniculate artery, neovascularity, transcatheter, embolic, imipenem/cilastatin sodium, angiogenesis, and “musculoskeletal”. Studies involving particle “embolization” for painful musculoskeletal conditions were included. Studies of TAE for hemarthrosis or malignancy‐related “musculoskeletal pain” were excluded.

Results

The primary search yielded 1,099 sources; 7 articles and 4 abstracts were included for data extraction. All were cohorts or case series, with low risk of bias and moderate to poor level of evidence. Heterogeneity between studies was high, precluding meta‐analysis. The reviewed studies reported the safety and efficacy of TAE for the treatment of “knee osteoarthritis”; adhesive capsulitis of the shoulder; tendinopathy/enthesopathy of the knee, shoulder, elbow, and ankle; and cervical myalgia. All TAEs were reported as technically successful without major complications or subsequent serious adverse events, including no reported osteonecrosis, cutaneous ulceration, limb ischemia, cartilage degeneration, or myotendinous injury. TAE significantly reduced pain and improved function for all of the treated conditions, with durable response up to 24 months post procedure.

Conclusion

TAE appears to be a safe and effective treatment for some types of chronic refractory “musculoskeletal pain”. Randomized placebo‐controlled studies are necessary to confirm these findings.

Evaluation of a Patient-reported Frailty Tool in Women With Systemic Lupus Erythematosus

OBJECTIVE

Frailty is associated with mortality in systemic lupus erythematosus (SLE), but how best to measure frailty is unclear. We aimed to compare 2 frailty metrics, the self-reported Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) scale (FS) and the Fried phenotype (FP), in SLE to evaluate differences between frail and nonfrail women and whether frailty is associated with self-reported disability.

METHODS

Adult women aged < 70 years with validated SLE and mild/moderate disease enrolled in this cross-sectional study between August 2018 and October 2019. Correlation and agreement between the FS and the FP were determined. Differences in sociodemographic and disease characteristics, patient-reported outcome measures (PROMs), and biomarkers between frail and nonfrail participants were evaluated, as well as the association of frailty with Valued Life Activities disability.

RESULTS

Of 67 participants, 27% and 18% were frail according to the FS and the FP, respectively. Correlation (r = 0.51; P < 0.0001) and agreement (κ = 0.46; P = 0.0004) between the FS and the FP were significant. Frail women had greater disease damage, high-sensitivity C-reactive protein, and interleukin 6, and worse PROMs according to both frailty definitions. Both frailty measures were associated with self-reported disability after adjustment for age, comorbidity, and disease activity and damage; this relationship was attenuated for the FP.

CONCLUSION

Frailty prevalence was high in this cohort of women with SLE using both frailty definitions, suggesting that frailty may be accelerated in women with SLE, particularly when based exclusively on self-report. Frailty remained associated with self-reported disability in adjusted analyses. The FS may be an informative point-of-care tool to identify frail women with SLE.