Recent evidence suggests that intramyocellular lipid (IMCL) accretion is associated with obesity and the development of insulin resistance and/or type 2 diabetes. However, trained endurance athletes are markedly insulin sensitive, despite an elevated mixed muscle lipid content. In an effort to explain this metabolic paradox, we compared muscle fiber type-specific IMCL storage between populations known to have elevated IMCL deposits. Immunofluorescence microscopy was performed on muscle biopsies obtained from eight highly trained endurance athletes, eight type 2 diabetes patients, and eight overweight, sedentary men after an overnight fast. Mixed muscle lipid content was substantially greater in the endurance athletes (4.0 ± 0.4% area lipid stained) compared with the diabetes patients and the overweight men (2.3 ± 0.4 and 2.2 ± 0.5%, respectively). More than 40% of the greater mixed muscle lipid content was attributed to a higher proportion type I muscle fibers (62 ± 8 vs. 38 ± 3 and 33 ± 7%, respectively), which contained 2.8 ± 0.3-fold more lipid than the type II fibers. The remaining difference was explained by a significantly greater IMCL content in the type I muscle fibers of the trained athletes. Differences in IMCL content between groups or fiber types were accounted for by differences in lipid droplet density, not lipid droplet size. IMCL distribution showed an exponential increase in lipid content from the central region toward the sarcolemma, which was similar between groups and fiber types. In conclusion, IMCL contents can be substantially greater in trained endurance athletes compared with overweight and/or type 2 diabetes patients. Because structural characteristics and intramyocellular distribution of lipid aggregates seem to be similar between groups, we conclude that elevated IMCL deposits are unlikely to be directly responsible for inducing insulin resistance.

Background: Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient’s self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it. Objective: This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed. Methods: A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures. Results: In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P<.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes. Conclusions: In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care. Trial Registration: Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992

A systematic literature review and meta-analysis on the effectiveness of lifestyle restrictions and precautions to prevent dislocation after total hip arthroplasty. MEDLINE and the Cochrane Library were searched in February 2015, with additional hand searching of systematic reviews and reference lists. This review was conducted in accordance with the PRISMA statement for reporting systematic reviews and meta-analysis. PubMed and the Cochrane Library were searched from their start date through to February 2015. Randomized controlled trials and comparative case series in English, Dutch or German language were included. Only primary total hip arthroplasty procedures managed with different postoperative restrictions and precautions protocols were included. Primary outcome was the total hip arthroplasty dislocation rate, secondary outcomes were patient functioning, return to activities of daily living and patient satisfaction. A total of 119 eligible articles were identified, six were included: three randomized controlled trials, one retrospective matched cohort study, one retrospective and one prospective cohort study, describing 1122 procedures (restrictions group: n = 528; no restrictions group: n = 594). Both the standard posterior and anterolateral surgical approaches were included. There were eight dislocations (1.5%) in the restricted group, vs. six dislocations (1.0%) in the unrestricted group. Patients in the unrestricted group resumed activities significantly faster and were more satisfied with their pace of recovery. A more liberal lifestyle restrictions and precautions protocol will not lead to worse dislocation rates after total hip arthroplasty, but will lead to earlier and better resumption of activities and higher patient satisfaction. These results appear to hold up for various surgical approaches.

The response rate on patient-reported outcome measurements (PROMs) necessary to adequately evaluate a treatment and improve patient care is unknown. Hospitals generally aim for the highest possible response rate without insight into the increase in costs involved. This study aimed to investigate which PROMs response rate is achievable in relation to the costs in an orthopaedic practice. In an observational study, patients planned for orthopaedic surgery were asked to participate per surgical procedure (5769 surgical procedures at 5300 patients). Patient-reported outcomes (PROs) collection with a digital online automated PROMs collection system (minimal effort) was compared to a combined automated system and manual collection (maximal effort). Response rate was calculated preoperative and at two postoperative time points separately, and on all three time points together. Costs were calculated for the study period, per year and per surgical procedure. Calculations were executed for all surgical procedures and for three subgroups: knee arthroplasty, hip arthroplasty and anterior cruciate ligament reconstruction (ACLR). Using maximal effort the response rate increased for all surgical procedures compared to minimal effort; the preoperative response rate from 86% to 100% and the postoperative response rates from 55% to 83% (3 or 6 months) and 53% to 83% (12 months). Concerning the response at all three time points for all surgical procedures, minimal effort resulted in 44% response rate and increased to 76% with maximal effort. Lowest postoperative response rates were found in the ACLR group for both maximal and minimal effort. A costs difference of €5.55–€5.98 per surgical procedure between maximal and minimal effort was found. A two times higher PROMs response rate for patients responding at all three time points (44% versus 76%) is achievable with maximal effort compared to the use of an automated PROMs collection system only. Manual collection adds a cost of €5.5–€6 per surgical procedure to automated PROMs collection alone. It is debatable if these additional costs are justifiable from a value-based health care perspective as the response rate for adequate evaluation of a treatment is still unknown.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Modern healthcare focuses on Shared Decision Making (SDM) because of its positive effects on patient satisfaction, therapy compliance, and outcomes. Patients’ knowledge about their illness and available treatment options, gained through medical education, is one of the key drivers for SDM. Current patient education relies heavily on medical consultation and is known to be ineffective. Objective: To determine whether providing patients with information in a subdivided, categorized, and interactive manner via an educational app for smartphone or tablet may increase the knowledge of their illness. Methods: A surgeon blinded randomized controlled trial was conducted with 213 patients who were referred to one of the six Dutch hospitals by their general practitioner owing to knee complaints that were indicative of knee osteoarthritis (OA). An interactive app that, in addition to standard care, actively sends informative and pertinent content to patients about their illness on a daily basis by means of push notifications in the week prior to their consultation. The primary outcome was the level of perceived and actual knowledge that patients had about their knee complaints and the relevant treatment options after the intervention. Results: In total 122 patients were enrolled in the control group and 91 in the intervention group. After the intervention, the level of actual knowledge (measured on a 0-36 scale) was 52% higher in the app group (26.4 versus 17.4, P < 0.001). Moreover, within the app group, the level of perceived knowledge (measured on a 0-25 scale) increased by 22% during the week within the app group (from 13.5 to 16.5, P < 0.001), compared to no gain in the control group. Conclusions: Actively offering patients information in a subdivided (per day), categorized (per theme), and interactive (video and quiz questions) manner significantly increases their levels of knowledge (both perceived and actual), compared to standard care educational practices. Clinical Trial: The trial was approved by the regional Medical Ethical Board (Maxima Medisch Centrum, Eindhoven, The Netherlands), reference number N16.130.