Federal Practitioner

TOPLINE: 

Among US veterans, same-day receipt of both the 2024-2025 COVID19 vaccine and the influenza vaccine was associated with lower risks for emergency department visits, hospitalizations, and deaths compared with receipt of the influenza vaccine alone.

METHODOLOGY:

• Researchers conducted an observational study to assess the effectiveness of the 2024-2025 COVID-19 vaccine by comparing veterans who received both the COVID-19 and influenza vaccines on the same day with those who received only the influenza vaccine between September 3 and December 31, 2024.
• Data on participants (mean age, approximately 71.5 years; approximately 92% men) were sourced from electronic health records of the Department of Veterans Affairs and included 164,132 veterans who received both vaccines vs 131,839 who received only the seasonal influenza vaccine, with a follow-up duration of 180 days.
• The vaccines used were mainly the 2024-2025 mRNA COVID19 vaccines: Moderna mRNA1273, Pfizer BNT162b2, and the highdose trivalent 2024-2025 seasonal influenza vaccine.
• Primary outcomes were COVID-19-associated emergency department visits, hospitalizations, and deaths.

TAKEAWAY:

• Receipt of both the COVID-19 and influenza vaccines was associated with a lower risk for COVID-19-associated emergency department visits compared with receipt of the influenza vaccine alone, resulting in a vaccine effectiveness of 29.3% and a risk difference of 18.3 per 10,000 persons (95% CI, 10.8-27.6).
• Similarly, COVID-19 vaccine effectiveness was 39.2% (95% CI, 21.6-54.5) against COVID-19-associated hospitalizations, with a risk difference of 7.5 per 10,000 persons (95% CI, 3.4-13.0).
• For COVID-19-associated deaths, vaccine effectiveness was 64% (95% CI, 23.0-85.8), with a risk difference of 2.2 per 10,000 persons (95% CI, 0.5-6.9).
• Benefits were consistent across age groups (< 65, 65-75, and > 75 years) and among people with various comorbidities, including cardiovascular disease and immunocompromised status.

IN PRACTICE:

“The evidence may help inform ongoing discussions about the value of COVID-19 vaccines in the current epidemiologic landscape,” the authors wrote.

SOURCE:

The study was led by Miao Cai, PhD , Research and Development Service, Veterans Affairs St. Louis Health Care System, and the Veterans Research and Education Foundation of St. Louis, Missouri. It was published online in The New England Journal of Medicine .

LIMITATIONS:

The demographic composition of the cohort — predominantly older, White, male veterans — may limit the generalizability of the study. Although numerous covariates were adjusted for, residual confounding could not be fully ruled out. Safety and variantspecific effectiveness were not assessed.

DISCLOSURES:

The study was supported by a grant from the Department of Veterans Affairs. Two authors disclosed consulting for Pfizer.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE: 

Among US veterans, same-day receipt of both the 2024-2025 COVID19 vaccine and the influenza vaccine was associated with lower risks for emergency department visits, hospitalizations, and deaths compared with receipt of the influenza vaccine alone.

METHODOLOGY:

• Researchers conducted an observational study to assess the effectiveness of the 2024-2025 COVID-19 vaccine by comparing veterans who received both the COVID-19 and influenza vaccines on the same day with those who received only the influenza vaccine between September 3 and December 31, 2024.
• Data on participants (mean age, approximately 71.5 years; approximately 92% men) were sourced from electronic health records of the Department of Veterans Affairs and included 164,132 veterans who received both vaccines vs 131,839 who received only the seasonal influenza vaccine, with a follow-up duration of 180 days.
• The vaccines used were mainly the 2024-2025 mRNA COVID19 vaccines: Moderna mRNA1273, Pfizer BNT162b2, and the highdose trivalent 2024-2025 seasonal influenza vaccine.
• Primary outcomes were COVID-19-associated emergency department visits, hospitalizations, and deaths.

TAKEAWAY:

• Receipt of both the COVID-19 and influenza vaccines was associated with a lower risk for COVID-19-associated emergency department visits compared with receipt of the influenza vaccine alone, resulting in a vaccine effectiveness of 29.3% and a risk difference of 18.3 per 10,000 persons (95% CI, 10.8-27.6).
• Similarly, COVID-19 vaccine effectiveness was 39.2% (95% CI, 21.6-54.5) against COVID-19-associated hospitalizations, with a risk difference of 7.5 per 10,000 persons (95% CI, 3.4-13.0).
• For COVID-19-associated deaths, vaccine effectiveness was 64% (95% CI, 23.0-85.8), with a risk difference of 2.2 per 10,000 persons (95% CI, 0.5-6.9).
• Benefits were consistent across age groups (< 65, 65-75, and > 75 years) and among people with various comorbidities, including cardiovascular disease and immunocompromised status.

IN PRACTICE:

“The evidence may help inform ongoing discussions about the value of COVID-19 vaccines in the current epidemiologic landscape,” the authors wrote.

SOURCE:

The study was led by Miao Cai, PhD , Research and Development Service, Veterans Affairs St. Louis Health Care System, and the Veterans Research and Education Foundation of St. Louis, Missouri. It was published online in The New England Journal of Medicine .

LIMITATIONS:

The demographic composition of the cohort — predominantly older, White, male veterans — may limit the generalizability of the study. Although numerous covariates were adjusted for, residual confounding could not be fully ruled out. Safety and variantspecific effectiveness were not assessed.

DISCLOSURES:

The study was supported by a grant from the Department of Veterans Affairs. Two authors disclosed consulting for Pfizer.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE: 

Among US veterans, same-day receipt of both the 2024-2025 COVID19 vaccine and the influenza vaccine was associated with lower risks for emergency department visits, hospitalizations, and deaths compared with receipt of the influenza vaccine alone.

METHODOLOGY:

• Researchers conducted an observational study to assess the effectiveness of the 2024-2025 COVID-19 vaccine by comparing veterans who received both the COVID-19 and influenza vaccines on the same day with those who received only the influenza vaccine between September 3 and December 31, 2024.
• Data on participants (mean age, approximately 71.5 years; approximately 92% men) were sourced from electronic health records of the Department of Veterans Affairs and included 164,132 veterans who received both vaccines vs 131,839 who received only the seasonal influenza vaccine, with a follow-up duration of 180 days.
• The vaccines used were mainly the 2024-2025 mRNA COVID19 vaccines: Moderna mRNA1273, Pfizer BNT162b2, and the highdose trivalent 2024-2025 seasonal influenza vaccine.
• Primary outcomes were COVID-19-associated emergency department visits, hospitalizations, and deaths.

TAKEAWAY:

• Receipt of both the COVID-19 and influenza vaccines was associated with a lower risk for COVID-19-associated emergency department visits compared with receipt of the influenza vaccine alone, resulting in a vaccine effectiveness of 29.3% and a risk difference of 18.3 per 10,000 persons (95% CI, 10.8-27.6).
• Similarly, COVID-19 vaccine effectiveness was 39.2% (95% CI, 21.6-54.5) against COVID-19-associated hospitalizations, with a risk difference of 7.5 per 10,000 persons (95% CI, 3.4-13.0).
• For COVID-19-associated deaths, vaccine effectiveness was 64% (95% CI, 23.0-85.8), with a risk difference of 2.2 per 10,000 persons (95% CI, 0.5-6.9).
• Benefits were consistent across age groups (< 65, 65-75, and > 75 years) and among people with various comorbidities, including cardiovascular disease and immunocompromised status.

IN PRACTICE:

“The evidence may help inform ongoing discussions about the value of COVID-19 vaccines in the current epidemiologic landscape,” the authors wrote.

SOURCE:

The study was led by Miao Cai, PhD , Research and Development Service, Veterans Affairs St. Louis Health Care System, and the Veterans Research and Education Foundation of St. Louis, Missouri. It was published online in The New England Journal of Medicine .

LIMITATIONS:

The demographic composition of the cohort — predominantly older, White, male veterans — may limit the generalizability of the study. Although numerous covariates were adjusted for, residual confounding could not be fully ruled out. Safety and variantspecific effectiveness were not assessed.

DISCLOSURES:

The study was supported by a grant from the Department of Veterans Affairs. Two authors disclosed consulting for Pfizer.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

The introduction of extended reality (XR) to the operating room (OR) has proved promising for enhancing surgical precision and improving patient outcomes. In the field of orthopedic surgery, precise alignment of implants is integral to maintaining functional range of motion and preventing impingement of adjacent neurovascular structures. XR systems have shown promise in arthroplasty including by improving precision and streamlining surgery by allowing surgeons to create 3D preoperative plans that are accessible intraoperatively. This article explores the current applications of XR in arthroplasty, highlights recent advancements and benefits, and describes limitations in comparison to traditional techniques.

Methods

A literature search identified studies involving the use of XR in arthroplasty and current US Food and Drug Administration (FDA)-approved XR systems. Multiple electronic databases were used, including PubMed, Google Scholar, and IEEE Xplore. Search terms included: extended reality, augmented reality, virtual reality, arthroplasty, joint replacement, total knee arthroplasty, total shoulder arthroplasty, and total hip arthroplasty. The study design, intervention details, outcomes, and comparisons with traditional surgical techniques were thematically analyzed, with identification of common ideas associated with XR use in arthroplasty. This narrative report highlights the integration of XR in arthroplasty.

Extended Reality Fundamentals

XR encompasses augmented reality (AR), virtual reality (VR), and mixed reality (MR). AR involves superimposing digitally rendered information and images onto the surgeon’s view of the real world, typically through the use of a headset and smart glasses.¹ AR allows the surgeon to move and interact freely within the OR, removing the need for additional screens or devices to display patient information or imaging. VR is a fully immersive simulation using a headset that obstructs the view of the real world but allows the user to move freely within this virtual setting, often with audio or other sensory stimuli. MR combines AR and VR to create a digital model that allows for real-world interaction, with the advantage of adapting information and models in real time.² Whereas in AR the surgeon can view the data projected from the headset, MR provides the ability to interact with and manipulate the digital content (Figure). Both AR and MR have been adapted for use in the OR, while VR has been adapted for use in surgical planning and training.

Extended Reality Use in Orthopedics

The HipNav system was introduced in 1995 to create preoperative plans that assist surgeons in accurately implanting the acetabular cup during total hip arthroplasty (THA).³ Although not commercially successful, this system spurred surgeons to experiment with XR to improve the accuracy and alignment of orthopedic implants. Systems capable of displaying the desired intraoperative implant placement have flourished, with applications in fracture reduction, arthroplasty, solid tumor resection, and hardware placement.^4-7 Accurate alignment has been linked to improvements in patient outcomes.^8-10 XR has great potential within the field of arthroplasty, with multiple new systems approved by the FDA and currently available in the US (Table).

Hip Arthroplasty

Orientation of the acetabular cup is a technically challenging part of THA. Accuracy in the anteversion and inclination angles of the acetabular cup is required to maintain implant stability, preserve functional range of motion (ROM), and prevent precocious wear.^11,12 Despite preoperative planning, surgeons often overestimate the inclination angle and underestimate anteversion.¹³ Improper implantation of the acetabular cup can lead to joint instability caused by aseptic loosening, increasing the risk of dislocation and the need for revision surgery.^14,15 Dislocations typically present to the emergency department, but primary care practitioners may encounter patients with pain or diminished sensation due to impingement or instability.¹⁶

The introduction of XR into the OR has provided the opportunity for real-time navigation and adjustment of the acetabular cup to maximize anteversion and inclination angles. Currently, 2 FDA-approved systems are available for THA: the Zimmer and Surgical Planning Associates HipInsight system, and the Insight Augmented Reality Visualization and Information System (ARVIS). The HipInsight system consists of a hologram projection using the Microsoft HoloLens2 device and optimizes preoperative planning, producing accuracy of anteversion and inclination angles within 3°.¹⁷ ARVIS employs existing surgical helmets and 2 mounted tracking cameras to provide navigation intraoperatively. ARVIS has also been approved for use in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty.¹⁸

HipInsight has shown utility in increasing the accuracy of acetabular cup placement along with the use of biplanar radiographic scans.¹⁹ However, there are no studies validating the efficacy of ARVIS and HipInsight and assessing long-term disease-oriented or patient-oriented outcomes.

Knee Arthroplasty

In the setting of TKA, XR is most effective in ensuring accurate resection of the tibial and femoral components. Achieving the planned femoral coronal, axial, and sagittal angles allows the prosthesis to be on the femoral axis of rotation, improving functional outcomes. XR systems for TKA have been shown to increase the accuracy of distal femoral resection with a limited increase in surgery duration.^20,21 For TKA in particular, patients are often less satisfied with the result than surgeons expect.²² Accurate alignment can improve patient satisfaction and reduce return-to-clinic rates for postoperative pain management, a factor that primary care practitioners should consider when recommending a patient for TKA.²³

Along with ARVIS, 3 additional XR systems are FDA-approved for use in TKA. The Pixee Medical Knee+ system uses smart glasses and trackers to aid in the positioning of instruments for improved accuracy while allowing real-time navigation.²⁴ The Medacta NextAR Knee’s single-use tracking system allows for intraoperative navigation with the use of AR glasses.²⁵ The Polaris STELLAR Knee uses MR and avoids the need for preoperative imaging by capturing real-time anatomic data.²⁶

The Pixee Medical Knee+ system was commercially available in Europe for several years prior to FDA approval, so more research exists on its efficacy. One study found that the Pixee Medical Knee+ system initially demonstrated an inferior clinical outcome, attributed to the learning curve associated with using the system.²⁷ However, more recent studies have shown its utility in improving alignment, regardless of implant specifications.^28,29 The Medacta NextAR Knee system has been shown to improve accuracy of tibial rotation and soft tissue balance and even increase OR efficiency.^30,31 The Polaris STELLAR Knee system received FDA approval in 2023; no published research exists on its accuracy and outcomes.²⁶

Shoulder Arthroplasty

Minimally invasive techniques are favored in total shoulder arthroplasty (TSA) due to the vitality of maintaining the surrounding soft tissue to maximize preservation of motility and strength.³² However, this complicates the procedure by decreasing the ability to effectively access and visualize key structures of the shoulder. Accordingly, issues with implant positioning and alignment are more common with TSA than other joint arthroplasties, making XR particularly promising.³³ Some studies report that up to 67% of patients experience glenohumeral instability, which can clinically present as weakness, decreased range of motion, and persistent shoulder pain.^34,35 The use of preoperative computed tomography to improve understanding of glenoid anatomy and glenohumeral subluxation is becoming increasingly common, and it can be combined with XR to improve accuracy.^36,37

Two FDA-approved systems are available. The Stryker Blueprint MR system is used for intraoperative guidance and integration for patient imaging used for preoperative planning. The Medacta NextAR Shoulder system is a parallel of the company’s TKA system. The Stryker Blueprint MR system combines the Microsoft HoloLens 2 headset to display preoperative plans with a secondary display for coordination with the rest of the surgical team.³⁸ Similar to the Medacta NextAR Knee, the Medacta NextAR Shoulder system uses the same single-use tracking system and AR glasses for intraoperative guidance.³⁹

Data on the long-term outcomes of using these systems are still limited, but the Stryker Blueprint MR system has not been shown to accurately predict postoperative ROM.⁴⁰ Cadaveric studies have demonstrated that the Medacta NextAR Shoulder system can provide accurate inclination, retroversion, entry point, depth, and rotation values based on the preoperative planned values.^41,42 However, this accuracy has yet to be confirmed in vivo, and the impact of using XR in TSA on long-term outcomes is still unknown.

Challenges and Limitations

Though XR has proven to be promising in arthroplasty, several limitations regarding widespread implementation exist. In particular, there is a steep learning curve associated with the use of XR systems, which can cause increased operative time and even initial inferior outcomes, as demonstrated with the Pixee Medical Knee+ system. The need for extensive practice and training prior to use could delay widespread adoption and may cause discrepancies in surgical outcomes. Unfamiliarity with the system and technological difficulties that may require troubleshooting can also increase operative time, particularly for surgeons new to using the XR system. Though intraoperative navigation is expected to improve accuracy of implant alignment, its added complexity may also result in longer surgeries.

In addition to the steep learning curve and increased operative time, there is a high upfront cost associated with XR systems. Exact costs of XR systems are not typically disclosed, but available estimates suggest an average sales price of about $1000 per case. Given the proprietary nature of these technologies, publicly available cost data are limited, making it challenging to fully assess the financial burden on health care institutions. Though some systems, such as ARVIS, can be integrated with existing surgical helmets, many require the purchase of AR glasses and secondary displays. This can cause further variation in the total expense for each system. In low-resource settings, this represents a significant challenge to widespread implementation. To justify this cost, additional research on long-term patient outcomes is needed to ensure the benefits of XR systems outweigh the cost. 

Although early studies on XR systems in arthroplasty have shown improvements in precision and short-term outcomes, long-term data regarding effectiveness remains. Even systems such as ARVIS and HipInsight have limited long-term follow-up, making it difficult to assess whether the improved accuracy with these XR systems translates into improved patient outcomes compared with traditional arthroplasty.

CONCLUSIONS

XR technologies have shown significant potential in enhancing precision and patient outcomes. Through the integration of XR in the OR, surgeons can visualize preoperative plans and even make intraoperative changes, with the benefit of improving implant alignment.

There are some disadvantages to its use, however, including high cost and increased operative time. Despite this, the integration of XR into surgical practice can deliver more precise implant alignment and address other challenges faced with conventional techniques. As these technologies evolve and studies on long-term outcomes validate their utility, XR has the potential to transform the field of arthroplasty.

The introduction of extended reality (XR) to the operating room (OR) has proved promising for enhancing surgical precision and improving patient outcomes. In the field of orthopedic surgery, precise alignment of implants is integral to maintaining functional range of motion and preventing impingement of adjacent neurovascular structures. XR systems have shown promise in arthroplasty including by improving precision and streamlining surgery by allowing surgeons to create 3D preoperative plans that are accessible intraoperatively. This article explores the current applications of XR in arthroplasty, highlights recent advancements and benefits, and describes limitations in comparison to traditional techniques.

Methods

A literature search identified studies involving the use of XR in arthroplasty and current US Food and Drug Administration (FDA)-approved XR systems. Multiple electronic databases were used, including PubMed, Google Scholar, and IEEE Xplore. Search terms included: extended reality, augmented reality, virtual reality, arthroplasty, joint replacement, total knee arthroplasty, total shoulder arthroplasty, and total hip arthroplasty. The study design, intervention details, outcomes, and comparisons with traditional surgical techniques were thematically analyzed, with identification of common ideas associated with XR use in arthroplasty. This narrative report highlights the integration of XR in arthroplasty.

Extended Reality Fundamentals

XR encompasses augmented reality (AR), virtual reality (VR), and mixed reality (MR). AR involves superimposing digitally rendered information and images onto the surgeon’s view of the real world, typically through the use of a headset and smart glasses.¹ AR allows the surgeon to move and interact freely within the OR, removing the need for additional screens or devices to display patient information or imaging. VR is a fully immersive simulation using a headset that obstructs the view of the real world but allows the user to move freely within this virtual setting, often with audio or other sensory stimuli. MR combines AR and VR to create a digital model that allows for real-world interaction, with the advantage of adapting information and models in real time.² Whereas in AR the surgeon can view the data projected from the headset, MR provides the ability to interact with and manipulate the digital content (Figure). Both AR and MR have been adapted for use in the OR, while VR has been adapted for use in surgical planning and training.

Extended Reality Use in Orthopedics

The HipNav system was introduced in 1995 to create preoperative plans that assist surgeons in accurately implanting the acetabular cup during total hip arthroplasty (THA).³ Although not commercially successful, this system spurred surgeons to experiment with XR to improve the accuracy and alignment of orthopedic implants. Systems capable of displaying the desired intraoperative implant placement have flourished, with applications in fracture reduction, arthroplasty, solid tumor resection, and hardware placement.^4-7 Accurate alignment has been linked to improvements in patient outcomes.^8-10 XR has great potential within the field of arthroplasty, with multiple new systems approved by the FDA and currently available in the US (Table).

Hip Arthroplasty

Orientation of the acetabular cup is a technically challenging part of THA. Accuracy in the anteversion and inclination angles of the acetabular cup is required to maintain implant stability, preserve functional range of motion (ROM), and prevent precocious wear.^11,12 Despite preoperative planning, surgeons often overestimate the inclination angle and underestimate anteversion.¹³ Improper implantation of the acetabular cup can lead to joint instability caused by aseptic loosening, increasing the risk of dislocation and the need for revision surgery.^14,15 Dislocations typically present to the emergency department, but primary care practitioners may encounter patients with pain or diminished sensation due to impingement or instability.¹⁶

The introduction of XR into the OR has provided the opportunity for real-time navigation and adjustment of the acetabular cup to maximize anteversion and inclination angles. Currently, 2 FDA-approved systems are available for THA: the Zimmer and Surgical Planning Associates HipInsight system, and the Insight Augmented Reality Visualization and Information System (ARVIS). The HipInsight system consists of a hologram projection using the Microsoft HoloLens2 device and optimizes preoperative planning, producing accuracy of anteversion and inclination angles within 3°.¹⁷ ARVIS employs existing surgical helmets and 2 mounted tracking cameras to provide navigation intraoperatively. ARVIS has also been approved for use in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty.¹⁸

HipInsight has shown utility in increasing the accuracy of acetabular cup placement along with the use of biplanar radiographic scans.¹⁹ However, there are no studies validating the efficacy of ARVIS and HipInsight and assessing long-term disease-oriented or patient-oriented outcomes.

Knee Arthroplasty

In the setting of TKA, XR is most effective in ensuring accurate resection of the tibial and femoral components. Achieving the planned femoral coronal, axial, and sagittal angles allows the prosthesis to be on the femoral axis of rotation, improving functional outcomes. XR systems for TKA have been shown to increase the accuracy of distal femoral resection with a limited increase in surgery duration.^20,21 For TKA in particular, patients are often less satisfied with the result than surgeons expect.²² Accurate alignment can improve patient satisfaction and reduce return-to-clinic rates for postoperative pain management, a factor that primary care practitioners should consider when recommending a patient for TKA.²³

Along with ARVIS, 3 additional XR systems are FDA-approved for use in TKA. The Pixee Medical Knee+ system uses smart glasses and trackers to aid in the positioning of instruments for improved accuracy while allowing real-time navigation.²⁴ The Medacta NextAR Knee’s single-use tracking system allows for intraoperative navigation with the use of AR glasses.²⁵ The Polaris STELLAR Knee uses MR and avoids the need for preoperative imaging by capturing real-time anatomic data.²⁶

The Pixee Medical Knee+ system was commercially available in Europe for several years prior to FDA approval, so more research exists on its efficacy. One study found that the Pixee Medical Knee+ system initially demonstrated an inferior clinical outcome, attributed to the learning curve associated with using the system.²⁷ However, more recent studies have shown its utility in improving alignment, regardless of implant specifications.^28,29 The Medacta NextAR Knee system has been shown to improve accuracy of tibial rotation and soft tissue balance and even increase OR efficiency.^30,31 The Polaris STELLAR Knee system received FDA approval in 2023; no published research exists on its accuracy and outcomes.²⁶

Shoulder Arthroplasty

Minimally invasive techniques are favored in total shoulder arthroplasty (TSA) due to the vitality of maintaining the surrounding soft tissue to maximize preservation of motility and strength.³² However, this complicates the procedure by decreasing the ability to effectively access and visualize key structures of the shoulder. Accordingly, issues with implant positioning and alignment are more common with TSA than other joint arthroplasties, making XR particularly promising.³³ Some studies report that up to 67% of patients experience glenohumeral instability, which can clinically present as weakness, decreased range of motion, and persistent shoulder pain.^34,35 The use of preoperative computed tomography to improve understanding of glenoid anatomy and glenohumeral subluxation is becoming increasingly common, and it can be combined with XR to improve accuracy.^36,37

Two FDA-approved systems are available. The Stryker Blueprint MR system is used for intraoperative guidance and integration for patient imaging used for preoperative planning. The Medacta NextAR Shoulder system is a parallel of the company’s TKA system. The Stryker Blueprint MR system combines the Microsoft HoloLens 2 headset to display preoperative plans with a secondary display for coordination with the rest of the surgical team.³⁸ Similar to the Medacta NextAR Knee, the Medacta NextAR Shoulder system uses the same single-use tracking system and AR glasses for intraoperative guidance.³⁹

Data on the long-term outcomes of using these systems are still limited, but the Stryker Blueprint MR system has not been shown to accurately predict postoperative ROM.⁴⁰ Cadaveric studies have demonstrated that the Medacta NextAR Shoulder system can provide accurate inclination, retroversion, entry point, depth, and rotation values based on the preoperative planned values.^41,42 However, this accuracy has yet to be confirmed in vivo, and the impact of using XR in TSA on long-term outcomes is still unknown.

Challenges and Limitations

Though XR has proven to be promising in arthroplasty, several limitations regarding widespread implementation exist. In particular, there is a steep learning curve associated with the use of XR systems, which can cause increased operative time and even initial inferior outcomes, as demonstrated with the Pixee Medical Knee+ system. The need for extensive practice and training prior to use could delay widespread adoption and may cause discrepancies in surgical outcomes. Unfamiliarity with the system and technological difficulties that may require troubleshooting can also increase operative time, particularly for surgeons new to using the XR system. Though intraoperative navigation is expected to improve accuracy of implant alignment, its added complexity may also result in longer surgeries.

In addition to the steep learning curve and increased operative time, there is a high upfront cost associated with XR systems. Exact costs of XR systems are not typically disclosed, but available estimates suggest an average sales price of about $1000 per case. Given the proprietary nature of these technologies, publicly available cost data are limited, making it challenging to fully assess the financial burden on health care institutions. Though some systems, such as ARVIS, can be integrated with existing surgical helmets, many require the purchase of AR glasses and secondary displays. This can cause further variation in the total expense for each system. In low-resource settings, this represents a significant challenge to widespread implementation. To justify this cost, additional research on long-term patient outcomes is needed to ensure the benefits of XR systems outweigh the cost. 

Although early studies on XR systems in arthroplasty have shown improvements in precision and short-term outcomes, long-term data regarding effectiveness remains. Even systems such as ARVIS and HipInsight have limited long-term follow-up, making it difficult to assess whether the improved accuracy with these XR systems translates into improved patient outcomes compared with traditional arthroplasty.

CONCLUSIONS

XR technologies have shown significant potential in enhancing precision and patient outcomes. Through the integration of XR in the OR, surgeons can visualize preoperative plans and even make intraoperative changes, with the benefit of improving implant alignment.

There are some disadvantages to its use, however, including high cost and increased operative time. Despite this, the integration of XR into surgical practice can deliver more precise implant alignment and address other challenges faced with conventional techniques. As these technologies evolve and studies on long-term outcomes validate their utility, XR has the potential to transform the field of arthroplasty.

The introduction of extended reality (XR) to the operating room (OR) has proved promising for enhancing surgical precision and improving patient outcomes. In the field of orthopedic surgery, precise alignment of implants is integral to maintaining functional range of motion and preventing impingement of adjacent neurovascular structures. XR systems have shown promise in arthroplasty including by improving precision and streamlining surgery by allowing surgeons to create 3D preoperative plans that are accessible intraoperatively. This article explores the current applications of XR in arthroplasty, highlights recent advancements and benefits, and describes limitations in comparison to traditional techniques.

Methods

A literature search identified studies involving the use of XR in arthroplasty and current US Food and Drug Administration (FDA)-approved XR systems. Multiple electronic databases were used, including PubMed, Google Scholar, and IEEE Xplore. Search terms included: extended reality, augmented reality, virtual reality, arthroplasty, joint replacement, total knee arthroplasty, total shoulder arthroplasty, and total hip arthroplasty. The study design, intervention details, outcomes, and comparisons with traditional surgical techniques were thematically analyzed, with identification of common ideas associated with XR use in arthroplasty. This narrative report highlights the integration of XR in arthroplasty.

Extended Reality Fundamentals

XR encompasses augmented reality (AR), virtual reality (VR), and mixed reality (MR). AR involves superimposing digitally rendered information and images onto the surgeon’s view of the real world, typically through the use of a headset and smart glasses.¹ AR allows the surgeon to move and interact freely within the OR, removing the need for additional screens or devices to display patient information or imaging. VR is a fully immersive simulation using a headset that obstructs the view of the real world but allows the user to move freely within this virtual setting, often with audio or other sensory stimuli. MR combines AR and VR to create a digital model that allows for real-world interaction, with the advantage of adapting information and models in real time.² Whereas in AR the surgeon can view the data projected from the headset, MR provides the ability to interact with and manipulate the digital content (Figure). Both AR and MR have been adapted for use in the OR, while VR has been adapted for use in surgical planning and training.

Extended Reality Use in Orthopedics

The HipNav system was introduced in 1995 to create preoperative plans that assist surgeons in accurately implanting the acetabular cup during total hip arthroplasty (THA).³ Although not commercially successful, this system spurred surgeons to experiment with XR to improve the accuracy and alignment of orthopedic implants. Systems capable of displaying the desired intraoperative implant placement have flourished, with applications in fracture reduction, arthroplasty, solid tumor resection, and hardware placement.^4-7 Accurate alignment has been linked to improvements in patient outcomes.^8-10 XR has great potential within the field of arthroplasty, with multiple new systems approved by the FDA and currently available in the US (Table).

Hip Arthroplasty

Orientation of the acetabular cup is a technically challenging part of THA. Accuracy in the anteversion and inclination angles of the acetabular cup is required to maintain implant stability, preserve functional range of motion (ROM), and prevent precocious wear.^11,12 Despite preoperative planning, surgeons often overestimate the inclination angle and underestimate anteversion.¹³ Improper implantation of the acetabular cup can lead to joint instability caused by aseptic loosening, increasing the risk of dislocation and the need for revision surgery.^14,15 Dislocations typically present to the emergency department, but primary care practitioners may encounter patients with pain or diminished sensation due to impingement or instability.¹⁶

The introduction of XR into the OR has provided the opportunity for real-time navigation and adjustment of the acetabular cup to maximize anteversion and inclination angles. Currently, 2 FDA-approved systems are available for THA: the Zimmer and Surgical Planning Associates HipInsight system, and the Insight Augmented Reality Visualization and Information System (ARVIS). The HipInsight system consists of a hologram projection using the Microsoft HoloLens2 device and optimizes preoperative planning, producing accuracy of anteversion and inclination angles within 3°.¹⁷ ARVIS employs existing surgical helmets and 2 mounted tracking cameras to provide navigation intraoperatively. ARVIS has also been approved for use in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty.¹⁸

HipInsight has shown utility in increasing the accuracy of acetabular cup placement along with the use of biplanar radiographic scans.¹⁹ However, there are no studies validating the efficacy of ARVIS and HipInsight and assessing long-term disease-oriented or patient-oriented outcomes.

Knee Arthroplasty

In the setting of TKA, XR is most effective in ensuring accurate resection of the tibial and femoral components. Achieving the planned femoral coronal, axial, and sagittal angles allows the prosthesis to be on the femoral axis of rotation, improving functional outcomes. XR systems for TKA have been shown to increase the accuracy of distal femoral resection with a limited increase in surgery duration.^20,21 For TKA in particular, patients are often less satisfied with the result than surgeons expect.²² Accurate alignment can improve patient satisfaction and reduce return-to-clinic rates for postoperative pain management, a factor that primary care practitioners should consider when recommending a patient for TKA.²³

Along with ARVIS, 3 additional XR systems are FDA-approved for use in TKA. The Pixee Medical Knee+ system uses smart glasses and trackers to aid in the positioning of instruments for improved accuracy while allowing real-time navigation.²⁴ The Medacta NextAR Knee’s single-use tracking system allows for intraoperative navigation with the use of AR glasses.²⁵ The Polaris STELLAR Knee uses MR and avoids the need for preoperative imaging by capturing real-time anatomic data.²⁶

The Pixee Medical Knee+ system was commercially available in Europe for several years prior to FDA approval, so more research exists on its efficacy. One study found that the Pixee Medical Knee+ system initially demonstrated an inferior clinical outcome, attributed to the learning curve associated with using the system.²⁷ However, more recent studies have shown its utility in improving alignment, regardless of implant specifications.^28,29 The Medacta NextAR Knee system has been shown to improve accuracy of tibial rotation and soft tissue balance and even increase OR efficiency.^30,31 The Polaris STELLAR Knee system received FDA approval in 2023; no published research exists on its accuracy and outcomes.²⁶

Shoulder Arthroplasty

Minimally invasive techniques are favored in total shoulder arthroplasty (TSA) due to the vitality of maintaining the surrounding soft tissue to maximize preservation of motility and strength.³² However, this complicates the procedure by decreasing the ability to effectively access and visualize key structures of the shoulder. Accordingly, issues with implant positioning and alignment are more common with TSA than other joint arthroplasties, making XR particularly promising.³³ Some studies report that up to 67% of patients experience glenohumeral instability, which can clinically present as weakness, decreased range of motion, and persistent shoulder pain.^34,35 The use of preoperative computed tomography to improve understanding of glenoid anatomy and glenohumeral subluxation is becoming increasingly common, and it can be combined with XR to improve accuracy.^36,37

Two FDA-approved systems are available. The Stryker Blueprint MR system is used for intraoperative guidance and integration for patient imaging used for preoperative planning. The Medacta NextAR Shoulder system is a parallel of the company’s TKA system. The Stryker Blueprint MR system combines the Microsoft HoloLens 2 headset to display preoperative plans with a secondary display for coordination with the rest of the surgical team.³⁸ Similar to the Medacta NextAR Knee, the Medacta NextAR Shoulder system uses the same single-use tracking system and AR glasses for intraoperative guidance.³⁹

Data on the long-term outcomes of using these systems are still limited, but the Stryker Blueprint MR system has not been shown to accurately predict postoperative ROM.⁴⁰ Cadaveric studies have demonstrated that the Medacta NextAR Shoulder system can provide accurate inclination, retroversion, entry point, depth, and rotation values based on the preoperative planned values.^41,42 However, this accuracy has yet to be confirmed in vivo, and the impact of using XR in TSA on long-term outcomes is still unknown.

Challenges and Limitations

Though XR has proven to be promising in arthroplasty, several limitations regarding widespread implementation exist. In particular, there is a steep learning curve associated with the use of XR systems, which can cause increased operative time and even initial inferior outcomes, as demonstrated with the Pixee Medical Knee+ system. The need for extensive practice and training prior to use could delay widespread adoption and may cause discrepancies in surgical outcomes. Unfamiliarity with the system and technological difficulties that may require troubleshooting can also increase operative time, particularly for surgeons new to using the XR system. Though intraoperative navigation is expected to improve accuracy of implant alignment, its added complexity may also result in longer surgeries.

In addition to the steep learning curve and increased operative time, there is a high upfront cost associated with XR systems. Exact costs of XR systems are not typically disclosed, but available estimates suggest an average sales price of about $1000 per case. Given the proprietary nature of these technologies, publicly available cost data are limited, making it challenging to fully assess the financial burden on health care institutions. Though some systems, such as ARVIS, can be integrated with existing surgical helmets, many require the purchase of AR glasses and secondary displays. This can cause further variation in the total expense for each system. In low-resource settings, this represents a significant challenge to widespread implementation. To justify this cost, additional research on long-term patient outcomes is needed to ensure the benefits of XR systems outweigh the cost. 

Although early studies on XR systems in arthroplasty have shown improvements in precision and short-term outcomes, long-term data regarding effectiveness remains. Even systems such as ARVIS and HipInsight have limited long-term follow-up, making it difficult to assess whether the improved accuracy with these XR systems translates into improved patient outcomes compared with traditional arthroplasty.

CONCLUSIONS

XR technologies have shown significant potential in enhancing precision and patient outcomes. Through the integration of XR in the OR, surgeons can visualize preoperative plans and even make intraoperative changes, with the benefit of improving implant alignment.

There are some disadvantages to its use, however, including high cost and increased operative time. Despite this, the integration of XR into surgical practice can deliver more precise implant alignment and address other challenges faced with conventional techniques. As these technologies evolve and studies on long-term outcomes validate their utility, XR has the potential to transform the field of arthroplasty.

TOPLINE:

Patients with COVID had a higher risk of developing diplopia and cranial nerve VI palsy than those with influenza. Compared with unvaccinated patients, recipients of mRNA vaccines against SARS-CoV-2 had a more than 30% reduced risk of developing posterior-segment complications including retinal edema, vitreous hemorrhage, and optic neuritis.

METHODOLOGY:

• Researchers conducted a retrospective cohort analysis of US electronic health records from March 2020 to April 2021 to assess eye complications after COVID and the effect of mRNA vaccination on them.
• They analyzed matched cohorts of 73,654 vaccinated patients with COVID (mean age, 60.6 years; 61.6% women) and 73,654 unvaccinated patients with the condition (mean age, 61.2 years; 62.8% women); vaccination status was determined based on recorded receipt of an mRNA vaccine.
• In a separate matched analysis, 77,809 patients with COVID (mean age, 39.3 years; 58.8% women) were compared with a historic cohort of 77,809 patients with influenza (mean age, 39.7 years; 58.9% women).
• The incidence of ophthalmic conditions — retinal artery occlusion, retinal vein occlusion, retinal edema, vitreous hemorrhage, and neuro-ophthalmic manifestations — was assessed within 4 months of infection.

TAKEAWAY:

• Vaccinated patients with COVID had 32% lower odds of retinal edema (odds ratio [OR], 0.68; 99.5% CI, 0.54-0.85), 45% lower odds of vitreous hemorrhage (OR, 0.55; 99.5% CI, 0.44-0.68), and 40% lower odds of optic neuritis (OR, 0.60; 99.5% CI, 0.43-0.85) than unvaccinated patients with the disease.
• No significant differences were found in the incidence of retinal artery occlusion, retinal vein occlusion, or retinal hemorrhage between the vaccinated and unvaccinated cohorts.
• Patients with COVID had markedly higher odds of diplopia (OR, 1.89; 99.5% CI, 1.53-2.32) and cranial nerve VI palsy (OR, 3.19; 99.5% CI, 1.82-5.59) than those with influenza.
• The incidence of other neuro-ophthalmic manifestations and retinal complications was similar between patients with COVID and those with influenza.

IN PRACTICE:

“The complications we assessed were rare, though our results showed an increased incidence of retinal edema, vitreous hemorrhage, and optic neuritis in the nonvaccinated COVID-19 cohort,” the researchers reported.

“The increased incidence of retinal edema and vitreous hemorrhage in the nonvaccinated cohort suggests a potential for COVID-19 to affect posterior segment structures,” they added.

SOURCE:

This study was led by Alexander E. Azar, Case Western Reserve University School of Medicine, Cleveland. It was published online in Eye.

LIMITATIONS:

This study could not determine if vaccination against COVID could prevent ophthalmic manifestations. Vaccination status may have been underreported since many participants received COVID vaccines at pharmacies or community centers not directly documented in the electronic health records. The study’s timeframe only reflected data from early strains of SARS-CoV-2 between March 2020 and April 2021, potentially limiting generalizability to newer variants or later vaccination phases. 

DISCLOSURES:

This study received support from the Clinical and Translational Science Collaborative of Cleveland, funded by the National Institutes of Health, National Center for Advancing Translational Science, and other sources. Some authors reported serving as consultants, participating in speakers’ bureaus, receiving personal fees, and having other ties with multiple pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Patients with COVID had a higher risk of developing diplopia and cranial nerve VI palsy than those with influenza. Compared with unvaccinated patients, recipients of mRNA vaccines against SARS-CoV-2 had a more than 30% reduced risk of developing posterior-segment complications including retinal edema, vitreous hemorrhage, and optic neuritis.

METHODOLOGY:

• Researchers conducted a retrospective cohort analysis of US electronic health records from March 2020 to April 2021 to assess eye complications after COVID and the effect of mRNA vaccination on them.
• They analyzed matched cohorts of 73,654 vaccinated patients with COVID (mean age, 60.6 years; 61.6% women) and 73,654 unvaccinated patients with the condition (mean age, 61.2 years; 62.8% women); vaccination status was determined based on recorded receipt of an mRNA vaccine.
• In a separate matched analysis, 77,809 patients with COVID (mean age, 39.3 years; 58.8% women) were compared with a historic cohort of 77,809 patients with influenza (mean age, 39.7 years; 58.9% women).
• The incidence of ophthalmic conditions — retinal artery occlusion, retinal vein occlusion, retinal edema, vitreous hemorrhage, and neuro-ophthalmic manifestations — was assessed within 4 months of infection.

TAKEAWAY:

• Vaccinated patients with COVID had 32% lower odds of retinal edema (odds ratio [OR], 0.68; 99.5% CI, 0.54-0.85), 45% lower odds of vitreous hemorrhage (OR, 0.55; 99.5% CI, 0.44-0.68), and 40% lower odds of optic neuritis (OR, 0.60; 99.5% CI, 0.43-0.85) than unvaccinated patients with the disease.
• No significant differences were found in the incidence of retinal artery occlusion, retinal vein occlusion, or retinal hemorrhage between the vaccinated and unvaccinated cohorts.
• Patients with COVID had markedly higher odds of diplopia (OR, 1.89; 99.5% CI, 1.53-2.32) and cranial nerve VI palsy (OR, 3.19; 99.5% CI, 1.82-5.59) than those with influenza.
• The incidence of other neuro-ophthalmic manifestations and retinal complications was similar between patients with COVID and those with influenza.

IN PRACTICE:

“The complications we assessed were rare, though our results showed an increased incidence of retinal edema, vitreous hemorrhage, and optic neuritis in the nonvaccinated COVID-19 cohort,” the researchers reported.

“The increased incidence of retinal edema and vitreous hemorrhage in the nonvaccinated cohort suggests a potential for COVID-19 to affect posterior segment structures,” they added.

SOURCE:

This study was led by Alexander E. Azar, Case Western Reserve University School of Medicine, Cleveland. It was published online in Eye.

LIMITATIONS:

This study could not determine if vaccination against COVID could prevent ophthalmic manifestations. Vaccination status may have been underreported since many participants received COVID vaccines at pharmacies or community centers not directly documented in the electronic health records. The study’s timeframe only reflected data from early strains of SARS-CoV-2 between March 2020 and April 2021, potentially limiting generalizability to newer variants or later vaccination phases. 

DISCLOSURES:

This study received support from the Clinical and Translational Science Collaborative of Cleveland, funded by the National Institutes of Health, National Center for Advancing Translational Science, and other sources. Some authors reported serving as consultants, participating in speakers’ bureaus, receiving personal fees, and having other ties with multiple pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Patients with COVID had a higher risk of developing diplopia and cranial nerve VI palsy than those with influenza. Compared with unvaccinated patients, recipients of mRNA vaccines against SARS-CoV-2 had a more than 30% reduced risk of developing posterior-segment complications including retinal edema, vitreous hemorrhage, and optic neuritis.

METHODOLOGY:

• Researchers conducted a retrospective cohort analysis of US electronic health records from March 2020 to April 2021 to assess eye complications after COVID and the effect of mRNA vaccination on them.
• They analyzed matched cohorts of 73,654 vaccinated patients with COVID (mean age, 60.6 years; 61.6% women) and 73,654 unvaccinated patients with the condition (mean age, 61.2 years; 62.8% women); vaccination status was determined based on recorded receipt of an mRNA vaccine.
• In a separate matched analysis, 77,809 patients with COVID (mean age, 39.3 years; 58.8% women) were compared with a historic cohort of 77,809 patients with influenza (mean age, 39.7 years; 58.9% women).
• The incidence of ophthalmic conditions — retinal artery occlusion, retinal vein occlusion, retinal edema, vitreous hemorrhage, and neuro-ophthalmic manifestations — was assessed within 4 months of infection.

TAKEAWAY:

• Vaccinated patients with COVID had 32% lower odds of retinal edema (odds ratio [OR], 0.68; 99.5% CI, 0.54-0.85), 45% lower odds of vitreous hemorrhage (OR, 0.55; 99.5% CI, 0.44-0.68), and 40% lower odds of optic neuritis (OR, 0.60; 99.5% CI, 0.43-0.85) than unvaccinated patients with the disease.
• No significant differences were found in the incidence of retinal artery occlusion, retinal vein occlusion, or retinal hemorrhage between the vaccinated and unvaccinated cohorts.
• Patients with COVID had markedly higher odds of diplopia (OR, 1.89; 99.5% CI, 1.53-2.32) and cranial nerve VI palsy (OR, 3.19; 99.5% CI, 1.82-5.59) than those with influenza.
• The incidence of other neuro-ophthalmic manifestations and retinal complications was similar between patients with COVID and those with influenza.

IN PRACTICE:

“The complications we assessed were rare, though our results showed an increased incidence of retinal edema, vitreous hemorrhage, and optic neuritis in the nonvaccinated COVID-19 cohort,” the researchers reported.

“The increased incidence of retinal edema and vitreous hemorrhage in the nonvaccinated cohort suggests a potential for COVID-19 to affect posterior segment structures,” they added.

SOURCE:

This study was led by Alexander E. Azar, Case Western Reserve University School of Medicine, Cleveland. It was published online in Eye.

LIMITATIONS:

This study could not determine if vaccination against COVID could prevent ophthalmic manifestations. Vaccination status may have been underreported since many participants received COVID vaccines at pharmacies or community centers not directly documented in the electronic health records. The study’s timeframe only reflected data from early strains of SARS-CoV-2 between March 2020 and April 2021, potentially limiting generalizability to newer variants or later vaccination phases. 

DISCLOSURES:

This study received support from the Clinical and Translational Science Collaborative of Cleveland, funded by the National Institutes of Health, National Center for Advancing Translational Science, and other sources. Some authors reported serving as consultants, participating in speakers’ bureaus, receiving personal fees, and having other ties with multiple pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

Efforts to identify older men at risk for osteoporosis and treat those who are eligible received a boost from results reported from a Veterans Affairs (VA) study that showed a significant increase in screening, treatment, and medication adherence.

The cluster randomized trial used a centralized nurse-led intervention to assess men for traditional osteoporosis risk factors, offer bone density testing, and recommend treatment for eligible men. Over 2 years, the intervention group had a higher average femoral neck bone density than patients who underwent usual care.

“We designed this study to see if a risk factor-based approach, which is what most of the guidelines use, made sense and was feasible — that men would be accepting of screening and [the approach] would yield a similar proportion of people who need osteoporosis treatment as screening in women, which is widely recommended and implemented. And sure enough, we found that about 85% of the men in the VA primary care practices in our target age range of between 65 and 85 actually met criteria for screening, and over half of them had low bone mass. They were very accepting of screening, very accepting of treatment, and had excellent compliance rates. So, our study, we believe, supports the idea of identifying men with at least one risk factor for fracture and offering them osteoporosis screening starting at age 65, similar to what we do for women,” Cathleen S. Colón-Emeric, MD, MHS, said in an interview. She is the lead author of the study, a physician in the Durham VA Health Care System, and professor of medicine at Duke University School of Medicine, Durham, North Carolina.

“We were able to see a positive effect on bone density in the bone health group, compared with the usual care group, which suggests that if we followed these folks longer and had enough of them, we would be able to show a fracture reduction benefit,” Colón-Emeric said.

There have been few randomized trials of screening interventions in men, leading to inconsistencies in guidelines, according to the authors of the new study, published online in JAMA Internal Medicine . Both the US Preventive Services Task Force and the Veterans Health Administration National Center for Health Promotion and Disease Prevention consider there to be insufficient evidence to recommend for or against screening in men who have not experienced a fracture. Some professional societies recommend such screening, but there are inconsistencies in the recommended criteria, such as age range or risk factors.

Beyond the age of 50 years, one in five men will experience an osteoporosis-related fracture at some point in their life, according to a 2009 study. Treatment is inexpensive and effective in both men and women, and economic models suggest that screening using dual-energy x-ray absorptiometry (DXA) would be cost-effective. Still, screening is rare among men, with fewer than 10% of men getting screened before having an osteoporosis-related fracture.

“It’s important to screen men at risk for osteoporosis due to the dramatically increased mortality men suffer after a fragility fracture compared with women. Within 1 year of a hip fracture, mortality is as high as 36%. Studies have also shown that osteoporosis in men is undertreated, with only 10%-50% being prescribed antifracture treatment within 1 year of a hip fracture. Most individuals do not regain their prior level of function after a hip fracture,” said Joe C. Huang, MD, who was asked for comment. He is a clinical assistant professor of gerontology and geriatric medicine at Harborview Medical Center Senior Care Clinic and Healthy Bones Clinic in Seattle.

 

Details of the Intervention

The bone health service (BHS) intervention employed an electronic health record case-finding tool and a nurse care manager who undertook screening and treatment monitoring. They identified potential risk factors that included hyperthyroidism, hyperparathyroidism, rheumatoid arthritis, alcohol dependence, chronic lung disease, chronic liver disease, stroke, parkinsonism, prostate cancer, smoking, diabetes, pernicious anemia, gastrectomy, or high-risk medication use in at least 3 months of the prior 2 years. These medications included traditional antiepileptics, glucocorticoids, and androgen deprivation therapy.

The BHS nurse invited eligible men to be screened using an initial letter, followed by up to three phone calls. After DXA screening, the nurse scheduled an electronic consult with an osteoporosis expert, and patients with a T-score between -1 and -2.4 and an elevated 10-year fracture risk as measured by the Fracture Risk Assessment Tool were recommended for osteoporosis medication, vitamin D, and dietary or supplemental calcium. Following the prescription, the nurse provided patient education over the phone and mailed out written instructions. The nurse also made phone calls at 1 month, 6 months, and 12 months to encourage adherence and address common treatment barriers such as forgetting to take medication or dealing with gastrointestinal effects. The researchers recruited 38 primary care physicians from two VA health systems. The study included 3112 male veterans between the ages of 65 and 85 years (40.4% Black and 56% White). Nearly all participants (85.5%) had at least one indication for screening according to VA undersecretary guidelines, and almost a third (32.1%) had been prescribed androgen deprivation therapy, traditional antiepileptic drugs, or glucocorticoids.

Over a mean follow-up of 1.5 years, there was a much higher screening rate in the BHS group (49.2% vs 2.3%; P < .001), with a similar overall yield of DXA results recommending osteoporosis treatment (22.4% vs 27.2%). In the BHS group, 84.4% of patients who had treatment recommended followed through with treatment initiation. The mean persistence over follow-up was 657 days (SD, 366 days), and adherence was high with a mean proportion of days covered of 91.7%.

It was not possible to statistically compare adherence with the usual-care group because there were too few screened patients found to be eligible for treatment in that group, but the historic mean proportion of days covered at the two participating facilities was 52%. 

After 2 years, the mean femoral neck T-score tested randomly in a subset of patients was better in the BHS arm, although it did not meet statistical significance according to the Bonferroni corrected criterion of P < .025 (-0.55 vs -0.70; P = .04). Fracture rates were similar between the two groups (1.8% vs 2.0%; P = .69). 

 

Can the Findings Be Translated Across Clinics?

It remains to be seen how well the model could translate to other healthcare settings, according to Kenny Lin, MD, MPH, who was asked for comment on the study. “Outside of the VA health system and perhaps integrated HMOs [health maintenance organizations] such as Kaiser, Geisinger, etc., it seems unlikely that most primary care docs will have access to a centralized bone health service. Who’s going to pay for it? It leaves unanswered the question of whether it’s more efficient to address [osteoporosis] screening on a practice or population level. I suspect the latter is probably superior, but this study doesn’t provide any empiric evidence that this is so,” said Lin, associate director of the Penn Medicine Lancaster General Hospital’s Family Medicine Residency Program, Lancaster, Pennsylvania. The findings could help sway recommendations to screen men for osteoporosis, according to Susan Ott, MD, who was also asked for comment. Guideline committees “have been trying to be very scientific [about it]. I think they overdo it because they only look at one or two kinds of studies, and there are more kinds of science than just a randomized clinical trial. But they’re kind of stuck on that. The fact that this study was a randomized trial maybe they will finally change their recommendation, because there really shouldn’t be any difference in screening for men and for women. The men are actually discriminated against,” said Ott, emeritus professor of medicine at the University of Washington, Seattle.

In fact, she noted that the risks for men are similar to those for women, except that men tend to develop issues 5-10 years later in life. To screen and treat men, healthcare systems can “do the same thing they do with women. Just change the age range,” Ott said.

Lin sounded a different note, suggesting that the focus should remain on improvement of screening and treatment adherence in women. “We know that up to two thirds of women discontinue osteoporosis drugs within a year, and if we can’t figure out how to improve abysmal adherence in women, it’s unlikely we will persuade enough men to take these drugs to make a difference,” he said.

The study was funded by a grant from the VA Health Systems Research. Colón-Emeric, Lin, Ott, and Huang reported having no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Efforts to identify older men at risk for osteoporosis and treat those who are eligible received a boost from results reported from a Veterans Affairs (VA) study that showed a significant increase in screening, treatment, and medication adherence.

The cluster randomized trial used a centralized nurse-led intervention to assess men for traditional osteoporosis risk factors, offer bone density testing, and recommend treatment for eligible men. Over 2 years, the intervention group had a higher average femoral neck bone density than patients who underwent usual care.

“We designed this study to see if a risk factor-based approach, which is what most of the guidelines use, made sense and was feasible — that men would be accepting of screening and [the approach] would yield a similar proportion of people who need osteoporosis treatment as screening in women, which is widely recommended and implemented. And sure enough, we found that about 85% of the men in the VA primary care practices in our target age range of between 65 and 85 actually met criteria for screening, and over half of them had low bone mass. They were very accepting of screening, very accepting of treatment, and had excellent compliance rates. So, our study, we believe, supports the idea of identifying men with at least one risk factor for fracture and offering them osteoporosis screening starting at age 65, similar to what we do for women,” Cathleen S. Colón-Emeric, MD, MHS, said in an interview. She is the lead author of the study, a physician in the Durham VA Health Care System, and professor of medicine at Duke University School of Medicine, Durham, North Carolina.

“We were able to see a positive effect on bone density in the bone health group, compared with the usual care group, which suggests that if we followed these folks longer and had enough of them, we would be able to show a fracture reduction benefit,” Colón-Emeric said.

There have been few randomized trials of screening interventions in men, leading to inconsistencies in guidelines, according to the authors of the new study, published online in JAMA Internal Medicine . Both the US Preventive Services Task Force and the Veterans Health Administration National Center for Health Promotion and Disease Prevention consider there to be insufficient evidence to recommend for or against screening in men who have not experienced a fracture. Some professional societies recommend such screening, but there are inconsistencies in the recommended criteria, such as age range or risk factors.

Beyond the age of 50 years, one in five men will experience an osteoporosis-related fracture at some point in their life, according to a 2009 study. Treatment is inexpensive and effective in both men and women, and economic models suggest that screening using dual-energy x-ray absorptiometry (DXA) would be cost-effective. Still, screening is rare among men, with fewer than 10% of men getting screened before having an osteoporosis-related fracture.

“It’s important to screen men at risk for osteoporosis due to the dramatically increased mortality men suffer after a fragility fracture compared with women. Within 1 year of a hip fracture, mortality is as high as 36%. Studies have also shown that osteoporosis in men is undertreated, with only 10%-50% being prescribed antifracture treatment within 1 year of a hip fracture. Most individuals do not regain their prior level of function after a hip fracture,” said Joe C. Huang, MD, who was asked for comment. He is a clinical assistant professor of gerontology and geriatric medicine at Harborview Medical Center Senior Care Clinic and Healthy Bones Clinic in Seattle.

 

Details of the Intervention

The bone health service (BHS) intervention employed an electronic health record case-finding tool and a nurse care manager who undertook screening and treatment monitoring. They identified potential risk factors that included hyperthyroidism, hyperparathyroidism, rheumatoid arthritis, alcohol dependence, chronic lung disease, chronic liver disease, stroke, parkinsonism, prostate cancer, smoking, diabetes, pernicious anemia, gastrectomy, or high-risk medication use in at least 3 months of the prior 2 years. These medications included traditional antiepileptics, glucocorticoids, and androgen deprivation therapy.

The BHS nurse invited eligible men to be screened using an initial letter, followed by up to three phone calls. After DXA screening, the nurse scheduled an electronic consult with an osteoporosis expert, and patients with a T-score between -1 and -2.4 and an elevated 10-year fracture risk as measured by the Fracture Risk Assessment Tool were recommended for osteoporosis medication, vitamin D, and dietary or supplemental calcium. Following the prescription, the nurse provided patient education over the phone and mailed out written instructions. The nurse also made phone calls at 1 month, 6 months, and 12 months to encourage adherence and address common treatment barriers such as forgetting to take medication or dealing with gastrointestinal effects. The researchers recruited 38 primary care physicians from two VA health systems. The study included 3112 male veterans between the ages of 65 and 85 years (40.4% Black and 56% White). Nearly all participants (85.5%) had at least one indication for screening according to VA undersecretary guidelines, and almost a third (32.1%) had been prescribed androgen deprivation therapy, traditional antiepileptic drugs, or glucocorticoids.

Over a mean follow-up of 1.5 years, there was a much higher screening rate in the BHS group (49.2% vs 2.3%; P < .001), with a similar overall yield of DXA results recommending osteoporosis treatment (22.4% vs 27.2%). In the BHS group, 84.4% of patients who had treatment recommended followed through with treatment initiation. The mean persistence over follow-up was 657 days (SD, 366 days), and adherence was high with a mean proportion of days covered of 91.7%.

It was not possible to statistically compare adherence with the usual-care group because there were too few screened patients found to be eligible for treatment in that group, but the historic mean proportion of days covered at the two participating facilities was 52%. 

After 2 years, the mean femoral neck T-score tested randomly in a subset of patients was better in the BHS arm, although it did not meet statistical significance according to the Bonferroni corrected criterion of P < .025 (-0.55 vs -0.70; P = .04). Fracture rates were similar between the two groups (1.8% vs 2.0%; P = .69). 

 

Can the Findings Be Translated Across Clinics?

It remains to be seen how well the model could translate to other healthcare settings, according to Kenny Lin, MD, MPH, who was asked for comment on the study. “Outside of the VA health system and perhaps integrated HMOs [health maintenance organizations] such as Kaiser, Geisinger, etc., it seems unlikely that most primary care docs will have access to a centralized bone health service. Who’s going to pay for it? It leaves unanswered the question of whether it’s more efficient to address [osteoporosis] screening on a practice or population level. I suspect the latter is probably superior, but this study doesn’t provide any empiric evidence that this is so,” said Lin, associate director of the Penn Medicine Lancaster General Hospital’s Family Medicine Residency Program, Lancaster, Pennsylvania. The findings could help sway recommendations to screen men for osteoporosis, according to Susan Ott, MD, who was also asked for comment. Guideline committees “have been trying to be very scientific [about it]. I think they overdo it because they only look at one or two kinds of studies, and there are more kinds of science than just a randomized clinical trial. But they’re kind of stuck on that. The fact that this study was a randomized trial maybe they will finally change their recommendation, because there really shouldn’t be any difference in screening for men and for women. The men are actually discriminated against,” said Ott, emeritus professor of medicine at the University of Washington, Seattle.

In fact, she noted that the risks for men are similar to those for women, except that men tend to develop issues 5-10 years later in life. To screen and treat men, healthcare systems can “do the same thing they do with women. Just change the age range,” Ott said.

Lin sounded a different note, suggesting that the focus should remain on improvement of screening and treatment adherence in women. “We know that up to two thirds of women discontinue osteoporosis drugs within a year, and if we can’t figure out how to improve abysmal adherence in women, it’s unlikely we will persuade enough men to take these drugs to make a difference,” he said.

The study was funded by a grant from the VA Health Systems Research. Colón-Emeric, Lin, Ott, and Huang reported having no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Efforts to identify older men at risk for osteoporosis and treat those who are eligible received a boost from results reported from a Veterans Affairs (VA) study that showed a significant increase in screening, treatment, and medication adherence.

The cluster randomized trial used a centralized nurse-led intervention to assess men for traditional osteoporosis risk factors, offer bone density testing, and recommend treatment for eligible men. Over 2 years, the intervention group had a higher average femoral neck bone density than patients who underwent usual care.

“We designed this study to see if a risk factor-based approach, which is what most of the guidelines use, made sense and was feasible — that men would be accepting of screening and [the approach] would yield a similar proportion of people who need osteoporosis treatment as screening in women, which is widely recommended and implemented. And sure enough, we found that about 85% of the men in the VA primary care practices in our target age range of between 65 and 85 actually met criteria for screening, and over half of them had low bone mass. They were very accepting of screening, very accepting of treatment, and had excellent compliance rates. So, our study, we believe, supports the idea of identifying men with at least one risk factor for fracture and offering them osteoporosis screening starting at age 65, similar to what we do for women,” Cathleen S. Colón-Emeric, MD, MHS, said in an interview. She is the lead author of the study, a physician in the Durham VA Health Care System, and professor of medicine at Duke University School of Medicine, Durham, North Carolina.

“We were able to see a positive effect on bone density in the bone health group, compared with the usual care group, which suggests that if we followed these folks longer and had enough of them, we would be able to show a fracture reduction benefit,” Colón-Emeric said.

There have been few randomized trials of screening interventions in men, leading to inconsistencies in guidelines, according to the authors of the new study, published online in JAMA Internal Medicine . Both the US Preventive Services Task Force and the Veterans Health Administration National Center for Health Promotion and Disease Prevention consider there to be insufficient evidence to recommend for or against screening in men who have not experienced a fracture. Some professional societies recommend such screening, but there are inconsistencies in the recommended criteria, such as age range or risk factors.

Beyond the age of 50 years, one in five men will experience an osteoporosis-related fracture at some point in their life, according to a 2009 study. Treatment is inexpensive and effective in both men and women, and economic models suggest that screening using dual-energy x-ray absorptiometry (DXA) would be cost-effective. Still, screening is rare among men, with fewer than 10% of men getting screened before having an osteoporosis-related fracture.

“It’s important to screen men at risk for osteoporosis due to the dramatically increased mortality men suffer after a fragility fracture compared with women. Within 1 year of a hip fracture, mortality is as high as 36%. Studies have also shown that osteoporosis in men is undertreated, with only 10%-50% being prescribed antifracture treatment within 1 year of a hip fracture. Most individuals do not regain their prior level of function after a hip fracture,” said Joe C. Huang, MD, who was asked for comment. He is a clinical assistant professor of gerontology and geriatric medicine at Harborview Medical Center Senior Care Clinic and Healthy Bones Clinic in Seattle.

 

Details of the Intervention

The bone health service (BHS) intervention employed an electronic health record case-finding tool and a nurse care manager who undertook screening and treatment monitoring. They identified potential risk factors that included hyperthyroidism, hyperparathyroidism, rheumatoid arthritis, alcohol dependence, chronic lung disease, chronic liver disease, stroke, parkinsonism, prostate cancer, smoking, diabetes, pernicious anemia, gastrectomy, or high-risk medication use in at least 3 months of the prior 2 years. These medications included traditional antiepileptics, glucocorticoids, and androgen deprivation therapy.

The BHS nurse invited eligible men to be screened using an initial letter, followed by up to three phone calls. After DXA screening, the nurse scheduled an electronic consult with an osteoporosis expert, and patients with a T-score between -1 and -2.4 and an elevated 10-year fracture risk as measured by the Fracture Risk Assessment Tool were recommended for osteoporosis medication, vitamin D, and dietary or supplemental calcium. Following the prescription, the nurse provided patient education over the phone and mailed out written instructions. The nurse also made phone calls at 1 month, 6 months, and 12 months to encourage adherence and address common treatment barriers such as forgetting to take medication or dealing with gastrointestinal effects. The researchers recruited 38 primary care physicians from two VA health systems. The study included 3112 male veterans between the ages of 65 and 85 years (40.4% Black and 56% White). Nearly all participants (85.5%) had at least one indication for screening according to VA undersecretary guidelines, and almost a third (32.1%) had been prescribed androgen deprivation therapy, traditional antiepileptic drugs, or glucocorticoids.

Over a mean follow-up of 1.5 years, there was a much higher screening rate in the BHS group (49.2% vs 2.3%; P < .001), with a similar overall yield of DXA results recommending osteoporosis treatment (22.4% vs 27.2%). In the BHS group, 84.4% of patients who had treatment recommended followed through with treatment initiation. The mean persistence over follow-up was 657 days (SD, 366 days), and adherence was high with a mean proportion of days covered of 91.7%.

It was not possible to statistically compare adherence with the usual-care group because there were too few screened patients found to be eligible for treatment in that group, but the historic mean proportion of days covered at the two participating facilities was 52%. 

After 2 years, the mean femoral neck T-score tested randomly in a subset of patients was better in the BHS arm, although it did not meet statistical significance according to the Bonferroni corrected criterion of P < .025 (-0.55 vs -0.70; P = .04). Fracture rates were similar between the two groups (1.8% vs 2.0%; P = .69). 

 

Can the Findings Be Translated Across Clinics?

It remains to be seen how well the model could translate to other healthcare settings, according to Kenny Lin, MD, MPH, who was asked for comment on the study. “Outside of the VA health system and perhaps integrated HMOs [health maintenance organizations] such as Kaiser, Geisinger, etc., it seems unlikely that most primary care docs will have access to a centralized bone health service. Who’s going to pay for it? It leaves unanswered the question of whether it’s more efficient to address [osteoporosis] screening on a practice or population level. I suspect the latter is probably superior, but this study doesn’t provide any empiric evidence that this is so,” said Lin, associate director of the Penn Medicine Lancaster General Hospital’s Family Medicine Residency Program, Lancaster, Pennsylvania. The findings could help sway recommendations to screen men for osteoporosis, according to Susan Ott, MD, who was also asked for comment. Guideline committees “have been trying to be very scientific [about it]. I think they overdo it because they only look at one or two kinds of studies, and there are more kinds of science than just a randomized clinical trial. But they’re kind of stuck on that. The fact that this study was a randomized trial maybe they will finally change their recommendation, because there really shouldn’t be any difference in screening for men and for women. The men are actually discriminated against,” said Ott, emeritus professor of medicine at the University of Washington, Seattle.

In fact, she noted that the risks for men are similar to those for women, except that men tend to develop issues 5-10 years later in life. To screen and treat men, healthcare systems can “do the same thing they do with women. Just change the age range,” Ott said.

Lin sounded a different note, suggesting that the focus should remain on improvement of screening and treatment adherence in women. “We know that up to two thirds of women discontinue osteoporosis drugs within a year, and if we can’t figure out how to improve abysmal adherence in women, it’s unlikely we will persuade enough men to take these drugs to make a difference,” he said.

The study was funded by a grant from the VA Health Systems Research. Colón-Emeric, Lin, Ott, and Huang reported having no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Military culture may hold 2 salient risk factors for eating disorders: exposure to trauma and body condition standards. A recent study from the US Department of Veteran Affairs (VA) Salisbury Health Care System (VASHCS) found that veterans with posttraumatic stress disorder (PTSD) are more likely to report eating disturbances—particularly issues related to body dissatisfaction and dissatisfaction with eating habits. A 2019 study found that one-third of veterans who were overweight or obese screened positive for engaging in “making weight” behaviors during military service, or unhealthy weight control strategies. Frequently reported weight management behavior was excessive exercise, fasting/skipping meals, sitting in a sauna/wearing a latex suit, laxatives, diuretics, and vomiting.

Service members who are “normal” weight by civilian standards may be labeled “overweight” by the military. In a March 12 memo, Secretary of Defense Pete Hegseth ordered a US Department of Defense review of existing standards for physical fitness, body composition, and grooming. “Our troops will be fit — not fat. Our troops will look sharp — not sloppy. We seek only quality — not quotas. BOTTOM LINE: our @DeptofDefense will make standards HIGH & GREAT again — across the entire force,” he posted on X.

The desire to control weight to fit military standards, however, isn’t the only risk factor. Researchers at VASHCS surveyed 527 post-9/11 veterans (80.7% male) who typically deployed 1 or 2 times. All participants completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Neuro-Quality of Life in Neurological Disorders Positive Affect and Well-Being Scale (PAWB); and the Eating Disturbances Scale. 

Nearly half (46%) of the sample met diagnostic criteria for a lifetime PTSD diagnosis. The study also reported significantly greater eating disturbances in veterans with a lifetime PTSD diagnosis than those without. Women reported significantly greater eating disturbances than men.

Most participants (80%) reported some level of dissatisfaction with their eating disturbances and 74% of participants reported feeling as if they were too fat.

Eating disturbances include refusing food, overexercising, overeating, and misusing laxatives or diuretic pills. Previous research that suggest that 10% to 15% of female veterans and 4% to 8% of male veterans report clinically significant disordered eating behaviors, especially binge eating. One study found that 78% of 45,477 overweight or obese veterans receiving care in VA facilities reported clinically significant binge eating. In a 2021 study, 254 veterans presenting for routine clinical care completed self‐report questionnaires assessing eating disorders, PTSD, depression, and shame, and 31% met probable criteria for bulimia nervosa, binge‐eating disorder, or purging disorder.

According to a 2023 study, eating disturbances that do not meet diagnostic criteria for a formal disorder can be problematic and may function as coping strategies for some facets of military life. The VASHCS researchers found that interventions focused on PAWB, such as acceptance and commitment therapy or compassion-focused therapy, may have potential as a protective factor. Including components that foster hope, optimism, and personal strength may positively mitigate the relationship between PTSD and eating disturbances. PAWB was significantly correlated with eating disturbances; individuals with a lifetime PTSD diagnosis reported significantly lower PAWB than those without.

Interventions grounded in positive psychology have shown promise. A group-based program found “noticeable” (although nonsignificant) improvements in optimistic thinking and treatment engagement. The study also cites that clinicians are beginning to incorporate positive psychology strategies (eg, gratitude journaling, goal setting, and “best possible self” visualization) as adjuncts to traditional treatments. Positive psychology, they write, holds “significant promise as a complementary approach to enhance recovery outcomes in both PTSD and eating disorders.” 

Military culture may hold 2 salient risk factors for eating disorders: exposure to trauma and body condition standards. A recent study from the US Department of Veteran Affairs (VA) Salisbury Health Care System (VASHCS) found that veterans with posttraumatic stress disorder (PTSD) are more likely to report eating disturbances—particularly issues related to body dissatisfaction and dissatisfaction with eating habits. A 2019 study found that one-third of veterans who were overweight or obese screened positive for engaging in “making weight” behaviors during military service, or unhealthy weight control strategies. Frequently reported weight management behavior was excessive exercise, fasting/skipping meals, sitting in a sauna/wearing a latex suit, laxatives, diuretics, and vomiting.

Service members who are “normal” weight by civilian standards may be labeled “overweight” by the military. In a March 12 memo, Secretary of Defense Pete Hegseth ordered a US Department of Defense review of existing standards for physical fitness, body composition, and grooming. “Our troops will be fit — not fat. Our troops will look sharp — not sloppy. We seek only quality — not quotas. BOTTOM LINE: our @DeptofDefense will make standards HIGH & GREAT again — across the entire force,” he posted on X.

The desire to control weight to fit military standards, however, isn’t the only risk factor. Researchers at VASHCS surveyed 527 post-9/11 veterans (80.7% male) who typically deployed 1 or 2 times. All participants completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Neuro-Quality of Life in Neurological Disorders Positive Affect and Well-Being Scale (PAWB); and the Eating Disturbances Scale. 

Nearly half (46%) of the sample met diagnostic criteria for a lifetime PTSD diagnosis. The study also reported significantly greater eating disturbances in veterans with a lifetime PTSD diagnosis than those without. Women reported significantly greater eating disturbances than men.

Most participants (80%) reported some level of dissatisfaction with their eating disturbances and 74% of participants reported feeling as if they were too fat.

Eating disturbances include refusing food, overexercising, overeating, and misusing laxatives or diuretic pills. Previous research that suggest that 10% to 15% of female veterans and 4% to 8% of male veterans report clinically significant disordered eating behaviors, especially binge eating. One study found that 78% of 45,477 overweight or obese veterans receiving care in VA facilities reported clinically significant binge eating. In a 2021 study, 254 veterans presenting for routine clinical care completed self‐report questionnaires assessing eating disorders, PTSD, depression, and shame, and 31% met probable criteria for bulimia nervosa, binge‐eating disorder, or purging disorder.

According to a 2023 study, eating disturbances that do not meet diagnostic criteria for a formal disorder can be problematic and may function as coping strategies for some facets of military life. The VASHCS researchers found that interventions focused on PAWB, such as acceptance and commitment therapy or compassion-focused therapy, may have potential as a protective factor. Including components that foster hope, optimism, and personal strength may positively mitigate the relationship between PTSD and eating disturbances. PAWB was significantly correlated with eating disturbances; individuals with a lifetime PTSD diagnosis reported significantly lower PAWB than those without.

Interventions grounded in positive psychology have shown promise. A group-based program found “noticeable” (although nonsignificant) improvements in optimistic thinking and treatment engagement. The study also cites that clinicians are beginning to incorporate positive psychology strategies (eg, gratitude journaling, goal setting, and “best possible self” visualization) as adjuncts to traditional treatments. Positive psychology, they write, holds “significant promise as a complementary approach to enhance recovery outcomes in both PTSD and eating disorders.” 

Military culture may hold 2 salient risk factors for eating disorders: exposure to trauma and body condition standards. A recent study from the US Department of Veteran Affairs (VA) Salisbury Health Care System (VASHCS) found that veterans with posttraumatic stress disorder (PTSD) are more likely to report eating disturbances—particularly issues related to body dissatisfaction and dissatisfaction with eating habits. A 2019 study found that one-third of veterans who were overweight or obese screened positive for engaging in “making weight” behaviors during military service, or unhealthy weight control strategies. Frequently reported weight management behavior was excessive exercise, fasting/skipping meals, sitting in a sauna/wearing a latex suit, laxatives, diuretics, and vomiting.

Service members who are “normal” weight by civilian standards may be labeled “overweight” by the military. In a March 12 memo, Secretary of Defense Pete Hegseth ordered a US Department of Defense review of existing standards for physical fitness, body composition, and grooming. “Our troops will be fit — not fat. Our troops will look sharp — not sloppy. We seek only quality — not quotas. BOTTOM LINE: our @DeptofDefense will make standards HIGH & GREAT again — across the entire force,” he posted on X.

The desire to control weight to fit military standards, however, isn’t the only risk factor. Researchers at VASHCS surveyed 527 post-9/11 veterans (80.7% male) who typically deployed 1 or 2 times. All participants completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Neuro-Quality of Life in Neurological Disorders Positive Affect and Well-Being Scale (PAWB); and the Eating Disturbances Scale. 

Nearly half (46%) of the sample met diagnostic criteria for a lifetime PTSD diagnosis. The study also reported significantly greater eating disturbances in veterans with a lifetime PTSD diagnosis than those without. Women reported significantly greater eating disturbances than men.

Most participants (80%) reported some level of dissatisfaction with their eating disturbances and 74% of participants reported feeling as if they were too fat.

Eating disturbances include refusing food, overexercising, overeating, and misusing laxatives or diuretic pills. Previous research that suggest that 10% to 15% of female veterans and 4% to 8% of male veterans report clinically significant disordered eating behaviors, especially binge eating. One study found that 78% of 45,477 overweight or obese veterans receiving care in VA facilities reported clinically significant binge eating. In a 2021 study, 254 veterans presenting for routine clinical care completed self‐report questionnaires assessing eating disorders, PTSD, depression, and shame, and 31% met probable criteria for bulimia nervosa, binge‐eating disorder, or purging disorder.

According to a 2023 study, eating disturbances that do not meet diagnostic criteria for a formal disorder can be problematic and may function as coping strategies for some facets of military life. The VASHCS researchers found that interventions focused on PAWB, such as acceptance and commitment therapy or compassion-focused therapy, may have potential as a protective factor. Including components that foster hope, optimism, and personal strength may positively mitigate the relationship between PTSD and eating disturbances. PAWB was significantly correlated with eating disturbances; individuals with a lifetime PTSD diagnosis reported significantly lower PAWB than those without.

Interventions grounded in positive psychology have shown promise. A group-based program found “noticeable” (although nonsignificant) improvements in optimistic thinking and treatment engagement. The study also cites that clinicians are beginning to incorporate positive psychology strategies (eg, gratitude journaling, goal setting, and “best possible self” visualization) as adjuncts to traditional treatments. Positive psychology, they write, holds “significant promise as a complementary approach to enhance recovery outcomes in both PTSD and eating disorders.” 

For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.

In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.

Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.

The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.

VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.

VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.

Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.

In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."

The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.

In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.

The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."

For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.

In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.

Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.

The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.

VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.

VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.

Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.

In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."

The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.

In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.

The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."

For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.

In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.

Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.

The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.

VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.

VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.

Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.

In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."

The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.

In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.

The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."

The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.

According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.

The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.

VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.

During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.

The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.

According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.

The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.

VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.

During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.

The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.

According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.

The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.

VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.

During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.

WASHINGTON (Reuters) - U.S. Health Secretary Robert F. Kennedy Jr. said on July 28 that he will work to “fix” the program that compensates victims of vaccine injuries, the National Vaccine Injury Compensation Program.

Kennedy, a long-time vaccine skeptic and former vaccine injury plaintiff lawyer, accused the program and its so-called “Vaccine Court” of corruption and inefficiency in a post on X. He has long been an outspoken critic of the program.

“I will not allow the VICP to continue to ignore its mandate and fail its mission of quickly and fairly compensating vaccine-injured individuals,” he wrote, adding he was working with Attorney General Pam Bondi. “Together, we will steer the Vaccine Court back to its original congressional intent.”

He said the structure disadvantaged claimants because the Department of Health & Human Services – which he now leads – is the defendant, as opposed to vaccine makers.

Changing the VICP would be the latest in a series of far-reaching actions by Kennedy to reshape U.S. regulation of vaccines, food and medicine.

In June, he fired all 17 members of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, a panel of vaccine experts, replacing them with 7 handpicked members, including known vaccine skeptics.

One of them earned thousands of dollars as an expert witness in litigation against Merck’s, Gardasil vaccine, court records show. Kennedy himself played an instrumental role in organizing mass litigation over the vaccine.

He also is planning to remove all the members of another advisory panel that determines what preventive health measures insurers must cover, the Wall Street Journal reported on July 25. An HHS spokesperson said Kennedy had not yet made a decision regarding the 16-member U.S. Preventive Services Task Force.

Kennedy has for years sown doubt about the safety and efficacy of vaccines. He has a history of clashing with the medical establishment and spreading misinformation about vaccines, including promoting a debunked link between vaccines and autism despite scientific evidence to the contrary.

He has also said the measles vaccine contains cells from aborted fetuses and that the mumps vaccination does not work, comments he made as the U.S. battles one of its worst outbreaks of measles in 25 years.

Kennedy made millions over the years from advocating against vaccines through case referrals, book sales, and consulting fees paid by a nonprofit he founded, according to ethics disclosures.

(Reporting by Ahmed Aboulenein; Additional reporting by Ryan Patrick Jones in Toronto; Editing by Doina Chiacu and Nia Williams)

A version of this article appeared on Medscape.com.

WASHINGTON (Reuters) - U.S. Health Secretary Robert F. Kennedy Jr. said on July 28 that he will work to “fix” the program that compensates victims of vaccine injuries, the National Vaccine Injury Compensation Program.

Kennedy, a long-time vaccine skeptic and former vaccine injury plaintiff lawyer, accused the program and its so-called “Vaccine Court” of corruption and inefficiency in a post on X. He has long been an outspoken critic of the program.

“I will not allow the VICP to continue to ignore its mandate and fail its mission of quickly and fairly compensating vaccine-injured individuals,” he wrote, adding he was working with Attorney General Pam Bondi. “Together, we will steer the Vaccine Court back to its original congressional intent.”

He said the structure disadvantaged claimants because the Department of Health & Human Services – which he now leads – is the defendant, as opposed to vaccine makers.

Changing the VICP would be the latest in a series of far-reaching actions by Kennedy to reshape U.S. regulation of vaccines, food and medicine.

In June, he fired all 17 members of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, a panel of vaccine experts, replacing them with 7 handpicked members, including known vaccine skeptics.

One of them earned thousands of dollars as an expert witness in litigation against Merck’s, Gardasil vaccine, court records show. Kennedy himself played an instrumental role in organizing mass litigation over the vaccine.

He also is planning to remove all the members of another advisory panel that determines what preventive health measures insurers must cover, the Wall Street Journal reported on July 25. An HHS spokesperson said Kennedy had not yet made a decision regarding the 16-member U.S. Preventive Services Task Force.

Kennedy has for years sown doubt about the safety and efficacy of vaccines. He has a history of clashing with the medical establishment and spreading misinformation about vaccines, including promoting a debunked link between vaccines and autism despite scientific evidence to the contrary.

He has also said the measles vaccine contains cells from aborted fetuses and that the mumps vaccination does not work, comments he made as the U.S. battles one of its worst outbreaks of measles in 25 years.

Kennedy made millions over the years from advocating against vaccines through case referrals, book sales, and consulting fees paid by a nonprofit he founded, according to ethics disclosures.

(Reporting by Ahmed Aboulenein; Additional reporting by Ryan Patrick Jones in Toronto; Editing by Doina Chiacu and Nia Williams)

A version of this article appeared on Medscape.com.

WASHINGTON (Reuters) - U.S. Health Secretary Robert F. Kennedy Jr. said on July 28 that he will work to “fix” the program that compensates victims of vaccine injuries, the National Vaccine Injury Compensation Program.

Kennedy, a long-time vaccine skeptic and former vaccine injury plaintiff lawyer, accused the program and its so-called “Vaccine Court” of corruption and inefficiency in a post on X. He has long been an outspoken critic of the program.

“I will not allow the VICP to continue to ignore its mandate and fail its mission of quickly and fairly compensating vaccine-injured individuals,” he wrote, adding he was working with Attorney General Pam Bondi. “Together, we will steer the Vaccine Court back to its original congressional intent.”

He said the structure disadvantaged claimants because the Department of Health & Human Services – which he now leads – is the defendant, as opposed to vaccine makers.

Changing the VICP would be the latest in a series of far-reaching actions by Kennedy to reshape U.S. regulation of vaccines, food and medicine.

In June, he fired all 17 members of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, a panel of vaccine experts, replacing them with 7 handpicked members, including known vaccine skeptics.

One of them earned thousands of dollars as an expert witness in litigation against Merck’s, Gardasil vaccine, court records show. Kennedy himself played an instrumental role in organizing mass litigation over the vaccine.

He also is planning to remove all the members of another advisory panel that determines what preventive health measures insurers must cover, the Wall Street Journal reported on July 25. An HHS spokesperson said Kennedy had not yet made a decision regarding the 16-member U.S. Preventive Services Task Force.

Kennedy has for years sown doubt about the safety and efficacy of vaccines. He has a history of clashing with the medical establishment and spreading misinformation about vaccines, including promoting a debunked link between vaccines and autism despite scientific evidence to the contrary.

He has also said the measles vaccine contains cells from aborted fetuses and that the mumps vaccination does not work, comments he made as the U.S. battles one of its worst outbreaks of measles in 25 years.

Kennedy made millions over the years from advocating against vaccines through case referrals, book sales, and consulting fees paid by a nonprofit he founded, according to ethics disclosures.

(Reporting by Ahmed Aboulenein; Additional reporting by Ryan Patrick Jones in Toronto; Editing by Doina Chiacu and Nia Williams)

A version of this article appeared on Medscape.com.

A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.

SSPs do not lead to increased drug use,¹ increased improperly disposed supplies needed for drug use in the community, or increased crime.^2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.^4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.^9-11

Syringe Services Program

SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20

Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.

SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.

Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.

The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.

Alaska VA Healthcare System

An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.

Southern Oregon Healthcare System

Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.

Discussion

The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.

The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.

Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.

No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.

Conclusions

The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.

A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.

SSPs do not lead to increased drug use,¹ increased improperly disposed supplies needed for drug use in the community, or increased crime.^2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.^4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.^9-11

Syringe Services Program

SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20

Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.

SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.

Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.

The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.

Alaska VA Healthcare System

An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.

Southern Oregon Healthcare System

Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.

Discussion

The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.

The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.

Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.

No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.

Conclusions

The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.

A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.

SSPs do not lead to increased drug use,¹ increased improperly disposed supplies needed for drug use in the community, or increased crime.^2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.^4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.^9-11

Syringe Services Program

SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20

Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.

SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.

Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.

The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.

Alaska VA Healthcare System

An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.

Southern Oregon Healthcare System

Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.

Discussion

The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.

The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.

Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.

No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.

Conclusions

The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.

TOPLINE:

Patients living in rural areas and those aged ≥ 65 y had increased odds of receiving mental health care exclusively by phone.

METHODOLOGY:

• Researchers explored factors linked to receiving phone-only mental health care among patients within the Department of Veterans Affairs.
• They included data for 1,156,146 veteran patients with at least one mental health-specific outpatient encounter between October 2021 and September 2022 and at least one between October 2022 and September 2023.
• Patients were categorized as those who received care through phone only (n = 49,125) and those who received care through other methods (n = 1,107,021. Care was received exclusively through video (6.39%), in-person (6.63%), or a combination of in-person, video, and/or phone (86.98%).
• Demographic and clinical predictors, including rurality, age, sex, race, ethnicity, and the number of mental health diagnoses (< 3 vs ≥ 3), were evaluated.

TAKEAWAY:

• The phone-only group had a mean of 6.27 phone visits, whereas those who received care through other methods had a mean of 4.79 phone visits.
• Highly rural patients had 1.50 times higher odds of receiving phone-only mental health care than their urban counterparts (adjusted odds ratio [aOR], 1.50; P < .0001).
• Patients aged 65 years or older were more than twice as likely to receive phone-only care than those younger than 30 years (aOR, ≥ 2.17; P < .0001).
• Having fewer than three mental health diagnoses and more than 50% of mental health visits conducted by medical providers was associated with higher odds of receiving mental health care exclusively by phone (aORs, 2.03 and 1.87, respectively; P < .0001).