Journals Watch - Cruciate tears and suicide

Missed this week's journals? Let Dr Bryan Palmer bring you up to date on the latest research.

Anterior cruciate tears in young adults require rehabilitation and delayed optional reconstruction (Photograph: SPL)
Anterior cruciate tears in young adults require rehabilitation and delayed optional reconstruction (Photograph: SPL)

Treatment of anterior cruciate ligament tears - N Engl J Med 2010; 363: 331-42
The optimal management of a torn anterior cruciate ligament (ACL) of the knee is unknown.

This RCT involving 121 young adults with acute ACL injury compared two strategies: structured rehabilitation plus early ACL reconstruction and structured rehabilitation with optional delayed ACL reconstruction.

The outcome was the change in average score on four subscales of the knee injury and osteoarthritis outcome score (KOOS) - pain, symptoms, function in sports and recreation, and knee-related quality of life.

The score ranges from zero (worst) to 100 (best). Of 62 subjects assigned to rehabilitation plus early ACL reconstruction, one did not undergo surgery.

Of 59 assigned to rehabilitation plus optional delayed ACL reconstruction, 23 underwent delayed ACL reconstruction and the other 36 underwent rehabilitation alone.

The change in KOOS score from baseline to two years was 39.2 points for rehabilitation plus early ACL reconstruction and 39.4 for rehabilitation plus optional delayed reconstruction. The researchers concluded that early reconstruction in this subset was not the best option.

Preventing second suicide attempts - BMJ 2010; 341: c3222
This large Swedish cohort study had a follow-up of 21-31 years of 50,000 individuals who were admitted to hospital after a suicide attempt.

The aim was to identify any association between method of attempted suicide and risk of subsequent successful suicide. Almost 12 per cent went on to commit suicide and individuals who had attempted suicide by hanging, strangulation or suffocation had the worst prognosis.

In this group, 87 per cent were successful within one year of their first attempt. For other methods (gassing, jumping, using a firearm or explosive, or drowning) risk was raised but significantly lower than hanging.

This information should be used for intensive aftercare for those at high risk of subsequent suicide.

HDL-cholesterol and cardiovascular risk - Lancet 2010, doi:10.1016/S0140-6736(10)60713-1
HDL-cholesterol concentrations are inversely associated with occurrence of cardiovascular events. The authors looked at the JUPITER trial cohort to assess whether this association remains when LDL-cholesterol concentrations are reduced to low ranges with high-dose statins.

The 17,000 participants were ?50 years of age with no cardiovascular disease or diabetes but either a CRP ?2 mg/L or LDL <3.37 mmol/L. They were then randomised to either placebo or rosuvastatin 20mg.

Results were compared by dividing the two groups into quartiles depending on HDL levels. They found HDL-cholesterol concentrations are not predictive of residual vascular risk among patients treated with potent statin therapy who attain very low concentrations of LDL cholesterol. This adds weight to targeting LDL as a measure of success of statin therapy.

Sensor-augmented insulin-pump therapy in type-1 diabetes - N Engl J Med 2010; 363: 311-20
With new technology comes the need for new research to ascertain that progress is being made.

This US RCT compared the efficacy of sensor-augmented pump therapy with daily insulin injections in 485 poorly-controlled patients.

At one year, the baseline mean glycated hemoglobin level (8.3 per cent in both groups) had decreased to 7.5 per cent in the pump-therapy group and with 8.1 per cent in the injection-therapy group.

Severe hypoglycemia rates were similar between the two groups and neither gained weight. This study supports the use of insulin pumps in type-1 diabetes.

Surgical treatment of endometrial cancer - Lancet Oncology 2010, doi: 10.1016/S1470-045(10)70143-1
Total laparoscopic hysterectomy (TLH) and bilateral salpingo-oophorectomy is challenging the traditional technique, total abdominal hysterectomy (TAH), for early stage endometrial cancer.

This study compared the complication rates between the two methods. It was carried out in 21 hospitals in the Netherlands where 283 patients with stage I endometrioid adenocarcinoma or complex atypical hyperplasia were randomly allocated to the intervention group (TLH, n=187) or control group (TAH, n=96).

The proportion of major complications was 14.6 per cent in the TLH group versus 14.9 per cent in the TAH group. Conversion to laparotomy occurred in 10.8 per cent of the laparoscopic procedures.

TLH was associated with significantly less blood loss, less use of pain medication, a shorter hospital stay, and a faster recovery, but the procedure takes longer than TAH. Therefore, in skilled hands, the TLH is the method of choice.

Medically unexplained symptoms - Fam Pract 2010, doi:10.1093/fampra/cmq051
Definitions and resulting prevalence rates for medically unexplained symptoms (MUS) vary widely between studies.

The objective of this study was to characterise physicians' estimates of MUS and to demonstrate how estimates vary based on the definition used.

A total of 213 physicians completed an online questionnaire regarding the number of patients with MUS.

Depending on how restrictive the definition is, the rates estimated ranged from 3 per cent to 11 per cent.

Approximately 3 per cent of patients were estimated to have chronic MUS that affected their daily functioning and only half of these were assigned a diagnosis of somatoform disorder or factitious disorder.

The authors noted that previous chart reviews had suggested higher rates and despite physicians' recognition of significant distress and dysfunction in these cases, formal diagnoses of somatoform or factitious disorder are rarely assigned.

  • Dr Palmer is a former Hampshire GP currently working in Australia, and a member of our team who regularly review the journals
The Quick Study
  • Anterior cruciate ligament reconstruction in young adults is not always required.
  • Suicide attempts involving hanging, strangulation or suffocation had the worst prognosis for further suicide attempts.
  • HDL-cholesterol concentrations are not predictive of vascular risk among patients treated who attain very low concentrations of LDL cholesterol through statin therapy.
  • Glycaemic control in type-1 diabetes was shown to improve using sensor-augmented insulin pumps.
  • Early stage endometrial cancer should be treated with laparoscopic surgery.
  • Somatoform disorder is rarely assigned for medically unexplained symptoms.

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