Journals Watch - Knee injuries, GAD and opioids

Don't have the time to catch up with the latest journals? Dr Alison Glenesk brings you up to date.

Meniscal tear: knee injuries had a good outcome after follow up in primary care
Meniscal tear: knee injuries had a good outcome after follow up in primary care

Outcome of knee injuries in general practice - Br J Gen Pract 2010; 60: e56-e63
We see quite a number of knee injuries in our daily work, some of which seem to take a long time to improve.

In this Dutch prospective cohort observational study of 134 patients, outcomes were assessed at one year. Patients presenting with a knee injury were assessed by MRI scan. A variety of injuries were seen including a meniscal tear, a ligament lesion, a combination, or no lesion.

A total of 37 (28 per cent) were referred to physical therapy and 17 (13 per cent) referred to secondary care.

During the year of follow up, a further 21 therapy, and 11 secondary care referrals took place. Eighteen arthroscopies were performed on 15 patients.

At one year, 34 patients were fully recovered and 67 reported major improvement.

Interestingly, there was no difference in recovery time between those with or without lesions on MRI scan.

The authors conclude that the vast majority of patients report clinically significant recovery.

I am not sure that the 33 who do not seem to have recovered at all would be quite so optimistic.

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis - Br J Surg 2010; 97: 141-50

As an out-of-hours GP, one of my frustrations was seeing patients suffering multiple attacks of biliary colic or cholecystitis while on the waiting list for surgery.

A meta-analysis of randomised controlled trials of early (within one week of onset of symptoms) versus delayed (at least six weeks after symptoms settled) laparoscopic cholecystectomy was carried out.

Five trials involving 451 patients were included. No difference was found for bile duct injury or conversion to open cholecystectomy, and the hospital stay was shorter in the early cholecystectomy group.

At present, only 20 per cent of UK surgeons perform laparoscopic cholecystectomy during acute cholecystitis.

With around 50,000 cholecytectomies being carried out each year, it appears that morbidity could be reduced by adopting the above approach.

Pregabalin for generalised anxiety disorder - Drug Ther Bull 2010; 48: 19-22

Generalised anxiety disorder (GAD) is common, affecting about 4 per cent of the population. Treatment is difficult, and it is useful to have a new therapeutic option.

Eight double-blind randomised controlled trials compared pregabalin, an inhibitory neurotransmitter, used in neuropathic pain, with placebo.

Three published meta-analyses, involving five of the above trials have found that pregabalin improved GAD scores in doses of 300-600mg daily; reduced associated depression in doses of 150-600mg daily, and improved insomnia in doses of 300-600mg daily. Twelve per cent of patients withdrew due to side-effects.

Though the efficacy is similar to benzodiazepines and venlafaxine, price may be an issue, as the necessary daily dose works out as an expensive option.

However, I am sure we can all think of patients in whom a combination treatment for neuropathic pain and its psychological effects would be an advantage.

Opioid prescriptions for chronic pain and overdose - Ann Intern Med 2010; 152: 85-92

Long-term opioid treatment for non-cancer pain is becoming more acceptable and increasingly common, but unfortunately concomitant rates of fatal opioid overdose have followed.

The objective of this study was to estimate the rate of opioid overdose and the association with average prescribed daily dose among patients receiving medically prescribed long-term opiates.

A total of 9,940 patients who received three or more opioid prescriptions within 90 days between 1997 and 2005 were identified. There were 51 overdoses and six deaths.

Compared with patients having 1-20mg opioids daily, those getting 50-99mg daily had a 3.7-fold increased overdose risk, while those on the highest doses of 100mg or more had an 8.9-fold increase.

It is possible that some of these overdoses may have been accidental, however the message is clear - give only if you can provide close supervision. Also, look for alternatives rather than allowing the dose to escalate.

Antibodies against phosphorylcholine predict development of stroke - Stroke 2010, doi: 10.1161/STROKEAHA.109.558742

In this population-based study from northern Sweden, 227 people who had suffered a stroke over a 13-year period were compared with 445 sex and age-matched controls.

After correcting for age, sex, smoking, cholesterol, diabetes, BMI and BP, researchers were able to show that those with the lowest levels of anti-phosphorylcholine (a naturally occurring antibody) had a higher risk of stroke, amounting to an almost threefold increase in women.

The theory is that low levels of anti-phosphorylcholine antibodies can contribute to the development of atherosclerosis, increasing the risk of both MI and stroke.

The researchers are looking at the possibility of developing a vaccine, which presumably would also be effective against MI and other vascular diseases - an exciting thought.

  • Dr Glenesk is a GP trainer in Aberdeen and a member of our team who regularly review the journals

The Quick Study

  • Knee injuries are seen to improve in the majority of patients.
  • Early laparoscopic cholecystectomy leads to a shorter hospital stay for patients than delayed laparoscopic cholecystectomy.
  • Generalised anxiety disorder scores improved for patients taking pregabalin.
  • Opioid use for non-cancer pain should be accompanied by close patient supervision.
  • Anti-phosphorylcholine antibodies in low levels are associated with an increased risk of stroke.


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