Journals Watch - Knee pain and maternal smoking

Not had time to read the journals? Let Dr Alison Glenesk bring you up to date with the latest research.

The study intervention consisted of stretching exercises (Photograph: SPL)
The study intervention consisted of stretching exercises (Photograph: SPL)

Exercise and the prevention of anterior knee pain
Am J Sports Med 2011; 39: 940-8

Patients frequently present with sports or exercise-related anterior knee pain (AKP). Although this study was carried out on army recruits, I wondered if it might be applicable to the general population.

This single-blind RCT included 39 male and 11 female training groups (average age 19.7 years) undergoing a 14-week programme who were randomly assigned to an intervention (n = 759) or control (n = 743).

The study intervention consisted of four strengthening and four stretching exercises performed as part of the programme.

Participants in the control group performed standard warm-up exercises. The primary endpoint was the incidence of AKP during the 14 weeks of training.

A total of 46 participants were diagnosed with AKP: 36 in the control group and 10 in the intervention group, equating to a 75 per cent reduction in risk of AKP in the latter group.

In the intervention group, three participants were discharged from the army for medical reasons, compared with 25 participants discharged in the control group.

This exercise strategy seems highly effective. The challenge would be to make this regimen known to sporting participants in the general public, thereby reducing the incidence of a distressing and painful condition.

Maternal smoking and offspring growth
Arch Dis Child 2011; 96: 519-25

The authors of this study used three approaches to explore the effects of maternal smoking during pregnancy on the growth of offspring. The first approach involved multiple adjustments for socioeconomic and parental factors. Second, maternal and paternal factors were considered as a test of possible intra-uterine effects, and finally, two birth cohort studies were compared.

The population-based birth cohort studies were carried out in Brazil in 1994 and 2003, with follow-up at three, 12, 24 and 48 months. To determine the relationship between maternal and paternal prenatal smoking and anthropomorphic data, multiple linear regression analysis was used.

It was found that maternal smoking during pregnancy was associated with reduced length/height at each age group for both cohorts and reduced leg length at 48 months in the 2004 cohort.

Children who were aged more than three months also had a higher BMI/age than children of non-smokers. This study strongly suggests a causal effect of maternal smoking on growth and weight of offspring.

Prognosis in screened and symptomatic breast cancer
Br J Cancer 2011; 104: 1680-5

This article caught my interest as we are awaiting three-yearly breast screening at our practice.

The authors present 10-year breast cancer survival data from 19,411 women aged 50-64 years in the West Midlands. The aim was to estimate the survival advantage in screening-detected cases compared with symptomatic cases and accredit this to shifts in prognostic variables or differences specific to prognostic categories.

Tumour size, histological grade and Nottingham prognostic index were analysed for each group. Ten-year survival for the screening-detected group was 85.5 per cent (79.3 per cent when adjusted for lead-time bias) compared to 62.8 per cent for the symptomatic group. Further analysis indicated that improved survival in the screening group was due to difference in tumour size and node status, rather than biological difference in tumour type.

This implies that screening-detected tumours are caught at an earlier stage, which improves survival. We shall be promoting breast screening to our female patients with renewed vigour.

Detection of child abuse in emergency departments
Arch Dis Child 2011; 96: 422-5

This study examined the detection rates of suspected child abuse in the emergency departments of seven Dutch hospitals, only some of which used screening guidelines for detection of child abuse.

Data on demographics, diagnosis and suspected child abuse were collected for all children aged 18 years and below who visited the emergency departments over a six-month period. The completion of a checklist in at least 10 per cent of all visits was considered to indicate compliance with screening guidelines.

A total of 2,472 visits were analysed, 54 per cent in emergency departments using screening guidelines. Child abuse was suspected in 52 cases. In 77 per cent of these cases, a checklist had been completed, compared with a 19 per cent completion rate for the whole sample.

The detection rate was higher in hospitals using screening checklists than in those not using the checklists (0.3 per cent versus 0.1 per cent).

The authors conclude that suspected child abuse rates are very low, and that using screening guidelines improves detection. I feel that, while checklists are useful in detecting this uncommon presentation, clinical judgment must also be relied on.

Very low energy diet and obstructive sleep apnoea
BMJ 2011; 342: d3017

The objective of this single-centre study was to determine whether initial improvements in sleep apnoea, seen after following a very low calorie diet, were maintained after one year in men with moderate to severe sleep apnoea.

This study was a prospective observational one-year follow-up of a cohort derived from an RCT, consisting of 63 men with BMI 30-40kg/m2 and moderate to severe sleep apnoea treated with continuous positive airway pressure.

Study participants followed a nine-week very low calorie diet followed by a weight management programme continuing for one year.

It was found that initial improvement was sustained for one year, with patients in the most severe category showing most benefit.

I find these results surprising, as we know that most patients embarking on weight-loss programmes frequently regain weight lost in the initial period of enthusiasm.

  • Dr Alison Glenesk is a GP trainer in Aberdeen

Reflect on this article and add notes to your CPD Organiser on MIMS Learning


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Hold a practice meeting to discuss smoking cessation in pregnant women and devise a poster for your waiting room.
  • Draw up a checklist of signs to look out for in child abuse and laminate it for the consulting room. This presents so rarely that it is easy to misinterpret some vitally important signs.
  • Look at your uptake of breast screening. Could you increase this using posters to emphasise its importance, or could you include personalised information in the patient's mailshot?

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