Journals Watch - Ligament damage and sunbeds

Don't have time to catch up on the latest journals? Let Dr Lizzie Croton bring you up to date.

Sensitivity of methods for examining the anterior cruciate ligament ranged from 15 to 85 per cent
Sensitivity of methods for examining the anterior cruciate ligament ranged from 15 to 85 per cent

Accuracy and reliability of anterior cruciate ligament clinical examination Clin J Sport Med 2010; 20 (2): 80-5
This is a US study regarding test reliability for anterior cruciate ligament damage.

Although taken from a multidisciplinary clinic, findings could be extrapolated to primary care as a high number of knee injuries are seen by GPs.

The study used a retrospective review of patient charting by resident physicians, physiotherapists and orthopaedic surgeons after they had examined patients with anterior cruciate injuries.

They rated three methods of examining the anterior cruciate ligament: the anterior drawer, the pivot shift and the Lachman test (similar to the anterior drawer but the knee is flexed at 20-30 degrees with the leg externally rotated).

They rated the tests for sensitivity by comparing clinical findings with arthroscopic surgery findings and also rated the tests for inter-rater reliability.

The Lachman test was the most sensitive when administered by orthopaedic surgeons and over the three tests the sensitivity ranged widely from 15-87 per cent. Inter-rater reliability was moderate in all tests. The authors were surprised that so much variability existed in a multidisciplinary knee clinic.

This study suggests the three tests should be carried out while maintaining a high level of suspicion for cruciate injury in patients with a good history.

Concurrent use of clopidogrel and proton pump inhibitors Ann Intern Med 2010; 152 (6): 337-45
Proton pump inhibitors (PPIs) are often co-prescribed with clopidogrel. This US retrospective cohort study aimed to identify the risks and benefits of the two therapies, the association between them and hospitalisation risk for GI bleeding and serious cardiovascular risk.

The study included 20,596 patients hospitalised between 1999 and 2005 for MI, coronary artery revascularisation and unstable angina pectoris. It also included 7,593 concurrent users of clopidogrel and PPIs.

Primary outcomes were hospitalisation for GI haemorrhage and serious cardiovascular disease including MI, sudden cardiac death, stroke or other cardiovascular death.

Hospitalisation for GI bleeding in concurrent PPI users was 50 per cent lower than in non-users. In patients at high risk of bleeding, PPI use was associated with an absolute reduction of 28.5 hospitalisations per 1,000 person years.

The hazard ratios for concurrent PPI use for risk of serious cardiovascular disease was 0.99 for the entire cohort and 1.01 for patients undergoing percutaneous coronary interventions and stenting during hospitalisation.

This study shows that clopidogrel and concurrent PPI use is associated with reduced hospitalisation for GI bleeding.

Are GPs under-investigating older women with symptoms of ovarian cancer? Br J Cancer 2010; 102: 947-51

This provocative study used data from the general practice research database (GPRD) and identified women aged 40-80 years with a Read code for ovarian cancer between June 2002 and May 2007.

The paper was produced on the back of research that suggested older patients in the UK were not benefiting as much from improvements in cancer treatments as younger patients.

One hypothesis suggested that differences in referral rates might account for this phenomenon. The GPRD data were compared with UK cancer registries and the relationship between age and coded investigations for ovarian cancer were investigated.

The GPRD rates peaked earlier at age 70-74 and were lower than the registry rates for nearly all ages, particularly for patients over 59. The proportion investigated and referred by the GP decreased significantly with age and delay between first coded symptoms and investigations showed a U-shaped relationship with age.

This study suggests GPs are less likely to recognise ovarian cancer as patients get older. The authors propose extrapolating this hypothesis to other cancers, which would be interesting.

Sunbed use in children BMJ 2010; 340: c877
With the incidence of malignant melanoma rising and a sunbed ban for those under the age of 18 looming, this paper is timely.

This study aimed to quantify sunbed use among children aged 11-17 years in England. They used data from two random location sampling surveys, the national prevalence study (NPS) and the six cities study (SCS).

The NPS used data from 3,101 children and the SCS included data from 6,209 children.

In the NPS, 6 per cent of children aged 1117 had used a sunbed. The use was higher in girls and in those aged from 15-17 than children aged 11-14 years. Use was also higher in those from lower social classes and in the north of the country, when compared with the Midlands and the south.

The median age of first use was 14 and 38.4 per cent used a sunbed at least once a week.

Nearly a quarter of children had used a sunbed at home and 24.7 per cent had used a sunbed unsupervised at a gym or tanning studio. These worrying figures reveal how widespread unsupervised sunbed use is in English children.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on lower urinary tract symptoms BJOG 2010; 117: 602-9
This Finnish RCT used a cohort of 236 women aged 35-49 referred for menorrhagia between 1994 and 1997.

They were randomly assigned to receive either treatment by hysterectomy or insertion of levonorgestrel-releasing intrauterine system (LNG-IUS). The researchers evaluated lower urinary tract symptoms at baseline and then at six months, 12 months, five years and 10 years.

Subsequent medications and surgery for urinary incontinence were obtained from their medical records and national registries. Ninety-four per cent were followed up after 10 years.

Women that underwent hysterectomy used more medication for urinary incontinence than LNG-IUS users (12 versus 1 per cent), and three women undergoing hysterectomies and one LNG-IUS user underwent surgery for stress incontinence.

Women treated by hysterectomy had more UTIs and also complained of more symptoms of stress incontinence and also feelings of incomplete emptying. There was no difference between the groups with regards to urge incontinence symptoms.

  • Dr Croton is a GP in Birmingham and a member of our team who regularly review the journals
The Quick Study

Anterior cruciate ligament damage clinical examinations vary in sensitivity and there is a high variability among different clinicians.

PPIs prescribed with clopidogrel decrease the risk of GI haemorrhage.

Ovarian cancer symptoms in older women may be being under-investigated by GPs.

Sunbed use is widespread among children in the UK and is a health hazard.

Hysterectomy increases risk of UTI and lower urinary tract symptoms.


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