Journals watch: Non-traumatic knee symptoms, prostate cancer and hypoglycaemia

Too busy to read the journals? Dr Liz Croton selects the latest papers of interest to GPs including non-traumatic knee symptoms, DRE in detecting prostate cancer, tramadol and hypoglycaemia

Non-traumatic knee symptoms

Br J Sports Med 2014; 0: 1-7. doi:10.1136 /bjsports-2014-093557

This study looked at 172 patients aged 12-35 years with non-traumatic knee pain, who attracted one of two diagnoses: unspecified knee symptoms (UKS) and patellofemoral pain syndrome (PFPS).

After 12 months of follow-up, 41% of patients with UKS still had pain, as did 19% of those available to follow up at six years. Of those with PFPS, 40% still had pain at six years.

Prognostic factors for persistent pain at one year in the UKS group were BMI >25, bilateral knee symptoms, low/middle education level and absence of self-reported knee crepitus. In the PFPS group, prognostic factors for persistent pain were BMI >25, bilateral symptoms, low/middle education level and self-reported swollen knees.

Being aware of these prognostic factors might help us to decide who might need early referral.

DRE in detecting prostate cancer

Br J Gen Pract 2014; doi: 10.3399/bjgp 14X682861

In this retrospective analysis of a cohort of men who had transrectal ultrasound guided prostate biopsy after an abnormal digital rectal examination (DRE), researchers correlated the pathology of the biopsy results with the clinical findings of the DRE.

They wanted to evaluate the usefulness of DRE and assess its positive predictive value and sensitivity.

Of 103 men referred over 53 months, 67% were referred on the basis of an abnormal DRE alone. All had normal age-adjusted PSA levels.

The remainder (33%) were referred because their PSA was perceived as raised, at >4g/L, but their age- adjusted PSA level was normal. Thirty-five per cent of those with abnormal PSA had prostate cancer; of these, 76% had high-grade disease.

The results indicated that DRE alone has a sensitivity of 81% and a specificity of 40% in diagnosing prostate cancer, and a positive predictive value of 42%.

Tramadol and hypoglycaemia

JAMA Intern Med 2014; doi:10.1001/jamainternmed.2014.6512

This case-control study examined tramadol use and hospitalisation for hypoglycaemia. It involved a cohort of 334,034 patients taking tramadol for non-cancer pain, of whom 1,105 were hospitalised for hypoglycaemia (incidence 0.7 per 1,000/year), matched with controls.

The study aimed to control for a number of confounders, such as liver disease, use of diabetic drugs and concurrent use of antidepressants.

The researchers found tramadol use was associated with an increased risk of hospitalisation for hypoglycaemia when compared with codeine (OR 1.52, 95% CI 1.09-2.10) and this was particularly elevated in the first 30 days of use. Codeine does not appear to have the same risks of hypoglycaemia as tramadol.

Aspirin use in healthy women

Heart 2014; doi:10.1136/heartjnl-2014-306342

The value of aspirin in the primary prevention of cardiovascular disease (CVD) and cancer remains unclear. This study aimed to identify which women would benefit from alternate-day aspirin (100mg) with respect to three clinical outcomes: cancer, CVD and major GI bleeding.

The subjects were healthy women enrolled in the Women's Health Study (n = 27,939), randomised to receive either 100mg alternate-day aspirin or placebo.

The results suggested aspirin was associated with a modest 15-year decreased risk of colorectal cancer and CVD. In most of the women, however, aspirin resulted in a negative treatment effect when taking into account the risk of GI bleeding.

Both the risk of bleeding and the beneficial effects with regard to colorectal cancer and CVD increased with age, and the study concluded that aspirin was only likely to be of benefit if used selectively in women aged ?65 years. The 15-year NNT to prevent one CVD/colorectal cancer event among this group was 29.

Alternative diagnoses in PE

Fam Pract 2014; 31(6): 670-7 doi: 10.1093/fampra/cmu055

The signs of pulmonary embolism (PE) are often non-specific and the diagnosis can be missed. In cases where the differential diagnosis includes PE, it would benefit the GP to have an empirical list of frequently occurring alternative diagnoses to aid clinical decision-making.

This study looked at 598 patients who had been referred to secondary care with suspected PE. After investigation, 516 were found not to have PE. In those without PE, the most frequent alternative diagnoses were non-specific thoracic pain (42.6%), pneumonia (13%), myalgia (11.8%), asthma/COPD (4.8%), hyperventilation (4.1%) and respiratory tract infection (2.3%). Pneumonia occurred almost as frequently as PE and a positive Wells rule or D-dimer test was positively associated with PE, but also with a higher probability of other clinically relevant disease.

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

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

  • Audit your practice to see how many healthy men receiving PSA tests have had a DRE.
  • Summarise the current recommendations for aspirin in primary prevention in a patient-friendly format and add this to your practice CVD prevention patient information leaflets.
  • Complete an online learning module on the diagnosis of PE and use the differential diagnoses listed above when assessing patients with chest pain and shortness of breath.

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