Total knee replacement provides benefits
TOTAL knee replacement for patients with moderate-to-severe knee osteoarthritis followed by non-surgical treatment provides better pain relief and improves function and quality of life after 12 months compared with non-surgical treatment alone, according to research published in the New England Journal of Medicine. However, the randomised controlled trial also found that total knee replacement was associated with a higher number of serious adverse events, including deep venous thrombosis and stiffness requiring brisement forcé (manipulation of the knee while the patient is under anaesthesia to improve range of motion). The study included 100 patients eligible for unilateral total knee replacement who were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or 12 weeks of non-surgical treatment, which included exercise, education, dietary advice, use of insoles and pain medication provided by physiotherapists and dietitians. In the non-surgical group, 13 of 50 patients (26%) had a total knee replacement before the 12-month follow-up and in the knee-replacement group, one of 50 patients decided not to undergo surgery and received only the non-surgical treatment. The researchers wrote that both groups in the study had improvements in most outcomes, with those in the non-surgical group having “clinically relevant improvements”. An accompanying editorial said rates of total knee replacement had tripled in the US in the past 20 years and were projected to increase further. The editorial author wrote that the study provided “the first rigorously controlled data to inform discussions between patients and their physicians about whether to undergo total knee replacement or rigorous nonsurgical therapy”. As patient preferences for treatment varied considerably, “physicians should present the relevant data to their patients and then listen carefully”.
 
No benefit with opioids for low back pain
ADDING cyclobenzaprine or andoxycodone/acetaminophen to naproxen does not improve functional outcomes or pain in patients with acute non-traumatic, non-radicular low back pain (LBP), according to a study published in JAMA. The randomised controlled trial of 323 patients was conducted in an emergency department (ED) setting, where physicians often prescribe non-steroidal anti-inflammatory drugs (NSAIDS), skeletal muscle relaxants and opioids in combination, or NSAIDS combined with an opioid. Trial participants had experienced pain for 2 weeks or less and had substantial functional impairment. They were randomised to receive a 10-day supply of cyclobenzaprine, or oxycodone/acetaminophen, or placebo. All participants received naproxen. The researchers found that measures of pain, functional impairment and the use of health care resources were no different between the study groups at 7 days after the ED visit or at three months. They found a modest difference in pain outcomes in patients who took oxycodone/acetaminophen more than once, compared with placebo, but when adverse effects were considered, data did not support providing it in addition to naproxen for all ED patients with LBP. “Regardless of allocation, nearly two-thirds of patients demonstrated clinically significant improvement in LBP and function 1 week later”, they wrote. “However, 40% of the cohort reported moderate or severe pain, half reported functionally impairing LBP, and nearly 60% were still using medication for their LBP 1 week later. By 3-month follow-up, nearly one-fourth of the cohort reported moderate or severe pain and use of medications for LBP.” The researchers said their study provided evidence against the use of opioids for acute LBP; but opioids were not associated with higher rates of functional impairment, more frequent visits to the ED, or an increased propensity for continued opioid use.
 
Helmets linked to more body injuries
RESEARCH comparing the injury patterns of helmet use by riders in motorcycle accidents has found that helmeted riders had a higher number of injuries to the spine, trunk and extremities than unhelmeted riders. The helmeted riders also had significantly more orthopaedic procedures. The research letter, published in JAMA Surgery, was based 85 689 patients with motorcycle-related trauma identified from the 2007–2010 US National Trauma Database. The researchers found the incidence of head injury was higher among the unhelmeted riders (63.81%) than helmeted riders (38.95%). However, helmeted riders had higher rates of thoracic injury (47.76%) and extremity injury (80.18%) than unhelmeted riders (42.05% and 70.46%, respectively). Only small differences were found in total length of hospital stay, number of days in intensive care and number of days on a ventilator, with unhelmeted riders having slightly longer lengths of stay and increased numbers of days in intensive care. The researchers wrote that because of significantly higher rates of head injury among unhelmeted riders they were expected to have a markedly increased length of hospital stay. However, they found that the higher rates of other injuries among the helmeted group resulted in only slightly longer lengths of stay for unhelmeted patients. “Given the change in injury patterns from the head to the rest of the body as a result of helmet use, updated recommendations for the use of supplemental protective gear could be beneficial to both the individual and the health care system”, the researchers wrote.
 
Collaborative care improves outcomes for healthy older adults
A RANDOMISED trial comparing a collaborative health risk assessment (HRA) and counselling model with usual care for older people living in the community has found the HRA results in better health behaviours, increased use of recommended preventive care interventions and improves survival. The research, published in PLOS Medicine, included people aged 65 years and older, without pre-existing disability, living in Sweden, with 874 participants randomly allocated to the intervention and 1410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and GP counselling over a 2-year period. At 2 years, the intervention group had more favourable health behaviours and use of preventive care than the control group, including 70% being physically active compared with 62%, and 66% having influenza vaccinations in the previous year compared with 59%. At 8 years follow-up, mortality was significantly lower in the intervention group (77.9% alive) than in the control group (72.8%). The researchers wrote that this was likely due to early detection and successful modification of risk factors for functional status decline identified with the HRA-based intervention and the improvement in recommended preventive care use. The researchers admitted limitations in the research, including it being a single-site study, the use of a brief self-administered questionnaire for 2-year outcome data collection, and the lack of long-term outcome and mortality data. However, they said their findings had important implications for policy and practice. “Several countries have introduced multimodal preventive care programmes available to healthy older individuals, and are challenged to decide whether, and if so how, these programmes should be continued”, they wrote. A key factor for success was to ensure personal reinforcement of HRA-based recommendations by specially trained counsellors and to develop regionally adapted approaches to integrate HRA into primary care, they said.
 
Breast-cancer risk anxiety starts young
GIRLS aged 10‒13 years from families with a history of breast cancer or familial BRCA1/2 mutation [BCFH+] experience greater breast cancer-specific distress than girls without familial risk, according to a large study of girls growing up in breast-cancer affected families. The study, published in Pediatrics, included a cohort of 869 mother–daughter pairs from the US and Canada. It found no differences in general psychosocial adjustment among girls aged ‒13 years, whether their families had BCFH+ or not. However, BCFH+ girls aged 10‒13 years were more likely to report themselves at increased risk of breast cancer than their BCFH- peers (38% v 13.7%). Despite many being unsure of their risk, 12% of the BCFH+ girls in this age-group met cut-offs for clinically significant breast cancer-specific distress. While this percentage was relatively low, the researchers warned that the girls’ perceived risk might increase over time, leading to greater breast cancer-specific distress in adolescence. “This is particularly important because distress and externalizing problems have been associated with risk-taking behaviors among youth”, they wrote. Compounding this, “modifiable risks factors in adolescence affect the risk of breast cancer in adulthood and are likely even more important for girls who are at increased risk for breast cancer”. They wrote that understanding the impact of being identified at familial or genetic increased risk for adult cancer during childhood or adolescence “is critically important to developing genetic risk assessment policies that minimize negative psychosocial and behavioural impact across the age span”. Given that higher daughter breast cancer-specific distress was associated with higher maternal breast cancer-specific distress, the researchers suggested that interventions to address mothers’ and daughters’ concerns might improve teens’ psychosocial outcomes.
 

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