Effect of stepped care on health outcomes in patients with osteoarthritis: an observational study in Dutch general practice

Background

A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.

Aim

To assess the association between care that is in line with the SCS recommendations and health outcomes.

Design and setting

Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.

Method

Care was considered ‘SCS-consistent’ if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0–100); active pain coping with the Pain Coping Inventory (range 10–40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12–48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.

Results

No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, −4.3 (95% confidence interval [CI] = −10.3 to 1.7) and −1.9 (95% CI = −7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.

Conclusion

The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.     

Defining knee pain trajectories in early symptomatic knee osteoarthritis in primary care: 5-year results from a nationwide prospective cohort study (CHECK)

Background

GPs have high consultation rates for symptoms related to knee osteoarthritis (OA). Many risk factors for symptomatic knee OA progression remain unknown.

Aim

To define distinct knee pain trajectories in individuals with early symptomatic knee OA and determine the risk factors for these pain trajectories.

Design and setting

Data were obtained from the multicentre prospective Cohort Hip and Cohort Knee study in the Netherlands. Participants with knee OA, according to the clinical criteria of the American College of Rheumatology, and a completed 5-year follow-up were included.

Method

Baseline demographic, anamnestic, and physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale for pain. Pain trajectories were retrieved by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios.

Results

In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. Statistically significant differences were found in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories. Higher BMI, lower level of education, greater comorbidity, higher activity limitation scores, and joint space tenderness were more often associated with trajectories characterised by more pain at first presentation and pain progression — compared with the reference group with a mild pain trajectory. No association was found for baseline radiographic features.

Conclusion

These results can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a ‘wait-and-see’ policy seems justifiable. Radiography provided no additional benefit over clinical diagnosis of early symptomatic knee OA in general practice.     

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

Background

The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.

Aim

To investigate whether using the rule adds to the GP’s clinical judgement.

Design and setting

A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.

Method

Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP’s clinical judgement aided by the MHS. Their accuracy was compared with the GPs’ unaided clinical judgement.

Results

Sensitivity and specificity of the GPs’ unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = −2.4 to 19.6) and the specificity was similar (difference −0.4%, 95% CI = −5.3 to 4.5); the sensitivity of the triage was similar (difference −1.5%, 95% CI = −9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = −6.9 to 23.0 and 5.8%, 95% CI = −1.6 to 13.2, respectively).

Conclusion

Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.     

Explosive Strength Imbalances in Professional Basketball Players

Context:

Despite the high rate of lower limb injuries in basketball players, studies of the dominant-limb effect in elite athletes often neglect injury history.

Objective:

To determine lower limb explosive-strength asymmetries in professional basketball players compared with junior basketball players and control participants.

Design:

Cohort study.

Setting:

Academic medical institution.

Patients or Other Participants:

15 professional basketball players, 10 junior basketball players, and 20 healthy men.

Main Outcome Measure(s):

We performed an isokinetic examination to evaluate the knee extensor (Ext) and flexor (Fl) concentric peak torque at 60°·s⁻¹ and 240°·s⁻¹ and (Fl only) eccentric peak torque at 30°·s⁻¹ and 120°·s⁻¹. Functional evaluation included countermovement jump, countermovement jump with arms, 10-m sprint, single-leg drop jump, and single-leg, 10-second continuous jumping. Variables were compared among groups using analysis of variance or a generalized linear mixed model for bilateral variables.

Results:

The 2 groups of basketball players demonstrated better isokinetic and functional performances than the control group did. No differences in functional or relative isokinetic variables were noted between professional and junior basketball players. Professional players with a history of knee injury failed to reach normal knee extensor strength at 60°·s⁻¹. Knee Ext (60°·s⁻¹) and Fl (eccentric 120°·s⁻¹) torque values as well as 10-second continuous jumping scores were higher in those professional players without a history of knee injury than those with such a history. Compared with the group without a history of knee injury, the group with a history of knee injury maintained leg asymmetry ratios greater than 10% for almost all isokinetic variables and more than 15% for unilateral functional variables.

Conclusions:

The relative isokinetic and functional performances of professional basketball players were similar to those of junior players, with no dominant-side effect. A history of knee injury in the professional athlete, however, was reflected in bilateral isokinetic and functional asymmetries and should be considered in future studies of explosive strength.     

Cost-effectiveness of magnetic resonance imaging of the knee for patients presenting in primary care

Background

Musculoskeletal problems generate high costs. Of these disorders, patients with knee problems are commonly seen by GPs. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test, but there is uncertainty as to whether GP access to MRI for these patients is a cost-effective policy.

Aim

To investigate the cost-effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems.

Design of study

Cost-effectiveness analysis alongside a pragmatic randomised trial.

Setting

Five-hundred and thirty-three patients consulting their GP about a knee problem were recruited from 163 general practices at 11 sites across the UK.

Method

Two-year costs were estimated from the NHS perspective. Health outcomes were expressed in terms of quality-adjusted life years (QALYs), based on patient responses to the EQ–5D questionnaire administered at baseline, and at 6, 12, and 24 months’ follow-up.

Results

Early MRI is associated with a higher NHS cost, by £294 ($581; €435) per patient (95% confidence interval [CI] = £31 to £573), and a larger number of QALYs, by 0.050 (95% CI = −0.025 to 0.118). Mean differences in cost and QALYs generated an incremental cost per QALY gained of £5840 ($11 538; €8642). At a cost per QALY threshold of £20 000, there is a 0.81 probability that early MRI is a cost-effective use of NHS resources.

Conclusion

GP access to MRI for patients presenting in primary care with a continuing knee problem represents a cost-effective use of health service resources.     

Activity Increase Despite Arthritis (A?DA): phase II randomised controlled trial of an active management booklet for hip and knee osteoarthritis in primary care

Background

The Hip & Knee Book: Helping you cope with osteoarthritis was developed to change disadvantageous beliefs and encourage physical activity in people with hip or knee osteoarthritis.

Aim

To assess the feasibility of conducting a definitive randomised controlled trial (RCT) of this evidence-based booklet in people with hip or knee osteoarthritis.

Design

Phase II feasibility randomised controlled trial (RCT).

Method

Computerised searches of patients'' record databases identified people with osteoarthritis of the hip or knee, who were invited to participate in the RCT comparing the new booklet with a control booklet. Outcomes were measured at baseline, 1 month, and 3 months, and included: beliefs about hip and knee pain, exercise, and fear avoidance; level of physical activity; and health service use.

Results

The trial methods were feasible in terms of recruitment, randomisation, and follow-up, but most participants recruited had longstanding established symptoms. After one and 3 months, there was a small relative improvement in illness, exercise, and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group (n = 59) compared with the control group (n = 60), which provides some proof of principle for using these outcomes in future trials.

Conclusion

This feasibility study provided proof of principle for testing The Hip & Knee Book in a larger definitive RCT.     

Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis

Background

Chronic pain and its associated distress and disability are common reasons for seeking medical help. Patients with chronic pain use primary healthcare services five times more than the rest of the population. Mindfulness has become an increasingly popular self-management technique.

Aim

To assess the effectiveness of mindfulness-based interventions for patients with chronic pain.

Design and setting

Systematic review and meta-analysis including randomised controlled trials of mindfulness-based interventions for chronic pain. There was no restriction to study site or setting.

Method

The databases MEDLINE^®, Embase, AMED, CINAHL, PsycINFO, and Index to Theses were searched. Titles, abstracts, and full texts were screened iteratively against inclusion criteria of: randomised controlled trials of mindfulness-based intervention; patients with non-malignant chronic pain; and economic, clinical, or humanistic outcome reported. Included studies were assessed with the Yates Quality Rating Scale. Meta-analysis was conducted.

Results

Eleven studies were included. Chronic pain conditions included: fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed aetiology. Papers were of mixed methodological quality. Main outcomes reported were pain intensity, depression, physical functioning, quality of life, pain acceptance, and mindfulness. Economic outcomes were rarely reported. Meta-analysis effect sizes for clinical outcomes ranged from 0.12 (95% confidence interval [CI] = −0.05 to 0.30) (depression) to 1.32 (95% CI = −1.19 to 3.82) (sleep quality), and for humanistic outcomes 0.03 (95% CI = −0.66 to 0.72) (mindfulness) to 1.58 (95% CI = −0.57 to 3.74) (pain acceptance). Studies with active, compared with inactive, control groups showed smaller effects.

Conclusion

There is limited evidence for effectiveness of mindfulness-based interventions for patients with chronic pain. Better-quality studies are required.     

Diclofenac Potassium Restores Objective and Subjective Measures of Sleep Quality in Women with Primary Dysmenorrhea

Study Objectives:

Primary dysmenorrhea is a common gynecological disorder that disrupts daytime functioning and nighttime sleep quality. We determined the effectiveness of diclofenac potassium, compared to placebo, in alleviating nighttime pain and restoring sleep architecture in women with primary dysmenorrhea.

Design:

Randomized, double-blind, crossover study

Setting:

Sleep laboratory

Participants:

Ten healthy women (21 ± 1 years) with a history of primary dysmenorrhea.

Interventions:

Placebo or diclofenac potassium (150 mg per day) for menstrual pain.

Measurements and results:

We assessed objective measures of sleep (polysomnography) and subjective measures of sleep quality, mood, and intensity of menstrual pain. Compared to a pain-free phase of the menstrual cycle (mid-follicular), women receiving placebo for their menstrual pain had a poorer mood (P < 0.01), decreased sleep efficiency (P < 0.05), less REM sleep (P < 0.05), more stage 1 sleep (P < 0.01), and more sleep stage changes per hour of sleep during the night. Administration of diclofenac potassium compared to placebo not only attenuated the women''s menstrual pain (P < 0.05), but also increased sleep efficiency (P < 0.05) and percentage of REM sleep (P < 0.01), decreased percentage of stage 1 sleep (P < 0.05) and number of sleep stage changes per hour of sleep (P < 0.05), and improved subjective ratings of sleep quality and morning vigilance (P < 0.05).

Conclusion:

Diclofenac potassium effectively attenuates nighttime dysmenorrheic pain and restores subjective and objective measures of sleep quality to values recorded in a pain-free phase of the menstrual cycle.

Citation:

Iacovides S; Avidon I; Bentley A; Baker FC. Diclofenac potassium restores objective and subjective measures of sleep quality in women with primary dysmenorrhea. SLEEP 2009;32(8):1019-1026.     

Mixture of Arnebia euchroma and Matricaria chamomilla (Marhame-Mafasel) for pain relief of osteoarthritis of the knee – a two-treatment,two-period crossover trial

Introduction

Osteoarthritis is the most prevalent chronic non-infective joint arthritis. Because of its chronic disease nature, local drugs are preferred due to lower complications. In the present study, the new herbal pomade Marhame-Mafasel for knee osteoarthritis was used in a double-blind crossover trial.The aim of the study was to assess the efficacy and safety of Marhame-Mafasel pomade, which consists of several medical herbs including Arnebia euchroma and Matricaria chamomilla, in osteoarthritis of the knee.

Material and methods

This study was a placebo-controlled double-blind crossover trial. Forty-two patients with pain associated with osteoarthritis of the knee (diagnosed by criteria of the European League against Rheumatism and physical examination) were drawn from patients attending the Clinic of Mostafa-Khomeini Hospital. In this study we assessed efficacy (analgesic effect and improved function) of herbal pomade Marhame-Mafasel, which was used locally in patients with primary osteoarthritis of the knee over three weeks. The instrument of the study was the Western Ontario and McMaster Universities (WOMAC) LK3.1 standard questionnaires.

Results

The participants in each group were 21 patients; 30 (71.4%) were women and 12 (28.6%) of them were men. The participants were between 40 and 76 years old. Six patients had mild arthritis, 15 had moderate arthritis and 21 had severe arthritis. The positive analgesic effect of the herbal pomade Marhame-Mafasel in primary knee osteoarthritis was proven. The herbal joint pomade Marhame-Mafasel had a significantly greater mean change in score compared to the placebo group for osteoarthritis severity (p < 0.05).

Conclusions

Herbal pomade Marhame-Mafasel in comparison to placebo has more effect on reduction of pain of primary knee osteoarthritis.     

Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study

Background

A growing body of evidence suggests that earlier diagnosis and treatment of diabetes may be beneficial; however, definitive evidence is lacking.

Aim

To evaluate the effectiveness of an intensified multifactorial treatment on cardiovascular risk factors in patients with screen-detected type 2 diabetes.

Design of study

Randomised controlled trial.

Setting

Seventy-nine general practices in the southwestern region of the Netherlands.

Method

In this randomised trial, patients diagnosed with diabetes by screen-detection were assigned to intensified (n = 255) or routine treatment (n = 243), and followed over 1 year. Intensified treatment consisted of pharmacological treatment combined with lifestyle education to achieve haemoglobin A1c (HbA1c) <7.0%, blood pressure <135/85 mmHg, and cholesterol <5.0 mmol/l (4.5 mmol/l if cardiovascular disease was present). Health-related quality of life (HRQoL) was assessed using the Short Form (SF)-36. Analyses were performed using generalised estimating equations models.

Results

Changes in body mass index were 0.2 (routine care) versus −1.4 kg/m² (intensified treatment), P<0.001; systolic blood pressure −19 versus −33 mmHg, P<0.001; diastolic blood pressure −7 versus −12 mmHg, P<0.001; HbA1c −0.9% versus −1.1%, P = 0.03; cholesterol −0.5 versus −1.2 mmol/l, P<0.001; high-density lipoprotein cholesterol 0.1 versus 0.1 mmol/l, P = 0.26; low-density lipoprotein cholesterol −0.5 versus −1.0 mmol/l, P<0.001; triglycerides −0.3 versus −0.4 mmol/l, P = 0.71. No difference in HRQoL between the two groups was reported.

Conclusion

Intensified multifactorial treatment of patients with screen-detected diabetes in general practice reduces cardiovascular risk factor levels significantly without worsening HRQoL.     

GP referral of patients with osteoarthritis for consideration of total joint replacement: a longitudinal study

Background

Individuals with hip or knee osteoarthritis (OA) are referred to orthopaedic surgeons if considered by their GP as potential candidates for total joint replacement (TJR). It is not clear which patients end up having this surgery.

Aim

The aim of the study was to investigate symptom variation in individuals with OA newly referred by GPs to an orthopaedic surgeon for consideration for TJR, and to determine the predictors of having this procedure.

Design and setting

A longitudinal study of patients at a regional orthopaedic centre with follow-up at 3, 6, and 12 months by postal questionnaire.

Method

GP referrals of patients with OA to orthopaedic surgeons were consecutively sampled. Of the 431 eligible patients, 257 (59.6%) were recruited. Validated measurement tools were used to measure pain, physical functioning, severity of OA, and health-related quality of life.

Results

Over half the participants were in constant pain, taking pain medication more than once per day. Only 67 of 134 (50%) hip and 40 of 123 (33%) knee patients had a TJR within 12 months. Those who had a replacement had been diagnosed with OAfora shorter time, reported more frequent pain, were more likely to use a walking stick, and had worse pain, stiffness, and physical functioning.

Conclusion

Many individuals considered for TJR ultimately may not have surgery, and more effective strategies of management need to be developed between primary and secondary care to achieve better outcomes and to improve quality of care.     

Weight-management interventions in primary care: a pilot randomised controlled trial

Background

There is a paucity of randomised controlled trials of weight management in primary care.

Aim

To ascertain the feasibility of a full trial of a nurse-led weight-management programme in general practice.

Design of study

Factorial randomised control trial.

Setting

Primary care, UK.

Method

A total of 123 adults (80.3% women, mean age 47.2 years) with body mass index ≥27 kg/m², recruited from eight practices, were randomised to receive structured lifestyle support (n = 30), structured lifestyle support plus pedometer (n = 31), usual care (n = 31), or usual care plus pedometer (n = 31) for a 12-week period.

Results

A total of 103 participants were successfully followed up. The adjusted mean difference in weight in structured support compared to usual care groups was −2.63 kg (95% confidence interval [CI] = −4.06 to −1.20 kg), and for pedometer compared to no pedometer groups it was −0.11 kg (95% CI = −1.52 to 1.30 kg). One in three participants in the structured-support groups (17/50, 34.0%) lost 5% or more of their initial weight, compared to less than one in five (10/53, 18.9%) in usual-care groups; provision of a pedometer made little difference (14/48, 29.2% pedometer; 13/55, 23.6% no pedometer). Difference in waist circumference change between structured-support and usual-care groups was −1.80 cm (95% CI = −3.39 to −0.20 cm), and between the pedometer and no pedometer groups it was −0.84 cm (95% CI = −2.42 to 0.73 cm). When asked about their experience of study participation, most participants found structured support helpful.

Conclusion

The structured lifestyle support package could make substantial contributions to improving weight-management services. A trial of the intervention in general practice is feasible and practicable.     

Efficacy of Combination of Meloxicam and Pregabalin for Pain in Knee Osteoarthritis

Purpose

Osteoarthritic pain is largely considered to be inflammatory pain. Sensory nerve fibers innervating the knee have been shown to be significantly damaged in rat models of knee osteoarthritis (OA) in which the subchondral bone junction is destroyed, and this induces neuropathic pain (NP). Pregabalin was developed as a pain killer for NP; however, there are no reports on pregabalin use in OA patients. The purpose of this study was to investigate the efficacy of pregabalin for pain in OA patients.

Materials and Methods

Eighty-nine knee OA patients were evaluated in this randomized prospective study. Patients were divided into meloxicam, pregabalin, and meloxicam+pregabalin groups. Pain scores were evaluated before and 4 weeks after drug application using a visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain scales among groups were compared using a Kruskal-Wallis test.

Results

Before drug application, there was no significant difference in VAS and WOMAC scores among the three groups (p>0.05). Significant pain relief was seen in the meloxicam+pregabalin group in VAS at 1, 2, and 4 weeks, and WOMAC score at 4 weeks, compared with the other groups (p<0.05). No significant pain relief was seen in the meloxicam only group in VAS during 4 weeks and WOMAC score at 4 weeks compared with the pregabalin only group (p>0.05).

Conclusion

Meloxicam+pregabalin was effective for pain in OA patients. This finding suggests that OA pain is a combination of inflammatory and NP.     

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Background

A recent review concluded that general health checks fail to reduce mortality in adults.

Aim

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

Design and setting

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Method

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

Results

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were −0.13 mmol/l (95% confidence interval [CI] = −0.19 to −0.07), −3.65 mmHg (95% CI = −6.50 to −0.81), −1.79 mmHg (95% CI = −2.93 to −0.64), and −0.45 kg/m² (95% CI = −0.66 to −0.24), respectively. The odds of a patient remaining at ‘high risk’ with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

Conclusion

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.     

Manual for guided home exercises for osteoarthritis of the knee

INTRODUCTION:

Physiotherapy is one of the most important components of therapy for osteoarthritis of the knee. The objective of this prospective case series was to assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain, range of movement , muscle strength and function, active goniometry, manual strength test and function.

METHODS:

Thirty-eight adults with osteoarthritis of the knee (≥ 45 years old) who were referred to the physiotherapy service at the university hospital (Santa Casa de Misericórdia de São Paulo) were studied. Patients received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home. They were evaluated for pain, range of movement, muscle strength and function. These evaluations were performed before they received the manual and three months later. Patients were seen monthly regarding improvements in their exercising abilities.

RESULTS:

The program was effective for improving muscle strength, controlling pain, maintaining range of movement of the knee joint, and reducing functional incapacity.

DISCUSSION:

A review of the literature showed that there are numerous clinical benefits to the regular practice of physical therapy exercises by patients with osteoarthritis of the knee(s) in a program with appropriate guidance. This study shows that this guidance can be attained at home with the use of a proper manual.

CONCLUSIONS:

Even when performed at home without constant supervision, the use of the printed manual for orientation makes the exercises for osteoarthritis of the knee beneficial.     

Effect of interval training programme on pulse pressure in the management of hypertension: a randomized controlled trial

Background

Pulse pressure (PP), might be a stronger determinants of cardiovascular risk.

Objective

To investigate the effect of interval training program on PP in subjects with hypertension.

Methods

Two hundred and forty five male patients with mild to moderate (Systolic Blood Pressure [SBP] between 140–179 & Diastolic Blood Pressure [DBP] between 90–109 mmHg) essential hypertension were age-matched and grouped into exercise and control groups. The exercise (work: rest ratio of 1:1) groups involved in an 8-weeks interval training programs of between 45–60 minutes, at intensities of 60–79% of HR max (maximum heart rate), while the control group remained sedentary during this period. SBP, DBP, VO₂max and PP were assessed.

Results

Findings of the study revealed significant correlation between PP and blood pressure; correlation of PP with SBP was much stronger (95% variance). Also, there was significant effect of the exercise training program on SBP, DBP and PP. Changes in VO₂max also negatively correlated with changes in PP (r= −.285) at p<0.05.

Conclusion

Moderate intensity interval training programs is effective in the non-pharmacological management of hypertension and may prevent cardiovascular event through the down regulation of PP in hypertension.     

Doctors record higher blood pressures than nurses: systematic review and meta-analysis

Background

The magnitude of the ‘white coat effect’, the alerting rise in blood pressure, is greater for doctors than nurses. This could bias interpretation of studies on nurse-led care in hypertension, and risks overestimating or overtreating high blood pressure by doctors in clinical practice.

Aim

To quantify differences between blood pressure measurements made by doctors and nurses.

Design and setting

Systematic review and meta-analysis using searches of MEDLINE, CENTRAL, CINAHL, Embase, journal collections, and conference abstracts.

Method

Studies in adults reporting mean blood pressures measured by doctors and nurses at the same visit were selected, and mean blood pressures extracted, by two reviewers. Study risk of bias was assessed using modified Cochrane criteria. Outcomes were pooled across studies using random effects meta-analysis.

Results

In total, 15 studies (11 hypertensive; four mixed hypertensive and normotensive populations) were included from 1899 unique citations. Compared with doctors’ measurements, nurse-measured blood pressures were lower (weighted mean differences: systolic −7.0 [95% confidence interval {CI} = −4.7 to −9.2] mmHg, diastolic −3.8 [95% CI = −2.2 to −5.4] mmHg). For studies at low risk of bias, differences were lower: systolic −4.6 (95% CI = −1.9 to −7.3) mmHg; diastolic −1.7 (95% CI = −0.1 to −3.2) mmHg. White coat hypertension was diagnosed more frequently based on doctors’ than on nurses’ readings: relative risk 1.6 (95% CI =1.2 to 2.1).

Conclusions

The white coat effect is smaller for blood pressure measurements made by nurses than by doctors. This systematic difference has implications for hypertension diagnosis and management. Caution is required in pooling data from studies using both nurse- and doctor-measured blood pressures.     

Outcome of knee injuries in general practice: 1-year follow-up

Background

Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.

Aim

To assess the outcome and management of knee injuries at 12 months'' follow-up in general practice.

Design of study

A prospective observational cohort study with a 1-year follow-up.

Setting

Primary health care.

Method

Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months'' follow-up.

Results

At 12 months'' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.

Conclusion

The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.     

Isokinetic assessment of the hip muscles in patients with osteoarthritis of the knee

OBJECTIVES:

To evaluate the difference in isokinetic strength of hip muscles between patients with knee osteoarthritis (OA) and matched healthy controls, and to establish the correlation between this isokinetic strength and pain and function in patients with knee OA.

METHODS:

25 patients with a diagnosis of unilateral knee OA, 25 patients with bilateral knee OA, and 50 matched controls were evaluated using the visual analog scale for pain, knee Lequesne index, Western Ontario and McMaster Universities questionnaire and an isokinetic test.

RESULTS:

The groups were matched for age, gender and body mass index. The results of the isokinetic test revealed lower peak torque of the hip in patients with OA of the knee than in the control group for all movements studied. Strong correlations were found between the peak torque, visual analog scale and function.

CONCLUSIONS:

Patients with OA of the knee exhibit lower isokinetic strength in the hip muscles than healthy control subjects. Strengthening the muscles surrounding the hip joint may help to decrease pain in people with knee OA. Some correlations between pain/function and peak torque were found.     

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.