2 Minute Medicine Rewind January 9, 2023

Consequences of anterior knee pain after anterior cruciate ligament reconstruction: A 2015–2020 cohort study 

1. Anterior knee pain (AKP) is a potential complication of ACL Reconstruction (ACLR) with hamstring tendon (HT) autograft.

2. Patients with AKP following ACLR with HT autograft have decreased isokinetic strength and functional pain 4 months post-operatively, but not at 7 months, compared to patients without AKP. 

Evidence Rating Level: 2 (Good)

Anterior knee pain (AKP) following anterior cruciate ligament reconstruction (ACLR) is a common complaint, with an estimated prevalence of 2.7 to 20%, more often seen in patellar tendon (PT) autografts than hamstring tendon (HT). AKP can increase the risk of deficits in quadriceps and hamstring strength, but the functional repercussions of AKP are not well-elucidated, particularly for HT autografts. Therefore, this cohort study compared patients with and without AKP after an HT ACLR, in terms of isokinetic knee strength and functional outcomes, at 4 and 7 months post-operation. The study population consisted of 330 patients from a single centre in France, undergoing ACLR between 2015 and 2020. Patients were divided into AKP and no AKP groups at 4 months post-op. At follow-up, the outcomes were measured using the limb symmetry index (LSI) for knee extensors and flexors, and the 100-point Lysholm score for functional rating of pain during activity. The results showed that AKP was reported in 14.8% of patients. At 4 months, the quadriceps LSI at 60°/s and 180°/s, and the hamstring LSI at 60°/s were significantly lower in the AKP group (p < 0.05), whereas the hamstring LSI at 180°/s was not different between the groups (p = 0.32). The Lysholm score was significantly lower in the AKP group as well (85.4±9.4 vs 96±7.2, p < 0.05). At 7 months however, there were no significant differences in LSI of the quadriceps or hamstring at 60°/s and 180°/s, and no difference in Lysholm score (93.1±6.3 for AKP vs 91.3±7 for no AKP, p = 0.17). Overall, this study demonstrated that AKP can be a complication of ACLR with HT autograft, and is associated with decreased isokinetic strength and functional pain at 4 months post-operatively, but not at 7 months.

Post-acute care for frail older people decreases 90-day emergency room visits, readmissions and mortality: An interventional study

1. Frail, elderly patients participating in a post-acute care (PAC) program for more than 2 weeks following hospitalization have decreased ER visits, readmissions, and mortality rates at 90 days, compared to those not participating in a PAC program.

Evidence Rating Level: 2 (Good)

Following a period of hospitalization, elderly adults with frailty are more vulnerable than those without frailty, with 20-35% of frail individuals over 70 becoming disabled within 1 month post-hospitalization. To address this, a model of care has been developed known as post-acute care (PAC), which can be hospital or home-based, to facilitate recovery after an acute illness. PAC for frail, elderly adults is a unique model in Taiwan, and so this multi-centre non-randomized trial aimed to compare the outcomes of patients who did and didn’t go through a PAC program. The study enrolled patients from 5 hospitals in Taiwan, with mild to severe frailty on the Clinical Frailty Scale (CFS). Patients were given the choice to participate in a PAC program or not, and patients who chose PAC were divided into home-based (HPAC) or inpatient-based (IPAC) programs, based on a number of factors. Patients were also matched by age, gender, and disability severity across groups. The PAC program involved a comprehensive geriatric assessment (CGA) and a multidisciplinary team providing physical, nutritional, psychosocial, and medical rehabilitation. The outcomes measured include ER visits at 90 days, readmissions, and mortality. In total, 254 patients were enrolled, 205 in the PAC group and 49 in the control, with the average duration of PAC being 14.4±5.6 days. The results showed that patients in the PAC group had lower ER visits at 90 days (p = 0.031), lower mortality rates at 90 days (5.9% vs 16.3%, p = 0.014). As well, duration of PAC for more than 2 weeks was an independent protective factor for 90-day ER visits (odds ratio 0.21, 95% CI 0.10-0.43, p = 0.024), readmissions (OR 0.30, 95% CI 0.16-0.56, p < 0.001), and mortality (OR 0.20, 95% CI 0.04-0.87, p = 0.032). Overall, this study showed that for frail, elderly patients, participation in a PAC program for more than 2 weeks following hospitalization is associated with decreased ER visits, readmissions, and mortality at 90 days. 

Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study 

1. Experiencing general chronic pain or somatic chronic pain are associated with increased risk of later suicidal behaviour at 10 years follow-up. 

2. For general chronic pain, this association remained significant within dizygotic twin pairs, but non-significant within monozygotic twin pairs. 

Evidence Rating Level: 2 (Good)

While experiencing chronic pain is a known risk factor for suicide, there are numerous chronic pain conditions that often co-exist together, such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome. It is unclear whether increased suicide risk is associated with specific pain conditions or chronic pain more generally. As well, both chronic pain and suicidality could have genetic and familial risk factors that confound the association between the two. Therefore, this population-based twin cohort study based in Sweden aimed to identify the association between general versus specific chronic pain factors, and suicidal behaviour, while controlling for confounding in twin pairs. The study population was drawn from a 2006 study of twins born in Sweden between 1958 and 1985. This included self-reporting symptoms of chronic pain on 9 pain scales, such as joint pain, lower back pain, and chronic widespread pain. National health records were used to identify suicidal behaviour, defined as intentional self-harm, injury of undetermined intent, and death by suicide, at 10 years follow-up. In total, there were 17,148 participants, including 7126 monozygotic twins and 10,022 dizygotic twins. The prevalence of suicidal behaviour was 1.6%. The results showed that participants scoring 1 standard deviation above the mean on the pain scales were at a higher risk of suicidal behaviour at follow-up, with ORs ranging from 1.13 to 1.47 depending on the scale. After combining all pain conditions into a multiple regression model however, only chronic fatigue syndrome (OR 1.26, 95% CI 1.14-1.40) and bladder pain (OR 1.19, 95% CI 1.08-1.31), were significantly associated with suicidal behaviour. This suggests that the experience of chronic pain more broadly is a major contributor to this association with suicidality. Furthermore, those scoring 1 SD above the mean on the general factor of pain and the specific factor of somatic symptoms were at higher risk of suicidal behaviour (OR 1.51, 95% CI 1.34-1.72 for general factor, OR 1.80, 95% CI 1.45-2.22 for somatic symptoms factor), while the specific factor of neck-shoulder pain had no significant association. However, with regards to the general pain factor, the association with suicidal behaviour remained significant within dizygotic twins (OR 1.46, 95% CI 1.11-1.93) but not within monozygotic twins (OR 0.89, 95% CI 0.59-1.33), suggesting that monozygotic twins were at approximately equivalent risk of later suicide regardless of pain factor score. A similar pattern was observed for the somatic symptoms factor (OR 1.46, 95% CI 0.89-2.39 for dizygotic; OR 1.02, 95% CI 0.49-2.11 for monozygotic). Overall, this study demonstrated that general and somatic chronic pain are associated with suicidal behaviour, but that this association is not significant within monozygotic twin pairs. 

Separating the effects of early and later life adiposity on colorectal cancer risk: a Mendelian randomization study

1. Greater early-life body size is not an independent risk factor for colorectal cancer (aside from distal colon cancer) but is rather a risk factor confounded by greater body habitus in adulthood. 

Evidence Rating Level: 2 (Good)

Early-life adiposity is a known risk factor for chronic disease, including colorectal cancer. However, it is unclear whether this risk exists independent of adiposity later in life, especially when considering the long latency period of colorectal cancer. Therefore, this multivariable Mendelian randomization (MR) study employed known genetic variations associated with self-reported early life body size and measured adult body size, to better elucidate this association with colorectal cancer. This study used data from 125,478 individuals of European descent participating in a UK Biobank genome-wide association study (GWAS). These participants self-reported their body size at 10 years old (thinner, plumper, or about average), and measured their body mass index as adults. Then, both univariable and multivariable MR analyses were performed to identify the total and independent associations respectively of early and adult body size on colorectal cancer. The results showed that for the univariable analysis, genetic variants associated with early-life body size increased the risk of some colorectal cancers, such as colon cancer (OR per category change of 1.16, 95% CI 1.00-1.35) and distal colon cancer (OR 1.25, 95% CI 1.04-1.51), but was not significant for colorectal cancer overall (OR 1.12, 95% CI 0.98-1.27). In the multivariable analysis, the direct association between early body size and cancer risk were attenuated for colorectal (OR 0.97, 95% CI 0.77-1.22) and colon (OR 0.97, 95% CI 0.76-1.25) cancers, but not for distal colon cancer (OR 1.27, 95% CI 0.90-1.77). However, the direct association between adult body size and cancer risk were increased for colorectal (OR 1.27, 95% CI 1.03-1.57), colon (OR 1.32, 95% CI 1.05-1.67), and proximal colon cancer (OR 1.57, 95% CI 1.21-2.05). Overall, this study demonstrated that aside from distal colon cancer, increased early-life body size is not an independent risk factor for colorectal cancer, and but is a risk factor confounded by persisting elevated body habitus in adulthood.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial 

1. For military personnel and veterans with PTSD, intensive outpatient prolonged exposure (IOP-PE) therapy had a significantly greater reduction at 6 months follow-up in clinician-rated symptoms, compared to patients randomized to massed prolonged exposure (massed-PE) therapy. 

2. Approximately half of patients treated in both IOP-PE or massed-PE groups maintained diagnostic remission at 6 months follow-up.

3. There were no significant differences in self-rated symptoms and functioning between IOP-PE and massed-PE patients.

Evidence Rating Level: 1 (Excellent)

Posttraumatic stress disorder (PTSD) is the leading psychological condition experienced by military combat personnel in the United States. One treatment for combat-related PTSD is prolonged exposure (PE) therapy. A previous RCT compared a standard delivery of 10 weekly PE sessions to a massed delivery of 10 daily PE sessions over 2 weeks, which found significant symptom reductions in both groups, but improved efficiency and fewer dropouts in the daily sessions group. However, no RCTs have examined the effectiveness of intensive outpatient programs (IOPs), one of the highest levels of delivery of care for PTSD patients. Therefore, this current RCT compared massed-PE and IOP-PE models delivered over 3 weeks, with the hypothesis that IOP-PE would be more effective in reducing clinician and self-rated PTSD symptoms. The study population consisted of US military veterans and personnel who had been deployed after September 11, 2001, randomized to either treatment. Both protocols consisted of 15 90-minute daily sessions over 3 weeks, whereas the IOP-PE protocol added 8 adaptations that would address issues specific to combat-related PTSD. Outcomes were measured using the 80-point Clinician-Administered PTSD Scale (CAPS-5) and a number of self-reported measures including the 20-item PCL-5 for PTSD symptoms, 3-item Sheehan Disability Scale (SDS) for functional impairment, and 7-item Brief Inventory of Psychosocial Functioning (B-IPF). These were done at baseline and at 1, 3, and 6-month follow-ups. In total, there were 234 participants, with 117 randomized to either group. Both groups had similar treatment completion rates of over 90%. The results showed that mean CAPS-5 scores had significant reductions at 1-month follow-up in both groups (-13.85, 95% CI -16.47 to -11.23, p < 0.001 for IOP-PE; -14.13, 95% CI -16.63 to -11.62, p < 0.001 for massed-PE). At 1 month, there were no differences in clinician-rated symptoms between groups. Between 1 and 6 months however,  the IOP-PE group maintained reduction of symptoms (-1.23, 95% CI -3.72 to 1.27, p = 0.33) while the massed-PE group had an increase in symptoms (3.21, 95% CI 0.65-5.77, p = 0.01). At 6 months, the IOP-PE group had a significantly lower CAPS-5 score than the massed-PE group (mean difference 4.44, 95% CI 0.86-8.01, p = 0.01). Additionally, diagnostic remission was achieved in 53% of IOP-PE patients (95% CI 40-66%) and 52% of massed-PE patients (95% CI 38-66%) at 6 months, and were not significantly different between groups at any timepoint. Furthermore, there was no significant difference between groups on the PCL-5, SDS, or B-IPF scores. Overall, this study demonstrated that the IOP-PE delivery model was associated with a greater reduction in clinician-rated PTSD symptoms at 6 months compared to massed-PE, but there were no differences in diagnostic remission or self-rated symptoms and functioning between groups. 

Image: PD

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