Geoffrey J McColl

Relationship of knee joint proprioception to pain and disability in individuals with knee osteoarthritis

Proprioception plays an integral role in neuromotor control of the knee joint and deficits in knee joint proprioception are well documented in individuals with knee osteoarthritis (OA). However, the functional relevance of these deficits is not clear. This crosssectional study evaluated the relationship between knee joint proprioception and pain and disability in a large cohort of individuals with knee OA. Two hundred and twenty participants (145 F, 75 M) with symptomatic knee OA were recruited from the community. Five non‐weight bearing active tests with ipsilateral limb matching responses were performed at 20° and 40° flexion to measure knee joint position sense. Pain and disability were assessed by self‐reported questionnaires and objective measures of balance and gait. Results showed little association between knee joint position sense variables and measures of pain and disability (r values <0.24, most p > 0.05). When comparing participants with the worst and best joint position sense, no significant differences in pain and disability could be found (p > 0.05). While our study design does not allow causality to be established, these results suggest that deficits in joint position sense may be due to factors other than pain and that deficits are not large enough to impact upon disability.

Tumour necrosis factor inhibitors: risks and benefits in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis and can, if left untreated, result in significant disability and early death. It is also associated with large direct and indirect costs to the individual and to society. Early and aggressive disease modifying anti‐rheumatic drug (DMARD) treatment of patients at risk of erosive disease has improved the outcome in the majority, but not all, RA patients. Tumour necrosis factor (TNF) appears to be a key mediator of the inflammatory and destructive process in RA, and consequently inhibitors of TNF action have been tested in randomized controlled trials in patients with RA. The results of these studies have suggested that TNF inhibitors are potent DMARD particularly when combined with methotrexate. They appear well tolerated with the commonest adverse events related to their parenteral route of administration, and the serious but rare side‐effects being various infections, notably tuberculosis, multiple sclerosis, and worsening of cardiac failure. Treatment costs are high and range from

Is the Human Activity Profile a useful measure in people with knee osteoarthritis

15 000 to

Adverse Outcomes Associated With Elective Knee Arthroscopy: A Population-Based Cohort Study

25 000 per patient per year. Etanercept, adalimumab and infliximab have recently been subsidised under the Pharmaceutical Benefits Scheme in Australia for patients with severe DMARD‐resistant RA. The availability of TNF inhibitors in RA represents a significant advance in the treatment of patients with severe RA. (Intern Med J 2004; 34: 687−693)

Comparing the academic performance of graduate- and undergraduate-entry medical students

This study evaluated the usefulness of the Human Activity Profile (HAP) in people with knee osteoarthritis (OA). People with OA (N = 226) completed the HAP and a battery of pain and physical function measures. Healthy elderly controls (N = 33) also completed the HAP, and 20 OA participants underwent repeat testing 2 to 7 days later. Test-retest reliability was excellent (intraclass correlation coefficients 0.96 and 0.95). The HAP was sensitive enough to detect differences in physical activity between people with (N = 33) and without OA (N = 33) (p < 0.01). When OA individuals were classified as impaired, moderately active, or active based on HAP score, differences in pain and physical function were detected (p < 0.05). Correlations between HAP and commonly used pain and physical function measures were weak to moderate (r = 0.18-0.63, all p < 0.01), indicating that the HAP measures additional information not gained by other assessment tools. The HAP is a reliable measure, and it is sensitive enough to discriminate between people with and without knee OA, and within an OA cohort. The HAP appears to have greater applicability in osteoarthritic women than men.

Clinical teaching and learning: from theory and research to application

PURPOSE The aims of this study were to quantify the frequency of adverse outcomes after elective knee arthroscopies in Victoria, Australia, and to identify risk factors associated with adverse outcomes. METHODS We performed a retrospective, longitudinal cohort study of elective orthopaedic admissions using the Victorian Admitted Episodes database, a routinely collected public and private hospital episodes database linked to death registry data, from July 1, 2000, to June 30, 2009. Adverse outcome measures included pulmonary embolism (PE), deep vein thrombosis (DVT), hemarthrosis, effusion and synovitis, cellulitis, wound infection, synovial fistula, acute renal failure, myocardial infarct, stroke, and death. Patients were excluded if they had an additional procedure performed during the arthroscopy admission. We identified complications during the admission and within readmissions up to 30 days after the procedure. PE, DVT, and death within 90 days of the arthroscopy episode were also examined. We used logistic regression analysis to identify risk factors associated with complications. RESULTS After we excluded 16,807 patients (8.5%) with an additional procedure during their admission, there were 180,717 episodes involving an elective arthroscopy during the period studied. The most common adverse outcomes within 30 days were DVT (579, 0.32%), effusion and synovitis (154, 0.09%), PE (147, 0.08%), and hemarthrosis (134, 0.07%). The 30-day orthopaedic readmission rate was 0.77%, and there were 55 deaths (0.03%). Within 90 days of arthroscopy, we identified 655 events of DVT (0.36%) and 179 PE events (0.10%). Logistic regression analysis identified that potential risk factors for complications were older age, presence of comorbidity, being married, major mechanical issues, and having the procedure performed in a public hospital. CONCLUSIONS Our study found 6.4 adverse outcomes per 1,000 elective knee arthroscopy procedures (0.64%), with the 3 most common complications being DVT, effusion and synovitis, and PE. We have also identified risk factors for adverse outcomes, particularly chronic kidney disease, myocardial infarction, cerebrovascular accident, and cancer. LEVEL OF EVIDENCE Level III, retrospective cohort study.

A mandatory intercalated degree programme: revitalising and enhancing academic and evidence-based medicine.

Medical Education 2010 44: 197–204

Early rheumatoid arthritis: can we predict its outcome?

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.

Clinical assessment performance of graduate- and undergraduate-entry medical students

Background: Recruitment of medical graduates to research careers is declining. Expansion of medical knowledge necessitates all graduates be equipped to critically evaluate new information. To address these challenges, a mandatory intercalated degree programme was introduced as part of curriculum reform. Aims: To review the place on intercalated degrees, the methods available for learning about research and to analyse experience with a new university programme focusing on research. Methods: A literature review followed by the analysis of experience with eight cohorts of students who had completed the new programme. Results: A total of 1599 students completed the programme. Laboratory-based research was the most common choice followed by clinical research, population health, epidemiology, medical humanities and mental health. Also, 93% of students spent over 75% of their time undertaking research. Sixty-three students published their research, half as first authors. Students and coordinators support the programme. Learning about research during the postgraduate phase is variable and frequently left to individual choice. Conclusion: Intercalating an additional degree focusing on research can achieve a number of learning objectives but demands a level of maturity, autonomy and preparedness, not uniformly present in students undertaking a mandatory intercalated programme. A more realistic goal is the development of ‘research-mindedness’ amongst all students.

Inflammatory arthritis-like and other MR findings in wrists of asymptomatic subjects

Abstract