Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Physicians\u27 Attitudes Toward Complementary and Alternative Medicine

Background: To assess physicians\u27 attitudes regarding the legitimacy of complementary and alternative medicine (CAM) in medical practice, as well as factors that affect referral or prescription of a complementary therapy.Methods: Questionnaires were mailed to 380 physicians on staff at a local hospital in a mid-sized southeastern city in the United States; 138 were completed, for a 38% response rate.Results: Physicians in practice for less than 10 years were significantly more likely to accept most CAM therapies as legitimate than those in practice greater than 10 years. Nearly two-thirds of the physicians surveyed (65%, n = 88) had prescribed or referred for at least one complementary therapy. More than one-third of the physicians (34.8%, n = 48) had personally utilized at least one of these therapies, and personal experience resulted in a higher level of acceptance of CAM as legitimate medical therapy.Conclusions: It is likely that more positive attitudes regarding complementary therapies among more recently trained physicians is related to increased exposure during training and an increased awareness within the medical community of patient utilization of CAM. Despite a relatively positive attitude toward some CAM therapies, patients continue to use alternative medicine without notifying their primary care physicians. Unsupervised use of these therapies is potentially harmful and reflects a deficiency in the doctor-patient relationship. Open communication between physicians and their patients will continue to be hindered until physicians become knowledgeable in this area

LUCA-I5-encoded sequence variants regulate CD95-mediated apoptosis

Using an expression cloning system to discover novel genes involved in apoptosis, we identified a 326 bp bone marrow cDNA fragment (termed Je2) that suppresses, upon transfection, CD95-mediated apoptosis in Jurkat T cells. Sequence homology revealed that Je2 maps to 3p21.3, to an intronic region of the candidate TSG LUCA-15 locus. It represents, in fact, an antisense transcript to the 3'-UTR of two novel splice variants of this gene. Overexpression of sequence representing one of these splice variants (a 2.6 kb cDNA termed Clone 26), inhibited proliferation of Jurkat cells and sensitized them to CD95-mediated apoptosis. This study therefore implicates the LUCA-15 gene locus in the control of apoptosis