Highlights of this issue

Anterior knee pain

Anterior knee pain is the most common knee problem seen by family physicians. In this latest article in our rheumatology series, Jack Taunton and Michael Wilkinson review the salient features of the history, physical examination, further investigation and management of anterior knee pain. Overtraining, malalignment of the hip or extensor mechanism, deficiencies in strength and flexibility, ill-fitting shoes and uneven training surfaces are common contributors. The history generally allows the physician to distinguish overuse or malalignment from traumatic causes. Most patients will respond to a combination of strategies intended to relieve discomfort, correct malalignment and improve conditioning beyond the level at which the original injury occurred.

See page 1595

Abuse and low birth weight

Low birth weight (< 2500 g) affected 5.8% of Canadian newborns in 1995 and is responsible for most neonatal deaths and substantial childhood morbidity in developed countries. Abuse during pregnancy is a potentially modifiable risk factor for low birth weight. Claire Murphy and coauthors examined the association in a systematic review of the literature and a meta-analysis of the results of 8 selected papers. Using a fixed-effects model, they found that women who reported physical, sexual or emotional abuse during pregnancy were more likely than nonabused women to give birth to a baby with low birth weight (odds ratio 1.4, 95% confidence interval 1.1–1.8). “So when do we start to act?” asks Jacquelyn Campbell in her commentary.

See pages 1567 and 1578

Bioethics and assisted reproduction technologies

Assisted reproductive technologies (ARTs) currently encompass noncoital insemination with partner or donor sperm, hormonal ovarian stimulation and in-vitro fertilization. Laura Shanner and Jeffrey Nisker consider the ethical issues surounding ARTs, including family relationships, informed choice, gender issues, embryo status and the commercialization of reproduction, as well as legal and policy issues. They summarize Canadian information on success rates and complications and advise how to approach ARTs in practice.

See page 1589

Following the Oregon trail

The Oregon Health Plan is regarded as having pioneered explicit, systematic and open rationing of health care by denying services. According to Jonathan Oberlander and colleagues, the reality is somewhat different: Oregon has neither achieved the universal coverage the plan was intended to allow, nor has widespread rationing been instigated. The number of services excluded has been small, physicians still provide uncovered services, savings have not been significant, and the original mathematical scoring system has been subverted by political concessions. Oregon's experience, from which Canada and others might learn, is that the explicit removal of items from the list of insured services is unlikely to save much in costs.

See page 1583

Quality of reporting in secondary journals

Secondary journals provide summaries of important articles from the medical literature, offering time-pressed physicians a solution to the challenge of keeping current. However, readers need crucial information to assess a study's validity. P.J. Devereaux and coworkers assessed the completeness of reporting by 3 secondary journals: the ACP Journal Club (ACP), Journal Watch (JW) and Internal Medine Alert (IMA). ACP always reported study design and was more likely than the other 2 journals to report on the conduct of intention-to-treat analysis and the precision of the treatment effect. The 3 journals were similar in reporting concealment of patient allocation (none did) and the blinding status of participants (62%–70%), health care workers (4%–12%) and assessors of outcomes (0%–4%). In a related commentary, Frank Davidoff expands on the implications of the study and what it did not tell us.

See pages 1573 and 1580