Journals Watch - DVT, contraception and STIs

A review of this week's medical research. By GP Dr Gwen Lewis

Giving asoirin after anticoagulation therapy reduces DVT recurrence (SPL)
Giving asoirin after anticoagulation therapy reduces DVT recurrence (SPL)

Aspirin for preventing recurrence of DVT N Engl J Med 2012; 366: 1959-67
It is known that 20% of patients with an unprovoked DVT have a recurrence within two years of stopping oral anticoagulation. Extending the duration of anticoagulation increases bleeding risk but is long-term aspirin beneficial?

In this double-blind study from Italy, 402 patients with a first ever, unprovoked DVT who had completed six to 18 months of anticoagulant therapy were assigned to receive aspirin 100mg daily or placebo for two years.

DVT recurred in 28 of 205 patients who received aspirin and in 43 of 197 who received placebo. One patient in each group had a major bleeding event.

So it does appear that aspirin reduces the risk of recurrence of DVT on completion of anticoagulant therapy with no increased risk of bleeding.

Effectiveness of long-acting methods of contraception N Engl J Med 2012; 366: 1998-2007

We have been encouraged to extend the use of long-acting reversible contraception (LARC) to reduce rates of unwanted pregnancy.

This US study looked at pregnancy rates for those using LARC compared with those using oral contraception, the vaginal ring and patch. All methods of contraception were provided free of charge.

Rate of failure for those using LARC compared with those using other methods of contraception was assessed overall and in cohort groups for those aged under 21 years and those aged 21 years and over.

A total of 7,486 women were involved in the study; 334 unintended pregnancies occurred.

In those using non-LARC methods a rate of 4.55 pregnancies per 100 participant-years was found, while the rate was only 0.27 in those using LARC. Those using non-LARC methods aged under 21 years had a risk that was almost twice as high as the risk in those aged 21 years and over. Rates for those using LARC methods were low regardless of age.

Treating plantar fasciitis BMJ 2012; 344: e3260

In Australia, 82 people with a clinical and ultrasound diagnosis of simple plantar fasciitis were randomly allocated to receive an ultrasound-guided injection of either 1ml of 4mg/ml dexamethasone in the experimental group or 1ml of normal saline in the placebo group.

Primary outcomes were pain as measured by the foot health status questionnaire on a point scale of 0-100 points and plantar fascia thickness measured by ultrasound at four, eight and 12 weeks.

Pain was reduced by 10.9 points in the dexamethasone group at four weeks, but at eight and 12 weeks there was no difference in pain score between the two groups. Plantar fascia thickness was reduced in the dexamethasone group at four, eight and 12 weeks. There were no adverse events in either group.

Ultrasound-guided steroid injection is a safe and effective short-term treatment for plantar fasciitis, providing greater pain relief than placebo at four weeks but not beyond. Abnormal plantar fascia swelling was reduced for up to three months.

Promoting breastfeeding in low-income women Fam Pract 2012; 29: 245-54
Breastfeeding rates are very different among social groups. This literature search study looked at ways in which breastfeeding may be promoted in low-income groups. Ten randomised controlled studies involving a total of 1,445 mother and child pairs were included.

It was found that educational programmes are effective for starting breastfeeding. Programmes to encourage mothers to breastfeed showed success after three months of delivery. Successful programmes usually involved multiple follow-up appointments lasting 20 to 30 minutes.

Early menopause and health risk BJOG 2012; 119: 810-16
Bone density is lost after the menopause with the risk of osteoporosis. Theoretically, therefore, early menopause is likely to increase the risk of osteoporosis. This Swedish study sought to clarify this.

A total of 390 white northern European women aged 48 years at baseline were included in the study. Bone mineral density (BMD) was measured by single photon absorptiometry (SPA) in the distal forearm and menopausal status was noted. Menopause was classified according to WHO criteria as being a minimum of 12 months of continuous amenorrhoea. Early menopause was classed as being before the age of 47 years and late menopause as being at age 47 years or later.

At age 77 years, forearm BMD was remeasured by SPA and proximal femur and lumbar spine BMD measured by DXA. Prevalence of osteoporosis was determined using DXA data. Mortality and incidence of fractures were registered up to the age of 82 years.

At age 77, women with early menopause had a risk ratio of 1.83 for osteoporosis, a risk ratio of 1.68 for fragility fracture and a mortality risk of 1.59. I shall be encouraging women with early menopause to take treatment to prevent osteoporosis more actively from now on.

Patient choice for attending STI testing services Sex Transm Infect 2012 doi: 10. 1136/sextrans-2011-050344

GPs are being encouraged to offer screening for STIs, in particular for chlamydia. However, our patients would often prefer to attend a GUM clinic for screening.

This qualitative study was set up to look at which aspects of STI testing services are important to STI testing service users.

Ten focus groups involving previous or existing users of STI services were conducted in the south-east of England and involved 65 participants. Perceived expertise of staff at GUM clinics was a key reason for attendance there. The apparently limited range of tests available in GP surgeries and potential lack of expertise in sexual health also discouraged attendance at GP surgeries. Past experience of place of testing was obviously important, as was whether the patient had another medical condition, such as HIV.

Services outside of GUM clinics need to be made more acceptable, to encourage testing. In particular, the perceived lack of expertise and limited range of tests available need to be addressed.

  • Dr Lewis is a GP in Windsor, Berkshire, and a member of our team who regularly review the journals

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Undertake a search of LARC use in women under 21 years of age and look at ways to increase use of LARC. Ensure that all methods of contraception are available for patients.
  • Search for women who have recently undergone an early menopause and invite them to discuss possible prophylactic treatment for osteoporosis.
  • Look at ways to encourage breastfeeding in low-income women and who could be involved in this intervention.

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