Journals Watch - DVT, opioids and headache

Not had time to read the latest research? Dr Bryan Palmer brings you up to date with the journals.

The benefit of compression stockings to prevent DVT is uncertain (Photograph: SPL)

Thigh-length versus below-knee stockings for DVT prophylaxis after stroke
Ann Intern Med 2010 (online ahead of print)

Graduated compression stockings are widely used for DVT prophylaxis. However, there is no reliable evidence comparing thigh-length and below-knee stockings.

The CLOTS-2 trial was designed to explore this by using a parallel-group trial with centralised randomisation to ensure allocation concealment. The ultrasonographers who looked for DVT were blinded, but the patients and carers were not.

A total of 3,114 immobile patients with acute stroke were randomised; 1,552 patients received thigh-length stockings and 1,562 received below-knee stockings to wear while they were in hospital.

The outcome showed a reduction in the number of DVTs in the thigh-length stocking group. However, the CLOTS-1 trial failed to show any significant benefit of thigh-length stockings compared with no stockings. The authors of an editorial published with the CLOTS-2 data say that although graduated compression stockings are popular, their net benefits and risks remain uncertain.

Opioid prescribing for non-cancer pain in primary care
Fam Pract 2010; doi: 10.1093/fampra/cmq083

Chronic joint pain is common. It is a leading cause of disability and mainly managed in primary care.

Opioid pain medication is one option for pain management, but it may be underutilised.

Supposedly there is a widespread concern among doctors about the misuse of opioids.

This study used information from qualitative semi-structured interviews that were conducted with 27 GPs. Using thematic analysis methods, the data were coded and grouped into themes.

The results showed that GPs described a variety of prescribing habits for chronic joint pain. Opioids prompted strong opinions. Although addiction and misuse were discussed, there was limited concern about these issues.

The overarching influence on prescribing decisions was GPs' previous experience, including previous outcomes and exposure to palliative care settings.

Home testing of INR
N Engl J Med 2010; 363: 1608-20

How effective is patient self-monitoring of warfarin compared with clinic testing? The authors of this American study randomly assigned 2,922 patients who were taking warfarin due to mechanical heart valves or AF to either weekly self-testing at home or monthly high-quality testing in a clinic.

All patients were competent in the use of point-of-care INR devices. The primary end point was the time to a first major event (stroke, major bleeding episode or death).

The patients were followed for two to five years and although there was no difference in the primary endpoints, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target.

At two years of follow-up, the self-testing group also had a small improvement in patient satisfaction with anticoagulation therapy and quality of life.

Efficacy and safety of corticosteroid injections for management of tendinopathy
Lancet 2010; doi:10.1016/S0140-6736(10)61160-9

Few evidence-based treatment guidelines for tendinopathy exist. The authors of this study from the University of Queensland undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.

Of the 3,824 trials that were identified only 41 met inclusion criteria, providing data for 2,672 participants.

They looked specifically at short-term, medium-term and long-term benefits and found that continued use of corticosteroid injections are worse in the long term than conservative interventions for tendinopathy.

This was particularly true for the treatment of lateral epicondylitis. The research found that in treating epicondylitis, corticosteroid injection had a large effect on reduction of pain compared with placebo in the short term.

But treatment with injections over a longer period, from four to 12 months, was not found to be beneficial and actually caused more harm than good.

Free meals and incentivised weight loss in overweight women
JAMA 2010; doi:10.1001/jama.2010.1503

Government-led cultural changes may be the only way to manage the obesity epidemic but research into interventions is still carried out.

Few studies have been done on whether commercial weight loss programmes actually work.

This study of 442 overweight or obese American women tested whether a free prepared meal and incentivised structured weight loss program promotes greater weight loss and weight loss maintenance at two years compared with usual care. It found that weight loss was largely maintained at two-year follow-up.

The authors saw an average one-year weight loss of 11 per cent and an average two-year weight loss of 7 per cent in response to the weight loss program intervention.

Tricyclic antidepressants and headaches
BMJ 2010; 341: c5222

We already know that tricyclic antidepressants are effective in treating tension-type and migraine headaches, but other information is lacking.

This meta-analysis looked at 37 studies to evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type and mixed headaches. Studies looked at frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache and headache index.

The resulting analysis revealed the effectiveness of tricyclics increased over time and that they are more effective than serotonin reuptake inhibitors for both migraine and tension-type headaches.

  • Dr Palmer is a former Hampshire GP currently working in Australia, and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: Earn More Credits

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

  • Develop a practice policy on opioid prescribing that might include patient information leaflets, patient-held management plans and addiction risk assessments.
  • Organise a practice meeting to discuss the drug and non-drug management of migraine.
  • Carry out a review of patients with epicondylitis who had corticosteroid injections. Considering referring treatment failures for physiotherapy.

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