Journals watch: Heparin, pain and paracetamol

Too busy to read the journals? Let Dr Simon Hunter guide you through the latest findings

DVT in cancer patients

Am J Med 2006; 119: 1,062-72

Patients with cancer are not only more likely to get DVT but they are also more likely to have a recurrent DVT. There is a higher chance that they will find it difficult to comply with the need for monitoring of warfarin.

This study compared long-term low-molecular-weight heparin (tinzaparin) with warfarin in 200 patients. Heparin more than halved the recurrence rate of venous thromboembolism from 16 to 7 per cent. Bleeding was higher in the tinzaparin group, but when selecting patients who were at a low risk of bleeding, this was not a problem.

The researchers showed that low-molecular-weight heparin is superior to warfarin for these patients and, as the need for monitoring is removed, this has to be considered.

Paracetamol safety

Lancet 2006; 368: 2,195-6

Just as you thought it was safe for patients to self-manage their pyrexial illnesses, this bad penny turns up again. It is already known that paracetamol can be hepatotoxic at 7mg, but new evidence indicates that paracetamol can irritate the liver in therapeutic doses.

In a recent study on an opiate/paracetamol combination, the lone paracetamol cohort showed raised alanine aminotransferase (ALT) levels up to eight times normal, while none of the placebo group did. The researchers went on to warn use of paracetamol with caution in anyone who might be at risk of liver disease or taking medication that affects the liver.

Antibiotics and quinsy

Br J Gen Pract 2007; 57: 45-9

A team from Southampton looked into the incidence of quinsy and whether antibiotics can prevent it. This study examined the electronic patient records and found that two thirds of patients with quinsy had not seen a doctor previously with a sore throat. Quinsy develops quickly. There was a suggestion that antibiotics might help prevent quinsy in tonsillitis, but not with a sore throat.

The researchers felt the current practice of low-dose penicillin with variable patient compliance is unlikely to prevent quinsy, but an acceptable strategy would be to give a delayed higher dose of antibiotic to take if symptoms get worse within 48 hours.

Referral for headache

Br J Gen Pract 2007; 57: 29-35

Headaches are a difficult diagnostic area because patients tend to think the worst. With a third of all neurological referrals for headaches and variation between GP referral rates, the researchers of this study looked at what factors influenced GPs to refer. The results were predictable. Patient pressure was the main problem. Other factors included time pressure of long explanations. The authors suggest training for GPs, but as the UK has a tenth of the neurological workforce of other European countries, I think I know where the bigger problem lies.

Pain in the neck

Br J Gen Pract 2007; 57: 23-8

Neck pain is common, but only about 15 per cent of people experiencing it see their GP. This Dutch study found that of 187 patients presenting with neck pain about half were referred for physiotherapy and 40 per cent had medication prescribed, mostly in the form of NSAIDs. A quarter were told to ‘wait and see'.

X-rays were rarely ordered and it was rare to refer to a consultant. Of those referred to physiotherapy 74 per cent recovered by the end of a year, compared to 79 per cent treated with NSAIDs.

Dr Hunter is a GP in Bishop's Waltham, Hampshire, and a member of our team who regularly review the medical journals

Cancer patients with DVT respond better to low-molecular-weight heparin than warfarin.

Paracetamol may be damaging to the liver at therapeutic doses.

Quinsy may be better managed with delayed high dose penicillin than with prophylactic low dose.

Patient pressure results in most referrals for headache.

Neck pain is more likely to be resolved by NSAIDs than physiotherapy.

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