Paracetamol little help in low back pain
AUSTRALIAN research has shown that neither regular nor as-needed dosing of paracetamol improves recovery from acute low back pain compared with placebo. The research, published in The Lancet, also showed paracetamol had no effect on pain, disability, function, global symptom change, sleep or quality of life. The Paracetamol for Low-Back Pain (PACE) study was a multicentre, double-dummy, randomised, placebo-controlled trial in 235 primary care centres in Sydney. More than 1600 patients with acute low back pain were randomly allocated in a 1:1:1 ratio to receive up to 4 weeks of regular doses of paracetamol (three times a day; 3990 mg a day), as-needed doses (taken when needed, maximum 4000 mg a day), or placebo. The researchers found median time to recovery was 17 days in the regular group and the as-needed group, and 16 days in the placebo group. Adherence to regular tablets and the number of participants reporting adverse events were similar between groups. “Our findings suggest that the efficacy of paracetamol should be carefully considered, with respect to the safe and effective use of medicines for low-back pain”, the researchers wrote. However, they said the safety profile of paracetamol was favourable compared with other analgesics recommended for low-back pain, such as non-steroidal anti-inflammatory drugs, which had not been shown to provide additional benefit beyond that of paracetamol, and were only marginally better than placebo. An accompanying commentary said the researchers should be “applauded for tackling this research question on a topic that has been without debate and evidence for such a long time”. The authors called for more research and said that efforts were needed “to establish if prescription of simple analgesics has additional benefit to advice and reassurance”.
    
Itch and pain help identify skin cancers
A LARGE, prospective, clinicopathological study published in JAMA Dermatology has highlighted the importance of the underlying histopathological features of cutaneous neoplasms and their associations with itch and pain. The research included 268 patients with 339 histopathologically confirmed cutaneous neoplasms — 166 basal cell carcinomas (BCC), 146 squamous cell carcinomas (SCC) and 27 melanomas. Across all skin cancers, the prevalence of itch was 36.9% and pain 28.2%. However, the researchers found these symptoms were mostly absent in melanomas. Pain intensity was significantly associated with the degree of inflammation (mild or none v moderate or marked), presence of neutrophils in the inflammatory infiltrate (predominantly mononuclear v mixed or neutrophilic), presence of eosinophils, ulceration, perineural invasion, depth of invasion and largest diameter length of skin lesion. Itch intensity was significantly associated with the degree of inflammation and the presence of eosinophils. The researchers wrote that the study “revealed that pain is associated with histologic features that involve deeper dermal processes in SCC lesions, such as ulceration and depth of invasion, whereas itch is linked with the more superficial BCC lesions”. They found the prevalence of pain and itch also increased the odds of all lesions having marked or moderate degrees of inflammation. Although the study showed melanomas had a significantly decreased prevalence of pain and itch compared with non-melanoma skin cancer, it “highlights the importance of a simple bedside evaluation for the presence and intensity of pain and itch as an easily implementable tool for physicians to use when evaluating suspicious skin lesions”, they wrote.

Stroke risk continues after cardiac surgery
PATIENTS who have cardiac surgery are not only at risk of stroke in the early postoperative period but also over the following 2 years, according to a study involving more than 100 000 patients published in the CMAJ. The research used linked data for patients who had cardiac surgery in Canada between 1996 and 2006 to analyse the incidence of stroke and death up to 2 years postoperatively. They found that 1.8% of the 108 711 patients had a stroke perioperatively and 3.6% within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 years), a history of stroke or transient ischaemic attack, peripheral vascular disease, combined coronary bypass grafting and valve surgery, and valve surgery alone. A CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes, 1 point each; prior stroke or transient ischaemic attack, 2 points) score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1. The risk factors predicting early and late stroke were similar except for new-onset postoperative atrial fibrillation and preoperative need for dialysis, which predicted only early stroke. The researchers wrote that the results extended observations made by others about predictors for the risk of early stroke. “The role of early anticoagulation, particularly in the presence of an elevated CHADS2 score, should be explored in future research”, they wrote. “Patients with an elevated score should be the focus for preventive strategies in future research irrespective of heart rhythm.”

Handovers miss important clinical issues
RESEARCHERS have found “strikingly low” documentation rates and the use of multiple methods during patient handovers at two Canadian tertiary hospitals. The prospective, point-prevalence study, published in JAMA Internal Medicine, assessed the morning handover practices of on-call overnight trainees in general medicine wards by recording omissions of clinically important issues found in a targeted medical record review. They identified 141 clinically important overnight issues during 26 days of observation, finding 40.4% were omitted during morning handover and that the trainees had not documented 85.8% of these issues in the patient’s medical record. The researchers wrote that “running the handover list patient-by-patient (ie, the entire team discusses each patient)” and a dedicated handover location were more likely to result in handover of an issue taking place. However, distractions in the meeting area had a negative impact on the handover of an issue. They wrote that the omissions had the potential to lead to delays in care and development of adverse events for patients. “Another major concern that arises from our findings is the fact that only 14% of clinically important issues from the overnight period had an accompanying progress note from the on-call trainee in the patient’s medical record”, they wrote. “This strikingly low documentation rate has important continuity of care and medicolegal implications.” They were critical of the lack of standardised morning handover practices, saying individual teams used multiple handover methods that were unpredictable and inconsistent. “Training programs should introduce new or expand existing handover curricula to raise awareness about the distinct entity of morning handover and to improve the communication process during this period”, they wrote. An accompanying perspective article blamed much of the problem on duty-hour restrictions.

CBT helps mums of premmie babes
AN intervention based on the principles of trauma-focused cognitive behaviour therapy (CBT) for mothers of premature infants was effective at reducing symptoms of post-traumatic stress disorder, anxiety and depression, according to research published in Pediatrics. The study included 105 mothers of preterm infants randomly assigned to a six- or nine-session intervention based on trauma-focused CBT (n = 62), or a one-session active comparison intervention based on education about the neonatal intensive care unit (NICU) and how to parent a premature infant (n = 43). The researchers wrote that at the 6-month assessment, “the differences between the intervention and comparison condition were all significant and sizable” and that these became more pronounced when compared with the 4- to 5-week outcomes. They found no differences in the size of the effect between the six- and nine-session interventions. The researchers said the intervention, which incorporated principles of psycho-education, cognitive restructuring and trauma exposure, was effective in reducing symptoms that occur in response to medical trauma, specifically for mothers who had experienced the trauma of preterm birth and NICU hospitalisation. Although conventional trauma-focused CBT usually included 12‒16 sessions, the researchers wrote their study suggested it was possible to deliver the core components of the intervention to mothers of preterm infants in just six sessions, with no added benefit from additional sessions. They wrote that the mothers generally reported greater satisfaction with the shorter treatment length partly because of the demands associated with having their infant in the NICU.

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