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Morphine and the heart, antibiotics and the appendix, sick notes, blood tests, painkillers

Duration:
28 minutes
First broadcast:
Tuesday 10 April 2012

Dr Mark Porter goes on a weekly quest to demystify the health issues that perplex us.

Professor Jeremy Pearson, Associate Medical Director of the British Heart Foundation, discusses with Mark new research that suggests that giving heart attack victims drugs to ease their chest pain could hamper the heart's ability to heal itself.

The standard approach to appendicitis is to remove the inflamed organ. But a new review argues that antibiotics could be an alternative to surgery in some cases. Dileep Lobo, Professor of Gastrointestinal Surgery at the University of Nottingham, explains his team's findings.

GP Margaret McCartney is on her soapbox about sick notes, following regulatory pressure from Europe that could allow people who fall ill on holiday getting compensatory time off work.

Dr Kamran Abbasi, Editor of the Journal of the Royal Society of Medicine, looks into the evidence that the change from sick notes to fit notes two years ago has had an impact on people returning to work.

Mark visits the pathology laboratories at St Thomas' Hospital in London to find out from Senior Biomedical Scientist Diane Murley how blood is analysed.

And Dr Andrew Moore from the Pain Research Unit at the Churchill Hospital in Oxford talks about which over the counter painkillers are likely to work best for acute pain.

Producer: Deborah Cohen.

  • Programme Transcript - Inside Health

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX: 11.04.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: DEBORAH COHEN


    Porter
    Hello and welcome to Inside Health. In today's programme: A new treatment for appendicitis - drugs rather than surgery.

    Sick notes. If you were unlucky enough to fall ill over the Easter break then you probably support proposed changes allowing people to claim extra time off if they are sick on holiday. Our resident sceptic, GP Margaret McCartney, explains why she is not so keen.

    And I will be discovering why age-old advice to manage a headache by taking two paracetamol, two aspirin, or a couple of ibuprofen may not be the best way to get rid of the pain.

    Moore
    Well what I'd be taking right now is one tablet - 500 milligrams - of paracetamol - one tablet - 200 milligrams - of ibuprofen and a nice strong cup of coffee, in fact it's what I did before I left the house this morning because I had a headache and it worked.

    Porter
    And, as we will be revealing a bit later, there is more to the coffee than something to simply wash the pills down.

    But first, new research suggesting that giving heart attack victims drugs to ease their chest pain could hamper the heart's ability to heal itself. A team from Bristol University has discovered that a chemical - substance P - produced by the nerve pathways responsible for pain, also plays a key role in attracting regenerative stem cells to the damaged area. Meaning, if you block the pain, you risk hindering the body's natural repair response. So might it be better to grin and bear some short term pain, for longer term gain?

    Jeremy Pearson is Professor of Vascular Biology at King's College, London and Associate Medical Director of the British Heart Foundation - the charity who helped fund the study. And he is on the line from offices of the BHF.

    Jeremy, this link between pain and repair seems fairly logical, were you surprised by these findings?

    Pearson
    They were not a surprise but they were quite interesting. We've known for some time that, as you say, that pain is a response to injury which is important because it signals to the brain and to other parts of the body that repair processes should be put into motion. The point about this paper is that it's actually shown a mechanism that we haven't expected before by which pain signals may help directly to trigger repair in the heart.

    Porter
    And this is the stem cells that are being - are they being drawn to the area and then what are they doing when they get there?

    Pearson
    Well they are homing to the site of injury caused by the release of this pain inducing compound - substance P - and as you say they come from the bone marrow and they arrive up in the heart and the belief is that once they arrive in the heart they're helping to stimulate the repair process as a consequence of the heart attack.

    Porter
    Can you explain in basic terms how pain relief is currently used in people having a heart attack and why?

    Pearson
    Heart attacks are obviously extremely painful and the pain is on-going after the heart attack for some time and so most patients will have significant amounts of pain relief during and for some period after they've got to hospital and are treated for their heart attack. And clearly the implications of this paper are that if you over treat the pain - clearly you want to dull the pain, you don't want patients in agony - but if you over treat the pain then you may actually be impairing the repair process.

    Porter
    Is there any evidence that the existing practice - I mean we would be using morphine, diamorphine type drugs, very powerful painkillers in people with heart attacks - does that affect the outcome, do we have any evidence to show that people who've had lots of these drugs have a poorer outcome in the long term?

    Pearson
    Yeah there is published evidence to suggest that patients who've had heavier use of morphine around the time of a heart attack actually have worse longer term outcomes than those who have less. That's obviously an association rather than a direct proof but it suggests what you're suggesting is correct.

    Porter
    Because it could be that they're simply having a bigger heart attack and therefore in more pain?

    Pearson
    Indeed, that's right. However, again the results of this study, which of course was in mice not in people, does suggest there is a direct mechanistic link which is relevant and therefore that you should be taking care not to over-suppress pain in response to this damage to the heart.

    Porter
    So how might clinicians - people looking after people who've come in with a heart attack - take this new evidence on board, how might it change their practice from now on and is it likely to do so?

    Pearson
    I don't think it'll change practice in the near future, simply because this is a study in mice, which is a long way from men, and it's suggesting an interesting mechanism whereby this substance - substance P - can contribute to mending or hoping to mend a heart after a heart attack by getting cells to come from the bone marrow to help with the repair process. So the authors of the paper I think have got two clinical messages: one is the one we've been talking about which is that perhaps clinicians should be aware that totally suppressing pain in response to a heart attack may actually also be suppressing the repair process, which I think most clinicians are aware of and they've always got to treat individual patients on an individual basis to decide how best to deal with that. I suspect in the longer term the hope of the authors of this paper is that there could be direct local treatment with something that does not induce pain but has the same effect as this same pain inducing substance which could actually attract cells from the bone marrow to repair the heart.

    Porter
    Professor Jeremy Pearson, thank you very much.

    Now, onto another study that has made the headlines this week and one that could radically alter the way we treat appendicitis. At the moment the standard approach is to remove an inflamed appendix surgically - something that happens to at least one in 10 of us during our lifetimes - but new research into whether antibiotics could be an alternative to surgery has challenged that.

    A team from Nottingham reviewed four trials comparing antibiotics to surgery and their conclusions will no doubt have prompted many a debate in operating theatres across the country.

    Dileep Lobo is Professor of Gastrointestinal Surgery at the University of Nottingham and led the research.

    Lobo
    Well we've shown that antibiotic therapy is a viable and safe alternative to surgery for uncomplicated acute appendicitis.

    Porter
    And by uncomplicated you mean what?

    Lobo
    We mean patients who have not had a perforation, who do not have gangrene of the appendix and who do not have peritonitis, which is widespread inflammation inside the abdomen.

    Porter
    So these are people with what we would perhaps refer to as an early - an early appendix?

    Lobo
    That is right.

    Porter
    Hopefully the majority of cases?

    Lobo
    Yes because up to 80% of patients present with uncomplicated appendicitis, only 20% present with the complicated variety.

    Porter
    And at the moment the option is when you see these people is you take them down to theatre and remove the appendix.

    Lobo
    That is correct.

    Porter
    And where do the antibiotics fit in?

    Lobo
    Appendicitis is an inflammatory disease and so in the early stages if we treat them with antibiotics the antibiotics may take care of the infection and inflammation and make the whole process subside. We have used it successfully for colonic diverticulitis, which is an inflammation of the large bowel, and most patients nowadays are treated with antibiotics rather than surgery for that condition. So just an extrapolation of that thought to the appendix and antibiotics do appear to work in a large number of patients.

    Porter
    And in your review how did antibiotics compare to the conventional surgical approach?

    Lobo
    Well of the patients who had antibiotic therapy it was successful in 63%, that's almost two-thirds of patients. And at the end of one year two-thirds of the patients treated with antibiotics did not need an operation. And the complication rates were much lower in patients who were treated with antibiotics than those who had surgery, so there was a 31% reduction in the risk of developing complications if patients had antibiotics rather than surgery.

    Porter
    And practically what does that involve for the patient, are they having these antibiotics in hospital?

    Lobo
    Yes because these were randomised control trials the investigators wanted to be absolutely sure that they weren't harming patients, so for the first 48 hours patients received intravenous antibiotics in hospital and if they weren't getting worse or if they were getting better these antibiotics were converted to oral antibiotics and then they were sent home when the investigators felt that the inflammation was subsiding.

    Porter
    What about the downsides of using antibiotics - I mean in effect that you might be undertreating some of the more serious cases?

    Lobo
    Well Mark this trial, for all the trials that we included, patients with complicated appendicitis were excluded at the start, so the 20% who present with complicated appendicitis were excluded.

    Porter
    So these are the more serious forms but how do you tell that they're the more serious forms?

    Lobo
    Clinically these patients are much sicker, they have a much higher temperature, they have a higher pulse rate and they've got more signs when you examine the abdomen. However, the best way of ruling out complicated appendicitis is to perform an ultrasound or a CT scan, which actually shows what's going on around the appendix and you can make a firm diagnosis in that situation. Some of the patients who were treated with antibiotics did go on to have an appendectomy and they did have complicated appendicitis but the risk of developing complicated appendicitis was no greater in those treated with antibiotics when compared with those treated with surgery.

    Porter
    Do you think your paper's going to change clinical practice - will we see people in British hospitals being given antibiotics instead of being whipped down to theatre?

    Lobo
    Well I don't think antibiotics are going to replace appendectomy altogether but yes I think doctors will consider treating patients with early appendicitis with antibiotics when they come in and I think a large number of these patients will have their symptoms resolved and they may be prevented from having an appendectomy. However, we do not know what the long term results are because in all these studies that we have analysed the follow up was for one year, so we don't know whether patients will develop appendicitis later on in their life or whether, especially in the women of the childbearing age group, whether antibiotic treatment may result in tubal infertility. So these are the unanswered questions but hopefully most patients will have successful treatment for uncomplicated appendicitis with antibiotics.

    Porter
    Because this is one of the problems with appendicitis, particularly in women as you get inflammation in the pelvis and that can damage the other organs, which would include the fallopian tubes of course.

    Lobo
    That is correct and that question is unanswered at the moment.

    Porter
    So it may be that the antibiotics are delaying the inevitable and you end up losing your appendix in the future, we don't know that yet?

    Lobo
    It is possible but as I say we don't know that.

    Porter
    Professor Dileep Lobo.

    And if you would like some more background to that study - or the Bristol research into pain relief and heart attack - then do visit our website - bbc.co.uk/radio4 and just follow the links to Inside Health.

    Sick notes have also been in the news following regulatory pressure from Europe that could soon see people who fall ill on holiday compensated with extra time off work. A move that has got GP Margaret McCartney thinking:

    McCartney
    One of the things I hadn't realised that my medical degree had conferred upon me was psychic abilities. Yes, the ability to divine whether or not a person, last week, was ill enough, to not be on holiday.

    I agree it's all a bit peculiar. Vince Cable, the Business Secretary, has been in the news because of his opposition to the forthcoming changes to European law - to allow workers further time off if they have been ill when on annual leave on production of a sick note.

    And where is the sick note going to come from? Currently, citizens are trusted to sign themselves off sick for the first week of any illness, which is quite right: most people are honest and sensible. It's not an efficient use of doctors' time to fill out notes for patients who are already getting better. In fact, the panoply of causes of the ‘GANFYD' syndrome - that's 'get a note from your doctor' - needs to be reduced, not increased. There are letters to say a child is fit to go on TV, a note to say that someone needs to use a lift not the stairs or an official document to state that someone feels a bit too sweaty in synthetic fibre work wear. The last thing we need are more bits of paper getting in the way of doctors seeing and treating people who are actually sick.

    There's an odd irony in the way that GPs are being used and abused when it comes to sick notes. Because the effects of an illness can be different in different people and because work places are not the same it's often rather hard to make blanket recommendations about many medical conditions and their effects on employment. GPs are not occupational health doctors yet in many cases they are asked to police some employees sick leave without the on the ground information that an occupational health physician would have.

    It seems to me that we have got this topsy turvy. We shouldn't be putting yet more needless paperwork into the system where we don't need it, with sick notes to cover holidays - but allow GPs instead to concentrate on helping people who really do have long term problems.

    Porter
    Margaret McCartney. And another member of the Inside Health team is here listening to that, Dr Kamran Abbasi, Editor of the Journal of the Royal Society of Medicine.

    Kamran, let's put some figures on this. How big an issue is sickness related absence from work?

    Abbasi
    It's a very big issue, there's no doubt about that at all. If we look at the stats say from the 1950s to the 1990s and we take back pain and sickness absence as a result of that, there's been a seven fold increase over that period. And we might imagine that physically demanding work has decreased over that time. So it's a big problem, it's potentially getting bigger and we've put some costs on that. The cost to the economy is something like £100 billion a year, not from back pain but from all sickness absence and £26 billion of that is probably caused by mental illness.

    Porter
    Remind us about the current rules - Margaret referred there to the fact that you can take a week off - what are the exact rules?

    Abbasi
    So the exact rules are this: You can self-certificate, which Margaret was talking about, you can do that for a week but after that, from the seventh day of your illness, you need a note from your GP. Now in the old days this used to be a sick note from your GP and that really stated that you were not fit for work until a particular date. Now what changed in 2010, in April, so it's nearly two years - it is two years ago - is that we introduced something called a fit note and the difference with the fit note is that it can still say that you're not fit for work but it can also say - and this is what we're encouraging, what the government's trying to encourage doctors to do - is to say that patients may be fit for work and if they may be fit for work these are the conditions that may enable them to return to work earlier than they might have previously.

    Porter
    Okay, so you've got a broken toe, you might not be able to walk round the factory floor in your steel capped boots but there's no reason why you can't sit at a computer and do some work there?

    Abbasi
    Yeah absolutely and that's precisely the reason it's been introduced, to say well let's try and encourage people back to work.

    Porter
    So two years in, I mean we can see why they introduced them, it keeps people at work, what's in it for the individual, the employer and any doctors stuck in the middle, I mean two years on do we have any hard figures to show that these things are working?

    Abbasi
    It's a figure free area, there's a bit of a drought, shall we say but let's...

    Porter
    Okay what's the theory then?

    Abbasi
    The theory's based on I think two premises which are reasonably evidence based. So the first one is that the benefits of work - of an individual going back to work - and let's talk about health issues, let's take a health angle to this rather than a political one - and if you enable people to return to work and they're happy in their job and it's a good job that they enjoy they will see the physical and psychological benefits of that. So that's pretty undeniable. And the other side of the coin is that if people stay out of work for a considerable period, if they have a long term illness related time off work, then they risk all sorts of consequences such as deprivation, social exclusion, ill health that are associated with long term illness and being out of work.

    Porter
    And actually for specific illnesses there are - there's some quite convincing evidence that being at work's good for you, I mean I'm thinking of back pain, we know that people with simple back pain that if you go back to work you tend to get better quicker. Which is the exact opposite of what most people think and what we've done historically in the past.

    Abbasi
    Yeah it's precisely that and if there is any evidence that suggests that getting people back to work early is good for them is in precisely those conditions.

    Porter
    And from the employers' angle - I suppose it's a bit of a no brainer, they've got the person back at work haven't they?

    Abbasi
    Possibly, I think the whole point about the fit note is that the patient - a patient can take that to an employer and say look these are the circumstances under which I can potentially return to work, what can you do to enable that to happen. Now an employer may or may not be able to do what's required. So in a way it potentially creates a more constructive dialogue.

    Porter
    Now I want to pick up on one more thing that Margaret said which is all very well if I know a lot about your job, so when I'm writing the fit note if I can say well I don't want him doing this, that and the other, but I don't know anything about most of my patients' jobs, I have to take what they tell me as what they can and can't do, so how useful is the fit note in practice or do we need independent experts to be producing these?

    Abbasi
    Well this is where we don't have much evidence, we know that if a GP fills in a fit note they're more likely to say that a patient may return to work and that's pretty obvious. Now in terms of how effective they are in saying well these are the things that need to be done, we know that GPs probably aren't always qualified. Now many companies have an occupational health department, the patient can be referred to that department but also you'd have thought most GPs they're quite good at ascertaining what a job entails and how an illness might impact on that.

    Porter
    And actually I have seen, Kamran, in practice that sometimes they don't want fit notes they want them either back to work or not at work and they'd rather have it that way which rather puts the kibosh on the whole affair.

    Abbasi
    Yes there's always that.

    Porter
    Dr Kamran Abbasi - thank you very much. Don't forget if there is a health related issue that is confusing you that you would like Kamran or anyone else in the team to look into then do get in touch. You can send a tweet to @bbcradio4 containing the hashtag insidehealth, or an e-mail to insidehealth@bbc.co.uk

    Which is exactly what Derek Maule did. Derek is confused by a recent full blood count he had - what does this common blood test measure, what sort of conditions can it pick up, and why did his show that he has fewer white cells than normal?

    To find out I went to the pathology labs at St Thomas' Hospital in London to meet Senior Biomedical Scientist Diane Murley

    Murley
    We process approximately 2,000 full blood counts a day, 60% of that work will come from inside the hospital and another 40% will come from GPs and outpatients.

    Porter
    So it's been taken in their surgeries and sent in?

    Murley
    Yes.

    Porter
    And that's just one test - the full blood count - and there are - how many tests would you offer - a lab like this?

    Murley
    There are hundreds of tests that can be offered by - not only by haematology but the other disciplines within pathology - so chemistry, immunology, cytology.

    Porter
    Liver, kidney tests - all of those sorts of things.

    Murley
    Yes many different - different tests.

    Porter
    Looking round the lab now I can see there's a - I mean there must be in this area we're in now 10 or 15 people in white coats but there's a lot of machinery as well. How much of this is automated?

    Murley
    Quite a lot of the - our work - is now automated because it allows us to process large volumes of samples very quickly. This is one of our automated full blood count analysers, it processes samples automatically, we can load the samples into a rack - it can do up to a hundred samples an hour and it takes less than a minute to produce each result.

    Porter
    And assuming that result is normal do you ever get to look at it?

    Murley
    No, if the result is normal and it fits within the ranges that we've set on our computer system that result will be transmitted from the analyser to our computer and then validated automatically. It doesn't actually know what it's counting, it's a particle counter, it doesn't know it's counting a white cell or a red cell or a platelet, it goes purely on size. The sample is taken through the analyser to various sections where different cells will be measured, validated by the computer system, we never see them.

    Porter
    So no human input?

    Murley
    No. But the abnormal ones will actually be flagged by the computer and then a scientist can actually examine those results and decide if that requires any further tests.

    Porter
    Let's talk about what you can see on a full blood count. We're looking at the major components of blood, which are?

    Murley
    We'd be looking at white cells, red cells and platelets. And also the haemoglobin that is actually within the red cells, that's what carries the oxygen around your body to the various tissues. The red cell will appear as a pink ring with a slightly paler middle, this is because the red cell is actually bi-concaved in shape and it's thinner in the middle, so it will appear paler in the middle.

    Porter
    So one of the common reasons why we might do a full blood count for instance is anaemia and what would you see if someone's got anaemia what are you likely to see on the - what clues can you learn from looking at their full blood count?

    Murley
    It depends on the type of anaemia that a patient has. If a patient had iron deficiency anaemia, which is one of the most common ones that we see, the haemoglobin would be very low and the red cells could be very small. Whereas if somebody has an anaemia due to something like B12 deficiency, vitamin B12 deficiency, those cells may be larger but again the haemoglobin may still be low.

    Porter
    What about the white cells - what sorts of problems might we look for with them?

    Murley
    White cells we can identify increases in number initially by the analyser and then we can actually look at the different types of white cells within the blood. There are five mature types of white cells that you would usually see in your bloodstream and they are concerned with dealing with different aspects of infection and immune problems that may be going on within your body. So, for example, your neutrophils may be increased if you've got a bacterial infection but it may be your lymphocytes that are increased if you have a viral infection. And by giving that information to the doctor we can then help them decide whether a patient should have antibiotics or not.

    Porter
    Our listener Derek Maule, who suggested that we look into full blood count, actually has had to have repeat test because one of his counts came back as low, he had a low neutrophil count, the white cells that we were talking about, that fight infection, that's a reading I quite often see in general practice, what sort of things could cause that?

    Murley
    It can be age related, it can be related to some drug treatments as well and also it can be race related - some races have lower levels of neutrophils than others. So we need to know the patient's history and background to be able to interpret that result.

    Porter
    And last but not least the smallest of them all, the platelets, what are they doing and what do you do with them here in a full blood count?

    Murley
    They're linked to actually forming the clot and stop you bleeding. So if you have low numbers of platelets you could be at a higher risk of bleeding. The full blood count will provide us with a number of platelets that you have within your circulation.

    Porter
    How quickly can you turn these results around?

    Murley
    It takes less than a minute to actually produce a full blood count result...

    Porter
    But it's got to get here and get back.

    Murley
    Yes, it's the transportation and actually the reporting and getting that information back to the ward clinicians and also the GPs that can take the time.

    Porter
    Diane Murley from St Thomas'.

    And from the complexities of an automated high tech pathology lab to the other extreme of healthcare - self-treatment with over-the-counter painkillers like aspirin, paracetamol and ibuprofen, and what we should be taking for acute, short lived discomfort like a headache.

    Dr Andrew Moore is from the Pain Research Unit at the Churchill Hospital in Oxford and has reviewed the use of painkillers in acute pain for the Cochrane Library and his conclusions may change the way many of us take them.

    Moore
    If you're looking at a league table, as it were, bottom of the list would be aspirin, which does well in about 35-40% of people; paracetamol may be in about 45%. Ibuprofen, 400 milligrams - and for all of these we're talking about two tablets - gets you up to 55% but for some of the largest percentages come from medicines that you can get where you are combining some of these drugs together.

    Porter
    So taking, for instance, paracetamol and ibuprofen together works better than either a full dose of each of those two drugs?

    Moore
    Oh yes, instead of being down at 45% or 55% you're up at 75%, so three quarters of the people are getting really good levels of pain relief - but not everybody, let me just make that point as well.

    Porter
    But I think people would be surprised that the paracetamol on its own and ibuprofen on its own at best they're not working in around half of people.

    Moore
    Well yes I suppose that is a surprise, it's less of a surprise to those of us who've been working in this for some time because we've been used to it. But whether one's talking here about acute pain or chronic pain it's the way in which the world is changing really almost as we speak, that we're beginning to think about the way in which we assess medicines, particularly in pain, in a completely different way.

    Porter
    Let's assume I've got an acute toothache and what your research suggests is that I'd probably be better off taking paracetamol and ibuprofen together than taking either one of those two, are you talking about taking a full dose of each?

    Moore
    No indeed, I mean a full dose would be two tablets - that's a 1,000 milligrams of paracetamol - and two tablets - that's 400 milligrams of ibuprofen. I mean what we'd be saying is that from our research is that you can get much better results by taking one tablet of each at the same time.

    Porter
    Which is not the sort of standard advice that people are given. I mean I think that's interesting, we generally recommend people take up to eight paracetamol a day, what you're suggesting is perhaps they should be taking four paracetamol and four ibuprofen?

    Moore
    Yes but of course we're talking here about acute pain not chronic pain and there may be differences there that need to be explored.

    Porter
    The other ingredient you sometimes see on these extra strength super strength painkillers is caffeine, where does that fit in?

    Moore
    Well the issue with caffeine has been a complicated one, largely because all the evidence on which caffeine has - adding caffeine to these medicines was based was hidden from us, we couldn't get it and we've managed to dig out really quite a bit more. And what it shows is that if you're taking in a medicine, say 100 milligrams of caffeine, which is roughly what you get in a good strong cup of coffee, you can add about 5-10% of people getting good levels of pain relief. So the evidence is strong that caffeine is helpful when taking in conjunction with analgesics like ibuprofen and paracetamol.

    Porter
    And do we know what it's doing - is it aiding absorption, is it aiding the action of the drug?

    Moore
    I haven't a clue. I don't know for certain, I mean certainly it's been suggested that it aids absorption of drugs and that might give you a better effect. It's also been suggested, and there's some good literature on it, that caffeine works at various receptors which frankly are so complicated that I don't understand what's going on and it would be very unclear as to how those helped with pain relief but there's a science there which is developing.

    Porter
    But it works, that's the important thing.

    Moore
    It works that's the important thing.

    Porter
    And does it work in the sort of doses that we see contained in over-the-counter remedies, often quite low amounts of caffeine, you're suggesting a 100 milligrams which is quite a hefty dose?

    Moore
    Well it is but in two tablets of many of the over-the-counter medicines contain 100 milligrams, indeed 100 milligrams is the threshold at which it begins working. There are some which have only 65 milligrams and you don't see much effect there. And there's some evidence that if you increase the dose to say 200 milligrams, although those are experimental studies rather than things that you'll buy over-the-counter, that you can get more. But basically yes the 100 milligrams you'll get in most over-the-counter medicines is helping.

    Porter
    Well let's go for a take home message - if you had a headache, a nasty headache, what would you take now?

    Moore
    Well what I'd be taking right now is one tablet - 500 milligrams - of paracetamol, one tablet - 200 milligrams - of ibuprofen and a nice strong cup of coffee, in fact it's what I did before I left the house this morning because I had a headache and it worked.

    Porter
    Dr Andrew Moore. And there is a link to that Cochrane review on our website, go to bbc.co.uk/radio4 and click on Inside Health.

    Just time to tell you about next week when I'll be finding out the best way to help extreme blushing as well as revealing a simple trick to assess whether your bowel is working as it is supposed to. All you need is some sweet corn.

    ENDS

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