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  1. Richard Lehman, MA, MRCGP
  1. Hightown Surgery
 Banbury, UK
 Department of Primary Care (Senior Research Fellow)
 Oxford University
 Oxford, UK

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    Cognitive behavioural therapy (CBT) can be useful for all sorts of illnesses with a mental component, so much so that in most places demand far outstrips supply. A team of Dutch researchers decided to try teaching some willing general practitioners the basic methods of CBT, and then to see if they achieved better outcomes in patients who were losing time off work with unexplained fatigue (controlled trial, 151 employees randomised). Alas, this made no difference, either because GPs aren’t very good at delivering CBT or because CBT isn’t very good at reducing absenteeism from chronic fatigue.

    Blood pressure (BP) is one of the most frequently measured human variables, but despite a century of study and at least 5 journals devoted entirely to it, we still don’t know the answers to many basic questions. For instance, there is a growing move towards home measurements by patients, but do they have any predictive advantage over office measurements, which tend to be higher because of the “white coat effect”? The first of 2 recent cohort studies in

    looked at a fairly typical mixed cohort and measured BP control, wellbeing, and left ventricular mass (LVM)—things that could be called “soft endpoints.” BP control was worse in the home group but LVM and wellbeing were the same. The second cohort study (291:1342–9) looked at older patients and “hard” endpoints: cardiovascular and total mortality, stroke, and coronary events. There was a significantly higher risk in patients with high BP both in the office and at home when compared with those with high BP in the office but normal BP at home.

    Are you the sort of doctor who gives corticosteroid injections intotheshoulder joint? If so, could you accurately describe the position of your needle as it enters that confusing region? A Spanish trial compared outcomes in patients randomised to “blind” injections with those who had injection under ultrasonic guidance. The second group fared better.

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    It’s fashionable to blame a “Western lifestyle” for the rise in type 2 diabetes, but although obesity and lack of exercise certainly play a part, a big systematic review of cohort studies in

    shows that alcohol is protective. So dine out happily, bearing in mind that dairy products (see

    ) and coffee (see

    ) might also help you avoid diabetes.

    A triumph for trickily tongue-tripping thiazolidinediones as third-line therapy. In type 2 diabetic patients poorly controlled with metformin and a sulphonylurea, is it better to add a glitazone or a single dose of long acting insulin? Hard to judge from a single 16–week open label study, but the results for pioglitazone were encouraging: there was less hypoglycaemia and a rise in high density lipoprotein cholesterol compared with the group treated with a bedtime dose of isophane insulin.

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    One of the bugbears of diabetes is neuropathy, for which there are few useful treatments. The antioxidant alpha-lipoic acid has to be given intravenously, and in a meta-analysis of 4 blinded randomised 3-week trials, there was a 37% response to placebo; but the active groups did even better at 53%. Perhaps this treatment may find a place in some centres, until we find better and more conveniently administered agents.

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    Gout is a nice condition for doctors, but never for patients. They may give you the diagnosis by limping in with one foot in a slipper with the toe cut away: you look forward to them coming back gratefully the next day, smiling and in normal footwear. But all too often, gratitude induced by indometacin is tempered with complaints of indigestion: reason perhaps to use etoricoxib 120 mg, which is equally effective and better tolerated.

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    Even more immediate gratitude can follow the relief of ureteric colic, for which a traditional drug is pethidine. However, a Cochrane Review suggests that (a) injected non-steroidal anti-inflammatory drugs are usually more effective and (b) pethidine is more likely to cause vomiting than other opioids.

    . My personal experience, for what it is worth, is that I always vomit with renal colic anyway, and that pethidine works nicely but makes me feel terrible afterwards.

    “Kills all known household germs”—so what? A team in New York did a double blind RCT in which they supplied mainly Hispanic households with antibacterial or non-antibacterial products for general cleaning, laundry, or hand washing. Over 48 weeks, there was no difference between groups in any symptoms of infectious disease.

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    “This preposterous quackery...” begins a famous essay on chiropractic by the bilious editor of the Baltimore Evening Sun, H L Mencken, in December 1924. It gets worse. “Any lout with strong hands and arms is perfectly equipped to become a chiropractor.” But gentle readers of Evidence-Based Medicine should at least give HLM credit for proposing one of the first blinded diagnostic studies: “Let a thousand patients be selected, let a gang of selected chiropractors examine their backbones and determine what is the matter with them, and then let these diagnoses be checked by the exact methods of scientific medicine.” The UCLA Neck Pain Study was less ambitious and more polite. Patients with neck pain were randomised to chiropractic neck manipulation or mobilization, and the mobilized complained less. “Chiropractors may... increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.”

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    Tai Chi is the sort of thing which would have driven H L Mencken to even dizzier heights of invective, but it may well be good for all sorts of chronic conditions: the trouble is, we don’t know. Three investigators went through all the Chinese as well as the English language studies they could find: there are 9 RCTs, 23 non-RCTs, and 15 observational studies. Unfortunately, they are mostly of poor quality, but there is enough evidence of benefit and safety to warrant well designed studies.

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