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  1. Richard Lehman, MRCGP, MA
  1. Department of Primary Care, University of Oxford
 Oxford, UK

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    Asthma is the oldest medical word in common use: it first appears in the writings of Hippocrates around 450 BCE and derives from a verb used by Homer. Two and a half millennia later, we continue to argue about its definition and treatment. The drugs we prescribe most are the β adrenergic agonists, both short acting and long acting, although they are associated with an increase in the risk of asthma-related death. We urge many patients to take inhaled corticosteroids, but many forget; for them a good idea might be to use metered dose inhalers with an audiovisual reminder device, according to a trial from New Zealand (

    ) . Recently, fixed dose combinations of long acting β stimulants and steroids have become popular with both doctors and patients, though we lack good data on their long term safety. A Polish study compared 2 frequently used combinations, salmeterol/fluticasone and formoterol/budesonide. They performed equally well over 6 months (
    ) . And a study aimed at reducing treatment for mild persistent asthma in the USA suggests that most patients who are well controlled on twice daily fluticasone do equally well on a once-daily fluticasone/salmeterol inhaler, whereas switching to oral montelukast is not as good (
    ) . Finally, it is nice know the safety of inhaled corticosteroids in the first trimester of pregnancy has been upheld by a large Canadian record linkage study (
    ) .
 A recent review in the New England Journal sang the praises of vitamin D (
    ) , arguing that when humans moved North, they could only get their daily ration if they remained half naked and ate a lot of oily fish and eggs; well clothed civilised modern northerners are likely to be vitamin D deficient, with serum levels below 80 nmol/l. A study carried out in Nebraska (
    ) randomised 1179 women over the age of 55 years to receive placebo, calcium alone, or calcium plus vitamin D. There were significantly fewer cancers in the vitamin D-treated group over 4 years. Benefits to the heart and brain can be expected too: there are plenty more studies to be done.
 Now the main reason we give calcium and vitamin D supplements to postmenopausal women is to help their bones, while many of these ladies also use soy products in the hope of warding off vasomotor symptoms through the oestrogenic effects of isoflavones (“phyto-oestrogens”). The most effective of these may be genistein, which was used in an Italian study in conjunction with calcium and vitamin D in 389 women to assess its effect on postmenopausal osteopenia (
    ) . Those given the genistein showed an improvement in spinal bone density while those given calcium and vitamin D alone showed a decline.
 Much was once expected of folic acid in the prevention of cardiovascular disease, but the randomised trials have disappointed (see
    ) . For stroke prevention, however, a small protective effect of around 18% emerges from a meta-analysis of 8 RCTs in
    . For this reason alone, it may deserve a place in any future Polypill for the over-50s. For the prevention of further vascular events after stroke, we already know enough to achieve a reduction of at least four-fifths, according to a modelling study in
    .
 The choice of analgesia for patients taking warfarin can be difficult. Paracetamol (acetaminophen) was once thought to be free of significant interaction, but a small study carried out on US veterans (
    ) proves the opposite: regular dosing above 2 g/day is more likely than not to send the international normalised ratio above the therapeutic range. On the other hand, an occasional 1g dose is unlikely to be harmful, and further studies are needed to show whether patients who need regular paracetamol might be able to continue with an adjustment of their warfarin dose.
 There has recently been much debate about the superiority of coronary artery bypass grafting (CABG) over angioplasty and stenting or medical management for symptomatic coronary artery disease. When an Oxford professor recently wrote an editorial about the superiority of CABG (
    ) he provoked vigorous dissent from the other professor in his department (335:111). The MASS II trial randomised 611 Brazilian patients to these 3 interventions, and the 5-year mortality is identical between groups, though CABG patients had significantly less non-fatal myocardial infarction (
    ) .
 Ultrasonic screening for abdominal aortic aneurysm (AAA) in men between 65 and 74 years of age seems a simple, sensible thing to do, and a large British trial (also confusingly called MASS) produced a good early reduction in AAA-related mortality. The long term results were also hailed as worthwhile and cost effective when reported in
    , but are reported by the same team in a less optimistic way in
    . During the follow-up period, AAA-related mortality was reduced by just 11%, and fewer than half of the AAA-related deaths in those screened could have been prevented. To lower my chances of developing AAA, I shall take a daily nibble of dark chocolate—it will lower my blood pressure and improve my endothelial health ( ) .