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This practice corner considers a clinical question that arose at the author’s outreach clinic at a soup kitchen in urban Sydney. It highlights some of the practical issues that affect the equitable application of evidence with disadvantaged patients.
THE PROBLEM
Jason dropped by the clinic looking fidgety and agitated. He is 32 years old with a history of substance abuse that includes paint sniffing and narcotic abuse. On a previous visit, he told me that he injects crushed and filtered morphine tablets twice a week “to relax,” and I suspect that he has harmed himself in the past.
He sleeps “rough” in parks, railway stations, and squats and presented to the clinic asking for something to help him sleep. He says it is “noisy” on the streets and he hasn’t had a decent night’s sleep for a long time, yet he refuses to access emergency shelter accommodation. I’m very reluctant to prescribe him benzodiazepines but sympathise with his sleeping problems. So I wondered about the effectiveness of the herbal root extract, valerian, as an alternative treatment for insomnia and went looking for the best available evidence.
SEARCHING AND APPRAISAL
My usual approach to searching is to look first in the Cochrane Library for systematic reviews and trials in the controlled trials register and then to search Medline via PubMed Clinical Queries (www.ncbi.nlm.nih.gov/entrez/query/static/clinical.html). No relevant systematic reviews were found in the Cochrane Library, but 1 was found in Medline.1 However, this review was a few years old, and I had noted that a more recent randomised controlled trial had appeared in the Cochrane Controlled Trials Register. A further search with the “treatment” filter on PubMed Clinical Queries for trials from 1999 onwards found 3 more recent trials among people with mild insomnia.2–4 After only a few minutes of searching, I had a full …