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Cochrane is a word which probably appears on the browser “Favorites” list of most EBM readers. But not many of us make time to browse through this awesome range of systematic reviews as they appear: aromatherapy and massage for symptom relief in patients with cancer, NSAIDs for preventing colorectal tumours, light therapy for non-seasonal depression: all in the past few weeks, together with much, much more. Those who live the easy life of the specialist can ignore most of this, but those who have risen to the challenge of the generalist need to know practically everything, and even remember some of it.
For example: acyclovir for treating varicella in otherwise healthy children and adolescents: less fever, fewer lesions, less itching, but no effect on major complications. Interventions for improvingadherence to treatment in patients with high blood pressure: a great synopsis of an important area, but the only firm conclusions are that simplifying the drug regime helps, and patient education does not. Antibiotics for sore throat: maybe 16 hours less soreness, with a reduction in rare complications such as quinsy and glomerulonephritis. Probiotics for infectious diarrhoea: useful, together with standard management.Most of us use Cochrane reviews as a source of “just-in-time” knowledge, when we want to know the evidence about a particular clinical problem, or do some research. But it’s also a huge mine of “just-in-case” knowledge. So if www.cochrane.org is not on your “Favorites,” put it there now, and make time to browse.
The nagging pain of inflamed joints and soft tissues has challenged human ingenuity from the dawn of history. The Sumerians and Ancient Egyptians tried virtually anything that came to hand, and the tradition continues. Oils have always been popular: the latest is a cetylated fatty acid topical cream which seems to improve pain and function in knee osteoarthritis (RCT, 40 patients, placebo controlled:
). Intra-articular hyaluronic acid is also safe and can provide symptom control for the same condition, according to a meta-analysis of 20 RCTs in
. And if all else fails, try explosives: topical glyceryl trinitrate worked for Achilles tendinopathy in an Australian double blinded RCT of 65 patients with chronic non-insertion tendonitis (
When it comes to imaging joints and soft tissues, we automatically think of magnetic resonance (MRI) as superior to simple ultrasound – but in looking for rotator cuff tears in the shoulder, they perform equally well. A study of 124 consecutive patients with shoulder pain selected 71 for arthroscopy, which was used as the gold standard (
Atopic dermatitis is a huge subject, and more than 20 distinguished US dermatologists went through 212 papers to produce the guidelines in
. The result is an invaluable graded summary of the evidence in all the major therapeutic areas. But by concentrating on such a comprehensive analysis of current issues, it risks hiding the most essential message of eczema care—use plenty of emollients, all the time. None the less, this guideline deserves to be promulgated to professionals working in dermatology, paediatrics, and primary care throughout the world, not just dermatologists in the US.
Proton pump inhibitors (PPIs) are so good at relieving any acid-related symptoms that they are often prescribed as a diagnostic test, for example in non-cardiac chest pain. A trial reported in
used high dose lansoprazole in a randomised, double-blind, placebo controlled crossover trial in 40 patients who had been assessed by a cardiologist for unexplained, recurrent chest pain. They also underwent upper GI endoscopy and pH studies. In this study, the lansoprazole test proved highly predictive, within 48 hours. Not all the studies in a meta-analysis published in
showed such methodological rigour. Overall, the reviewers concluded that successful short term treatment with a PPI does not confidently establish a diagnosis of gastro-oesophageal reflux disease in all contexts, with only modest sensitivity (78%) and specificity (54%) when compared with 24 hour Ph monitoring.
When conventional treatment fails, as it often does in irritable bowel syndrome (IBS), patients often turn to herbal remedies, which are often foul tasting mixtures of charmingly named wild plants. And speaking of charming names, did you know that you can say “meteorism” in place of “flatulent bloating”? This is one of the symptoms assessed in a German study of herbal mixtures for IBS, and like the others, it improved with the mixtures more than with the “placebo”, which contained bitter candytuft (
). Two mixtures were used, and both were equally successful–commercial STW 5, which contains bitter candytuft, chamomile flower, peppermint leaves, caraway fruit, licorice root, lemon balm leaves, celandine herbs, angelica root, and milk thistle fruit; and the research mixture STW 5-II, which omitted the last 3 ingredients. You can see that investigations could go on for some time yet.
↵* These summaries are of additional articles that passed our validity criteria but were not abstracted.