No compliments for complementary therapy

Congratulations to Norwegian chiropractor, Steinar Forshei, who joined an RCT of spinal manipulation for infantile colic (page 138). Previous observational studies had suggested it might be helpful and many parents seek this type of treatment for their babies. Entry criteria were reasonably strict, essential when investigating this ill defined condition, and the placebo arm consisted of the baby simply being held for the same length of time as the treatment. In a neat paediatric twist, parents were blinded rather than the patients. Fourteen chiropractors (!) agreed methodology before one experienced practitioner carried it out. There was no difference in outcome between the groups; two thirds of each tended to improve. The authors call for similar investigative rigour in other forms of alternative medicine. Our referee, while approving the science, was doubtful about the desirability of publishing papers on this sort of topic. The editors disagreed: patients frequently ask their paediatrician's opinion on consulting alternative practitioners, so we believe it to be valuable to have something of an evidence base on which to advise them.

2001: Spacer odyssey (parts 1 & 2—more to come)

ADC does its best to avoid institutional prejudice so why is it there is a collective groan when yet another spacer paper thuds through the letter box? It may have something to do with a large number of unoriginal “me too” projects or design studies of commercial, but probably not scientific, interest. This preamble is by way of justification for two exceptions.

Laboratory work had suggested that a metal spacer might be more effective because of the absence of an electrostatic charge so Dr Dompeling and colleagues from the Netherlands compared the bronchodilator response of inhaled salbutamol in different spacers with different electrostatic charge (page 178). They all worked well and what mattered was dose, not charge. So, another in vitro hypothesis bites the house dust.

Meanwhile, in sunny but asthmatic Australia, Dr Powell and colleagues determined to put paid to what they term “the nebuliser culture” (page 142). Based on the hypothesis that what the teaching hospital does today the outback does eventually, they set out to develop evidence based guidelines for using spacers and—most importantly—implement them. As I have stated here before,ADC treats guidelines with more than a pinch of salt. Our justification this time is the careful exposition of the managerial and pedagogic action needed to overcome scepticism and inertia, which we believe might serve as a model for others wishing to change practice in their hospital. In his commentary, Warren Lenney cites Ptolemy, Copernicus, Galileo, and HG Wells. We forgive him for not providing the references as the journals concerned would add to nobody's impact factor.

What fills the space also counts

In a commendably short paper (would that others might follow suit), a group from Manchester, UK has measured bone mineral density (BMD) in 20 children with asthma treated with moderate to high doses of inhaled corticosteroids (page 183). The authors, after a suitable display of caveats, reassure us that the patients' skeletons seemed unaffected: they call for an RCT to test their view that fluticasone is less likely to adversely affect BMD in prepubertal children than budesonide or beclomethasone.

Incidentally, the corresponding author, Dr Zulf Mughal, sends us the most courteous letters we ever receive. ADCfrequently imposes on him to review submissions. He always writes that it is an honour and a pleasure to do so. Well, I'd just like to take this opportunity of thanking him and his word processor and letting them know that we find it an honour and a pleasure too.

Poverty, disease and how to succeed

Several papers this month look at the relationships between poverty, ethnicity and illness—especially communicable disease. Ulrich Heininger summarises the WHO strategy for eradicating polio (page 124); Costello and White provide an overview of global poverty and health trends (page 98); a group from Leeds investigates the associations between ethnicity, deprivation and tuberculosis (page 109). Larcher and colleagues leave us with an optimistic message (page 114). Writing from one of London's most deprived boroughs they show how attention to detail and hard work can produce an effective hepatitis B immunisation programme, despite battling with the problems of families who move, change their names, fail to understand the importance of immunisation and often need translators. And all for £138 (US$200) per successfully immunised baby.