In This Issue

Chronobiologically speaking

Did you know that non-steroidal anti-inflammatory drugs (NSAIDs) are more effective for osteoarthritis (symptoms worse at night) when taken around noon, but are more effective for rheumatoid arthritis (symptoms worse in the morning) when taken after the evening meal? In an editorial about circadian rhythms, Stampfer and Hood describe recent basic and clinical research findings, including a relationship between mood disorders and circadian regulation, and developments in chronobiology and, in particular, chronotherapy, which considers the impact of circadian variation on diseases and treatment, including side effects (→ Circadian rhythms: keeping pace with developments?).

What’s the evidence?

Vertebroplasty, the percutaneous injection of polymethylmethacrylate (PMMA) into an affected vertebral body, has been widely accepted to be a safe and effective treatment for vertebral fractures on the basis of observational and quasi-experimental studies, say Buchbinder and colleagues. Recently, two randomised controlled trials have found that vertebroplasty appears to confer no benefit over placebo for treating painful osteoporotic vertebral fractures, and also poses some risk. Both trials — an Australian trial led by Buchbinder and an international trial led by Kallmes — recently published in the New England Journal of Medicine. In this editorial for the MJA, Buchbinder and Kallmes, together with Osborne, highlight the trials’ results and their implications (→ Vertebroplasty appears no better than placebo for painful osteoporotic spinal fractures, and has potential to cause harm).

Uniform transparency

Journal authors are often asked to provide similar, but not necessarily identical, information to different journals in multiple formats. Now, a new, uniform “disclosure of competing interests” form has been adopted by all journals that are members of the International Committee of Medical Journal Editors (ICMJE), including the MJA. By adopting a uniform format, Drazen and colleagues say the ICMJE hopes to make the process easier for authors and less confusing for readers (→ Introducing a new disclosure form for member journals of the International Committee of Medical Journal Editors). The form is posted on the ICMJE website (www.icmje.org/format.pdf).

Speedy diagnosis

Quick diagnostic units (QDUs) — outpatient assessment units for patients with suspected severe disease — are an effective alternative to conventional hospitalisation, say Bosch and colleagues. They report the activities of two QDUs operating in or near Barcelona, Spain. Patients needed to be well enough to attend a range of appointments; most had non-specific symptoms with significant comorbidities; and about one in four were found to have cancer. Would this model be applicable in Australia? (→ Quick diagnosis units: a potentially useful alternative to conventional hospitalisation.)

Less may be more

Lower drug doses may be as effective as higher doses in managing chronic disease, say Dimmitt and Stampfer. Further, lower doses carry the advantages of reduced adverse effects and potentially improved quality of life. More research to guide optimal dosage is needed; in the meantime, we need to “start low and go slow” when treating mild chronic disease in primary care (→ Low drug doses may improve outcomes in chronic disease.).

Real medicine returns

“As clinicians, we must not lose sight of what we are actually trained for: to treat patients”, say Lancashire and colleagues. With increased demands being placed on clinicians, they may well have less and less time to focus on, and spend quality time with, their patients. The authors call for consultants to lead a reversal of this undesirable trend by abiding by some simple rules: physically see the patient, talk to the patient and take a clinical history, perform a relevant clinical examination, and document this clinical interaction in the medical record. Further, medical students need clinical contact with real patients so they can gain the cognitive and intuitive skills that develop through real rather than simulated experience (→ The decline of clinical contact in medicine).

The silent epidemic

In the 13 years since the MJA last published a supplement on otitis media, not enough has happened to address the ramifications of neglect of this silent epidemic, according to Coates (→ Current management of otitis media in Australia — foreword). In a foreword to the supplement with this issue, he reports that in 2008, over 650 000 Australians had otitis media and about one in 10 of them were Indigenous; and that the estimated health systems costs in that year ranged from $85.6 million to $163.2 million. The supplement Otitis media 2009: an update covers the recent concepts of biofilm and intracellular infection, the importance of nasopharyngeal carriage, and other developments in our understanding and management of otitis media in both non-Indigenous and Indigenous children in Australia.

Another time . . . another place

That we are not much sicker and much madder than we are is due exclusively to that most blessed and blessing of all natural graces, sleep.