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  1. Ian Forgacs, Associate Editor

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ACUPUNCTURE: DON’T MISS THE POINT

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For many doctors, the term “evidence based medicine” smacks of self-righteousness, for others, the present writer included, there is concern about its misuse by politicians and others who hold the purse strings. Whatever your perspective, do read Sung’s leading article on acupuncture. Evidence based medicine it is not—and he tells us why. Yet it does seem to me inherently unlikely that this treatment would have been around for 2,500 years if it was just quackery. China 1: EBM 0.

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YOU GET WHAT YOU SEE

It is difficult to recall any gastrointestinal condition that has given rise to as much controversy as the management of Barrett’s oesophagus is doing just now. One particular problem is what the clinician should do with the information he receives from the pathologist. The situation is not helped by the fact that consensus in interpreting biopsies often remains elusive. Neither clinicians not pathologists (let alone, one assumes, patients with Barrett’s oesophagus) will draw much comfort from the report by Ormsby and colleagues (also see Alderson’s commentary). The study shows how much pathologists disagree in the distinction of high grade dysplasia from intramucosal carcinoma. One can only offer continuing sympathy to those trying to draw up guidelines with which more than two people will agree.

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PSC—THE SMALLER THE BETTER

The course of primary sclerosing cholangitis (PSC) is variable but tends to be progressive. While large series show that a majority of patients are symptomatic at diagnosis, others have cholestatic features, characteristic liver histology but normal cholangiography. Such patients are considered to have small duct PSC. A study from Oxford and Oslo found that patients with small duct PSC carry a much better prognosis than those who have structural duct disease at presentation.

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YOUNG, OSTEOPOROTIC AND FRACTURED

The identification and treatment of reduced bone mass has become an important part of the management of patients with inflammatory bowel disease. The high prevalence of osteopenia is well characterised; the prevalence of actual fracture is less well known. Klaus and colleagues found 156 of 293 patients with Crohn’s disease to have low bone density. They then looked at x rays of their spines. Sixty-three osteoporotic fractures were found in 34 patients (22%). What most grabbed my attention was that a third of the patients with vertebral fractures were under 30 years old.

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STAND UP FOR WHAT YOU BELIEVE

Patients with pre-ascitic cirrhosis retain sodium while upright but have natriuresis in bed. The horizontal diuresis is considered to be the result of decreased tubular sodium reabsorption, and independent of any variation in glomerular filtration rate (GFR) and filtered sodium load. Yet, like much of renal pathophysiology in chronic liver disease, the explanation is unlikely to be that simple. Sansoé and colleagues studied intra-renal sodium handling in erect cirrhotics. They showed that fluid and sodium delivery to the distal nephron was reduced when patients stood for 4 hours and the patients also lost the associated feedback increase in GFR. Horizontal (if not lateral) thinking.

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HEDGEHOG GENES: A PARTICULARLY PRICKLY PROBLEM

Mesenchymal-endothermal interactions seem an unlikely topic to raise a smile. However, hedgehog genes sound jolly cheery and certainly amuse those interested in gut development. Sonic hedgehog (Shh) is particularly involved in controlling gastric gland formation. van den Brink and colleagues looked at Shh expression in the adult human GI tract and showed that it was expressed in normal fundic glands—as well as in gland metaplasia and heterotopia. Shh is a player in differentiation as well as development.

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