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  1. Adrian White

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Papers published in medical journals are supposed to be useful by having ‘implications’. At the end of any decently written Discussion section, you should find paragraphs on the study's ‘implications for practice’ and on its ‘implications for research’. But what becomes of these implications? In reality, clinicians find it difficult to change their practice, and researchers' main conclusion (so the joke goes) is that more research should be done, preferably by themselves. So let us consider whether there are any implications of the various items in this issue, for clinicians and for researchers.

Our Image of acupuncture shows the resolution of a keloid scar with acupuncture needles. As clinicians, it would be easy to introduce this treatment, but will the researcher in each of us demand a control for the natural history of the condition?

In our first of our eight (yes, eight!) original papers, Liodden and colleagues were invited by anaesthetists into their busy surgical unit to see whether acupuncture could make a difference – in this case, to postoperative vomiting in children after throat surgery – which can cause bleeding and delayed discharge. Read their nice paper – and then read the commentary on the work by one of the authors, Norheim. In order to appreciate to the story, you have to read the original paper first.

The anaesthetic room just before an operation is a busy environment: efficiency and safety demand strict routines and well defined functions, and distractions cannot be tolerated. So, if you want to offer preoperative acupuncture for postoperative pain relief, when else can you give it? Why not try it on the ward, the day before? Coura and colleagues did and report some likely effect on opioid use and on the pain scores as shown in the figure. Lundeberg has comment ed on the possible mechanisms and the implication – which is clear and rather urgent: we need more studies on acupuncture one day before surgery, probably comparing it with acupuncture immediately before surgery.

Will dog-owners see implications in the study by Araujo and Puchi, and ask their vets to give acupuncture for otitis externa? The authors have previously shown that it enhances treatment in the acute phase, and now provide some evidence that it prevents relapse. Research-minded owners might find the study a bit small to change practice yet.

The authors of the next paper, Sunay et al, say that acupuncture can be considered an ‘alternative’ treatment for hot flushes, but we want to know if it can be considered as a conventional treatment. Their findings certainly help, though overall the evidence remains balanced as to whether the clear effect on these symptoms is specific or not.

Our next paper links smoothly from the clinical to the research context: Wright and Aickin gave women acupuncture for hot flushes, and explored their heart rate variability (HRV). The flushes changed but the HRV did not, and our commentary by Alraek and Tan which might stop us worrying too much about the inconsistency in acupuncture effects on HRV.

Next come three papers whose implications appear resolutely directed towards the research community: they tackle ‘methodology’ and ‘feasibility’ – the sort of concept that is a whiff of petrol to researchers, but send clinicians to sleep. Actually, clinicians will stay awake if the paper provides positive evidence of effects, or deepens their understanding of acupuncture.

TCM diagnosis relies on pattern recognition, just like Western medical diagnosis, so should be reasonably reliable in practice, however much one questions its theory. Birkeflet and colleagues tested the reliability of two practitioners – carefully ensuring that they used exactly the same information about the patient, which is an important innovation in study design. In many cases, the two practitioners interpreted the information to reach different diagnoses, which has worrying implications. And they seem to be well trained practitioners, since the two of them both chose similar points to treat any given TCM diagnosis.

There are still more implications in acupuncture – to do with its relationship with the health service. Should we offer it at all to a patient who wants it even though evidence suggests it will ‘not work’ for his diagnosis? Foell addresses this thorny issue in a fascinating case report. And Lie's letter raises the problem from the other side: when doctors aren't allowed to use acupuncture as their employing hospitals won't cover them.

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