A paper in JAMA last month reported a meta-analysis of reducing sodium in 58 trials in hypertensive persons, and 56 trials in normotensives. The authors concluded that their ‘results do not support a general recommendation to reduce sodium intake’.

However salt restriction lowers blood pressure in hypertensives and normotensives. The effect in normotensives makes less credible the argument that there is a special population of salt-sensitive individuals and salt restriction should be limited to them.

Observational studies such as INTERSALT show that populations with lower mean salt intake have a shallower rise of blood pressure with age. The jury still seems to be out on this one

The debate will continue for some time yet.

Babies suffering from hypothermia will warm up more quickly if their mothers than cuddle them if they are put in an incubator, according to a study in the Lancet, this month.

Skin to skin contact, also known as kangaroo care, began in Bogota, Columbia, where doctors advised mothers to hold and breast-feed their premature babies because of a shortage of incubators. In the Lancet trial hypothermic infants did better than those in an incubator. In addition there was no danger that their body temperature could become too high. Once the skin to skin babies reached 37 Celsius, they lost heat to their mothers.

There is a lot of pressure from general practitioners and consultants to use the newer antidepressants despite continuing evidence that they are not more effective. Recently the argument has focussed on them being safer in overdose.

Jick et al. (Br Med J. 1995; 310: 215-218.) have examined the relationship between occurrence of suicide and use of 10 common antidepressants in a database containing data from more than 4 million patients in the United Kingdom.

Within 6 months the overall suicide rate was 8.5 per 10,000 person-years. When dothiepin, the most commonly used antidepressant, was arbitrarily set as an index, only those patients taking fluoxetine (Prozac/Dista) and mianserin had significantly higher relative risks for suicide--2.1 and 1.8, respectively.

Case-control analysis determined that only patients taking fluoxetine had a significantly higher risk. However, this increased risk for fluoxetine may have resulted from selection bias.

The relative risk of suicide for patients with a history of suicidal behaviour was 19.2. Men were 2.8 times as likely as women to commit suicide. Patients receiving high doses of antidepressants were 2.3 times more likely to commit suicide as those receiving low doses. When the analysis took such factors as these into account, however, the use of a particular antidepressant did not influence the risk of suicide.

In the debate on selective serotonin reuptake inhibitors versus tricyclic drugs the safety in overdose of selective serotonin reuptake inhibitors has been offered as the most compelling reason for their use as first line treatment; the work of Jick et al. militates against this argument.

Chiropractic includes various techniques used in the hope of correcting vertebral disc displacements, freeing spinal joint adhesion, inhibiting nocieptive impulses, or correcting spinal misalignment. Several national guidelines on the treatment of low back pain recommend spinal manipulation, including chiropractic, as a symptomatic treatment for acute uncomplicated cases where pain fails to resolve spontaneously within the first months.

There are many controlled trials of spinal manipulation and no fewer than 51 reviews. Surprisingly, in the review which provided the basis for the recommendations mentioned above, the subset of randomised clinical trials on acute low back pain did not contain one trial of chiropractic.

A recent systematic review restricted to chiropractic manipulation included only eight randomised controlled trials, all of which were methodologically flawed and "did not provide convincing evidence for the effectiveness of chiropractic for acute or chronic [low back pain]".⁴ Consequently, we can conclude only that the effectiveness of chiropractic as a treatment for low back pain has not been established beyond reasonable doubt.

In addition Cervical manipulations are burdened with severe adverse reactions, such as vertebrobasilar accidents and paralyses due to fractures. A literature review identified 165 vertebrobasilar accidents, including 29 deaths. Estimates of their incidence range from 1 per 200 000 to 1 per million cervical manipulations.

The risks of manipulating the lower spine seem to be lower, with fractures and cauda equina syndrome being the most serious reactions. Nevertheless, upper spinal manipulation is also occasionally performed in lower back pain. Finally, there may be important indirect risks associated with chiropractic. Potential overuse of radiographs by chiropractors is one example; another is the negative attitude of some chiropractors towards immunisation. Thus, even if chiropractic manipulation were totally devoid of risks, the approach of chiropractors may not always be so.

As a number of general practitioners did not receive last month’s Quince we thought it important to repeat a message which is especially timely at this time of the year.

Several studies have shown substantial savings in direct medical costs during successive influenza seasons among all elderly people who had been vaccinated. "Influenza vaccination works, it's inexpensive, and it saves money". The DoH recommendation is now to give it to all those aged 75 and over. The evidence suggests cost and morbidity savings from giving it to all over 65s