State of the art

I’ll start with an ending. Des Spence, who has both delighted and upset our readers over many years with his writing from the frontline of primary care, is stopping his weekly BMJ column next month. An unstoppable force is corporatising UK general practice, Des concludes this week (doi:10.1136/bmj.g1322), and he needs to “concentrate on what I trained to do—building a doctoring business.” His job long ago in a Glasgow pub, where he used to break up fights, may well stand him in good stead. We wish Des well and can assure him that we’ll keep up the fight against bad medicine.

Now for some good medicine. Andrew Bush and colleagues (doi:10.1136/bmj.g15) review recent developments in managing wheeze in preschool children. First, they unpick the evidence on differentiation by phenotype. A child might have episodic viral wheeze, multiple trigger wheeze, or asthma with airway obstruction and eosinophilic inflammation, each of which should be managed differently. Drawing on recent high quality evidence, the authors point out serious concerns about misuse and overuse of inhaled corticosteroids in young children: these drugs should not be used by preschool children with no wheeze between viral colds. For preschoolers who may or may not have more prolonged symptoms there is a dearth of evidence on treatment. So the authors recommend a therapeutic trial of inhaled corticosteroids or montelukast in its standard dose, letting it run for no more than two months. Even better, make that an n of 1 trial and write it up. Let’s fill that evidence gap.

I’ll end with a beginning: the launch of a major new BMJ series. In the first of our State of the Art reviews on bmj.com, Steven Cohen and Jianren Mao examine the mechanisms leading to neuropathic pain (doi:10.1136/bmj.f7656). Around a third of people in the United States and Europe experience chronic pain. In about a fifth of them that pain is largely neuropathic, resulting from injury or dysfunction of the somatosensory system. For complex reasons neuropathic pain is more likely than nociceptive pain to be accompanied by a wide range of symptoms that reduce quality of life—and to be altered by emotional and social factors. No wonder, then, that drugs that reduce neuropathic pain in animal studies don’t always work for human patients, say Cohen and Mao. To develop better treatments we need animal models that account for comorbidities such as depression, more nuanced behavioural assessment tools, deeper understanding of how changes on brain imaging relate to behaviours and responses to treatment, and a range of biomarkers and genomic tools to differentiate pain types and formulate individualised treatments.

One of the reviewers for this article said, “The authors have done a very good job in steering an effective course between oversimplification and overcomplication.” That’s just what we’re aiming for with these State of the Art reviews. They will cover a breadth of topics relevant to all BMJ readers, with enough depth and novelty for specialists, academic clinicians, and researchers. And meanwhile our traditional clinical reviews will continue to cover good medicine every week.