The authors thank Henke Giele for his contribution to this discussion. We are pleased to see that he allows for some delaying of a curative operation in isolated cases when the inconvenience of the procedure and its recovery are untimely. He goes on to state that there is a correlation between severity of post-operative complaints and chronicity of symptoms and cites three papers that come to that conclusion. However this is not a situation where the literature offers an unambiguous view. There are other publications, which have come to the contrary opinion (Yu et al and Choi and Ahn). We have also looked at the relationship between the duration and severity of symptoms and outcome after carpal tunnel decompression (using the same patients that were studied in the Primary Care Management paper)(Burke et al). Symptom duration corrected for gender was not associated with Levine-Katz symptom severity, Levine-Katz functional status or changes in these scores from the pre-treatment to six months follow-up evaluations.

We feel it is overly simplistic to classify all patients with Carpal Tunnel Syndrome as in need of operative intervention. Mr Giele is undoubtedly aware of the extended spectrum of symptom severity in these cases and not all patients will consider the symptoms they are experiencing justify the need to consider surgery. Over and above that there is the characteristic remitting nature of the condition where patients not uncommonly go through periods of resolution or easing of symptoms for several months. The issue from our point of view is that of patient choice. There are conservative methods of treating Carpal Tunnel Syndrome, which are known to be effective and are underused. We prefer the strategy of giving the patients the facts about their condition and all treatment modalities that might benefit them, and allow the patient to decide if they wish to explore the non-operative interventions. No operative procedure is without its risks and the complications arising from the use of non-operative methods in cases of mild to moderate Carpal Tunnel Syndrome are slight. We remain of the view that the correlation between extended duration of symptoms and poor outcome is not proven and Mr Giele’s view that virtually all patients with Carpal Tunnel Syndrome require expeditious decompression is not justified.

Yours sincerely

Frank Burke & Shaw Wilgis

Yu GZ Firrell JC Tsai TM. Pre-operative factors and treatment outcome following carpal tunnel release. J Hand Surg 1992:17B:646-650

Choi SJ Ahn DS. Correlation of clinical history and electrodiagnostic abnormalities with outcome after surgery for Carpal Tunnel Syndrome. Plast Reconstr Surg 1998;102:2374-2380

Burke FD Wilgis EFS Dubin NH Bradley MJ Sinha S: Relationship between the duration and severity of symptoms and the outcome of carpal tunnel surgery. J Hand Surg 2006: 31A:1478-1482

Yes, the poor use of non-operative interventions (as reported in this article) does indeed seem to be the effective use of these interventions that (the authors themselves acknowledge) are not curative but merely delay the curative operation.

On both economic and patient parameters it is more economic to proceed directly with the curative intervention than waste resources and time attempting non-curative interventions that merely delay the procedure and add to the overall cost of the event. Delaying a curative operation may be of benefit in some isolated cases when the inconvenience of the procedure and its recovery are untimely. Non- curative symptom controlling interventions can also be of use whilst waiting for the procedure. However, the symptom controlling interventions can lead to delay in the performance of the curative operation possibly resulting in worse outcomes. There is a correlation between severity and chronicity of symptoms with poorer outcome (Hobby et al, Townshend et al, Bland et al.) As carpal tunnel syndrome progresses the annoying symptoms of pain and paraesthesia may actually dissipate leading the sufferer to believe their condition is improving whilst unbeknown to them the severity of their condition is worsening, their obvious symptoms being insidiously replaced by the less obvious loss of sensibility and motion. Intervention at this later stage is less likely to result in complete cure.

In carpal tunnel syndrome, as in most diseases the intervention likely to cure the condition should be implemented without unnecessary costly steps or delay.

Hobby JL, Venkatesh R, Motkur P. The effect of age and gender upon symptoms and surgical outcomes in carpal tunnel syndrome. J Hand Surg [Br]. 2005 Dec;30(6):599-604. Epub 2005 Sep 6.

Townshend DN, Taylor PK, Gwynne-Jones DP. The outcome of carpal tunnel decompression in elderly patients. J Hand Surg [Am]. 2005 May;30(3):500-5.

Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40.

Adrenal crisis is a medical emergency. If suspected treatment should be started as soon as possible. Every emergency physician should be familiar with adrenocortical insufficiency—a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings. Delay in treatment while attempting to confirm this diagnosis can result in poor patient outcomes.

The predominant manifestation of adrenal crisis is shock, but the patients often have nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion or coma and hyperpigmentation [3]. Hypoglycemia is a rare presenting manifestation of acute adrenal insufficiency; it is more common in secondary adrenal insufficiency caused by isolated corticotropin (ACTH) deficiency [1,2].

Treatment consists of starting an intravenous line, taking the blood samples for plasma cortisol levels, acth, serum electrolytes and glucose. Fluid deficit should be corrected with 5 percent DNS or normal saline. Initially 2-3 litres may be required. Thereafter give IV fluids according to the central venous pressure. Patients with addisons disease have low cardiac reserve, so watch for fluid overload. Give hydrocortisone 100-300 mg IV, there after 50-100mg every six hourly for the first day. On the second day give the same amount of dose eight hourly. Then according to the clinical response. Then switch to oral hydocortisone 10-20 mg every six hours. Most patients settle with a BD dose of 10-20mg of hydrocortisone daily. A few may need mineralocorticoid therapy in the form of fludrocortisone. Instead of hydrocortisone, dexamethasome can also be used. Hydrocortisone should not be given for atleast eight hours before ACTH stimulation test. Correct the electrolyte abnormalities as per the lab reports. Broad spectrum antibiotics should be given at this time.

1. Burke, CW. Adrenocortical insufficiency. Clin Endocrinol Metab 1985; 14:947.

2. Stacpoole, PW, Interlandi, JW, Nicholson, WE, Rabin, D. Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases. Medicine 1982; 61:13.

3. Barnett, AH, Espiner, EA, Donald, RA. Patients presenting with Addison's disease need not be pigmented. Postgrad Med J 1982; 58:690.

Response to: R Guo, PH Canter, E Ernst. A systematic review of randomised clinical trials of individualised herbal medicine in any indication. Postgrad Med J 2007;83:633-637

From: Ally Broughton Bsc (Hons) MNIMH Director of Research for, and Member of, the National Institute of Medical Herbalists (NIMH) Contact: ally.broughton@blueyonder.co.uk

I am a trained herbal practitioner of 12 years and teach research methodology on BSc and MSc courses in herbal medicine.

A herbal practitioner undergoes a 3-4 year degree level accredited training course which includes clinical skills and differential diagnosis, materia medica (plant medicine), and clinical experience in accredited training clinics. Professional bodies are currently self regulating and exist to ensure professional and best clinical practice.

In teaching, I use critical appraisal tools developed by the Critical Appraisal Skills Programme (CASP)(i) , I used a tool to evaluate this review to minimise bias.

Study validity Only 3 small scale clinical studies are included for review, one of which is a pilot study. The review can have no statistical significance.

The studies have very different outcome measures and investigate entirely different conditions, making comparison difficult.

Selection criteria From the 1345 references identified, 3 studies were selected. There was no clear pre-determined strategy used to determine which studies were included.

The reviewers recognise this limitation saying they had ‘difficulties designing a search strategy to locate RCTs of individualised herbal medicine because of the large number of potential descriptors for such studies’. This is a strong limitation in the review methodology.

Statistical Analysis The results for each of the studies are assessed by statistical significance, however there is no clear indication given of p values or confidence intervals used by any of the studies.

Critical Analysis The analysis focus is on statistical data. Some potentially valid points are not reviewed. For example in the Bensoussan trial(ii) there was no significant difference between the individualised and standard treatments at 16 weeks were reported, however, on follow-up 14 weeks after treatment, only the individualised treatment group maintained improvement. The reviewers entirely dismissed this as statistically non significant. It is an important point considering that individualised, holistic treatment addresses underlying causes of illness which takes longer to resolve but often with longer lasting benefit compared to symptomatic treatments.

Discussion Analysis In the discussion analysis there is consistently inadequate links made between the review evidence and the conclusions made by the authors. Discussion on herbal practice and safety issues are not substantiated or referenced, in fact there are only 7 references for the entire review.

Conclusions There is a lack of scientific rigour in the review methodology. Based on the evidence presented in the review the conclusions made by the authors appear arbitrary and insufficiently based on the evidence presented.

Designing a randomised controlled trial to investigate individual treatment is highly complex and not without limitations. Within the field of complementary medicine current research is looking for new or adapted research paradigms appropriate to holistic medicine (iii,iv) .

(i)Oxman AD, Cook DJ, Guyatt GH, Users’ guides to medical literature. VI. How to use an overview. JAMA 1994; 272(17): 1367-1371

(ii) Bensoussan A et al. Treatment of irritable bowel syndrome with Chinese herbal medicine. JAMA 1998;280:1585-9

(iii)Boon H et al. Evaluating complex healthcare systems: A critique of four approaches. eCAM Advance Access 2006; doi:10.1093/ecam/nel079 (iv) Fonnebo V et al. Researching complementary and alternative treatments – the gatekeepers are not at home. BMC Medical Research Methodology 2007;7:7