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One 'Flu over the Cuckoo's nest
Far be it from us to compare those having charge of the Nation's Health with birds of rather limited intelligence and rapacious behaviour, because after the absence of any advertising campaign for influenza immunisation, the drying up of supplies of the immunisation, and the inundation of Intensive Care Units all over the country with cases of H1N1, our Lawyers advise us that were we to do so, we would be inundated with lawsuits brought by affronted Cuckoos. If only the politicians had read Thorax, they would have had early warning from our Hot off the Breath alert and could have taken some action (Thorax 2010;65:855–6). We reflect the importance of H1N1 in five manuscripts published this month. Bewick et al report on a clinical score based on five simple parameters; a high score is strongly predictive of H1N1, a low score has a good negative predictive value. Clearly this needs to be validated in a second cohort, but nonetheless it is a valuable practical contribution in targeting anti-viral therapy (assuming the UK still has any!). H1N1 in CF is the subject of three research letters. Nash et al and Colombo et al report re-assuringly that the pre-morbid state of the H1N1 infected patients did not differ from the generality of the clinic, nor were the changes during infection any different from non-H1N1 viral infections. Alghisi et al report that the vaccine has good immunogenicity in the CF population. Finally, in an editorial, Segal and Woodhead review the evolving history of H1N1, and stressing that it causes a pneumonic picture very different from standard community acquired pneumonia. (See pages 187, 247, 259, 260)
Sick of it?
To what extent is gastro-oesophageal reflux (GOR) a phenomenon desperately looking for an important role, any role, perhaps a little like one of the Coalition partners? After numerous unsuccessful attempts to link GOR to asthma, the focus this month is on idiopathic pulmonary fibrosis. In this issue of the Journal, Tcherakian et al report (shock, horror, probe!—the R-WORD!!) a retrospective case-control study of adults with IPF and suggest that the asymmetry may be related to reflux and aspiration preferentially into the affected lung. These patients seemed particularly prone to IPF lung attacks (‘lung attacks’?—watch this Journal!). In an editorial replete with splendid classical quotations, Maher and Wells entertainingly defend the value of retrospective studies in general, and this one in particular, as a necessary prelude to a definitive study. Indeed, no-one is going to fund or embark on adefinitive study without such preliminary data. A word of caution—GOR is commonest in the first year of life, when IPF is rare indeed. So perhaps GOR may be necessary but not sufficient to cause IPF. Great hypothesis generating work, now bring on some more data! (See pages 183, 226)
Are we capable of learning from the Developing World?
One of us recently attended a dynamic and energetic talk which reviewed how Brazil was moving towards meeting the Millennium Development Goals (MDGs) by gathering regional data to identify areas of poor performance and putting in resources to address the problem (and go stand in the corner if you do not know about MDGs). In this issue, Calderon-Larranag et al report a more than fivefold difference in COPD admissions between PCTs (and far, far more between GP practices) in a huge population based across England. Surprise, surprise! It is better to be rich and sick than poor and sick, and the problem is in deprived areas, with lower standards of care. Better access to the GP, and more specialist nurses were among the factors predictive of a reduced admission rate. However, this sort of study can generate hypotheses, but intervention is required to prove them. In an accompanying editorial, Jones rightly highlights methodological issues such as accuracy of diagnosis, but the timeless lesson that if you cannot measure something precisely, measure it lots of times holds true for this impressive dataset. Encouragingly, as Jones documents, there are efforts being made to target resources to areas of need, but only time will tell how effective they will be. Surely though, this sort of exercise, determining need and trying to address it, is infinitely more useful than collecting data about arbitrary ‘targets’ as a prelude to a witch-hunt of Winston Salem proportions, targeting those who have been unable adequately to massage whatever arbitrary data have been demanded. And finally—and politically unpopular in circles in which poverty is a crime—may be we need to tackle the causes of social deprivation? (See pages 185, 191)
Hard to swallow?
A 45 year old man had odd globus sensations at odd times, but not much else. Nuts or what, so someone stuck a needle somewhere? See below and the Pulmonary Puzzle.