Highlights from this issue
- Asthma guidelines
- cystic fibrosis
- exhaled airway markers
- lung physiology
- paediatric asthma
- paediatric lung disaese
- COPD mechanisms
- asthma mechanisms
- COPD exacerbations
This issue coincides with the American Thoracic Society meeting, and we have tried to have a USA theme, showcasing work from North America to emphasise our wish to attract the best manuscripts from all round the world. These include a variety of topics: primary ciliary dyskinesia (with an attempt to recreate the cordial Anglo-American relationships extant at the time of the Boston Tea party in the correspondence columns!), COPD, interstitial lung disease and the basic science of lung development, reflecting the diversity of the Journal and the readership.
Actions not words
In days of yore, the MRC led the world in randomised controlled trials, not least in establishing the evidence base for the treatment of tuberculosis. Times change and increasing energy is devoted to process not outcome, and frenetic reforms of everything possible and impossible by those who make headless chickens seem like Einstein. While we have squandered our splendid legacy, the USA has come to the fore in executing a superb series of randomised controlled trials, not least in asthma and cystic fibrosis. Stan Szefler and colleagues (see page 450) review nearly 20 years of the NHLBI Asthma Clinical Research Network, their achievements and the lessons learnt. Can we hope that this will inspire us in the UK to join the fray, with properly funded networks that mean something and work, and do not have to dissipate endless time and energy in meaningless box-ticking?
Too fat to breathe
A less welcome import from the USA has been obesity, now epidemic in the UK and other developed countries. Treatment of obesity has come a long way, as has the Minister of Health—who would have thought MacDonald's were the best advisers on the obesity epidemic? Bariatric surgery is the most effective intervention, resulting in a 10–20 kg/m2 reduction in body mass index. Should we be offering this to more of our patients with respiratory complications of obesity? Ashrafian et al (see page 442) suggest we should. They review the impressive observational evidence that bariatric surgery improves obstructive sleep apnoea and the associated metabolic complications. Perhaps it is time to move away from providing crutches such as CPAP and focus more on the root cause of the problem. This is an important and topical area and we would like to see more research evaluating the effect of anti-obesity treatments on the respiratory complications of this disease.
Coughing phone boxes
The UK lags behind other developed countries in Lung Cancer outcomes, perhaps because patients present too late for curative treatment. Simon et al (see page 426) describe the development of a measure of awareness of lung cancer symptoms and show that at risk patients have low awareness. Lung cancer mortality and low awareness of lung cancer symptoms is a particular problem in Doncaster. Recognising this, Athey et al (see page 412) teamed up with their public health colleagues and developed an innovative multifaceted social marketing intervention, which included bus stops fitted with a sound chip that coughed at opportune times. The intervention raised awareness and increased the number of patients reporting potentially important symptoms. We found this an excellent example of identifying local problems and coming up with imaginative solutions and applaud the team for a job well done. Early curable lung cancer can also be identified by screening but might this target the worried well rather than those at high risk? Some reassurance is provided by Patel et al (see page 418). They report that patients at risk of lung cancer have generally positive attitudes to participation in screening programmes. Mick Peake (see page 379) emphasises that much more needs to be done to improve awareness and detection of early, curable disease. But as with obesity (see previous section) much but not all of the problem is in the hands of the individual, not society or the NHS. Phillip Morris to advise the Minister on Tobacco control, perhaps?
No Paul Revere, so are the English landing?
Now for something completely different—what is the molecular basis of the steroid resistance seen in really severe asthmatics? One hypothesis has been that the expression of glucocorticoid receptor-β leads to reduced HDAC-2 expression and steroid resistance. Butler et al (see page 392) studied endobronchial biopsies of severe asthmatics, mild asthmatics and healthy controls and apparently found message (glucocorticoid receptor-β protein) in all groups, but rarely any messenger (mRNA). Detailed work revealed that the message was bogus and due to cross-reactivity with Clathrin. A nice piece of clarification of previously murky literature.
Brilliantly lit up?
As was the both the fleet at Spithead and the BBC commentator who so memorably described the Royal Review in 1937, see http://www.youtube.com/watch?v=-hYIGte7fBs, so also the lung mass seen in the pulmonary puzzle. What lit up the commentator is easy to surmise; what about the mass? Try to work it out, and then see page 468.