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Tis the season to be miserable
Christmas is the traditional time for happiness and harmony (unless you are planning a quiet family time: “The General was essentially a man of peace, except in his domestic life,” - Lady Bracknell). So what better way for the journal to celebrate than to publish an article on psychological stress in patients with cystic fibrosis (CF) and their parents (see page 1090, Editor's choice), and an editorial that starts a fight over the findings (see page 1067)? Alexandra Quittner and TIDES colleagues reporting on more than 6000 patients with CF, and more than 4000 family members from more than 150 centres across the USA and Europe, found that depression and anxiety were 2–3 times more common in patients and parents. Definitive? Surely! Write a guideline recommending annual screening for anxiety and depression in CF (even though it won't recommend expensive placebos)? Absolutely! Not so, say Webb and Bryon. They write about the HADS and the HADS NOTS and contrast the TIDES findings with UK data from more than 2000 patients from 39 UK centres, pointing out with tongues rammed firmly into cheek that three of these authors have also appeared on the TIDES paper (clearly the Liberal Democrats of Psychological research). So read both and decide—add psychological questionnaires to CF annual assessments to detect significant and prevalent morbidity, or refrain from further inflating an already over-bloated annual ritual?
A SALT but no battery
This duet between investigators and editorialist is rather more seasonally harmonious. As certain as the cycles of politicians promising much and delivering nothing comes the annual winter bronchiolitis season, flooding children's wards and intensive care units beyond bursting point. Generally, therapy is restricted to supportive care while the baby gets better spontaneously. However, a recent Cochrane review, casting aside the usual ‘more work needed’ caution of the genre, recommended the use of nebulised 3% saline in these infants. The SABRE investigators, unlike Khachaturian, did not dance about the issue. They recruited more than 300 children with bronchiolitis and showed that 3% saline did not have any discernable effects other than in one infant who became bradycardic and desaturated (see page 1105). This was a pragmatic, open label trial (words which normally trigger a decerebrate rage reaction in your editors) but reasonably so given that the placebos in previous trials may have been harmful. Even with a potential bias in favour of active treatment, no benefit was found. It is difficult to see how the trial could have been better conceived, nor how the impending NICE guidelines can do other than discard hypertonic saline for bronchiolitis. Steve Cunningham (see page 1065) speculates as to the reasons for previous discrepant results, and points to the benefits of doing big trials rather than meta-analyzing often unsatisfactory small ones. So the take-home message, with rather less than Steve's Christmas charity, is to do your own research rather than picking over the bones of other people's, and keep the sodium chloride in the cruet.
Positive pressure or high pressure?
Treatment of obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) has been shown to reduce blood pressure, particularly in individuals with resistant hypertension. Should we recommend this treatment in patients with hypertension and OSA irrespective of symptoms? Perhaps, conclude Bratton et al. (see page 1128), who carried out a careful meta-analysis of this question. This analysis was rather more than picking over the bones of other peoples unsatisfactory research as individual patient data was analysed using a novel and more powerful method for evaluating treatment effect interactions. Overall, no beneficial effect was seen but patients who used CPAP for more than 4 hours per night had a significant fall in diastolic blood pressure. A bit like inhaled corticosteroids for asthma, amazing how well they work if they are used!
Please SIR, I want some real world evidence
SIR stands for the Salford Integrated Record, a comprehensive electronic patient record spanning primary and secondary care in Salford. Its existence makes Salford an attractive site for real world effectiveness and safety research. Real world research is also prone to trigger a decerebrate rage reaction in some. Susceptible readers might change their views if they turn to (see page 1152) where John New and colleagues describe the Salford Lung Study, an ambitious and innovative attempt to carry out a phase 3 trial of Relvar in asthma and COPD using a pragmatic randomised control trial design. This world's first is well advanced and data on effectiveness and safety should be available over the next 2 years. We applaud the research team for overcoming the considerable regulatory and administrative hurdles to get this study up and running and hope they are right in concluding that it will reshape the future of clinical trials and meet the demand for value-based medical evidence (and another big step would be to frame regulations to facilitate not road block research).
Christmas whimsy from Thorax
Why did we choose an Old Master for our cover picture (see page 1161)? What is the cause of the nodular infiltrate, which led to prolonged illness in two adults and the death of the young patient whose chest radiograph we reproduce here (see page 1159)? And what did the Motorbikin' man do to make his partner start to hear things in the night (see page 1155)? When you are tired of pretending to have a good time with people you don't really want to talk to, take a glass of Christmas whisky to a quiet corner, go with it to make sure it's not disturbed, and try to crack these conundrums.⇓