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SAFE TRAINING FOR THORACIC SURGEONS
As Aggarwal and Darzi point out in their editorial in this month’s Thorax, recent changes in the delivery of health care have led to difficulties in reconciling service and training priorities, particularly the training of thoracic surgeons. Chaudhuri and colleagues report an interesting study where outcomes of patients undergoing lobectomy (used as a marker operation) were studied and results compared between trainee thoracic surgeon led operations and consultant led operations. 35% of lobectomies were performed with the trainee as the first operator and outcomes—including mortality, respiratory, cardiovascular, bleeding, renal and neurological complications—were similar in the two operative groups. Survival rates at 1 year were also similar in procedures led by trainees and those by experienced consultants. The authors conclude that, with appropriate supervision, trainee surgeons can perform lobectomies safely and without compromising short or intermediate term results. The accompanying editorial also gives us an insight into the future of surgical training and concludes that, although the current apprenticeship model of training through graded exposure works and is safe, this should be used in conjunction with simulation based practice, adequate supervision, and constructive feedback following each surgical case.
See 278 and 327
HYPERGLYCAEMIA IN COPD EXACERBATIONS
Although hyperglycaemia has been shown to affect outcome in a number of conditions such as myocardial infarction and pneumonia, the effect of hyperglycaemia on COPD exacerbations has not been studied. In this issue Baker and colleagues report a study where they related exacerbation outcomes to levels of blood sugar. They found that death or longer hospital length of stay were worse in patients whose blood sugar was more than 7 mmol/l. The authors calculate that, for every 1 mmol/l increase in blood glucose, the risk of an adverse outcome increases by 15%. In the accompanying editorial, Finney and Evans discuss the strengths and limitations of the study and emphasise the complex physiological effects associated with hyperglycaemia. They conclude that, if tight glycaemic control affects mortality in COPD, this will have an enormous impact on the management of a common condition.
See 275 and 284
GENDER DIFFERENCES FOR TB
In low income countries twice as many cases of pulmonary tuberculosis (TB) are reported in men than in women. These differences have been attributed to a number of factors. In this month’s Thorax Jiménez-Corona and colleagues report a population based prospective study of pulmonary TB in southern Mexico using molecular epidemiological methods. The study found higher overall rates of pulmonary TB in men than in women, with higher rates of reactivation of latent infection and recently transmitted disease. Men were also more likely to default from treatment, to require repeat treatment, and were more likely to die from TB. These observations are important in directing public health strategies aimed at reducing TB.
See page 348
FREQUENT EXACERBATORS AND ANTIBIOTIC RESPONSES
Although antibiotics are widely used in exacerbations of chronic bronchitis and COPD, the magnitude of the effect and longer term outcomes have not been clearly defined. The MOSAIC study compared moxifloxacin with three comparator antibiotics and, in this issue, Wilson and colleagues report a further exploratory analysis of factors that predict short and long term outcomes. My attention was directed to the multivariate analysis showing that patients with chronic bronchitis who were frequent exacerbators (four or more exacerbations in the previous year) had a worse clinical cure rate with antibiotic treatment than infrequent exacerbators. Frequent exacerbators have increased airway inflammation and this may explain the findings, although there is no evidence to date that these patients respond better than infrequent exacerbators to anti-inflammatory treatment. In contrast, long term outcomes were better in the frequent exacerbation group and, as exacerbation frequency is related to lower airway bacterial colonisation, this suggests that moxifloxacin may have modified the airway bacterial load.
See page 337
LEPTIN AND ASTHMA (IN WOMEN?)
Leptin is a proinflammatory cytokine produced by adipose tissue and is related to several features of obesity. Associations have previously been shown between serum leptin levels and asthma in children, and Sood and colleagues now report data on the association of leptin and asthma in adults using data from the Third National Health and Nutrition Examination Survey (NHANES III). Current asthmatics had higher leptin levels, but this association was greater in women and particularly in premenopausal women. Body mass index (BMI) was also associated with asthma, but this relationship was not influenced by leptin levels which suggests that the effect of BMI on asthma is mediated by other pathways.
See page 300