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Outstaying and unwelcome
‘Hot off the Breath’ is a new feature in Thorax, which aims to allow rapid publications of annotations addressing a hot topic, which will either be commissioned, or more likely, as in this case, suggested by the Authors. The H1N1 pandemic burst on the scene last year, causing substantial morbidity and mortality across the world. The WHO has declared the pandemic to be over, which may well be the correct global perspective. However, no sooner was the pandemic declared over than the UKILALI group reported five admissions to Hospital in the Midlands, two patients becoming severely ill. The lesson for individual clinicians is that H1N1 is still a diagnostic consideration. The authors also remind us of the current diagnostic criteria for H1N1, but it may be that these will need to be refined if H1N1 has become rarer but remains a definite threat. Finally, please email the Editors if you have an idea for another ‘Hot off the Breath’ topic. See page 855
Prevention of chronic infection with Pseudomonas aeruginosa is the single biggest Holy Grail of cystic fibrosis care. Many studies have addressed how to eradicate the infection in its early stages, but this month we publish a three year randomised controlled trial comparing three monthly cycling nebulised colistin and oral ciprofloxacin with placebo (mannitol, which actually might if anything encourage the growth of Pseudomonas, thus biasing the trial in favour of the active treatment). Disappointingly, after a great trial, no benefit was seen. In an accompanying editorial, it is suggested that continuous rather than cycled prophylaxis may be effective, and this needs to be tested prospectively in a randomised controlled trial. Currently, intermittent prophylactic regimes cannot be recommended, but a trial of continuous therapy should be done. See pages 849 and 915
A tough call
When do you stop a trial early? We publish a high quality randomised controlled trial comparing two pleural biopsy techniques, which reported superior results using ultrasound guided Abrams needle pleural biopsy. The trial was terminated because of unexpected early superiority of the Abrams needle technique. In an accompanying editorial, Rahman and Davies contrast the standard of significance required to stop a trial early, and that needed to declare a technique superior at the end of planned completion. Very difficult; the head says that a very rigorous level of significance is needed to terminate a trial prematurely, to avoid a chance result being reported as clinically meaningful. However, how many patients would wish to be enrolled in the trial if as part of informed consent they were told that the findings to date favoured one arm at the p=0.015 level? Not easy, but either way, congratulations to the South African team on showing the trial can be done. See pages 851 and 857
A really big sleep?
Neurocognitive consequences of obstructive sleep apnoea are well recognised in children and adults, and animal work has established a neurophysiological basis for some of these changes. In this issue of Thorax, Morrell and colleagues report that adults with obstructive sleep apnoea have loss of grey matter in the cerebellum and mid-temporal gyrus compared to normal controls. Longer term studies are needed to determine the significance of these findings, but perhaps you should be thinking, is my snoring partner also noisily dementing? And perhaps polysomnography should be part of the work up of early onset dementia? See page 908
Worms corner: where early birds can see what is coming
First independent replication study confirms the strong genetic association of ANXA11 with sarcoidosis (Research Letter): This important replication study (nearly 700 patients and controls) independently confirms the strong association previously reported in Nature Medicine between variations in ANXA11 and sarcoidosis and support the hypothesis that ANXA11 represents a strong genetic risk factor for sarcoidosis. This is strongly suggestive that this is a robust association, and should open up new research avenues in sarcoidosis. See Thorax Published Online First: 30 August 2010 doi:10.1136/thx.2010.138743