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Partners in crime?
Despite the greatest series of randomised controlled trials of treatment in Thoracic Medicine (and probably as good as any done anywhere), TB is as unassailable as Captain Cook (the cricketer not the explorer) as the Captain of the men of death (or defeat, in Cook's case). Modern medicines have brought great benefit when used appropriately, but TB and its increasingly important cousins and partners in crime, the atypicals, come ghosting in on the blind side as effectively as Martin Peters in 1966 (for younger readers, when we won a football trophy for the last time). We have previously published how inhaled corticosteroids increase the risk of TB (Thorax 2013;68:1105–13) and atypical Mycobacterial (Thorax 2013;68:256–62) disease in adults, and the potential mechanisms of impairment of mucosal immunity (Thorax 2013;68:1085–7). In this issue of the Journal, Sarah Brode and colleagues (see page 677) show that anti-TNF strategies in rheumatoid arthritis, but also other potent Immunosuppressives, were associated with increased risk of both diseases. Even hydroxychloroquine did not escape censure—implications for malaria treatment? However, at least the rheumatologists have progressed beyond ‘arthritis’ as a diagnosis, and one can be reasonably confident that the prescriptions were appropriate. However, the respiratory community is regressing into the Jurassic age, unless a scholarly Australian dissection of ACOS (see page 683) and an editorial diatribe against this and other umbrella terms can turn the tide (see page 609).
A pregnant pause?
In asthma treatment? Despite Peter Gibson's group showing better mother (Lancet 2011;378:983–90). and child (Thorax 2014;69:383–4) outcomes if asthma is well controlled and FeNO is monitored, many pregnant women are understandably reluctant to take any medication for fear of compromising their unborn child. Lucie Blaise and colleagues studied more than 36,000 pregnancies recorded on the Quebec province administrative databases (see page 647; Editors' choice). There are no data on how much asthma medication was taken during pregnancy, but one has to assume some was, and unless you had a severe asthma attack requiring hospitalisation, the risk of a congenital malformation in the baby was not increased. Whether it was the attacks themselves, something about the nature of severe asthma, or the treatments of the severe asthma that were responsible cannot be determined from this sort of study, but these huge numbers surely tell us firstly that standard asthma medications are safe in pregnancy, and secondly, we must do everything we can to prevent severe asthma attacks in pregnant women. We cannot guarantee (at least from these data) that aggressive treatment will reduce congenital malformations; but we can be certain that doing nothing is a BAD THING. Should FeNO measurements become as commonplace as dipping the urine in the antenatal clinic?
CURRYING FAVOUR WITH STEM CELLS!
We still have no specific treatments to offer patients with ARDS, which has a 30% mortality. Is this about to change? Rachel Dancer and colleagues (see page 617) put Vitamin D deficiency firmly in the frame as a potentially modifiable factor and sets the scene for the gloriously named VINDALOO study, an obvious Hot Topic candidate. VINDALOO stands for Vitamin D to prevent acute lung injury following oesophagectomy—a great candidate for the acronym of the year along with the last month's BATMAN study. We hope this prophylactic Vitamin D study is more encouraging than other recent attempts. Mesenchymal stem cells have pleiotropic beneficial effects on the host response to injury and infection and have shown considerable promise in preclinical animal models. Devaney et al. (see page 625; this month's real Hot Topic) advance the field by showing in an animal model that cryopreserved cells retain their efficacy and that IV administration is as effective as intratracheal. Our editorialists (see page 611) point out that the stage is now set for the ongoing killer phase IIa studies needed to take this interesting area forward.
2014 year in review results:
Over the last three months we have published the last of our year in review articles and this month we announce the results of our prestigious and eagerly awaited paper of the year award for 2014. We had a number of excellent candidates in our usual categories (adult clinical, paediatrics, basic science and epidemiology) and there was a vigorous debate amongst the editorial team. In the end we awarded the Gold medal to the two Korean papers (Thorax 2014;69:694–702 and Thorax 2014;69:703–8) identifying a disinfectant used in air humidification systems as the cause of a cluster of cases of fatal acute lung injury in women and children. We all agreed that this was classical epidemiology and life-saving research. The judges are particularly partial to clinical trials and the other overall medal winners were excellent examples. The silver medal winner was the terrific SABRE study (Thorax 2014;69:1105–12), a definitively negative study of nebulised hypertonic saline in infants with RSV bronchiolitis. The bronze medal winner was perhaps less definitively negative, but nevertheless an excellent study of nocturnal non-invasive ventilation following a hospital admission with a COPD lung attack and persistent hypercapnoea (Thorax 2014;69:826–34). Congratulations to all the lucky winners and many thanks to all for sending us such excellent work.