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  1. The Triumvirate

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A NICE dilemma we have here…

The 2016 revision of the UK NICE guidance on tuberculosis ( is a hefty document, weighing in at 177 pages. For children screened as household contacts of TB, old timers would have used 15mm Mantoux cut off for children who had previously received BCG. Not any longer! The 2016 NICE guidelines advocate using a lower threshold of 5mm, whether or not the child has had BCG. On page 932 of this month's Thorax, Beate Kampmann and colleagues put this strategy to the test. They find that the use of a 5mm cut off for the Mantoux test reduces the specificity of the test for children under 5 years. This is less problematic for older children where the effect of BCG on the tuberculin skin test wanes.

The drugs don't work…

In their 1997 album “Urban Hymns” the Verve could have been referring to drug resistant TB with the track “The Drugs Don't Work”. Helen Stagg and colleagues describe a systematic review and network meta-analysis of treatment regimens for isoniazid resistant TB (see page 940). The importance of the topic is underlined by the incidence of isoniazid resistance which approaches 50% in Eastern Europe. The take home message is that regimens are more likely to be effective if they continue rifampicin for longer and use a greater number of effective drugs at the 4 month stage of treatment. In the meta-analysis, these regimens perform better than the WHO recommended regimen.

A step by step guide to recovery…

The physical and psychological consequences of critical illness are seen many years after ICU admission. For a series of insightful reflections from ex-patients on their ICU admissions take a look at the ICU Steps webpage of patient experiences. Bronwen Connolly and colleagues perform a “systematic review of systematic reviews”, summarising a number of physiotherapy interventions, designed to help with long term physical recovery (see page 881). They find good evidence that early mobilisation, cycle ergometry and electrical muscle stimulation help improve key long term outcomes, provided they are started during the ICU admission. The authors call for more trials of interventions following discharge.

Podcast anyone?

The paper by Sandrah Eckel on air pollution and cancer survival, in this month's issue has already had almost 400 “plays” of its podcast version (see page 891).

The authors studied Californian cancer registry data on over 350,000 people. They found that air pollution in an individual's residential area decreases their chances of survival from lung cancer, with hazard ratios between 1.04 and 1.38 for each of 4 pollutants. The biggest effect was seen in those with early stage, non-small cell cancers.

Shock therapy…

Many trials of devices fail to include an adequate control group. Pengo and colleagues avoid this trap for the unwary in their sham controlled trial of transcutaneous electrical stimulation to dilate the oropharangeal muscles in patients with obstructive sleep apnoea (see page 923). They found a modest improvement in the primary outcome of the 4% desaturation index. The authors recommend assessing the “…feasibility of the method in a domiciliary setting…”. Don't try this at home just yet!

Move over Jeremy Kyle – time for thoracic chyle…

If the word chyle puts you in mind of Jeremy rather than lymph and emulsified fat, then you have been watching too much daytime TV . The proper place for chyle in the thorax is in the thoracic duct. Find out what happens when non tuberculous mycobacteria get involved. See Tanaka and colleagues Images in Thorax on page 960.

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  • The Triumvirate

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