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Not throwing a sickie
Respiratory symptoms are amongst the most common reasons for not attending work, but some occupations lend more to respiratory illness than others. Welding has been shown to increase the risk of pneumococcal illness and in the manuscript by Marongiu et al welders have a two-fold increase in respiratory symptoms and nearly a 50% increase in consultations for respiratory symptoms over the Winter suggesting that welders have increased susceptibility to infection compared with other manual workers (see page 601). Maybe welders need to “tumble outa bed, stumble into the kitchen, pour a cup of ambition” and put on appropriate PPE.
A spoonful of Metformin
There have been concerns for some years about the veracity of Mary Poppins' advice. Indeed in recent years Saint Mary might have been subject to litigation as the evidence mounts that elevated blood glucose during acute illness contributes to adverse outcome. However, the effect of normalising blood glucose during acute exacerbations of COPD had, until recently, not been tested. In this issue of Thorax, Hitchings and colleagues demonstrate that undertaking a trial of Metformin in acute exacerbations of COPD is as challenging as getting children to take their medicine, and ultimately less rewarding (see page 587). However, it is unlikely that Mary Poppins herself could have undertaken a better study in these circumstances.
Unlocking Pandora's Box
Recent studies assessing the lungs of patients in cardiovascular risk studies are leading to alarming results. Alveolar diseases are particularly problematic with the increased mortality associated with Interstitial Lung Abnormalities1 and now Emphysema being reported (see page 624). It is clear that even in the absence of traditional risk factors, patients with mild abnormalities on their CT scans have an adverse prognosis but at the current time we are wholly limited in our management. The medical and legal consequences of this are clear. We give you the contents of Pandora's box, but may be more than “hope” remains.
‘Please sir, I want some more’. It is unusual for people to ask for more tablets but, short of recommending adding statins to the water, this is one consequence that may result from the observation that statins offer protection from TB infection. In this issue of Thorax, Lai and colleagues found that statins reduced the risk of active TB (see page 646). Indeed, the longer the duration of prescription the lower was the risk. In an age of increasing demand and declining resource I can already hear the voices of NICE, “What, what, what they want more statins?!” “What the Dickens!” we hear you all cry.
To be or not to be
Hamlet considered a number of questions, but we wonder whether he considered ‘do never smokers with airflow limitation have undiagnosed asthma? A very reasonable question that is addressed by Çolak and colleagues (see page 614). Although the investigators expected to identify a cohort of undiagnosed asthmatic patients, the results were surprising. Indeed, the participants with airflow limitation without diagnosed asthma had less allergy and respiratory symptoms. The authors conclude that never smoking individuals with airflow limitation do not have asthma. Hamlet may have got there in the end.
Life is divided into three terms
As Wordsworth considered life in three groups so have Beerthuizen and colleagues who performed a cost-effectiveness trial that compared standard care with a web-based monthly monitoring programme and a FENO monitoring programme to improve asthma control (see page 607). The authors showed no difference in terms of QALYs, albeit the web-based approach was more likely to be cost-effective from a healthcare perspective and FENO-based strategy was most cost-effective from a societal perspective. So, again we see more work needs to be done to bring society and health together.
Just as A Bug's life was inspired by one of Aesop's fables, Nolan and colleagues have been inspired to develop novel approaches to understanding the pathogenesis of ventilator acquired pneumonia (VAP) in critically ill patients in the ICU (see page 594, Editors' choice). This multicentre study not only showed a high prevalence of Mycoplasma species in patients with VAP, but also that Mycoplasma species, in particular Mycloplasma salivarium, has an immunoparetic action, which could have a major role in the pathogenesis of VAP. Watch out bugs, were closing in on you!
Thorax – for renaissance men and women
Pectus excavatum or cadaverous habitus? On page 669 of this month's journal we introduce you to the caravaggisti and the art of tenebrism.