Post Brexit Blues—Building Strong Links Across the UK, EU and Beyond…

The Baltic states have seen big improvements in the quality of health care, and TB in particular in recent years. Whether this is due to membership of the EU is not certain, but the temporal relationship does support this hypothesis. However they still have a considerable problem with multi-drug, and extremely drug resistant TB. In this issue of Thorax, Balabanova and colleagues describe the experience of Eastern Europe dealing with MDR and XDR-TB (see page 854). Not surprisingly, older age, and co-infection with HIV worsen outcomes but at least fluorquinolones and injectable anti-tuberculous therapy appeared to be effective in a substantial proportion of patients.

The Canadian model of trade with the EU has been postulated as one of the post-BREXIT options. Maybe the UK can also learn about off-label use of inhaled Tobramycin, it seems that in Canada the large increase in inhaled Tobramycin use is due to off-label prescriptions for patients with COPD and pseudomonas infection (see page 862). A model we want to adopt in the UK? We will need more evidence first.

Will the UK still have the nose to determine a fine Claret? Certainly Thorax has benefitted from a vintage study from Bordeaux assessing a non-invasive approach to assessing pulmonary artery hypertension in patients with COPD. By carefully measuring the cross sectional area of blood vessels, bronchial wall thickness and oxygen measurements Coste and colleagues were able to predict severe PAH in patients with COPD, which may help guide those patents who require further investigation (see page 830). Bottoms up!

Despite much of Holland being below sea level, the country has managed to control the flow of water. In this month's Thorax Loyman's and colleagues develop a prediction model to try und control the number of Asthma Exacerbations (see page 838). This Anglo-Dutch (and Aussie) collaboration describes that smoking, previous exacerbations and spirometry were the best predictions models in both the test and validation cohorts, with FeNO of marginal extra value. I guess we will have to go Dutch on the Niox's.

A clear alternative to the EU is to strengthen links with our Commonwealth friends. Bissett and colleagues from Australia report a randomised controlled trial of the effect of inspiratory muscle training in a cohort of patients who were successful weaned from prolonged mechanical ventilation (see page 812). They hypothesised that the respiratory muscles can be weak following invasive ventilation which can lead to breathlessness and limited functional recovery. Although inspiratory muscle strength, which was the primary outcome, increased, there were no improvements observed in dyspnoea or physical function. Indeed, we need to be careful as there was a higher hospital mortality in the treatment group. The editorial from our Belgian colleagues clears the picture (see page 779).

So we may break up the UK as we leave the EU, but we will continue to embrace our Scottish allies. Griffith and colleagues report a prospective cohort study, as a secondary analysis of the post ICU rehabilitation and RECOVER study (see page 820). Although it is acknowledged that maximising physical recovery following critical illness is a key priority, there is limited beneficial effect shown from the clinical trials. These data from Edinburgh demonstrated that a pro-inflammatory state persisted for up to 3 months post discharge in a subgroup of patients, which was associated with reduced peripheral muscle strength and physical function. Perhaps, we can use rehabilitation as a new anti-inflammatory agent as discussed in the Anglo-Australian editorial (see page 783).

Le Tunnel Sous La Manche will permanently join us with our French friends. However, we will also need to integrate across the UK similar to Soumagne and colleagues who have joined research forces from capital of the Franche-Comté with the capital of France and asked whether asymptomatic subjects with airway obstruction have exercise limitation (see page 804). They investigated the impact of mild airways obstruction on pulmonary mechanics and exercise capacity. Although the subjects did not report chronic activity-related dyspnoea, the subjects had reduced exercise tolerance with 50% demonstrating dynamic hyperinflation. We need to identify these hidden patients, wherever they may be.

…and finally from the North part of the Emerald Isle, Einarsson and colleagues compared the lower airway microbiota in COPD patients, smokers and non-smokers (see page 795, Editors' choice). Despite the extended-cultures showing similar bacterial load, importantly, culture-independent analysis revealed that the prevalence of Pseudomonas spp. in the COPD patients with increased community diversity in the healthy subjects. Thorax will always embrace and build on the rich diversity that we hold in our respiratory research community across the UK, EU and beyond…