Seasonal COPD

‘Season of mists and mellow fruitfulness …’ was John Keats’ description of the current autumn season. However, autumn does more than just ‘… fill all fruit with ripeness to the core ….’ It heralds the beginning of the peak season for COPD exacerbations. On page 919 of this issue, Wilkinson and colleagues describe the seasonal changes in airway pathogens in COPD exacerbations. They found that non-typeable Haemophilus influenzae increased the risk of COPD exacerbations from October to March. Moraxella catarrhalis, on the other hand, exerted its malign influence year-round. All this will leave respiratory physicians very little time for seasonal leisure activities such as sitting by the ‘… cyder-press, with patient look …’ watching ‘… the last oozings, hours by hours …’ Time please gentlemen!

Biomarkers: poetic and prophetic …

In 1821, John Keats died of what is believed to have been tuberculosis, though the tubercle bacillus was not described until 1882 (by Robert Koch). Keats is reported to have said (on having a haemoptysis): ‘That drop of blood is my death warrant’. Keats was certain of his diagnosis—based on the biomarker of blood in the sputum. However, there is a great deal less certainty about the use of biomarkers such as interferon-γ release assays (IGRAs) in the presence of corticosteroids and infliximab. On page 946, Edwards et al describe how these agents greatly impair the performance of IGRAs and suggest that interferon-γ-induced protein 10 may be a better biomarker in these circumstances. Hopefully better biomarkers will allow diagnosis before ‘… youth grows pale, and spectre-thin, and dies …’

The sign of four?

Even Sherlock Holmes would have struggled to predict the clinical outcome in acute respiratory distress syndrome. His creator Sir Arthur Conan Doyle might have believed himself more capable, both as a physician and a believer in spiritualism.

On page 876 of this month’s Thorax, Bos and colleagues describe their cluster analysis (complete with validation cohort) which uses a panel of four biomarkers to assign patients to ‘non-inflamed’ and ‘reactive’ phenotypes. The reactive phenotype carried a much higher mortality in both the training and validation cohorts. ‘Elementary my dear Watson?’

A three-pipe problem …

Holmes was an avid pipe smoker (as well as using other illicit drugs) and he would therefore have been eligible for the study of CT scan screening for lung cancer, described by Brain et al (Editors’ choice), on page 912. The authors describe how secondary prevention (screening with CT scans) might lead to primary prevention (quitting smoking). Far from being falsely reassured by being on a screening programme, smoking participants who were randomised to the CT scan group were 60% more likely to have quit at 2 years follow-up. The OR for quitting in the scanned arm of the trial was 1.6 (95% CI 1.17 to 2.18) compared with non-scanned controls. Lung cancer screening offers a ‘teachable moment’. However, ‘Dr Watson’ and other health professionals will have to do the health promotion spade work!

An improbable cause of wheezing in a toddler

Holmes famously said: ‘When you have eliminated the impossible, whatever remains, however improbable, must be the truth.’ In a case-based discussion on page 953 of Thorax, Shanthikumar and colleagues describe an improbable cause of wheezing in a toddler.