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‘There is a great deal to be seen in the tilt of a man’s hat’
So said John Steinbeck in his novella The Pearl, a parable about society, greed and evil. In essence the value of the pearl was associated with poor outcomes, including envy, fire, destruction and death. While not quite so apocalyptic the study by Echevarria et al showed that increasing values of the simple clinical score, incorporating: (1) previous admissions; (2) the extended Medical Research Council dyspnoea score; (3) age; (4) right- and (5) left-sided heart failure, lead to a shorter time to readmission ( see page 686 ). So while we might be tempted to predict a successful discharge by appearance perhaps the more objective PEARL score will help to guide discharge planning.
‘Give me a child until he is seven and I will show you the man’
This statement has been attributed to the Greek scientist and philosopher Aristotle and later to the Jesuit priest St Francis Xavier and the hypothesis was famously tested by the Granada Television series. It is clear now that all these great minds were wrong on so many levels. Two studies from Australia published in this month’s Thorax by Simpson et al ( see page 702 ) and Doyle et al ( see page 712 ) illustrate the importance of pre-term birth on airway obstruction. Simpson et al describe the effect of extreme prematurity (born before 32 weeks' gestational age) on lung function at the end of the first decade of life. They show that more severe findings are associated with increasing prematurity and this is compounded by the development of bronchopulmonary dysplasia. The study by Doyle and colleagues assessed lung function at 8 years and 18 years and again found that preterm birth and bronchopulmonary dysplasia was associated with reduced lung function in both age groups, with spirometry deteriorating from 8 to 18. Sadly, a substantial portion of children had started smoking (and had smoked on average for 3 years!) and although there was a trend towards this impairing lung function in 18 year olds, it did not reach statistical significance. So give us the gestational age of the neonate and we will tell you the lung function of the teenager. More importantly, do not give a child of 7, 14 or indeed any age any type of cigarette!
Crime and punishment
Fyodor Dostoyevsky’s novel was set in 1860's St Petersburg when public health measures were sparse but the only effective treatment for tuberculosis at the time. Given the poverty and overcrowding associated with St Petersburg at the time it is hardly surprising that TB was such a prominent feature in novels from that era, exemplified by the polemic character of Katerina Ivanovna. Even in the current era of antituberculous medication public health measures remain vital and the factors associated with tuberculosis infection remain the same. It is therefore crucial that public health strategies are thoroughly evaluated as described by Cavany et al ( see page 736 ). In London in 2015, 86% of patients with TB had at least one contact identified, revealing up to 4.1% of active infection and up to 10% latent in infection in children. Contacts of men and ex-prisoners were less likely to be identified than those of never-prisoners or females. So, as Dostoyevsky postulated last century, does punishment extend beyond the criminal justice system?
‘Before I go to sleep…’
SJ Watson’s novel describes a woman with anterograde amnesia such that she wakes every morning with no knowledge of who she is. This is a problem that patients with severe COPD may long for as the quality of sleep in such patients can be poor. Gabriele Spina and colleagues report an observational cohort study of 932 patients with COPD who underwent objective sleep and physical activity monitoring for almost a week ( see page 794 ). Actigraphic measurements of poor sleep quality were greater in patients with worse airflow limitation and worse exertional dyspnoea. Importantly, they observed that patients with better sleep quality were more active during the day. Poor sleep quality and low physical activity is an important observation but can we enhance sleep to enhance physical activity or vice versa? It is the stuff only dreams are made of…
‘Little Briar Rose…’
Little Briar Rose is the German version of Sleeping Beauty by the Brothers Grimm describing the dark fairy tale of a young beautiful princess who is drugged with a sleeping enchantment only to be awakened by a kiss from a handsome prince. Although Carole Marcus and colleagues did not use sedation or kissing in their study, they were interested in understanding the mechanisms involved in the development of upper airways obstruction in adolescence ( see page 720 ). They investigated 42 obese adolescents with obstructive sleep apnoea syndrome (OSAS) and 37 weight-matched controls to determine the anatomical and physiological neuromotor factors involved. Indeed, in addition to OSAS being mediated by these anatomical and neuromotor factors, these factors were demonstrated to be independent of age, gender, body mass index and race. New treatments targeting these anatomical and neuromotor factors will be important and may involve medication but probably not any canoodling…
Our teaser image is an MR brain scan. Respiratory colleagues please don’t switch off! The image shows an unusual cause of central hypoventilation. Turn to page 764 , to find out more.