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  1. The Triumvirate

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Brexit special

‘I see no ships…’

As Britain made contingency plans for a no deal Brexit, the hapless UK Transport Secretary, Chris Grayling, might have uttered these words. He awarded a £13.8 million contract for ferry services to Seabourne Freight – a company which possessed no ships. However the phrase originated with Horatio Nelson who, when ordered to flee during a sea battle, raised his telescope to his blind eye and claimed not to see the signal to retreat. The NELSON CT lung cancer screening study ( see page 247 ) had more vision than its namesake. In this month’s Thorax, the authors report that over half of new solid nodules resolve spontaneously and only 7% are new lung cancers. The best predictors of malignancy are volume doubling time and nodule volume. Nelson (the Admiral) blockaded French ports to prevent an attach on England. Let’s hope there is no similar disruption to sea farers on 29 March…

Research but not as we know it…

The European Research Group, claims to conduct research on the merits of the United Kingdom leaving the EU. However, this might not be from a position of equipoise… In this issue of Thorax, ( see page 229 ) Smyth and colleagues point out the gaps in the evidence for treatment decisions in cystic fibrosis. The authors found 30 ‘known knowns’ – questions where there is robust evidence to support treatment decisions. In contrast there were 111 ‘evidence gaps’ – areas where there was insufficient clinical trial evidence to guide clinical teams in patient care. Clearly ‘more research is needed’ but not the sort of research conducted by the Jacob Rees-Mogg and his colleagues…

Disruption at Dover

The impact of a ‘no-deal BREXIT’ on UK supply chain is well described although the inventor James Dyson did say ‘it will not change anything’. In the human body one of the mechanisms that cells use to deliver information and signals to other cells is through specialised extracellular vesicles called ‘exosomes’. Like a no-deal BREXIT the exosomal supply chain is disrupted during disease. In this issue of Thorax ( see page 309 ) Njock and colleagues identified three microRNAs that could discriminate Hypersensitivity Pneumonitis from Idiopathic Pulmonary Fibrosis and were associated with disease severity. They suggest that the contents of exosomes observed in sputum could be used as a biomarker of disease analogous to increased disruption at Dover being a biomarker of a poor UK Health in a No-deal BREXIT.

The positive Brexit agenda

Boris Johnson has said that BREXIT is ‘not some great V-sign from the cliffs of Dover’ and we should still go on ‘cheapo flights to stag dos’! Another positive feature of BREXIT will be the reduced availability of cheap cigarettes from Calais. In this month’s Thorax ( see page 254 ) Dizier and colleagues from France describe elegant studies showing the interaction between Environmental Tobacco Smoke (ETS) and genes responsible for airway epithelial cell homeostasis in 253 families from 253 Saguenay-Lac-Saint-Jean (SLSJ). While we can’t confirm that UK families will also show a similar gene environment interaction it is hard to believe that reduced ETS as a result of BREXIT will not be a good thing for the UK.

‘The Government cannot just be consumed by Brexit. There is so much more to do’…

Theresa May, in her plight to focus attention away from Brexit over the last 2 years, highlighted that ‘poverty is about people lacking the tools they need to get on in life’ and to solve it we all need to tackle ‘educational failure, antisocial behaviour, debt problems and addiction’. This holistic approach has been acknowledged by Brighton and colleagues ( see page 270 ) in their systematic review and meta-analysis of advanced disease and chronic breathlessness. Importantly, holistic services for chronic breathlessness were shown to reduce distress in patients with advanced disease and improve anxiety and depression. Patients and carers valued tailored education, self-management interventions and expert staff providing person-centred, dignified care. Perhaps Mrs May could consider incorporating such a holistic approach to the NHS Long Term Plan after Brexit.

‘Take no-deal off the table now please prime minister’

By the time the Brexit Airwaves Special has been published, Mrs May and Mr Corbyn may have met, which would definitely wake up British politics and a step towards rehabilitating the political parties. In line with this, Berlowitz and colleagues ( see page 282 ) have focused on daytime somnolence and neurocognitive function in acute quadriplegic patients with sleep disordered breathing. In this randomised controlled trial, 3 months of auto-titrating CPAP was applied to improve attention and information processing using the Paced Auditory Serial Addition Task. 149 patients completed the trial but there was no difference demonstrated in terms of Paced Auditory Serial Addition Task (mean improvement of 2.28, 95% CI −7.09 to 11.6; p=0.63). Although only 21% of patients were adherent to treatment (4 hours use on 5 days per week), sleepiness was improved by CPAP. Unlike this RCT, let’s hope that a meeting between Mr Corbyn and Mrs May not only wakes up the country but also leads to some clear thinking.

Paralysis relieved by surgery

This month’s image ( see page 313 ) describes an unusual cause of paralysis that was relieved by surgery. By the time this month’s Thorax lands on your doormat, the paralysis gripping the UK parliament may have resolved. If not, the Triumvirate are happy to assist…

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