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  1. The Triumvirate

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As we write this edition of Airwaves, the UK has abandoned lockdown and is relying on a high immunisation uptake and a world beating test and trace programme to keep COVID-19 at bay. The immediate effects have been a “pingdemic” where keyworkers across the nation are asked to self-isolate by the NHS app and there are fears that supermarket shelves may soon be bare. The pages of the current issue of Thorax however are far from bare, with a sumptuous display of excellent science. This month’s Airwaves endeavours to provide comic relief while showcasing the very best we have to offer.

The Holy Stone of Clonrichert

A classic episode of the situation comedy (sitcom) Father Ted hinges around a visit to Craggy Island by the church hierarchy to upgrade the Holy Stone of Clonrichert to a “class 2 relic”. Ted and his companions debate what miracles would be required to upgrade the monument – including time travel and cloning dinosaurs. The effects of CFTR modulators in cystic fibrosis while perhaps not miraculous, have certainly been dramatic. But are they sustained? In this month’s journal Barry and colleagues (see page 874) describe the effects of the CFTR modulator Ivacaftor over a 5 year period in 35 patients with the G551D mutation. After 6 months of therapy, FEV1 had increased by almost 10% from baseline however within 5 years FEV1 had returned to pre-Ivacaftor levels. A reduced requirement for intravenous antibiotics was sustained throughout the study period. The beneficial effects on FEV1 were more sustained in patients who appeared to have better adherence. When the Bishops visit Craggy Island Father Ted tries to ensure his feckless companions are on their best behaviour. Good behaviour is sadly not sustained resulting in a defrocking, a heart attack and a very close encounter with the Holy Stone…

Jake the poacher

Much of the action of the 1987 film “Withnail and I” takes place in a cottage in the Lake District where two out of work actors take refuge from an angry poacher (Jake). During months of lockdown, many have felt under siege in their own homes with coronavirus roaming outside. But what effect did this have on people with asthma? In this issue of the journal (see page 860), Shah and colleagues describe a time series analysis looking at the effects of lockdown on asthma presentations (hospital attendance or oral steroids) in a primary care cohort. After the lockdown was imposed, the authors find significant fall in exacerbations managed in primary care but no significant decrease in exacerbation episodes managed in hospital. In a related study, which looked at asthma admissions in Scotland and Wales, Davies et al (see page 867) found a reduction in asthma admissions of over a third, following lockdown. There was no corresponding increase in asthma deaths. In a linked editorial (see page 852) Skene and Pfeffer speculate that asthma patients may have optimised self-management in response to the pandemic. The siege of Withnail and I at Crow Crag ends with the arrival of Uncle Monty, which is when their problems really begin, and escape from the cottage does not quite live up to their expectations. “We've gone on holiday by mistake…”

“Be curious. Not judgemental”

Ted Lasso is a college level American football coach hired to coach Premier league AFC Richmond by Rebecca the new owner of the club following her divorce from the cheating multi-millionaire Rupert who loves AFC Richmond more than anything in the world! Ted was meant to destroy the club to get back at Rupert, but his positive EQ brings the club together. Despite the positives the club loses to Manchester United in the deciding game and gets relegated. We tend to think of greenness in our environment as always being a positive influence that will improve particularly respiratory health, but it appears it is far more complex. In this issue of the journal, Zhou et al (see page 880) report on a cross sectional survey of spirometry in school age in China and the relation with greenness and air pollution and their surprising results suggest that, while generally greenness was associated with better lung health, greenness in the highest areas of pollution were associated with poorer lung function. Fuertes and Jarvis speculate on the possibility that different forms of vegetation might have different effects as well as the very high pollution levels seen in this study and how early life effects of pollution might have the greatest impact. Maybe Ted Lasso is right about human development when he tells the team “All right fellas, you gotta remember, your body is like day-old rice. If it aint warmed up properly, something real bad could happen”.

“Every fibrocyte is sacred”

Monty Python famously, but controversially, used comedy to address the meaning of life in a number of films. Although scarring was not a theme they addressed specifically, the Black Night may well have benefitted from it following his ‘drawn’ combat with King Arthur during the search for the Holy Grail. In this edition of Thorax, Sato and colleagues (see page 895) address the controversial issue of how fibrocyte derived extracellular vesicles (EV) may impact the development of pulmonary fibrosis. EVs are lipid containers, gourds if you will, carrying cellular contents from one cell to another. In an elegant series of experiments using both a rodent model and human samples they show that circulating fibrocytes secrete EV containing the pro-fibrotic micro-RNA miR-21–5 p. They demonstrate that in samples from patients with interstitial lung disease, or fibrocytes cultured on stiff or fibrotic matrix secrete more ‘gourds’ containing miR-21 than healthy controls. These studies demonstrate a role for EV and fibrocytes in the development of pulmonary fibrosis. Maybe the girl in the Life of Brian was correct after all and we should ‘cast off our shoes, and follow the Gourd’

Vibrating Headgear

Headgear, such as the fez, the sombrero, the beret, clown, witches and wizards hats have always had huge comedy value. This was probably the inspiration for Armas and colleagues (see page 930) who have used a vibrating forehead device to reduce sleep disordered breathing in patients with positional obstructive sleep apnoea. The authors carried out a three arm multicentre clinical trial and enrolled 128 patients with the primary outcome of apnoea–hypopnoea index (AHI) measured at 3 months. The investigators showed that the treatment group, wearing the positional vibrating device, had a 2-fold reduction in AHI compared with the group that received general advice only, and 3-fold reduction in AHI compared with the group that received advice but with an inactive device. The device was also effective in reducing time spent in the supine position as well as improving sleep architecture. From comedy to clinical treatment, headgear has come a long way.

“Give us a wheeze on that fag…”

Withnail and I spend much of the film chain smoking and so are highly likely to have pulmonary nodules. Our teaser image reveals an uncommon cause of pulmonary nodules.

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