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  1. The Triumvirate

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In the Northern hemisphere, February is one of the colder, darker months of the year (though thankfully shorter). Here we put a positive spin on the last month of meteorological winter and celebrate some Thorax highlights.

Super bowl spirometry

To our US cousins, February is marked by the super bowl – the annual contest between two leading American football teams. The big game typically attracts over 100 million viewers – more than the UK Football Association (FA) cup, played in May, which garners around 88 million. Match audiences are not the only thing which is bigger in the US. It appears that the same applies for lung function values in children with cystic fibrosis (CF). In this month’s journal, Daniela Schlüter and colleagues (see page 136) present a comparison of lung function values from the UK and US registries. Using mixed effects regression analysis, the authors model lung function trajectories in children homozygous for F508del. After correcting for possible confounding variables, they find that lung function was higher in the US than the UK at age 6 years and remained higher throughout childhood. The inhaled mucoactive drugs dornase alfa and hypertonic saline were more frequently used in the US and the authors suggest that a possible causal role should be investigated further. There was no difference in nutrition between the US and UK children. No so for the super bowl which is the second biggest eating event in the US calendar after Thanksgiving!

The end of the virus season…?

February traditionally brings the respiratory syncytial virus (RSV) season to a close at children’s hospitals across the Northern hemisphere. However, the COVID-19 pandemic has disrupted the usual seasonality in paediatric workload. But how do outcomes for hospitalised children and adults with COVID-19 compare with more conventional virus such as RSV and influenza? In this issue of Thorax, a group of investigators from Sweden (see page 154) make this comparison for the period 2011–2020. They find that SARS-CoV-2 was associated with higher 30-day mortality compared with influenza, RSV and other respiratory viruses. ICU admissions were also higher and (in adults) pulmonary embolism was more common. Let’s hope that 2022 brings the end of the 2 year COVID-19 pandemic globally and we can return to milder and more seasonal viral infections.

Celebrating the return of daylight

Each year as the days start to get longer Icelanders gather to celebrate the pagan festival of þorrablót during the month of þorri. The origin of the name is unclear but may be in reverence Thor, the famous Norse god of Thunder, or less likely the international respiratory journal þorax. Icelanders will partake in culinary delicacies including rotten shark’s meat (hákarl), boiled sheep’s head, (svið) and congealed sheep’s blood wrapped in a ram’s stomach (blóðmör)! After such indulgence it is possible there may be some metabolic derangements but what does this mean for the development of pulmonary fibrosis? In this issue of Th(þ)orax Whalen and colleagues describe the association of metabolic derangements and circulating cell free double stranded DNA (ccf-ds-DNA) in IPF (see page 186). Using samples from patients from the COMET Study they found that ccf-dsDNA levels are elevated in patients with IPF who are rapid progressors compared with healthy controls and slow progressors and are furthermore associated with alterations in multiple central metabolic pathways particularly those associated with collagen and lipid metabolism. We are not sure what effect triple therapy with hákarl, svið and blóðmör would have on the development of fibrosis but I suspect most participants would prefer the control arm.

Skate day

As if one winter celebration isn’t enough for those from Iceland, this edition of airways was written on Þorláksmessa, otherwise known as Skautadagur, which takes place every year in the 23rd December. This celebratory feast is made up of steamed, fermented (putrefied) skate and Brennivín. If the taste of ammonia is your thing then you are in for a treat, but take it slow or you risk exposing a whole range of epithelial antigens which can lead to its own consequences. Enomoto and colleagues describe the consequence of auto-antibodies in patients with Interstitial Idiopathic Pneumonias (IIP) (see page 143). They find of 376 patients with IIP 18.6% met the criteria for autoimmune features (IPAF) although this was much lower in patients with IPF. However, they found that the presence of IPAF was associated with a better prognosis. More rationale for a feast-based therapy in diffuse parenchymal lung diseases? Probably not. However, if you have an interest in pulmonary fibrosis and traditional Nordic cuisine head on to ICLAF2022 (www.iclaf.org) and we look forward to seeing you there!

Pagan festival of Lupercalia

February is the month for celebration with St. Valentine’s feast day at the ides of February originally ordered by the church to Christianise the pagan celebration of Lupercalia, a fertility festival. In the modern era, February 14th is symbolised with roses, hearts, doves and the colours red and pink. Indeed, it is the heart that Tamisier and colleagues, as part of the FACE study, investigated in the study of adaptive servo ventilation (ASV) for sleep apnoea in heart failure (see page 178). These investigators focused on 503 patients with a left ventricular ejection fraction (LVEF) above 45%, ASV is contraindicated in patients with LVEF <45%, and employed latent class analysis to categorise the effects of 3 months ASV therapy on morbidity and mortality in patients with heart failure and sleep-disordered breathing (SDB). The primary endpoint was time to all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of heart failure. 6 patient clusters were identified characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. Males with low LVEF, severe heart failure and central sleep apnoea had the worse outcome. This patient phenotyping allowing personalised and targeted intervention really does pull on the heart strings, something that both St. Valentine and Lupercalia would be impressed by.

COVΙD bounce back

Just as mild February days can be followed rapidly by a bounce back of winter, this month’s teaser image describes a patient in whom COVID-19 ‘bounced back’ following discharge. Spot the complications and apply your diagnostic skills to this month’s teaser image.

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