The fourth monkey

We all know of the three monkeys, who respectively see no evil, hear no evil and do no evil. The fourth monkey, not (as far as we know, infiltrated into MI5) has asthma but perceives no evil. This is a major problem in paediatric practice—asthmatic children may not perceive that they are bronchoconstricting, so they may not take their reliever medication or indeed realise they are on the verge of a serious asthma attack. This has important implications for the use of questionnaire scores, no matter how well validated, for the assessment of asthma control. Feldman et al gave children from the Bronx a device which automatically recorded their peak flow; half were blinded to the results, half received immediate feedback (Editor's Choice, page 1040). These children were found to be at high risk, both from under-perception of symptoms and (unsurprisingly) poor adherence. However the feedback group, who estimated their peak flow and then found out immediately how wrong they were, not merely improved their perception over time (presumably harnessing the innate spirit of competition, I won't be beaten by a machine) but also took their medication more frequently. In an accompanying editorial, Paton (page 1023) highlights some of the problems of the study, but also highlights the new technological options such as the devices used in the present studies, which we should be using to try to improve control. Those who believe Flicker is what candles do should turn the page, but the more technology-savvy should ponder the use of novel methods for a new e-age.

Obama or Woodcock: who is most ozone friendly?

A new and hopefully annual feature this month is ‘The President Speaks’ (see page 1028) in which Ashley Woodcock, the incoming President of the BTS, reviews progress in phasing out CFC containing inhaler use thus limiting their impact on the ozone layer (see cover). By any measure, this has been an international success story with many millions of patients being successfully switched over to non-CFC containing inhalers. We all offer Ashley our best wishes for his year in office and our sincere thanks for a job well done as co-chair of the Montreal Protocol Medical Technical Options Committee.

More or less—does allergen avoidance damage your health (as well as your sanity)?

Allergen avoidance to prevent asthma has had a chequered career, with well-meaning attempts leading to the expenditure of a lot of money, the exacerbation of many obsessive-compulsive syndromes, but often little or no benefit, or even harm. However, in this issue, Scott et al (page 1046) report on an 18-year follow up of a group of infants who were at high risk of atopic disorders. They were randomised to a fairly hard core programme of allergen avoidance or standard advice, and interestingly, the intervention group had a sustained reduction in asthma prevalence. Challengingly, prevalence of atopy at age 18 was not affected at all. So what does this mean? Obviously careful thought is mandatory before inflicting interventions on families of new-born infants, although this study is very convincing that benefits can be attained in a highly selected group; but also, further evidence that atopy and asthma are much more loosely related than the diehard allergists would have us believe?

Weighty evidence: cPAP is not a cure-all

Two well designed and appropriately controlled studies published this month potentially put to rest the notion that treatment of obstructive sleep apnoea with CPAP improves obesity, insulin resistance and cardiac risk profiles (see pages 1081 and 1090, Hot topic). Jean-Louis Pepin and colleagues (editorial, page 1025) contrast the findings with those of Sharma et al (NEJM 2011;365:2277–86) and speculate that the positive findings reported by Sharma et al might have been because the participants were not receiving any treatment for associated metabolic or cardiac risk factors. Could CPAP be an alternative to drug treatment for cardiac risk reduction? Is it possible to find patients who are not already taking treatment? These are important questions for the future.

Christmas crackers (1)—beyond the frostie

Have you got your inhaler with you, son? The cri-de-couer of parents and physicians, but at least one patient reported here is pretty certain to adhere to inhaler therapy, if not in quite the manner intended by his physician. Turn to page 1120 to find out why (and remind yourself that not all Frosties are eaten for breakfast)

Christmas crackers (2)–remembrance of things past

How good are you at history (or remembering your medical school days, depending on your age)? An 80-year-old Russian man had an ‘incidental’ chest radiograph (risking VOMIT syndrome, see Airwaves passim), and a complete opacity of the hemithorax was found (what happened to good, old-fashioned physical examination?). The cause went back 60 years—turn to Images in Thorax (pp 1124) and see if you would have made the diagnosis?

Christmas crackers (3)—bone up on the subject

This 80-year-old had a chronically discharging chest wall sinus. Look—what is going on—before you leap into action, and above all before you turn to page 1120.

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