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Though deliberately moved back to mid- autumn to avoid the blistering July heat, the Mexico City Olympics could only be described as gold-medal-sultry. Add to this, the altitude, advantageous only for the short sprints where the reduced air resistance gave an edge. In the longer events, the lactic acid build-up proved such a hindrance that any hopes of records were quickly banished. The men’s high jump final was expected to be (as usual) a contest between the best of the straddlers, the time- honoured technique requiring a 180 degree turn around the time the bar was crossed. Ungainly but effective would be a fair description. The unheralded Dick Fosbury arrived quietly behind the scenes for the competition. Though his completely novel technique had crossed the athletics community’s radar, no one took him seriously. He did, though. He had spent years of working on, reimagining and refining his style, the ‘flop’, first humoured by and then encouraged by his coaches. Outside his inner circle, this was simply a 5-minute phenomenon: one for the annals of ‘quirky sporting moments’ than revolution. Wrong: spectacularly wrong. One by one his straddling counterparts, hit, missed and failed to match his peerless leaps. The rostrum was his. The new technique was embraced. The athletics world changed – as a result of his guts and imagination – forever.
We’ve published data in the recent past about the use of adjunctive pulsus paradoxus (PP) estimation in acute asthma as a severity predictor.1 David Wertheim and colleagues in Brighton, develop this concept by testing a standard pulse oximeter (enhanced by adapted software) in measuring both (the notoriously observer dependent) respiratory rate and degree of PP against the yardstick, plethysmography. Aside from a modest degree of artefact, the tool performed well both technically and predictively, a step forward in refining what is usually a crude barometer of severity: oxygen saturation, heart rate and gut feeling. We know that illness scores including PEWS (you’ve all read the eye-opening EPOCH trial) are at best vague approximations and, on a good day, only modest predictors of outcome. This refinement, therefore, is welcome news. See page 1083
Same aura: better selection
As someone who’s had more than one stroke resembling episode related to migraine, I feel I could be a little bit more adventurous in the advice I give children with the same problem. I knew of some alternatives to the bread-and-butter topiramate, beta blocker, pizotifen approach but, Ne Ron Loh and colleagues’ review article completely (re)opened my eyes. Though many examples are still adult only tested and the placebo effect a source of type two error but, there is a whole new world out there, complete, as one would expect with its own monoclonal antibody treatment. See page 1067
You know the drill: an unremarkable Wednesday afternoon general clinic winds to a close, soft drizzle smearing the windowpanes. The tailender (who for once shows up), a 15-year-old asthmatic seen as often in ED as in outpatients who has garnered a reputation as a habitual non-complier, the aroma of her coat, pointing to triggers she so far has bashfully denied. Just before she arrives, the ADC Online First mail reaches you. The study by Wen-Yi Lie and colleagues in Zhejiang, China catches the corner of your peripheral vision. Her bus is running late – you have time to read it before she arrives – your curiosity is aroused, gusto follows. This systematic review has to be the final word in the value of asthma education and outcome, interventions, both individually and pooled, consistently in the same, protective direction, effect sizes for emergency department visits, hospitalisations, outpatient visits all in the pooled OR 0.4–0.6 region. Fired by newfound energy, you spend a full hour with A, re-introduce her to the asthma nurse, show the smoking video and data on e-cigarettes, teach her to take her own peak flows, take an exhaled NO and check her eosinophil count, give her a tailored exercise programme and check her inhaler technique. For the first time, she listens and assimilates. See page 1100
Just a matter of time
It wasn’t that long ago, that standard treatment for immune thrombocytopaenic purpura (ITP) involved 1 to 2 weeks of inpatient bedrest, high dose oral steroids and, often, platelet transfusion. In short, a package of misery and adrenal suppression. Sometime around the turn of the millennium, common sense regained a foothold, the ‘less is more’ aphorism, popular at the time, a good fit. Suddenly, it seemed perfectly reasonable to discharge a child with close-to- zero platelets on the count, provided they were well, rather than inflict a hospital jail sentence on her. In the intervening years, selective IVIG treatment became popular, to some extent riding the fall from favour of its steroid predecessor. Lianna Edwards and colleagues in Manchester, assess the predictive value of long duration epistaxis for severe bleeding in the long-term using the longstanding national ITP database. Only those who had bled for more than 30 min, were at greater risk for chronic severe bleeding or falls in haemoglobin. Maybe not, surprising, but, even the expected needs to be shown once and, as a masterpiece in restraint, exemplary. See page 1117
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.