Idiopathic pulmonary fibrosis is a chronic, progressive fibrotic disease with a poor prognosis. The balance between transforming growth factor β1 and bone morphogenetic protein (BMP) signaling plays an important role in tissue homeostasis, and alterations can result in pulmonary fibrosis. We hypothesized that multiple BMP accessory proteins may be responsible for maintaining this balance in the lung. Using the bleomycin mouse model for fibrosis, we examined an array of BMP accessory proteins for changes in mRNA expression. We report significant increases in mRNA expression of gremlin 1, noggin, follistatin, and follistatin-like 1 (Fstl1), and significant decreases in mRNA expression of chordin, kielin/chordin-like protein, nephroblastoma overexpressed gene, and BMP and activin membrane-bound inhibitor (BAMBI). Protein expression studies demonstrated increased levels of noggin, BAMBI, and FSTL1 in the lungs of bleomycin-treated mice and in the lungs of idiopathic pulmonary fibrosis patients. Furthermore, we demonstrated that transforming growth factor β stimulation resulted in increased expression of noggin, BAMBI, and FSTL1 in human small airway epithelial cells. These results provide the first evidence that multiple BMP accessory proteins are altered in fibrosis and may play a role in promoting fibrotic injury.

Sinead M Walsh, PhD, Gerard T Flaherty, MD; Sleep apnoea: no obstruction to international travel, Journal of Travel Medicine, , taaa078, https://doi.org/10.109

Summary: Parasomnias are undesirable events that occur during sleep. They can be classified into rapid eye movement parasomnias and non‐rapid eye movement parasomnias. Those who experience parasomnias may be anxious about travel for many reasons, including the occurrence of unwanted events during the trip, increased exposure to environmental trigger factors, and the propensity for harm to occur due to unfamiliar surroundings while travelling. There is a paucity of literature examining this area. This review summarizes the relevant literature and the clinical experience of the authors to compile clinical practice recommendations. The clinical features of parasomnias and how they relate to trans‐meridian and long‐distance travel are described. Triggers for non‐rapid eye movement parasomnias, particularly the use of sedative hypnotic drugs, alcohol, drug withdrawal, sleep deprivation, emotional stress and environmental stimulations, are described. Management of parasomnias whilst travelling is reviewed, with a particular focus on trigger minimalization. The role for clonazepam and melatonin is outlined. At the pre‐travel health consultation, the physician is strongly advised to screen the traveller for co‐morbid sleep conditions, which exacerbate parasomnias. Areas for further research are explored, including the extent to which these sleep disorders impact on the travel experience.

The letter provides practical tips for developing, implementing and scaling an effective simulation‑based education programme at a large scale for undergraduate medical students. Using time-lapsed scenarios and the pause-discuss method of debrief are some of the useful tips that are discussed further in the letter.

Asthma is a very prevalent condition. A significant proportion of patients with asthma will engage in travel for work or leisure purposes. Patients may be fearful of travel, especially during the current COVID-19 global pandemic. However, there are health benefits to be obtained, including leaving an area of high air pollution and travelling to an area of lower air pollution, travelling to high altitude, the beneficial effects of a low trigger environment and the psychological benefits associated with travel. Travel can be associated with improved diet and increased vitamin D exposure. Caution should be taken with alcohol consumption as it may worsen asthma. Whilst bariatric surgery has been shown to improve asthma symptoms and control, there are dangers associated with bariatric surgery tourism that the traveller should be made aware of. Travellers with asthma may experience jet lag and a worsening in their symptoms. Caution is required around exogenous melatonin use. Optimal asthma control pre-travel is essential. The destination should be carefully considered, in terms of air pollution, altitude and possible environmental triggers. Pre-travel, written asthma management plans should be reviewed and updated if necessary. Patients should carry more asthma medications than they think is necessary, including oral corticosteroids and a pressurised metered dose inhaler via spacer. Travellers with asthma should have a self-management plan in the event of exacerbations occurring during travel.