Multicenter Randomized Controlled Trial of Withdrawal of Inhaled Corticosteroids in Cystic Fibrosis

Rationale: Lung inflammation and injury is critical in cystic fibrosis. An ideal antiinflammatory agent has not been identified but inhaled corticosteroids are widely used despite lack of evidence.

Objectives: To test the safety of withdrawal of inhaled corticosteroids with the hypothesis this would not be associated with an earlier onset of acute chest exacerbations.

Methods: Multicenter randomized double-blind placebo-controlled trial in 18 pediatric and adult UK centers. Eligibility criteria included age > 6.0 yr, FEV1 ? 40% predicted, and corticosteroid use > 3 mo. During the 2-mo run-in period, all patients received fluticasone; they then took either fluticasone or placebo for 6 mo.

Measurements and Main Results: Fluticasone group: n = 84, median age 14.6 yr, mean (SD) FEV1 76% (18); placebo group: n = 87, median age 15.8 yr, mean (SD) FEV1 76% (18). There was no difference in time to first exacerbation (primary outcome) with hazard ratio (95% confidence interval) of 1.07 (0.68 to 1.70) for fluticasone versus placebo. There was no effect of age, atopy, corticosteroid dose, FEV1, or Pseudomonas aeruginosa status. There was no change in lung function or differences in antibiotic or rescue bronchodilator use. Fewer patients in the fluticasone group withdrew from the study due to lung-related adverse events (9 vs. 15%); with a relative risk (95% confidence interval) of 0.59 (0.23–1.48) fluticasone versus placebo.

Conclusions: In this study population (applicable to 40% of patients with cystic fibrosis in the UK), it appears safe to consider stopping inhaled corticosteroids. Potential advantages will be to reduce the drug burden on patients, reduce adverse effects, and make financial savings.

New Ways of Looking at the State Apparatus and the State Archive in Nineteenth Century Ireland: Curiosities from that Phonetic Museum - Royal Irish Constabulary Reports and their Political Uses, 1879-91

This essay seeks to contextualise the intelligence work of the Royal Irish Constabulary, particularly in the 1880s, in terms of the wider British and imperial practice and, as a corollary, to reflect upon aspects of the structure of the state apparatus and the state archive in Ireland since the Union. The author contrasts Irish and British police and bureaucratic work and suggests parallels between Ireland and other imperial locations, especially India. This paper also defines the narrowly political, indeed partisan, uses to which this intelligence was put, particularly during the Special Commission of 1888 on 'Parnellism and crime', when governmentheld police records were made available to counsel for The Times. By reflecting on the structure of the state apparatus and its use in this instance, the author aims to further the debate on the governance of nineteenth-century Ireland and to explore issues of colonial identity and practice. The line of argument proposed in this essay is prefigured in Margaret O'Callaghan, British high politics and a nationalist Ireland: criminality, land and the law under Forster and Balfour (Cork, 199