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Correspondence to Dr James H Hull, Respiratory Medicine, Royal Brompton Hospital, London, UK; j.hull@rbht.nhs.uk Introduction This British Thoracic Society (BTS) Clinical Statement addresses the diagnosis, evaluation and management of respiratory problems in athletic individuals. [...]it is estimated that at least one in four individuals report troublesome exercise-related respiratory issues, such as breathlessness, cough and/or wheeze.1 Moreover, in competitive athletes, asthma is the most prevalent medical condition and encountered in approximately a quarter of those partaking in endurance sport.2 3 Although athletic individuals can develop any cardiorespiratory illness and thus general clinical guideline documents are broadly applicable, studies over the past three decades have highlighted issues that are particularly relevant when assessing respiratory problems in athletic individuals or in certain sporting scenarios. Scope The purpose of this document was to provide concise and pragmatic guidance to help clinicians from all aspects of the multidisciplinary team (ie, including doctors, physiotherapists, speech and language therapists, pharmacists, physiologists, psychologists and specialist nurses), in both primary and secondary care settings, in assessing and managing respiratory problems in athletic individuals. A thorough history should characterise the precise nature of exercise-related clinical features (eg, breathlessness and wheeze) and their relationship with exercise intensity and recovery.

NUT midline carcinoma (NMC) is a rare and aggressive malignant epithelial tumor defined by rearrangement of the NUT gene on chromosome 15. In two thirds of cases, NUT is involved in a balanced translocation with BDR4 on chromosome 19, while in the remaining cases, NUT is rearranged with variant fusion partners such as BRD3. These undifferentiated tumors primarily affect midline structures, usually in the upper aerodigestive tract and mediastinum. Most reported cases have followed a rapidly lethal clinical course. We report the clinical and pathological findings of NMC in the youngest patients identified so far. The 1st case involves a newborn who presented with a supraorbital mass and extensive multiorgan involvement, including the spine, lungs, liver, pancreas, adrenal glands, and subcutaneous tissue. The 2nd patient was a 2-year-old male with an abdominal mass involving the liver and pancreas with pulmonary metastasis. Histopathological analysis of both tumors showed undifferentiated malignant neoplasms, and immunohistochemistry showed positivity for epithelial markers. Both tumors demonstrated t(15;19), and immunohistochemistry with NUT monoclonal antibodies and fluorescent in situ hybridization confirmed NUT rearrangement. The patients died from disease at 1 and 2 months postpresentation. Thus far, 25 cases have been reported, including our 2 current cases. Presentation ages range from 0 to 78 years (mean, 23 years). Herein, we report the 2 youngest reported cases of NMC, including the 1st congenital case and the 1st case arising within the liver/pancreas. Increased awareness and further molecular studies are required for a better understanding of NMC pathobiology and improved therapeutic outcomes.

Alliances are the organizations of the future. This article builds on the lessons from industry identifying important areas requiring definition and basic understanding of alliance structure, process, and outcome in health care services.

'The ambiguous status of Kipling's poetry', observes Jan Montefiore in her 2007 critical study Rudyard Kipling, 'is aptly summed up by Dan Jacobson's exasperated tribute to \"Kipling, a poet I cannot abide yet cannot stop reading\".' This sentence might stand as an epigraph for any discussion of Kipling's poetry.Jacobson's remark was made in the Times Literary Supplement in 2005. A century earlier in 1904, a cartoon by Max Beerbohm was fuelled by a similar combination of extremes. (This was in the immediate aftermath of the Boer War, during which Kipling had 'come out' as the undisputed bard of empire and literary spokesperson for imperial values.) In the cartoon, a diminutive, check-suited Kipling, kicking up his heels and blowing on a toy trumpet, hangs on the arm of a tall, languid Britannia. The two have swapped hats: he wears her war helmet, she his bowler. She leans away, seemingly unimpressed by his pipsqueak imperial trumpetings. The caption, mimicking the cockney idiom of his soldier ballads, reads: 'Mr Rudyard Kipling takes a bloomin' day aht on the blasted 'eath, along with Britannia, 'is gurl.' Only someone well versed in Kipling's work could have put the knife in so wittily.

Renal cell carcinoma is histologically heterogeneous and can be considered as a group of closely related but distinct tumour types that differ in histopathology and genetic findings. In most cases renal tumours occur sporadically but a minority occur in individuals with an inherited predisposition to kidney cancer and, sometimes, other tumours. Knowledge of the molecular basis of inherited kidney tumours has provided important insights into the key cellular pathways that are disordered in the pathogenesis of kidney cancer. Here we review the relationship between aetiology, histopathology and molecular characteristics of differing subtypes of renal cell carcinoma.

In an increasingly turbulent environment, companies around the world are turning to alliances as cooperative, interorganizational mechanisms for adaptation. The development and operation of alliances in industry and their applicability to health care are discussed. Alliances arise out of mutual need and a willingness between and among organizations to share risks and costs, to share knowledge and capabilities, and to take advantage of interdependencies to reach common objectives. Alliances in health care function in a larger environment, and that larger environment is likely to influence the development and performance of alliances. The 2 general types of alliances in health care are the lateral or services alliances and the integrative alliances. The future will demand greater insight in the development and operation of alliances in health care.

The importance of small business in the US economy suggests that an understanding of why firms fail is crucial to the stability and health of the economy. The focus of a study is limited to a single industry within one region of the country. The study examined perceived causes of small business failure in the apparel and accessory retailing industry. The study found that perceived failure factors of discontinued small business apparel and accessory retailers clustered in 4 areas: poor managerial functions, capital management, competitive environment, and growth and expansion. While the results show that apparel and accessory small business failures are a result of poor performance and inefficiencies in the 4 areas, neither the factors nor the variables within each factor should be viewed as being independent.

This article assesses the extent to which managed competition could be successful in rural areas. Using 1990 Medicare hospital patient origin data, over 8 million rural residents were found to live in areas potentially without provider choice. Almost all of these areas were served by providers who compete for other segments of their market. Restricting use of out-of-State providers would severely limit opportunities for choice. These findings suggest that most residents of rural States would receive cost benefits from a managed competition system if purchasing alliances are carefully defined, but consideration should be given to boundary issues when forming alliances.