Colonisation is a fundamental determinant of Indigenous peoples' health. Indigenous is a term defined by dislocation, and the effects of that displacement are felt by Indigenous peoples around the world. Aug 9, International Day of the World's Indigenous Peoples, is a chance to look at the continuing effects of territorial removal, the destruction of people, culture, and languages, and the lack of self-determination (the right to determine one's own social, cultural, and economic development), and their impact on Indigenous peoples' health.

Whether surgery or cast immobilisation offers the best outcomes for acute scaphoid fractures has been debated for almost two decades. Since 2001, numerous small randomised trials1 have been done, but none have shown a clear advantage of one treatment over the other. Historically, it was considered that an extended period of cast immobilisation was necessary to achieve union of the scaphoid fracture, and even then, a high proportion of non-unions were to be expected.2 This expectation fuelled enthusiasm for surgery, as proponents cited a higher fracture union success rate, more rapid recovery, and faster time to union when compared with cast immobilisation.

The dual epidemics of tuberculosis and HIV have had a substantial toll on health outcomes, service delivery, and economies in many countries. Additionally, diagnosis of tuberculosis remains a challenge, especially with HIV infection, where the commonly used smears are of limited benefit; compounded by limitations of detecting drug-resistant tuberculosis.1

At least seven doctors and two pharmacists have been detained for criticising the Egyptian Government's approach to the pandemic and working conditions. Sharmila Devi reports.

Mainly resulting from cookware and recycled batteries, lead exposure, even at low concentrations, can result in cognitive and neurological problems. Talha Burki reports.

Could there be a stranger time for a book about social connections than during a period when we have seen the most dramatic global effort ever to keep people away from one another? In the first half of 2020, the world was in the grip of fear about the COVID-19 pandemic. Many countries instituted some form of physical distancing for their whole populations to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Emerging data from this period showed that reports of loneliness and attendant depression and anxiety increased compared with 2019.

All doctors have responsibilities to protect and promote health. These responsibilities lie at the heart of medicine, providing its moral foundation. Some doctors meet their responsibilities treating individuals with diseases, some teach or do research, while others safeguard or promote the health of populations. These responsibilities arise from the social role of doctors that is enshrined—but not always clearly delineated—in social, legal, ethical, and professional standards and norms. The health and wellbeing of the patient is, according to various codes, the pre-eminent responsibility of medicine, and it is for patient care that doctors are primarily held accountable.

Daniel Sessler and colleagues1 compared regional (paravertebral blocks and propofol) with general (sevoflurane and opioid-based analgesia) anaesthesia on breast cancer recurrence in their randomised controlled trial. They concluded that regional anaesthesia did not reduce cancer recurrence after surgery for primary breast cancer compared with general anaesthesia.

We congratulate Daniel Sessler and colleagues1 for completing their large multicentre trial, but we have concerns regarding the methodology and results. The authors report that paravertebral block techniques varied per study site across the 13 hospitals in eight countries. Typically, five levels are blocked with long-acting local anaesthetic and supplementation with sevoflurane was permitted.1

Daniel Sessler and colleagues1 presented the findings from their multicentre, randomised trial that compared the effect of regional anaesthesia (paravertebral block and propofol) with general anaesthesia (sevoflurane) and opioids on breast cancer recurrence and postoperative pain after potentially curative surgery. Regional anaesthesia was reported to be equivalent to general anaesthesia regarding disease recurrence and postoperative pain.1

I thank Masashi Ishikawa and colleagues, Karen Nielsen and colleagues, and Dimitrios Moris and Michael Kontos for their comments on the results of the randomised controlled trial of recurrance of breast cancer after regional or general anaesthesia.1

Recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) denotes a difficult-to-treat patient population. Most of these recurrent tumours are pretreated with chemoradiotherapy, and hence could represent resistant tumours that are clonally selected. Although these pretreated tumours are biologically less likely to respond to chemotherapy than tumours that have not been pretreated, a strong rationale exists for the use of checkpoint inhibitor immunotherapy because the pretreated tumours are likely to harbour a high tumour-mutational burden.

Based on hazard ratio (HR) analyses, Barbara Burtness and colleagues1 reported that pembrolizumab, alone or with chemotherapy, significantly improved overall survival versus cetuximab with chemotherapy. For example, among patients with a programmed cell death ligand 1 combined positive score of 20 or more, the HR comparing the combination of pembrolizumab and chemotherapy with the combination of cetuximab and chemotherapy was 0·60 (95% CI 0·45–0·82). However, the Kaplan-Meier curves for overall survival in figure 2F cross at least once during the study follow-up period, indicating that the assumption of proportional hazards was not met.

We congratulate the investigators of the KEYNOTE-048 trial for having successfully completed this pivotal trial, bringing immune checkpoint inhibitors to the first-line recurrent or metastatic setting of squamous cell carcinoma of the head and neck.1 In a subgroup analysis, no survival benefit was found in patients presenting with local or regional recurrence only, irrespective of the combined positive score (CPS) or assigned immunotherapy arm (monotherapy or combination treatment). We would like to discuss possible implications for clinical practice.

Swaroop Revannasiddaiah and colleagues write about the adverse events that occurred in patients during the KEYNOTE-048 trial.1 Recurrent or metastatic head and neck cancer is morbid and historically associated with short survival; therefore, selection of systemic therapy should incorporate performance status and patient preferences. A phase 3 trial in 1985 showing that cisplatin significantly prolongs survival for recurrent or metastatic head and neck cancer compared with no treatment2 was followed by trials of regimens that yield more objective responses; however, even doublet regimens lead to a median survival of only 7·4 months, or 10·1 months when adding cetuximab.

Chinthrajah RS, Purington N, Andorf S, et al. Sustained outcomes in oral immunotherapy for peanut allergy (POISED study): a large, randomised, double-blind, placebo-controlled, phase 2 study. Lancet 2019; 394: 1437–49—In table 1 of this Article and in the appendix the units for Peanut-specific IgG4 should have been mg/L. These corrections have been made to the online version as of Aug 6, 2020.

I read with interest the Correspondence by Johan Giesecke.1 Applauding the Swedish model, Giesecke1 posits a “relaxed strategy” or the development of a herd immunity as the way forward in dealing with the COVID-19 pandemic. He recommends that the crucial task is not to stop the spread, “which is all but futile, but to concentrate on giving the unfortunate victims optimal care”. Given the drastic adverse economic consequences of the lockdown globally, the advocacy of herd immunity as a way out appears attractive.

We read the Correspondence by Johan Giesecke,1 a senior consultant to the Swedish Public Health Agency, with considerable concern.

Johan Giesecke1 referred to the COVID-19 pandemic as an invisible pandemic, estimating that 25% of the Stockholm population was infected by the end of April, 2020, of which 98–99% are unaware of being infected. On April 1, 2020, the media reported that half of the Swedish population might be infected by the end of April, 2020.2 More conservative estimates suggested that at least one-third of the Stockholm population may be seropositive by mid-May, and later that Stockholm might reach herd immunity by mid-June.

The COVID-19 pandemic is exacting a confronting and extraordinarily visible toll in lives and livelihoods globally. The last occasion where humanity fought a similar calamitous infectious disease threat was the 1918–19 influenza pandemic. There are many lessons from that pandemic that are still relevant. The first pandemic wave did not grant adequate herd immunity and was followed by one or more subsequent waves, with those waves being more deadly than the initial wave.1 Additionally, stringent public health measures flattened the epidemic curve, preserving hospital capacity and saving many lives.