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[Editorial] COVID-19: the intersection of education and health

Sab, 23/01/2021 - 00:00
What lessons does the COVID-19 syndemic offer when considering the convergence between health and education? The International Day of Education, on Jan 24, provides an opportunity to reflect on the weaknesses of the education system before COVID-19, and on the impact of school closures and education disruptions on children and adolescents. Since March, 2020, more than 1·5 billion students worldwide—an unprecedented number—have been affected by school or university closures. The implications of these closures are enormous.

[Comment] A source of hope for platinum-resistant ovarian cancer?

Sab, 23/01/2021 - 00:00
Effective and well tolerated treatment for platinum-resistant ovarian cancer remains a substantial unmet need. Despite the introduction of targeted and immunological therapies for its management, platinum-based chemotherapy with carboplatin or cisplatin remains the backbone of treatment. Although up to 25% of women with ovarian cancer have innately (or primary) platinum-refractory disease, most patients are sensitive to front-line platinum therapy but will unfortunately develop recurrence and acquire progressive resistance over time.

[Comment] Metabolic surgery versus conventional therapy in type 2 diabetes

Sab, 23/01/2021 - 00:00
In The Lancet, Geltrude Mingrone and colleagues report their trial in which they randomly assigned patients to metabolic surgery or medical therapy for type 2 diabetes.1 60 white European patients (32 [53%] women) were evaluated 10 years after Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion (BPD), or conventional medical therapy. The primary endpoint was type 2 diabetes remission, defined as glycated haemoglobin (HbA1c) less than 6·5% plus fasting glucose less than 5·55 mmol/L without medication.

[Comment] Precision medicine in rheumatology: are we getting closer?

Sab, 23/01/2021 - 00:00
The overarching aim of precision (also referred to as personalised) medicine is to identify the best possible management approach for an individual with a certain disease. The main prerequisite for such an approach is the identification of characteristics linked to a favourable outcome of a certain treatment. The characteristics of interests might be clinical or molecular biomarkers or identified through imaging, allowing for stratification of patients and prediction of response. The size of the strata might range from big subgroups covering a substantial proportion of patients to individual patients.

[Comment] Offline: The danger of unreliable narrators

Sab, 23/01/2021 - 00:00
“We can see the way out”, ran the headline in last week's Sunday Express. Governments across Europe are increasingly optimistic. Ministers are looking visibly more relaxed. US President Joe Biden is now in the White House and he is serious about science, unlike his predecessor. Vaccines are being delivered at scale. Claims are now being confidently made that all adults in the UK will have been vaccinated by June or September, 2021. Although other countries have been slower to start, they will catch up.

[World Report] India begins COVID-19 vaccination amid trial allegations

Sab, 23/01/2021 - 00:00
Trial participants in Bhopal say that they could not read consent forms and have not been able to report adverse events. Anoo Bhuyan reports from Bhopal.

[World Report] CEPI criticised for lack of transparency

Sab, 23/01/2021 - 00:00
The publicly funded epidemic response agency CEPI has been criticised for the lack of transparency in its grant agreements with COVID-19 vaccine developers. Ann Danaiya Usher reports.

[World Report] South Africa responds to new SARS-CoV-2 variant

Sab, 23/01/2021 - 00:00
Land borders have been closed and restrictions continue as a new variant stresses the health system. Munyaradzi Makoni reports.

[Perspectives] Poverty and love

Sab, 23/01/2021 - 00:00
“Whit a funny wee bastard ye are.” Shuggie Bain is often subjected to such pointed observation: he is an outsider, jutting against the grain of his surroundings, even as he tries, heartbreakingly hard, to fit in. He is the child of Agnes and Shug Bain. Agnes is a glamorous, proud woman who can be funny, charming, and beautiful; and she is an alcoholic. Shug is a violent, belligerent womaniser who rapes and beats Agnes regularly. Agnes is trapped in her relationships—as is Shuggie. By the time Agnes dies, sinking, drunk in a chair “like a melted candle”, Shuggie is starving, the benefits of money having gone on alcohol.

[Perspectives] Transformative experiences and A Young Doctor's Notebook

Sab, 23/01/2021 - 00:00
Can the decision to become a physician ever be a truly rational choice? According to philosopher L A Paul, the answer is more complicated than it may seem. In her book Transformative Experience, Paul argues that when we make consequential decisions, we are limited by our inability to know what that experience will be like in advance. For Paul, a transformative experience is one that has this characteristic and is also likely to radically reshape our future point of view. The decision to undergo a transformative experience amounts to a philosopher's dilemma, because the person choosing the experience and the person who will emerge on the other side of it are not one and the same.

[Perspectives] COVID duets

Sab, 23/01/2021 - 00:00
It was a Saturday afternoon in March, 2020. COVID-19 cases had started to trickle into our hospital, but I had a different sort of acute case on my hands. Thanks to the sweltering heat in New York City apartments, two seams on my cello had splayed open. If I didn't get them sutured, stat, the entire instrument could eviscerate.

[Obituary] Suhaila Siddiq

Sab, 23/01/2021 - 00:00
Afghan Public Health Minister, surgeon, and lieutenant general. Born in Kabul, Afghanistan, she died there on Dec 4, 2020, after reportedly contracting COVID-19. She was believed to be in her early 80s.

[Correspondence] Reaffirming health and safety precautionary principles for COVID-19 in the UK

Sab, 23/01/2021 - 00:00
In their case for a sustainable UK strategy for COVID-19, Deepti Gurdasani and colleagues1 recommend “restoration of an adequate health and safety inspectorate”. We do not believe that the UK Health and Safety Executive (HSE) should, like Public Health England, be made a scapegoat for lack of ministerial direction2 but rather that the HSE should be restored the wherewithal to fulfil its mandate.

[Correspondence] Considering dose in pharmacological therapies for heart failure

Sab, 23/01/2021 - 00:00
Muthiah Vaduganathan and colleagues'1 analysis was insightful in contextualising the potential benefits observed in trials for the medical treatment of heart failure with reduced ejection fraction (HFrEF). A noted shortcoming of the analysis was not accounting for the role of the dose of disease-modifying medication in the disease course of HFrEF. Vaduganathan and colleagues1 correctly identified the CHAMP-HF,2 QUALIFY,3 and CHECK-HF4 registries as evidence of the underuse of mineralocorticoid receptor antagonists (MRAs) and angiotensin receptor neprilysin inhibitors, but they also attributed the stagnation in HFrEF mortality to this underuse.

[Correspondence] Considering dose in pharmacological therapies for heart failure – Authors' reply

Sab, 23/01/2021 - 00:00
The contemporary trials in heart failure with reduced ejection fraction (HFrEF) included in our analysis1 tested a strategy of titrating therapies to a target dose (as tolerated) and many participants did not reach this target. Among those who did, a subset of participants required dose reduction (or even temporary or permanent discontinuation) during the trials because of issues related to haemodynamics, kidney function, electrolytes, symptoms, or intervening clinical events.

[Correspondence] Neuropathology associated with SARS-CoV-2 infection

Sab, 23/01/2021 - 00:00
We read with interest the Correspondence by Claus Hann von Weyhern and colleagues,1 in which they report pronounced CNS involvement with pan-encephalitis in six patients with COVID-19 who were on invasive ventilation, some of whom were also receiving extracorporeal membrane oxygenation. Of these, three patients were further reported to have “massive intracranial” and “diffuse petechial haemorrhage in the entire brain”.1 These changes are then attributed directly or indirectly to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

[Correspondence] Neuropathology associated with SARS-CoV-2 infection

Sab, 23/01/2021 - 00:00
We believe that many of the key findings described in the Correspondence by Claus Hann von Weyhern and colleagues1 should be interpreted differently. The exact nature of CNS involvement in COVID-19 is not only of fundamental importance for our understanding of the disease, but might have substantial consequences in directing clinical efforts to achieve better patient management in the future. Thus, observations about CNS inflammation as described by von Weyhern and colleagues will cause a great stir among biomedical scientists and clinicians if proven to be correct.

[Correspondence] Neuropathology associated with SARS-CoV-2 infection

Sab, 23/01/2021 - 00:00
Claus Hann von Weyhern and colleagues1 describe autopsy findings of six patients who died of COVID-19. Better understanding of the central effects of COVID-19 is crucial, and we read with great interest their findings that included pan-encephalitis and meningitis in all six patients, regardless of whether cause of death was due to cardiorespiratory failure, pulmonary embolism, or intracranial haemorrhage. However, the images provided in the appendix of the Correspondence1 do not clearly show meningitis or encephalitis.

[Correspondence] Neuropathology associated with SARS-CoV-2 infection – Authors' reply

Sab, 23/01/2021 - 00:00
We welcome the opportunity to respond to the comments about our Correspondence.1 To increase the availability of data, we reported our findings, which were produced by a team that included an experienced neuropathologist and was subjected to the The Lancet's peer-review process. The three responses are similar as they all challenge our interpretation of the findings presented. Striking is the fact that the three responses disagree among themselves, with each offering yet another interpretation.

[Correspondence] Causal ordering among risk factors in the PURE study

Sab, 23/01/2021 - 00:00
Salim Yusuf and colleagues'1 findings on the heterogeneity of risk factors associated with cardiovascular disease in low-income, middle-income, and high-income countries are important. However, hazard ratios (HRs) and population-attributable fractions (PAFs) need to account for causal ordering among risk factors.2,3 PAFs calculated by use of HRs from regression models that include all risk factors simultaneously violate the principle that causation occurs in sequential steps. The calculated HR is what is left over after adjusting for risk factors that are, at least partly, on the causal pathway leading to cardiovascular disease.