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[Editorial] Modernising the NHS: leading the way with diabetes

10 ore 26 min ago
The release of the National Health Service (NHS) Long Term Plan on Jan 7, which provides an ambitious roadmap for transforming health care in the UK over the next decade, has been met with both optimism and scepticism. The plan proposes to expand patient access to services through use of digital general practitioner (GP) consultations, integration of primary care services with community and social care, strengthening prevention programmes, and addressing widening health and social inequities within the UK.

[Comment] Moving to a higher echelon in CD30-positive T-cell lymphoma

10 ore 26 min ago
Peripheral T-cell lymphoma is a rare and heterogeneous subgroup of non-Hodgkin lymphoma, comprising approximately 10–15% of all cases.1 Although there is no consensus on the optimal front-line therapy, cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) has been widely adopted as the default reference regimen, with autologous stem cell transplantation consolidation performed in eligible patients. However, with the exception of younger low-risk International Prognostic Index patients with anaplastic lymphoma kinase-positive systemic anaplastic large cell lymphoma,2 outcomes in peripheral T-cell lymphoma are suboptimal, with a meta-analysis3 showing a 5-year overall survival of just 38·5% with CHOP or CHOP-like regimens.

[Comment] Harnessing synergies at the interface of public health and the security sector

10 ore 26 min ago
In response to epidemic outbreaks of Ebola virus disease in 2014 and Zika virus in 2015, militaries and public security agencies mobilised to bolster public health interventions in partnership with host governments, civil society, and humanitarian actors.1,2 Conversely, military action, authoritarian enforcement, and criminal justice systems have fuelled public health crises—eg, military operations have affected cholera outbreaks in Yemen3 and incarceration exacerbates transmission of tuberculosis.

[Comment] Real-world studies no substitute for RCTs in establishing efficacy

10 ore 26 min ago
We live in the real world, so it is reasonable to expect that data collected from the real world should help identify effective therapies. Indeed, rapid increases in the availability of registries, electronic health records, and insurance claims, and the ability to access, process, link, and analyse data from these sources at fairly low cost lend support for calls to replace randomised controlled trials (RCTs) with so-called real-world studies to establish the efficacy of a therapy,1,2 particularly for common serious diseases with abundant, easily collected data such as diabetes.

[Comment] With thanks to The Lancet's reviewers in 2018

10 ore 26 min ago
The trust that authors place in editors, and editors in reviewers, creates a precious opportunity to strengthen manuscripts and advance science. The Lancet values deeply the relationships with our peer reviewers, and never, not even in our requests for overdue reviews, do we take your time and contributions for granted. Therefore, to the almost 2000 reviewers (appendix) who joined a conversation with The Lancet in 2018, we say a heart-felt thank you.

[Comment] Offline: Our common language

10 ore 26 min ago
Primo Levi was born a century ago on July 31, 1919, in Turin, Italy. His most famous book is The Periodic Table, a collection of allusive reflections about his life, including his imprisonment in Auschwitz, organised into 21 chapters named according to a particular chemical element. By a strange coincidence, 2019 is also the 150th anniversary of the first publication of the periodic table by Russian chemist Dimitri Ivanovich Mendeleev (1834–1907). The UN has designated 2019 the International Year of the Periodic Table of Chemical Elements (a launch event will be held at the headquarters of UNESCO in Paris on Jan 29).

[World Report] Health-care inequity a challenge for Brazil's new Government

10 ore 26 min ago
Jair Bolsonaro takes office as many health challenges face the country. Barbara Fraser, in Lima, and Lise Alves, in São Paulo, report.

[World Report] Syrian refugees hit by heavy rains

10 ore 26 min ago
Harsh weather worsens an already dire situation in Lebanon for refugees from the Syrian conflict. Sharmila Devi reports.

[Perspectives] Drawing on the NHS

10 ore 26 min ago
I grew up accompanied with the Bunty. The stories were funny, challenging, always interesting. The hard work of this child's reading was made easier by the drawings that explained meanings rapidly and non-verbally. Drawn communication can be direct and powerful. I recall Harry Horse, a political cartoonist, explaining that he could not say that a political leader was wicked, vain, and cruel but could draw them in a way that left little doubt as to his opinion. The cartoons of Private Eye can pithily capture what would otherwise have taken a paragraph or two, and be neither as memorable nor funny.

[Perspectives] Cholera

10 ore 26 min ago
From 1817 onwards European governments, struggling in the aftermath of the Napoleonic Wars, watched with growing horror as a new and terrible disease left its historical heartland in south Asia and began to move west. Cholera, in the words of an editorial in the Quarterly Review, was “one of the most terrible pestilences which have ever devastated the earth”. Like malaria or HIV/AIDS, cholera has an inescapably global history: seven subsequent pandemics have provoked revolutions in public health, and an entirely new vision of global medicine in an age of interconnection.

[Perspectives] Leana Wen: President of Planned Parenthood

10 ore 26 min ago
After Leana Wen's family immigrated to the USA when she was 8 years old, her mother went to a Planned Parenthood clinic in California. Wen and her sister were also patients there. In November, 2018, Wen became President of the Planned Parenthood Federation of America, an organisation that cared for 2·4 million people last year at more than 600 health centres across the USA. Wen is only the second physician to lead Planned Parenthood since it was founded in 1916. At Planned Parenthood clinics, patients can receive services, including birth control, vaccinations, cancer screenings, testing and treatment for sexually transmitted diseases, transgender health services, and safe abortions.

[Perspectives] What's the story? A guide for the clinician writer

10 ore 26 min ago
One Monday afternoon not long ago my daughter and I sat in my car outside a train station, chatting. We'd had a lovely weekend visit—her first since getting married and starting a new career in another city a few months earlier—and we wanted to enjoy each other's company right until her train was scheduled to depart. I gazed out the windscreen looking at nothing in particular, happy that my daughter was happy, basking in a moment at once ordinary and perfect.

[Obituary] Arti Hurria

10 ore 26 min ago
Leader in geriatric oncology. Born in Canarsie, Brooklyn, NY, USA, on Sept 7, 1970, she died in California, USA, on Nov 7, 2018, of injuries from a traffic accident, aged 48 years.

[Correspondence] Skeletal fluorosis in a resettled refugee from Kakuma refugee camp

10 ore 26 min ago
“I suspected some contamination of the water of the much-frequented street pump in Broad Street, near the end of Cambridge Street”, said John Snow, about the contaminated water pump of the cholera outbreak of 1854, in London, UK.1

[Correspondence] Expanding safe waste management to public health systems

10 ore 26 min ago
Media focus on plastic waste, urban air pollution, and the way it affects our environment, health, and communities has been increasing. Environmental pollution has been recognised as a growing public health problem for many years, but the size of the problem and the urgency of a solution have risen only recently to a higher level of public consciousness. Although the media are effective mobilisers for these issues, they do not articulate who is responsible for leading or assisting solutions. This may be because we are all individually, communally and globally responsible.

[Correspondence] Credibility in published data sources

10 ore 26 min ago
Boerma and colleagues (Aug 18, 2018, p 607)1 do well to raise the issue of reliability and credibility of computed mortality statistics.1 However, this is not just a problem for lower-income countries. The Models of Child Health Appraised Project,2 funded by the EU Horizon 2020 programme, is charged with assessing the primary health-care systems for children in the 30 EU and European Economic Area countries.2 We have found worrying discrepancies between official data sources on items supposedly as unequivocal as child death.

[Correspondence] The costs of drug prescriptions for diabetes in the NHS

10 ore 26 min ago
The costs to the UK's National Health Service (NHS) for treating diabetes took prominence in the media in November, 2018, as the NHS bill for blood glucose-lowering drugs for the first time surpassed £1 billion.1 Almost one in 20 general practitioners' (GP) prescriptions are now for diabetes treatment; the largest increase was for type 2 diabetes treatment. Among the questions raised by the public is whether this money is actually spent wisely, given the appearance of new classes of drugs over the past decade still mostly on patent—and, therefore, more expensive than older generic preparations.

[Correspondence] The MANAGE trial

10 ore 26 min ago
We appreciate the efforts by P J Devereaux and colleagues (June 9, p 2325)1 in completing a difficult interventional study with patients who have postoperative increase in troponin. As discussed in the accompanying Comment,2 several issues make the findings less compelling. However, in addition to low recruitment rates and post-hoc changes in the outcomes measures, we feel other important concerns should be emphasised.

[Correspondence] The MANAGE trial

10 ore 26 min ago
I congratulate P J Devereaux and colleagues1 for completing the first large randomised trial aiming to improve outcomes for patients with myocardial injury after non-cardiac surgery (MINS). However, several questions need to be addressed before the adoption of the recommended strategy. First, comparison of an anticoagulant such as dabigatran with placebo is not as useful as a comparison with the current recommended management strategy for MINS, which is aspirin and a statin.2 Second, to group venous and arterial thrombotic events into the same group and to manage them all with dabigatran goes against established myocardial injury management strategies, such as low molecular weight heparins for venous events and dual antiplatelet therapy for arterial events.

[Correspondence] The MANAGE trial – Authors' reply

10 ore 26 min ago
Wilton A van Klei and colleagues erroneously state that there were post-hoc changes in the outcomes in our Article.1 The only changes that were made in the outcomes were done during the trial, without knowledge of the trial results. We added amputation and symptomatic proximal deep-vein thrombosis to the primary composite outcome to enhance trial power, and because the COMPASS trial2 showed that an oral direct anticoagulant reduced the risk of these outcomes in patients with vascular disease. Dabigatran not only showed a significant reduction in our primary outcome of a major vascular complication (hazard ratio [HR] 0·72, 95% CI 0·55–0·93), but also significantly reduced the original composite outcome (ie, vascular mortality and non-fatal myocardial infarction, stroke, peripheral arterial thrombosis, and symptomatic pulmonary embolism; 0·74, 0·56–0·99).