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[Editorial] Australia on fire

Sab, 18/01/2020 - 00:00
28 people dead and rising, tens of thousands forced from their homes, Indigenous communities displaced, up to 1 billion animals dead, and some of the world's most beautiful and unique natural landscapes burned. The sheer scale of Australia's bushfires is hard to comprehend.

[Editorial] Protecting health research in the UK: culture and collaboration

Sab, 18/01/2020 - 00:00
From the discoveries of Fleming and Lister to the more recent work on aromatase inhibitors done by the Royal Marsden Hospital and Institute for Cancer Research, research and health care have had a long and illustrious relationship in the UK. This relationship resulted in many discoveries and innovations that have benefited patients worldwide, and it is also clear that patients have better outcomes when they are managed in research-active settings. However, this symbiotic relationship is under threat, from both an increasing divergence of academia and the National Health Service (NHS), and a worsening research culture.

[Editorial] Trump's steady erosion of health insurance protections

Sab, 18/01/2020 - 00:00
43% of US households report that at least one family member has a pre-existing medical condition, according to a survey released by Gallup on Dec 6, 2019. 49% of Americans (156 million people) receive health insurance through employers, and before the 2010 Affordable Care Act (ACA), a change of situation, such as losing or switching a job, would have allowed insurance companies to decline coverage or potentially make people uninsurable because of chronic health conditions. Although Democrats and Republicans both argue that they support the ACA ban on pre-existing condition denials, in power, Republicans have actively (but so far unsuccessfully) worked to repeal the ACA without providing an alternative.

[Comment] Patients with left main coronary artery disease: stent or surgery?

Sab, 18/01/2020 - 00:00
In The Lancet, Niels Holm and colleagues1 report 5-year results of the NOBLE trial, in which 1201 patients with symptomatic left main coronary artery lesions were randomly assigned to receive percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Median age was 66·2 years (IQR 9·9) in the PCI group and 66·2 (9·4) years in the CABG group; 116 (20%) patients in the PCI group and 140 (24%) in the CABG group were women. As in the initial report,2 the study found no evidence of non-inferiority of PCI compared with surgery in terms of the composite primary endpoint of major adverse cardiac or cerebrovascular events (5-year Kaplan-Meier estimate of 28% [165 events] for PCI and 19% [110 events] for CABG; hazard ratio 1·58 [95% CI 1·24–2·01], exceeding the non-inferiority limit of 1·35), and CABG was even found to be superior in the study population (p=0·0002).

[Comment] A global accounting of sepsis

Sab, 18/01/2020 - 00:00
For the past two decades, attention to sepsis has intensified because of growing recognition that it is one of the most common and lethal conditions we face, whether as a patient, provider, hospital, or public health agency. Until now, we have had an incomplete accounting of the global epidemiology of sepsis, with several reports from high-income countries and relatively few from countries of low and middle income (LMICs). In The Lancet, Kristina Rudd and colleagues1 present an analysis of data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, which is the most comprehensive assessment of the worldwide sepsis burden to date.

[Comment] Femtosecond laser-assisted vs conventional cataract surgery

Sab, 18/01/2020 - 00:00
Cataract surgery is one of the most commonly performed operations. Lasers are used for many applications in ophthalmology; however, their use in cataract surgery is fairly recent. On introduction to clinical practice, laser cataract surgery platforms were marketed as bringing a stepwise improvement in surgical technique and were used as a differentiating factor between many cataract surgery providers. The surgical steps automated in femtosecond laser-assisted cataract surgery (FLACS) are corneal incisions, opening of the crystalline lens capsule (capsulotomy), and crystalline lens fragmentation, with less phacoemulsification (ultrasound) energy subsequently needed to complete lens removal.

[Comment] Rebuilding Sudan's health system: opportunities and challenges

Sab, 18/01/2020 - 00:00
The power-sharing agreement between Sudan's military and opposition groups signed in July, 2019, marked the end of nearly three decades of military dictatorship, and brought genuine hope of a lasting peace. As of January, 2020, negotiations continue between the transitional government and rebel groups, and the path towards permanent civilian rule is uncertain. Meanwhile, the country faces escalating humanitarian catastrophe, with 7·8 million people facing critical problems related to mental and physical wellbeing, including 1·6 million internally displaced people and 1·1 million refugees.

[Comment] Offline: After 2000 years, an answer arrives

Sab, 18/01/2020 - 00:00
The fabric of humanity is unravelling. That is not a 21st-century diagnosis of our collective ills. It was the conclusion drawn by Lucretius, a Roman poet whose epic De Rerum Natura (The Nature of Things) was published in the first century BCE. Divided into six books, Lucretius described the “architects of Death” as Disease and Pain. But he rooted his analysis of human life in the wider predicaments facing his society—“our land in her hour of need”. Lucretius linked prospects for the human condition to the state of Nature and the Earth, to the natural and physical systems on which human existence depended.

[World Report] Bushfires expose weaknesses in Australia's health system

Sab, 18/01/2020 - 00:00
Doctors have been left unprepared and climate change has not been considered a health issue. Sophie Cousins reports.

[World Report] Indian health care caught up in violence

Sab, 18/01/2020 - 00:00
Protests and police violence are leaving many in the medical community feeling threatened. Anoo Bhuyan reports from New Delhi.

[Perspectives] A brighter future for kidney disease?

Sab, 18/01/2020 - 00:00
It wasn't until the 19th century that diseases of the kidney began to be recognised under the eponymous diagnosis of Bright's disease, named after the father of nephrology Richard Bright (1789–1858). While our understanding of various types of kidney injury and pathologies has broadened over time, the complexities and clinical overlap of kidney diseases have led to less than adequate prevention and treatment strategies. Chronic kidney disease is present in about 10% of the world's population—more than diabetes and cancer combined—ranks as the ninth leading cause of death in the USA, and accounts for billions of dollars in medical costs, suffering, and lost quality life-years.

[Perspectives] The world behind the world: art and the climate emergency

Sab, 18/01/2020 - 00:00
On a morning in a colder than average winter in Salem, Missouri, USA, a stranger approached my husband and said, “I guess this cold snap blows that global warming theory out of the water.” Salem is a town of about 5000 people, the county seat of Dent County. Most of the county's residents are white. More than 80% of voters chose Donald Trump for US President. When my husband hopped out of his VW camper with his full white beard and a baseball cap that read Powell's Books, he looked like what he is: a philosophy professor from the University of Missouri on his way to fish the Current River.

[Obituary] Tetsu Nakamura

Sab, 18/01/2020 - 00:00
Japanese physician and humanitarian. Born in Fukuoka, Japan, on Sept 15, 1946, he died after being shot in Jalalabad, Afghanistan, on Dec 4, 2019, aged 73 years.

[Correspondence] Pakistan's children need better protection by the health-care system

Sab, 18/01/2020 - 00:00
When children in Ratodero, a small town in the Sindh province of Pakistan, suddenly became ill in the early months of 2019, HIV was not a cause anyone would have suspected. Unlike many other infectious diseases in Pakistan, HIV prevalence, especially in children, has been relatively low.1 However, in April, 2019, local journalists reported that the children were indeed infected with HIV. Further investigations revealed that many of the children were being cared for by a self-proclaimed, low-cost paediatrician (whose qualifications have not been established) who had been reusing needles and telling patients that they were too poor to afford new needles.

[Correspondence] Oral diseases: a global public health challenge

Sab, 18/01/2020 - 00:00
We read the Series paper by Marco Peres and colleagues1 and woul dlike to highlight the state of oral health in India.

[Correspondence] Oral diseases: a global public health challenge

Sab, 18/01/2020 - 00:00
In their Series paper, Marco Peres and colleagues1 reproduce a map of the estimated global prevalence of untreated dental caries in permanent teeth for 2017. France is reported to be one of the five countries in the world where prevalence is higher than 50%. This prevalence seems surprisingly high for a country where the public health insurance system leaves routine dental treatments (examinations, extractions, restorations, and endodontic treatments) with no out-of-pocket charges for more than 95% of the population.

[Correspondence] Oral diseases: a global public health challenge – Authors' reply

Sab, 18/01/2020 - 00:00
We thank Jean-Noel Vergnes and Marco Mazevet for their interest in our Series paper on the global public health challenge of oral diseases,1 and we thank Himmatrao and Pramodini Bawaskar for sharing their experience of oral health in India.

[Correspondence] Prophylactic antibiotics after operative vaginal delivery

Sab, 18/01/2020 - 00:00
In their large, randomised controlled trial on prophylactic antibiotics for prevention of maternal infection following operative vaginal delivery, Marian Knight and colleagues1 conclude that a change in WHO guidelines is warranted. This recommendation stems from the reduction shown in the primary outcome of confirmed or suspected infection in the 6 weeks after birth. A global recommendation for prophylactic antibiotics following operative vaginal delivery is, however, not without risk.

[Correspondence] Prophylactic antibiotics after operative vaginal delivery

Sab, 18/01/2020 - 00:00
We read with great interest the results of the impressive randomised controlled trial by Marian Knight and colleagues,1 which showed reduced rates of confirmed or suspected infections in women allocated amoxicillin and clavulanic acid compared with placebo following operative vaginal delivery. However, the issue that drew our attention is the almost uniform need for perineal suturing (99% in the study cohort vs 100% in controls), and the high rates of episiotomy (89% in both groups).

[Correspondence] Prophylactic antibiotics after operative vaginal delivery

Sab, 18/01/2020 - 00:00
Antibiotic prophylaxis is not recommended for operative vaginal birth because of insufficient evidence of the effectiveness in protecting against maternal infection. Marian Knight and colleagues1 show benefits from a single post-delivery antibiotic dose on maternal infection rates. However, this well designed and well conducted controlled trial has some important limitations. First, the trial includes short-term follow-up only. Second, a possible bias might arise due to a high (24%) loss of participants to follow-up (although blinding or masking reduces bias).