The Lancet

The Lancet

Editorial Is the concept of hypertension as a disease unhelpful?

24-08-2019 – The Lancet

Ahead of the annual conference of the European Society of Cardiology together with the World Congress of Cardiology held in Paris, France (Aug 31–Sept 4), this issues research section is devoted to Articles on hypertension. These Articles paint an interesting picture of the global state of, and discussions about, this important risk factor for cardiovascular diseases and other non-communicable diseases (NCDs). The NCD Risk Factor Collaboration authors show increases in awareness and control in 12 selected high-income countries over the past four decades.

Editorial Better evidence needed for preventing paediatric migraine

24-08-2019 – The Lancet

Migraines are the most common disabling type of headache among children and adolescents. Globally, of all non-communicable diseases in children aged 5–14 years, migraine ranks third for disease burden after conduct disorder and anxiety disorder. On Aug 14, the American Academy of Neurology (AAN) and the American Headache Society released new guidelines on the pharmacological prevention and acute treatment of migraine in children and adolescents. These are the first updates to AAN guidance in this area in 15 years, and outline that although there are now more evidence-based treatments for acute migraine attacks, finding the right approach for preventing migraines remains a challenge.

Editorial Proposal to screen all US adult patients for substance use

24-08-2019 – The Lancet

On Aug 13, the US Preventive Services Task Force (USPSTF) published a draft recommendation on screening for illicit drugs, including the non-medical use of prescription drugs. The announcement comes amid the opioid crisis in the USA and is motivated by the need for early identification of people at risk for drug use. The task force draws on data from a 2017 national survey in which 11·5% of Americans reported illicit drug use with more than 700 000 overdoses. In contrast to the 2008 recommendation against drug screening in both adults and adolescents because of insufficient evidence, for the first time, USPSTF is now advising physicians to screen all adult patients for illicit drug use without biological drug testing.

Comment Progressing polypills beyond concepts to outcomes

24-08-2019 – Anushka A Patel, Mark D Huffman

In 2001, combined use of blood pressure-lowering drugs, a statin, and aspirin was proposed as a new approach to prevent cardiovascular disease.1 Reconceptualised soon thereafter as a population-level, so-called polypill strategy for all individuals aged 55 years and older, regardless of pretreatment risk factors, a modelling paper2 predicted that this approach would reduce cardiovascular disease by more than 80%. However, to date, empirical data have been scarce. A 2017 Cochrane review update3 identified 13 randomised controlled trials of polypills (defined as fixed-dose combinations of blood pressure-lowering and cholesterol-lowering drugs, with or without aspirin, in a single pill), including 9059 predominantly male participants with age ranging from 53 to 64 years.

Comment From primary health care to universal health coverage—one step forward and two steps back

24-08-2019 – David Sanders, Sulakshana Nandi, Ronald Labonté, Carina Vance, Wim Van Damme

Primary health care (PHC), codified at the historic 1978 Alma Ata Conference, was advocated as the means to achieve health for all by the year 2000.1 The principles of PHC included universal access and equitable coverage; comprehensive care emphasising disease prevention and health promotion; community and individual participation in health policy, planning, and provision; intersectoral action on health determinants; and appropriate technology and cost-effective use of available resources.2 These principles were to inform health-care provision at all levels of the health system and the programmatic elements of PHC that focused primarily on maternal and child health, communicable diseases, and local social and environmental issues.

Comment Defining primary palliative care for universal health coverage

24-08-2019 – Daniel Munday, Kirsty Boyd, Jenifer Jeba, Kellen Kimani, Sebastien Moine, Liz Grant, Scott Murray

Much has been achieved in advancing palliative care on the global health agenda, but there is more to do. The 2014 World Health Assembly (WHA) committed countries to integrating palliative care into their health systems and WHO was tasked with monitoring progress.1 By 2017, WHO had updated the definition of universal health coverage (UHC)—Sustainable Development Goal 3.8—to include palliation along with promotion, prevention, treatment, and rehabilitation.2 A Lancet Commission in 2017 highlighted the global need to take action when 61 million people are living with serious health-related suffering due to uncontrolled pain and without access to an affordable essential package for palliative care.

World Report Palliative care in Tajikistan

24-08-2019 – Jacqui Thornton

Provision of palliative care in Tajikistan is growing rapidly, after being non-existent just 15 years ago, despite political sensitivities over opioids for medical use. Jacqui Thornton reports.

Perspectives Paula Rego: personal and political

24-08-2019 – Lesley Hoggart

Political dictatorship, racism, slavery, abortion, and gender-based violence are all themes that feature in Paula Rego: Obedience and Defiance. This remarkable retrospective of Regos work, ranging from the 1960s to the 21st century, at MK Gallery in Milton Keynes, UK, showcases what the curator, Catherine Lampert, describes as the “moral challenges to humanity, particularly in the face of violence, gender discrimination and political tyranny”. Rego grew up under Portuguese dictator António de Oliveira Salazar and attended the UKs Slade School of Art in the 1950s, where she met painter Victor Willing who became her husband.

“Perspectives Biological psychiatrys decline and fall”

24-08-2019 – Steven Rose

As the 20th century drew to a close, there was an air of optimism among psychiatrists. Long gone were the days when mental disorder and distress were attributed to childhood trauma or “refrigerator mothers” to be treated—if the patient could afford it—by psychoanalysis. Rather, they were manifestations of a biological disease, a malfunctioning of brain processes, either genetically or developmentally caused. The psychiatrists bible was the monumental US Diagnostic and Statistical Manual of Mental Disorders (DSM) or WHOs equivalent, the International Classification of Diseases.

Perspectives The soul in medicine

24-08-2019 – Arthur Kleinman

“Things have a life of their own…Its simply a matter of waking up their souls.”Gabriel García Márquez, One Hundred Years of Solitude

Obituary Marc Mitchell

24-08-2019 – Adam Marcus

Paediatrician who used digital technologies to improve global health. Born on Sept 1, 1948, in Newton, MA, USA, he died while hiking in Alaska, USA, on June 25, 2019, aged 70 years.

Correspondence High-quality evidence to inform clinical practice

24-08-2019 – Alexander C Fanaroff, Robert M Califf, Renato D Lopes

One of the basic tenets of evidence-based medicine is that randomisation is crucial to understanding treatment effects. Observational studies are subject to confounding and selection bias. Researchers can adjust for measured differences between treatment groups, but unmeasured or unmeasurable differences might exist between groups that obscure true treatment effects and cannot be accounted for by any statistical method.1 The published medical literature is filled with examples of associations between treatment and outcome identified in observational studies that were subsequently disproven by well conducted randomised controlled trials (RCTs).

Correspondence The importance of randomised vs non-randomised trials

24-08-2019 – Andreas Rieckmann, Christine S Benn

We thank Hertzel Gerstein and colleagues1 for reminding us of the importance of randomised controlled trials (RCTs). However, RCTs require uncertainty about the benefits of an intervention, and once an intervention has already become health policy, ethical issues with doing an RCT arise.

Correspondence The importance of randomised vs non-randomised trials

24-08-2019 – Benjamin Djulbegovic, Paul Glasziou, Iain Chalmers

Hertzel Gerstein and colleagues1 propose that estimates of treatment effects with a relative risk (RR) of more than 4 might show that randomised controlled trials (RCTs) are not needed because confounders are less likely to obscure the true treatment effects when effect sizes are this large. Other studies have suggested different thresholds of an RR of 10 or higher,2 or 5 or higher (or RR <0·2)3 to avoid an RCT. We agree that larger effects are less likely to be explained by confounding factors, but regulatory agencies appear to have no explicit or implicit thresholds for approval without requiring further testing in RCTs.

“Correspondence The importance of randomised vs non-randomised trials – Authors reply”

24-08-2019 – Hertzel C Gerstein, John McMurray, Rury R Holman

We thank the correspondents for their responses to our Comment.1

Correspondence Trial re-investment to build better research for better impact

24-08-2019 – “Thomas A Fox, Gillian A Horne, Charles Craddock, Gordon Cook, Stephen OBrien, Sonia Fox, Anna Hockaday, Graham Silk, Peter Hillmen”

Clinical trials play a pivotal role in improving patient outcomes and are a crucial factor in the National Institute of Clinical Excellences assessment of novel therapies.1 From 2016–17 670 000 people were recruited into over 4700 trials across the National Health Service (NHS),2 thanks to more than £200 million of annual investment in the National Institute for Health Researchs (NIHR) Clinical Research Network.3 UK cancer trials are developed by the National Cancer Research Institute (NCRI) and delivered by the NIHR.

Correspondence Management of rheumatic mitral stenosis

24-08-2019 – Eamon P McCarron, Monica Monaghan, Shiva Sreenivasan

We read with interest the Lancet Clinical Picture by Mariam Chekhchar and colleagues.1 The authors describe a history of recurrent tonsillitis, suggestive of possible rheumatic heart disease—the most common cause of acquired mitral stenosis.2

Correspondence Management of rheumatic mitral stenosis

24-08-2019 – Hourmazd Haghbayan, Brian G Ballios, Eric A Coomes

Mariam Chekhchar and colleagues1 discuss branch retinal artery occlusion in a young woman, probably due to occult cardioembolus from rheumatic mitral stenosis. Despite decreasing incidence in developed nations, rheumatic heart disease remains a major source of preventable morbidity and mortality worldwide2 and we commend the authors for bringing attention to this important clinical entity. However, given this valvulopathys highly thrombogenic nature, therapeutic anticoagulation should be considered.

Department of Error Department of Error

24-08-2019 –

McCann ME, de Graaff JC, Dorris L, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet 2019; 393: 664–77—The copyright line of this Article has been updated to reflect that the paper is now Gold Open Access. This correction has been made to the online version as of August 22, 2019.

Correspondence Surgery for intracerebral haemorrhage

24-08-2019 – Nicolas Engrand, Mikael Mazighi, Caroline Le Guerinel, Matthieu Dorison, Vera Dinkelacker

The MISTIE III study by Daniel F Hanley and colleagues1 did not show a long-term benefit of minimally invasive surgery with thrombolysis in the management of patients with deep or lobar spontaneous intracerebral haematoma of more than 30 m

Correspondence Surgery for intracerebral haemorrhage

24-08-2019 – Angelos G Kolias, Hani J Marcus, Marike L Broekman, Peter J Hutchinson, Peter McCulloch

We congratulate Daniel F Hanley and the MISTIE III investigators1 for completing their phase 3 randomised controlled trial that assessed the effectiveness of a novel, minimally invasive surgical intervention for intracerebral haemorrhage.1 Surgical learning curves are important, especially in the case of novel interventions.2

“Correspondence Surgery for intracerebral haemorrhage – Authors reply”

24-08-2019 – Daniel F Hanley, Wendy C Ziai, Mario Zuccarello, Issam A Awad

We are pleased to answer questions concerning the interpretation of results from the MISTIE III trial.1

Correspondence Blood pressure reduction and intravenous thrombolysis

24-08-2019 – Nyika D Kruyt, Yvo B Roos, Paul J Nederkoorn

In ischaemic stroke a high blood pressure (>140 mm Hg) is well known to be associated with poor outcome, caused, at least partly, by an increased risk of haemorrhagic transformation of the cerebral infarct, particularly in patients who have been treated with intravenous thrombolysis. Therefore, guidelines recommend intravenous thrombolysis in patients with increased blood pressure only after active reduction of blood pressure below 185/110 mm Hg in patients who are otherwise eligible for intravenous thrombolysis.

“Correspondence Blood pressure reduction and intravenous thrombolysis – Authors reply”

24-08-2019 – Craig S Anderson, Philip M Bath

In light of the neutral findings of two major clinical trials—the international ENCHANTED study1 of increased intensive blood pressure reduction in patients receiving intravenous thrombolysis for acute ischaemic stroke, and the UK-based RIGHT-2 study2 of prehospital, ambulance-administered nitrate patch for patients with suspected acute stroke—Nyika Kruyt and colleagues appropriately highlight some ongoing uncertainty over the best approach to blood pressure control before intravenous thrombolysis and hope that their ongoing registry study (TRUTH)3 will shed further light on this topic.

Correspondence Patient–doctor engagement in cardiovascular prevention

24-08-2019 – Panagiota Anyfanti, Eugenia Gkaliagkousi, Stella Douma

We are grateful to Ulf Näslund and colleagues1 for addressing the effect of visualisation of asymptomatic atherosclerosis for cardiovascular prevention. The study showed improvement in cardiovascular risk scores at follow-up in the intervention group, which was attributed to the pictorial presentation of silent carotid atherosclerosis. However, we believe that some other aspects need to be underscored as potential contributors to these outcomes.

“Correspondence Patient–doctor engagement in cardiovascular prevention – Authors reply”

24-08-2019 – Ulf Näslund, Nawi Ng, Patrik Wennberg, Margareta Norberg

We thank Panagiota Anyfanti and colleagues for comments on the VIPVIZA trial.1 We agree that patient–doctor mutual engagement and communication is crucial for improved prevention and is a prerequisite for drug treatment, and preferably for all aspects of prevention.

Articles Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial

24-08-2019 – Gholamreza Roshandel, Masoud Khoshnia, Hossein Poustchi, Karla Hemming, Farin Kamangar, Abdolsamad Gharavi, Mohammad Reza Ostovaneh, Alireza Nateghi, Masoud Majed, Behrooz Navabakhsh, Shahin Merat, Akram Pourshams, Mahdi Nalini, Fatemeh Malekzadeh, Masoumeh Sadeghi, Noushin Mohammadifard, Nizal Sarrafzadegan, Mohammad Naemi-Tabiei, Abdolreza Fazel, Paul Brennan, Arash Etemadi, Paolo Boffetta, Neil Thomas, Tom Marshall, Kar Keung Cheng, Reza Malekzadeh

Use of polypill was effective in preventing major cardiovascular events. Medication adherence was high and adverse event numbers were low. The polypill strategy could be considered as an additional effective component in controlling cardiovascular diseases, especially in LMICs.

Clinical Picture Electric shocks and weakness of the right hand in a young man: Hirayama disease

24-08-2019 – “Christopher D Witiw, John E OToole”

A 25-year-old man presented to our department with a 5-year history of an insidious, progressive weakness in his right hand. Despite being right-handed, he had recently become reliant on his left hand to carry out tasks needing manual dexterity. Clinical examination showed muscular atrophy without fasciculations of the first dorsal interosseous muscle and weakness of both the thenar and hypothenar muscles of the right hand; he also had atrophy but no fasciculation of the lumbrical and interosseous muscles.

Series Primary prevention of ischaemic heart disease: populations, individuals, and health professionals

24-08-2019 – Rajeev Gupta, David A Wood

Ischaemic heart disease has a multifactorial aetiology and can be prevented from developing in populations primordially, and in individuals at high risk by primary prevention. The primordial approach focuses on social determinants of health in populations: political, economic, and social factors, principally unplanned urbanisation, illiteracy, poverty, and working and living conditions. Implementation of the UN Sustainable Development Goals can lead to major improvements in cardiovascular health, and adequate health-care financing and universal health care are important for achieving these goals.

Series Pharmacological lipid-modification therapies for prevention of ischaemic heart disease: current and future options

24-08-2019 – Kausik K Ray, Pablo Corral, Enrique Morales, Stephen J Nicholls

Atherosclerosis and its clinical manifestation as ischaemic heart disease remains a considerable health burden. Given that many factors contribute to ischaemic heart disease, a multifactorial approach to prevention is recommended, starting with lifestyle advice, smoking cessation, and control of known cardiovascular risk factors, such as blood pressure and lipids. Within the lipid profile, the principal target is lowering LDL cholesterol, firstly with lifestyle interventions and subsequently with pharmacological therapy.