The Lancet

Editorial Australia on fire

18-01-2020 – The Lancet

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 worlds most beautiful and unique natural landscapes burned. The sheer scale of Australias bushfires is hard to comprehend.

Editorial Protecting health research in the UK: culture and collaboration

18-01-2020 – The Lancet

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 Trumps steady erosion of health insurance protections”

18-01-2020 – The Lancet

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?

18-01-2020 – Marie-Claude Morice

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

18-01-2020 – Jordan A Kempker, Greg S Martin

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

18-01-2020 – Alexander C Day, Oliver Findl

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 Sudans health system: opportunities and challenges”

18-01-2020 – George Wharton, Omar E Ali, Siddiq Khalil, Hatim Yagoub, Elias Mossialos

The power-sharing agreement between Sudans 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

18-01-2020 – Richard Horton

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 Australias health system”

18-01-2020 – Sophie Cousins

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

18-01-2020 – Anoo Bhuyan

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?

18-01-2020 – Evan D Muse, Eric J Topol

It wasnt until the 19th century that diseases of the kidney began to be recognised under the eponymous diagnosis of Brights 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 worlds 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

18-01-2020 – Lise Saffran

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 countys 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 Powells 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

18-01-2020 – Andrew Green

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 Pakistans children need better protection by the health-care system”

18-01-2020 – Mishal Khan

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

18-01-2020 – Himmatrao Saluba Bawaskar, Pramodini Himmatrao Bawaskar

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

18-01-2020 – Jean-Noel Vergnes, Marco Mazevet

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”

18-01-2020 – Marco A Peres, Blánaid Daly, Carol C Guarnizo-Herreño, Habib Benzian, Richard G Watt

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

18-01-2020 – Kelly Jane Thompson, Jane Elizabeth Hirst

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

18-01-2020 – Lena Sagi-Dain, Shlomi Sagi, Reuven Kedar, Mordechai Bardicef, Eli Gutterman

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

18-01-2020 – Martin J Blaser, Brian L Strom, Maria G Dominguez Bello

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).

Correspondence Prophylactic antibiotics after operative vaginal delivery

18-01-2020 – Petra Zimmermann, Nigel Curtis

Marian Knight and colleagues1 reported that antibiotics given after operative delivery (forceps or vacuum) significantly reduce maternal infection. Up to 40% of infants are exposed to antibiotics as a result of intrapartum antibiotic prophylaxis for maternal group B streptococcus colonisation or surgical prophylaxis for caesarean section.2 Adding antibiotic prophylaxis for women who need operative assistance during delivery would lead to an additional 2–15% of women and infants being exposed to antibiotics.

Correspondence Prophylactic antibiotics after operative vaginal delivery

18-01-2020 – Kaho Iwabu, Yuto Maeda, Tetsuya Tanimoto

Marian Knight and colleagues1 showed that a single dose of prophylactic antibiotic effectively prevented infection after operative vaginal delivery. However, to apply these results to daily clinical practice, the selection of antibiotics and candidates receiving prophylaxis for infection after operative vaginal delivery should be carefully considered. According to their previous report,2 Knight and colleagues chose co-amoxiclav as a prophylactic antibiotic after operative vaginal delivery because it has adequate coverage of group A streptococcus and is less likely to select for antibiotic resistance, such as meticillin-resistant Staphylococcus aureus and extended-spectrum β-lactamases-producing Gram-negative bacteria.

“Correspondence Prophylactic antibiotics after operative vaginal delivery – Authors reply”

18-01-2020 – Marian Knight, ANODE collaborative group

We agree with Kelly Thompson and Jane Hirst regarding the need for an emphasis on infection control precautions at the time of operative vaginal birth other than solely antibiotic prophylaxis. All infections were not prevented in the ANODE trial,1 which highlights the importance of other infection prevention interventions. Selective versus routine episiotomy use might be one such intervention. The episiotomy rate observed in the ANODE trial is not unusual for the UK setting, and the infection rate we observed is similar to studies done in other settings where episiotomy use might be more restrictive.

Department of Error Department of Error

18-01-2020 –

Williams R, Aithal G, Alexander GJ, et al. Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK. Lancet 2020; 395: 226–39—In this Health Policy, an additional line has been added to the acknowledgments section regarding The Southampton Liver Pathway. Moreover, in table 1, the headings to the fifth and sixth column have been amended. These corrections have been made to the online version as of Jan 16, 2020, and the printed version is correct.

Correspondence Optimising first-line treatment for metastatic renal cell carcinoma

18-01-2020 – Elif Hindié

Brian Rini and colleagues1 reported results of a phase 3 trial (IMmotion151) comparing atezolizumab plus bevacizumab with sunitinib as first-line treatment of metastatic renal cell carcinoma. In the intention-to-treat population, combination therapy offered significant improvement in progression-free survival (hazard ratio HR 0·83 95% CI 0·70–0·97; p=0·0219), but not in overall survival (HR 0·93; 0·76–1·14; p=0·4751).1 Among other trials comparing combinations of immune checkpoint inhibitors and angiogenesis inhibitors with sunitinib, avelumab plus axitinib improved progression-free survival in the overall population (HR 0·69 0·56–0·84; p<0.001) but not overall survival (HR 0·78 0·55–1·08; p=0·14),2 whereas pembrolizumab plus axitinib improved overall survival (HR 0·53 0·38 −0·74; p<0·0001).

Correspondence Optimising first-line treatment for metastatic renal cell carcinoma

18-01-2020 – Guillermo de Velasco

Brian Rini and colleagues1 reported the results of IMmotion151, a randomised controlled trial in patients with advanced renal cell carcinoma. This study met its coprimary endpoint in patients whose disease expressed programmed death ligand 1, by showing an increased median progression-free survival for atezolizumab plus bevacizumab (11·2 months; IQR 8·9–15·0) compared with sunitinib (7·7 months; IQR 6·8–9·7; hazard ratio 0·74 95% CI 0·57–0·96; p=0·022). The authors conclude that this study supports atezolizumab plus bevacizumab as a first-line treatment for selected patients.

Correspondence Optimising first-line treatment for metastatic renal cell carcinoma

18-01-2020 – Fei Liang

Brian Rini and colleagues1 claimed that the results of the IMmotion151 trial support atezolizumab plus bevacizumab over sunitinib as a first-line treatment for selected patients with advanced renal cell carcinoma. However, the survival results, safety results, and overall cost do not support this claim. In the first interim analysis of overall survival, the hazard ratio was 0·81 (95% CI 0·63–1·03), but in the second interim analysis, it was attenuated to 0·93 (0·76–1·14). These results indicate that the benefit to progression-free survival is unlikely to be translated into survival benefit, because more patients in the sunitinib group are expected to receive second-line life-extending programmed death ligand 1 therapy.

Correspondence Life-threatening hyperkalaemia after succinylcholine

18-01-2020 – Jamie Strachan, Matthew Frise

We read with interest the Clinical Picture by Anne-Flore Plane and colleagues1 describing life-threatening hyperkalaemia after succinylcholine use to facilitate endotracheal intubation in a patient who was critically ill. The authors note that this complication is well known but imply that such a profound response was unexpected. We wish to make two observations regarding this case.

“Correspondence Life-threatening hyperkalaemia after succinylcholine – Authors reply”

18-01-2020 – Anne-Flore Plane, Pierre-Emmanuel Marsan, Damien du Cheyron, Xavier Valette

We thank Jamie Strachan and Matthew Frise for their interest and comments on our Clinical Picture1 showing electrocardiogram modifications related to life-threatening hyperkalaemia induced by succinylcholine in a patient who was critically ill.

Articles Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study

18-01-2020 – Kristina E Rudd, Sarah Charlotte Johnson, Kareha M Agesa, Katya Anne Shackelford, Derrick Tsoi, Daniel Rhodes Kievlan, Danny V Colombara, Kevin S Ikuta, Niranjan Kissoon, Simon Finfer, Carolin Fleischmann-Struzek, Flavia R Machado, Konrad K Reinhart, Kathryn Rowan, Christopher W Seymour, R Scott Watson, T Eoin West, Fatima Marinho, Simon I Hay, Rafael Lozano, Alan D Lopez, Derek C Angus, Christopher J L Murray, Mohsen Naghavi

Despite declining age-standardised incidence and mortality, sepsis remains a major cause of health loss worldwide and has an especially high health-related burden in sub-Saharan Africa.

Articles Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial

18-01-2020 – Cedric Schweitzer, Antoine Brezin, Beatrice Cochener, Dominique Monnet, Christine Germain, Stephanie Roseng, Remi Sitta, Aline Maillard, Nathalie Hayes, Philippe Denis, Pierre-Jean Pisella, Antoine Benard, FEMCAT study group

Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems.

Clinical Picture Infectious mononucleosis diagnosed by Downey cells: sometimes the old ways are better

18-01-2020 – Henry M Feder, William N Rezuke

An 18-year-old woman visited her physician because she had a fever, a sore throat, and painful swellings in her neck for the past 5 days. A rapid antigen detection test for streptococcus was negative, and because of exudates on the patients tonsils and very enlarged cervical lymph nodes, the physician tested for infectious mononucleosis or glandular fever. A rapid point-of-care test for heterophile antibodies—the Monospot test—was negative, a full blood count with autodifferential was normal, and a throat culture for group A streptococcus was negative.