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[Comment] Offline: From 1918 to 2018—the lessons of influenza

Sa, 06/01/2018 - 00:00
Estimates of mortality during the 1918–20 influenza pandemic range from 20 million to 100 million deaths. Mortality between countries varied enormously. A large part of this variation was related to wealth. Resource-poor countries, with weak health systems, pervasive undernutrition, and widespread poverty, had higher death rates. When 1918 mortality rates are modelled for the modern era, an epidemic of influenza with similar virulence and pathogenicity would cause around 62 million deaths, with younger age groups especially vulnerable.

[World Report] Syria: 7 years into a civil war

Sa, 06/01/2018 - 00:00
Years of conflict have killed thousands, but the toll of war on Syria's health systems extends the cost of war beyond the front lines as de-escalation efforts seem to be faltering. Sharmila Devi reports.

[World Report] Zimbabwe post-Mugabe era: reconstructing a health system

Sa, 06/01/2018 - 00:00
A once-functioning health system was weakened by Robert Mugabe's antagonistic policies. Some hope the Mnangagwa administration will bring renewal. Andrew Green reports.

[Perspectives] Using comics to change lives

Sa, 06/01/2018 - 00:00
Comics are a popular source of entertainment, activism, education, and subversion. Within health care the use of comics has been steadily growing for the past 50 years, with comics used to reach all age groups but particularly younger readers. I recall in the early 1980s sending a coupon I had clipped from a comic off to the Health Education Council for a smoking prevention information pack. This followed my reading about the evil Nick O Tine—overpowered by Superman (who never said yes to a cigarette) in a powerful anti-smoking story created by DC Comics.

[Perspectives] In search of a teacher

Sa, 06/01/2018 - 00:00
“Written and Illustrated by…” These words were written on a blackboard in September, 1971, in crisp, authoritative chalk. We first graders at Colton Elementary School sat in awe as a young, energetic teacher took the stage in our lives. Ms Zive (and she was the first person we knew who ever used the term Ms) beguiled us with a dazzling smile, a secret store of Bugle corn snacks, plus the tantalising promise to let us in on the magic that adults possessed: reading.

[Obituary] Geoffrey Christopher Schild

Sa, 06/01/2018 - 00:00
Influenza virologist. He was born in Sheffield, UK, on Nov 28, 1935, and died in Bergen, Norway, on Aug 3, 2017, aged 81 years.

[Correspondence] Another perspective on the Foundation for a Smoke-Free World

Sa, 06/01/2018 - 00:00
Much has, and is, being said about the Foundation for a Smoke-Free World,1 an independent foundation funded by Philip Morris International, but one elemental point has been overlooked. A principal focus of the foundation, as stated on its website, is on treatment of addicted smokers to decrease mortality, including promoting the switch to reduced-risk products, such as e-cigarettes. Geoffrey Rose, in his masterful monograph The Strategy of Preventive Medicine, pointed to the so-called risk paradox, giving the example “whereby it was seen that many people exposed to a small risk may generate more disease than a few exposed to a conspicuous risk.

[Correspondence] WHO washes its hands of older people

Sa, 06/01/2018 - 00:00
Older people (≥60 years) constitute more than 12% of the world's population, which will rise to 16·5% by 2030.1 This age group will represent 10% of the population in less developed regions by 2030. Although older people account for a greater proportion of the global burden of disease and health-care needs than younger people, their positive societal contribution should not be overlooked. This age group often provide unpaid care for children or grandchildren, or other adults with disabilities. Improved health of older people is an essential goal to reduce health-care costs and maintain the societal support older people provide.

[Correspondence] Reducing childhood obesity in the UK

Sa, 06/01/2018 - 00:00
The Lancet's Editorial (Aug 26, 2017, p 882)1 is right about childhood obesity remaining an urgent public health challenge. Unfortunately, there is a certain naivety to The Lancet's view of Public Health England's (PHE) role in policy development.

[Correspondence] Reducing childhood obesity in the UK and France

Sa, 06/01/2018 - 00:00
The Lancet's Editorial (Aug 26, 2017, p 822)1 suggested that the UK's plan for reducing childhood obesity was inadequate as Public Health England announced it will be “working closely” with the food industry in seeking voluntary calorie reductions in high-energy food sources popular with children and young people.

[Correspondence] Targeted radiotherapy for early breast cancer

Sa, 06/01/2018 - 00:00
We congratulate Charlotte E Coles and colleagues (Sept 9, 2017, p 1048)1 on their randomised trial (IMPORT LOW) ratifying partial-breast irradiation and confirming the original hypothesis2 proposed in The Lancet 20 years ago.3 In 2010, the independent commentary accompanying the first results of the TARGIT-A trial4 of single-dose targeted intraoperative radiotherapy (TARGIT-IORT), published in The Lancet by the authors of this letter, presented partial-breast irradiation as the new standard for suitable patients.

[Correspondence] Targeted radiotherapy for early breast cancer – Authors' reply

Sa, 06/01/2018 - 00:00
We reject the inference of a survival benefit for patients receiving partial-breast irradiation within the IMPORT LOW trial and caution against any such interpretation when the number of events reported is so small.1 There is no suggestion of a difference in disease-free and overall survival across IMPORT LOW treatment groups.1 The TARGIT trialists' claim of survival benefit in their own trial relates to non-breast cancer deaths, and the data they cite are from a selected subset of patients. In IMPORT LOW, there were nine cardiac deaths occurring 6–36 months following randomisation, four after left-sided and five after right-sided breast cancer.

[Correspondence] How does azithromycin improve asthma exacerbations?

Sa, 06/01/2018 - 00:00
We read with interest the Article by Peter G Gibson and colleagues (July 4, 2017, p 659),1 which clearly showed the beneficial effects of macrolide therapy on the incidence of asthma exacerbations. Increasingly, asthma is recognised as a heterogeneous disease with multiple phenotypes and endotypes. By contrast with the effects of anti-inflammatory treatment with inhaled corticosteroids, leukotriene receptor antagonists, and biological therapies—for which therapeutic efficacy depends on the inflammatory profile—Gibson and colleagues showed no differential benefit in terms of eosinophilic inflammation over non-eosinophilic inflammation.

[Correspondence] How does azithromycin improve asthma exacerbations? – Author's reply

Sa, 06/01/2018 - 00:00
Two key findings of the AMAZES trial1 are relevant to asthma management. First, the addition of low-dose azithromycin to a combination of inhaled corticosteroids and long-acting bronchodilators led to a clinically significant reduction in asthma exacerbations in adults with poorly controlled asthma. This finding provides an additional therapeutic option for these patients. Second, the effect occurred equally in both eosinophilic and non-eosinophilic asthma, by an as yet unidentified mechanism, but acting on pathways other than type 2 inflammation.

[Correspondence] Hypothyroidism and hypertension: fact or myth?

Sa, 06/01/2018 - 00:00
We read with interest the thorough Seminar on hypothyroidism (Sept 23, 2017, p 1550),1 in which the authors implicate that hypothyroidism is a cause of hypertension. However, hypertension is not a typical sign of hypothyroidism. This misconception is more than 80 years old with Owen Thompson and colleagues2 reporting a high incidence of hypertension in myxoedema. Since then, many uncontrolled observational studies have shown that elevated blood pressure in patients with hypothyroidism returns to within normal range after thyroid hormone substitution.

[Correspondence] Hypothyroidism and hypertension: fact or myth? – Authors' reply

Sa, 06/01/2018 - 00:00
We thank Louis Hofstetter and Franz H Messerli for their interest in our Seminar on hypothyroidism in The Lancet.1 We agree that hypothyroidism is rarely the sole underlying cause of hypertension in the general population and that hypertension should always be treated in the context of primary cardiovascular disease prevention. However, several observational studies have shown a difference in blood pressure between those with hypothyroidism (clinical or subclinical) and euthyroid individuals, even after adjusting for age.

[Department of Error] Department of Error

Sa, 06/01/2018 - 00:00
Al-Lamee R, Thompson D, Dehbi H-M, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet 2018; 391: 31–40—In this Article (published online first on Nov 2, 2017) there were data analysis errors, including the erroneous exclusion of the final batch of 24 dobutamine stress echocardiograms. The analyses have been checked and the data corrected in table 3 under headings “SAQ-angina frequency” and “Peak stress wall motion index score”, as well as any text referring to these data in the Results and Discussion.

[Editorial] Artificial intelligence in health care: within touching distance

Sa, 23/12/2017 - 00:00
Replacing the doctor with an intelligent medical robot is a recurring theme in science fiction, but the idea of individualised medical advice from digital assistants like Alexa or Siri, supported by self-surveillance smartphone data, no longer seems implausible. A scenario in which medical information, gathered at the point of care, is analysed using sophisticated machine algorithms to provide real-time actionable analytics seems to be within touching distance. The creation of data-driven predictions underpins personalised medicine and precision public health.

[Editorial] Our responsibility to protect the Rohingya

Sa, 23/12/2017 - 00:00
Much has been made of the Rohingya being stateless. But how they are being treated is utterly heartless. The almost 1 million Rohingya Muslims displaced from Myanmar's Rakhine State to Bangladesh are housed in squalid camps quickly becoming reservoirs of disease and despair. A new outbreak of diphtheria comes on the heels of cholera and measles outbreaks. Insufficient food, shelter, health care, and hope add to the almost unimaginable suffering of these most disenfranchised refugees.

[Editorial] Dangerous words

Sa, 23/12/2017 - 00:00
Medicine is underpinned by both art and science. Art that relies upon strong therapeutic relationships with patients and populations. And science that brings statistical rigour to clinical and public health practice. If allegations reported in The Washington Post on Dec 15 are credible, the Trump administration has seriously undermined both foundations by banning the words “vulnerable”, “entitlement”, “diversity”, “transgender”, “fetus”, “evidence-based”, and “science-based” from government documents for the US$7 billion budget discussions about the Centers for Disease Control and Prevention (CDC).