Riviste scientifiche

[Editorial] The US election 2020

The Lancet - %age fa
100 years ago, voters in the presidential election of 1920 were weary, trepidatious, and living with the spectre of pandemic and uncertainty. After the carnage of World War 1 and the multiple waves of influenza that enveloped the world between 1918 and 1920 (of the 50 million lives lost, 675 000 were American), the US economy had sunk into a deep recession as it adjusted to post-wartime production and consumption. Presidential candidate Warren G Harding expounded that “America's present need is not heroics, but healing; not nostrums, but normalcy”.

[Comment] Offline: COVID-19—a crisis of power

The Lancet - %age fa
COVID-19 is about the politics of the body. In a series of lectures and essays in the 1970s and early 1980s, Michel Foucault (who died in 1984) argued that the discipline of public health emerged with the birth of capitalism in the 18th century. The body came to be understood as an instrument of economic production, of labour power, and so became a subject of significant political interest. Medicine and public health were endorsed as tools to enhance these productive forces, to ensure that people were fit for work.

[World Report] US election 2020: the future of the Affordable Care Act

The Lancet - %age fa
President Donald Trump pledges to replace the Affordable Care Act while his Democratic opponent Joe Biden offers detailed proposals to improve it. Susan Jaffe reports from Washington, DC.

[World Report] Slovakia to test all adults for SARS-CoV-2

The Lancet - %age fa
Slovakia plans to be the first country to test its whole population for SARS-CoV-2, but experts warn of logistical and technical challenges. Ed Holt reports from Bratislava.

[Perspectives] Kevin Fenton: pursuing equity and equality in public health

The Lancet - %age fa
Kevin Fenton is a public health polymath. He's worked successfully in health prevention and health improvement for more than three decades and is currently the Regional Director of Public Health England (PHE) London and the Regional Director of Public Health for NHS London. “I have a passion for learning and throughout my career it is about looking for the next set of opportunities to make a difference to the people who I have been called to serve”, he says.

[Correspondence] The effect of Medicare for All on rural hospitals

The Lancet - %age fa
Alison Galvani and colleagues1 robustly modelled the effect of the Medicare for All Act on US national health expenditures and outcomes. Spending on hospital care and physician or clinical services accounts for 53% of total spending. Their model assumes that Medicare rates are uniformly 22% lower than are private-payer rates and that, by switching all fees to Medicare rates, overall reimbursements will be 6% lower for hospitals and 7% lower for physicians.

[Correspondence] The effect of Medicare for All on rural hospitals – Authors' reply

The Lancet - %age fa
The USA's rural hospitals are a lifeline for the communities that they serve, as evidenced by the catastrophic effects of their closures. Subsequent to the closure of a rural hospital, mortality rises by 5·9% among residents of the service area.1

[Correspondence] Asymptomatic health-care worker screening during the COVID-19 pandemic

The Lancet - %age fa
We applaud the establishment of the COVIDsortium by Thomas Treibel and colleagues1 as a bioresource focusing on asymptomatic health-care workers (HCWs).1 However, we disagree with the authors' conclusion that “the rate of asymptomatic infection among HCWs more likely reflects general community transmission than in-hospital exposure”. This report was an ecological study subject to the ecological fallacy. Moreover, the figure compares symptomatic inpatients who were tested in hospital with asymptomatic HCWs.

[Correspondence] Asymptomatic health-care worker screening during the COVID-19 pandemic

The Lancet - %age fa
Mass testing of asymptomatic health-care workers (HCWs) has been suggested to reduce nosocomial transmission of COVID-19.1 This level of testing might not be necessary in hospitals with protocols for personal protective equipment,2 despite recommendations by Thomas Treibel and colleagues.3 The 1600-bed Tan Tock Seng Hospital, Singapore, is colocated with the 330-bed National Centre for Infectious Diseases, Singapore, which, together, manage most patients with COVID-19 in Singapore. At this hospital, HCWs use fit-tested N95 respirators, eye protection, gloves, and gowns in areas where patients with COVID-19 are treated and wear surgical masks across the campus.

[Correspondence] Asymptomatic health-care worker screening during the COVID-19 pandemic – Authors' reply

The Lancet - %age fa
Kevin Fennelly and Christopher Whalen emphasise that health-care workers (HCWs) are at a higher risk of severe acute respiratory syndrome coronavirus 2 infection than are the general population. Angela Chow and colleagues describe their experience in Singapore of very low rates of HCW infections and nosocomial transmission when effective personal protective equipment is implemented. We agree with both perspectives, and our Correspondence1 did not contradict either of these viewpoints.

[Correspondence] Organ procurement and transplantation in Germany during the COVID-19 pandemic

The Lancet - %age fa
The COVID-19 pandemic has introduced unique challenges to health-care systems worldwide. Organ procurement and transplantation activities were affected in this context as previously described by Alexandre Loupy and colleagues.1

[Correspondence] Transplant programmes in areas with high SARS-CoV-2 transmission

The Lancet - %age fa
We read Alexandre Loupy and colleagues' account of a significant reduction in transplant activity in France and the USA with interest.1 The UK also has a high burden of COVID-19 with high severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission leading to a significant reduction in organ donation and transplant activity. In the UK, in April, 2020, only five out of 23 kidney transplant centres were active during lockdown.2 According to NHS Blood and Transplant, on May 8, 2020, deceased-donor organ retrieval was down by 63% and kidney transplantation by 57% compared with 2019.

[Correspondence] Host or pathogen-related factors in COVID-19 severity?

The Lancet - %age fa
Lucy Okell and colleagues1 observed that the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently in marked decline in many countries. Okell and colleagues suggest two possible explanations for this decline, namely the effect of lockdowns, physical distancing, and other interventions; or, alternatively, herd immunity. After analysing trends in cumulative deaths over time in many European countries that went into lockdown at different stages of their epidemic, and data obtained from serology studies on the proportion of the population that had the infection previously, Okell and colleagues found few data to support an explanation that relies on herd immunity.

[Correspondence] Host or pathogen-related factors in COVID-19 severity? – Authors' reply

The Lancet - %age fa
Christian Gortázar and colleagues, in their response to our Correspondence about herd immunity in COVID-19,1 suggest that the mutation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might provide an alternative explanation for the observed decline in deaths in Europe. As evidence, they highlight the observation that the SARS-CoV-2 virus has mutated,2,3 alongside their own report arguing that the severity of COVID-19 has decreased over time.4 Unfortunately, their own study appears to have ended before many recoveries could have occurred, severely undermining the main conclusion.

[Clinical Picture] A baby with red plaques on the face and a first-degree heart block: neonatal lupus

The Lancet - %age fa
A 3-month-old boy was brought by his mother to our clinic who had noticed that her child had developed several round red lesions on his face (figure). She said that the problem had begun 3 weeks post partum. The baby had been born at full term following an uncomplicated pregnancy. The patient's mother was fit and well with no medical history of note—specifically she did not report any previous infections, or dermatological or autoimmune diseases.

[Series] Stroke systems of care in high-income countries: what is optimal?

The Lancet - %age fa
Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service.

[Series] Stroke systems of care in low-income and middle-income countries: challenges and opportunities

The Lancet - %age fa
The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs—eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers.

[Series] Stroke rehabilitation in low-income and middle-income countries: a call to action

The Lancet - %age fa
The WHO Rehabilitation 2030 agenda recognises the importance of rehabilitation in the value chain of quality health care. Developing and delivering cost-effective, equitable-access rehabilitation services to the right people at the right time is a challenge for health services globally. These challenges are amplified in low-income and middle-income countries (LMICs), in which the unmet need for rehabilitation and recovery treatments is high. In this Series paper, we outline what is happening more broadly as part of the WHO Rehabilitation 2030 agenda, then focus on the specific challenges to development and implementation of effective stroke rehabilitation services in LMICs.

Revisiting child and adolescent health in the context of the Sustainable Development Goals

PLoS Medicine - Ve, 30/10/2020 - 22:00

by Zulfiqar A. Bhutta, Kathryn M. Yount, Quique Bassat, Artur A. Arikainen

Acute kidney injury associated with COVID-19: A retrospective cohort study

PLoS Medicine - Ve, 30/10/2020 - 22:00

by Nitin V. Kolhe, Richard J. Fluck, Nicholas M. Selby, Maarten W. Taal

Background

Initial reports indicate a high incidence of acute kidney injury (AKI) in Coronavirus Disease 2019 (COVID-19), but more data are required to clarify if COVID-19 is an independent risk factor for AKI and how COVID-19–associated AKI may differ from AKI due to other causes. We therefore sought to study the relationship between COVID-19, AKI, and outcomes in a retrospective cohort of patients admitted to 2 acute hospitals in Derby, United Kingdom.

Methods and findings

We extracted electronic data from 4,759 hospitalised patients who were tested for COVID-19 between 5 March 2020 and 12 May 2020. The data were linked to electronic patient records and laboratory information management systems. The primary outcome was AKI, and secondary outcomes included in-hospital mortality, need for ventilatory support, intensive care unit (ICU) admission, and length of stay. As compared to the COVID-19–negative group (n = 3,374), COVID-19 patients (n = 1,161) were older (72.1 ± 16.1 versus 65.3 ± 20.4 years, p < 0.001), had a greater proportion of men (56.6% versus 44.9%, p < 0.001), greater proportion of Asian ethnicity (8.3% versus 4.0%, p < 0.001), and lower proportion of white ethnicity (75.5% versus 82.5%, p < 0.001). AKI developed in 304 (26.2%) COVID-19–positive patients (COVID-19 AKI) and 420 (12.4%) COVID-19–negative patients (AKI controls). COVID-19 patients aged 65 to 84 years (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.11 to 2.50), needing mechanical ventilation (OR 8.74, 95% CI 5.27 to 14.77), having congestive cardiac failure (OR 1.72, 95% CI 1.18 to 2.50), chronic liver disease (OR 3.43, 95% CI 1.17 to 10.00), and chronic kidney disease (CKD) (OR 2.81, 95% CI 1.97 to 4.01) had higher odds for developing AKI. Mortality was higher in COVID-19 AKI versus COVID-19 patients without AKI (60.5% versus 27.4%, p < 0.001), and AKI was an independent predictor of mortality (OR 3.27, 95% CI 2.39 to 4.48). Compared with AKI controls, COVID-19 AKI was observed in a higher proportion of men (58.9% versus 51%, p = 0.04) and lower proportion with white ethnicity (74.7% versus 86.9%, p = 0.003); was more frequently associated with cerebrovascular disease (11.8% versus 6.0%, p = 0.006), chronic lung disease (28.0% versus 19.3%, p = 0.007), diabetes (24.7% versus 17.9%, p = 0.03), and CKD (34.2% versus 20.0%, p < 0.001); and was more likely to be hospital acquired (61.2% versus 46.4%, p < 0.001). Mortality was higher in the COVID-19 AKI as compared to the control AKI group (60.5% versus 27.6%, p < 0.001). In multivariable analysis, AKI patients aged 65 to 84 years, (OR 3.08, 95% CI 1.77 to 5.35) and ≥85 years of age (OR 3.54, 95% CI 1.87 to 6.70), peak AKI stage 2 (OR 1.74, 95% CI 1.05 to 2.90), AKI stage 3 (OR 2.01, 95% CI 1.13 to 3.57), and COVID-19 (OR 3.80, 95% CI 2.62 to 5.51) had higher odds of death. Limitations of the study include retrospective design, lack of urinalysis data, and low ethnic diversity of the region.

Conclusions

We observed a high incidence of AKI in patients with COVID-19 that was associated with a 3-fold higher odds of death than COVID-19 without AKI and a 4-fold higher odds of death than AKI due to other causes. These data indicate that patients with COVID-19 should be monitored for the development of AKI and measures taken to prevent this.

Trial registration

ClinicalTrials.gov NCT04407156

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