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[Perspectives] In pursuit of polymathy

Sa, 11/05/2019 - 00:00
Medicine, despite its penchant for specialism, has always been responsive to polymathy. In ancient Egypt, Imhotep—most famous as the architect of the Step Pyramid—was also a physician, worshipped as the god of medicine and linked with the ancient Greek god of medicine, Asclepius, mentioned in the Hippocratic oath. Imhotep was the real “Father of Medicine”, wrote William Osler in the 19th century, as quoted by Waqās Ahmed in The Polymath: Unlocking the Power of Human Versatility. Other notable historical examples are Avicenna (Ibn Sina), the Persian physician from the 11th-century Islamic golden age, who wrote on astronomy, geography, mathematics, physics, and philosophy, as well as works of poetry, and Leonardo da Vinci, who pursued not only painting but many other disparate subjects, including anatomy.

[Perspectives] Mike Grocott: climbing high in critical care medicine

Sa, 11/05/2019 - 00:00
Besides his clinical and academic roles as Professor of Anaesthesia and Critical Care Medicine at the UK's University of Southampton, Mike Grocott is director of the Xtreme Everest Oxygen Research Consortium, a group of doctors, nurses, and scientists who use research done at high altitude to improve the treatment of critically ill patients. During his childhood, Grocott's family holidays were mostly in Scotland, the Lake District, and north Wales. “Mountains were a part of growing up and family life”, he recalls.

[Perspectives] Eglantyne Jebb and the war against children

Sa, 11/05/2019 - 00:00
This year, on May 16, Save the Children is 100 years old. It is the second oldest humanitarian organisation in the world (the International Committee of the Red Cross is the oldest), and the largest to focus entirely on the welfare of the child. Not only has it saved the lives of millions of children, it has helped transform the way we think about the nature of childhood itself.

[Obituary] James Lance

Sa, 11/05/2019 - 00:00
Neurologist who specialised in headache and motor control. Born in Wollongong, NSW, Australia, on Oct 29, 1926, he died of acute leukaemia in Sydney, NSW, Australia, on Feb 20, 2019, aged 92 years.

[Correspondence] Trend analysis of diabetic mortality

Sa, 11/05/2019 - 00:00
We read with great interest the Article by Edward Gregg and colleagues (June 16, 2018, p 2430).1 Here, we note some of our concerns on the methodology.

[Correspondence] Trend analysis of diabetic mortality – Authors' reply

Sa, 11/05/2019 - 00:00
We appreciate Xiaoling Yuan and colleagues' Correspondence about our Article.1 We used age adjustment instead of age standardisation because we considered it to be more efficient and appropriate to account for the reduced power in younger age strata in the context of discretised Poisson regression models, which we used to transform serial cohorts into nationally representative, year-specific estimates. Our analyses also modelled mortality trends as a continuous variable and evaluated non-linear terms, in addition to presenting point estimates at 10-year intervals.

[Correspondence] Biodegradable-polymer stents versus durable-polymer stents

Sa, 11/05/2019 - 00:00
In their randomised trial, Thomas Pilgrim and colleagues (Aug 28, 2018, p 737)1 assessed the non-inferiority of ultrathin-strut biodegradable-polymer sirolimus-eluting stents to thin-strut durable-polymer erolimus-eluting stents. The rate ratio (RR) for the primary composite outcome of target lesion failure (biodegradable-polymer stents vs durable-polymer stents) was 1·07 (95% CI 0·88–1·31; p=0·487). On the basis of this quantification, the two stents were claimed to be similar. However, the RR does not capture the temporal profile of event occurrences.

[Correspondence] Biodegradable-polymer stents versus durable-polymer stents – Authors' reply

Sa, 11/05/2019 - 00:00
The BIOSCIENCE trial1 was powered to assess non-inferiority for the primary outcome of target lesion failure at 12 months. Biodegradable-polymer siroliumus-eluting stents were found to be non-inferior to durable-polymer sirolimus-eluting stents because the upper limit of the one-sided 95% CI of the absolute risk difference at 12 months was smaller than 3·5%.1 Since no further non-inferiority analyses were planned, we carefully refrained from claims of non-inferiority in the analyses of 5-year outcomes and only included rate ratios (RRs) with two-sided 95% CIs and two-sided p values for superiority.

[Correspondence] Drug-coated balloons: room for development of BASKET-SMALL 2

Sa, 11/05/2019 - 00:00
We read with interest the BASKET-SMALL 2 randomised study by Raban Jeger and colleagues (Sep 8, 2018, p 849),1 which provided compelling clinical evidence of the efficacy of drug-coated balloons in patients with de-novo lesions in small coronary vessels. Because of the clinical implications of this trial, the first powered for clinical events in small coronary vessels, we feel that addressing some of the methodological issues will be of major scientific value. First, small vessels (<3 mm on visual assessment) account for up to a third of coronary interventions in clinical practice;2 therefore, the 5-year time period needed to complete patient enrolment in this multicentre (14 sites) study suggests the possibility of selection bias.

[Correspondence] Drug-coated balloons: room for development of BASKET-SMALL 2

Sa, 11/05/2019 - 00:00
We read with great interest the results of the BASKET-SMALL 2 trial by Raban Jeger and colleagues.1 According to their protocol, “All patients with an indication for PCI [percutaneous coronary intervention] either due to acute coronary syndrome, chronic angina pectoris, or silent ischemia, and angiographic lesions in native coronary arteries with a diameter of 2 mm to less than 3 mm were eligible for enrolment”. Stable angina was the indication in 544 (72%) of the 758 patients assigned to receive drug-coated balloons (DCB) or drug-eluting stents (DES).

[Correspondence] Drug-coated balloons: room for development of BASKET-SMALL 2 – Authors' reply

Sa, 11/05/2019 - 00:00
Fernando Alfonso and colleagues address some methodological issues in the BASKET-SMALL 2 study.1 They are correct in highlighting that patients were enrolled over a 5-year period, between April 10, 2012, and Feb 1, 2017, in 14 participating centres. However, this duration was not due to selection bias, and can easily be explained by the fact that centres did not start enrolment simultaneously. Eligible centres were difficult to find because of the little financial compensation in this investigator-initiated study, and because the initially used drug-eluting stents in the trial were withdrawn from the market and had to be replaced by another drug-eluting stent after enrolment of 94 (28%) of 341 patients in the per protocol population, which made an increase in sample size necessary.

[Correspondence] Trial (management) and error

Sa, 11/05/2019 - 00:00
Ian Roberts (Sept 1, 2018, p 732)1 presented a parody of clinical trial research, which contributed a voice for trial managers to broaden discussions about gender inequality and role recognition. Humour serves to illustrate the challenge trial managers can experience: their contribution to the successful delivery of what can often be complex clinical trials is frequently underestimated and unrecognised. However, it should also be noted that this is not, or not solely, a gender issue.

[Correspondence] A stitch in time saves nine

Sa, 11/05/2019 - 00:00
Jeroen de Filette and Vincent Michiels (Sept 29, 2018, p E9)1 report a bleeding due to a drug–drug interaction between warfarin and fluconazole. Inhibition of warfarin's primary metabolic enzyme cytochrome P450 (CYP) 2C9 is mentioned as the main cause. CYP 2C9 is responsible for the metabolism of the S-warfarin enantiomer.2 Additionally, the concentration of the less active R-warfarin enantiomer will also increase due to inhibition of CYP 3A4 and 2C19 by fluconazole, thereby contributing to the increased international normalised ratio.

[Department of Error] Department of Error

Sa, 11/05/2019 - 00:00
Zhong D, Yi Y, Lin C. A kidney changes size: first increasing and then decreasing. Lancet 2019; 393: 1641—In this Clinical Picture, the authors' affiliation and corresponding author's address have been corrected to “Department of Urology, Longyan First Hospital Affiliated to Fujian Medical University, Longyan 364000, China”. These corrections have been made to the online version as of May 9, 2019.

[Department of Error] Department of Error

Sa, 11/05/2019 - 00:00
Heerspink HJL, Parving H-H, Andress DL, et al. Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial. Lancet 2019; 393: 1937–47—In table 2, the upper limit of the 95% CI for the hazard ratio for the cardiorenal composite endpoint has been corrected to 0·999. This correction has been made to the online version as of May 9, and the printed version is correct.

[Department of Error] Department of Error

Sa, 11/05/2019 - 00:00
van Dijk AH, Wennmacker SZ, de Reuver PR, et al. Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial. Lancet 2019; published online April 26. http://dx.doi.org/10.1016/S0140-6736(19)30941-9—In this Article, the name of the co-author “Klass H in het Hof” should be “Klaas in ‘t Hof”. This correction has been made to the online version as of May 9, 2019.

[Department of Error] Department of Error

Sa, 11/05/2019 - 00:00
Wright S, Mabejane R. The 2019 UN high-level meeting on universal health coverage. Lancet 2019; 393: 1931—In this Correspondence, the authors' affiliation was mistakenly written as “Civil Society Engagement Mechanism for UHC2013 Secretariat” instead of “Civil Society Engagement Mechanism for UHC2030 Secretariat”. This correction has been made to the online version as of May 9, 2019, and the printed version is correct.

[Clinical Picture] Rapidly changing ECG in hyperkalaemia after succinylcholine

Sa, 11/05/2019 - 00:00
A 58-year-old man was hospitalised in our intensive care unit for severe, acute respiratory distress syndrome caused by an influenza virus infection. After 31 days, he was gradually weaned off mechanical ventilation. However, on the day after extubation, he had to be reintubated because of further respiratory distress. Emergency intubation was performed after rapid sequence induction using the short-acting anaesthetic agent etomidate, intravenously, at a dose of 0·3 mg/kg, and the muscle relaxant succinylcholine, intravenously, at a dose of 1 mg/kg.

[Editorial] The erosion of women's sexual and reproductive rights

Sa, 04/05/2019 - 00:00
The use of rape as a weapon of war is an unconscionable yet common phenomenon. An annual report from the UN Secretary General last month documents active use of sexual violence in 37 current conflicts, including in the Democratic Republic of the Congo, Myanmar, Somalia, South Sudan, and Syria. Sexual violence in conflict, which is mostly perpetrated against women and girls, is horrific and devastating to individuals, but also intended to destroy whole communities. Over history, it has usually been done with impunity and with little attention by the international community.

[Editorial] The emerging voices of youth activists

Sa, 04/05/2019 - 00:00
We are living in the midst of a wave of worldwide cultural change. Peaceful global activism led by young people is gaining momentum, challenging power structures at every level of society. But, as yet, this potential opportunity has not been seized for health. What more could be done to infuse energy and constructive anger into campaigns for a better health?