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[Editorial] A shared future for all: let's talk about homelessness


The World Economic Forum meeting in Davos is almost upon us again. From Jan 23 to 26, more than 2500 participants from over 100 countries will contemplate the state of the world in over 400 sessions (and many more side events and corridor conversations). This year's theme, Creating a Shared Future in a Fractured World, is certainly an apt motto in today's geopolitical context. The 48th annual meeting “aims to rededicate leaders from all walks of life to developing a shared narrative to improve the state of the world”—lofty goals in a lofty location.

[Editorial] Preparing for seasonal influenza


During the current northern hemisphere's winter, seasonal influenza activity has become worrisome. According to the US Centers for Disease Control and Prevention (CDC), influenza activity is affecting the entire continental USA for the first time in 13 years and this year's season might well be severe. In the UK, in the first week of 2018, GP consultation rates for influenza rose 78%, and influenza-confirmed hospitalisations increased by 50% from the previous week, according to Public Health England.

[Editorial] The peril and promise of traffic


Just after the new year, a bus in Peru plunged off a winding cliffside road following a collision, leading to over 50 deaths. The road lacked guardrails or other safety equipment. The incident dramatically underscores the conclusions from a World Bank Group report published last week, The High Toll of Traffic Injuries. Addressing the burden of road traffic injuries (RTIs) will not only save lives but can greatly increase the social welfare of people in low and middle income countries (LMICs).

[Comment] Secondary prevention shifts into second gear


Aspirin has been a mainstay in the secondary prevention of cardiovascular events since the 1990s.1 In the mid-1990s, the antiplatelet clopidogrel was tested against aspirin in patients with atherosclerotic vascular disease and was found to reduce vascular death, ischaemic stroke, and myocardial infarction by 8·7%.2 The combination of clopidogrel and aspirin for secondary prevention to reduce cardiovascular events was tested in patients with symptomatic atherothrombosis; however, no benefit was observed.

[Comment] Antithrombotic therapy in peripheral artery disease


Peripheral artery disease is a systemic atherothrombotic disease in which plaque builds up in the arteries that carry blood to the limbs. If severe enough, impaired blood flow can cause critical limb ischaemia, which presents as resting pain, ulceration, or gangrene, and might require a limb amputation in the most extreme cases.1 People with peripheral artery disease often have plaque in other arterial beds, and thus are at increased risk for myocardial infarction, ischaemic stroke, and cardiovascular death.

[Comment] Prevention of fractures in patients with osteoporosis


Patients with osteoporosis who have previously had fragility fractures have the highest risk of recurrent fractures, and 10–20% of those with recent fractures will re-fracture within just 2 years.1 Yet most patients who have had fractures are untreated and those who are tend to be treated conservatively, namely with an oral bisphosphonate.2 Antiresorptive drugs, such as bisphosphonates and denosumab, and bone-forming agents, such as teriparatide, both increase bone mineral mass and reduce fragility fractures in patients with osteoporosis.

[Comment] Inclusion health: addressing the causes of the causes


The social gradient in health describes a graded association between an individual's position on the social hierarchy and health: the lower the socioeconomic position of an individual, the worse their health.1 The fact that the social gradient extends from the highest echelons of society to the lowest suggests that everyone is affected to a greater or lesser extent by the social determinants of health. One component of social cohesion is making common cause between people at various points on the social ladder.

[Comment] The Lancet–CAMS Health Summit 2018: a call for abstracts


The Lancet and the Chinese Academy of Medical Sciences (CAMS) have held three successful health summits in 2015–17 in Beijing, China. We continue to support China's health science research communities and invite abstract submissions from China for the 2018 The Lancet–CAMS Health Summit, to be held on Oct 27–28 in Beijing. Submissions are invited from all aspects of health science, including, but not limited to: translational medicine; clinical medicine; public health; global health; health policy; the environment and ecological systems; primary care; maternal, newborn, child, and adolescent health, health professionalism; and medical education.

[Comment] A time to remember and thank The Lancet's reviewers of 2017


Charles Dickens's A Christmas Carol provides an excellent opportunity to recalibrate what is important in life. An edgy adaptation by David Edgar is being performed by the Royal Shakespeare Company at Stratford-upon-Avon, UK, until February, 2018. The production emphasises that the social inequalities Dickens and his contemporary, Thomas Wakley—founder of The Lancet—railed at, remain uncomfortably present today. By contrast to the exploitative commercial and criminal relationships portrayed in this story, is the timeless theme of relationships that sustain, nurture, and redeem.

[Comment] Offline: The misuse of universal health coverage


Health workers are taught to see their purpose as imbued with special human importance. Possessed with the values of knowledge, judgment, respect, responsibility, integrity, compassion, altruism, excellence, continuous improvement, and partnership, medicine is often said to be endowed with particularly moral attributes. This vocational foundation gives ethical momentum to the case for universal health coverage, the big idea of the Sustainable Development Goals. The creation of national health services, we doctors may suggest, are critical humanitarian milestones in the histories of nations.

[World Report] Changes in the US tax system will also affect health care


The tax overhaul pushed by Republicans could jeopardise the ACA's health insurance marketplaces. Susan Jaffe, The Lancet's Washington correspondent, reports.

[World Report] Bolivia backtracks on malpractice law


In the midst of a health-care reform, a malpractice law put forward by the government has triggered strikes from the medical community. Amy Booth reports from Cochabamba.

[World Report] Universal health coverage law approved in Egypt


A universal health coverage law expanding access to health care in Egypt was approved by parliament, ahead of presidential elections. Sharmila Devi reports.

[Perspectives] Type 1 diabetes


Writing in 1649, the English herbalist Nicholas Culpeper despaired of his patients with diabetes: their “continual pissinge” was resistant to all treatment, and their deaths were rapid and certain. No longer: type 1 diabetes is a striking example of the transformation of the meaning of a diagnosis by application of clinical research. Its history reflects the trajectory of medicine away from heroic interventions and towards long-term treatment, from cure to care.

[Perspectives] Encounters with Indian medicine


In 1911, an Indian-born medical doctor called Paira Mall was recruited by Henry Wellcome's Historical Medical Museum in London, UK. Overseen by its curator, C J S Thompson, Mall was sent to collect objects from the south Asian subcontinent; artifacts that would capture the art and science of healing throughout the ages, as well as medicinal plants for Wellcome's chemical research labs in the UK. Mall was well travelled, having served as an army surgeon in the Russo–Japanese War. A linguist and an expert in Asian cultures, he was by then fluent in German, French, Italian, Sanskrit, Persian, Hindi, Punjabi, and Arabic (as well as in English).

[Perspectives] Health care as a cultural borderland


As a clinician, how do you best care for patients from a wide variety of backgrounds? Cultural diversity is not merely a matter of pluralism or multiculturalism; it is often accompanied by unequal or inadequate health care. Very often, cultural diversity and health disparity go hand in hand. As a response to such inequities, various forms of cultural competence training are now viewed as an essential curriculum component in medical education programmes and a key element of effective practice. However, these educational innovations have also come under fire.

[Perspectives] Peter Robert Mason


Clinical microbiologist with a commitment to Zimbabwe. Born in Aldridge, UK, on July 9, 1948, he died of prostate cancer in Amsterdam, the Netherlands, on Sept 28, 2017, aged 69 years.

[Correspondence] A new era for medical education in Colombia


During Nov 1–3, 2017, most of the Deans of Medicine who belong to the Colombian Association of Faculties of Medicine (ASCOFAME)—a nationwide network of higher education institutions or universities with medical faculties—met in Monteria, Colombia. Their objective was to develop a consensus on medical education.1

[Correspondence] A public health approach to opioid addiction in North America


Keith Humphreys' Comment in The Lancet (July 29, 2017, p 437)1 describes the main drivers of the opioid crisis in the USA and advocates for global restriction of prescription opioids as an effective public health response to addressing the overdose epidemic. We argue that although the dominant narrative about the opioid crisis circulating around careless prescribing and unscrupulous pharmaceutical companies has some merit, it does not tell the whole story of the epidemic of opioid addiction in North America because it occurs among medical and non-medical opioid users.

[Correspondence] A public health approach to opioid addiction in North America – Author's reply


I agree with Mohammad Karamouzian and Thomas Kerr that “restricting access to prescription opioids for opioid-naive populations should be included in the primary strategies” in response to the epidemic of opioid overdose and addiction, as discussed in my Comment.1 Karamouzian and Kerr are also correct to note that people currently taking opioids will require different clinical and policy strategies. For example, some people with chronic pain conditions will need to remain on their medication indefinitely because the net costs and benefits of doing so are favourable.

[Correspondence] The definition of acute kidney injury


We read with interest the Comment in The Lancet by Jon Barasch and colleagues (Feb 25, 2017, p 779)1 with its controversial title “Acute kidney injury: a problem of definition”. We appreciate the opportunity to clarify what is written in the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline on acute kidney injury (AKI),2 in the hope that clinicians will read beyond the headlines. The guideline clearly states that AKI is a clinical diagnosis and stresses the importance of clinical judgment: “While the definitions and classification system discussed in Chapter 2.1 provide a framework for the clinical diagnosis of AKI, they should not be interpreted to replace or to exclude clinical judgment”.

[Correspondence] The definition of acute kidney injury – Authors' reply


We thank John A Kellum and Norbert Lameire for their letter in response to our Comment.1 An acute increase in serum creatinine (sCr) is caused by direct injury to kidney cells (ie, pathophysiological processes resulting from ischaemia, sepsis, medications, metals, or enzymes) or a compromise in cardiovascular homoeostasis (ie, substantial volume depletion,2 congestive heart failure,3 or portal hypertension4). Hence, we appreciate that an acute rise in sCr can indicate several pathophysiological processes with worsened patient population outcomes.

[Department of Error] Department of Error


Kendler DL, Marin F, Zerbini CAF, et al. Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet 2017; 391: 230–40—In figure 2F of this Article (published online first on Nov 9, 2017), the confidence interval around the hazard ratio should have been 0·14–0·58. This correction has been made to the online version as of Nov 30, 2017, and the printed Article is correct.

[Department of Error] Department of Error


Connolly SJ, Eikelboom JW, Bosch J, et al. Rivaroxaban with or without aspirin in patients with stable coronary artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 391: 205–18—In this Article (published online first on Nov 10, 2017) the TIMI score was calculated incorrectly, without the use of all nine factors that made up the score, which resulted in changes to the composite primary outcome described in the text and shown in figure 4. There were also a few GUSTO bleeds that qualified in one of the categories, which resulted in changes to table 3.

[Articles] Rivaroxaban with or without aspirin in patients with stable coronary artery disease: an international, randomised, double-blind, placebo-controlled trial


In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.

[Articles] Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial


Low-dose rivaroxaban taken twice a day plus aspirin once a day reduced major adverse cardiovascular and limb events when compared with aspirin alone. Although major bleeding was increased, fatal or critical organ bleeding was not. This combination therapy represents an important advance in the management of patients with peripheral artery disease. Rivaroxaban alone did not significantly reduce major adverse cardiovascular events compared with asprin alone, but reduced major adverse limb events and increased major bleeding.

[Articles] Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial


Among post-menopausal women with severe osteoporosis, the risk of new vertebral and clinical fractures is significantly lower in patients receiving teriparatide than in those receiving risedronate.

[Articles] Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis


Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised.

[Clinical Picture] Xanthoma disseminatum


A 20-year-old man presented to the dermatology department of our hospital in November, 2012, with a 5-year history of multiple brownish-yellow xanthoma-like papules and nodules affecting the face, flexures of the trunk, and limbs, with no systemic symptoms. The lesions had initially appeared as discrete or grouped papules, which then coalesced into plaques and nodules, especially in the axillae, over a period of 2 years. They were painless and asymptomatic, and the patient sought medical help only for cosmetic resions, particularly regarding the lesions on his face.

[Seminar] Soil-transmitted helminth infections


More than a quarter of the world's population is at risk of infection with the soil-transmitted helminths Ascaris lumbricoides, hookworm (Ancylostoma duodenale and Necator americanus), Trichuris trichiura, and Strongyloides stercoralis. Infected children and adults present with a range of medical and surgical conditions, and clinicians should consider the possibility of infection in individuals living in, or returning from, endemic regions. Although safe and effective drugs are donated free to endemic countries, only half of at-risk children received treatment in 2016.

[Review] What works in inclusion health: overview of effective interventions for marginalised and excluded populations


Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery.