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  • Innovations to cut US healthcare prices
    BMJ (IF 20.7) Pub Date : 2018-04-20
    Dhruv Khullar, Rahul Rajkumar

    Efforts to limit healthcare spending should focus on lowering prices as well as reducing use, argue Dhruv Khullar and Rahul Rajkumar Healthcare spending is the product of usage and prices, but recent efforts to limit cost growth have focused almost exclusively on the former Prices paid for healthcare goods and services are much higher in the US than in other developed countries Substantial variation also occurs in price without clear relation to quality or outcomes Various mechanisms to reduce prices are discussed Americans pay higher prices for healthcare than people living in other developed countries. That is true of prices for doctors, especially proceduralists and specialists, and for non-physician goods and services such as drugs, imaging, and technologies. In the US, the price of inpatient medications is generally twice what it is in Canada; a magnetic resonance imaging (MRI) scan costs three times as much as in Australia; and the price of bypass surgery is four times higher than in the Netherlands.1 A recent international comparison found that, while Americans visit doctors and hospitals at similar rates to citizens of other high income countries, they pay a higher unit price for each intervention.2 This simple truth—often overlooked in health policy discussions—drives higher overall healthcare spending in the United States.34 As well as country differences, drug prices vary within the United States: some Americans pay much more than others for the same service. Spending for people with private insurance varies by a factor of three across US healthcare markets and is driven principally by disparities in prices.5 Prices for MRIs are 12 times higher in the most expensive markets than in the least expensive ones and can vary by a factor of nine even within the same area. The price of knee replacement surgery ranges from …

    更新日期:2018-04-20
  • Narrow terms of reference mean that Jeremy Hunt’s review of gross negligence manslaughter will miss the point
    BMJ (IF 20.7) Pub Date : 2018-04-20
    Toby Reynolds

    In February England’s health secretary announced a review into gross negligence manslaughter in healthcare.1 This followed Hadiza Bawa-Garba’s 2015 conviction on this charge and the subsequent High Court decision to strike her from the medical register. It may come too late for Bawa-Garba, but many hoped that this review, led by Norman Williams, would tackle the alarming …

    更新日期:2018-04-20
  • Junior doctors lose legal test case over right to have breaks every four hours
    BMJ (IF 20.7) Pub Date : 2018-04-20
    Clare Dyer

    Junior doctors have lost a High Court test case backed by the BMA over their right to have a 30 minute break every four hours or be paid at a higher rate.1 The group of 21 doctors, led by Sarah Hallett, argued that Derby Teaching Hospitals NHS Foundation Trust breached their employment contracts by using an incorrect system to monitor rotas to check whether doctors took their breaks.2 Hallett brought the case on behalf of herself and another 20 doctors training at the trust between August 2013 and August 2014, when she was in her foundation year. She is now a paediatric trainee and deputy chair for education and training of the BMA’s Junior Doctors Committee. The junior doctors argued that Department …

    更新日期:2018-04-20
  • MPs call for urgent ban on surgical mesh
    BMJ (IF 20.7) Pub Date : 2018-04-20
    Jacqui Wise

    MPs have called on the government to urgently suspend all mesh implant operations and for the National Institute for Health and Care Excellence (NICE) to bring forward guidelines on using mesh in stress related urinary incontinence from 2019 to 2018. Leading the debate in the House of Commons on 19 April, Emma Hardy, MP for Kingston upon Hull West and Hessle, also called for pelvic floor physiotherapy to be offered to all new mothers as standard on the NHS, as happens in France. She said, “Mesh was given to lots of young women following childbirth—many women still in their 30s—and it has left them feeling disabled. These women were injured. These women were ignored. These women …

    更新日期:2018-04-20
  • NHS risks missing out on benefits of genomics, MPs warn
    BMJ (IF 20.7) Pub Date : 2018-04-20
    Gareth Iacobucci

    The advancement of genomic medicine in the NHS is being held back by delays in infrastructure development and reduced training budgets, a committee of MPs has warned. The report by the House of Commons Science and Technology Committee also warned that public support for deploying the UK’s world leading genomics capabilities in the NHS could waver unless more were done to alleviate ethical concerns about the process and to promote the potential benefits.1 The committee said …

    更新日期:2018-04-20
  • Multiple sclerosis
    Lancet (IF 47.831) Pub Date : 2018-03-22
    Alan J Thompson, Sergio E Baranzini, Jeroen Geurts, Bernhard Hemmer, Olga Ciccarelli
    更新日期:2018-04-20
  • Malaria
    Lancet (IF 47.831) Pub Date : 2018-04-06
    Elizabeth A Ashley, Aung Pyae Phyo, Charles J Woodrow
    更新日期:2018-04-20
  • Re-emergence of yaws after single mass azithromycin treatment followed by targeted treatment: a longitudinal study
    Lancet (IF 47.831) Pub Date : 2018-02-07
    Oriol Mitjà, Charmie Godornes, Wendy Houinei, August Kapa, Raymond Paru, Haina Abel, Camila González-Beiras, Sibauk V Bieb, James Wangi, Alyssa E Barry, Sergi Sanz, Quique Bassat, Sheila A Lukehart
    更新日期:2018-04-20
  • Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study
    Lancet (IF 47.831) Pub Date : 2018-01-03
    Bruce M Biccard, Thandinkosi E Madiba, Hyla-Louise Kluyts, Dolly M Munlemvo, Farai D Madzimbamuto, Apollo Basenero, Christina S Gordon, Coulibaly Youssouf, Sylvia R Rakotoarison, Veekash Gobin, Ahmadou L Samateh, Chaibou M Sani, Akinyinka O Omigbodun, Simbo D Amanor-Boadu, Janat T Tumukunde, Tonya M Esterhuizen, Yannick Le Manach, Patrice Forget, Abdulaziz M Elkhogia, Ryad M Mehyaoui, Eugene Zoumeno, Gabriel Ndayisaba, Henry Ndasi, Andrew K N Ndonga, Zipporah W W Ngumi, Ushmah P Patel, Daniel Zemenfes Ashebir, Akwasi A K Antwi-Kusi, Bernard Mbwele, Hamza Doles Sama, Mahmoud Elfiky, Maher A Fawzy, Rupert M Pearse, Hippolyte Abadagan, N Abbas, A Ibrahim Abdelatif, Traoré Abdoulaye, A Abd-rouf, A Abduljalil, A Abdulrahman, S Abdurazig, A Abokris, W Abozaid, SOA Abugassa, F Abuhdema, SA Abujanah, R Abusamra, A Abushnaf, SA Abusnina, TS Abuzalout, HM Ackermann, YB Adamu, A Addanfour, DM Adeleke, TA Adigun, AO Adisa, Sèhivè Valéry Adjignon, NA Adu-Aryee, BB Afolabi, AFX Agaba, PKA Agaba, K Aghadi, H Agilla, B Ahmed, El-Z Ahmed, Al-J Ahmed, M Ahmed, Rene Ahossi, SA Aji, S Akanyun, I Akhideno, M Akhter, OA Akinyemi, M Akkari, Joseph Akodjenou, AL AL Samateh, ES al Shams, OT Alagbe-Briggs, EA Alakkari, RB Alalem, M Alashhab, OI Alatise, A Alatresh, MSI Alayeb Alayeb, BA Albakosh, F Albert, ANJD Alberts, AD Aldarrat, A Alfari, A Alfetore, M Algbali, A Algddar, HA Algedar, IA Alghafoud, A Alghazali, M Alhajj, A Alhendery Alhendery, FFH Alhoty, A Ali, YA Ali, A Ali, Beye Seïdina Alioune, MA Alkassem, MA Alkchr, TS Alkesa, A Alkilani, F Alkobty Alkobty, Thomas Allaye, SBM Alleesaib, A Alli, K Allopi, NL Allorto, A Almajbery, R Almesmary, SHA Almisslati, F Almoraid, H Alobeidi, MA Alomami, Christella S Alphonsus, OA Alqawi, AA Alraheem, SA Alsabri, A Alsayed, B Alsellabi, M Al-Serksi, MSA Alshareef, AA Altagazi, JS Aluvale, HW Alwahedi, EA Alzahra, MA Alzarouk, K Al-Zubaidy, M Amadou, Maiga Amadou, Simbo D Amanor-Boadu, Al-A Amer, BT Amisi, MA Amuthenu, TWA Anabah, Felix Anani, PGR Anderson, AGB Andriamampionona, L Andrianina, A Anele, R Angelin, N Anjar, O Antùnez, Akwasi Antwi-Kusi, LJC Anyanwu, AA Aribi, OA Arowolo, O Arrey, Daniel Zemenfes Ashebir, SB Assefa, Guy Assoum, V Athanse, JS Athombo, M Atiku, E Atito-Narh, Anatole Atomabe, A Attia, M Aungraheeta, DMA Aurélia, OO Ayandipo, AET Ayebale, HMZ Azzaidey, NB Babajee, HB Badi, EK Badianga, RB Baghni, MT Bahta, M Bai, Y Baitchu, AM Baloyi, KA Bamuza, MI Bamuza, L Bangure, OB Bankole, ML Barongo, MM Barow, Apollo Basenero, L Bashiya, CH Basson, Sudha Bechan, S Belhaj, MM Ben Mansour, D Benali, ASB Benamour, A Berhe, JD Bertie, JJA Bester, M Bester, JD Bezuidenhout, K Bhagwan, DR Bhagwandass, KAP Bhat, MMZU Bhuiyan, Bruce M Biccard, F Bigirimana, CJ Bikuelo, BE Bilby, SS Bingidimi, KE Bischof, David G Bishop, C Bitta, M Bittaye, Thuli Biyase, CA Blake, E Blignaut, F Blignaut, BN BN Tanjong, A Bogoslovskiy, PM Boloko, SKB Boodhun, I Bori, F Boufas, M Brand, Nicholas T Brouckaert, JD Bruwer, I Buccimazza, IM Bula Bula, Fred Bulamba, BC Businge, YB Bwambale, SRC Cacala, MA Cadersa, Chris Cairns, F Carlos, ME Casey, AC Castro, ND Chabayanzara, MS Chaibou, TNO Chaibva, NK Chakafa, C Chalo, C Changfoot, MC Chari, L Chelbi, JT Chibanda, HN Chifamba, N Chikh, E Chikumba, P Chimberengwa, J Chirengwa, FM Chitungo, MC Chiwanga, MM Chokoe, TM Chokwe, B Chrirangi, M Christian, B Church, JC Cisekedi, JN Clegg-Lamptey, Estie Cloete, Megan Coltman, W Conradie, N Constance, Youssouf Coulibaly, L Cronje, MA Da Silva, H Daddy, L Dahim, D Daliri, MS Dambaki, A Dasrath, JG Davids, Gareth L Davies, JT De Lange, JB de Wet, B Dedekind, MA Degaulle, V Dehal, PD Deka, S Delinikaytis, IS Desalu, Hubert Dewanou, MB Moussa Deye, C Dhege, BSG Diale, DF Dibwe, BJS Diedericks, JM Dippenaar, L Dippenaar, MP Diyoyo, Edith Djessouho, SN Dlamini, A Dodiyi-Manuel, BA Dokolwana, DP Domoyyeri, Leanne W Drummond, DE du Plessis, WM du Plessis, LJ du Preez, K Dube, NZ Dube, KD Dullab, R Duvenhage, RC Echem, SA Edaigbini, AK Egote, A Ehouni, G Ekwen, NC Ekwunife, M El Hensheri, IE Elfaghi, MA Elfagieh, S Elfallah, Mahmoud Elfiky, S Elgelany, AM Elghallal, MG Elghandouri, ZS Elghazal, AM Elghobashy, FT Elharati, Abdulaziz M Elkhogia, RM Elkhwildi, S Ellis, L Elmadani, HB Elmadany, H Elmehdawi, A Elmgadmi, H Eloi, D Elrafifi, G Elsaadi, RB Elsaity, A Elshikhy, M Eltaguri, A Elwerfelli, IE Elyasir, AZ Elzoway, AM Elzufri, EO Enendu, BC Enicker, EO Enwerem, R Esayas, M Eshtiwi, AA Eshwehdi, JL Esterhuizen, Tonya M Esterhuizen, EB Etuk, O Eurayet, OR Eyelade, RF Fanjandrainy, Lionelle Fanou, Z Farina, Maher Fawzy, A Feituri, NL Fernandes, LM Ford, Patrice Forget, T François, T Freeman, YBM Freeman, VM Gacii, B Gadi, M Gagara, A Gakenia, PD Gallou, GGN Gama, MG Gamal, YG Gandy, A Ganesh, Diallo Gangaly, M Garcia, AP Gatheru, SSD Gaya, Oswald Gbéhadé, G Gerbel, A Ghnain, R Gigabhoy, DG Giles, GT Girmaye, S Gitau, B Githae, Said Gitta, Veekash Gobin, Riaz Goga, AAG Gomati, ME Gonzalez, J Gopall, Christina Salmina Gordon, O Gorelyk, M Gova, K Govender, P Govender, S Govender, V Govindasamy, JTK Green-Harris, MB Greenwood, SV Grey-Johnson, Mariette Grobbelaar, MA Groenewald, KK Grünewald, Ambroise Guegni, M Guenane, S Gueye, Marius Guezo, T Gunguwo, MG Gweder, M Gwila, L Habimana, Rodrigue Hadecon, E Hadia, L Hamadi, M Hammouda, MI Hampton, R Hanta, Tim C Hardcastle, JA Hariniaina, S Hariparsad, AH Harissou, R Harrichandparsad, SHA Hasan, HB Hashmi, MP Hayes, A Hdud, SH Hebli, HMSN Heerah, S Hersi, AH Hery, Adam Hewitt-Smith, TC Hlako, SCH Hodges, Richard Eric Hodgson, M Hokoma, H Holder, EB Holford, E Horugavye, C Houston, M Hove, D Hugo, CM Human, H Hurri, O Huwidi, AI Ibrahim, Traoré Ibrahim, OK Idowu, IE Igaga, John Igenge, O Ihezie, K Ikandi, IAR Ike, JJN Ikuku, MN Ilbarasi, IBB Ilunga, JPM Ilunga, NAV Imbangu, Z Imessaoudene, DH Imposo, AM Iraya, M Isaacs, M Isiguzo, A Issoufou, P Izquirdo, A Jaber, UV Jaganath, CS Jallow, S Jamabo, ZS Jamal, L Janneh, MJ Jannetjies, I Jasim, Megan AJ Jaworska, S Jay Narain, K Jermi, R Jimoh, S Jithoo, M Johnson, S Joomye, RM Judicael, M Judicaël, A Juwid, LP Jwambi, R Kabango, JK Kabangu, DK Kabatoro, AN Kabongo, K Kabongo, LT Kabongo, MD Kabongo, N Kady, S Kafu, M Kaggya, BNK Kaholongo, PCK Kairuki, SI Kakololo, K Kakudji, Amina Kalisa, R Kalisa, MR Kalufwelu, S Kalume, RJ Kamanda, MK Kangili, H Kanoun, Kapesa, P Kapp, JK Karanja, M Karar, K Kariuki, K Kaseke, PNK Kashuupulwa, KJP Kasongo, SK Kassa, GK Kateregga, MIS Kathrada, PM Katompwa, L Katsukunya, KAM Kavuma, Khalfallah, A Khamajeet, SB Khetrish, Kibandwa, W Kibochi, AM Kilembe, AK Kintu, B Kipng'etich, B Kiprop, VMK Kissoon, Theroshnie K Kisten, JK Kiwanuka, Hyla-Louise Kluyts, MEK Knox, AK Koledale, VL Koller, MA Kolotsi, M Kongolo, ND Konwuoh, WJ Koperski, MYK Koraz, AA Kornilov, M Zach Koto, Samantha Kransingh, D Krick, S Kruger, C Kruse, W Kuhn, WP Kuhn, AM Kukembila, KL Kule, M Kumar, Belinda S Kusel, VK Kusweje, KJ Kuteesa, YY Kutor, MA Labib, M Laksari, F Lanos, TA Lawal, Yannick Le Manach, C Lee, RM Lekoloane, SN Lelo, B Lerutla, MT Lerutla, AI Levin, TB Likongo, ML Limbajee, DM Linyama, C Lionnet, MM Liwani, E Loots, A Garrido Lopez, CLC Lubamba, KF Lumbala, AJM Lumbamba, John Lumona, RF Lushima, L Luthuli, HL Luweesi, TSK Lyimo, HM Maakamedi, BM Mabaso, M Mabina, ME Maboya, I Macharia, AM Macheka, AZ Machowski, Thandinkosi E Madiba, ASM Madsen, Farai Madzimbamuto, LJ Madzivhe, SC Mafafo, M Maghrabi, Diango Djibo Mahamane, A Maharaj, A Maharaj, AD Maharaj, MR Mahmud, M Mahoko, NA Mahomedy, O Mahomva, TM Mahureva, RK Maila, DM Maimane, M Maimbo, SN Maina, Dela A Maiwald, MD Maiyalagan, N Majola, N Makgofa, V Makhanya, WP Makhaye, NM Makhlouf, S Makhoba, EK Makopa, O Makori, Alex M Makupe, MA Makwela, ME Malefo, SM Malongwe, DM Maluleke, MR Maluleke, K Touré Mamadou, MP Mamaleka, Y Mampangula, RM Mamy, MNR Mananjara, MTM Mandarry, DM Mangoo, C Manirimbere, A Manneh, A Mansour, I Mansour, M Manvinder, DV Manyere, VT Manzini, JK Manzombi, PM Mapanda, LC Marais, O Maranga, JPB Maritz, FK Mariwa, RS Masela, MM Mashamba, Doreen M Mashava, MV Mashile, E Mashoko, OR Masia, JN Masipa, ATM Masiyambiri, MW Matenchi, W Mathangani, RC Mathe, Christopher Y Matola, PM Matondo, R Matos-Puig, FFH Matoug, JT Matubatuba, HP Mavesere, R Mavhungu, S Maweni, CJM Mawire, T Mawisa, S Mayeza, R Mbadi, M Mbayabu, N Mbewe, WD Mbombo, T Mbuyi, WMS Mbuyi, MW Mbuyisa, Bernard Mbwele, RM Mehyaoui, ID Menkiti, LVM Mesarieki, A Metali, Serge Mewanou, L Mgonja, N Mgoqo, S Mhatu, TM Mhlari, S Miima, IM Milod, P Minani, F Mitema, A Mlotshwa, JE Mmasi, T Mniki, BO Mofikoya, JO Mogale, A Mohamed, A Mohamed, A Mohamed, S Mohamed, S Mohamed, TS Mohamed, A Mohamed, A Mohamed, AM Mohamed, P Mohamed, I Mohammed, FAM Mohammed, M Mohammed, NM Mohammed, MP Mohlala, R Mokretar, FM Molokoane, KN Mongwe, L Montenegro, OD Montwedi, QK Moodie, M Moopanar, M Morapedi, TG Morulana, VL Moses, P Mossy, H Mostafa, SR Motilall, SP Motloutsi, Kanté Moussa, M Moutari, OM Moyo, PE Mphephu, Busi Mrara, C Msadabwe, VM Mtongwe, FK Mubeya, K Muchiri, J Mugambi, GIM Muguti, AB Muhammad, IF Mukama, MM Mukenga, FK Mukinda, PM Mukuna, ARW Mungherera, Dolly M Munlemvo, TW Munyaradzi, AA Munyika, JM Muriithi, MP Muroonga, R Murray, VK Mushangwe, M Mushaninga, VEM Musiba, JM Musowoya, S Mutahi, MGH Mutasiigwa, G Mutizira, A Muturi, T Muzenda, KR Mvwala, NM Mvwama, A Mwale, CN Mwaluka, JD Mwamba, HAM Mwanga, CM Mwangi, S Mwansa, V Mwenda, IM Mwepu, TM Mwiti, SZ Mzezewa, L Nabela, MTN Nabukenya, SM Nabulindo, K Naicker, D Naidoo, L Naidoo, LC Naidoo, N Naidoo, R Naidoo, RD Naidoo, S Naidoo, TD Naidoo, TK Naidu, NZ Najat, Y Najm, F Nakandungile, P Nakangombe, CN Namata, ES Namegabe, A Nansook, NP Nansubuga, C Nantulu, Rodrigue Nascimento, GT Naude, H Nchimunya, MA Ndaie, PN Ndarukwa, Henry Ndasi, Gabriel Ndayisaba, D Ndegwa, R Ndikumana, Andrew KN Ndonga, C Ndung'u, MC Neil, MS Nel, EV Neluheni, DS Nesengani, NT Nesengani, LE Netshimboni, AM Ngalala, BM Ngari, NBM Ngari, E Ngatia, GK Ngcobo, TS Ngcobo, D Ngorora, D Ngouane, K Ngugi, Zipporah WW Ngumi, Z Nibe, E Ninise, JC Niyondiko, PW Njenga, MN Njenga, M Njoroge, S Njoroge, W Njuguna, PN Njuki, T Nkesha, TN Nkuebe, NP Nkuliyingoma, M Nkunjana, Ernest Nkwabi, RN Nkwine, C Nnaji, I Notoane, Shaaban Nsalamba, LM Ntlhe, C Ntoto, B Ntueba, MT Nyassi, Z Nyatela-Akinrinmade, HO Nyawanda, NN Nyokabi, VN Nziene, S Obadiah, OJP Ochieng, PK Odia, OEO Oduor, EO Ogboli-Nwasor, SWO Ogendo, O Ogunbode, TO Ogundiran, O Ogutu, RW Ojewola, M Ojujo, DO Ojuka, OS Okelo, S Okiya, N Okonu, PR Olang, Akinyinka O Omigbodun, S Omoding, J Omoshoro-Jones, R Onyango, A Onyegbule, O Orjiako, MO Osazuwa, Kpatinvo Oscar, BB Osinaike, AO Osinowo, OM Othin, FFH Otman, J Otokwala, F Ouanes, Ongoïba Oumar, AO Ousseini, S Padayachee, SM Pahlana, J Pansegrouw, FP Paruk, MB Patel, Ushmaben Patel, AP Patience, Rupert M Pearse, JD Pembe, GN Pengemale, N Perez, MF Aguilera Perez, A Mallier Peter, M Phaff, RM Pheeha, BH Pienaar, V Pillay, KA Pilusa, MP Pochana, O Polishchuk, Owen S Porrill, EF Post, A Prosper, M Pupyshev, A Rabemazava, MS Rabiou, L Rademan, M Rademeyer, RAR Raherison, FR Rajah, MSR Rajcoomar, Z Rakhda, AHR Rakotoarijaona, AHN Rakotoarisoa, Sylvia R Rakotoarison, RR Rakotoarison, L Ramadan, MLR Ramananasoa, M Rambau, TPR Ramchurn, HE Ramilson, Rajesh J Ramjee, H Ramnarain, R Ramos, TJ Rampai, SR Ramphal, T Ramsamy, R Ramuntshi, R Randolph, DMA Randriambololona, WAP Ras, RAF Rasolondraibe, JDLC Rasolonjatovo, RM Rautenbach, S Ray, Sarah R Rayne, FAR Razanakoto, SR Reddy, Anthony R Reed, JR Rian, FR Rija, B Rink, AT Robelie, CA Roberts, AGL Rocher, S Rocher, Reitze N Rodseth, I Rois, W Rois, S Rokhsi, J Roos, Nicolette F Rorke, H Roura, FJ Rousseau, N Rousseau, L Royas, D Roytowski, Devan Rungan, SSR Rwehumbiza, BB Ryabchiy, V Ryndine, CR Saaiman, HK Sabwa, S Sadat, SS Saed, E Salaheddin, H Salaou, M Saleh, HM Salisu-Kabara, Hamza Doles Sama, Ahmadou L Samateh, W Sam-Awortwi (Jnr), N Samuel, DK Sanduku, Chaibou M Sani, LN Sanyang, HN Sarah, A Sarkin-Pawa, R Sathiram, T Saurombe, H Schutte, MP Sebei, MD Sedekounou, MP Segooa, EM Semenya, BO Semo, CS Sendagire, SA Senoga, FS Senusi, T Serdyn, MD Seshibe, GB Shah, R Shamamba, CS Shambare, TN Shangase, SH Shanin, IE Shefren, AA Sheshe, OB Shittu, AS Shkirban, T Sholadoye, A Shubba, N Sigcu, SE Sihope, DS Sikazwe, BS Sikombe, K Simaga Abdoul, WAG Simo, K Singata, AS Singh, S Singh, Usha Singh, V Sinoamadi, N Sipuka, NLM Sithole, S Sitima, David Lee Skinner, GC Skinner, OI Smith, CAG Smits, MSI Sofia, Gaoussou Sogoba, A Sohoub, SS Sookun, O Sosinska, Rosalie Souhe, G Souley, Thiam Souleymane, JM Spicer, Sandra Spijkerman, H Steinhaus, A Steyn, G Steyn, HC Steyn, Heidi L Stoltenkamp, S Stroyer, A Swaleh, E Swayeb, AJ Szpytko, NA Taiwo, A Tarhuni, D Tarloff, Blaise Tchaou, Charles Tchegnonsi, M Tchoupa, MO Teeka, B Thakoor, MM Theunissen, BP Thomas, MB Thomas, A Thotharam, O Tobiko, AM Torborg, SM Tshisekedi, SK Tshisola, R Tshitangano, F Tshivhula, HT Tshuma, Janat Tumukunde, M Tun, IA Udo, DI Uhuebor, KU Umeh, AO Usenbo, JdD Uwiteyimbabazi, DJ Van der Merwe, FH van der Merwe, JE van der Walt, Dominique van Dyk, JG Van Dyk, JJS van Niekerk, S van Wyk, HA van Zyl, B Veerasamy, PJ Venter, AJ Vermeulen, R Villarreal, J Visser, L Visser, M Voigt, Richard P von Rahden, A Wafa, A Wafula, PK Wambugu, P Waryoba, EN Waweru, M Weideman, Robert D Wise, EE Wynne, AI Yahya, AA Yahya, R Yahya, Y Yakubu, JJ Yanga, YM Yangazov, O Yousef, G Yousef, Coulibaly Youssouf, AA Yunus, AS Yusuf, AZ Zeiton, HZ Zentuti, Henry Zepharine, AB Zerihun, S Zhou, A Zidan, Sanogo Zimogo Zié, CZ Zinyemba, A Zo, Lidwine Zomahoun, NZ Zoobei, Eugene Zoumenou, NZ Zubia
    更新日期:2018-04-20
  • Effectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two factorial design trial
    Lancet (IF 47.831) Pub Date : 2018-04-11
    Natacha Protopopoff, Jacklin F Mosha, Eliud Lukole, Jacques D Charlwood, Alexandra Wright, Charles D Mwalimu, Alphaxard Manjurano, Franklin W Mosha, William Kisinza, Immo Kleinschmidt, Mark Rowland
    更新日期:2018-04-20
  • Department of Error
    Lancet (IF 47.831) Pub Date : 2018-04-21

    Chen I, Cooney R, Feachem RGA, Lal A, Mpanju-Shumbusho W. The Lancet Commission on malaria eradication. Lancet 2018; 391: 1556–58—In this Comment (published online first on April 16, 2018), the affiliation for Winnie Mpanju-Shumbusho should be RBM Partnership to End Malaria, and the weblink should be RBM Partnership to End Malaria. These corrections have been made to the online version as of April 19, 2018, and the printed Comment is correct.

    更新日期:2018-04-20
  • Department of Error
    Lancet (IF 47.831) Pub Date : 2018-04-21

    Cohen AJ, Brauer M, Burnett R, et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017; 389: 1907–18—In this Article (published online first on April 10, 2017), the mathematical form for the IER has been corrected. This correction has been made to the online version as of April 19, 2018.

    更新日期:2018-04-20
  • Department of Error
    Lancet (IF 47.831) Pub Date : 2018-04-05

    The Lancet. Dementia in the UK: preparing the NHS for new treatments. Lancet 2018; 391: 1237— In the second sentence of this Editorial, the cost of dementia to the National Health Service in the UK should have been £26 billion. This correction has been made to the online version as of April 5, 2018.

    更新日期:2018-04-20
  • Department of Error
    Lancet (IF 47.831) Pub Date : 2018-04-10

    Das P, Horton R. Pollution, health, and the planet: time for decisive action. Lancet 2018; 391: 407–08—In the acknowledgments section of this Comment (published online first on Oct 19, 2017), the Governments of Germany, Norway, and Sweden should have been thanked for their “funding of the report, input, or both”. This correction has been made to the online version as of April 10, 2018.

    更新日期:2018-04-20
  • Prevention of dementia by targeting risk factors – Authors' reply
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Gill Livingston, Andrew Sommerlad, Lon Schneider, Naaheed Mukadam, Sergi Costafreda
    更新日期:2018-04-20
  • Prevention of dementia by targeting risk factors
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Jason D Warren, Doris-Eva Bamiou

    The Lancet Commission (Dec 16, 2017, p 2673)1 on prevention and management of dementia reviews the mounting evidence that hearing loss is a major risk factor for cognitive decline. Crucial information is still absent about the nature of this linkage and what factors might modify the cognitive effect of peripheral hearing loss. Particularly, the potential relevance of central hearing impairment should not be underestimated. As Gill Livingston and colleagues1 acknowledge, on pathophysiological and neuroanatomical grounds, central auditory processing is likely to be susceptible early in the course of Alzheimer's disease and other dementias.

    更新日期:2018-04-20
  • Prevention of dementia by targeting risk factors
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Mika Kivimäki, Archana Singh-Manoux

    The report by Gill Livingston and colleagues (Dec 16, 2017 p 2673)1 is a valuable collation of a large body of medical research evidence that aims to combat the dementia epidemic, the greatest global challenge for health and social care in the 21st century. One of the key messages of the Commission is the need to be ambitious in terms of prevention. Using population attributable fractions (PAF), the authors estimate that as much as 35% of dementia cases could be prevented by targeting nine modifiable risk factors.

    更新日期:2018-04-20
  • Prophylactic mesh augmentation in midline laparotomy
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Manuel Jakob, Guido Beldi

    The conclusions of the PRIMA (PRImary Mesh closure of Abdominal midline wounds) trial1 (Aug 5, 2017, p 567) need to be taken with caution for several reasons. The rate of 18% of incisional hernia in patients receiving prophylactic sublay mesh implantation is very high compared with frequencies below 5% in many other reports.2,3 Furthermore, most series report a lower recurrence rate after sublay than onlay mesh implantation in the repair of incisional hernia.4,5 Therefore, the technical problems or insufficient training with the sublay group does not allow the conclusion that onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients having elective midline laparotomy.

    更新日期:2018-04-20
  • Prophylactic repair to prevent midline incisional hernia
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Badri M Shrestha
    更新日期:2018-04-20
  • Mesh augmentation for midline abdominal closure
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Tetsuji Fujita

    In the 2-year follow-up of the PRIMA (PRImary Mesh closure of Abdominal midline wounds) trial (Aug 5, 2017, p 567),1 prophylactic onlay mesh augmentation for midline abdominal closure significantly reduced the risk of incisional hernia, with similar risks of surgical site infection compared with primary closure. Consequently, An Jairam and colleagues1 conclude that onlay mesh augmentation has the potential to become the standard treatment for patients at high risk of incisional hernia.

    更新日期:2018-04-20
  • The hepatitis B epidemic in China should receive more attention
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Shanquan Chen, Jun Li, Dan Wang, Hong Fung, Lai-yi Wong, Lu Zhao

    China's childhood hepatitis B virus (HBV) vaccination programme is a great public health success, resulting in a prevalence of HBsAg of only 1% in children under 5 years. However, the burden of HBV infection in China is still the highest in the world, with one third of the world's 240 million people with chronic HBV living in China.1 Nevertheless, most people with HBV infection in China are unaware that they carry the disease, making HBV infection a truly silent epidemic.2

    更新日期:2018-04-20
  • Healthier lives for all Africans
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Robert Mash, Akye Essuman, Innocent Besigye, Olayinka Ayankogbe, Per Kallestrup, Jan De Maeseneer

    In their Commission, Irene Agyepong and colleagues (Dec 23, 2017, p 2803)1 provide a comprehensive report on the pathway to healthier lives for all Africans by 2030. As highlighted in the Commission, we have been involved in training family physicians in Africa for the past 20 years within the framework of the Primary Care and Family Medicine Education (Primafamed) network, a South–South cooperation that brings together family medicine, primary care, and public health in more than 20 African countries.

    更新日期:2018-04-20
  • Surgical surveillance in resource-poor settings
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Abi Beane, Duncan Wagstaff, Anuja Abayadeera, David Walker, Rashan Haniffa
    更新日期:2018-04-20
  • Dame Beulah Rosemary Bewley
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Geoff Watts
    更新日期:2018-04-20
  • Stories of shame
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Barry Lyons, Matthew Gibson, Luna Dolezal
    更新日期:2018-04-20
  • Water and our planet
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Helen Bynum, Bill Bynum
    更新日期:2018-04-20
  • Winnie Mpanju-Shumbusho: leader in the fight against malaria
    Lancet (IF 47.831) Pub Date : 2018-04-21
    John Zarocostas
    更新日期:2018-04-20
  • Claims of sexual harassment and assault threaten UN agency
    Lancet (IF 47.831) Pub Date : 2018-04-21
    John Zarocostas

    Sexual harassment and assault investigation at UNAIDS draws attention to an endemic problem. Critics say the UN's internal system is flawed and call for external oversight. John Zarocostas reports.

    更新日期:2018-04-20
  • Offline: The legacy and lessons of May '68
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Richard Horton
    更新日期:2018-04-20
  • Social lobbying: a call to arms for public health
    Lancet (IF 47.831) Pub Date : 2018-04-21
    Alessandro Demaio, Robert Marshall
    更新日期:2018-04-20
  • The Lancet Commission on malaria eradication
    Lancet (IF 47.831) Pub Date : 2018-04-16
    Ingrid Chen, Rebecca Cooney, Richard G A Feachem, Altaf Lal, Winnie Mpanju-Shumbusho

    20 years ago, infectious diseases dominated the global health agenda. Policy makers, researchers, implementers, and donors united in the fight against infectious diseases, creating the Millennium Development Goals, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi, the Vaccine Alliance, the US President's Emergency Plan For AIDS Relief (PEPFAR), the Roll Back Malaria Partnership, the Multilateral Initiative on Malaria (MIM),1 and more. Tremendous progress was made. Malaria benefited spectacularly and there has been a 47% reduction in global deaths from the disease since 2000.

    更新日期:2018-04-20
  • Macrolide resistance in yaws
    Lancet (IF 47.831) Pub Date : 2018-02-07
    David Šmajs, Petra Pospíšilová
    更新日期:2018-04-20
  • A snapshot of surgical outcomes and needs in Africa
    Lancet (IF 47.831) Pub Date : 2018-01-03
    Anna J Dare, Bisola Onajin-Obembe, Emmanuel M Makasa
    更新日期:2018-04-20
  • Insecticide-resistant malaria vectors must be tackled
    Lancet (IF 47.831) Pub Date : 2018-04-11
    Gerry F Killeen, Hilary Ranson
    更新日期:2018-04-20
  • UK COPD treatment: failing to progress
    Lancet (IF 47.831) Pub Date : 2018-04-21
    The Lancet
    更新日期:2018-04-20
  • Sexual harassment and abuse—the sinister underbelly
    Lancet (IF 47.831) Pub Date : 2018-04-21
    The Lancet
    更新日期:2018-04-20
  • Orban not delivering health for Hungary
    Lancet (IF 47.831) Pub Date : 2018-04-21
    The Lancet
    更新日期:2018-04-20
  • Choosing Wisely CampaignsA Work in Progress
    JAMA (IF 44.405) Pub Date : 2018-04-19
    Wendy Levinson, Karen Born, Daniel Wolfson

    Choosing Wisely, a campaign to stimulate conversations between physicians and patients about unnecessary tests, treatments, and procedures, began in the United States in 2012. It was designed as a national campaign about overuse. Yet since its launch, the campaign has spread to more than 20 countries worldwide. Choosing Wisely has been hailed by some as a success, evident in its spread internationally and measured through structure and process indicators, such as recommendations developed, societies engaged, and physicians apprised. The conversation has been stimulated, and now delivery systems and clinical practices are beginning to develop interventions that go beyond conversations and recommendations. The success of the campaign in the next 5 years will be measured by the ongoing engagement of physicians in these interventions and, more importantly, associated outcomes. The effectiveness of quality improvement efforts by these delivery systems will determine how influential campaigns are in actually reducing unnecessary tests and treatments—a true measure of benefit.1

    更新日期:2018-04-19
  • How do I raise patient safety concerns, and when does this become whistleblowing?
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Abi Rimmer

    It can be difficult to know how and when to raise a concern, but help is available, Abi Rimmer finds “‘Raising concerns,’ ‘speaking up,’ and ‘whistleblowing’ are all essentially terms that describe telling someone in authority about wrongdoing, be that your manager, chief executive, regulator, or even the media. However, each of these terms can feel quite different. “Often ‘whistleblowing’ is used as a term when a concern feels unwelcome or when it’s external, and ‘speaking up’ is seen as being at the softer end of the spectrum, when a staff member first raises a concern. But we know from experience on our advice line that difficulties and opportunities exist at each stage of raising a concern, so this distinction can be misleading. “The reality is that they’re all part of the same spectrum, and knowing what to do if your concerns aren’t resolved at an early stage or if you’re unable to raise the matter locally is an important part of protecting patients. Escalating these issues and having the support to do so, no matter what the process is called, is what should be in place at any organisation …

    更新日期:2018-04-19
  • Good communication is key to good care
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Sophie Cook

    For women with medical conditions the routine physical and emotional challenges of pregnancy are amplified by fluctuating symptoms and difficult treatment decisions that must balance risks and benefits to both mother and unborn child. Choosing the best option is rarely straightforward when drugs are needed. A discussion to consider the treatment options well before conception is helpful. Valproate is a good example. An effective treatment for epilepsy, it is also licensed for bipolar disorder and, in some countries, migraine. But its teratogenic potential is well established, and there is no current agreement on the appropriate regulation of the drug in women who may become pregnant. Recently, European and UK drug regulators strengthened their advice on use of valproate in this context12: it should not be used unless a comprehensive “pregnancy prevention programme is followed.” Our editorialists Angelika Wieck and Sarah Jones explain that the European Commission will soon decide whether to make these recommendations legally binding (doi:10.1136/bmj.k1609). “A positive decision would be desirable and looks likely,” they say. The related analysis by Heather Angus-Leppan and Rebecca Liu (doi:10.1136/bmj.k1609) considers alternative approaches to valproate regulation, ranging from a ban to restricted availability. They emphasise that women should not be denied the human right to make their own decisions after fully informed discussion: “Banning valproate imposes less effective treatment for some female patients than for other people with a similar life threatening or serious condition, without their consent.” Good communication is central to good healthcare, and talking to colleagues is high on Margaret McCartney’s agenda this week (doi:10.1136/bmj.k1602). She reflects on a time when colleagues communicated directly about patients, unlike today when referrals can be rejected simply for being on the wrong form. “People make the NHS; and people, in the end, are the only way to make it work” she says. As our countdown continues to the NHS’s 70th birthday, McCartney finds it “hard to escape the feeling that the NHS is in terminal decline.” A new series of articles called Provocations will examine how to halt that decline and explore the NHS’s future direction. We kick off this week with Mark Britnell (doi:10.1136/bmj.k1685), who argues that health leaders must engage with the productivity debate. Productivity “is about harnessing the talents of NHS staff” and is not to be feared, he says. Do join the debate online.

    更新日期:2018-04-19
  • A woman with intractable nausea and vomiting
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Yan Zhang, Guanjun Kou, Yi Li, Yanqing Li

    A previously healthy 44 year old Chinese woman was referred by the emergency department to the gastroenterology ward with a seven week history of progressively worsening nausea and vomiting and weight loss of 13 kg. She did not have abdominal pain, distension, or diarrhoea. A general physician and a gastroenterologist had prescribed antidepressants (first flupentixol, then melitracen tablets, and finally olanzapine) for a functional gastrointestinal disorder, and she had been taking these for three weeks, as well as prokinetics (domperidone), and anti-emetics (domperidone and ondansetron), but she had not responded to treatment. Liver, kidney, thyroid function, and basic autoimmune antibodies were within normal ranges. Fasting blood glucose and glycated haemoglobin were normal. Previous gastroscopy and a computed tomography scan of the abdomen (conducted during the seven weeks of symptoms) showed no obvious abnormalities. Previous sagittal magnetic resonance imaging (MRI) of the head and cervical spine (taken three weeks after the first episode of nausea and vomiting) had shown a very small hyperintense lesion in the medulla oblongata, which had been considered normal (fig 1A). (A) Sagittal MRI of the head before admission. (B) Sagittal MRI of the head two months later. Arrows show a hyperintense lesion in the medulla oblongata Eight days after admission, the woman experienced metabolic alkalosis (caused by acute vomiting and hypokalaemia) and acute respiratory failure (caused by central hypoventilation and aspiration), and she was transferred to the intensive care unit for mechanical ventilation. Clinical examination found paralysis of the right limbs horizontal nystagmus loss of the pharyngeal reflex loss of tendon reflex on …

    更新日期:2018-04-19
  • The BMJ Awards 2018: Patient Partnership Team of the Year
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Nigel Hawkes

    Nigel Hawkes discovers how shortlisted teams are using the principles of co-production to provide the care that patients want and need Many people die in hospital, though they might not choose to. So, it is legitimate to ask how good hospitals are at dealing with bereavement, as did the Cheshire and Merseyside Palliative and End of Life Care Network. Working with a group of service users under the banner People’s Voice, they commissioned a survey of relatives of those who had died in hospices, hospitals, or at home. “The experience of hospitals fell below those of the other two,” says Julie Raj, a palliative care consultant at Aintree Hospital in Liverpool and chair of the group. A shortage of information and a lack of adequate support were among the complaints. The group set out to produce guidance, in the form of a specification which trusts should seek to meet. “We know that resources are limited,” she says, “so we produced both a minimum and a gold specification. All hospitals should have the minimum standard in place, while the gold standard is an aspiration.” The specification includes what should be on hospital websites, signposting and information leaflets, facilities for families and carers, bereavement office and mortuary support, and staff training and education. “Our aim is to inform people who work in hospitals and make them look at the services they offer, and where the gaps are,” Raj says. “Measuring outcomes is difficult with an initiative like this, but our plan is to visit all the trusts in Cheshire and Merseyside and measure how they’re implementing the guidance. I hope a survey of bereaved relatives will also show an improved experience.” Irritable bowel disease (IBD) is a lifelong …

    更新日期:2018-04-19
  • Chemical weapons are intentionally deployed against the most vulnerable groups of people
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Paul Gee

    The ongoing chemical attacks in the Syrian conflict are shocking.1 Chemical weapons are considered indiscriminate, affecting both military and civilian targets. From a toxicology point of view, this is untrue. In a gas attack poison …

    更新日期:2018-04-19
  • BMJ Careers launches recruitment tool to help NHS trusts fill vacancies
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Abi Rimmer

    BMJ Careers has launched a new initiative designed to help NHS trusts fill medical vacancies (recruiter.bmj.com). The recruitment packages give trusts unlimited access to posting jobs online, regular updates, and opportunities for branding and promotion, for a fixed annual subscription. Last year a census of UK consultants and higher specialty …

    更新日期:2018-04-19
  • Poorly performing general practices are more likely to prescribe homeopathy
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Gareth Iacobucci

    General practices in England with the worst prescribing quality scores are more than twice as likely to prescribe homeopathy than those with the best prescribing scores, a study has shown.1 Researchers from the universities of Oxford and Exeter examined practices that prescribe homeopathy, to determine whether they differed in their prescribing of other drugs. The cross sectional analysis, published by the Journal of the Royal …

    更新日期:2018-04-19
  • Medical school holds joint funeral for 74 children whose preserved bodies were found on site
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Ned Stafford

    A German medical school has held a joint funeral service for 74 children, whose bodies had been inexplicably preserved in phenol solutions for more than half a century in the basement of the university. The service was organised by the department of medicine at Martin Luther University of Halle-Wittenberg in Germany. Heike Kielstein, director of the Institute of Anatomy and Cell Biology at the university, learned of the preserved bodies in 2011 on her first day on the job as director. The bodies were stored in two fixation containers and were not used for teaching or scientific …

    更新日期:2018-04-19
  • Treatment for those with multiple serious illnesses is “ineffective,” warns major review
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Nigel Hawkes

    Medicine is poorly equipped to treat people that develop multiple chronic diseases concurrently, and must commit more resources to improving their treatment, a major global report1 has said. The report, produced by the UK’s Academy of Medical Sciences, warns that multimorbidity is increasing “on a massive scale.” But it admits that nobody knows how massive, for lack of an agreed definition. The report, which claims to be the first to look at global multimorbidity, attempts to give a definition, as well as suggest new research initiatives to understand it better and work out how best to organise services to treat it. While having several chronic conditions at once was previously viewed as part of the ageing …

    更新日期:2018-04-19
  • Court rejects parents’ appeal over life support for son
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Clare Dyer

    The case of Alfie Evans, a profoundly brain damaged toddler, is back with the UK Supreme Court after three appeal court judges ruled that his parents’ latest appeal was “wholly misconceived.” Thomas Evans and Kate James are awaiting a decision from a panel of three Supreme Court justices on whether they will hear a further appeal. Alfie, who will be 2 years old in May, has an undiagnosed condition, thought to be mitochondrial, …

    更新日期:2018-04-19
  • Seven days in medicine: 11-17 April 2018
    BMJ (IF 20.7) Pub Date : 2018-04-19
    British Medical Journal Publishing Group

    The UK parliament’s House of Commons health and social care select committee reiterated its call for NHS Digital to withdraw from a memorandum of understanding with the Home Office that allows personal details to be shared, including a patient’s address and date of birth. NHS Digital is failing in its ethical duty to protect confidentiality by sharing these data with the Home Office to help track potential immigration offenders, said a damning report from the committee published on 15 April. (Full story doi:10.1136/bmj.k1676) The number of doctors from outside the EU applying to work in the UK has increased year on year since 2012, the General Medical Council said. Over 5000 non-EU doctors are expected to apply to work in the UK this year, 2000 more than in 2017. The regulator warned that some overseas doctors who met its requirements and were ready to work in the UK were prevented from doing so because of visa difficulties, calling on the government to tackle this. (Full story doi:10.1136/bmj.k1621) The Home Office dropped its legal case to deport a GP trainee who trained in the UK, and it will now reconsider his application to remain. Luke Ong, from Singapore, launched a petition on Change.org after …

    更新日期:2018-04-19
  • Patience for patients
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Daniel Sokol

    It is tempting to take shortcuts when dealing with patients whose English is poor When the midwife visited the home of Sinthiya Rajatheepan the day after she gave birth, she found the baby boy lying in bed, pale and lethargic. Unfed for nearly 16 hours, he was hypoglycaemic. Although he was rushed to hospital, he developed cerebral palsy and severe disabilities.12 No one at the hospital had explained to Rajatheepan, who had just turned 21, how to feed her baby properly and what to do in the event of poor feeding. On the day of her discharge from hospital the baby had been crying all day. None of the midwives, however, had paid much attention to mother or baby. The …

    更新日期:2018-04-19
  • Posterior circulation ischaemic stroke
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Gargi Banerjee, Sheldon P Stone, David J Werring

    Posterior circulation stroke causes a wide range of non-specific presenting symptoms More than a third of posterior circulation strokes are initially misdiagnosed Explore the possibility of posterior circulation stroke in patients with new vertigo or disequilibrium, and those with new headache or changed migraine A negative HINTS examination in a patient with isolated vertigo can help rule out posterior circulation ischaemia A 63 year old man with a history of migraine with visual aura, hypertension, and anxiety presented to the local emergency department with a five day history of headache (see “A patient’s perspective”). This headache started similarly to previous migrainous episodes, but became more severe than usual and was accompanied by intermittent double vision and disturbed balance, speech, and swallowing. The patient was treated in the emergency department with intravenous fluids and analgesia and discharged with a diagnosis of migraine. The following day, his symptoms worsened; clinical examination revealed vertical diplopia, gaze-evoked jerk nystagmus, right sided past-pointing, and an ataxic gait. Computed tomography (CT) of the head and CT angiography demonstrated an acute right superior cerebellar artery territory infarct and thrombus in the V3 and V4 (distal) segments of the right vertebral artery; subsequent brain magnetic resonance imaging (MRI) revealed other posterior circulation infarcts (fig 1). Magnetic resonance imaging (MRI) of brain of the patient described in the case history. Axial T2 sequences (A, B) and axial diffusion weighted sequences (C, D) show acute infarcts (arrows) in the right occipital lobe (A, C) and right cerebellum (B, D). Contrast enhanced magnetic resonance angiography (E) shows an abrupt occlusion of the right vertebral artery (thick arrow). The left vertebral artery (thin arrow) continues via a tortuous route, before terminating in the posterior inferior cerebellar artery (interrupted arrow). The basilar artery (arrowhead) receives no flow from either vertebral artery, and …

    更新日期:2018-04-19
  • An approach to hip pain in a young adult
    BMJ (IF 20.7) Pub Date : 2018-04-19
    Alastair G Dick, Jonathan M Houghton, Marcus J K Bankes

    Initial management of hip pain in young adults includes simple analgesics or non-steroidal anti-inflammatory medication (NSAIDs), activity modification, and an anteroposterior radiograph of the hip Refer young adults with persistent hip pain for orthopaedic/sports and exercise medicine specialist opinion, even if imaging studies in primary care are reported as normal Most common causes of persistent hip pain in young adults are femoroacetabular impingement syndrome (FAI), hip dysplasia, and early osteoarthritis Early referral and treatment can improve pain and function but might also enable joint preserving treatments before the onset of osteoarthritis Appropriate surgical correction of the anatomical abnormalities in FAI and dysplasia safely and reliably reduces pain and improves function; failure of these procedures usually reflects failure to identify pre-existing arthritic change in the joint or to correct the anatomical deformity Hip pain in young adults is not normal and can be severe and disabling, affecting work, parenting, and leisure activities.12 The causes of hip pain in young adults (aged 16-50) tend to receive less attention than those in children (including Perthes’ disease, slipped capital femoral epiphysis, and septic arthritis) and in older patients (usually osteoarthritis). Imaging studies might not reveal an underlying problem, even where the patient’s symptoms are a consequence of clinically significant pathology. Research has improved understanding of the causes of hip pain in young adults, including femoroacetabular impingement syndrome (FAI) and dysplasia of the hip, and has identified new treatments, although evidence is still limited.34 Importantly, both FAI and hip dysplasia are treatable causes of hip pain in young adults.456 This Practice Pointer aims to help the non-specialist evaluate young adults presenting with hip pain, and provides an update on common young adult hip pathologies. Hip problems in young adults can be considered as problems within the joint itself …

    更新日期:2018-04-19
  • Monoclonal Antibodies for Emerging Infectious Diseases — Borrowing from History
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Hilary D. Marston; Catharine I. Paules; Anthony S. Fauci

    Although antibodies play pivotal roles in the immune response to infection, they have seen limited use as therapeutic agents for infectious diseases. Yet there is a long history of plasma-derived treatments for several pathogens. Emil Adolf von Behring, for example, won the Nobel Prize in Physiology or Medicine in 1901 for the application of animal-derived serum therapies, principally against diphtheria.1 Since then, plasma-based therapy has been attempted for infectious disease outbreaks ranging from the 1918 influenza pandemic to Ebola outbreaks from 1976 onward. Despite this history and the rapidly accelerating development of monoclonal antibodies (mAbs) for noncommunicable diseases such as cancer and autoimmune conditions, only a handful of antibody therapies have been licensed for infectious diseases (e.g., palivizumab for prophylaxis against respiratory syncytial virus in at-risk infants). Recent conceptual and technological advances in mAb development could have an enormous impact on the field of infectious diseases, particularly in the context of emerging infectious disease (EID) outbreaks, in which the process of vaccine development for new pathogens may be difficult and prolonged. The rapid development and strategic deployment of effective, highly specific preventive and therapeutic interventions have the potential to alter the course of an epidemic.

    更新日期:2018-04-19
  • Saline Shortages — Many Causes, No Simple Solution
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Maryann Mazer-Amirshahi; Erin R. Fox

    Severe and long-standing prescription-drug shortages have become a major threat to public health and patient safety.1 Despite increased awareness and mitigation strategies, the United States has experienced shortages of many lifesaving drugs and other supplies essential to patient care. There was already a shortage of saline solution, for example, when Hurricane Maria devastated Puerto Rico, home to a key saline manufacturer, causing the problem to reach critical levels.2

    更新日期:2018-04-19
  • Facing the Shortage of IV Fluids — A Hospital-Based Oral Rehydration Strategy
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Andrés M. Patiño; Regan H. Marsh; Eric J. Nilles; Christopher W. Baugh; Shada A. Rouhani; Stephanie Kayden

    Puerto Rico produces 44% of the intravenous (IV) fluid bags used in the United States.1 On September 20, 2017, Hurricane Maria struck the island, causing a humanitarian crisis and widespread devastation that escalated a critical shortage of IV fluids throughout the United States. Initially, small-volume bags — 50- and 100-ml bags used to dilute medications — became scarce. Today, the larger 500- and 1000-ml IV-fluid bags are also in short supply. U.S. hospitals are scrambling to develop strategies for rationing IV fluids to ensure availability for the patients who need them most.

    更新日期:2018-04-19
  • Gene Therapy in Patients with Transfusion-Dependent β-Thalassemia
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Alexis A. Thompson; Mark C. Walters; Janet Kwiatkowski; John E.J. Rasko; Jean-Antoine Ribeil; Suradej Hongeng; Elisa Magrin; Gary J. Schiller; Emmanuel Payen; Michaela Semeraro; Despina Moshous; Francois Lefrere; Hervé Puy; Philippe Bourget; Alessandra Magnani; Laure Caccavelli; Jean-Sébastien Diana; Felipe Suarez; Fabrice Monpoux; Valentine Brousse; Catherine Poirot; Chantal Brouzes; Jean-François Meritet; Corinne Pondarré; Yves Beuzard; Stany Chrétien; Thibaud Lefebvre; David T. Teachey; Usanarat Anurathapan; P. Joy Ho; Christof von Kalle; Morris Kletzel; Elliott Vichinsky; Sandeep Soni; Gabor Veres; Olivier Negre; Robert W. Ross; David Davidson; Alexandria Petrusich; Laura Sandler; Mohammed Asmal; Olivier Hermine; Mariane De Montalembert; Salima Hacein-Bey-Abina; Stéphane Blanche; Philippe Leboulch; Marina Cavazzana

    BackgroundDonor availability and transplantation-related risks limit the broad use of allogeneic hematopoietic-cell transplantation in patients with transfusion-dependent β-thalassemia. After previously establishing that lentiviral transfer of a marked β-globin (βA-T87Q) gene could substitute for long-term red-cell transfusions in a patient with β-thalassemia, we wanted to evaluate the safety and efficacy of such gene therapy in patients with transfusion-dependent β-thalassemia.MethodsIn two phase 1–2 studies, we obtained mobilized autologous CD34+ cells from 22 patients (12 to 35 years of age) with transfusion-dependent β-thalassemia and transduced the cells ex vivo with LentiGlobin BB305 vector, which encodes adult hemoglobin (HbA) with a T87Q amino acid substitution (HbAT87Q). The cells were then reinfused after the patients had undergone myeloablative busulfan conditioning. We subsequently monitored adverse events, vector integration, and levels of replication-competent lentivirus. Efficacy assessments included levels of total hemoglobin and HbAT87Q, transfusion requirements, and average vector copy number.ResultsAt a median of 26 months (range, 15 to 42) after infusion of the gene-modified cells, all but 1 of the 13 patients who had a non–β0/β0 genotype had stopped receiving red-cell transfusions; the levels of HbAT87Q ranged from 3.4 to 10.0 g per deciliter, and the levels of total hemoglobin ranged from 8.2 to 13.7 g per deciliter. Correction of biologic markers of dyserythropoiesis was achieved in evaluated patients with hemoglobin levels near normal ranges. In 9 patients with a β0/β0 genotype or two copies of the IVS1-110 mutation, the median annualized transfusion volume was decreased by 73%, and red-cell transfusions were discontinued in 3 patients. Treatment-related adverse events were typical of those associated with autologous stem-cell transplantation. No clonal dominance related to vector integration was observed.ConclusionsGene therapy with autologous CD34+ cells transduced with the BB305 vector reduced or eliminated the need for long-term red-cell transfusions in 22 patients with severe β-thalassemia without serious adverse events related to the drug product. (Funded by Bluebird Bio and others; HGB-204 and HGB-205 ClinicalTrials.gov numbers, NCT01745120 and NCT02151526.)FREE QUICK TAKE VIDEO SUMMARYLentiGlobin Gene Therapy for β-Thalassemia 02:03

    更新日期:2018-04-19
  • Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Sanjay V. Desai; David A. Asch; Lisa M. Bellini; Krisda H. Chaiyachati; Manqing Liu; Alice L. Sternberg; James Tonascia; Alyssa M. Yeager; Jeremy M. Asch; Joel T. Katz; Mathias Basner; David W. Bates; Karl Y. Bilimoria; David F. Dinges; Orit Even-Shoshan; David M. Shade; Jeffrey H. Silber; Dylan S. Small; Kevin G. Volpp; Judy A. Shea

    BackgroundConcern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.MethodsWe randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.ResultsThere were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees’ perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees’ workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, −0.43; 95% CI, −2.38 to 1.52; P=0.06 for noninferiority).ConclusionsThere was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blood Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818.)

    更新日期:2018-04-19
  • Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    José R. Banegas; Luis M. Ruilope; Alejandro de la Sierra; Ernest Vinyoles; Manuel Gorostidi; Juan J. de la Cruz; Gema Ruiz-Hurtado; Julián Segura; Fernando Rodríguez-Artalejo; Bryan Williams

    BackgroundEvidence for the influence of ambulatory blood pressure on prognosis derives mainly from population-based studies and a few relatively small clinical investigations. This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care.MethodsWe analyzed data from a registry-based, multicenter, national cohort that included 63,910 adults recruited from 2004 through 2014 in Spain. Clinic and 24-hour ambulatory blood-pressure data were examined in the following categories: sustained hypertension (elevated clinic and elevated 24-hour ambulatory blood pressure), “white-coat” hypertension (elevated clinic and normal 24-hour ambulatory blood pressure), masked hypertension (normal clinic and elevated 24-hour ambulatory blood pressure), and normotension (normal clinic and normal 24-hour ambulatory blood pressure). Analyses were conducted with Cox regression models, adjusted for clinic and 24-hour ambulatory blood pressures and for confounders.ResultsDuring a median follow-up of 4.7 years, 3808 patients died from any cause, and 1295 of these patients died from cardiovascular causes. In a model that included both 24-hour and clinic measurements, 24-hour systolic pressure was more strongly associated with all-cause mortality (hazard ratio, 1.58 per 1-SD increase in pressure; 95% confidence interval [CI], 1.56 to 1.60, after adjustment for clinic blood pressure) than the clinic systolic pressure (hazard ratio, 1.02; 95% CI, 1.00 to 1.04, after adjustment for 24-hour blood pressure). Corresponding hazard ratios per 1-SD increase in pressure were 1.55 (95% CI, 1.53 to 1.57, after adjustment for clinic and daytime blood pressures) for nighttime ambulatory systolic pressure and 1.54 (95% CI, 1.52 to 1.56, after adjustment for clinic and nighttime blood pressures) for daytime ambulatory systolic pressure. These relationships were consistent across subgroups of age, sex, and status with respect to obesity, diabetes, cardiovascular disease, and antihypertensive treatment. Masked hypertension was more strongly associated with all-cause mortality (hazard ratio, 2.83; 95% CI, 2.12 to 3.79) than sustained hypertension (hazard ratio, 1.80; 95% CI, 1.41 to 2.31) or white-coat hypertension (hazard ratio, 1.79; 95% CI, 1.38 to 2.32). Results for cardiovascular mortality were similar to those for all-cause mortality.ConclusionsAmbulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension. (Funded by the Spanish Society of Hypertension and others.)

    更新日期:2018-04-19
  • Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Jacqueline E. Tate; Jason M. Mwenda; George Armah; Bhavin Jani; Richard Omore; Ayesheshem Ademe; Hilda Mujuru; Evans Mpabalwani; Bagrey Ngwira; Margaret M. Cortese; Richard Mihigo; Hope Glover-Addy; Mwajabu Mbaga; Francis Osawa; Amezene Tadesse; Bothwell Mbuwayesango; Julia Simwaka; Nigel Cunliffe; Benjamin A. Lopman; Goitom Weldegebriel; Daniel Ansong; David Msuya; Billy Ogwel; Thomas Karengera; Portia Manangazira; Bruce Bvulani; Catherine Yen; Felicitas R. Zawaira; Clement T. Narh; Lazaro Mboma; Peter Saula; Fasil Teshager; Halle Getachew; Rebecca M. Moeti; Christabel Eweronu-Laryea; Umesh D. Parashar

    BackgroundPostlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries.MethodsUsing active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method.ResultsData on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk.ConclusionsThe risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.)

    更新日期:2018-04-19
  • Placenta Accreta Spectrum
    N. Engl. J. Med. (IF 72.406) Pub Date : 2018-04-19
    Robert M. Silver; D. Ware Branch

    Placenta accreta spectrum (abnormal adherence of the placental trophoblast to the uterine myometrium) is increasingly common. Previous cesarean delivery is a risk factor. Management generally involves planned preterm cesarean hysterectomy with the placenta left in situ.

    更新日期:2018-04-19
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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