One of the most poignant representations of the devastating impact of morphine addiction on a family comes from Eugene O'Neill's play Long Day's Journey Into Night, written in 1941–42 but published only in 1956. In this work, rightly considered one of the best American plays of the 20th century, O'Neill drew inspiration for the characters from his own family who had to face his mother's morphine addiction. Time has not dented the intensity of this seminal work now on stage in a superb production directed by Richard Eyre at the Wyndham's Theatre in London, UK.
The impending minimum unit pricing (MUP) of alcohol in Scotland, commented on by Richard Horton in The Lancet (Jan 13, p 106),1 focuses attention on this public health strategy again. However, this strategy is a live issue well beyond the UK. An MUP has existed in Canadian provinces since the 1990s and in several eastern European countries since 2008.2 Nevertheless, the Scottish MUP of £0·50 per unit of alcohol is likely to have only a moderate effect because the amount was based on 2010 prices.
We welcome the Lecture by Samuel S Myers (Dec 23, 2017, p 2860)1 on planetary health. Paul J Crutzen assigned the term Anthropocene to “the present, in many ways human-dominated, geological epoch”.2 The capacity of mankind to shape its own habitat is a major environmental force. More than 15 000 scientists proclaimed that urgent changes are needed to avoid the consequences of humanity's impact on the environment and reverse the trend of collapsing the delicate planetary health.3
In their Viewpoint, Harry Rutter and colleagues (Dec 9, 2017, p 2602)1 make another welcomed call for increased uptake and investment in systems modelling tools to provide evidence better suited to addressing complex public health problems. We note the authors' assessment that systems modelling tools and approaches are “rarely operationalised in ways that generate relevant evidence” to support public health policy and practice. We disagree with this assessment and provide a broader perspective to show the efforts and progress in using systems modelling tools to support complex public health problems.
Lucy Clark and colleagues1 (July 22, 2017, p 363) reported that guided graded exercise self-help (GES) for chronic fatigue syndrome was “more useful in those with worse physical functioning”, defined as a Short Form-36 physical function (SF-36 PF) score of 40 or less. As follow-up GES sessions were done by Skype and telephone, this result might suggest to some clinicians the possibility of modifying and extending this intervention to patients with severe and very severe chronic fatigue syndrome, all of whom are housebound and some of whom are bedbound.
The mean score for physical functioning (measured by the Short Form-36 [SF-36] subscale)1 for people aged 35–44 years is 93·3 (SD 13·4).2 Participants in the GETSET trial by Lucy Clark and colleagues3 had a mean age of 38·1 years in the active treatment arm (guided graded exercise self-help [GES] group) and 38·7 years in the control group. After the short 12-week intervention, participants' mean self-reported physical functioning score using the SF-36 scale was 55·7 (23·3) in the GES group, an increase from 47·3 (22·2) before the intervention, compared with a slight increase in physical functioning in the control group from 50·1 (22·6) to 50·8 (25·3).
I was surprised to read that the GETSET trial by Lucy Clark and colleagues1 excluded participants who had physical contraindications to exercise, as such a criterion would appear to exclude anyone suffering from post-exertional malaise (PEM). In its 2015 report,2 the US Institute of Medicine concluded: “There is sufficient evidence that PEM is a primary feature that helps distinguish ME/CFS [myalgic encephalomyelitis/chronic fatigue syndrome] from other conditions”. Indeed, post-exertional neuroimmune exhaustion is a compulsory requirement for a diagnosis of myalgic encephalomyelitis under the International Consensus Criteria.
The results of the guided graded exercise self-help trial (GETSET) by Lucy Clark and colleagues1 reaffirm that graded exercise therapy (GET) is not a rehabilitative treatment for chronic fatigue syndrome.2 Although fatigue (measured by Chalder Fatigue Questionnaire [CFQ]) and physical functioning (assessed using the Short Form-36 physical function [SF-36 PF] subscale) improved in the guided graded exercise self-help (GES) group (and the non-intervention group), these effects were by far insufficient to come close to the normal levels defined previously3 by one of the GETSET authors (CFQ ≤6 and SF-36 PF ≥85).
The CONSORT statement on harms notes that “it is important to report participants who are non-adherent or lost to follow-up because their actions may reflect their inability to tolerate the intervention.”1 It is thus welcome that Lucy Clark and colleagues2 report physiotherapist-rated data on adherence; they considered that only 42% of participants adhered to guided graded exercise self-help (GES) completely or very well. The protocol notes that to “measure departure from intended treatment, participants will be asked at follow-up whether they adhered to the booklet and guidance, and how much PA [physical activity] they undertook in the past week.”3 It would be useful if Clark and colleagues could now also publish such data.
In the graded exercise therapy guided self-help treatment (GETSET) trial,1 we found that addition of guided graded exercise self-help (GES) to specialist medical care (SMC) safely improved fatigue and physical functioning more than did the comparison treatment of SMC alone.
Lucey M, Clark J, Glasziou P. Public availability of trial protocols. Lancet 2017; 390: e54–55. In this Comment, PG should not have been listed as a founding member of SPIRIT in the competing interests statement. This correction has been made to the online version as of March 22, 2018.
Harrison SA, Rinella ME, Abdelmalek MF, et al. NGM282 for treatment of non-alcoholic steatohepatitis: a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. Lancet 2018; 391: 1174–85 —In this Article (published online first on March 5, 2018), Prof Rohit Loomba's affiliation, the y-axis title of figure 2C, and the version of the appendix available online have been updated. These corrections have been made to the online version as of March 22, 2018, and the printed Article is correct.
Multiple sclerosis continues to be a challenging and disabling condition but there is now greater understanding of the underlying genetic and environmental factors that drive the condition, including low vitamin D levels, cigarette smoking, and obesity. Early and accurate diagnosis is crucial and is supported by diagnostic criteria, incorporating imaging and spinal fluid abnormalities for those presenting with a clinically isolated syndrome. Importantly, there is an extensive therapeutic armamentarium, both oral and by infusion, for those with the relapsing remitting form of the disease.
Relapsing-remitting multiple sclerosis (RRMS) has been treatable for over 20 years and increasingly effective therapies continue to be developed.1 Unfortunately, therapies that convincingly affect the progressive phase of MS have yet to be identified. The International Progressive MS Alliance was formed to combat this multifaceted problem.2 This alliance of several MS societies, scientists, foundations, pharmaceutical sponsors, and individuals has been working together since 2012 to accelerate the understanding of, develop therapies for, and undertake clinical trials in progressive MS.
Siponimod reduced the risk of disability progression with a safety profile similar to that of other S1P modulators and is likely to be a useful treatment for SPMS.
Not only can Leo Martinez work opponents on the chess board—he began playing aged 8 and reached national level—he's also a talented scientist who was awarded the 2017 Stephen Lawn TB-HIV Research Leadership Prize for his contributions to reducing the burden of tuberculosis (TB) and HIV/AIDS in Africa. “Leo has done outstanding innovative research on reducing the childhood TB burden—a much needed and underappreciated area”, says Professor Heather Zar, Chair of the Department of Paediatrics and Director of the MRC Unit on Child & Adolescent Health at the University of Cape Town in South Africa.
A public antibody lineage that potently inhibits malaria infection through dual binding to the circumsporozoite protein
A public antibody lineage that potently inhibits malaria infection through dual binding to the circumsporozoite protein, Published online: 19 March 2018; doi:10.1038/nm.4513
Volunteers who develop protection against malaria produce potent antibodies binding to a site of vulnerability on the parasite circumsporozoite protein that is absent in vaccines currently being tested in humans
A human monoclonal antibody prevents malaria infection by targeting a new site of vulnerability on the parasite
A human monoclonal antibody prevents malaria infection by targeting a new site of vulnerability on the parasite, Published online: 19 March 2018; doi:10.1038/nm.4512
The identification of antibodies targeting a conserved site of vulnerability in the Plasmodium falciparum circumsporozoite protein reveals opportunities for passive prevention of malaria in vulnerable individuals and provides insights for rational vaccine design.
On March 11, China's National People's Congress, the top legislative body, approved major constitutional changes that would enable President Xi Jinping to stay in power for more than two terms in office. The healthy China strategy was reviewed in the annual government work report, released by Chinese Premier Li Keqiang at the National People's Congress on March 5, with several key aspects highlighted.
In the first 11 weeks of 2018, there have been 12 school shootings. Although shootings on school campuses only make up a tiny fraction of gun injuries and deaths annually, a March report from the Giffords Law Center focuses on the deep impact of gun violence on children in the USA, elaborating on how it extends far beyond the classroom.