Description: Publication date: 30 June–6 July 2018 Source: The Lancet, Volume 391, Issue 10140 Author(s): Andrew J King, Lars Hanssen, Toby Eyre, Caroline Watson, Ying Ying Peng

Description: Publication date: 30 June–6 July 2018 Source: The Lancet, Volume 391, Issue 10140 Author(s): Emanuele Di Angelantonio, Simon G Thompson, Stephen Kaptoge, David J Roberts, John Danesh

Description: Publication date: 30 June–6 July 2018 Source: The Lancet, Volume 391, Issue 10140 Author(s): Fei Xiao, Xin Tian, Xue-feng Wang

Description: Publication date: 30 June–6 July 2018 Source: The Lancet, Volume 391, Issue 10140 Author(s): Duminda N Wijeysundera, Rupert M Pearse, Mark A Shulman, Tom E F Abbott, Elizabeth Torres, Althea Ambosta, Bernard L Croal, John T Granton, Kevin E Thorpe, Michael P W Grocott, Catherine Farrington, Paul S Myles, Brian H Cuthbertson Background Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (〈4), moderate (4–10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03). Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Description: Publication date: Available online 28 June 2018 Source: The Lancet Author(s): Friends of the UN HLM on NCDsKentBuseRobertMartenSarahHawkesGeorgeAlleynePhillipBakerFranBaumRobertBeagleholeChantalBlouinRuthBonitaLuisaBrumanaJohnButlerSimonCapewellSallyCasswellJosé LuisCastroMickeyChopraHelenClarkKatieDainSandroDemaioAndreaFeiglPatriciaFrenzPeterFribergSharonFrielAmandaGlassmanUnniGopinathanLawrenceGostinSofiaGruskinCorinnaHawkesDavidHipgravePaulaJohnsAlexandraJonesSowmyaKadandaleRogerMagnussonPatricio V.MarquezMartinMcKeeBenjamin MasonMeierCarlos A.MonteiroModiMwatsamaRachelNugentDavidPattersonStefanPetersonYoganPillayJohannaRalstonSrinathReddyJuan A.RiveraSandhyaSinghSudhvirSinghTimSladdenRichardSmithKristinaSperkovaThaksaphonThamarangsiFrancisThompsonDouglasWebb

Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): Chris Salisbury, Mei-See Man, Peter Bower, Bruce Guthrie, Katherine Chaplin, Daisy M Gaunt, Sara Brookes, Bridie Fitzpatrick, Caroline Gardner, Sandra Hollinghurst, Victoria Lee, John McLeod, Cindy Mann, Keith R Moffat, Stewart W Mercer Background The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention. Methods We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958. Findings Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention. Interpretation To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients' quality of life. Funding National Institute for Health Research.

Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): Robert Landewé, Joachim Sieper, Philip Mease, Robert D Inman, Robert G Lambert, Atul Deodhar, Helena Marzo-Ortega, Marina Magrey, Uta Kiltz, Xin Wang, Mei Li, Sheng Zhong, Nael M Mostafa, Apinya Lertratanakul, Aileen L Pangan, Jaclyn K Anderson Background Success of treatment withdrawal in patients with non-radiographic axial spondyloarthritis who are in remission remains unknown. The ABILITY-3 study explored the ability to withdraw adalimumab treatment in patients with non-radiographic axial spondyloarthritis who achieved sustained clinical remission after open-label treatment with adalimumab. Methods ABILITY-3 was a multicentre, two-period study done in 107 sites in 20 countries. We enrolled adult patients (≥18 years) diagnosed with non-radiographic axial spondyloarthritis, fulfilling Assessment of SpondyloArthritis international Society classification criteria but not the modified New York radiologic criterion, who had objective evidence of active inflammation, active disease, and inadequate response to at least two non-steroidal anti-inflammatory drugs. Patients who achieved Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease (〈1·3) with open-label adalimumab (40 mg subcutaneously every other week for 28 weeks) at weeks 16, 20, 24, and 28 were randomly assigned (1:1) using an interactive voice or web response system to 40-week, double-blind treatment with adalimumab (continuation) or placebo (withdrawal). The primary efficacy endpoint was the proportion of patients who did not experience a flare (defined as ASDAS ≥2·1 at two consecutive visits) during the double-blind period. Patients who flared were rescued with open-label adalimumab. This study is registered with ClinicalTrials.gov , number NCT01808118 . Findings Between June 27, 2013, and October 22, 2015, 673 patients were enrolled to the study. The trial completed on April 14, 2017. Of 673 enrolled patients, 305 (45%) achieved sustained remission and were randomly assigned to double-blind treatment (152 patients to adalimumab and 153 to placebo). A greater proportion of patients continuing adalimumab than those receiving placebo did not experience a flare (107 [70%] of 152 patients vs 72 [47%] of 153 patients; p〈0·0001) up to and including week 68. Among 673 patients receiving adalimumab at any time, 516 (77%) patients reported an adverse event and 28 (4%) experienced a serious adverse event. The most common adverse events in both the adalimumab and placebo groups were nasopharyngitis (25 [16%] vs 20 [13%]), upper respiratory tract infection (20 [13%] vs 12 [8%]), and worsening of axial spondyloarthritis (ten [7%] vs 21 [14%]). Interpretation In patients with active non-radiographic axial spondyloarthritis who achieved sustained remission with adalimumab, continued therapy was associated with significantly fewer patients flaring than was treatment withdrawal. Funding AbbVie.

Description: Publication date: Available online 28 June 2018 Source: The Lancet Author(s): Christopher Dowrick

Description: Publication date: Available online 28 June 2018 Source: The Lancet Author(s): Jürgen Braun

Description: Publication date: Available online 28 June 2018 Source: The Lancet Author(s): Rajiv Chowdhury, Rian Lawrence, Kim van Daalen, Sarah Hawkes, Joerg Feldmann