Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): Ganesan Karthikeyan, Luiza Guilherme Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes . Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.

Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): Joseph A Lewnard

Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): Krisztián Bányai, Mary K Estes, Vito Martella, Umesh D Parashar Enteric viruses, particularly rotaviruses and noroviruses, are a leading cause of gastroenteritis worldwide. Rotaviruses primarily affect young children, accounting for almost 40% of hospital admissions for diarrhoea and 200 000 deaths worldwide, with the majority of deaths occurring in developing countries. Two vaccines against rotavirus were licensed in 2006 and have been implemented in 95 countries as of April, 2018. Data from eight high-income and middle-income countries showed a 49–89% decline in rotavirus-associated hospital admissions and a 17–55% decline in all-cause gastroenteritis-associated hospital admissions among children younger than 5 years, within 2 years of vaccine introduction. Noroviruses affect people of all ages, and are a leading cause of foodborne disease and outbreaks of gastroenteritis worldwide. Prevention of norovirus infection relies on frequent hand hygiene, limiting contact with people who are infected with the virus, and disinfection of contaminated environmental surfaces. Norovirus vaccine candidates are in clinical trials; whether vaccines will provide durable protection against the range of genetically and antigenically diverse norovirus strains remains unknown. Treatment of viral gastroenteritis is based primarily on replacement of fluid and electrolytes.

Description: Publication date: Available online 29 June 2018 Source: The Lancet Author(s): The Ebola Outbreak Epidemiology TeamAhmadouBarrySteveAhuka-MundekeYahayaAli AhmedYokouideAllarangarJulienneAnokoBrett NicholasArcherAaronAruna AbediJayshreeBagariaMarie Roseline DarnyckaBelizaireSangeetaBhatiaThéophileBokengeEmanueleBruniAnneCoriErnestDabireAmadou MouctarDialloBoubacarDialloChristl AnnDonnellyIlariaDorigattiTshewang ChodenDorjiAura RocioEscobar Corado WaeberIbrahima SocéFallNeil MFergusonRichard GarethFitzJohnGervais LeonFolefack TengomoPierre Bernard HenriFormentyAlphaFornaAnneFortinTiniGarskeKaty AMGaythorpeCelineGurryEstherHamblionMamoudouHarouna DjingareyChristopherHaskewStéphane Alexandre LouisHugonnetNatsukoImaiBenidoImpoumaGuylainKabongoOly IlungaKalengaEmerencienneKibangouTheresa Min-HyungLeeCharles OkotLukoyaOusmaneLySheilaMakiala-MandandaAugustinMambaPlacideMbala-KingebeniFranck Fortune RolandMboussouTamayiMlandaVitalMondonge MakumaOliverMorganAnastasieMujinga MulumbaPatrickMukadi KakoniDanielMukadi-BamulekaJean-JaquesMuyembeNdjoloko TambweBathéPatriciaNdumbi NgamalaRolandNgomGuillaumeNgoyPierreNouvelletJustusNsioKevin BabilaOusmanEmiliePeronJonathan AaronPolonskyMichael J.RyanAlhassaneTouréRodneyTownerGastonTshapendaReinhildeVan De WeerdtMariaVan KerkhoveAnnikaWendlandN'Da Konan MichelYaoZabulonYotiEtienneYumaGuyKalambayi KabambaJean de DieuLukwesa MwatiGiseleMbuyLeopoldLubulaAnnyMutomboOscarMavilaYyonneLayEmmaKitenge Background On May 8, 2018, the Government of the Democratic Republic of the Congo reported an outbreak of Ebola virus disease in Équateur Province in the northwest of the country. The remoteness of most affected communities and the involvement of an urban centre connected to the capital city and neighbouring countries makes this outbreak the most complex and high risk ever experienced by the Democratic Republic of the Congo. We provide early epidemiological information arising from the ongoing investigation of this outbreak. Methods We classified cases as suspected, probable, or confirmed using national case definitions of the Democratic Republic of the Congo Ministère de la Santé Publique. We investigated all cases to obtain demographic characteristics, determine possible exposures, describe signs and symptoms, and identify contacts to be followed up for 21 days. We also estimated the reproduction number and projected number of cases for the 4-week period from May 25, to June 21, 2018. Findings As of May 30, 2018, 50 cases (37 confirmed, 13 probable) of Zaire ebolavirus were reported in the Democratic Republic of the Congo. 21 (42%) were reported in Bikoro, 25 (50%) in Iboko, and four (8%) in Wangata health zones. Wangata is part of Mbandaka, the urban capital of Équateur Province, which is connected to major national and international transport routes. By May 30, 2018, 25 deaths from Ebola virus disease had been reported, with a case fatality ratio of 56% (95% CI 39–72) after adjustment for censoring. This case fatality ratio is consistent with estimates for the 2014–16 west African Ebola virus disease epidemic (p=0·427). The median age of people with confirmed or probable infection was 40 years (range 8–80) and 30 (60%) were male. The most commonly reported signs and symptoms in people with confirmed or probable Ebola virus disease were fever (40 [95%] of 42 cases), intense general fatigue (37 [90%] of 41 cases), and loss of appetite (37 [90%] of 41 cases). Gastrointestinal symptoms were frequently reported, and 14 (33%) of 43 people reported haemorrhagic signs. Time from illness onset and hospitalisation to sample testing decreased over time. By May 30, 2018, 1458 contacts had been identified, of which 746 (51%) remained under active follow-up. The estimated reproduction number was 1·03 (95% credible interval 0·83–1·37) and the cumulative case incidence for the outbreak by June 21, 2018, is projected to be 78 confirmed cases (37–281), assuming heterogeneous transmissibility. Interpretation The ongoing Ebola virus outbreak in the Democratic Republic of the Congo has similar epidemiological features to previous Ebola virus disease outbreaks. Early detection, rapid patient isolation, contact tracing, and the ongoing vaccination programme should sufficiently control the outbreak. The forecast of the number of cases does not exceed the current capacity to respond if the epidemiological situation does not change. The information presented, although preliminary, has been essential in guiding the ongoing investigation and response to this outbreak. Funding None.

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 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 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 28 June 2018 Source: The Lancet Author(s): Nafsiah Mboi, Indra Murty Surbakti, Indang Trihandini, Iqbal Elyazar, Karen Houston Smith, Pungkas Bahjuri Ali, Soewarta Kosen, Kristin Flemons, Sarah E Ray, Jackie Cao, Scott D Glenn, Molly K Miller-Petrie, Meghan D Mooney, Jeffrey L Ried, Dina Nur Anggraini Ningrum, Fachmi Idris, Kemal N Siregar, Pandu Harimurti, Robert S Bernstein, Tikki Pangestu, Yuwono Sidharta, Mohsen Naghavi, Christopher J L Murray, Simon I Hay Background As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care. Methods We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results. Findings In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3–8·8) to 71·7 years (71·0–72·3): the increase was 7·4 years (6·4–8·6) for males and 8·7 years (7·8–9·5) for females. Total DALYs due to communicable, maternal, neonatal, and nutritional causes decreased by 58·6% (95% UI 55·6–61·6), from 43·8 million (95% UI 41·4–46·5) to 18·1 million (16·8–19·6), whereas total DALYs from non-communicable diseases rose. DALYs due to injuries decreased, both in crude rates and in age-standardised rates. The three leading causes of DALYs in 2016 were ischaemic heart disease, cerebrovascular disease, and diabetes. Dietary risks were a leading contributor to the DALY burden, accounting for 13·6% (11·8–15·4) of DALYs in 2016. Interpretation Over the past 27 years, health across many indicators has improved in Indonesia. Improvements are partly offset by rising deaths and a growing burden of non-communicable diseases. To maintain and increase health gains, further work is needed to identify successful interventions and improve health equity. Funding The Bill & Melinda Gates Foundation.

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

Description: Publication date: 30 June–6 July 2018 Source: The Lancet, Volume 391, Issue 10140 Author(s): The Lancet