Lancet

The assassination of Brian Thompson, UnitedHealthcare's Chief Executive Officer, on Dec 4, 2024, in New York City, has catapulted American medicine, with all of its tragic inconsistencies and injustices, once again into the political spotlight. With the words “deny”, “depose”, and “defend” inscribed on three bullet casings, attention was drawn to the questionable practices of America's health insurance companies. They faced allegations of delaying payments, denying settlements, and defending obstructive behaviours by tying patients up in expensive litigation.

Professor Sabina Faiz Rashid is the Mushtaque Chowdhury Chair in Health and Poverty and the Director of the Center of Excellence for Gender, Sexual and Reproductive Health and Rights at the BRAC James P Grant School of Public Health, BRAC University in Dhaka, Bangladesh. She is also an Honorary Professor at the Liverpool School of Tropical Medicine in the UK. Through her 30-year career she has “continued to work on health and poverty and gender, and rights, expanding how public health is defined…critiquing how gender and health is understood, and how public health itself is very disease centric, despite evidence indicating that health is deeply interconnected to housing, food, jobs, water and sanitation, environment, and many other structural factors”, Rashid explains.

There have been extensive evaluations of artificial intelligence (AI) systems for narrow medical tasks, but more work is needed to systematically evaluate and deploy AI systems that can perform a broad range of medical tasks. The medical training process itself might offer a template for addressing this challenge. Clinicians undergo rigorous education and training, progressing through stages of increasing responsibility and autonomy. Similarly, generalist medical AI systems could be subjected to a phased certification model before they are granted greater autonomy in patient care.

Tamarin Norwood is a member of a club nobody wants to join. It is not short of members. UNICEF records around 1·9 million stillbirths annually and 4·0 stillbirths per 1000 births occurred in the UK in 2023, rising to 6·3 for Black mothers. Other club members are people who miscarry (of which I am one), experience ectopic pregnancy, have a molar pregnancy, or have terminations for medical reasons. Prevalence of loss is higher in many low-income countries, and access to pregnancy and baby loss care varies depending on state and country legislation.

War and the Mind, a temporary exhibition at IWM London, UK, asks what it is within the human mind that initiates and maintains conflict, and how conflict, in turn, affects the workings of the human mind. Its focus is on wars in which the UK has engaged since the outbreak of World War 1 in 1914; however, it sets these in a wider context, with the first room featuring digital projections of neurons, brains, orchestras, and construction. Our brains are formed of cooperative networks, and this is reflected in the great joint endeavours that form human civilisation.

Trailblazing neurosurgeon. She was born on Aug 12, 1940, in Palo Alto, CA, USA, and died on Aug 5, 2024, in Sea Ranch, CA, USA, of complications from dementia, aged 83 years.

Primary immune thrombocytopenia is an autoimmune disease in which autoreactive B cells play a crucial role in pathogenesis by producing autoantibodies primarily directed against platelet surface glycoproteins (eg, glycoprotein IIb/IIIa; fibrinogen receptor) that trigger platelet destruction, resulting in severe thrombocytopenia. The annualised incidence of primary immune thrombocytopenia is approximately 3·3 cases per 100 000 people among adults.1 Despite several treatment options, including approved thrombopoietin receptor agonists and commonly used antibody-reducing approaches—such as B-cell depletion with the anti-CD20 monoclonal antibody rituximab, BTK inhibitors, SYK inhibitors, corticosteroids, and splenectomy—a subset of patients develop refractory immune thrombocytopenia.

Amanda I Adler and colleagues provided the striking evidence that the legacy effect of hyperglycaemia extends for up to 42 years of follow-up.1 Previous meta-analyses evidenced that the legacy effect becomes more apparent with a progressive longer duration of follow-up, but the benefit is not observed when only the events recorded during the observational phases of the trials are considered.2 The data presented by the authors might suggest a possible increasing benefit over time for intensive therapy, especially compared with the incidence of myocardial infarction.

We read Amanda I Adler and colleagues’ study on intensive glycaemic control in type 2 diabetes with keen interest. The 24-year post-trial follow-up provides unprecedented long-term insights.1 However, we have identified areas for enhancement.

We thank Francesco Prattichizzo and Antonio Ceriello, and Ruirui Hou and Jian Ren for their interest in our Article.1 Examining UK Prospective Diabetes Study (UKPDS) observational data separately is difficult because adjusting appropriately for survivor effects is problematic. We continue to prefer to analyse the entirety of the data according to primary randomisation categories. The glycaemic legacy effect was seen with all randomised therapies used in the UKPDS, suggesting that the mode of glucose lowering is less important than achieving good glycaemic control.

We read with great interest the SWITCH trial,1 which is an important amendment to the literature on the role of decompressive craniectomy for deep-seated intracranial haemorrhage. We applaud the authors for the trial. Sample size calculation was based on a dichotomised modified Rankin scale (mRS) 5–6 versus 0–4 and the primary analysis follows all recommendations in clinical trial planning, analysis, and reporting. However, the study's interpretation is overly optimistic and concerning. Death (mRS 6) has been exchanged by high-level dependence (mRS 4) among participants undergoing decompressive craniectomy and no secondary outcomes suggest benefit: the analysis dichotomised at mRS 0–3 versus 4–6 was neutral; quality of life measures at 180 years and 365 years were essentially the same; and permanent residential care at 180 days (71% vs 62%) and 1 year (43% vs 38%) was high in both groups and underpowered to detect a detrimental result.

The SWITCH trial advances knowledge regarding the optimal management of large, deep intracerebral haemorrhage.1 This study showed a small benefit for decompressive hemicraniectomy in addition to optimal medical management for minimising death or severe disability (modified Rankin scale 5–6) at 6 months. A substantial proportion of the observed benefit was driven by reductions in mortality in the intervention group. However, the authors do not elaborate on the rates of withdrawal of life-sustaining therapy (WOLST) in each group, or if there was a protocolised approach to goals of care conversations.

The SWITCH trial by Jürgen Beck and colleagues showed a trend towards improved 6-month outcome (although not statistically significant) when deep intracerebral haemorrhage was treated with decompressive craniectomy in addition to best medical treatment, and even had no effect if the modified Rankin score of 4 was considered a poor outcome.1

I read with interest the Article by Jürgen Beck and colleagues1 presenting the SWITCH clinical trial, assessing whether decompressive craniectomy added to best medical treatment improves outcomes after spontaneous deep intracerebral haemorrhage. The Article is methodologically important because it presents a confidence distribution for the treatment effect, which is a new and advantageous approach to reporting clinical trial results.2

We thank Roberta Muriel Longo Roepke and Bruno Adler Maccagnan Pinheiro Besen, Jennifer A Frontera and Nicholas A Morris, Nicolas Engrand and Loïc Miry, and Ian C Marschner for their interest in the SWITCH trial.1 A spontaneous severe deep supratentorial intracerebral haemorrhage is a devastating disease: without treatment, more than 50% of victims die or are severely disabled. Decompressive craniectomy tends to reduce mortality without an increase in the number of severely disabled patients recovering from intracerebral haemorrhage (modified Rankin score [mRS] 5).

Watts G. Timothy Danforth Baker. Lancet 2014; 383: 690—In this Obituary, the date of birth has been corrected to July 4, 1925. This correction has been made to the online version as of Jan 2, 2025.

Rydelius J, Hognert H, Kopp-Kallner H, et al. First dose of misoprostol administration at home or in hospital for medical abortion between 12–22 gestational weeks in Sweden (PRIMA): a multicentre, open-label, randomised controlled trial. Lancet 2024; 404: 864–73—In this Article, the definition of 21 gestational weeks and 6 days should have read “153 days” in the Participants section of the Methods. This correction has been made as of Jan 2, 2025.

Werring DJ, Dehbi H-M, Ahmed N, et al. Optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS): a multicentre, blinded-endpoint, phase 4, randomised controlled trial. Lancet 2024; 404: 1731–41—In the Summary of this Article, the first line should have read “acute ischaemic stroke”. In figure 2 of this Article, the number at risk in the delayed DOAC initiation group at 0 days should have read “1807”. These corrections have been made to the online version as of Jan 2, 2025.

A 26-year-old woman with a 2-month history of postcoital bleeding—which she described as very heavy loss and lasting 2 days—attended our unit.

Osteoarthritis is a heterogeneous disorder that is increasingly prevalent largely due to aging and obesity, resulting in a major disease burden worldwide. Knowledge about the underlying aetiology has improved, with increased understanding of the role of genetic factors, the microbiome, and existence of different pain mechanisms. However, this knowledge has not yet been translated into new treatment options. New evidence has questioned the efficacy of recommended treatments, such as therapeutic exercise programmes and the focus on weight loss, but managing obesity and maintaining activity remain important for the prevention and management of osteoarthritis.