12-year-old Tommy lay listlessly in his hospital bed. I noticed, however, that his eyes were becoming a bit brighter since I had bounded into the room a moment earlier with my satchel of magic paraphernalia and made three red foam balls disappear into thin air.

A warm light suffuses an empty stage surrounded by nine pianos. A young woman walks to the front and she is caught by a panic attack. Thus the new production of Tennessee Williams' Summer and Smoke, directed by Rebecca Frecknall at London's Almeida Theatre, begins. Written in 1948, just after the success of A Streetcar Named Desire, the play, in its deceptive simplicity, touches some of the key themes of Williams' early works: the marginalisation of women in the southern states of the USA, the dichotomy between spirituality and carnality, and the lability of mental health.

Comedian Robert Newman first came to prominence in the UK during the 1990s and readers of a certain age will remember how classrooms across the UK once abounded with his catchphrases. Newman subsequently largely rejected fame and reinvented himself as iconoclastic stand-up tackling complex subjects with wit and erudition. Whilst one of his early sketches—“History Today”—mocks scholars by having two elderly professors tirelessly trading playground insults, Newman has now graduated to challenging academics directly.

Neurologist and athletic record-breaker. He was born in Harrow, UK, on March 23, 1929, and died in Oxford, UK, on March 3, 2018, aged 88 years.

The insurgency by the Boko Haram terrorist group in northeast Nigeria has had devastating effects on the region including thousands of deaths, internal displacement, destruction of private and public properties, and considerable economic ruin. The violent conflict perpetuated by the group also has public health implications and has affected the spread and management of HIV, which remains a huge public health issue in Nigeria.

We read the Offline Comment by Richard Horton (Jan 13, p 106)1 that summarised the evidence and current policy debate in England around minimum unit pricing for alcohol with interest. Unfortunately, the Comment contained an important error, which has already been repeated in UK parliamentary hearings and that we would like to correct to avoid it being repeated elsewhere. This error is the statement that “liver disease is on a trajectory to become the biggest cause of death in England and Wales”.

The Cro-Magnon 1 skeleton corresponds to a 28?000 BCE Homo sapiens male individual that was discovered in 1868 in a rock shelter in Les Eyzies, France.1 Since its discovery, various diagnoses have been proposed with regards to a round polycyclic osteolytic lesion on the right frontal bone, measuring 37 mm?x?27 mm (appendix): post-mortem alteration due to the soil,2 rickets,3 actinomycosis,4 and Langerhans cell histiocytosis.5

We read with interest the Lancet Editorial on artificial intelligence (AI) in health care (Dec 23, 2017, p 2739).1 Deep learning as a form of AI risks being overhyped. Deep neural networks contain multiple layers of nodes connected by adjustable weights. Learning occurs by adjusting these weights until the desired input-to-output function is achieved.2 With many millions of weights, huge amounts of data are required for learning, a process facilitated by recent increases in computational power. However, the learning algorithm, known as the error back-propagation algorithm, was invented in the 1980s and has been used to train neural networks ever since.

Our research into the UN Relief and Works Agency (UNRWA)'s delivery of health services to Palestinian refugees during the Syria crisis1 puts us in a unique position to anticipate the challenges of the organisation's current funding crisis.2 We have conducted over 90 interviews with health workers and managers, a series of systems modelling sessions, and rigorous analysis of UNRWA health data from 2007–16, and conclude the following.

We read with great interest the Seminar (Feb 9, 2017, p 2239)1 on type 2 diabetes by Sudesna Chatterjee and colleagues. However, we were surprised by the articles selected and believe that detailed selection criteria with the level of evidence of reported studies would have been useful to the reader. According to the research method described, we would expect other papers to be cited, including meta-analyses of randomised controlled trials that could have balanced the authors' outlook.2–6 For example, intensive glycaemic control probably has some beneficial effect on diabetic complications, such as non-fatal myocardial infarctions3–5 or retinopathy assessed with the Early Treatment Diabetic Retinopathy Study scale.

In the summary of their Seminar,1 Sudesna Chatterjee and colleagues state that the incidence of type 2 diabetes “continues to rise globally”. There is no evidence to support this claim and most recent literature suggests that, in developed countries, incidence peaked sometime in the last decade and then levelled off or slightly decreased.2–5

We thank A Rosemary Tate for her insightful comments on our Seminar.1 Tate indicates that there is no evidence to support the rise in global incidence of type 2 diabetes mentioned in the summary by citing a number of references published between 2014 and 2017 in the USA and UK.

The global need for new antimalarial drugs and new combinations is enormous and urgent,1,2 but their successful delivery needs resilience to overcome the barriers imposed by expensive and lengthy clinical development plans. Attention is often directed to areas such as southeast Asia, where some antimalarial combinations are failing but transmission intensities are much lower than in sub-Saharan African countries. Children in Africa have frequent and life-threatening malaria infections as they grow up, and these need to be treated safely.

Pyronaridine–artesunate and dihydroartemisinin–piperaquine treatment and retreatment of malaria were well tolerated with efficacy that was non-inferior to first-line ACTs. Greater access to these efficacious treatments in west Africa is justified.

Sudden infant death syndrome (SIDS) remains a leading cause of infant mortality, despite a steadily decreasing incidence since the 1990s.1 The reasons for this decline are debated, but it could be due to methodological reasons (eg, changes in reporting or advances in diagnosis of specific diseases) or a reduction of risks, such as an increase in supine sleeping position for infants, as advocated by the Back to Sleep campaign.2 A better understanding of the causes of SIDS is needed to identify infants at high risk and to develop interventions and guidelines that will prevent SIDS for all infants.

Rare SCN4A variants that directly alter NaV1.4 function occur in infants who had died from SIDS. These variants are predicted to significantly alter muscle membrane excitability and compromise respiratory and laryngeal function. These findings indicate that dysfunction of muscle sodium channels is a potentially modifiable risk factor in a subset of infant sudden deaths.

No abstract available

No abstract available

Objectives: The optimum duration of antimicrobial treatment for patients with bacteremia is unknown. Our objectives were to determine duration of antimicrobial treatment provided to patients who have bacteremia in ICUs, to assess pathogen/patient factors related to treatment duration, and to assess the relationship between treatment duration and survival. Design: Retrospective cohort study. Settings: Fourteen ICUs across Canada. Patients: Patients with bacteremia and were present in the ICU at the time culture reported positive. Interventions: Duration of antimicrobial treatment for patients who had bacteremia in ICU. Measurements and Main Results: Among 1,202 ICU patients with bacteremia, the median duration of treatment was 14 days, but with wide variability (interquartile range, 9–17.5). Most patient characteristics were not associated with treatment duration. Coagulase-negative staphylococci were the only pathogens associated with shorter treatment (odds ratio, 2.82; 95% CI, 1.51–5.26). The urinary tract was the only source of infection associated with a trend toward lower likelihood of shorter treatment (odds ratio, 0.67; 95% CI, 0.42–1.08); an unknown source of infection was associated with a greater likelihood of shorter treatment (odds ratio, 2.14; 95% CI, 1.17–3.91). The association of treatment duration and survival was unstable when analyzed based on timing of death. Conclusions: Critically ill patients who have bacteremia typically receive long courses of antimicrobials. Most patient/pathogen characteristics are not associated with treatment duration; survivor bias precludes a valid assessment of the association between treatment duration and survival. A definitive randomized controlled trial is needed to compare shorter versus longer antimicrobial treatment in patients who have bacteremia.

Objective: Despite telemedicine’s potential to improve patients’ health outcomes and reduce costs in the ICU, hospitals have been slow to introduce telemedicine in the ICU due to high up-front costs and mixed evidence on effectiveness. This study’s first aim was to conduct a cost-effectiveness analysis to estimate the incremental cost-effectiveness ratio of telemedicine in the ICU, compared with ICU without telemedicine, from the healthcare system perspective. The second aim was to examine potential cost saving of telemedicine in the ICU through probabilistic analyses and break-even analyses. Design: Simulation analyses performed by standard decision models. Setting: Hypothetical ICU defined by the U.S. literature. Patients: Hypothetical adult patients in ICU defined by the U.S. literature. Interventions: The intervention was the introduction of telemedicine in the ICU, which was assumed to affect per-patient per-hospital-stay ICU cost and hospital mortality. Telemedicine in the ICU operation costs included the telemedicine equipment-installation (start-up) costs with 5-year depreciation, maintenance costs, and clinician staffing costs. Telemedicine in the ICU effectiveness was measured by cumulative quality-adjusted life years for 5 years after ICU discharge. Measurements and Main Results: The base case cost-effectiveness analysis estimated telemedicine in the ICU to extend 0.011 quality-adjusted life years with an incremental cost of $516 per patient compared with ICU without telemedicine, resulting in an incremental cost-effectiveness ratio of $45,320 per additional quality-adjusted life year (= $516/0.011). The probabilistic cost-effectiveness analysis estimated an incremental cost-effectiveness ratio of $50,265 with a wide 95% CI from a negative value (suggesting cost savings) to $375,870. These probabilistic analyses projected that cost saving is achieved 37% of 1,000 iterations. Cost saving is also feasible if the per-patient per-hospital-stay operational cost and physician cost were less than $422 and less than $155, respectively, based on break-even analyses. Conclusions: Our analyses suggest that telemedicine in the ICU is cost-effective in most cases and cost saving in some cases. The thresholds of cost and effectiveness, estimated by break-even analyses, help hospitals determine the impact of telemedicine in the ICU and potential cost saving.