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Molly Bartlett discusses how to have those difficult conversations around not continuing treatment, and how she made the decision to enjoy the time she has left

Mark Lesselroth describes how information and peer support helped him to accept that his vision impairment could worsen

mRNA vaccines have proven themselves as the most effective covid-19 vaccines, and their makers are now seeking to help conditions from cancer to HIV. Andy Extance investigates their promise and limitations

Photo credit: Paul Fetters Howard Hughes was one of the most flamboyant billionaires of the mid-20th century. Think Elon Musk or Richard Branson, then add another healthy dollop of ego and media showmanship. As a young man, Hughes built and flew record breaking fast aeroplanes, created a company to build them, and gained control of Trans World Airlines, one of the few globe spanning carriers. As a sideline he ran a Hollywood motion picture studio and squired a bevy of starlets with names such as Joan Crawford, Bette Davis, and Ava Gardner. He made a lot of money too. He had a lifelong interest in medicine and established the namesake institute in 1953. Initially it was little more than a tax dodge. Hughes would donate stock to the institute and write off the charitable contribution against tax. But he maintained voting control of the stock and of his company. Congress investigated, changed the law, and slowly the institute began to spend more money supporting research. …

Dominic Lipinksi/PA/Alamy Frank Acquaah, a trauma and orthopaedic surgeon, stands in front of an art installation, Tunnel of Light, at Guy’s and St Thomas’s Hospital in south London. The tunnel, created by the art group Squidsoup, produces the …

Photo credit: Courtesy of Chain of Hope In 1964 Magdi Yacoub was a senior registrar working at the Royal Brompton Hospital in London. He said, “I was doing my round late at night, preparing for the following day, and I found a young doctor reviewing the notes. We got talking and she told me ‘I have studied every patient on the ward and your patient has x, y, and z.’” The young woman was cardiologist Rosemary Radley-Smith, and she and Yacoub were to forge a close working partnership that lasted nearly 50 years. Born in 1939 in Epsom, Surrey, Radley-Smith was the eldest of four children. Her father, Eric, was a neurosurgeon and her mother, Eileen, was a nurse at King’s College Hospital. After studying at Trevelyan School in Hayward’s Heath and Cheltenham Ladies’ College, Radley-Smith went to the Royal Free Hospital in London to study medicine, qualifying in 1963. Anxious, according to colleagues, to free herself from her father’s shadow and to prove her …

Steve Parsons/PA To the sound of organ music, hundreds of people aged over 80 receive their Pfizer-BioNTech covid-19 vaccination inside the grandeur of Salisbury Cathedral transept. On Saturday 16 January the cathedral was turned into a pop-up vaccination hub by Sarum South Primary Care Network. Its co-clinical director Dan Henderson said around 1000 patients and …

Jeff McLane, courtesy the artist and Anton Kern Gallery, New York The stories of NHS workers contending with the covid pandemic in Liverpool have been celebrated in a series of portraits by the internationally famous artist Aliza Nisenbaum. The Mexican born, New York based painter met her sitters over video calls that lasted many hours. …

Jonathan Ramael/GDIF-wright To pay tribute to people who have died from covid-19 and to honour the sacrifice of health workers in the NHS and across Europe, …

Hospitals under attack are struggling to provide healthcare to a badly damaged Syria, reports Elisabeth Mahase

Debate on whether new drugs are too expensive for the NHS continues to rage, and contradictory news stories reflect the polarisation, reports Adrian O’Dowd

Disseminated intravascular coagulation has long been associated with increased mortality in patients with sepsis. An effective treatment is now available, and the authors of this review describe how improved understanding and earlier diagnosis could lead to targeted treatment and improved prognosis Although the first clinical observations on disseminated intravascular coagulation (DIC) were reported in the 19th century,1 this condition of widespread and disordered coagulation has probably afflicted mankind for as long as trauma and infection have beset us. Indeed, DIC is generally associated with an adverse outcome by most clinicians, and its acronym has been synonymous with “death is coming.” However, a drug targeted at the coagulopathy of severe sepsis (activated protein C) has now emerged as the first successful treatment for the condition.2 We provide an updated overview of DIC and how its onset may indicate the turning point from which an adaptive response becomes maladaptive and potentially injurious to the host. Precise laboratory definition of this process could provide a therapeutic window in critical illness that may finally deliver an improved outcome. A systematic search of PubMed with the search term “disseminated intravascular coagulation” and related keywords yielded 10 262 publications, most of which related to pathophysiology and case reports. Owing to a lack of systematic controlled clinical trials, many recommendations are based on expert opinion and consensus driven guidelines rather than a secure evidence base. However, an increasing number of randomised controlled trials studying the diagnosis and management of DIC have been reported in the past five years, and we have incorporated these in the review. DIC represents a continuum in clinical-pathological severity, characterised by the increasing loss of localisation or compensated control in intravascular activation of coagulation. It has definable phases that characterise patients at risk for increased mortality. The International Society of Thrombosis …

A doctor who cares for 750 000 people, seven days a week, in Sudan’s war ravaged Nuba Mountains has scooped a $1m (£777 000; €894 000) humanitarian prize that was set up to mark the Armenian genocide. The $1m will go to charities of the winner’s choice. Tom Catena, a Catholic missionary from the US, is the only medic in the remote, violence plagued region and can see as many as 400 patients a day. He regularly has to dive into makeshift, dug-out bomb shelters along with patients, for whom he provides everything from paediatrics and general surgery to psychiatric care. Accepting the Aurora prize for awakening humanity in the …

Chemists in California have modified the molecule of the antibiotic vancomycin to make it harder for bacteria to avoid destruction.1 The result could provide one answer to the growing problem of antibiotic resistance, said Dale Boger and colleagues, from the Scripps Research Institute in La Jolla. “Doctors could use this modified form of vancomycin without fear of resistance emerging,” claimed Boger, who has been working on enhancing vancomycin for some years. The drug was discovered in 1956 and first used in 1958. The fact that it is still highly effective attests to the …

Robert Hope Mackay (“Rob”) was born in Cairo, Egypt, and educated in England from a young age. He trained at Guy’s Hospital Medical School and later worked in junior hospital posts in London, where he met and married Fran, a nurse. After spending a year working in Bermuda, he completed his training for general practice in Evesham before moving to Churchdown, Gloucestershire, to take up the post of GP partner in a training practice in 1976. During his 30 years in the practice, Rob epitomised all the very best qualities of personal family doctoring. His abilities went beyond medical knowledge and technical expertise into the territory of compassion, empathy, and shared humanity. His patients’ comments in his retirement book reveal a doctor who was always professional, dedicated, and willing to go the extra mile. …

Scientists at Edinburgh University have developed a service to store testicular tissue from boys as young as 1 who are at risk of infertility because of cancer treatment. In future boys as well as girls might be able to have their fertility restored subsequent to chemotherapy. The announcement comes after the birth of the first UK baby to be born after his mother had a transplant of her own, previously frozen, ovary tissue. The 33 year old woman from Edinburgh had a section of her ovary removed 11 years ago, …

Among claims made in an article in the Times for the efficacy of essential fatty acids in treating osteoporosis, restenosis after angioplasty, and human immunodeficiency virus was a claim of “impressive results in delaying death in patients suffering from pancreatic tumours.” A friend of my fiance's family was recently diagnosed as having pancreatic carcinoma with hepatic metastases and is now in a hospice. My future father in law telephoned me in a state of some excitement. He is not a medical man, but claimed a healthy scepticism: “95% chance that it's a load of cobblers, …

More women are turning to egg freezing to beat their biological clock despite uncertain success rates. Sophie Arie sets out the facts

After graduating Robin John Hope did house jobs at the Middlesex and Chase Farm hospitals, followed by six months as ship’s surgeon on Blue Star Line, travelling to South America. He then worked as a general practitioner in Lagos, Nigeria, for 18 months. On returning to the UK he became a …

The free flow of trade and money around the world has brought economic growth for the fortunate in the largest and strongest economies but has also created widening gaps in wealth and health between, and within, countries. These polarising forces have intensified in the past decade, creating a hundred million poor within the rich “core” in addition to the 1.3 billion people in the “periphery” who exist on $1 a day or less.1 Sub-Saharan Africa is the most dramatic loser. Here poverty is at its most stark and marginalisation from the global economy most pronounced. The continent contains 33 of the world's 50 poorest countries. Improvements in health, education, and living standards have reversed in the past two decades, and standards continue to fall. By the end of the decade, two thirds of Africans will live in “absolute poverty.”2 More than half still lack safe water and 70% are without proper sanitation; 40 million children are not in primary school. Infant mortality is 55% higher than in the rest of the world's low income, developing countries, and average life expectancy, at 51 years, is 11 years less.3 Malaria and tuberculosis are increasing, and in parts of central, southern, and eastern Africa 30-40% of pregnant women are now HIV positive.2 #### Summary points Two thirds of people living in sub-Saharan Africa are desperately poor Health and education standards continue to deteriorate More money is spent on debt servicing than on health and education Within Africa, corruption, wars, and lack of commitment to health (especially women's health) have contributed towards the appalling health indices The role of the industrialised countries in destabilising Africa needs to be openly debated Poverty causes ill health, but ill health also imposes immense economic costs on individuals, their families, and society. African productivity could increase by …

Advertisements for cancer centers in the United States promote treatments rather than screening and supportive care and rely on emotional appeals that focus on the hope of cure rather than the comfort and quality of life, a new study has found. In the study, researchers looked at 409 magazine and television advertisements placed by 102 US cancer centers in 2012. Their results were published online in the journal Annals of Internal Medicine . Laura B Vater, of the University of Pittsburgh Graduate School of Public Health in Pittsburgh, Pennsylvania, was the study’s lead author.1 Vater and her …

“Welcome to Sarajevo,” Semir said. “You see that everything is exactly the same—no gas, no water, no electricity, shelling, and sniping.” Three hours earlier I had arrived back in Bosnia to work with children with special needs and was startled to find myself in a city with brightly lit shops, including a Benetton in the main street, and full cafes. One hour later the city's fragile power supply had given in to the heaviest December snowfall in 10 years, and Sarajevo was plunged into foggy gloom. So now I sat huddled under blankets in the flat of Dr Narcisa Pojskic and her husband, Dr Semir Beslija, two physicians who had stayed in Sarajevo throughout the war. Dr Beslija had divided his time between clinical duties in the city and the front line. Dr Pojskic had helped to set up and run the mental health project of one of the larger nongovernmental organisations. Both viewed the peace plan with a mixture of cautious optimism and ambivalence. They were all too aware of the flaws. They could not, for example, imagine how the unprecedented creation of a supposedly unified state with three separate armies was supposed to work. Nor did they believe that Bosnians expelled from cities remaining under Serb control would exercise their right to return. “So the Serbs will have their ethnically pure state, at least in the immediate future,” said Semir. And the reality of an undivided Sarajevo had yet to be brought about. On the day the Dayton agreement was signed in Paris there had been some 300 sniping incidents and four shells lobbed into the city. The following day demonstrating Serbs had blocked convoys through the Karazic controlled suburbs of Iliza. “We do not feel it is peace yet,” Narcisa explained. “We can smell it, but until …

A tetravalent dengue vaccine has shown efficacy against dengue fever and severe dengue fever and led to fewer hospitalisations in a randomised, blinded, placebo controlled trial. The efficacy trial, reported in the New England Journal of Medicine ,1 was carried out in five Latin American countries in which dengue is endemic. A total of 20 869 healthy children aged 9 to 16 were randomly assigned in a 2:1 ratio to receive either three injections of recombinant, live attenuated tetravalent dengue vaccine (CYD-TDV) or placebo. Dengue is transmitted by mosquitoes …

Pesticides may be to blame for cancers among Punjab’s farmers. Indian Railways is helping farmers get the care they need, writes Akhil Kapoor, miles away at a cancer centre in the middle of a desert

Blackhall faces the challenges of the US system, whereby Medicare hospice benefit is payable only to those certified by a physician to be in the last six months of life and willing to forgo potentially curative treatment.1 This places a greater emphasis on accurate prognostication, and takes away the “hope” of potentially curative treatment being …

When Jesus said “the poor always ye have with you,” he presumably wasn’t joking, but governments repeatedly try to prove him wrong. Every time a new underclass disaster makes headlines, the social work equivalent of the SAS is mobilised to persuade the family to become, well, “more like us,” but it rarely works. Families Without Hope explains why and describes some typical families. “The front garden is characteristic. An overgrowth of natural flora competes with broken bottles, sodden cardboard and the rusting remains of once-expensive toys, prams, cycle parts and other scrap. A well-worn earth path leads from the dominant …

The UK could follow Australia’s historic lead and introduce standardised plain packaging for all cigarettes, a conference heard this week. In November 2011 Australia became the first country to ban all branding and advertising on cigarette packs. By December 2012 all cigarettes in Australia will be sold in uniform olive green cartons with a graphic health warning and the name of the brand shown only in a small, standardised font. Campaigners and public health specialists believe that New Zealand will be next to emulate Australia, and hope that Britain, Thailand, Panama, and Uruguay …

Dancer eloquently explained what patients and the public have long thought—today’s doctors look scruffy and cannot easily be identified.1 I recently observed surgery in North America and France, where doctors were easily identifiable by their white coat and professional attire. At home, my colleagues are happy to come to work in …

Patients with dementia and their families still face hurdles in getting support and care, a conference in London on 27 June heard. But despite the problems—and against a backdrop of recent disappointments in drug development—the mood was not downcast. Advocates of people with dementia believe that at last they have the ear of government and that change is possible. David Blunkett, MP, set the tone by welcoming what he called David Cameron’s “continuing commitment” on dementia. “It matters that the prime minister is interested,” said Blunkett, a former Labour cabinet minister whose speech gained force by its avoidance of political point scoring. Almost the only political point he made was against his own side, an acknowledgment that the £150m (€175m; $230m) the Labour government put into dementia care when Alan Johnson was health secretary ought to have been ringfenced to ensure that it was spent as intended. Blunkett also disclosed …

The media went crazy for a recent research paper that showed some benefit in long term antibiotic use for some patients with back pain. But was this science or sensationalism, is talk of a Nobel prize premature, and what of the author’s potential conflicts of interest? Margaret McCartney investigates

I hope that the doctor looking after the psychological health of the miners was misquoted or mistranslated, but if he did say, “Now the men are starting to demand certain things, and we restrict others. We are measuring each other’s strength” and that the miners would be rewarded if they cooperated but “If not, okay, you don’t want to …

At the age of 33, John Hope Henderson became physician superintendent of Elgin Hospital, embarking on a five year programme of ambitious and innovative community and hospital service modernisation. A few years later he became head of the much larger Bangour Village Hospital in East Lothian and continued reforming and modernising services. He became one of the early exponents of social psychiatry, in which clinical skills were melded with the ability to understand and respond to the social circumstances of patients and families. His influence on mental health in Scotland expanded further in 1974, …

One of the hardest parts of being a GP is seeing people who you know well suffer. I knew that the death of one of my patients would hit her husband hard. He seemed almost grey with grief. Nothing mattered to him. Her ashes were at home, and he could hardly bear to leave the house because it felt like abandoning her. After caring for her in chronic ill health for years, he now lacked both companionship and …

One of the most recent techniques of assisted reproduction, intracytoplasmic sperm injection, offers hope for those suffering from subfertility, and particularly male factor infertility. This hope is tempered by worry, since couples who undergo this procedure might never become pregnant or, if they do, may not carry the pregnancy to term. Added to these known risks are theoretical risks regarding birth defects: intracytoplasmic sperm injection involves fertility drugs, chemical baths, and physical procedures, any of which could increase malformation rates. Moreover, if left to nature, the sperm manipulated by this procedure would probably not produce a pregnancy, and these sperm themselves may carry an increased risk for birth defects. Some reassurance about these theoretical concerns was offered recently when researchers from Belgium reported that major birth defects affected only 3.3% (14) of 423 children born after intracytoplasmic sperm injection,1 a rate no higher than in the general population. In the current issue, however, Kurinczuk and Bower provide a less reassuring interpretation.2 Using the classification scheme and data from the highly regarded Western Australia birth defects registry, they note that many major defects in the Belgian series …

In the mid-1990s the World Health Organization seemed doomed to either “flounder in a morass of petty corruption and ineffective bureacracy”1 or to die.2 Neither of these happened. Instead, Gro Harlem Brundtland, who took office as director general in July 1998, restored the organisation's reputation as a credible force in global health.3 Last week the World Health Assembly approved Jong-Wook Lee as Brundtland's successor. Unlike Brundtland, Lee is not being charged with saving the organisation but with harnessing its potential to transform the lives of the poorest. There are four things he must do to help achieve this. Firstly, he must start to close the huge gap between what WHO is doing on the global stage and what is happening at country level. Where Brundtland focused her energies and much of WHO's resources on headquarters—a strategy that was useful for launching new, high profile public-private partnerships—Lee must think globally and act locally. High profile public-private initiatives are being rolled out in countries with weak public health systems. The poorest countries struggle with epidemics, natural …

Local authorities are not the only guardians of public health who invest in tobacco companies.1 I recently sought advice from Wesleyan, a company that specialises in financial …

Researchers have identified a single receptor on the surface of red blood cells on which the malaria parasite Plasmodium falciparum relies to invade the cells. It is hoped that the discovery will lead to the development of the first fully effective vaccine against this or any other parasite. The stage of the Plasmodium lifecycle when the parasite invades human erythrocytes is the stage that is responsible for the symptoms of malaria and mortality, so vaccine researchers have been targeting the erythrocyte entry mechanism for years. Several receptors on the surface of the erythrocyte that interact with ligands on the merozoite, the …

If you disagree with what someone says, don’t resort to insult If you came across someone searching the pages of a tabloid newspaper for philosophical principles and ethical values you’d be inclined to doubt their sincerity of purpose. But you might be being unfair. Last year the Daily Mail carried an article that set out 10 enduring philosophical ideas and discussed why they were easier to agree with than to follow in everyday life (www.dailymail.co.uk/home/moslive/article-1279320/Ten-greatest-Philosophical-principles.html). It is well worth a look if you’ve forgotten David Hume’s reasons for not believing in miracles or just what Aristotle was on about when he talked of the golden mean. One of the things that impressed me about the piece was the way in which its author managed to compress his account into 1500 words for a readership that he had to assume knew next to nothing about the subject. It’s true that he didn’t discuss any of his 10 principles in much depth, but he succeeded brilliantly in making these abstract ideas accessible and relevant without recourse to jargon or fancy language. Educated people tend to sneer …