The past decade in bench research into pulmonary infectious diseases: What do clinicians need to know?

Respiratory infections are primarily treated with antibiotics, drugs that are mostly inexpensive and have been widely available since the 1940s and 1950s. Nevertheless, despite antibiotics, the burden of disease in pneumonia, bronchiectasis, cystic fibrosis, COPD and rare respiratory infections remains exceptionally high. There is an urgent need for translational studies to develop new treatments or new biomarkers to improve outcomes in these conditions. The ‘translational gaps’ between bench science and clinical practice are particularly challenging in respiratory infections. This is partly due to the poor representativeness of animal models of infection to human disease, and a long‐term lack of investment into pulmonary infection research. The revolution in genomics and other omics technologies, however, is beginning to unlock clinically important information about the host response to infection, the behaviour of bacterial communities and the development of new antibiotics. It is not possible to review the extensive progress made in the last decade into the pathophysiology of the different respiratory infections and so here, we focus on major technologies that are now changing respiratory infection research, specifically bacterial whole‐genome sequencing, the microbiota, personalized medicine with omics technologies, new antibiotic development and host inflammatory cell biology.     

‘Digoxin conundrum – Time for validation?’

Despite no incontrovertible data, Digoxin use has been demonised. As a consequence, a lot of patients, stable on Digoxin, have been taken off it and offered alternative drugs. However, there is some light at the end of the tunnel for Digoxin, with the reporting of RATE-AF Trial at the recent European Society of Cardiology Congress. Compared to Bisoprolol, Digoxin use was associated with statistically significantly greater improvements in symptomatology and NT ProBNP levels making Digoxin a first line drug for rate control in permanent AF.     

Making ‘Good Trouble’: Time for Organized Medicine to Call for Racial Justice in Medical Education and Health Care

“Never, ever be afraid to make some noise and get in good trouble, necessary trouble.”– Representative John LewisIt is time now for organized medicine to make “good trouble” and call for racial justice in medical education and health care. It is also time to have an honest confrontation with reality in order to bring about racial healing and become anti-racist organizations. Using a racial justice framework, 4 elements described here can chart our course. Organized medicine must come together in solidarity to make “good trouble” and fight collectively for racial justice so that every community we serve can achieve their full health potential and achieve racial equity—that is, giving people what they need to enjoy full, healthy lives regardless of race.     

Cholesterol lowering and mortality: Time for a new paradigm?

Sudden cardiac death is the main cause of cardiac mortality. Is blood cholesterol a determinant of sudden cardiac death? Does cholesterol lowering result in fewer sudden cardiac deaths? Answering these two questions may shed new light on the epidemiology of coronary heart disease and on prevention options. In fact, careful analysis of the available data, including randomised trials, indicates that, contrary to a widespread opinion, cholesterol lowering does not appear to be a very effective way of reducing cardiac and overall mortality in the general population.     

The Ethics of Offering Dialysis for AKI to the Older Patient: Time to Re-Evaluate?

Older patients are more susceptible to AKI. In the elderly, AKI has been associated with increased morbidity and mortality, and it is a significant risk factor for CKD and dialysis-dependent ESRD. There are now accumulating data that the start of dialysis for some older patients is associated with poor outcomes, such as high treatment intensity, suffering, and limited life prolongation, which occur at the expense of dignity and quality of life. The biomedicalization of aging is a relatively recent field of ethical inquiry with two directly relevant features to decisions about starting dialysis for older patients with AKI: (1) the routinization of geriatric clinical interventions, such as dialysis, which results in the overshadowing of patient choice, and (2) the transformation of the technological imperative into the moral imperative. A major consequence of the biomedicalization of aging is that societal expectations about standard medical care have resulted in the relatively unquestioned provision of dialysis for AKI to older patients. This paper calls for nephrologists to re-examine the data and their attitudes to offering dialysis to older patients with AKI, especially those patients with underlying CKD and significant comorbidities. Shared decision-making and the reinforcement of the right of the patient to make a choice need to slow down the otherwise ineluctable routinization of starting old and very sick patients on dialysis. In the process of shared decision-making, nephrologists should not automatically recommend dialysis for older patients; in those patients who can be predicted to do poorly, recommending against dialysis upholds the Hippocratic maxim to be of benefit and do no harm. This paper challenges the automatic transformation of the technological imperative into the moral imperative for older patients with AKI and points to the need for a re-evaluation of dialysis ethics in this population.