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Current best available evidence should guide urgent policy While public health decisions should be evidence-based, drawing on randomised controlled trials (RCT) as an important source of information, the methodological challenges of evaluating large-scale public health interventions need to be recognised.12 When there is logistic difficulty in conducting an RCT, evidence from other data sources can provide valid support for an urgent public health action.13 The mechanistic effects of handwashing and wearing a face mask have been demonstrated, thus offering some scientific basis for their benefits in terms of disease control.4 5 A recently published article shows turbulent gas cloud can prolong the life of pathogen-bearing droplets and allow them to travel a longer distance. Some experts suggested that while there is a perception that wearing a face mask may help, there is little evidence of any benefit outside the clinical setting.15 In a recent meta-analysis, six RCTs were identified reporting the effect of wearing a face mask with enhanced hand hygiene in reducing laboratory-confirmed influenza in the community.2 Although none of them supported a significant protective effect,2 all the authors acknowledged that their studies may have underestimated the effect of the intervention (see table 1 for their limitations).16–21 Their results also may not be generalisable to the universal use of face masks in the community during an actual pandemic which should result in heightened level of public awareness and community efforts. Furthermore, an absence of evidence (from RCTs in this instance) should be distinguished from evidence of absence.22 A previous systematic review identified two case controlled observational studies to assess the effectiveness of wearing a face mask in the community.23–25 Subsequent to that systematic review, one further relevant observational study was published.26 All these three observational studies concurred with each other, showing a significant protective effect of face masks in the community, although their findings may be limited by misclassification and reporting bias (see table 2 for details). While there are occasions when systematic review (of RCTs) is the ideal approach to answering specific forms of questions, the absence of thoughtful, interpretive critical reflection can render such products hollow, misleading and potentially harmful’.27 Table 2 Summary of evidence—observational studies for the effectiveness of face mask wearing in the community Observational studies OR (95% CI) Setting

Spinal root avulsion is an excellent model for studying the re- sponse of motoneurons to severe injury to their axons （Koliat- sos et al., 1994）. In this model （‘Avulsion Model＇）, spinal roots are torn off from spinal cord without removing the vertebra at different levels of spinal segments, usually at cervical and lum- bar segments. Step-by-step procedures are described in detail elsewhere （Chu and Wu, 2009）. The Avulsion Model resembles very well brachial plexus injuries in human beings. Around 70% of severe brachial plexus injuries in human involved avulsion of one or more roots （Narakas, 1985） and the main causes of traumatic brachial plexus injuries were motor vehicle accidents, sport injuries and difficult deliveries （Terzis et al., 2001）. The Avulsion Model involves injury to both central nervous system （CNS） and peripheral nervous system （PNS） while nerve axoto- my, transection and crush injuries only involve PNIS.

This is a novel case of idiopathic chylopericardium and chylothorax in a young male who had no significant medical history. He first presented with dyspnea due to idiopathic chylopericardium, which was refractory to medical and surgical treatments, including a medium-chain triglyceride diet, octreotide, and video-assisted pericardial window. The chylopericardium persisted and progressed to concomitant left-sided chylothorax. He subsequently underwent multiple imaging studies, including lymphoscintigraphy and an intranodal lymphangiogram, both of which confirmed leakage in the thoracic duct. Finally, thoracic duct embolization was performed via a retrograde transvenous approach, which was successful, with good results. Although idiopathic chylopericardium and chylothorax are extremely rare, it can greatly impact patient quality of life if left undiagnosed and untreated. While surgery can relieve cardiac tamponade, lymphatic imaging and intervention are key in diagnosing and treating the root cause of the condition. This case highlights the importance of multidisciplinary efforts in managing rare cases and how interventional radiology is a minimally invasive but effective way to treat thoracic duct leakage. Retrograde thoracic duct embolization is technically challenging but safe and effective.

[...]the guiding principles for populational vaccine selection are delineated. [...]in the process of vaccine uptake pending herd immunity, vaccines of higher efficacy could reduce more cases at possible subsequent peaks, permitting less use of highly restrictive measures such as ‘suppress and lift strategy’ and ‘strict quarantine’ [11]. [...]vaccines of higher efficacy would likely be more capable of reducing transmission. [...]it should be concluded that Comirnaty currently demonstrates a better efficacy-safety profile compared with CoronaVac.

When a patient regains consciousness from Cryptococcus meningitis, the clinician may offer an HIV test (in case it has not already been done) (scenario 1) or offer to tell the patient his HIV status (in case the test has already been performed with a positive result while the patient was unconscious) (scenario 2). Youngs and Simmonds proposed that the patient has the prima facie right to refuse an HIV test in scenario 1 but not the prima facie right not to be told the HIV status in scenario 2. I submit that the claims to the right of refusal in both scenarios are similarly strong as they should both be grounded in privacy, self determination or dignity. But a conscientious agent should bear in mind that members of the public also have the right not to be harmed. When the circumstance allows, a proper balance of the potential benefits and harm for all the competing parties should guide the clinical decision as to whose right should finally prevail. Where a full ethical analysis is not possible, the presumption should favour respecting the patient's right of refusal in both scenarios.

Adults without the capacity to make their own medical decisions have their rights protected under the Mental Capacity Act (2005) in the UK. The underlying principle of the court's decisions is the best interests test, and the evaluation of best interests is a welfare appraisal. Although the House of Lords in the well-known case of Bland held that the decision to withhold treatment for patients in a persistent vegetative state should not be based on their best interests, judges in recent cases have still held that the best interests of persistently vegetative patients demand that the right to die with dignity prevails over society's interest to preserve life. The basis of suggesting that it is in the best interests for one who is alive (although vegetative) in peace to die in peace is weak. Even if it may not be in their best interests to live on, it may not be so to die either. The phrase ‘the right to dignity/to die with dignity’ has been misused as a trump card to justify the speculation that a vegetative patient would necessarily refuse to live on machines. Without disrespect to the court's decision, we argue that the use of the best interests test to authorise withdrawing/withholding treatment from persistently vegetative patients without an advance directive is problematic. We propose that the court could have reached the same decision by considering only the futility of treatment without working through the controversial best interests of the patient.

Background With a view to addressing the moral concerns about the use of donor siblings, the Policy Statement of the American Academy of Pediatrics - Children as Hematopoietic Stem Cell Donors (the Policy) has laid out the criteria upon which tissue harvest from a minor would be permissible. Discussion Although tissue harvest serves the best interests of recipient siblings, parents are also obliged to act in the best interests of the donor sibling in the UK. Tissue harvest should proceed if and only if it serves the best interests of both the donor and recipient. Parents should be forbidden, and they are by UK law, to consent to tissue harvest unless there are substantial benefits for an incompetent minor that can outweigh the potential harm. There is no basis to subject a minor to the medical risks of tissue harvest if the recipient sibling can wait without significant risks of complications until the donor becomes Gillick competent. We also argue that the Policy fails to take into account recent advances in haematopoietic transplantation from haploidentical donors or related tissue-matched donors. Summary Unless a recipient sibling will suffer from serious complications or die without the transplantation and no other medically equivalent donors are available, there is no moral or legal basis to violate the donor sibling’s right to bodily integrity. Accordingly, we propose that the Policy should be modified in order to fully satisfy the legal requirements for application in the UK and other commonwealth jurisdictions with similar statute laws protecting minors.

Advances in medical technology inevitably bring about different kinds of ethical challenges for practising doctors. The following hypothetical case of assisted reproduction is presented as an example. A boy is born with Edward's syndrome following assisted reproduction. The parents suspect that there has been an error of embryo mix-up. They challenge the parenthood and request a genetic test to determine the biological parentage of the neonate. Should the attending paediatrician in this case accede to the request? We argue that the paediatrician has no legal obligation to offer the test, although it might be lawful and ethical to provide the test subject to the outcome of our proposed three-step risk assessment.

Wilkinson and Savulescu did not agree with the court's decision to continue M's treatment and suggested in their recent commentary that the magnitude of benefits of being alive for M is small compared with the potential use of health resources for other patients. We argue that the benefits of being sensate to the surroundings for an otherwise unconscious person are not necessarily small. One cannot assess on behalf of another person the magnitude of benefits of being alive according to the intensity or the duration of negative experiences. Denying life-sustaining treatment to patients in a minimally conscious state solely on the grounds that they are less capable of enjoying the benefits represents grave discrimination against disabled persons. For patients in a minimally conscious state who have not delegated a surrogate or made any advance decision about their medical treatment, the duty of doctors is to preserve their right to self-determination and maximise their capacity to enjoy their life. M should live on, and life-sustaining treatment should not be withdrawn.