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www.thelancet.com Vol 394 October 26, 2019 1485 Hydrocephalus, a build-up of cerebrospinal fluid within the ventricles of the brain, is the most common paediatric neurosurgical diagnosis, and is among the most common conditions in all age groups treated by neurosurgeons. Surgical treatment is usually either a mechanical diversion with a ventriculoperitoneal shunt or creation of an internal drainage pathway (third ventriculostomy). Shunts have been used for more than six decades to treat hydrocephalus, meaning that the advantages and risks of the procedure are well known. Conor Mallucci and colleagues report in The Lancet a multicentre, single-blind, randomised trial and economic evaluation (BASICS) of the clinical effectiveness and costeffectiveness of antibiotic-impregnated (rifampicin and clindamycin) or silver-impregnated shunts compared with standard shunts at reducing infection. 1605 UK patients (49% women, 31% aged 65 years or older) with hydrocephalus of any aetiology who were undergoing insertion of their first ventriculoperitoneal shunt were evaluated. The primary outcome was time to shunt failure caused by infection and was analysed with Fine and Gray survival regression models for competing risk. 32 (6%) of 533 evaluable patients in the standard shunt group had a shunt revision for infection compared with 12 (2%) of 535 evaluable patients in the antibiotic shunt group (cause-specific hazard ratio 0·38, 97·5% CI 0·18–0·80; p=0·0038) and 31 (6%) of 526 patients in the silver shunt group (0·99, 0·56–1·74; p=0·96). Adverse events, most of which were related to valve or catheter malfunction, occurred in 135 (25%) patients in the standard shunt group, 127 (23%) in the antibiotic shunt group, and 134 (36%) in the silver shunt group. The authors report that in the UK’s National Health Service health-care system, the use of antibiotic shunts saves £135 753 per infection avoided. This trial advances the current evidence base on hydrocephalus surgery. Few neurosurgical randomised controlled trials of good quality exist since the complexity of neurosurgical problems, their relative scarcity in the population, and the diversity of their pathology make them poor candidates for such trials. Hydrocephalus is one of the few diagnoses that is amenable to the randomised controlled trial design because of its frequency, which allows the recruitment of an adequate population size, and the small number of treatment alternatives, of which ventriculoperitoneal shunt insertion is the most frequent. Evidence for ventriculoperitoneal shunt insertion before the BASICS trial was restricted to meta-analyses of relatively small, mostly non-controlled studies. Our systematic review and evidence-based guidelines on paediatric hydrocephalus showed that only a few studies had been done until 2012 and all had class 2 evidence at Comparing antibiotic, silver, and standard ventriculoperitoneal shunts 9 Abul-Ghani MA, Puckett C, Triplitt C, et al. Initial combination therapy with metformin, pioglitazone and exenatide is more effective than sequential add-on therapy in subjects with new-onset diabetes. Results from the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT): a randomized trial. Diabetes Obes Metab 2015; 17: 268–75. 10 Zelniker TA, Wiviott SD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet 2019; 393: 31–39. 11 Kristensen SL, Rørth R, Jhund PS, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet Diabetes Endocrinol 2019; published online Aug 14. http://dx.doi.org/10.1016/S2213-8587(19)30249-9. 12 Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2019; published online Aug 31. DOI:10.1093/ eurheartj/ehz486.