Hot off the presses! Aug 01 Lancet

The Aug 01 issue of the Lancet is now up on Pubget (About Lancet): if you're at a subscribing institution, just click the link in the latest link at the home page. (Note you'll only be able to get all the PDFs in the issue if your institution subscribes to Pubget.)

Latest Articles Include:

• Remaking America's health-care system
  - Lancet 374(9687):357 (2009)
  
• Women's health in rural China
  - Lancet 374(9687):358 (2009)
  
• Supply and safety issues surrounding an H1N1 vaccine
  - Lancet 374(9687):358 (2009)
  
• Surgery in stage III non-small-cell lung cancer
  - Lancet 374(9687):359-360 (2009)
  
• Child survival and IMCI: in need of sustained global support
  - Lancet 374(9687):361-362 (2009)
  
• Cutaneous melanoma in the era of molecular profiling
  - Lancet 374(9687):362-365 (2009)
  
• Clinical staging: a new scenario for the treatment of psychosis
  - Lancet 374(9687):365-367 (2009)
  
• Why multiple sexual partners?
  - Lancet 374(9687):367-369 (2009)
  
• Use of patient-reported outcomes in clinical practice
  - Lancet 374(9687):369-370 (2009)
  
• East African countries struggle with visceral leishmaniasis
  - Lancet 374(9687):371-372 (2009)
  
• Chilling side-effects
  - Lancet 374(9687):373 (2009)
  
• Cecil Gerald Helman
  - Lancet 374(9687):374 (2009)
  
• Elsevier should divest itself of either its medical publishing or pharmaceutical services division
  - Lancet 374(9687):375 (2009)
  
• Elsevier should divest itself of either its medical publishing or pharmaceutical services division
  - Lancet 374(9687):375-376 (2009)
  
• HIV testing in the UK
  - Lancet 374(9687):376 (2009)
  
• HIV testing in the UK
  - Lancet 374(9687):376-377 (2009)
  
• HIV testing in the UK
  - Lancet 374(9687):377 (2009)
  
• HIV testing in the UK
  - Lancet 374(9687):377 (2009)
  
• Could early cord clamping harm neonatal stabilisation?
  - Lancet 374(9687):377-378 (2009)
  
• What is the "primary" prevention of congenital anomalies?
  - Lancet 374(9687):378 (2009)
  
• Department of Error
  - Lancet 374(9687):378 (2009)
  
• Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial
  - Lancet 374(9687):379-386 (2009)
  Background Results from phase II studies in patients with stage IIIA non-small-cell lung cancer with ipsilateral mediastinal nodal metastases (N2) have shown the feasibility of resection after concurrent chemotherapy and radiotherapy with promising rates of survival. We therefore did this phase III trial to compare concurrent chemotherapy and radiotherapy followed by resection with standard concurrent chemotherapy and definitive radiotherapy without resection. Methods Patients with stage T1-3pN2M0 non-small-cell lung cancer were randomly assigned in a 1:1 ratio to concurrent induction chemotherapy (two cycles of cisplatin [50 mg/m2 on days 1, 8, 29, and 36] and etoposide [50 mg/m2 on days 1–5 and 29–33]) plus radiotherapy (45 Gy) in multiple academic and community hospitals. If no progression, patients in group 1 underwent resection and those in group 2 continued radiotherapy uninterrupted up to 61 Gy. Two additional cycles of cisplatin and etoposide were given in both groups. The primary endpoint was overall survival (OS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00002550. Findings 202 patients (median age 59 years, range 31–77) were assigned to group 1 and 194 (61 years, 32–78) to group 2. Median OS was 23·6 months (IQR 9·0–not reached) in group 1 versus 22·2 months (9·4–52·7) in group 2 (hazard ratio [HR] 0·87 [0·70–1·10]; p=0·24). Number of patients alive at 5 years was 37 (point estimate 27%) in group 1 and 24 (point estimate 20%) in group 2 (odds ratio 0·63 [0·36–1·10]; p=0·10). With N0 status at thoracotomy, the median OS was 34·4 months (IQR 15·7–not reached; 19 [point estimate 41%] patients alive at 5 years). Progression-free survival (PFS) was better in group 1 than in group 2, median 12·8 months (5·3–42·2) vs 10·5 months (4·8–20·6), HR 0·77 [0·62–0·96]; p=0·017); the number of patients without disease progression at 5 years was 32 (point estimate 22%) versus 13 (point estimate 11%), respectively. Neutropenia and oesophagitis were the main grade 3 or 4 toxicities associated with chemotherapy plus ra! diotherapy in group 1 (77 [38%] and 20 [10%], respectively) and group 2 (80 [41%] and 44 [23%], respectively). In group 1, 16 (8%) deaths were treatment related versus four (2%) in group 2. In an exploratory analysis, OS was improved for patients who underwent lobectomy, but not pneumonectomy, versus chemotherapy plus radiotherapy. Interpretation Chemotherapy plus radiotherapy with or without resection (preferably lobectomy) are options for patients with stage IIIA(N2) non-small-cell lung cancer. Funding National Cancer Institute, Canadian Cancer Society, and National Cancer Institute of Canada.
• Late donor cardiectomy after paediatric heterotopic cardiac transplantation
  - Lancet 374(9687):387-392 (2009)
  Background Cardiac transplantation is a life-saving procedure in infants and children with advanced cardiomyopathy. However, it is greatly limited by shortage of paediatric donors and the complications of long-term immunosuppression, including post-transplant lymphoproliferative disorder (PTLD). We report the management of an infant who had heterotopic cardiac transplantation for advanced cardiomyopathy with secondary pulmonary hypertension who developed seemingly incurable PTLD. Methods An 8-month-old girl presented in 1994 with signs of severe heart failure, secondary to dilated cardiomyopathy. At age 11 months, the patient underwent a heterotopic cardiac transplantation. Findings The patient developed many episodes of PTLD associated with Epstein-Barr virus infection that were resistant to several therapies, including reduction of immunosuppression. Native heart recovery enabled removal of the donor heart 10·5 years after the original operation to allow complete cessation of immunosuppression. Her postoperative course was uncomplicated and the outcome was excellent. 3·5 years after surgery, the patient remains well, in complete remission from her PTLD, and has normal cardiac function. Interpretation This case shows several issues relating to the use of heterotopic cardiac transplantation in infants and the capacity of the heart to recover. It also provides new insights into the interaction between the immune system with several aspects of modern management of post-transplantation PTLD. Funding None.
• Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial
  - Lancet 374(9687):393-403 (2009)
  Background WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. Methods In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI—health-worker training, health-systems improvements, and family and community activities—were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. Findings The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8·6% vs 7·8%). In the last 2 years of the study, the mortality rate was 13·4% lower in IMCI than in comparison areas (95% CI −14·2 to 34·3), corresponding to 4·2 fewer deaths per 1000 livebirths (95% CI −4·1 to 12·4; p=0·30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76% vs 65%, difference of differences 10·1%, 95% CI 2·65–17·62), and prevalence of stunting in children aged 24–59 months decreased more rapidly (difference of differences −7·33, 95% CI −13·83 to −0·83) than in comparison areas. Interpretation IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. Funding Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.
• The many faces of tension pneumothoraces
  - Lancet 374(9687):404 (2009)
  
• Blast injuries
  - Lancet 374(9687):405-415 (2009)
  Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air–tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications—especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries! can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.
• Men who have sex with men and HIV/AIDS in sub-Saharan Africa
  - Lancet 374(9687):416-422 (2009)
  Globally, men who have sex with men (MSM) continue to bear a high burden of HIV infection. In sub-Saharan Africa, same-sex behaviours have been largely neglected by HIV research up to now. The results from recent studies, however, indicate the widespread existence of MSM groups across Africa, and high rates of HIV infection, HIV risk behaviour, and evidence of behavioural links between MSM and heterosexual networks have been reported. Yet most African MSM have no safe access to relevant HIV/AIDS information and services, and many African states have not begun to recognise or address the needs of these men in the context of national HIV/AIDS prevention and control programmes. The HIV/AIDS community now has considerable challenges in clarifying and addressing the needs of MSM in sub-Saharan Africa; homosexuality is illegal in most countries, and political and social hostility are endemic. An effective response to HIV/AIDS requires improved strategic information about all! risk groups, including MSM. The belated response to MSM with HIV infection needs rapid and sustained national and international commitment to the development of appropriate interventions and action to reduce structural and social barriers to make these accessible.
• The breastmilk brand: promotion of child survival in the face of formula-milk marketing
  - Lancet 374(9687):423-425 (2009)
  
• Chest pain and small red cells: size does matter
  - Lancet 374(9687):426 (2009)