Hot off the presses! Jun 17 Lance

The Jun 17 issue of the Lance is now up on Pubget (About Lance): 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:

• World Report on Disability
  - Lance 377(9782):1977 (2011)
  
• Global CO2 emissions: time to mitigate and adapt
  - Lance 377(9782):1978 (2011)
  
• Responding to disease outbreaks in Europe
  - Lance 377(9782):1978 (2011)
  
• Iodine nutrition in the UK: what went wrong?
  - Lance 377(9782):1979-1980 (2011)
  
• Vascular events after stroke: terutroban fails to PERFORM
  - Lance 377(9782):1980-1982 (2011)
  
• Glucocorticoid treatment in community-acquired pneumonia
  - Lance 377(9782):1982-1984 (2011)
  
• The impact of the Brazil experience in Latin America
  - Lance 377(9782):1984-1986 (2011)
  
• The English strategy to reduce health inequalities
  - Lance 377(9782):1986-1988 (2011)
  
• Staff skills not staff types for community-based rehabilitation
  - Lance 377(9782):1988-1989 (2011)
  
• Offline: One evening in Lombardy
  - Lance 377(9782):1990 (2011)
  
• Germany reels in the wake of E coli outbreak
  - Lance 377(9782):1991 (2011)
  
• Anti-abortion laws gain more ground in the USA
  - Lance 377(9782):1992-1993 (2011)
  
• State policies worsen HIV/AIDS crisis in Mississippi
  - Lance 377(9782):1994 (2011)
  
• The Lancet Technology: June 2011
  - Lance 377(9782):1995 (2011)
  
• Bill Roedy
  - Lance 377(9782):1996 (2011)
  
• Costing lives
  - Lance 377(9782):1996 (2011)
  
• Helen Rees on the quest for global equity
  - Lance 377(9782):1997 (2011)
  
• Retraining the King's left hand
  - Lance 377(9782):1998-1999 (2011)
  
• Ann McPherson
  - Lance 377(9782):2000 (2011)
  
• The health of prisoners
  - Lance 377(9782):2001 (2011)
  
• The health of prisoners
  - Lance 377(9782):2001 (2011)
  
• The health of prisoners
  - Lance 377(9782):2001-2002 (2011)
  
• The health of prisoners
  - Lance 377(9782):2002 (2011)
  
• Mediator: who's to blame?
  - Lance 377(9782):2002-2003 (2011)
  
• Mediator: who's to blame?
  - Lance 377(9782):2003 (2011)
  
• Mediator: who's to blame?
  - Lance 377(9782):2003-2004 (2011)
  
• Non-communicable diseases in southeast Asia
  - Lance 377(9782):2004 (2011)
  
• Non-communicable diseases in southeast Asia
  - Lance 377(9782):2004-2005 (2011)
  
• Non-communicable diseases in southeast Asia – Authors' reply
  - Lance 377(9782):2005 (2011)
  
• Prevention of elder abuse
  - Lance 377(9782):2005-2006 (2011)
  
• Use of systematic reviews in WHO recommendations
  - Lance 377(9782):2006 (2011)
  
• Department of Error
  - Lance 377(9782):2006 (2011)
  
• Department of Error
  - Lance 377(9782):2006 (2011)
  
• Department of Error
  - Lance 377(9782):2006 (2011)
  
• Iodine status of UK schoolgirls: a cross-sectional survey
  - Lance 377(9782):2007-2012 (2011)
  Background Iodine deficiency is the most common cause of preventable mental impairment worldwide. It is defined by WHO as mild if the population median urinary iodine excretion is 50–99 μg/L, moderate if 20–49 μg/L, and severe if less than 20 μg/L. No contemporary data are available for the UK, which has no programme of food or salt iodination. We aimed to assess the current iodine status of the UK population. Methods In this cross-sectional survey, we systematically assessed iodine status in schoolgirls aged 14–15 years attending secondary school in nine UK centres. Urinary iodine concentrations and tap water iodine concentrations were measured in June–July, 2009, and November–December, 2009. Ethnic origin, postcode, and a validated diet questionnaire assessing sources of iodine were recorded. Findings 810 participants provided 737 urine samples. Data for dietary habits and iodine status were available for 664 participants. Median urinary iodine excretion was 80·1 μg/L (IQR 56·9–109·0). Urinary iodine measurements indicative of mild iodine deficiency were present in 51% (n=379) of participants, moderate deficiency in 16% (n=120), and severe deficiency in 1% (n=8). Prevalence of iodine deficiency was highest in Belfast (85%, n=135). Tap water iodine concentrations were low or undetectable and were not positively associated with urinary iodine concentrations. Multivariable general linear model analysis confirmed independent associations between low urinary iodine excretion and sampling in summer (p<0·0001), UK geographical location (p<0·0001), low intake of milk (p=0·03), and high intake of eggs (p=0·02). Interpretation Our findings suggest that the UK is iodine deficient. Since developing fetuses are the most susceptible to adverse effects of iodine deficiency and even mild perturbations of maternal and fetal thyroid function have an effect on neurodevelopment, these findings are of potential major public health importance. This study has drawn attention to an urgent need for a comprehensive investigation of UK iodine status and implementation of evidence-based recommendations for iodine supplementation. Funding Clinical Endocrinology Trust.
• Terutroban versus aspirin in patients with cerebral ischaemic events (PERFORM): a randomised, double-blind, parallel-group trial
  - Lance 377(9782):2013-2022 (2011)
  Background Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of recurrent stroke or other cardiovascular events. We compared the selective thromboxane-prostaglandin receptor antagonist terutroban with aspirin in the prevention of cerebral and cardiovascular ischaemic events in patients with a recent non-cardioembolic cerebral ischaemic event. Methods This randomised, double-blind, parallel-group trial was undertaken in 802 centres in 46 countries. Patients who had an ischaemic stroke in the previous 3 months or a TIA in the previous 8 days were randomly allocated with a central interactive response system to 30 mg per day terutroban or 100 mg per day aspirin. Patients and investigators were masked to treatment allocation. The primary efficacy endpoint was a composite of fatal or non-fatal ischaemic stroke, fatal or non-fatal myocardial infarction, or other vascular death (excluding haemorrhagic death). We planned a sequential statistical analysis of non-inferiority (margin 1·05) followed by analysis of superiority. Analysis was by intention to treat. The study was stopped prematurely for futility on the basis of the recommendation of the Data Monitoring Committee. This study is registered, number ISRCTN66157730. Findings 9562 patients were assigned to terutroban (9556 analysed) and 9558 to aspirin (9544 analysed); mean follow-up was 28·3 months (SD 7·7). The primary endpoint occurred in 1091 (11%) patients receiving terutroban and 1062 (11%) receiving aspirin (hazard ratio [HR] 1·02, 95% CI 0·94–1·12). There was no evidence of a difference between terutroban and aspirin for the secondary or tertiary endpoints. We recorded some increase in minor bleedings with terutroban compared with aspirin (1147 [12%] vs 1045 [11%]; HR 1·11, 95% CI 1·02–1·21), but no significant differences in other safety endpoints. Interpretation The trial did not meet the predefined criteria for non-inferiority, but showed similar rates of the primary endpoint with terutroban and aspirin, without safety advantages for terutroban. In a worldwide perspective, aspirin remains the gold standard antiplatelet drug for secondary stroke prevention in view of its efficacy, tolerance, and cost. Funding Servier, France.
• Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial
  - Lance 377(9782):2023-2030 (2011)
  Background Whether addition of corticosteroids to antibiotic treatment benefits patients with community-acquired pneumonia who are not in intensive care units is unclear. We aimed to assess effect of addition of dexamethasone on length of stay in this group, which might result in earlier resolution of pneumonia through dampening of systemic inflammation. Methods In our double-blind, placebo-controlled trial, we randomly assigned adults aged 18 years or older with confirmed community-acquired pneumonia who presented to emergency departments of two teaching hospitals in the Netherlands to receive intravenous dexamethasone (5 mg once a day) or placebo for 4 days from admission. Patients were ineligible if they were immunocompromised, needed immediate transfer to an intensive-care unit, or were already receiving corticosteroids or immunosuppressive drugs. We randomly allocated patients on a one-to-one basis to treatment groups with a computerised randomisation allocation sequence in blocks of 20. The primary outcome was length of hospital stay in all enrolled patients. This study is registered with ClinicalTrials.gov, number NCT00471640. Findings Between November, 2007, and September, 2010, we enrolled 304 patients and randomly allocated 153 to the placebo group and 151 to the dexamethasone group. 143 (47%) of 304 enrolled patients had pneumonia of pneumonia severity index class 4–5 (79 [52%] patients in the dexamethasone group and 64 [42%] controls). Median length of stay was 6·5 days (IQR 5·0–9·0) in the dexamethasone group compared with 7·5 days (5·3–11·5) in the placebo group (95% CI of difference in medians 0–2 days; p=0·0480). In-hospital mortality and severe adverse events were infrequent and rates did not differ between groups, although 67 (44%) of 151 patients in the dexamethasone group had hyperglycaemia compared with 35 (23%) of 153 controls (p<0·0001). Interpretation Dexamethasone can reduce length of hospital stay when added to antibiotic treatment in non-immunocompromised patients with community-acquired pneumonia. Funding None.
• Towards an improved investment approach for an effective response to HIV/AIDS
  - Lance 377(9782):2031-2041 (2011)
  Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development ! sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.
• Health conditions and health-policy innovations in Brazil: the way forward
  - Lance 377(9782):2042-2053 (2011)
  Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradi! ction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.
• Learning from Haiti
  - Lance 377(9782):2054 (2011)