Hot off the presses! Sep 09 Lancet

The Sep 09 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:

• 9/11: ten years on
  - Lancet 378(9794):849 (2011)
  
• 9/11—new data, reviews, and reflections
  - Lancet 378(9794):850 (2011)
  
• War and peace
  - Lancet 378(9794):850 (2011)
  
• Taking the terror out of terrorism: mortality data after 9/11
  - Lancet 378(9794):851-852 (2011)
  
• 9/11: the view ahead
  - Lancet 378(9794):852-854 (2011)
  
• Medical care for workers exposed to the WTC disaster
  - Lancet 378(9794):854-855 (2011)
  
• Suicide attacks—the rationale and consequences
  - Lancet 378(9794):855-857 (2011)
  
• Fighting a war, sparing civilians
  - Lancet 378(9794):857-859 (2011)
  
• Role of law in global response to non-communicable diseases
  - Lancet 378(9794):859-860 (2011)
  
• To err is human
  - Lancet 378(9794):861 (2011)
  
• Offline: History, but not as we know it
  - Lancet 378(9794):862 (2011)
  
• lraq's health system yet to heal from ravages of war
  - Lancet 378(9794):863-866 (2011)
  
• A chronicle of the dark days of 9/11
  - Lancet 378(9794):867 (2011)
  
• Mechthild Prinz: using DNA to identify the victims of 9/11
  - Lancet 378(9794):868 (2011)
  
• JoAnn Difede: emotional engagement with victims of trauma
  - Lancet 378(9794):869 (2011)
  
• Just work
  - Lancet 378(9794):870-871 (2011)
  
• 9/11: (Polyclinique de Savoie, November, 2001)
  - Lancet 378(9794):872 (2011)
  
• National, regional, and worldwide estimates of stillbirth rates
  - Lancet 378(9794):873 (2011)
  
• National, regional, and worldwide estimates of stillbirth rates
  - Lancet 378(9794):873 (2011)
  
• National, regional, and worldwide estimates of stillbirth rates – Authors' reply
  - Lancet 378(9794):873-874 (2011)
  
• Stillbirth in high-income countries
  - Lancet 378(9794):874 (2011)
  
• Stillbirth in high-income countries
  - Lancet 378(9794):874-875 (2011)
  
• Stillbirth in high-income countries – Authors' reply
  - Lancet 378(9794):875 (2011)
  
• Stillbirth and healthy timing and spacing of pregnancy
  - Lancet 378(9794):876 (2011)
  
• Stillbirth and healthy timing and spacing of pregnancy – Authors' reply
  - Lancet 378(9794):876-877 (2011)
  
• Trials of antenatal syphilis screening urgently needed
  - Lancet 378(9794):877 (2011)
  
• Trials of antenatal syphilis screening urgently needed – Authors' reply
  - Lancet 378(9794):877-878 (2011)
  
• Better understanding needed of physiology of sustaining life in utero
  - Lancet 378(9794):878 (2011)
  
• Genetic factors in stillbirths
  - Lancet 378(9794):878 (2011)
  
• Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort
  - Lancet 378(9794):879-887 (2011)
  Background The Sept 11, 2001 (9/11) World Trade Center (WTC) disaster has been associated with several subacute and chronic health effects, but whether excess mortality after 9/11 has occurred is unknown. We tested whether excess mortality has occurred in people exposed to the WTC disaster. Methods In this observational cohort study, deaths occurring in 2003–09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. Eligible participants were rescue and recovery workers and volunteers; lower Manhattan area residents, workers, school staff and students; and commuters and passers-by on 9/11. Study participants were categorised as rescue and recovery workers (including volunteers), or non-rescue and non-recovery participants. Standardised mortality ratios (SMR) were calculated with New York City rates from 2000–09 as the reference. Within the cohort, proportional hazards were used to examine the relation between a three-tiered WTC-related exposure level (high, intermediate, or low) and total mortality. Findings We identified 156 deaths in 13 337 rescue and recovery workers and 634 deaths in 28 593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38–0·53) and non-rescue and non-recovery participants (0·61, 0·56–0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1·22, 95% CI 1·01–1·48, for intermediate exposure and 1·56, 1·15–2·12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart-disease-related mortality (adjusted hazard ratio 2·06, 1·10! –3·86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56–2·78, for high exposure and 1·03, 0·52–2·06, for intermediate exposure when compared with low exposure). Interpretation This exploratory study of mortality in a well defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants. Funding US Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health, Agency for Toxic Substances and Disease Registry, and National Center for Environmental Health); New York City Department of Health and Mental Hygiene.
• Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study
  - Lancet 378(9794):888-897 (2011)
  Background More than 50 000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities. Methods In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27 449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud). Findings 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders. Interpretation 9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population. Funding Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health.
• Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study
  - Lancet 378(9794):898-905 (2011)
  Background The attacks on the World Trade Center (WTC) on Sept 11, 2001 (9/11) created the potential for occupational exposure to known and suspected carcinogens. We examined cancer incidence and its potential association with exposure in the first 7 years after 9/11 in firefighters with health information before 9/11 and minimal loss to follow-up. Methods We assessed 9853 men who were employed as firefighters on Jan 1, 1996. On and after 9/11, person-time for 8927 firefighters was classified as WTC-exposed; all person-time before 9/11, and person-time after 9/11 for 926 non-WTC-exposed firefighters, was classified as non-WTC exposed. Cancer cases were confirmed by matches with state tumour registries or through appropriate documentation. We estimated the ratio of incidence rates in WTC-exposed firefighters to non-exposed firefighters, adjusted for age, race and ethnic origin, and secular trends, with the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) reference population. CIs were estimated with overdispersed Poisson models. Additional analyses included corrections for potential surveillance bias and modified cohort inclusion criteria. Findings Compared with the general male population in the USA with a similar demographic mix, the standardised incidence ratios (SIRs) of the cancer incidence in WTC-exposed firefighters was 1·10 (95% CI 0·98–1·25). When compared with non-exposed firefighters, the SIR of cancer incidence in WTC-exposed firefighters was 1·19 (95% CI 0·96–1·47) corrected for possible surveillance bias and 1·32 (1·07–1·62) without correction for surveillance bias. Secondary analyses showed similar effect sizes. Interpretation We reported a modest excess of cancer cases in the WTC-exposed cohort. We remain cautious in our interpretation of this finding because the time since 9/11 is short for cancer outcomes, and the reported excess of cancers is not limited to specific organ types. As in any observational study, we cannot rule out the possibility that effects in the exposed group might be due to unidentified confounders. Continued follow-up will be important and should include cancer screening and prevention strategies. Funding National Institute for Occupational Safety and Health.
• Casualties in civilians and coalition soldiers from suicide bombings in Iraq, 2003–10: a descriptive study
  - Lancet 378(9794):906-914 (2011)
  Background Suicide bombs in Iraq are a major public health problem. We aimed to describe documented casualties from suicide bombs in Iraq during 2003–10 in Iraqi civilians and coalition soldiers. Methods In this descriptive study, we analysed and compared suicide bomb casualties in Iraq that were documented in two datasets covering March 20, 2003, to Dec 31, 2010—one reporting coalition-soldier deaths from suicide bombs, the other reporting deaths and injuries of Iraqi civilians from armed violence. We analysed deaths and injuries over time, by bomb subtype and victim demographics. Findings In 2003–10, 1003 documented suicide bomb events caused 19% (42 928 of 225 789) of all Iraqi civilian casualties in our dataset, 26% (30 644 of 117 165) of injured civilians, and 11% (12 284 of 108 624) of civilian deaths. The injured-to-killed ratio for civilians was 2·5 people injured to one person killed from suicide bombs. Suicide bombers on foot caused 43% (5314 of 12 284) of documented suicide bomb deaths. Suicide bombers who used cars caused 40% (12 224 of 30 644) of civilian injuries. Of 3963 demographically identifiable suicide bomb fatalities, 2981 (75%) were men, 428 (11%) were women, and 554 (14%) were children. Children made up a higher proportion of demographically identifiable deaths from suicide bombings than from general armed violence (9%, 3669 of 40 276 deaths; p<0·0001). The injured-to-killed ratio for all suicide bombings was slightly higher for women than it was for men (p=0·02), but the ratio for children was lower than it was for both women (p<0·! 0001) and men (p=0·0002). 200 coalition soldiers were killed in 79 suicide bomb events during 2003–10. More Iraqi civilians per lethal event were killed than were coalition soldiers (12 vs 3; p=0·004). Interpretation Suicide bombers in Iraq kill significantly more Iraqi civilians than coalition soldiers. Among civilians, children are more likely to die than adults when injured by suicide bombs. Funding None.
• Effectiveness of battlefield-ethics training during combat deployment: a programme assessment
  - Lancet 378(9794):915-924 (2011)
  Background Breakdowns in the ethical conduct of soldiers towards non-combatants on the battlefield are of grave concern in war. Evidence-based training approaches to prevent unethical conduct are scarce. We assessed the effectiveness of battlefield-ethics training and factors associated with unethical battlefield conduct. Methods The training package, based on movie vignettes and leader-led discussions, was administered 7 to 8 months into a 15-month high-intensity combat deployment in Iraq, between Dec 11, 2007, and Jan 30, 2008. Soldiers from an infantry brigade combat team (total population about 3500) were randomly selected, on the basis of company and the last four digits of each soldier's social security number, and invited to complete an anonymous survey 3 months after completion of the training. Reports of unethical behaviour and attitudes in this sample were compared with a randomly selected pre-training sample from the same brigade. The response patterns for ethical behaviour and reporting of ethical violations were analysed with chi-square analyses. We developed two logistic regression models using self-reported unethical behaviours as dependent variables. Factors associated with unethical conduct, including combat experiences and post-traumatic stress disorder (PTSD), were assessed with va! lidated scales. Findings Of 500 randomly selected soldiers 421 agreed to participate in the anonymous post-training survey. A total of 397 soldiers of the same brigade completed the pre-training survey. Training was associated with significantly lower rates of unethical conduct of soldiers and greater willingness to report and address misconduct than in those before training. For example, reports of unnecessary damage or destruction of private property decreased from 13·6% (54 of 397; 95% CI 10·2–17·0) before training to 5·0% (21 of 421; 2·9–7·1) after training (percent difference −63·2%; p<0·0001), and willingness to report a unit member for mistreatment of a non-combatant increased from 36·0% (143 of 397; 31·3–40·7) to 58·9% (248 of 421; 54·2–63·6; percent difference 63·6; p<0·0001). Nearly all participants (410 [97%]) reported that training made it clear how to respond towards non-combatants. Combat frequency and intensity was the strongest predictor of unethical behavio! ur; PTSD was not a significant predictor of unethical behaviour after controlling for combat experiences. Interpretation Leader-led battlefield ethics training positively influenced soldiers' understanding of how to interact with and treat non-combatants, and reduced reports of ethical misconduct. Unethical battlefield conduct was associated with high-intensity combat but not with PTSD. Funding None.
• Short-term and medium-term health effects of 9/11
  - Lancet 378(9794):925-934 (2011)
  The New York City terrorist attacks on Sept 11, 2001 (9/11), killed nearly 2800 people and thousands more had subsequent health problems. In this Review of health effects in the short and medium terms, strong evidence is provided for associations between experiencing or witnessing events related to 9/11 and post-traumatic stress disorder and respiratory illness, with a correlation between prolonged, intense exposure and increased overall illness and disability. Rescue and recovery workers, especially those who arrived early at the World Trade Center site or worked for longer periods, were more likely to develop respiratory illness than were other exposed groups. Risk factors for post-traumatic stress disorder included proximity to the site on 9/11, living or working in lower Manhattan, rescue or recovery work at the World Trade Center site, event-related loss of spouse, and low social support. Investigators note associations between 9/11 exposures and additional disord! ers, such as depression and substance use; however, for some health problems association with exposures related to 9/11 is unclear.
• Islam, medicine, and Arab-Muslim refugee health in America after 9/11
  - Lancet 378(9794):935-943 (2011)
  Islam is the world's second largest religion, representing nearly a quarter of the global population. Here, we assess how Islam as a religious system shapes medical practice, and how Muslims view and experience medical care. Islam has generally encouraged the use of science and biomedicine for the alleviation of suffering, with Islamic authorities having a crucial supportive role. Muslim patients are encouraged to seek medical solutions to their health problems. For example, Muslim couples who are infertile throughout the world are permitted to use assisted reproductive technologies. We focus on the USA, assessing how Islamic attitudes toward medicine influence Muslims' engagement with the US health-care system. Nowadays, the Arab–Muslim population is one of the fastest growing ethnic-minority populations in the USA. However, since Sept 11, 2001, Arab–Muslim patients—and particularly the growing Iraqi refugee population—face huge challenges in seeking and recei! ving medical care, including care that is judged to be religiously appropriate. We assess some of the barriers to care—ie, poverty, language, and discrimination. Arab–Muslim patients' religious concerns also suggest the need for cultural competence and sensitivity on the part of health-care practitioners. Here, we emphasise how Islamic conventions might affect clinical care, and make recommendations to improve health-care access and services for Arab–Muslim refugees and immigrants, and Muslim patients in general.
• Adverse health consequences of US Government responses to the 2001 terrorist attacks
  - Lancet 378(9794):944-952 (2011)
  In response to the attacks on Sept 11, 2001 (9/11), and the related security concerns, the USA and its coalition partners began a war in Afghanistan and subsequently invaded Iraq. The wars caused many deaths of non-combatant civilians, further damaged the health-supporting infrastructure and the environment (already adversely affected by previous wars), forced many people to migrate, led to violations of human rights, and diverted resources away from important health needs. After 9/11 and the anthrax outbreak shortly afterwards, the USA and other countries have improved emergency preparedness and response capabilities, but these actions have often diverted attention and resources from more urgent health issues. The documentation and dissemination of information about the adverse health effects of these wars and about the diversion of resources could help to mitigate these consequences and prevent their recurrence.
• Public health preparedness and response in the USA since 9/11: a national health security imperative
  - Lancet 378(9794):953-956 (2011)
  
• Redefining of public health preparedness after 9/11
  - Lancet 378(9794):957-959 (2011)
  
• Sepsis and spontaneous bacterial peritonitis in Thailand
  - Lancet 378(9794):960 (2011)