Hot off the presses! Sep 30 Lancet

The Sep 30 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:

• Malaria: control vs elimination vs eradication
  - Lancet 378(9797):1117 (2011)
  
• New US target to prevent 1 million heart attacks and strokes
  - Lancet 378(9797):1118 (2011)
  
• Gender empowerment: beyond education
  - Lancet 378(9797):1118 (2011)
  
• Grappling with uncertainties along the MDG trail
  - Lancet 378(9797):1119-1120 (2011)
  
• Immunoadsorption for haemolytic uraemic syndrome
  - Lancet 378(9797):1120-1122 (2011)
  
• Disparities by sex in early childhood and adolescence
  - Lancet 378(9797):1122-1123 (2011)
  
• Why is Japanese life expectancy so high?
  - Lancet 378(9797):1124-1125 (2011)
  
• Development of a disaster cardiovascular prevention network
  - Lancet 378(9797):1125-1127 (2011)
  
• Offline: Sumptuous and symphonic opportunities
  - Lancet 378(9797):1128 (2011)
  
• Lasker Foundation honours malaria researcher
  - Lancet 378(9797):1129 (2011)
  
• Ukraine failing to provide evidence-based palliative care
  - Lancet 378(9797):1130 (2011)
  
• Reappraising the work of R B Kitaj
  - Lancet 378(9797):1131 (2011)
  
• Alice Roberts: the skull beneath the skin
  - Lancet 378(9797):1132 (2011)
  
• Doodling and the default network of the brain
  - Lancet 378(9797):1133-1134 (2011)
  
• Infectious disease control in Brazil
  - Lancet 378(9797):1135 (2011)
  
• Infectious disease control in Brazil
  - Lancet 378(9797):1135 (2011)
  
• Infectious disease control in Brazil
  - Lancet 378(9797):1135-1136 (2011)
  
• Infectious disease control in Brazil – Authors' reply
  - Lancet 378(9797):1136 (2011)
  
• Epileptologists struggle to make their voices heard
  - Lancet 378(9797):1136-1137 (2011)
  
• Inequities in suicide prevention in Brazil
  - Lancet 378(9797):1137 (2011)
  
• Cardiotocography and ST analysis for intrapartum fetal monitoring
  - Lancet 378(9797):1137-1138 (2011)
  
• Cardiotocography and ST analysis for intrapartum fetal monitoring – Author's reply
  - Lancet 378(9797):1138 (2011)
  
• Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis
  - Lancet 378(9797):1139-1165 (2011)
  Background With 4 years until 2015, it is essential to monitor progress towards Millennium Development Goals (MDGs) 4 and 5. Although estimates of maternal and child mortality were published in 2010, an update of estimates is timely in view of additional data sources that have become available and new methods developed. Our aim was to update previous estimates of maternal and child mortality using better data and more robust methods to provide the best available evidence for tracking progress on MDGs 4 and 5. Methods We update the analyses of the progress towards MDGs 4 and 5 from 2010 with additional surveys, censuses, vital registration, and verbal autopsy data. For children, we estimate early neonatal (0–6 days), late neonatal (7–28 days), postneonatal (29–364 days), childhood (ages 1–4 years), and under-5 mortality. We use an improved model for estimating mortality by age under 5 years. For maternal mortality, our updated analysis includes greater than 1000 additional site-years of data. We tested a large set of alternative models for maternal mortality; we used an ensemble model based on the models with the best out-of-sample predictive validity to generate new estimates from 1990 to 2011. Findings Under-5 deaths have continued to decline, reaching 7·2 million in 2011 of which 2·2 million were early neonatal, 0·7 million late neonatal, 2·1 million postneonatal, and 2·2 million during childhood (ages 1–4 years). Comparing rates of decline from 1990 to 2000 with 2000 to 2011 shows that 106 countries have accelerated declines in the child mortality rate in the past decade. Maternal mortality has also continued to decline from 409 100 (uncertainty interval 382 900–437 900) in 1990 to 273 500 (256 300–291 700) deaths in 2011. We estimate that 56 100 maternal deaths in 2011 were HIV-related deaths during pregnancy. Based on recent trends in developing countries, 31 countries will achieve MDG 4, 13 countries MDG 5, and nine countries will achieve both. Interpretation Even though progress on reducing maternal and child mortality in most countries is accelerating, most developing countries will take many years past 2015 to achieve the targets of the MDGs 4 and 5. Similarly, although there continues to be progress on maternal mortality the pace is slow, without any overall evidence of acceleration. Immediate concerted action is needed for a large number of countries to achieve MDG 4 and MDG 5. Funding Bill & Melinda Gates Foundation.
• Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial
  - Lancet 378(9797):1166-1173 (2011)
  Background In May 2011, an outbreak of Shiga toxin-producing enterohaemorrhagic E coli O104:H4 in northern Germany led to a high proportion of patients developing post-enteritis haemolytic uraemic syndrome and thrombotic microangiopathy that were unresponsive to therapeutic plasma exchange or complement-blocking antibody (eculizumab). Some patients needed ventilatory support due to severe neurological complications, which arose 1 week after onset of enteritis, suggesting an antibody-mediated mechanism. Therefore, we aimed to assess immunoadsorption as rescue therapy. Methods In our prospective non-controlled trial, we enrolled patients with severe neurological symptoms and confirmed recent E coli O104:H4 infection without other acute bacterial infection or raised procalcitonin concentrations. We did IgG immunoadsorption processing of 12 L plasma volumes on 2 consecutive days, followed by IgG replacement (0·5 g/kg intravenous IgG). We calculated a composite neurological symptom score (lowest score was best) every day and assessed changes before and after immunoadsorption. Findings We enrolled 12 patients who initially presented with enteritis and subsequent renal failure; 10 (83%) of 12 patients needed renal replacement therapy by a median of 8·0 days (range 5–12). Neurological complications (delirium, stimulus sensitive myoclonus, aphasia, and epileptic seizures in 50% of patients) occurred at a median of 8·0 days (range 5–15) and mandated mechanical ventilation in nine patients. Composite neurological symptom scores increased in the 3 days before immunoadsorption to 3·0 (SD 1·1, p=0·038), and improved to 1·0 (1·2, p=0·0006) 3 days after immunoadsorption. In non-intubated patients, improvement was apparent during immunoadsorption (eg, disappearance of aphasia). Five patients who were intubated were weaned within 48 h, two within 4 days, and two patients needed continued ventilation for respiratory problems. All 12 patients survived and ten had complete neurological and renal function recovery. Interpretation Antibodies are probably involved in the pathogenesis of severe neurological symptoms in patients with E coli O104:H4-induced haemolytic uraemic syndrome. Immunoadsorption can safely be used to rapidly ameliorate these severe neurological complications. Funding Greifswald University and Hannover Medical School.
• Cost containment and quality of care in Japan: is there a trade-off?
  - Lancet 378(9797):1174-1182 (2011)
  Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8·5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissez-faire approach to how services are delivered; this combination has l! ed to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.
• Population ageing and wellbeing: lessons from Japan's long-term care insurance policy
  - Lancet 378(9797):1183-1192 (2011)
  Japan's population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Only services are provided, not cash allowances, and recipients can choose their services and providers. Analysis of national survey data before and after the programme started shows increased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges to the success of the system include dissatisfaction with home-based care, provision of necessary support for family carers, and fiscal sustainability. J! apan's strategy for long-term care could offer lessons for other nations.
• The 2012 Olympics: assessing the public health effect
  - Lancet 378(9797):1193-1195 (2011)
  
• Liver mass in a young adult
  - Lancet 378(9797):1196 (2011)