Hot off the presses! Oct 21 Lancet

The Oct 21 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:

• Towards risk reduction in non-cardiac surgery
  - Lancet 378(9800):1355 (2011)
  
• Twins or triplets?
  - Lancet 378(9800):1356 (2011)
  
• Ethics and organ transplantation
  - Lancet 378(9800):1356 (2011)
  
• The consequences of successful transplantation
  - Lancet 378(9800):1357-1359 (2011)
  
• Bypass, circulatory arrest, and pulmonary endarterectomy
  - Lancet 378(9800):1359-1360 (2011)
  
• Chopping and changing: long-term results of epilepsy surgery
  - Lancet 378(9800):1360-1362 (2011)
  
• Patient blood management is key before elective surgery
  - Lancet 378(9800):1362-1363 (2011)
  
• Treatment intensity at end of lifeâ€"time to act on the evidence
  - Lancet 378(9800):1364-1365 (2011)
  
• Offline: Everything has gone mad
  - Lancet 378(9800):1366 (2011)
  
• Nobel prize for medicine marred by death and controversy
  - Lancet 378(9800):1367 (2011)
  
• From 2D to 3D: the future of surgery?
  - Lancet 378(9800):1368 (2011)
  
• The Lancet Technology: October, 2011
  - Lancet 378(9800):1369 (2011)
  
• The discreet harm of the Bourgeoisie
  - Lancet 378(9800):1370 (2011)
  
• Anthony Atala: at the cutting edge of regenerative surgery
  - Lancet 378(9800):1371 (2011)
  
• The origins of organ transplantation
  - Lancet 378(9800):1372-1373 (2011)
  
• Fritz Heinz Bach
  - Lancet 378(9800):1374 (2011)
  
• Health care and the Palestinian bid for statehood
  - Lancet 378(9800):1375 (2011)
  
• Benefits of lowering cholesterol in chronic kidney disease
  - Lancet 378(9800):1375 (2011)
  
• Benefits of lowering cholesterol in chronic kidney disease
  - Lancet 378(9800):1376 (2011)
  
• Benefits of lowering cholesterol in chronic kidney disease
  - Lancet 378(9800):1376 (2011)
  
• Benefits of lowering cholesterol in chronic kidney disease
  - Lancet 378(9800):1376-1377 (2011)
  
• Benefits of lowering cholesterol in chronic kidney disease â€" Authors' reply
  - Lancet 378(9800):1377-1378 (2011)
  
• Single-disease health campaigns: the case of cervical cancer
  - Lancet 378(9800):1378 (2011)
  
• Single-disease health campaigns: the case of cervical cancer â€" Authors' reply
  - Lancet 378(9800):1378 (2011)
  
• Circulatory arrest versus cerebral perfusion during pulmonary endarterectomy surgery (PEACOG): a randomised controlled trial
  - Lancet 378(9800):1379-1387 (2011)
  Background For some surgical procedures to be done, a patient's blood circulation needs to be stopped. In such situations, the maintenance of blood flow to the brain is perceived beneficial even in the presence of deep hypothermia. We aimed to assess the benefits of the maintenance of antegrade cerebral perfusion (ACP) compared with deep hypothermic circulatory arrest (DHCA). Methods Patients aged 18–80 years undergoing pulmonary endarterectomy surgery in a UK centre (Papworth Hospital, Cambridge) were randomly assigned with a computer generated sequence to receive either DHCA for periods of up to 20 min at 20°C or ACP (1:1 ratio). The primary endpoint was change in cognitive function at 12 weeks after surgery, as assessed by the trail-making A and B tests, the Rey auditory verbal learning test, and the grooved pegboard test. Patients and assessors were masked to treatment allocation. Primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, number ISRCTN84972261. Findings We enrolled 74 of 196 screened patients (35 to receive DHCA and 39 to receive ACP). Nine patients crossed over from ACP to DHCA to allow complete endarterectomy. At 12 weeks, the mean difference between the two groups in Z scores (the change in cognitive function score from baseline divided by the baseline SD) for the three main cognitive tests was 0·14 (95% CI −0·14 to 0·42; p=0·33) for the trail-making A and B tests, −0·06 (−0·38 to 0·25; p=0·69) for the Rey auditory verbal learning test, and 0·01 (−0·26 to 0·29; p=0·92) for the grooved pegboard test. All patients showed improvement in cognitive function at 12 weeks. We recorded no significant difference in adverse events between the two groups. Three patients died (two in the DHCA group and one in the ACP group). Interpretation Cognitive function is not impaired by either ACP or DHCA. We recommend circulatory arrest as the optimum modality for patients undergoing pulmonary endarterectomy surgery. Funding J P Moulton Charitable Foundation.
• The long-term outcome of adult epilepsy surgery, patterns of seizure remission, and relapse: a cohort study
  - Lancet 378(9800):1388-1395 (2011)
  Background Surgery is increasingly used as treatment for refractory focal epilepsy; however, few rigorous reports of long-term outcome exist. We did this study to identify long-term outcome of epilepsy surgery in adults by establishing patterns of seizure remission and relapse after surgery. Methods We report long-term outcome of surgery for epilepsy in 615 adults (497 anterior temporal resections, 40 temporal lesionectomies, 40 extratemporal lesionectomies, 20 extratemporal resections, 11 hemispherectomies, and seven palliative procedures [corpus callosotomy, subpial transection]), with prospective annual follow-up for a median of 8 years (range 1–19). We used Kaplan-Meier survival analysis to estimate time to first seizure, and investigated patterns of seizure outcome. Findings We used survival methods to estimate that 52% (95% CI 48–56) of patients remained seizure free (apart from simple partial seizures [SPS]) at 5 years after surgery, and 47% (42–51) at 10 years. Patients who had extratemporal resections were more likely to have seizure recurrence than were those who had anterior temporal resections (hazard ratio [HR] 2·0, 1·1–3·6; p=0·02); whereas for those having lesionectomies, no difference from anterior lobe resection was recorded. Those with SPS in the first 2 years after temporal lobe surgery had a greater chance of subsequent seizures with impaired awareness than did those with no SPS (2·4, 1·5–3·9). Relapse was less likely the longer a person was seizure free and, conversely, remission was less likely the longer seizures continued. In 18 (19%) of 93 people, late remission was associated with introduction of a previously untried antiepileptic drug. 104 of 365 (28%) seizure-free individuals had discontinued drugs at latest! follow-up. Interpretation Neurosurgical treatment is appealing for selected people with refractory focal epilepsy. Our data provide realistic expectations and indicate the scope for further improvements in presurgical assessment and surgical treatment of people with chronic epilepsy. Funding UK Department of Health National Institute for Health Research (NIHR) Biomedical Research Centres funding scheme, Epilepsy Society, Dr Marvin Weil Epilepsy Research Fund.
• Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study
  - Lancet 378(9800):1396-1407 (2011)
  Background Preoperative anaemia is associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. We aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery. Methods We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) effect of anaemia, which was defined as mild (haematocrit concentration >29–<39% in men and >29–<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes. Findings We obtained data for 227 425 patients, of whom 69 229 (30·44%) had preoperative anaemia. After adjustment, postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1·42, 95% CI 1·31–1·54); this difference was consistent in mild anaemia (1·41, 1·30–1·53) and moderate-to-severe anaemia (1·44, 1·29–1·60). Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia (adjusted OR 1·35, 1·30–1·40), again consistent in patients with mild anaemia (1·31, 1·26–1·36) and moderate-to-severe anaemia (1·56, 1·47–1·66). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone. Interpretation Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery. Funding Vifor Pharma.
• The intensity and variation of surgical care at the end of life: a retrospective cohort study
  - Lancet 378(9800):1408-1413 (2011)
  Background Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. Methods We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ2 tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. Findings Of 1 802 029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9–32·0; 575 596 of 1 802 029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2–18·4; 329 771 of 1 802 029) underwent a procedure in their last month of life, and 8·0% (8·0–8·1; 144 162 of 1 802 029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% [95% CI 34·7–35·9; 8858 of 25 094] to 23·6% [22·9–24·3; 3340 of 14 152]). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7–35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3–11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27–0·46; p<0·0001), as did regions with high to! tal Medicare spending (r=0·50, 0·41–0·58; p<0·0001). Interpretation Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. Funding None.
• A call for government accountability to achieve national self-sufficiency in organ donation and transplantation
  - Lancet 378(9800):1414-1418 (2011)
  Roughly 100 000 patients worldwide undergo organ transplantation annually, but many other patients remain on waiting lists. Transplantation rates vary substantially across countries. Affluent patients in nations with long waiting lists do not always wait for donations from within their own countries. Commercially driven transplantation, however, does not always ensure proper medical care of recipients or donors, and might lengthen waiting times for resident patients or increase the illegal and unethical purchase of organs from living donors. Governments should systematically address the needs of their countries according to a legal framework. Medical strategies to prevent end-stage organ failure must also be implemented. In view of the Madrid Resolution, the Declaration of Istanbul, and the 63rd World Health Assembly Resolution, a new paradigm of national self-sufficiency is needed. Each country or region should strive to provide a sufficient number of organs from! within its own population, guided by WHO ethics principles.
• Prevention of cardiovascular disease in adult recipients of kidney transplants
  - Lancet 378(9800):1419-1427 (2011)
  Although advances in immunosuppression, tissue typing, surgery, and medical management have made transplantation a routine and preferred treatment for patients with irreversible renal failure, successful transplant recipients have a greatly increased risk of premature mortality because of cardiovascular disease and malignancy compared with the general population. Conventional cardiovascular risk factors such as hyperlipidaemia, hypertension, and diabetes are common in transplant recipients, partly because of the effects of immunosuppressive drugs, and are associated with adverse outcomes. However, the natural history of cardiovascular disease in such recipients differs from that in the general population, and only statin therapy has been studied in a large-scale interventional trial. Thus, the management of this disease and the balance between management of conventional risk factors and modification of immunosuppression is complex.
• Diagnosis and prevention of chronic kidney allograft loss
  - Lancet 378(9800):1428-1437 (2011)
  Kidney transplantation is the best possible treatment for many patients with end-stage renal failure, but progressive dysfunction and eventual allograft loss with return to dialysis is associated with increased mortality and morbidity. Immune injury from acute or chronic rejection and non-immune causes, such as nephrotoxicity from calcineurin inhibitors, ischaemia-reperfusion injury, recurrent glomerular disease, and allograft BK viral infection, are potential threats. Serial monitoring of renal function enables early recognition of chronic allograft dysfunction, and investigations such as therapeutic drug concentrations, urinalysis, imaging, and a diagnostic biopsy should be undertaken before irreversible nephron loss has occurred. Specific interventions targeting the pathophysiological cause of dysfunction include strengthening of immunosuppression for chronic rejection, or calcineurin inhibitor minimisation, substitution, or elimination if nephrotoxicity dominates. ! Recommended proactive preventive measures are control of hypertension, proteinuria, dyslipidaemia, diabetes, smoking, and other comorbidities. Strategies to maintain transplant function and improve long-term graft survival are important goals of translational research.
• Cervical lump? The clue is in the hotspot
  - Lancet 378(9800):1438 (2011)