for Journals by Title or ISSN
for Articles by Keywords
help
Followed Journals
Journal you Follow: 0
 
Sign Up to follow journals, search in your chosen journals and, optionally, receive Email Alerts when new issues of your Followed Journals are published.
Already have an account? Sign In to see the journals you follow.
Journal Cover The Lancet
  [SJR: 14.638]   [H-I: 600]   [2067 followers]  Follow
    
   Full-text available via subscription Subscription journal
   ISSN (Print) 0140-6736 - ISSN (Online) 1474-547X
   Published by Elsevier Homepage  [3043 journals]
  • A positive randomised trial in cutaneous T-cell lymphoma
    • Authors: Pierluigi Porcu; Joya Sahu
      Pages: 533 - 534
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Pierluigi Porcu, Joya Sahu


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31473-3
       
  • PRIMA, non nocere
    • Authors: John A Harvin; Lillian S Kao
      Pages: 535 - 536
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): John A Harvin, Lillian S Kao


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31616-1
       
  • Responding to the adolescent in distress
    • Authors: George Patton; Rohan Borschmann
      Pages: 536 - 538
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): George Patton, Rohan Borschmann


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31331-4
       
  • Family-delivered rehabilitation services at home: is the glass empty'
    • Authors: Gert Kwakkel; Erwin E H van Wegen
      Pages: 538 - 539
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Gert Kwakkel, Erwin E H van Wegen


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31489-7
       
  • After Charlie Gard: ethically ensuring access to innovative treatment
    • Authors: Dominic Wilkinson; Julian Savulescu
      Pages: 540 - 542
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Dominic Wilkinson, Julian Savulescu


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32125-6
       
  • The Green Helmets: providing care in Venezuela's protests
    • Authors: Manuel Rueda
      Pages: 543 - 544
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Manuel Rueda


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32099-8
       
  • Al Gore's truth is still inconvenient
    • Authors: Laurie Garrett
      Pages: 545 - 546
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Laurie Garrett


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31999-2
       
  • The world of surrogacy
    • Authors: Marco De Ambrogi
      First page: 547
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Marco De Ambrogi


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32001-9
       
  • Police surgeons and sexual violence: a history
    • Authors: Joanna Bourke
      Pages: 548 - 549
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Joanna Bourke


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32000-7
       
  • John Walley Littlefield
    • Authors: Alison Snyder
      First page: 550
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Alison Snyder


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32002-0
       
  • Venezuela's health-care crisis
    • Authors: Ricardo J Bello; José J Damas; Francisco J Marco; Julio S Castro
      First page: 551
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Ricardo J Bello, José J Damas, Francisco J Marco, Julio S Castro


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31831-7
       
  • The reality of the mortality statistics of the nurses’ strike in
           Kenya
    • Authors: Phoebe C M Williams
      First page: 551
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Phoebe C M Williams


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31944-x
       
  • Ending our shame: call for a fundamental reconsideration of Australian
           refugee policy
    • Authors: Elizabeth A Bennett; Louise Newman; Julian WK Burnside; Barri Phatarfod; Robert M Thomas; A Rob Moodie; Michael J Moore
      First page: 552
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Elizabeth A Bennett, Louise Newman, Julian WK Burnside, Barri Phatarfod, Robert M Thomas, A Rob Moodie, Michael J Moore


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31914-1
       
  • Dementia-friendly public toilets
    • Authors: Andrea Tales; Vanessa Burholt; Paul Nash; Jo-Anne Bichard; Angela Clayton-Turner
      Pages: 552 - 553
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Andrea Tales, Vanessa Burholt, Paul Nash, Jo-Anne Bichard, Angela Clayton-Turner


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31813-5
       
  • Post-deployment screening for mental disorders and help-seeking in the UK
           military
    • Authors: Lyndsay S Baines; Lee Mitchell; Kevin Long; Caroline Abbot; Nicky Clarke; Domon Tyler; Daniel Ireton; Faria Khan
      Pages: 553 - 554
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Lyndsay S Baines, Lee Mitchell, Kevin Long, Caroline Abbot, Nicky Clarke, Domon Tyler, Daniel Ireton, Faria Khan


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31627-6
       
  • Post-deployment screening for mental disorders and help-seeking in the UK
           military – Authors’ reply
    • Authors: Roberto J Rona; Howard Burdett; Neil Greenberg; Nicola T Fear; Simon Wessely
      First page: 554
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Roberto J Rona, Howard Burdett, Neil Greenberg, Nicola T Fear, Simon Wessely


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31629-x
       
  • Prevention of incisional hernia with prophylactic onlay and sublay mesh
           reinforcement versus primary suture only in midline laparotomies (PRIMA):
           2-year follow-up of a multicentre, double-blind, randomised controlled
           trial
    • Authors: An P Jairam; Lucas Timmermans; Hasan H Eker; Robert E G J M Pierik; David van Klaveren; Ewout W Steyerberg; Reinier Timman; Arie C van der Ham; Imro Dawson; Jan A Charbon; Christoph Schuhmacher; André Mihaljevic; Jakob R Izbicki; Panagiotis Fikatas; Philip Knebel; René H Fortelny; Gert-Jan Kleinrensink; Johan F Lange; Hans J Jeekel; Jeroen Nieuwenhuizen; Wim C J Hop; Pim C W Burger; Hence J Verhagen; Pieter J Klitsie; Michiel van de Berg; Markus Golling
      Pages: 567 - 576
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): An P Jairam, Lucas Timmermans, Hasan H Eker, Robert E G J M Pierik, David van Klaveren, Ewout W Steyerberg, Reinier Timman, Arie C van der Ham, Imro Dawson, Jan A Charbon, Christoph Schuhmacher, André Mihaljevic, Jakob R Izbicki, Panagiotis Fikatas, Philip Knebel, René H Fortelny, Gert-Jan Kleinrensink, Johan F Lange, Hans J Jeekel
      Background Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia. Methods We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m2 or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475. Findings Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20–0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30–1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement). Interpretation A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy. Funding Baxter; B Braun Surgical SA.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31332-6
       
  • Causes of death up to 10 years after admissions to hospitals for
           self-inflicted, drug-related or alcohol-related, or violent injury during
           adolescence: a retrospective, nationwide, cohort study
    • Authors: Annie Herbert; Ruth Gilbert; David Cottrell; Leah Li
      Pages: 577 - 587
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Annie Herbert, Ruth Gilbert, David Cottrell, Leah Li
      Background Emergency hospital admission with adversity-related injury (ie, self-inflicted, drug-related or alcohol-related, or violent injury) affects 4% of 10–19-year-olds. Their risk of death in the decade after hospital discharge is twice as high as that of adolescents admitted to hospitals for accident-related injury. We established how cause of death varied between these groups. Methods We did a retrospective, nationwide, cohort study comparing risks of death in five causal groups (suicide, drug-related or alcohol-related, homicide, accidental, and other causes of death) up to 10 years after hospital discharge following adversity-related (self-inflicted, drug-related or alcohol-related, or violent injury) or accident-related (for which there was no recorded adversity) injury. We included adolescents (aged 10–19 years) who were admitted as an emergency for adversity-related or accident-related injury between April 1, 1997, and March 31, 2012. We excluded adolescents who did not have their sex recorded, died during the index admission, had no valid discharge date, or were admitted with injury related to neither adversity nor accidents. We identified admissions for adversity-related or accident-related injury to the National Health Service in England with the International Classification of Diseases-10 codes in Hospital Episode Statistics data, linked to the Office for National Statistics mortality data for England, to establish cause-specific risks of death between the first day and 10 years after discharge, and to compare risks between adversity-related and accident-related index injury after adjustment for age group, socioeconomic status, and chronic conditions. Findings We identified 1 080 368 adolescents (388 937 [36·0%] girls, 690 546 [63·9%] boys, and 885 [0·1%] adolescents who did not have their sex recorded). Of these adolescents, we excluded 40 549 (10·4%) girls, 56 107 (8·1%) boys, and all 885 without their sex recorded. Of the 333 009 (30·8%) adolescents admitted with adversity-related injury (181 926 [54·6%] girls and 151 083 [45·4%] boys) and 649 818 (60·2%) admitted with accident-related injury (166 462 [25·6%] girls and 483 356 [74·4%] boys), 4782 (0·5%) died in the 10 years after discharge (1312 [27·4%] girls and 3470 [72·6%] boys). Adolescents discharged after adversity-related injury had higher risks of suicide (adjusted subhazard ratio 4·54 [95% CI 3·25–6·36] for girls, and 3·15 [2·73–3·63] for boys) and of drug-related or alcohol-related death (4·71 [3·28–6·76] for girls, and 3·53 [3·04–4·09] for boys) in the next decade than they did after accident-related injury. Although we included homicides in our estimates of 10-year risks of adversity-related deaths, we did not explicitly present these risks because of small numbers and risks of statistical disclosure. There was insufficient evidence that girls discharged after adversity-related injury had increased risks of accidental deaths compared with those discharged after accident-related injury (adjusted subhazard ratio 1·21 [95% CI 0·90–1·63]), but there was evidence that this risk was increased for boys (1·26 [1·09–1·47]). There was evidence of decreased risks of other causes of death in girls (0·64 [0·53–0·77]), but not in boys (0·99 [0·84–1·17]). Risks of suicide were increased following self-inflicted injury (adjusted subhazard ratio 5·11 [95% CI 3·61–7·23] for girls, and 6·20 [5·27–7·30] for boys), drug-related or alcohol-related injury (4·55 [3·23–6·39] for girls, and 4·51 [3·89–5·24] for boys), and violent injury in boys (1·43 [1·15–1·78]) versus accident-related injury. However, the increased risk of suicide in girls following violent injury versus accident-related injury was not significantly increased (adjusted subhazard ratio 1·48 [95% CI 0·73–2·98]). Following each type of index injury, risks of suicide and risks of drug-related or alcohol-related death were increased by similar magnitudes. Interpretation Risks of suicide were significantly increased after all types of adversity-related injury except for girls who had violent injury. Risks of drug-related or alcohol-related death increased by a similar magnitude. Current practice to reduce risks of harm after self-infli...
      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31045-0
       
  • Cataracts
    • Authors: Yu-Chi Liu; Mark Wilkins; Terry Kim; Boris Malyugin; Jodhbir S Mehta
      Pages: 600 - 612
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Yu-Chi Liu, Mark Wilkins, Terry Kim, Boris Malyugin, Jodhbir S Mehta
      An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)30544-5
       
  • Peptic ulcer disease
    • Authors: Angel Lanas; Francis K L Chan
      Pages: 613 - 624
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): Angel Lanas, Francis K L Chan
      The rapidly declining prevalence of Helicobacter pylori infection and widespread use of potent anti-secretory drugs means peptic ulcer disease has become substantially less prevalent than it was two decades ago. Management has, however, become more challenging than ever because of the threat of increasing antimicrobial resistance worldwide and widespread use of complex anti-thrombotic therapy in the ageing population. Peptic ulcers not associated with H pylori infection or the use of non-steroidal anti-inflammatory drugs are now also imposing substantial diagnostic and therapeutic challenges. This Seminar aims to provide a balanced overview of the latest advances in the pathogenetic mechanisms of peptic ulcers, guidelines on therapies targeting H pylori infection, approaches to treatment of peptic ulcer complications associated with anti-inflammatory analgesics and anti-thrombotic agents, and the unmet needs in terms of our knowledge and management of this increasingly challenging condition.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(16)32404-7
       
  • Progress of The Lancet Palestinian Health Alliance
    • Authors: Graham Watt; Rita Giacaman; Huda Zurayk
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Graham Watt, Rita Giacaman, Huda Zurayk


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32046-9
       
  • Women's anxieties relating to documentation, registration, time, and place
           of childbirth in Kufr ‘Aqab, East Jerusalem: a qualitative study
    • Authors: Doaa Hammoudeh; Layaly Hamayel; Rita Giacaman
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Doaa Hammoudeh, Layaly Hamayel, Rita Giacaman
      Background Since 1967, about 14 000 Palestinians have had their Jerusalem residency revoked, and thousands struggle to maintain Jerusalem residency. Although physically located outside the Separation Wall, the Kufr ‘Aqab neighbourhood is inside Israeli-defined greater Jerusalem, thereby providing legal basis for holders of Jerusalem identity cards to maintain their Jerusalem residency status. It also provides Jerusalem identity card holders who are married to West Bank identity card holders with a place to live with family members who otherwise cannot access or reside in Jerusalem without a permit (required to cross checkpoints to reach Jerusalem). In this paper, we focus on a specific vulnerability during childbearing through exploring select case studies of women's narratives as they relate to childbirth-related anxiety and dilemmas before and after Jerusalem residency registration. Methods We conducted in-depth semi-structured interviews with 27 women residing in Kufr ‘Aqab, carrying Jerusalem or West Bank IDs (age range 24–44 years). Participants were recruited through snowballing. Interviews were transcribed verbatim in Arabic and analysed thematically through repeated reading, whereby patterns, themes, and sub-themes gradually appeared. Key sub-themes related to childbearing were extrapolated. Participants provided oral informed consent. Findings Women's narratives pointed to strong anxiety related to their need to give birth within Jerusalem boundaries, and specifically inside the Separation Wall, to facilitate the birth registration process for Jerusalem residency. Cases of psychological distress related to fears of checkpoint delays and of an ensuing birth at a checkpoint, and a perceived link between political violence and negative health outcomes, including miscarriages, were discussed. Although many women reported compromised familial support systems during childbirth, including their husband's presence during birth, women also negotiated these restrictions and where possible, used childbirth interventions to bypass occupation-imposed obstacles. Interpretation During pregnancy and childbirth, women residing in Kufr ‘Aqab face specific challenges and make unique political decisions related to giving birth in Jerusalem, attesting to a particular vulnerability that could affect the wellbeing of the mother and child. Moreover, this study highlights women's fears of severe consequences of the absence of registration for children. Funding Reproductive Health Working Group in the Arab World and Turkey.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32052-4
       
  • Prevention of unintentional injuries at home in children younger than 5
           years in Ramallah District: a case study approach
    • Authors: Intima Alrimawi; Michael C Watson; Carol Hall
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Intima Alrimawi, Michael C Watson, Carol Hall
      Background Unintentional child injuries are a growing public health problem, representing a major cause of mortality, morbidity, and disability worldwide. Injuries are a substantial burden on health-care systems, particularly in low-income countries. We aimed to explore the perceptions and practices of parents, health professionals, and key individuals about the prevention of home-related unintentional injuries in children younger than 5 years, and the potential factors that might affect such practices. Methods We followed a case study approach, whereby we interviewed four parents from four households (one parent from each) in each of the three different settings within Ramallah District (camp, rural, and urban), and observed the rooms in their houses for potential hazards at a single timepoint using a standardised checklist. We interviewed 24 health professionals who worked with children in a primary health-care setting, and nine senior managers within organisations concerned with children's safety. We analysed data using inductive thematic analysis. Findings We recorded many hazards in all settings (48 in camp settings, 43 in rural settings, and 39 in urban settings). Parents attempted to prevent injuries to children in the home, and we noted many similarities between the perspectives of parents within the three settings. However, many factors affected their practice, mainly related to lack of awareness and low financial status. Environmental factors affected injury prevention, including the physical environment of the house, sociocultural environment (eg, belief in fatalism), and governmental policy (eg, lack of home safety regulations). 18 of the 24 health professionals and five of the nine senior managers interviewed were positive about prevention of home injuries, but workload and lack of training were the main barriers to their practice in this area. Interpretation The causes of child home injuries are embedded within families' culture and social and economic status, and are affected by government policies. Interventions to prevent home injuries in Ramallah District should acknowledge these factors to increase the potential for success. Funding The University of Nottingham, Birzeit University.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32004-4
       
  • The effect of prenatal maternal nutrition and eating habits on low
           birthweight in the Gaza Strip: a case-control study
    • Authors: Akram Abusalah; Khalil Shuaib; Imad El Awour
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Akram Abusalah, Khalil Shuaib, Imad El Awour
      Background Poor prenatal nutrition is recognised as an important cause of low birthweight, defined as a weight of less than 2·5 kg at birth. We aimed to assess the association between prenatal maternal nutrition and delivery of infants with low birthweight in the Gaza Strip. Methods 446 women were selected in a ratio of 1:1 during May–June and July–August, 2007, from attendants of Al-Tahrier Hospital and Shifa Medical Centre, respectively. Cases were all women who delivered live singleton infants with a weight of less than 2·5 kg. Matched controls were mothers who delivered single live newborns weighing 2·5 kg or more during the first 24 h after their respective cases were identified. We computed univariately unadjusted matched odds ratios (mOR) and 95% CIs with conditional logistic regression. Univariate and multivariate logistic regression were used with analyses completed in two integrated steps. In model 1, we analysed prenatal predictors that remained after stepwise backward selection at univariate p value <0·20. In model 2, we analysed the significant variables from model 1 and other principal confounding factors (parents’ education, occupation, and residence by districts’ distribution), stress, income, consanguinity, and body-mass index). Maternal nutritional status and eating habits were assessed subjectively by asking mothers about their appetite during pregnancy, number of meals, time space between meal ingestion and caffeine intake (tea and coffee), quality of the ingested food, and tea and coffee consumption. Findings The findings showed independently adjusted significant linear trend for increased odds of low birthweight with poor (mOR 3·80, 95% CI 1·65–8·74) and moderate (2·28, 1·20–4·33) maternal appetite status, and diminished frequency of eating meat during pregnancy(women who ate meat fewer than three times a month and once a week had, respectively, 4·25 times [95% CI 1·70–10·6] and 2·77 times [1·42–5·38] higher risk of low birthweight compared with who consumed meat two or more times a week). Likewise, short time (<1 h) between maternal meal ingestion and tea consumption (mOR 2·48, 95% CI 1·14–5·41), and high intake of coffee (≥2 cups a day; 2·48, 1·14–5·41) were independently associated with increased likelihood of low birthweight after adjustment for principal confounders. Interpretation Our results suggest that several maternal nutritional factors are associated with low birthweight in the Gaza Strip. Such associations might have implications for clinical antenatal work, especially since the identified exposures are modifiable. Emphasis should be given to educational health strategies combined with concrete developmental policies aiming to improve the socioeconomic conditions that determine the presence of diverse health-damaging exposures. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32053-6
       
  • Needs assessment for a reproductive health registry towards a harmonised
           reproductive health registry in the occupied Palestinian territory: a
           qualitative study
    • Authors: Buthaina Ghanem; Rand Salman; Bjorn G Iversen
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Buthaina Ghanem, Rand Salman, Bjorn G Iversen
      Background Reductions of maternal and child mortality are among the UN's Millennium Development Goals. The estimated maternal mortality ratio (MMR) in the occupied Palestinian territory in 2010 was 64 per 100 000 livebirths. WHO has developed a global initiative, the harmonised reproductive health registry (hRHR), to improve data quality and to reduce maternal and infant mortality. We undertook a needs assessment to identify strengths, opportunities, and gaps in the present information system for reproductive health in the occupied Palestinian territory before development of a strategic action plan for the future. Methods We used a qualitative needs assessment tool (NAT) that has been developed in the International hRHR project and adapted to the Palestinian context. The tool was developed with sections on legal issues, essential indicators, minimum dataset, data collection, data dissemination, and data use. This assessment will help to identify data gaps, which can then be filled to help reduce maternal and child deaths. Through in-depth interviews with senior managers at the Ministry of Health, we adapted the NAT to the Palestinian context. A 1 day workshop with 20 participants from Ministry of Health stakeholder institutions (eg, Department of Primary Health Care) completed the NAT. Findings The needs assessment showed substantial current data collection in antenatal, perinatal, and postnatal care in local health facilities. However, very little information is exchanged between primary and secondary care, jeopardising the continuum of care and preventing data being used to benefit services provided or for public health purposes. Nationally, reports consist mostly of aggregated, monthly reports of health status and activities that are then published annually. Data are not used for management, to improve quality of care, or to give feedback to health-care providers. Although many of the interventions practised are in line with the essential interventions recommended by WHO, legislation about confidentiality of health data is restricted, and no national agreement has been made about essential interventions, indicators, or a minimum dataset to be collected. Interpretation Data that are collected should be kept at a necessary minimum and be selected according to evidence-based essential interventions. A way to improve the system would be to introduce a comprehensive computerised hRHR in a consensus-driven process with the major stakeholders in maternal–child health. Funding WHO Palestinian National Institute of Public Health Project.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32005-6
       
  • Alcohol versus dry umbilical cord care among newborn infants in occupied
           Palestinian territory: a controlled trial
    • Authors: Maher Shahrour; Nour AlHuda Sawalha; Murad Masri; Hanan Rajabi; Mohammad Salah Eddin; Taha Jo'beh; Sundus Shalabi; Ala' Lafi; Ebtihal Jawabra; Waseem Khreim; Sa'eed Natsheh; Motee Abu Awwad; Hatem Khammash
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Maher Shahrour, Nour AlHuda Sawalha, Murad Masri, Hanan Rajabi, Mohammad Salah Eddin, Taha Jo'beh, Sundus Shalabi, Ala' Lafi, Ebtihal Jawabra, Waseem Khreim, Sa'eed Natsheh, Motee Abu Awwad, Hatem Khammash
      Background Omphalitis is considered a leading cause of sepsis among newborn infants and topical antiseptic cord care is usually recommended. In 2003, WHO recommended the use of dry cord care in settings where the risk of omphalitis and sepsis is low. In Palestine, recommendations on umbilical cord care are not clear; the 70% alcohol cord care method is still used as standard by many and the chlorhexidene method is virtually unknown. In this study we compared the alcohol and dry cord care methods among healthy newborns in two urban hospitals in the occupied Palestine territory. Methods A non-randomised controlled trial was conducted in the newborn nurseries of two tertiary hospitals in East Jerusalem and Hebron. Newborn infants born at 37 or more weeks’ gestation between March and October, 2014, were enrolled. Infants with major congenital anomalies who were admitted to neonatal intensive care unit, required antibiotics at birth, or had a hospital stay of more than 72 h, were excluded. One group of parents was asked to clean the infant's stump with 70% alcohol, and the other group to use dry cord care, changing methods on a weekly basis. The study was approved by the ethics committees of both hospitals. Written consent was obtained from participating parents. Findings 692 newborn babies were enrolled to both treatment groups. 344 used dry cord care and 348 the alcohol cord care method. No infants developed cord infection. The mean time to separation of the umbilical cord was 7·03 days (SD 2·47) in the dry cord care group and 8·13 days (2·47) in the alcohol cord care group (p<0·001). Interpretation Our findings suggest that dry cord care is safe, is associated with a reduced separation time, and can be recommended for use in our context. Neither method of cord care was associated with the development of omphalitis in any of the study participants. A limitation of our study was that randomisation was impossible in view of the work overload and limited human resources at our hospitals. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32054-8
       
  • Fatalities and injuries in the 2014 Gaza conflict: a descriptive study
    • Authors: Yehia Abed; Seham Abu Haddaf
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Yehia Abed, Seham Abu Haddaf
      Background Deaths and injuries during conflict are a growing public health problem that requires urgent attention. We aimed to describe mortality and injuries among Palestinians in Gaza Strip and to assess effects on health system performance during the 2014 war. Methods The study was based on analysis of data available in the Health Information Centre in Gaza, after ethical and administrative permissions had been obtained. Data covered all of the Gaza Strip population. We calculated numbers of injuries and deaths per 100 000 population, case fatality for conflict-related injuries, and Dirty War Index (DWI: a public health tool that systematically identifies rates of particularly undesirable or prohibited war outcomes—so-called dirty war outcomes). Findings During the 51 days of war, 11 228 injuries (6487 per 100 000) and 2147 deaths (1241 per 100 000) were reported. Overall case fatality was 19·1%; the highest case fatality was reported in Rafah (39·1%), and case fatality in El Najar hospital was 45·4%. The DWI highlighted the suffering of children, women, and older people. The DWI was 46·2% for mortality and 56·5% for injuries. Dirty war outcomes were not limited to killed and injured people but extended to health institutions, ambulances, and health staff. Local community hospitals succeeded in admission of more than 95% of injured people in each governorate. Cases referred to the major hospital (Shifa) in Gaza Strip were mainly from Gaza city (83%). Interpretation Our findings indicate the presence of dirty war outcomes, as defined by the DWI, in the 2014 conflict and highlight the strains placed on the health system in Gaza, which has been severely affected by the frequent attacks. Community hospitals and the non-governmental sector have to be supported to enable them to face emergencies. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32055-x
       
  • Smoking and life-course events among youths living in Area C of the
           occupied Palestinian territory: an analysis of data from the Palestinian
           Family Health Survey
    • Authors: Hendia A Abu-Nabaa; Niveen Abu-Rmeileh
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Hendia A Abu-Nabaa, Niveen Abu-Rmeileh
      Background Individuals' maturity, independence, and freedom of choice involve five risky behaviours; smoking is the one that most seriously affects individual and public health. Since OSLO accord in 1993, 60% of the West Bank has been under Israeli military control (known as Area C) and is home to about 300 000 Palestinians and a settler population of at least 325 500 people. Israel retains the area to serve military training, economic interests, and settlement development, potentially affecting Palestinian people's life course. We aimed to compare smoking and life-course events among youths aged 14–29 years in 2010 living in Palestinian areas under Palestinian control (PA) of the West Bank and Gaza Strip (population 837 099 youths) with those residing in Area C (population 90 000 youths) in the West Bank. Methods We used data from the Palestinian Family Health Survey (which was done by the Palestinian Centre Bureau of Statistics in 2010), in which smoking was the dependent variable. A youth's life-course events, including school enrolment, employment status, marital status, combined with employment (ie, married and employed), and waiting (ie, not married, employed, or studying), were regarded as independent variables in addition to other important factors using SPSS software (version 17). Findings 25 484 youths were included in the analyses (1714 [7%] living in Area C and 24 132 [93%] living in PA). 255 (15%) youths in Area C were smokers compared with 3163 (13%) in PA. Bivariate analyses showed a significant association between smoking statuses and sex (p≤0·05), age (p≤0·05), life course (p≤0·05), region of residency (p≤0·05), wealth-index quintiles (p≤0·05), and area (p≤0·05). Logistic regression showed that youths living in Area C were more likely to smoke than those living in PA (odds ratio [OR] 1·55, 95% CI 1·29–1·86). Moreover, more youths reported to be smokers who were employed and married (41·6%) than workers not married (38·9%) and waiting (19·1%). Youths older than 17 years were more likely to smoke (aged 18–25 years: OR 4·19, 95% CI 3·63–4·85; aged 26–29 years: OR 5·45, 4·55–6·53) than were those aged younger than 17 years. Those living in the West Bank were more likely to smoke than those living in Gaza (4·70, 4·19–5·27). Living in rural refugee camps doubled the probability of being smokers than living in urban camps (1·48 1·27–1·72). Finally, men had an increased probability to be smokers compared with women (74·02, 57·70–94·98). Of youths living in Area C, only students were most likely to smokers. In PA, unemployed youths and students were both most likely to be smokers. Interpretation Additional in-depth research is needed to understand the coping mechanisms used by youths to reach adulthood under stressful situations. A limitation of our study was that socioeconomic status was not included in the statistical model. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32006-8
       
  • Effect of the 2014 attack on Gaza on the use of medical services in
           Al-Nasser Pediatric Hospital: a comparative study
    • Authors: Nabil Al-Barqouni; Mustafa AlKahlut; Sherin Abed; Loai Albarqouni; Yehia Abed
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Nabil Al-Barqouni, Mustafa AlKahlut, Sherin Abed, Loai Albarqouni, Yehia Abed
      Background During the 51-day attack on Gaza in 2014, approximately 2145 people were killed, of whom 20% were children. This study was done to evaluate the use of medical services in Al-Nasser Paediatric Hospital during the attack. Methods We retrospectively compared the number and pattern of admissions to Al-Nasser Paediatric Hospital, the largest paediatric hospital in Gaza Strip, during the period of attacks in July to August, 2014, with those during July to August in 2013. Data were obtained from the patients’ medical records. Findings 3018 patients were admitted during the 2014 attacks and 1706 during the corresponding period in 2013. There were no significant differences in sex (male: 60·6% in 2014 vs 59·4% in 2013) and geographical distribution (children from Gaza: 75·6% in 2014 vs 78·1% in 2013; North-governorate: 17·8% vs 18·8%) of the patients between the two periods. Moreover, there were no significant differences in the distribution of different disease categories, except for that of meningitis (43·2% in 2014 vs 21·9% in 2013; odds ratio [OR] 2·7, 95% CI 2·2–3·3). Number of emergency room visits (20 100 patients in 2014 and 20 400 in 2013) and hospital mortality rate (1·2% in 2014 and 1·3% in 2013) were similar in the two periods. Bed occupancy rate nearly doubled during the attack period (180% vs 95%; OR 1·9, 95% CI 1·3–2·7]). The median hospital stay was significantly shortened during the attack period (2 [IQR 1–3] days vs 3 [1–6] days; difference in means 0·67, 95% CI 0·65–0·68). Interpretation The admission rate during the attack period was increased, without a significant increase in emergency room visits. This finding could be due to the closure of other health-care facilities (because of damage or insecurity), but also might be attributable to changes in health-care seeking behaviour during the attack period because only patients who are severely ill take the risk to come to the emergency department; this behaviour could be reflected by the increase in meningitis-related admissions during the attacks. Despite the increase in admission and bed-occupancy rate during the attack period, hospital mortality rates were similar in both periods. Required resources (including human workforce) should be prepared in advance to accommodate the increase in admission rate during emergency state. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32056-1
       
  • Assessment of diabetic care and patients' satisfaction: an exploratory
           study
    • Authors: Imad El Aour; Alla Abu Teima; Iyad Jomah
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Imad El Aour, Alla Abu Teima, Iyad Jomah
      Background It is expected that 438 million people will be affected by diabetes mellitus worldwide by 2030. Therefore, assessment of the quality of diabetic care from different dimensions, including patients' perspectives, is necessary. We did an exploratory study at Shouka Health Center, Gaza Strip, occupied Palestinian territory. Methods We collected medical records of patients with diabetes from August, 2011, to October, 2011, to assess completeness of diabetic files. We assessed nurses' and doctors' management plans using a modified United Nations Relief and Works Agency (UNRWA) Gaza Field Health Programme Checklist. Each item had three components; we summed scores for each item for the three components to produce an overall scaled index as a percentage for diabetic care. Additionally, we assessed patient satisfaction through exit interviews with five domains addressing health-provider care, health-provider communication, and self-care using a modified version of the Diabetic Continuity of Care Scale (Cronbach's α 0·75). We assessed differences between grouped variables using χ2 and t tests at a significance level of p<0·05. Statistical analysis was done with SPSS software (version 11.5). The study was approved by the ethics committee and written informed consent was obtained. Findings We collected 81 records. The overall scale of diabetic care quality was 85·5%. Overall patient satisfaction was 78·1% and satisfaction with doctors' care was 89·6%. Doctors' management plans scored the lowest satisfaction (77·9%) whereas completeness of patient records scored the highest (97·8%). We noted a significant positive correlation between doctors' management plans and overall satisfaction (r=0·24, p=0·03), completeness of files and overall satisfaction (r=0·27, p=0·02), doctors' management plans and access or care domain (r=0·28, p=0·01), and completeness of files and access or care domain (r=0·23, p=0·05). However, there was no significant correlation between the quality of diabetic care index and the overall satisfaction (r=0·16, p=0·19). Factor analysis showed that staff attitude was the most influential factor on overall satisfaction. Interpretation Staffs' attitude and their commitments seem important to patients' overall satisfaction. Training of doctors properly to manage diabetic patients should be intensified. The relationship between overall satisfaction and the diabetic care quality was obscured by self-care and other health professional care dissatisfaction. Limitations of our study include that exit interviews only capture patients who attend, and do not include those who do not attend, which might be affected by quality of the care. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32007-x
       
  • Lung function and respiratory symptoms among female hairdressers in
           Palestine: a 5-year prospective study
    • Authors: Maysaa Nemer; Petter Kristensen; Khaldoun Nijem; Espen Bjertness; Øivind Skare; Marit Skogstad
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Maysaa Nemer, Petter Kristensen, Khaldoun Nijem, Espen Bjertness, Øivind Skare, Marit Skogstad
      Background Hairdressers are at risk of respiratory health problems due to exposure to chemicals in the workplace. We aimed to examine possible changes in self-reported respiratory symptoms and lung function over 5 years. Also, we examined the associations between occupational factors and lung function changes between baseline and follow-up. Methods A cohort of 170 female hairdressers in Hebron answered a questionnaire and did a lung function test in 2008. A follow-up study was conducted on the same cohort in 2013. Changes in respiratory symptoms and lung function over the period were measured using generalised and linear mixed models. The lung function test was done using a PC spirometer and a disposable mouthpiece filter and nose clip. Participants were given instructions on the forced maximal expiratory manoeuvres. Respiratory symptoms that were assessed with the questionnaire included chest tightness, shortness of breath, wheezing, cough, and phlegm during the past 12 months. Furthermore, we asked questions on doctor-diagnosed asthma. Differences between current and former hairdressers in respiratory symptoms and lung function at follow-up were measured using mixed models. Written informed consent was obtained from all participants. Findings 161 individuals participated in the follow-up study. 28 (16%) of the participants had left their profession. Current hairdressers reported significantly greater changes in chest tightness (prevalence difference [PD] 0·037, 95% CI 0·005 to 0·069) and shortness of breath (0·038, 0·001 to 0·076) between baseline and 2013, compared with former hairdressers Former hairdressers reported fewer symptoms at follow-up than did current hairdressers (PD 0·071, 95% CI –0·0167 to 0·024 for wheezing; 0·071, CI –0·167 to 0·023 for shortness of breath). At follow-up current hairdressers showed a significant decrease in forced expiratory volume in 1 s (FEV1) of 31 mL per year (95% CI 25 to 36). Hairdressers who had been working for 4 years or longer at baseline showed a stronger annual mean decline in FEV1 than those who had worked for less than 4 years (difference 13 mL, 95% CI 1 to 25). Interpretation Current hairdressers developed more respiratory symptoms and had a larger lung function decline than former hairdressers. Working for more years was associated with increased lung function decline. These findings suggest that workplace-related factors, including chemical exposures, might have a negative effect on the respiratory health of hairdressers. Thus, there might be a need to monitor exposures and eventually improve the workplace conditions. Funding NUFU “Building Competence in Epidemiology in Palestine” Pro 50-2002 and supportive measures 2008–2009.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32057-3
       
  • Prevalence and predictors of double burden of malnutrition in Palestinian
           children younger than 5 years: analysis of data from the Multiple
           Indicator Cluster Surveys round four
    • Authors: Hala Ghattas; Khalil El Asmar; Moubadda J Assi; Carla M Obermeyer
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Hala Ghattas, Khalil El Asmar, Moubadda J Assi, Carla M Obermeyer
      Background In the context of the global nutrition transition, large inequalities in the burden of child undernutrition persist across populations and are often concomitantly reported with increases in rates of overweight in these same communities. We aimed to compare the prevalence of stunting and overweight in Palestinian children younger than 5 years living in Lebanon and the occupied Palestinian territories and to investigate the predictors of undernutrition and overnutrition in these populations. Methods We used maternal and child health data, sociodemographic variables, and anthropometric measurements from the 2010 Multiple Indicator Cluster Surveys (MICS) undertaken among Palestinian refugees living in Lebanon (1922 children) and the occupied Palestinian territories (11 273 children). Z-scores for height-for-age and body-mass index-for-age for children younger than 5 years were based on WHO's child growth standards. Prevalence of stunting, overweight, and double burden (ie, children with stunted growth and overweight) was estimated. Logistic regression adjusted for survey design was used to model predictors of stunting, overweight, and double burden (STATA version 13). Findings Prevalence of stunting, overweight, and double burden were all higher in Lebanon than in the occupied Palestinian territories (for stunting, 10·9% vs 10·1%, p<0·0001; for overweight, 11·3% vs 5·8%, p<0·0001; and for double burden, 3·2% vs 1·9%, p=0·0007). After adjusting for covariates, predictors of stunting were age 6–24 months (p=0·05) and region of residence in Lebanon, with Tyre having the highest probability of stunting (p=0·001). Boys (p=0·02), low level of maternal education (p=0·01), and region of residence predicted stunting in the occupied Palestinian territory, with the highest odds of stunting in central West Bank (p<0·0001). Predictors of being overweight were stunting (in Lebanon, odds ratio [OR] 4·30, 95% CI 2·98–6·20; in the occupied Palestinian territories, OR 4·48, 3·63–5·54), male sex (in Lebanon, OR 0·72, 95% CI 0·53–0·98; in the occupied Palestinian territories, OR 0·79, 0·66–0·96), region (highest odds in Bekaa and Tyre [p=0·003], and Central West Bank [p<0·0001]), and higher wealth index in the occupied Palestinian territories (OR 1·3, 95% CI 1·1–1·5). Double burden varied only by region, with highest odds in Lebanon in Tyre (p=0·006) and in the occupied Palestinian territory in the central West Bank (p<0·0001). Interpretation Stunting of growth was a predictor for being overweight in Palestinian children younger than 5 years, with boys at a higher risk than girls. Susceptibility to child malnutrition varied most by region of residence, highlighting the role of structural factors. Nutritional interventions aimed at addressing the common structural determinants of stunting and overweight should be targeted to these subpopulations. Funding Faculty of Health Sciences, American University of Beirut.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32008-1
       
  • Management of non-variceal upper gastrointestinal bleeding in the Gaza
           Strip: survey of evidence-based practice
    • Authors: Alaa eldeen Al-Masri; Marwan Al-Aqad; Khamis Elessi; Khaled Matar; Oseid Alser; Afaf Elsafeen
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Alaa eldeen Al-Masri, Marwan Al-Aqad, Khamis Elessi, Khaled Matar, Oseid Alser, Afaf Elsafeen
      Background Early recognition, comprehensive assessment, and evidence-based care are crucial to reduce morbidity and mortality due to non-variceal upper gastrointestinal bleeding (UGIB). The aim of this study was to compare the present treatment of non-variceal UGIB in Gaza hospitals with the best available, evidence-based recommendations. Methods We distributed 47 questionnaires to doctors in medical departments of three hospitals (Naser Hospital, Alshifa Hospital, and the European Gaza Hospital) about current management strategies for non-variceal UGIB in two hospitals in the Gaza Strip—the European Gaza Hospital and the Shifa hospital. The questions covered target haemoglobin for blood transfusion, duration of proton pump inhibitors (PPI) infusion after endoscopic therapy, use of nasogastric tubes, and use of endoscopic stigmata of recent haemorrhage for therapeutic decisions. Answers from both hospitals were compared with the best available evidence from guidelines by the American College of Gastroenterology (ACG), published in 2012. Findings 47 questionnaires were completed and returned. Only ten (20%) of responders considered the ACG-reccommended 7 g/100 mL as the best threshold for transfusion (most used a higher dose), and only 12 (25%) followed the evidence with respect to the dose and duration of intravenous infusion of PPIs after endoscopic therapy. By contrast, 42 (90%) respondents complied with ACG recommendations of not to routinely use nasogastric tubes, and 38 (80%) used endoscopic stigmata of recent haemorrhage to guide treatment decisions for patients. Finally, only 25 (53%) respondents matched the ACG guidelines about the optimum time to reuse aspirin after non-variceal UGIB. Interpretation Overall, about half of the responses matched that stated in ACG guidelines, which suggests that only half of the decisions about treatment of non-variceal UGIB made by doctors in Gaza hospitals are based on the best available evidence. A potential limitation of our study was that our questionnaire only covered common and relevant aspects of management, not all aspects of therapy. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32009-3
       
  • Lebanese perceptions of citizenship rights for children of Lebanese
           mothers and Palestinian fathers: a cross-sectional survey
    • Authors: Sawsan Abdulrahim; Dalia Mikdashi; Zeinab Cherri
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 2
      Author(s): Sawsan Abdulrahim, Dalia Mikdashi, Zeinab Cherri
      Background Nationality in Lebanon is conveyed through patrilineal descent, depriving the children of women married to foreigners from citizenship rights, legal protections, and health and social services. Children of Palestinian fathers are especially excluded because they become stateless. Calls to remove gender discrimination from the Lebanese nationality law are often stymied by the Lebanese fear of naturalising a large number of Palestinians. We examined whether this fear extends to prevention of Lebanese women married to Palestinian men from conferring their nationality on their children. Methods The study was based on mixed qualitative (13 focus group discussions, each of which included 8–15 Lebanese participants of similar age, socioeconomic status, and political orientation) and quantitative data (a survey of 450 adult Lebanese citizens, 41·4% men and 58·6% women, who resided in Greater Beirut) collected in 2011. Focus group data were analysed using open and thematic coding. Survey data were used to test the hypothesis that Lebanese public perceptions are in fact in favour of granting citizenship to children of women married to Palestinian men. Findings Qualitative findings highlighted that the Lebanese see Palestinian men as undesirable husbands and fathers, mainly because of legal restrictions that could cause hardships to women and their children. Survey data, however, suggested strong public support overall for granting Lebanese women married to Palestinian men the right to confer citizenship on their children. Women were significantly more supportive compared with men; 84·5% of women replied that they agreed or strongly agreed with the policy versus 74·2% of men (χ2=15·70, p=0·003). This high level of support was consistent across sociodemographic categories and was not influenced by strength of identification with religion or sect. The children's right to citizenship received stronger public support than all other rights (eg, employment). Interpretation Our findings suggest that Lebanese public opinion supports Lebanese women's right to confer nationality on their children even if the child's father is Palestinian. Support for gender equality in citizenship seems to override anti-Palestinian prejudice in relation to the wellbeing of the children of Lebanese women. Funding Data collection for the study was supported by a grant from the Issam Fares Institute for Public Policy and International Affairs at the American University of Beirut.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32058-5
       
  • Mechanical bowel preparation before elective colorectal surgery in the
           Gaza Strip: a survey of surgical practice
    • Authors: Spero A Tawil; Khamis A K Elessi; Zuhdi O Elifranji
      Abstract: Publication date: August 2017
      Source:The Lancet, Volume 390, Supplement 1
      Author(s): Spero A Tawil, Khamis A K Elessi, Zuhdi O Elifranji
      Background Many surgeons believe that postoperative complications and anastomotic leakage after colorectal surgery can be reduced by preoperative mechanical bowel preparation (MBP). We surveyed the practice of surgeons in the Gaza Strip, occupied Palestinian territory, and compared this with best available evidence for use of MBP. Methods A five item questionnaire was given to the seven most senior surgeons who did almost all surgeries in the European Gaza Hospital and the Al-Shifa Hospital (the two main hospitals in the Gaza Strip). We searched the Cochrane Library for relevant evidence using the search terms “colonic” or “colon”, or “colorectal electives surgery” in combination with “mechanical bowel preparation”. Findings All seven surgeons stated that they routinely prescribe MBP before elective colonic or rectal surgery. Two surgeons used MBP only for left colonic surgery; the other five surveyed reported using MBP for both right and left colonic surgery. For one surgeon, MBP consisted of rectal enemas and rectal enema plus oral fluids for 48 h. Another surgeon added oral laxatives to this regimen. Two surgeons used rectal enemas plus oral MBP, and three surgeons used oral quick preparation formulae, alone. All seven surgeons used systemic antibiotics before operating. We recorded no clear evidence from the available systematic review that MBP with rectal enema reduces complications after surgery, but the confidence interval around the estimates of its effects are wide (anastomotic leakage for MBP [95% CI 0·74–1·31] vs rectal enema [95% CI 0·74–2·36]; for wound infection [95% CI 0·95–1·42]). Interpretation Generally, surgeons in the two main hospitals in Gaza use different approaches to MBP for elective colorectal surgery because they believe that it lowers the incidence of postoperative complications and anastomotic leakage in patients. However, a wide variation in their use of many forms of MBP was noted, representing the absence of clear evidence from research. MBP is reported as unpleasant by many patients and more research is needed to provide better evidence to assess whether this procedure has the believed beneficial effects and to guide future practice. Funding None.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32010-x
       
  • Benefit with adjuvant chemotherapy in anaplastic astrocytoma
    • Authors: David Schiff
      Abstract: Publication date: Available online 8 August 2017
      Source:The Lancet
      Author(s): David Schiff


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31477-0
       
  • Interim results from the CATNON trial (EORTC study 26053-22054) of
           treatment with concurrent and adjuvant temozolomide for 1p/19q
           non-co-deleted anaplastic glioma: a phase 3, randomised, open-label
           intergroup study
    • Authors: Martin J van den Bent; Brigitta Baumert; Sara C Erridge; Michael A Vogelbaum; Anna K Nowak; Marc Sanson; Alba Ariela Brandes; Paul M Clement; Jean Francais Baurain; Warren P Mason; Helen Wheeler; Olivier L Chinot; Sanjeev Gill; Matthew Griffin; David G Brachman; Walter Taal; Roberta Rudà; Michael Weller; Catherine McBain; Jaap Reijneveld; Roelien H Enting; Damien C Weber; Thierry Lesimple; Susan Clenton; Anja Gijtenbeek; Sarah Pascoe; Ulrich Herrlinger; Peter Hau; Frederic Dhermain; Irene van Heuvel; Roger Stupp; Ken Aldape; Robert B Jenkins; Hendrikus Jan Dubbink; Winand N M Dinjens; Pieter Wesseling; Sarah Nuyens; Vassilis Golfinopoulos; Thierry Gorlia; Wolfgang Wick; Johan M Kros
      Abstract: Publication date: Available online 8 August 2017
      Source:The Lancet
      Author(s): Martin J van den Bent, Brigitta Baumert, Sara C Erridge, Michael A Vogelbaum, Anna K Nowak, Marc Sanson, Alba Ariela Brandes, Paul M Clement, Jean Francais Baurain, Warren P Mason, Helen Wheeler, Olivier L Chinot, Sanjeev Gill, Matthew Griffin, David G Brachman, Walter Taal, Roberta Rudà, Michael Weller, Catherine McBain, Jaap Reijneveld, Roelien H Enting, Damien C Weber, Thierry Lesimple, Susan Clenton, Anja Gijtenbeek, Sarah Pascoe, Ulrich Herrlinger, Peter Hau, Frederic Dhermain, Irene van Heuvel, Roger Stupp, Ken Aldape, Robert B Jenkins, Hendrikus Jan Dubbink, Winand N M Dinjens, Pieter Wesseling, Sarah Nuyens, Vassilis Golfinopoulos, Thierry Gorlia, Wolfgang Wick, Johan M Kros
      Background The role of temozolomide chemotherapy in newly diagnosed 1p/19q non-co-deleted anaplastic gliomas, which are associated with lower sensitivity to chemotherapy and worse prognosis than 1p/19q co-deleted tumours, is unclear. We assessed the use of radiotherapy with concurrent and adjuvant temozolomide in adults with non-co-deleted anaplastic gliomas. Methods This was a phase 3, randomised, open-label study with a 2 × 2 factorial design. Eligible patients were aged 18 years or older and had newly diagnosed non-co-deleted anaplastic glioma with WHO performance status scores of 0–2. The randomisation schedule was generated with the electronic EORTC web-based ORTA system. Patients were assigned in equal numbers (1:1:1:1), using the minimisation technique, to receive radiotherapy (59·4 Gy in 33 fractions of 1·8 Gy) alone or with adjuvant temozolomide (12 4-week cycles of 150–200 mg/m2 temozolomide given on days 1–5); or to receive radiotherapy with concurrent temozolomide 75 mg/m2 per day, with or without adjuvant temozolomide. The primary endpoint was overall survival adjusted for performance status score, age, 1p loss of heterozygosity, presence of oligodendroglial elements, and MGMT promoter methylation status, analysed by intention to treat. We did a planned interim analysis after 219 (41%) deaths had occurred to test the null hypothesis of no efficacy (threshold for rejection p<0·0084). This trial is registered with ClinicalTrials.gov, number NCT00626990. Findings At the time of the interim analysis, 745 (99%) of the planned 748 patients had been enrolled. The hazard ratio for overall survival with use of adjuvant temozolomide was 0·65 (99·145% CI 0·45–0·93). Overall survival at 5 years was 55·9% (95% CI 47·2–63·8) with and 44·1% (36·3–51·6) without adjuvant temozolomide. Grade 3–4 adverse events were seen in 8–12% of 549 patients assigned temozolomide, and were mainly haematological and reversible. Interpretation Adjuvant temozolomide chemotherapy was associated with a significant survival benefit in patients with newly diagnosed non-co-deleted anaplastic glioma. Further analysis of the role of concurrent temozolomide treatment and molecular factors is needed. Funding Schering Plough and MSD.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31442-3
       
  • Trends in international asthma mortality: analysis of data from the WHO
           Mortality Database from 46 countries (1993–2012)
    • Authors: Stefan Ebmeier; Darmiga Thayabaran; Irene Braithwaite; Clément Bénamara; Mark Weatherall; Richard Beasley
      Abstract: Publication date: Available online 7 August 2017
      Source:The Lancet
      Author(s): Stefan Ebmeier, Darmiga Thayabaran, Irene Braithwaite, Clément Bénamara, Mark Weatherall, Richard Beasley
      Background International time trends in asthma mortality have been strongly affected by changes in management and in particular drug treatments. However, little is known about how asthma mortality has changed over the past decade. In this study, we assessed these international trends. Methods We collated age-standardised country-specific asthma mortality rates in the 5–34 year age group from the online WHO Mortality Database for 46 countries. To be included in the analysis, we specified that a country must have 10 years of complete data in the WHO Mortality Database between 1993 and 2012. In the absence of consistent and accurate asthma prevalence and prescribing data, we chose to use a locally weighted scatter plot smoother (LOESS) curve, weighted by the individual country population in the 5–34-year age group to show the global trends in asthma mortality rates with time. Findings Of the 46 countries included in the analysis of asthma mortality, 36 were high-income countries, and 10 were middle-income countries. The LOESS estimate of the global asthma mortality rate was 0·44 deaths per 100 000 people (90% CI 0·39–0·48) in 1993 and 0·19 deaths per 100 000 people (0·18–0·21) in 2006. Despite apparent further reductions in some countries and regions of the world, there was no appreciable change in global asthma mortality rates from 2006 through to 2012, when the LOESS estimate was also 0·19 deaths per 100 000 people (0·16–0·21). Interpretation The trend for reduction in global asthma mortality observed since the late 1980s might have stalled, with no appreciable difference in a smoothed LOESS curve of asthma mortality from 2006 to 2012. Although better implementation of established management strategies that have been shown to reduce mortality risk is needed, to achieve a further substantive reduction in global asthma mortality novel strategies will also be required. Funding The Medical Research Institute of New Zealand, which is supported by Health Research Council of New Zealand Independent Research Organisation.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31448-4
       
  • Eliminating asthma deaths: have we stalled'
    • Authors: Christine Jenkins
      Abstract: Publication date: Available online 7 August 2017
      Source:The Lancet
      Author(s): Christine Jenkins


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31587-8
       
  • Charlie Gard and the limits of medicine
    • Authors: Lancet
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): The Lancet


      PubDate: 2017-08-09T10:58:59Z
       
  • Health providers—helping to disrupt human trafficking
    • Authors: Lancet
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): The Lancet


      PubDate: 2017-08-09T10:58:59Z
       
  • Breastfeeding: a missed opportunity for global health
    • Authors: Lancet
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): The Lancet


      PubDate: 2017-08-09T10:58:59Z
       
  • Department of Error
    • Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094


      PubDate: 2017-08-09T10:58:59Z
       
  • Department of Error
    • Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094


      PubDate: 2017-08-09T10:58:59Z
       
  • Brentuximab vedotin or physician's choice in CD30-positive cutaneous
           T-cell lymphoma (ALCANZA): an international, open-label, randomised, phase
           3, multicentre trial
    • Authors: Miles Prince; Youn Kim Steven Horwitz Reinhard Dummer Julia Scarisbrick
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): H Miles Prince, Youn H Kim, Steven M Horwitz, Reinhard Dummer, Julia Scarisbrick, Pietro Quaglino, Pier Luigi Zinzani, Pascal Wolter, Jose A Sanches, Pablo L Ortiz-Romero, Oleg E Akilov, Larisa Geskin, Judith Trotman, Kerry Taylor, Stephane Dalle, Michael Weichenthal, Jan Walewski, David Fisher, Brigitte Dréno, Rudolf Stadler, Tatyana Feldman, Timothy M Kuzel, Yinghui Wang, Maria Corinna Palanca-Wessels, Erin Zagadailov, William L Trepicchio, Wenwen Zhang, Hui-Min Lin, Yi Liu, Dirk Huebner, Meredith Little, Sean Whittaker, Madeleine Duvic
      Background Cutaneous T-cell lymphomas are rare, generally incurable, and associated with reduced quality of life. Present systemic therapies rarely provide reliable and durable responses. We aimed to assess efficacy and safety of brentuximab vedotin versus conventional therapy for previously treated patients with CD30-positive cutaneous T-cell lymphomas. Methods In this international, open-label, randomised, phase 3, multicentre trial, we enrolled adult patients with CD30-positive mycosis fungoides or primary cutaneous anaplastic large-cell lymphoma who had been previously treated. Patients were enrolled across 52 centres in 13 countries. Patients were randomly assigned (1:1) centrally by an interactive voice and web response system to receive intravenous brentuximab vedotin 1·8 mg/kg once every 3 weeks, for up to 16 3-week cycles, or physician's choice (oral methotrexate 5–50 mg once per week or oral bexarotene 300 mg/m2 once per day) for up to 48 weeks. The primary endpoint was the proportion of patients in the intention-to-treat population achieving an objective global response lasting at least 4 months per independent review facility. Safety analyses were done in all patients who received at least one dose of study drug. This trial was registered with ClinicalTrials.gov, number NCT01578499. Findings Between Aug 13, 2012, and July 31, 2015, 131 patients were enrolled and randomly assigned to a group (66 to brentuximab vedotin and 65 to physician's choice), with 128 analysed in the intention-to-treat population (64 in each group). At a median follow-up of 22·9 months (95% CI 18·4–26·1), the proportion of patients achieving an objective global response lasting at least 4 months was 56·3% (36 of 64 patients) with brentuximab vedotin versus 12·5% (eight of 64) with physician's choice, resulting in a between-group difference of 43·8% (95% CI 29·1–58·4; p<0·0001). Grade 3–4 adverse events were reported in 27 (41%) of 66 patients in the brentuximab vedotin group and 29 (47%) of 62 patients in the physician's choice group. Peripheral neuropathy was seen in 44 (67%) of 66 patients in the brentuximab vedotin group (n=21 grade 2, n=6 grade 3) and four (6%) of 62 patients in the physician's choice group. One of the four on-treatment deaths was deemed by the investigator to be treatment-related in the brentuximab vedotin group; no on-treatment deaths were reported in the physician's choice group. Interpretation Significant improvement in objective response lasting at least 4 months was seen with brentuximab vedotin versus physician's choice of methotrexate or bexarotene. Funding Millennium Pharmaceuticals Inc (a wholly owned subsidiary of Takeda Pharmaceutical Company Ltd), Seattle Genetics Inc.

      PubDate: 2017-08-09T10:58:59Z
       
  • Family-led rehabilitation after stroke in India (ATTEND): a randomised
           controlled trial
    • Authors: ATTEND Collaborative; GroupR ILindleyC SAndersonLBillotAForsterM LHackettL AHarveySJanQLiHLiuPLanghorneP KMaulikG SMurthyM FWalkerJ
      Abstract: Publication date: 5–11 August 2017
      Source:The Lancet, Volume 390, Issue 10094
      Author(s): The ATTEND Collaborative GroupR ILindleyC SAndersonLBillotAForsterM LHackettL AHarveySJanQLiHLiuPLanghorneP KMaulikG V SMurthyM FWalkerJ DPandianMAlimCFelixASyrigapuD KTugnawatS JVermaB RShamannaGHankeyAThriftJBernhardtM MMehndirattaLJeyaseelanPDonnellyDByrneSSteleyVSanthoshSChilappagariJMysoreJRoyM VPadmaLJohnSAaronN CBorahPVijayaSKaulDKhuranaP NSylajaD SHalprashanthB KMadhusudhanVNambiarSSureshbabuM CKhannaG SNarangDChakrabortyS SChakrabortyBBiswasSKauraHKoundalPSinghAAndriasD SThambuIRamyaJGeorgeA TPrabhakarPKirubakaranPAnbalaganMGhoseKBordoloiPGohainN MReddyK VReddyT N MRaoSAlladiV R RJalapuKManchireddyARajanSMehtaCKatochBDasAJangirTKaurSSreedharanSSivasambathSDineshB SShibiAThangarajAKarunanithiS M SSulaimanKDehingiaKDasCNandiniN JThomasT SDhanyaNThomasRKrishnaVAneeshRKrishnaSKhullarSThoumanISebastian
      Background Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting. Methods The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training—including information provision, joint goal setting, carer training, and task-specific training—that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3–6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707). Findings Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78–1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80). Interpretation Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care. Funding The National Health and Medical Research Council of Australia.

      PubDate: 2017-08-09T10:58:59Z
       
  • Insulin signalling: new target for Parkinson's treatments'
    • Authors: Werner Poewe; Klaus Seppi
      Abstract: Publication date: Available online 3 August 2017
      Source:The Lancet
      Author(s): Werner Poewe, Klaus Seppi


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)32101-3
       
  • Exenatide once weekly versus placebo in Parkinson's disease: a randomised,
           double-blind, placebo-controlled trial
    • Authors: Dilan Athauda; Kate Maclagan; Simon S Skene; Martha Bajwa-Joseph; Dawn Letchford; Kashfia Chowdhury; Steve Hibbert; Natalia Budnik; Luca Zampedri; John Dickson; Yazhou Li; Iciar Aviles-Olmos; Thomas T Warner; Patricia Limousin; Andrew J Lees; Nigel H Greig; Susan Tebbs; Thomas Foltynie
      Abstract: Publication date: Available online 3 August 2017
      Source:The Lancet
      Author(s): Dilan Athauda, Kate Maclagan, Simon S Skene, Martha Bajwa-Joseph, Dawn Letchford, Kashfia Chowdhury, Steve Hibbert, Natalia Budnik, Luca Zampedri, John Dickson, Yazhou Li, Iciar Aviles-Olmos, Thomas T Warner, Patricia Limousin, Andrew J Lees, Nigel H Greig, Susan Tebbs, Thomas Foltynie
      Background Exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, has neuroprotective effects in preclinical models of Parkinson's disease. We investigated whether these effects would be apparent in a clinical trial. Methods In this single-centre, randomised, double-blind, placebo-controlled trial, patients with moderate Parkinson's disease were randomly assigned (1:1) to receive subcutaneous injections of exenatide 2 mg or placebo once weekly for 48 weeks in addition to their regular medication, followed by a 12-week washout period. Eligible patients were aged 25–75 years, had idiopathic Parkinson's disease as measured by Queen Square Brain Bank criteria, were on dopaminergic treatment with wearing-off effects, and were at Hoehn and Yahr stage 2·5 or less when on treatment. Randomisation was by web-based randomisation with a two strata block design according to disease severity. Patients and investigators were masked to treatment allocation. The primary outcome was the adjusted difference in the Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor subscale (part 3) in the practically defined off-medication state at 60 weeks. All efficacy analyses were based on a modified intention-to-treat principle, which included all patients who completed any post-randomisation follow-up assessments. The study is registered at ClinicalTrials.gov (NCT01971242) and is completed. Findings Between June 18, 2014, and March 13, 2015, 62 patients were enrolled and randomly assigned, 32 to exenatide and 30 to placebo. Our primary analysis included 31 patients in the exenatide group and 29 patients in the placebo group. At 60 weeks, off-medication scores on part 3 of the MDS-UPDRS had improved by 1·0 points (95% CI −2·6 to 0·7) in the exenatide group and worsened by 2·1 points (−0·6 to 4·8) in the placebo group, an adjusted mean difference of −3·5 points (−6·7 to −0·3; p=0·0318). Injection site reactions and gastrointestinal symptoms were common adverse events in both groups. Six serious adverse events occurred in the exenatide group and two in the placebo group, although none in either group were judged to be related to the study interventions. Interpretation Exenatide had positive effects on practically defined off-medication motor scores in Parkinson's disease, which were sustained beyond the period of exposure. Whether exenatide affects the underlying disease pathophysiology or simply induces long-lasting symptomatic effects is uncertain. Exenatide represents a major new avenue for investigation in Parkinson's disease, and effects on everyday symptoms should be examined in longer-term trials. Funding Michael J Fox Foundation for Parkinson's Research.

      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31585-4
       
  • Early-stage breast cancer: falling risks and emerging options
    • Authors: Reshma Jagsi
      Abstract: Publication date: Available online 2 August 2017
      Source:The Lancet
      Author(s): Reshma Jagsi


      PubDate: 2017-08-09T10:58:59Z
      DOI: 10.1016/s0140-6736(17)31599-4
       
  • Partial-breast radiotherapy after breast conservation surgery for patients
           with early breast cancer (UK IMPORT LOW trial): 5-year results from a
           multicentre, randomised, controlled, phase 3, non-inferiority trial
    • Authors: Charlotte Coles; Clare Griffin Anna Kirby Jenny Titley Rajiv Agrawal
      Abstract: Publication date: Available online 2 August 2017
      Source:The Lancet
      Author(s): Charlotte E Coles, Clare L Griffin, Anna M Kirby, Jenny Titley, Rajiv K Agrawal, Abdulla Alhasso, Indrani S Bhattacharya, Adrian M Brunt, Laura Ciurlionis, Charlie Chan, Ellen M Donovan, Marie A Emson, Adrian N Harnett, Joanne S Haviland, Penelope Hopwood, Monica L Jefford, Ronald Kaggwa, Elinor J Sawyer, Isabel Syndikus, Yat M Tsang, Duncan A Wheatley, Maggie Wilcox, John R Yarnold, Judith M Bliss
      Background Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy. Methods IMPORT LOW is a multicentre, randomised, controlled, phase 3, non-inferiority trial done in 30 radiotherapy centres in the UK. Women aged 50 years or older who had undergone breast-conserving surgery for unifocal invasive ductal adenocarcinoma of grade 1–3, with a tumour size of 3 cm or less (pT1–2), none to three positive axillary nodes (pN0–1), and minimum microscopic margins of non-cancerous tissue of 2 mm or more, were recruited. Patients were randomly assigned (1:1:1) to receive 40 Gy whole-breast radiotherapy (control), 36 Gy whole-breast radiotherapy and 40 Gy to the partial breast (reduced-dose group), or 40 Gy to the partial breast only (partial-breast group) in 15 daily treatment fractions. Computer-generated random permuted blocks (mixed sizes of six and nine) were used to assign patients to groups, stratifying patients by radiotherapy treatment centre. Patients and clinicians were not masked to treatment allocation. Field-in-field intensity-modulated radiotherapy was delivered using standard tangential beams that were simply reduced in length for the partial-breast group. The primary endpoint was ipsilateral local relapse (80% power to exclude a 2·5% increase [non-inferiority margin] at 5 years for each experimental group; non-inferiority was shown if the upper limit of the two-sided 95% CI for the local relapse hazard ratio [HR] was less than 2·03), analysed by intention to treat. Safety analyses were done in all patients for whom data was available (ie, a modified intention-to-treat population). This study is registered in the ISRCTN registry, number ISRCTN12852634. Findings Between May 3, 2007, and Oct 5, 2010, 2018 women were recruited. Two women withdrew consent for use of their data in the analysis. 674 patients were analysed in the whole-breast radiotherapy (control) group, 673 in the reduced-dose group, and 669 in the partial-breast group. Median follow-up was 72·2 months (IQR 61·7–83·2), and 5-year estimates of local relapse cumulative incidence were 1·1% (95% CI 0·5–2·3) of patients in the control group, 0·2% (0·02–1·2) in the reduced-dose group, and 0·5% (0·2–1·4) in the partial-breast group. Estimated 5-year absolute differences in local relapse compared with the control group were −0·73% (−0·99 to 0·22) for the reduced-dose and −0·38% (−0·84 to 0·90) for the partial-breast groups. Non-inferiority can be claimed for both reduced-dose and partial-breast radiotherapy, and was confirmed by the test against the critical HR being more than 2·03 (p=0·003 for the reduced-dose group and p=0·016 for the partial-breast group, compared with the whole-breast radiotherapy group). Photographic, patient, and clinical assessments recorded similar adverse effects after reduced-dose or partial-breast radiotherapy, including two patient domains achieving statistically significantly lower adverse effects (change in breast appearance [p=0·007 for partial-breast] and breast harder or firmer [p=0·002 for reduced-dose and p<0·0001 for partial-breast]) compared with whole-breast radiotherapy. Interpretation We showed non-inferiority of partial-breast and reduced-dose radiotherapy compared with the standard whole-breast radiotherapy in terms of local relapse in a cohort of patients with early breast cancer, and equivalent or fewer late normal-tissue adverse effects were seen. This simple radiotherapy technique is implementable in radiotherapy centres worldwide.
      PubDate: 2017-08-09T10:58:59Z
       
 
 
JournalTOCs
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Email: journaltocs@hw.ac.uk
Tel: +00 44 (0)131 4513762
Fax: +00 44 (0)131 4513327
 
Home (Search)
Subjects A-Z
Publishers A-Z
Customise
APIs
Your IP address: 54.81.42.111
 
About JournalTOCs
API
Help
News (blog, publications)
JournalTOCs on Twitter   JournalTOCs on Facebook

JournalTOCs © 2009-2016