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The Lancet    [912 followers]  Follow    
  Full-text available via subscription Subscription journal
     ISSN (Print) 0140-6736 - ISSN (Online) 1474-547X
     Published by Elsevier Homepage  [2556 journals]   [SJR: 7.074]   [H-I: 477]
  • Classification of mental disorders: a global mental health perspective
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): K S Jacob , Vikram Patel



      PubDate: 2014-04-21T06:58:28Z
       
  • Henna tattoo: infection or allergy'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Natasha Ip , Jane Hoddes



      PubDate: 2014-04-21T06:58:28Z
       
  • Factitious disorders and malingering: challenges for clinical assessment
           and management
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Christopher Bass , Peter Halligan
      Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.


      PubDate: 2014-04-21T06:58:28Z
       
  • Early recognition and management of fabricated or induced illness in
           children
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Christopher Bass , Danya Glaser
      Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver elicits health care on the child's behalf in an unjustified way. Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies deception as a perpetrator characteristic, a far wider range is encountered clinically and is included in this Review. We describe the features of fabricated or induced illness, its effect on the child, and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission of abnormal illness behaviour from the caregiver to the child. Paediatricians' early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to return to healthy functioning and understand the fabricated or induced illness experience. Management of the perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping agencies. If separation is necessary, reunification of mother and child is rare, but can be achieved in selected cases. More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff from both paediatric and adult mental health services.


      PubDate: 2014-04-21T06:58:28Z
       
  • The prognosis of common mental disorders in adolescents: a 14-year
           prospective cohort study
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): George C Patton , Carolyn Coffey , Helena Romaniuk , Andrew Mackinnon , John B Carlin , Louisa Degenhardt , Craig A Olsson , Paul Moran
      Background Most adults with common mental disorders report their first symptoms before 24 years of age. Although adolescent anxiety and depression are frequent, little clarity exists about which syndromes persist into adulthood or resolve before then. In this report, we aim to describe the patterns and predictors of persistence into adulthood. Methods We recruited a stratified, random sample of 1943 adolescents from 44 secondary schools across the state of Victoria, Australia. Between August, 1992, and January, 2008, we assessed common mental disorder at five points in adolescence and three in young adulthood, commencing at a mean age of 15·5 years and ending at a mean age of 29·1 years. Adolescent disorders were defined on the Revised Clinical Interview Schedule (CIS-R) at five adolescent measurement points, with a primary cutoff score of 12 or higher representing a level at which a family doctor would be concerned. Secondary analyses addressed more severe disorders at a cutoff of 18 or higher. Findings 236 of 821 (29%; 95% CI 25–32) male participants and 498 of 929 (54%; 51–57) female participants reported high symptoms on the CIS-R (≥12) at least once during adolescence. Almost 60% (434/734) went on to report a further episode as a young adult. However, for adolescents with one episode of less than 6 months duration, just over half had no further common mental health disorder as a young adult. Longer duration of mental health disorders in adolescence was the strongest predictor of clear-cut young adult disorder (odds ratio [OR] for persistent young adult disorder vs none 3·16, 95% CI 1·86–5·37). Girls (2·12, 1·29–3·48) and adolescents with a background of parental separation or divorce (1·62, 1·03–2·53) also had a greater likelihood of having ongoing disorder into young adulthood than did those without such a background. Rates of adolescent onset disorder dropped sharply by the late 20s (0·57, 0·45–0·73), suggesting a further resolution for many patients whose symptoms had persisted into the early 20s. Interpretation Episodes of adolescent mental disorder often precede mental disorders in young adults. However, many such disorders, especially when brief in duration, are limited to the teenage years, with further symptom remission common in the late 20s. The resolution of many adolescent disorders gives reason for optimism that interventions that shorten the duration of episodes could prevent much morbidity later in life. Funding Australia's National Health and Medical Research Council.


      PubDate: 2014-04-21T06:58:28Z
       
  • Cognitive therapy for people with schizophrenia spectrum disorders not
           taking antipsychotic drugs: a single-blind randomised controlled trial
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Anthony P Morrison , Douglas Turkington , Melissa Pyle , Helen Spencer , Alison Brabban , Graham Dunn , Tom Christodoulides , Rob Dudley , Nicola Chapman , Pauline Callcott , Tim Grace , Victoria Lumley , Laura Drage , Sarah Tully , Kerry Irving , Anna Cummings , Rory Byrne , Linda M Davies , Paul Hutton
      Background Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs. Methods We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16–65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432. Findings 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of −6·52 (95% CI −10·79 to −2·25; p=0·003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). Interpretation Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed. Funding National Institute for Health Research.


      PubDate: 2014-04-21T06:58:28Z
       
  • Treatment of paracetamol overdose – Authors'reply
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): David Nicholas Bateman , James W Dear , H K Ruben Thanacoody , Simon H L Thomas , Michael Eddleston



      PubDate: 2014-04-21T06:58:28Z
       
  • Late effects of breast radiotherapy
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Joanne S Haviland , Judith M Bliss , Mark Sydenham , John R Yarnold



      PubDate: 2014-04-21T06:58:28Z
       
  • Effectiveness of a community-based intervention for people with
           schizophrenia and their caregivers in India (COPSI): a randomised
           controlled trial
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Sudipto Chatterjee , Smita Naik , Sujit John , Hamid Dabholkar , Madhumitha Balaji , Mirja Koschorke , Mathew Varghese , Rangaswamy Thara , Helen A Weiss , Paul Williams , Paul McCrone , Vikram Patel , Graham Thornicroft
      Background Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middle-income countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care. Methods We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16–60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013. Findings 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference −3·75, 95% CI −7·92 to 0·42; p=0·08; IDEAS −0·95, −1·68 to −0·23; p=0·01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0·89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (−9·29, −15·41 to −3·17; p=0·003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease. Interpretation The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas. Funding Wellcome Trust.


      PubDate: 2014-04-21T06:58:28Z
       
  • North Korea: a challenge for global solidarity
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Espen Bjertness , Ahmed Ali Madar



      PubDate: 2014-04-21T06:58:28Z
       
  • North Korea: a challenge for global solidarity
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Cai-Yue Liu , An-Tang Liu , Hua-Peng Guan , Hua Jiang



      PubDate: 2014-04-21T06:58:28Z
       
  • Treatment of paracetamol overdose
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Benjamin Kessler , Robert Hoffman



      PubDate: 2014-04-21T06:58:28Z
       
  • Commission on Global Governance for Health: just another report'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Pricivel M Carrera



      PubDate: 2014-04-21T06:58:28Z
       
  • Commission on Global Governance for Health: just another report'
           – Authors' reply
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Ole Petter Ottersen , Desmond McNeill , Jashodhara Dasgupta , Inger Scheel , Sidsel Roalkvam



      PubDate: 2014-04-21T06:58:28Z
       
  • MDG 7c for safe drinking water in India: an illusive achievement
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Mira Johri , Dinesh Chandra , S V Subramanian , Marie-Pierre Sylvestre , Smriti Pahwa



      PubDate: 2014-04-21T06:58:28Z
       
  • Commission on Global Governance for Health: just another report'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Pol De Vos , Claudio Schuftan , David Sanders , Ronald Labonte , David Woodward , Anne-Emanuelle Birn , Chiara Bodini , Angelo Stefanini , Hani Serag



      PubDate: 2014-04-21T06:58:28Z
       
  • Abdisalan Noor: mapping malaria
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): David Holmes



      PubDate: 2014-04-21T06:58:28Z
       
  • A sharp scratch
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Stephen Ginn



      PubDate: 2014-04-21T06:58:28Z
       
  • Wide horizons KelleySwainDonPatersonPocket Horizon2013Valley
           Press9781908853295Pp 48. £7·99.
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Jonathan Barnes



      PubDate: 2014-04-21T06:58:28Z
       
  • Robert E Cooke
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Alison Snyder



      PubDate: 2014-04-21T06:58:28Z
       
  • Abnormal illness behaviours: a developmental perspective
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Kasia Kozlowska



      PubDate: 2014-04-21T06:58:28Z
       
  • Offline: The dis-eases of exile
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Richard Horton



      PubDate: 2014-04-21T06:58:28Z
       
  • New era dawns for the South African MRC
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Anna Petherick



      PubDate: 2014-04-21T06:58:28Z
       
  • Cognitive therapy: at last an alternative to antipsychotics'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Oliver Howes



      PubDate: 2014-04-21T06:58:28Z
       
  • Common adolescent mental disorders: transition to adulthood
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Olga Eyre , Anita Thapar



      PubDate: 2014-04-21T06:58:28Z
       
  • Health disparities in Europe: hope for the future'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): The Lancet



      PubDate: 2014-04-21T06:58:28Z
       
  • April 19–25, 2014
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926




      PubDate: 2014-04-21T06:58:28Z
       
  • Water and sanitation: addressing inequalities
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): The Lancet



      PubDate: 2014-04-21T06:58:28Z
       
  • Cigarette packaging in China—not going far enough
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): The Lancet



      PubDate: 2014-04-21T06:58:28Z
       
  • Do we underestimate the benefits of antidepressants'
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Mazda Adli , Ulrich Hegerl



      PubDate: 2014-04-21T06:58:28Z
       
  • Challenges in rolling out interventions for schizophrenia
    • Abstract: Publication date: 19–25 April 2014
      Source:The Lancet, Volume 383, Issue 9926
      Author(s): Derrick Silove , Philip B Ward



      PubDate: 2014-04-21T06:58:28Z
       
  • Recombinant phenylalanine ammonia lyase in phenylketonuria
    • Abstract: Publication date: Available online 14 April 2014
      Source:The Lancet
      Author(s): Francjan J van Spronsen , Terry G J Derks



      PubDate: 2014-04-17T06:49:05Z
       
  • Transformation of HIV from pandemic to low-endemic levels: a public health
           approach to combination prevention
    • Abstract: Publication date: Available online 14 April 2014
      Source:The Lancet
      Author(s): Alexandra Jones , Ide Cremin , Fareed Abdullah , John Idoko , Peter Cherutich , Nduku Kilonzo , Helen Rees , Timothy Hallett , Kevin O'Reilly , Florence Koechlin , Bernhard Schwartlander , Barbara de Zalduondo , Susan Kim , Jonathan Jay , Jacqueline Huh , Peter Piot , Mark Dybul
      Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.


      PubDate: 2014-04-17T06:49:05Z
       
  • Single-dose, subcutaneous recombinant phenylalanine ammonia lyase
           conjugated with polyethylene glycol in adult patients with
           phenylketonuria: an open-label, multicentre, phase 1 dose-escalation trial
           
    • Abstract: Publication date: Available online 14 April 2014
      Source:The Lancet
      Author(s): Nicola Longo , Cary O Harding , Barbara K Burton , Dorothy K Grange , Jerry Vockley , Melissa Wasserstein , Gregory M Rice , Alejandro Dorenbaum , Jutta K Neuenburg , Donald G Musson , Zhonghua Gu , Saba Sile
      Background Phenylketonuria is an inherited disease caused by impaired activity of phenylalanine hydroxylase, the enzyme that converts phenylalanine to tyrosine, leading to accumulation of phenylalanine and subsequent neurocognitive dysfunction. Phenylalanine ammonia lyase is a prokaryotic enzyme that converts phenylalanine to ammonia and trans-cinnamic acid. We aimed to assess the safety, tolerability, pharmacokinetic characteristics, and efficacy of recombinant Anabaena variabilis phenylalanine ammonia lyase (produced in Escherichia coli) conjugated with polyethylene glycol (rAvPAL-PEG) in reducing phenylalanine concentrations in adult patients with phenylketonuria. Methods In this open-label, phase 1, multicentre trial, single subcutaneous injections of rAvPAL-PEG were given in escalating doses (0·001, 0·003, 0·010, 0·030, and 0·100 mg/kg) to adults with phenylketonuria. Participants aged 18 years or older with blood phenylalanine concentrations of 600 μmol/L or higher were recruited from among patients attending metabolic disease clinics in the USA. The primary endpoints were safety and tolerability of rAvPAL-PEG. Secondary endpoints were the pharmacokinetic characteristics of the drug and its effect on concentrations of phenylalanine. Participants and investigators were not masked to assigned dose group. This study is registered with ClinicalTrials.gov, number NCT00925054. Findings 25 participants were recruited from seven centres between May 6, 2008, and April 15, 2009, with five participants assigned to each escalating dose group. All participants were included in the safety population. The most frequently reported adverse events were injection-site reactions and dizziness, which were self-limited and without sequelae. Two participants had serious adverse reactions to intramuscular medroxyprogesterone acetate, a drug that contains polyethylene glycol as an excipient. Three of five participants given the highest dose of rAvPAL-PEG (0·100 mg/kg) developed a generalised skin rash. By the end of the study, all participants had developed antibodies against polyethylene glycol, and some against phenylalanine ammonia lyase as well. Drug concentrations peaked about 89–106 h after administration of the highest dose. Treatment seemed to be effective at reducing blood phenylalanine in all five participants who received the highest dose (mean reduction of 54·2% from baseline), with a nadir about 6 days after injection and an inverse correlation between drug and phenylalanine concentrations in plasma. Phenylalanine returned to near-baseline concentrations about 21 days after the injection. Interpretation Subcutaneous administration of rAvPAL-PEG in a single dose of up to 0·100 mg/kg was fairly safe and well tolerated in adult patients with phenylketonuria. At the highest dose tested, rAvPAL-PEG reduced blood phenylalanine concentrations. In view of the development of antibodies against polyethylene glycol (and in some cases against phenylalanine ammonia lyase), future studies are needed to assess the effect of repeat dosing. Funding BioMarin Pharmaceutical.


      PubDate: 2014-04-17T06:49:05Z
       
  • Tackling violence against health-care workers
    • Abstract: Publication date: Available online 15 April 2014
      Source:The Lancet
      Author(s): Roxanne Nelson



      PubDate: 2014-04-17T06:49:05Z
       
  • Functional brain imaging: gatecrashing the clinical party'
    • Abstract: Publication date: Available online 15 April 2014
      Source:The Lancet
      Author(s): Jamie Sleigh , Catherine E Warnaby



      PubDate: 2014-04-17T06:49:05Z
       
  • Delayed cord clamping: does gravity matter'
    • Abstract: Publication date: Available online 17 April 2014
      Source:The Lancet
      Author(s): Tonse N K Raju



      PubDate: 2014-04-17T06:49:05Z
       
  • Diagnostic precision of PET imaging and functional MRI in disorders of
           consciousness: a clinical validation study
    • Abstract: Publication date: Available online 15 April 2014
      Source:The Lancet
      Author(s): Johan Stender , Olivia Gosseries , Marie-Aurélie Bruno , Vanessa Charland-Verville , Audrey Vanhaudenhuyse , Athena Demertzi , Camille Chatelle , Marie Thonnard , Aurore Thibaut , Lizette Heine , Andrea Soddu , Mélanie Boly , Caroline Schnakers , Albert Gjedde , Steven Laureys
      Background Bedside clinical examinations can have high rates of misdiagnosis of unresponsive wakefulness syndrome (vegetative state) or minimally conscious state. The diagnostic and prognostic usefulness of neuroimaging-based approaches has not been established in a clinical setting. We did a validation study of two neuroimaging-based diagnostic methods: PET imaging and functional MRI (fMRI). Methods For this clinical validation study, we included patients referred to the University Hospital of Liège, Belgium, between January, 2008, and June, 2012, who were diagnosed by our unit with unresponsive wakefulness syndrome, locked-in syndrome, or minimally conscious state with traumatic or non-traumatic causes. We did repeated standardised clinical assessments with the Coma Recovery Scale–Revised (CRS–R), cerebral 18F-fluorodeoxyglucose (FDG) PET, and fMRI during mental activation tasks. We calculated the diagnostic accuracy of both imaging methods with CRS–R diagnosis as reference. We assessed outcome after 12 months with the Glasgow Outcome Scale–Extended. Findings We included 41 patients with unresponsive wakefulness syndrome, four with locked-in syndrome, and 81 in a minimally conscious state (48=traumatic, 78=non-traumatic; 110=chronic, 16=subacute). 18F-FDG PET had high sensitivity for identification of patients in a minimally conscious state (93%, 95% CI 85–98) and high congruence (85%, 77–90) with behavioural CRS–R scores. The active fMRI method was less sensitive at diagnosis of a minimally conscious state (45%, 30–61) and had lower overall congruence with behavioural scores (63%, 51–73) than PET imaging. 18F-FDG PET correctly predicted outcome in 75 of 102 patients (74%, 64–81), and fMRI in 36 of 65 patients (56%, 43–67). 13 of 42 (32%) of the behaviourally unresponsive patients (ie, diagnosed as unresponsive with CRS–R) showed brain activity compatible with (minimal) consciousness (ie, activity associated with consciousness, but diminished compared with fully conscious individuals) on at least one neuroimaging test; 69% of these (9 of 13) patients subsequently recovered consciousness. Interpretation Cerebral 18F-FDG PET could be used to complement bedside examinations and predict long-term recovery of patients with unresponsive wakefulness syndrome. Active fMRI might also be useful for differential diagnosis, but seems to be less accurate. Funding The Belgian National Funds for Scientific Research (FNRS), Fonds Léon Fredericq, the European Commission, the James McDonnell Foundation, the Mind Science Foundation, the French Speaking Community Concerted Research Action, the University of Copenhagen, and the University of Liège.


      PubDate: 2014-04-17T06:49:05Z
       
  • Effect of gravity on volume of placental transfusion: a multicentre,
           randomised, non-inferiority trial
    • Abstract: Publication date: Available online 17 April 2014
      Source:The Lancet
      Author(s): Nestor E Vain , Daniela S Satragno , Adriana N Gorenstein , Juan E Gordillo , Juan P Berazategui , M Guadalupe Alda , Luis M Prudent
      Background Delayed cord clamping allows for the passage of blood from the placenta to the baby and reduces the risk of iron deficiency in infancy. To hold the infant for more than 1 min at the level of the vagina (as is presently recommended), on the assumption that gravity affects the volume of placental transfusion, is cumbersome, might result in low compliance, and interferes with immediate contact of the infant with the mother. We aimed to assess whether gravity affects the volume of placental transfusion Methods We did a multicentre non-inferiority trial at three university-affiliated hospitals in Argentina. We obtained informed consent from healthy mothers with normal term pregnancies admitted early in labour. Vigorous babies born vaginally were randomly assigned in a 1:1 ratio by computer-generated blocks and sequentially numbered sealed opaque envelopes to be held for 2 min before clamping the umbilical cord, at the level of the vagina (introitus group) or on the mother's abdomen or chest (abdomen group). Newborn babies were weighed immediately after birth and after cord clamping. The primary outcome was the difference in weight (as a proxy of placental transfusion volume). The prespecified non-inferiority margin was 18 g (20%). We used t test and χ2 test for group comparison, and used a multivariable linear regression analysis to control for covariables. This trial is registered with ClinicalTrials.gov, number NCT01497353. Findings Between Aug 1, 2011, and Aug 31, 2012, we allocated 274 newborn babies to the introitus group and 272 to the abdomen group. 77 newborn babies in the introitus group and 78 in the abdomen group were ineligible after randomisation (eg, caesarean section, forceps delivery, short umbilical cord or nuchal cord). Mean weight change was 56 g (SD 47, 95% CI 50–63) for 197 babies in the introitus group compared with 53 g (45, 46–59) for 194 babies in the abdomen group, supporting non-inferiority of the two approaches (difference 3 g, 95% CI −5·8 to 12·8; p=0·45). We did not note any serious adverse events during the study. Interpretation Position of the newborn baby before cord clamping does not seem to affect volume of placental transfusion. Mothers could safely be allowed to hold their baby on their abdomen or chest. This change in practice might increase obstetric compliance with the procedure, enhance maternal-infant bonding, and decrease iron deficiency in infancy. Funding Foundation for Maternal and Child Health (FUNDASAMIN).


      PubDate: 2014-04-17T06:49:05Z
       
  • Prevention of varicella: time for two-dose vaccination
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): Kristine Macartney



      PubDate: 2014-04-12T06:47:54Z
       
  • Chronic kidney disease and the ageing population
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): Marcello Tonelli , Miguel Riella



      PubDate: 2014-04-12T06:47:54Z
       
  • Expression of concern: the SCIPIO trial
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): The Lancet Editors



      PubDate: 2014-04-12T06:47:54Z
       
  • Nephrology in developing countries: the ISN's story
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): John Feehally , William Couser , Sophie Dupuis , Fredric Finkelstein , Paul Harden , David Harris , Norbert Lameire , Sarala Naicker , Giuseppe Remuzzi , Luca Segantini , Marcello Tonelli



      PubDate: 2014-04-12T06:47:54Z
       
  • STOPping peanut allergy: the saga of food oral immunotherapy
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): Matthew J Greenhawt



      PubDate: 2014-04-12T06:47:54Z
       
  • International comparisons of acute myocardial infarction
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): Chris P Gale , Keith A A Fox



      PubDate: 2014-04-12T06:47:54Z
       
  • April 12–18, 2014
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925




      PubDate: 2014-04-12T06:47:54Z
       
  • Neglected tropical diseases: becoming less neglected
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): The Lancet



      PubDate: 2014-04-12T06:47:54Z
       
  • A new direction for hepatitis C
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): The Lancet



      PubDate: 2014-04-12T06:47:54Z
       
  • Sound advice for public health
    • Abstract: Publication date: 12–18 April 2014
      Source:The Lancet, Volume 383, Issue 9925
      Author(s): The Lancet



      PubDate: 2014-04-12T06:47:54Z
       
  • Standardised packaging and tobacco-industry-funded research
    • Abstract: Publication date: Available online 9 April 2014
      Source:The Lancet
      Author(s): Anthony A Laverty , Hilary C Watt , Deborah Arnott , Nicholas S Hopkinson



      PubDate: 2014-04-12T06:47:54Z
       
 
 
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