Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. Lancet 2014; 384: 1775–88. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, aﬀective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014; 384: 1789–99. Sharma, V, Burt, VK, Ritchie, HL Bipolar II postpartum depression: detection, diagnosis, and treatment. Am J Psychiatry 2009; 166: 1217–21.
agreement with international trends and the Hellenic Society of Obstetrics and Gynecology committee’s opinion, the new guidelines aim to balance clinical eﬀectiveness and cost, reducing unnecessary therapeutic interventions and protecting women from the potential harm of overdiagnosis and overtreatment. We declare no competing interests.
Nikolaos Vrachnis, *Nikolaos Vlachadis
For NHS cancer screening programmes see http://www. cancerscreening.nhs.uk
For the Hellenic Society of Obstetrics and Gynecology see www.hsog.gr
Guidelines on cervical and breast cancer screening in Greece
Andreas Tsounis and colleagues (Dec 13, p 2110)1 worry that the new measures from the Hellenic Ministry of Health on cervical and breast cancer screening will increase cancer cases and, as a consequence, social security expenses for cancer treatment in the near future. In fact, the screening regulations in Greece are evidence-based and in accordance with the oﬃcial guidelines for early detection of cervical and breast cancer of the most authoritative international agencies, including the American Cancer Society, American Society for Colposcopy and Cervical Pathology, American Society for Clinical Pathology, and US Preventive Services Task Force,2,3 and NHS breast and cervical cancer screening programmes. Furthermore, the new cervical and breast cancer presymptomatic check recommendations are in accordance with the official guidelines of the Hellenic Society of Obstetrics and Gynecology.4,5 The Greek population is at a very low risk of both cervical and breast cancer; in 2012, the estimated age-standardised incidence of breast cancer in Greece was the lowest of the 27 EU countries, and cervical cancer the fourth lowest.6 The absence of central guidance in the country has led to burgeoning artificial demand for diagnostic tests, with a noticeable increase in health expenditure. In
Hellenic Society of Obstetrics and Gynecology, Athens, Greece, and Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, School of Medicine, Aretaieio Hospital, GR-11528, Athens, Greece
Tsounis A, Saraﬁs P, Alexopoulos EC. Austerity and its consequences on cancer screening in Greece. Lancet 2014; 384: 2110. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62: 147–72. US Preventive Services Task Force. Breast cancer screening. http://www. uspreventiveservicestaskforce.org/Page/ Document/RecommendationStatementFinal/ breast-cancer-screening (accessed Dec 27, 2014). Hellenic Society of Obstetrics and Gynecology guideline no 13. Primary and secondary prevention of cervical cancer. March, 2014. http://www.hsog-test.com/ﬁles/prolipsi_ karkinou_mitras.pdf (accessed Dec 28, 2014). Hellenic Society of Obstetrics and Gynecology guideline no 17. Secondary prevention of breast cancer. March, 2014. http://www.hsogtest.com/ﬁles/defterogenis_prolipsi_karninou_ tou_mastou.pdf (accessed Dec 28, 2014). Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013; 49: 1374–403.
Raising awareness against acid attacks Between 2·4% and 10·7% of burns worldwide are due to chemical exposure.1 Raising awareness of the high incidence of acid attacks and ways to care for and prevent future medical complications is important. Although statistics are scarce, incidence of acid attacks seems to be increasing and most of the victims
are women. The increasing occurrence of acid attacks observed in several countries,2 such as Iran,3 is a call for medical, social, and government authorities to explore solutions to prevent such terrible acts from happening and mitigate further complications to their victims, such as burns complications, mental health, and stigma. Mannan and colleagues4 reported that Jamaica, Bangladesh, and Taiwan have the highest incidence of acid assaults. In Iran, of 121 cases of chemical injury that were reported between 2003 and 2008, ten cases were criminal assaults.5 According to Farhad and colleagues,3 acid burns are associated with poverty, larceny, and social issues, such as marital trouble (eg, rejected marriage proposal or divorce). Acid attacks should receive wider media coverage than they do at present: detailed information about the crime’s irreversible and terrible outcomes and the legal penalties should be stressed to the public. Furthermore, education around safety issues could reduce the incidence of chemical burns and their consequences. Prevention strategies have to be coordinated at national level. Victims—often from low socioeconomic areas—should receive the best medical care possible, first locally and then in a specialised centre. The damage caused by an acid burn is dependent on the concentration and quantity of acidic solution used and the duration of contact with the skin. Acid attack injuries are initially treated by neutralising the inciting solution.1 The affected skin should be washed with distilled water for at least 30 min.1 Neutralising agents do not oﬀer an advantage over dilution with water, can delay treatment, and can worsen the injury because of the exothermic reactions that might occur.1 After initial treatment these patients have to be transported to a burns centre for speciﬁc surgical and medical management. We declare no competing interests.
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[email protected] Trauma Research Center, Baqiyatallah University of Medial Sciences, Tehran, Iran (HRR, AE, MHKM); and Molla Sadra Street, PO Box 1436614313, Tehran, Iran (AE) 1
Hardwicke J, Hunter T, Staruch R, Moiemen N. Chemical burns—an historical comparison and review of the literature. Burns 2012; 38: 383–87. Olaitan PB, Jiburum BC. Chemical injuries from assaults: an increasing trend in a developing country. Indian J Plast Surg 2008; 41: 20–23. Farhad H, Naghibzadeh B, Nouhi AH, Rad HE. Acid burn violence in Iran. Ann Burns Fire Disasters 2011; 24: 138–40. Mannan A, Ghani S, Clarke A, Butler PE. Cases of chemical assault worldwide: a literature review. Burns 2007; 33: 149–54. Maghsoudi H, Gabraely N. Epidemiology and outcome of 121 cases of chemical burn in East Azarbaijan province, Iran. Injury 2008; 39: 1042–46.
Prevalence of tuberculosis in China The findings of the study by Lixia Wang and colleagues (June 14, p 2057)1 about tuberculosis prevalence should be interpreted with caution. The 2010 survey was smaller than previous surveys and diagnosed only 188 smear-positive cases from 176 sites. 2,3 The strategy of the 2000 survey3 was to select individuals in proportion to population size, whereas an even split between rural and urban participants was prioritised in 2010. The present analyses 1 were not standardised for age or urbanisation. Diﬀerences also existed in residency requirements, duration of cough (symptom screen), and number of sputa cultured. The diagnostic algorithms differed between the surveys, making comparisons diﬃcult. The authors claim that the absence of a decrease in overall pulmonary tuberculosis is explained by greater sensitivity of radiography compared with fluoroscopy. The 2000 survey provides an opportunity to address this claim. Excluding radiographs from the algorithm, the prevalence dropped by less than 6%.3 A much greater www.thelancet.com Vol 385 February 28, 2015
difference is needed to explain the 2010 results (>35%). A substantial decrease in the prevalence of known, but not new, laboratory-confirmed tuberculosis cases was reported. 1 The decrease in known tuberculosis cases suggests improved clinical care, whereas no decrease in new cases suggests insufficient measures to prevent Mycobacterium tuberculosis transmission. Together, these results imply a case detection problem. In this study, sputum quality 4 might have affected the results. We note that 54% of culture-positive cases were sputum-smear positive compared with more than 70% in the past surveys.2,3 Tuberculosis indicators can decrease in the absence of chemotherapy.5 The estimated annual decrease in tuberculosis prevalence in China during 1990–2010 was similar to the 1979–90 period.1,3 With ongoing human development, which inversely associates with tuberculosis indicators,6 cohort effects should be considered, and an accelerated decrease in tuberculosis prevalence is needed to indicate effectiveness of directly observed therapy short-course. We declare no competing interests.
*Philip C Hill, Christopher C Whalen [email protected] Centre for International Health and the Otago International Health Research Network, Department of Preventive and Social Medicine, University of Otago School of Medicine, Dunedin 9054, New Zealand (PCH); and Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Health Sciences Campus, Athens, GA 30602, USA (CCW) 1
Wang L, Zhang H, Ruan Y, et al. Tuberculosis prevalence in China, 1990–2010; a longitudinal analysis of national survey data. Lancet 2014; 383: 2057–64. Ministry of Public Health. Nationwide random survey of the epidemiology of tuberculosis in 1990. Beijing: Ministry of Public Health China, 1990. China Tuberculosis Control Collaboration. The eﬀect of tuberculosis control in China. Lancet 2004; 364: 417–22. Sakundarno M, Nurjazuli N, Jati SP, et al. Insuﬃcient quality of sputum submitted for tuberculosis diagnosis and associated factors, in Klaten district, Indonesia. BMC Pulm Med 2009; 9: 16.
McKeown T, Record RG. Reasons for the decline of mortality in England and Wales during the Nineteenth Century. Popul Stud 1962; 16: 94–122. Dye C, Lonnroth K, Jaramillo E, Williams BG, Raviglione M. Trends in tuberculosis incidence and their determinants in 134 countries. Bull World Health Organ 2009; 87: 683–91.
Antibiotic pollution threatens public health in China In December, 2014, antibiotics were detected in residents’ tap water and China’s major rivers.1 Antibiotic pollution has become a serious public health problem in China.2,3 Two antibiotics (amoxicillin [8 ng/L] and 6-aminopenicilanic acid [19 ng/L]) were found in tap water samples randomly collected in Nanjing, Jiangsu Province. Six antibiotics were also found in tap water in cities of Anhui Province.1 Antibiotics were found in major rivers, including the Yangtze River and Pearl River. 68 antibiotics, at high concentrations, were found in surface water.2 While antibiotic concentrations found in the Pearl River were as high as 1080 ng/L,2 these are usually lower than 20 ng/L in rivers in the USA,4 France, and the UK.5 Antibiotic pollution poses a grave risk to millions of residents and to local ecosystems.6 The concentrations of antibiotics in the surface water are far smaller than those of medical doses, but these antibiotics can induce bacterial resistance in human beings, rendering many drugs ineﬀective and damaging ecological systems. Additionally, long-term antibiotics pollution will contaminate groundwater and soil, which could result in contamination of food.2 Antibiotic pollution in China is linked to two main issues: the misuse of antibiotics in the medical and livestock industries,1,2 and effluent containing high concentrations of antibiotics being discharged by pharmaceutical companies. Antibiotic comsumption is ten times the global
Hamid Reza Rasouli, *Ali Ebrahimi, Mohammad Hosein Kalantar Motamedi
Raising awareness against acid attacks.
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