- Email: [email protected]
Endovascular aneurysm repair: important mid-term results
Comment
1 2
3 4
5 6
Johns B, Baltussen R. Accounting for the cost of scaling-up health interventions. Health Econ 2004; 13: 1117–24. Hanson K, Ranson MK, Oliveira-Cruz V, Mills A. Constraints to scaling up health interventions: a conceptual framework and empirical analysis. CMH WG5 Background paper 14. May, 2001: www.cmhealth.org/docs/ wg5_paper14.pdf (accessed June 8, 2005). Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet 2004; 364: 1451–56. Global Health Trust. Human resources for health and development: a joint learning initiative. July 24, 2003: http://globalhealthtrust.org/doc/ JLIBrochure.pdf (accessed June 8, 2005). Kober K, van Damme W. Scaling up access to antiretroviral treatment in southern Africa: who will do the job? Lancet 2004; 364: 103–07. Mukasa S. Are expatriate staff necessary in international development NGOs? A case study of an international NGO in Uganda. CVO International
7 8 9
10
11
Working Paper 4. http://www.lse.ac.uk/collections/CCS/pdf/int-workpaper4.pdf (accessed June 8, 2005). Brugha R, Starling M, Walt G. GAVI, the first steps: lessons for the Global Fund. Lancet 2002; 359: 435–38. Brugha R, Donoghue M, Starling M, et al. The Global Fund: managing great expectations. Lancet 2004; 364: 95–100. Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Hum Resour Health 2003; 1: 12. Oliveira-Cruz V, Hanson K, Mills A. Approaches to overcoming health systems constraints at the peripheral level: a review of the evidence. CMH WG5 Background paper 15. May, 2001: www.cmhealth.org/docs/ wg5_paper15.pdf (accessed June 8, 2005). WHO. The Mexico Statement on Health Research. Nov 16, 2004: http://www.who.int/rpc/summit/agenda/en/mexico_statement_on_ health_research.pdf (accessed June 8, 2005).
Endovascular aneurysm repair: important mid-term results Published online June 17, 2005 DOI:10.1016/S0140-6736(05) 66629-9 See Articles pages 2179 and 2187
2156
If elderly patients develop a 5·5 cm diameter abdominal aortic aneurysm, do they benefit most from open surgical repair, endovascular aneurysm repair (EVAR), or no intervention? This important question has finally been addressed by the two randomised trials in today's Lancet by the EVAR trialists. Endovascular repair was developed to provide a less invasive alternative to conventional open repair of an abdominal aortic aneurysm. Like other less invasive procedures, many patients and physicians presumed a benefit, even though this was not proven. Initially, EVAR was only used for higher risk patients, and early nonrandomised studies showed shorter hospital-stay and less morbidity than with open surgery.1 Although operative mortality should also be reduced, this was not convincingly proven until the initial results of EVAR-1 were published last year.2 This randomised trial showed a 30-day mortality of 4·7% after open repair versus 1·7% after EVAR, a substantial 65% reduction in operative deaths. Soon after, the smaller randomised trial from Holland reported a nearly identical 30-day mortality of 4·6% for open repair versus 1·2% for EVAR.3 Also in 2004, two population-based reports from the USA with more than 10 000 patients showed an inhospital mortality of 3·8% for open repair versus 1·2% for EVAR, a 70% relative risk reduction.4,5 Thus there was a remarkable convergence of data to indicate that EVAR reduces operative mortality by about two-thirds compared with open repair. Although this news was welcomed, major concerns remained about the durability of EVAR and the potential need for costly and possibly complicated reintervention. Although graft-related complications,
such as pseudoaneurysm, can occur after open repair of an abdominal aortic aneurysm, their incidence is low enough that frequent follow-up is not required.6 By contrast, initial experience with EVAR quickly showed that endografts could become unsealed, leading to “endoleak” of pressurised blood into the residual aneurysm sac, potentially causing rupture—the very complication that the procedure is supposed to prevent. As a result, frequent follow-up with CT scanning has been used to detect endoleak or graft migration that might need endovascular re-intervention to insert additional graft components, or even conversion to open repair. Although such complications appear to be decreasing as endovascular device technology improves, large registries, such as EUROSTAR, have estimated a reintervention rate of over 5% a year, and a rupture rate as high as 1% a year despite EVAR.7,8 Thus the key question to be answered is whether the initial 3% absolute improvement in operative mortality in EVAR-1 would be overcome by later complications in terms of survival, cost, or quality of life. Despite a much higher rate of late complications and re-intervention after EVAR compared with open repair, aneurysmrelated mortality remained 3% lower with EVAR throughout the 4-year follow-up reported so far in EVAR-1. This benefit of EVAR required a 33% increase in cumulative hospital costs without a sustained benefit in quality of life. Furthermore, there was no significant difference in overall survival between EVAR and open repair after 4 years (72%), but only 24% of patients had reached that point in follow-up. So, further study is required, including a more detailed cost-effectiveness analysis. www.thelancet.com Vol 365 June 25, 2005
Comment
www.thelancet.com Vol 365 June 25, 2005
High Medical management
Operative risk
Do these results mean that EVAR is the preferred option for patients who need repair of an abdominal aortic aneurysm? Before answering that question, several caveats are in order. First, durability and re-intervention rate after EVAR are strongly influenced by anatomical suitability for the initial procedure. Such suitability is mainly determined by whether the diameter, angulation, and length of the proximal aorta will allow adequate attachment of the graft for aneurysm exclusion. In EVAR-1, 54% of potentially eligible patients were found to be anatomically “suitable” for EVAR. But this proportion ranged from 6% to 100% across the 34 centres, illustrating the current variation in assessment of this important variable. This area requires better definition to improve overall results. Second, abdominal aortic aneurysms repaired in EVAR1 were large, with an average diameter of 6·5 cm.2 The EUROSTAR registry has shown substantially higher aneurysm-related mortality after EVAR with large aneurysms than with smaller ones.9 Thus, had these aneurysms been detected and repaired earlier, even better results might have been obtained. Third, although EVAR-1 provides 3–4-year results for currently available third-generation endografts, 72% of patients were still alive at the midterm analysis reported today and require further follow-up to assure durable effectiveness of EVAR. And these patients were relatively old (average age of 76 years). Because the rate of reintervention after EVAR continues to increase with time, it is logical that EVAR will be most costly for patients with long life-expectancy, if not less effective. Thus the current practice of recommending open repair for patients with long life-expectancy is recommended until even longer follow-up is available. Finally, all patients in EVAR-1 were of suitable operative risk for open repair of their aneurysm, and were quite low-risk on the basis of the low operative mortality observed in both arms of this trial. Yet EVAR was specifically designed for higher risk patients who might not tolerate the systemic stress associated with a large abdominal operation. Of patients evaluated for EVAR-1, 21% were considered unfit for open repair because of cardiac, pulmonary, or renal co-morbidities. The question of whether EVAR would benefit such patients was addressed in the EVAR-2 trial, also reported in today’s issue, in which patients considered unfit for open repair were randomised to EVAR or no intervention.
Chose EVAR
Patient’s preference
Chose open repair
Low Poor
Excellent Anatomical suitability for EVAR
Figure: Choosing the best management of abdominal aortic aneurysm for individual patients
Patients in EVAR-2 were older, with more cardiopulmonary co-morbidities, which translated into a high 30-day operative mortality rate of 9% and a 4-year survival of only 36%. Although more deaths from aneurysm rupture occurred in the non-intervention group of EVAR-2, the initial high operative mortality in the EVAR group resulted in no late difference in aneurysm-related mortality, and no difference in overall survival. However, two unexpected events probably influenced the outcome of EVAR-2 which make it more difficult to interpret. First, EVAR was not done until a median of 57 days after randomisation despite a mean aneurysm diameter of 6·7 cm. During this time, nine aneurysms ruptured, causing nearly half of the total of 20 aneurysm-related deaths in the EVAR group. Second, after randomisation to the nonintervention group, 20% of patients subsequently underwent elective repair of their aneurysm in violation of the protocol. Amazingly, only one of these patients died as a result of their operation or an aneurysm complication during follow-up, indicating prescient selection of patients. Taken together, however, these effects bias the study against EVAR and reduce the power for a conclusive analysis. Nonetheless, the takehome message of EVAR-2 is clear and not surprising. Prophylactic operations designed to improve survival cannot be effective in patients with short lifeexpectancy. Thus selection of patients is critically important, because EVAR was much more costly than no intervention, without a survival benefit in high-risk patients. 2157
Comment
Returning to my earlier question, how should these results influence current practice? In a decision-analysis model, the key variables that determine the benefit of open repair versus EVAR are operative mortality and subsequent aneurysm-related mortality.10 Sensitivity analysis shows the interaction of these variables (figure). In this example, as in real practice, preoperative assessment of anatomical suitability for EVAR is a proxy for subsequent complications, re-intervention, and potential aneurysm-related mortality. Patients with low operative risk, who are usually younger with longer life-expectancy, are the best candidates for open repair and should not be considered for EVAR unless they have excellent anatomical suitability. Patients at higher operative risk are better candidates for EVAR, if anatomical suitability is adequate. However, there are many high-risk patients with marginal anatomical suitability for EVAR who have short life-expectancy and will not benefit from repair of their abdominal aortic aneurysm; they are best managed medically. Finally, there is still a large grey area where patients’ preference should influence the choice of EVAR versus open repair, given their similar outcomes. Current results from the EVAR-1 trial have shifted the choice point slightly toward the endovascular option, but ultimate clarity will await the long-term results of this trial. Furthermore, future subanalyses will provide details to assist individual selection of patients. Until then, patients are best advised to select well-informed surgeons with good results to assist their decision
making, such as the UK surgeons who designed and participated in these important trials. Jack L Cronenwett Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03755, USA [email protected] I declare that I have no conflict of interest. 1
Adriaensen ME, Bosch JL, Halpern EF, Myriam Hunink MG, Gazelle GS. Elective endovascular versus open surgical repair of abdominal aortic aneurysms: systematic review of short-term results. Radiology 2002; 224: 739–47. 2 Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364: 843–48. 3 Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351: 1607–18. 4 Anderson PL, Arons RR, Moskowitz AJ, et al. A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results. J Vasc Surg 2004; 39: 10–19. 5 Lee WA, Carter JW, Upchurch G, Seeger JM, Huber TS. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg 2004; 39: 491–96. 6 Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg 1997; 25: 277–84. 7 Harris PL, Vallabhaneni SR, Desgranges P, for the European Collaborators. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2000; 32: 739–49. 8 Harris PL, Buth J. An update on the important findings from the EUROSTAR EVAR registry. Vascular 2004; 12: 33–38. 9 Peppelenbosch N, Buth J, Harris PL, van Marrewijk C, Fransen G. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004; 39: 288–97. 10 Schermerhorn ML, Finlayson SR, Fillinger MF, Buth J, van Marrewijk C, Cronenwett JL. Life expectancy after endovascular versus open abdominal aortic aneurysm repair: results of a decision analysis model on the basis of data from EUROSTAR. J Vasc Surg 2002; 36: 1112–20.
Paternal postnatal depression: fathers emerge from the wings See Articles page 2201
2158
Although human beings have explored the moon and Mars, the development of infants, children, and adolescents remains a source of equal surprise and delight, filled with unexpected turns and new revelations. The paper in today’s Lancet by Paul Ramchandani and colleagues opens a new chapter on child-development research: the researchers have included fathers into the equation. But what is so new about fathers? Fathers have existed as long as there have been children. The concept is very simple: fathers and their well-being have an effect on their babies, even to the point that paternal depression is reflected in the babies’ development.
Research on maternal postpartum depression fills libraries. It is possibly one of the most researched areas in developmental psychopathology during the past 10 years. Clinical interventions usually focus on mothers and babies. Fathers, on the other hand, have been kept in the wings. Whether one considers developmental theories and research, health and social services, or organisation of child-care after birth, fathers’ roles have been defined as providing social and economic security to the family and emotional support for the mother during the infant period. At most, fathers have been seen as welcome playmates, but with only marginal effect on infants’ development. www.thelancet.com Vol 365 June 25, 2005
1 2
3 4
5 6
Johns B, Baltussen R. Accounting for the cost of scaling-up health interventions. Health Econ 2004; 13: 1117–24. Hanson K, Ranson MK, Oliveira-Cruz V, Mills A. Constraints to scaling up health interventions: a conceptual framework and empirical analysis. CMH WG5 Background paper 14. May, 2001: www.cmhealth.org/docs/ wg5_paper14.pdf (accessed June 8, 2005). Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet 2004; 364: 1451–56. Global Health Trust. Human resources for health and development: a joint learning initiative. July 24, 2003: http://globalhealthtrust.org/doc/ JLIBrochure.pdf (accessed June 8, 2005). Kober K, van Damme W. Scaling up access to antiretroviral treatment in southern Africa: who will do the job? Lancet 2004; 364: 103–07. Mukasa S. Are expatriate staff necessary in international development NGOs? A case study of an international NGO in Uganda. CVO International
7 8 9
10
11
Working Paper 4. http://www.lse.ac.uk/collections/CCS/pdf/int-workpaper4.pdf (accessed June 8, 2005). Brugha R, Starling M, Walt G. GAVI, the first steps: lessons for the Global Fund. Lancet 2002; 359: 435–38. Brugha R, Donoghue M, Starling M, et al. The Global Fund: managing great expectations. Lancet 2004; 364: 95–100. Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Hum Resour Health 2003; 1: 12. Oliveira-Cruz V, Hanson K, Mills A. Approaches to overcoming health systems constraints at the peripheral level: a review of the evidence. CMH WG5 Background paper 15. May, 2001: www.cmhealth.org/docs/ wg5_paper15.pdf (accessed June 8, 2005). WHO. The Mexico Statement on Health Research. Nov 16, 2004: http://www.who.int/rpc/summit/agenda/en/mexico_statement_on_ health_research.pdf (accessed June 8, 2005).
Endovascular aneurysm repair: important mid-term results Published online June 17, 2005 DOI:10.1016/S0140-6736(05) 66629-9 See Articles pages 2179 and 2187
2156
If elderly patients develop a 5·5 cm diameter abdominal aortic aneurysm, do they benefit most from open surgical repair, endovascular aneurysm repair (EVAR), or no intervention? This important question has finally been addressed by the two randomised trials in today's Lancet by the EVAR trialists. Endovascular repair was developed to provide a less invasive alternative to conventional open repair of an abdominal aortic aneurysm. Like other less invasive procedures, many patients and physicians presumed a benefit, even though this was not proven. Initially, EVAR was only used for higher risk patients, and early nonrandomised studies showed shorter hospital-stay and less morbidity than with open surgery.1 Although operative mortality should also be reduced, this was not convincingly proven until the initial results of EVAR-1 were published last year.2 This randomised trial showed a 30-day mortality of 4·7% after open repair versus 1·7% after EVAR, a substantial 65% reduction in operative deaths. Soon after, the smaller randomised trial from Holland reported a nearly identical 30-day mortality of 4·6% for open repair versus 1·2% for EVAR.3 Also in 2004, two population-based reports from the USA with more than 10 000 patients showed an inhospital mortality of 3·8% for open repair versus 1·2% for EVAR, a 70% relative risk reduction.4,5 Thus there was a remarkable convergence of data to indicate that EVAR reduces operative mortality by about two-thirds compared with open repair. Although this news was welcomed, major concerns remained about the durability of EVAR and the potential need for costly and possibly complicated reintervention. Although graft-related complications,
such as pseudoaneurysm, can occur after open repair of an abdominal aortic aneurysm, their incidence is low enough that frequent follow-up is not required.6 By contrast, initial experience with EVAR quickly showed that endografts could become unsealed, leading to “endoleak” of pressurised blood into the residual aneurysm sac, potentially causing rupture—the very complication that the procedure is supposed to prevent. As a result, frequent follow-up with CT scanning has been used to detect endoleak or graft migration that might need endovascular re-intervention to insert additional graft components, or even conversion to open repair. Although such complications appear to be decreasing as endovascular device technology improves, large registries, such as EUROSTAR, have estimated a reintervention rate of over 5% a year, and a rupture rate as high as 1% a year despite EVAR.7,8 Thus the key question to be answered is whether the initial 3% absolute improvement in operative mortality in EVAR-1 would be overcome by later complications in terms of survival, cost, or quality of life. Despite a much higher rate of late complications and re-intervention after EVAR compared with open repair, aneurysmrelated mortality remained 3% lower with EVAR throughout the 4-year follow-up reported so far in EVAR-1. This benefit of EVAR required a 33% increase in cumulative hospital costs without a sustained benefit in quality of life. Furthermore, there was no significant difference in overall survival between EVAR and open repair after 4 years (72%), but only 24% of patients had reached that point in follow-up. So, further study is required, including a more detailed cost-effectiveness analysis. www.thelancet.com Vol 365 June 25, 2005
Comment
www.thelancet.com Vol 365 June 25, 2005
High Medical management
Operative risk
Do these results mean that EVAR is the preferred option for patients who need repair of an abdominal aortic aneurysm? Before answering that question, several caveats are in order. First, durability and re-intervention rate after EVAR are strongly influenced by anatomical suitability for the initial procedure. Such suitability is mainly determined by whether the diameter, angulation, and length of the proximal aorta will allow adequate attachment of the graft for aneurysm exclusion. In EVAR-1, 54% of potentially eligible patients were found to be anatomically “suitable” for EVAR. But this proportion ranged from 6% to 100% across the 34 centres, illustrating the current variation in assessment of this important variable. This area requires better definition to improve overall results. Second, abdominal aortic aneurysms repaired in EVAR1 were large, with an average diameter of 6·5 cm.2 The EUROSTAR registry has shown substantially higher aneurysm-related mortality after EVAR with large aneurysms than with smaller ones.9 Thus, had these aneurysms been detected and repaired earlier, even better results might have been obtained. Third, although EVAR-1 provides 3–4-year results for currently available third-generation endografts, 72% of patients were still alive at the midterm analysis reported today and require further follow-up to assure durable effectiveness of EVAR. And these patients were relatively old (average age of 76 years). Because the rate of reintervention after EVAR continues to increase with time, it is logical that EVAR will be most costly for patients with long life-expectancy, if not less effective. Thus the current practice of recommending open repair for patients with long life-expectancy is recommended until even longer follow-up is available. Finally, all patients in EVAR-1 were of suitable operative risk for open repair of their aneurysm, and were quite low-risk on the basis of the low operative mortality observed in both arms of this trial. Yet EVAR was specifically designed for higher risk patients who might not tolerate the systemic stress associated with a large abdominal operation. Of patients evaluated for EVAR-1, 21% were considered unfit for open repair because of cardiac, pulmonary, or renal co-morbidities. The question of whether EVAR would benefit such patients was addressed in the EVAR-2 trial, also reported in today’s issue, in which patients considered unfit for open repair were randomised to EVAR or no intervention.
Chose EVAR
Patient’s preference
Chose open repair
Low Poor
Excellent Anatomical suitability for EVAR
Figure: Choosing the best management of abdominal aortic aneurysm for individual patients
Patients in EVAR-2 were older, with more cardiopulmonary co-morbidities, which translated into a high 30-day operative mortality rate of 9% and a 4-year survival of only 36%. Although more deaths from aneurysm rupture occurred in the non-intervention group of EVAR-2, the initial high operative mortality in the EVAR group resulted in no late difference in aneurysm-related mortality, and no difference in overall survival. However, two unexpected events probably influenced the outcome of EVAR-2 which make it more difficult to interpret. First, EVAR was not done until a median of 57 days after randomisation despite a mean aneurysm diameter of 6·7 cm. During this time, nine aneurysms ruptured, causing nearly half of the total of 20 aneurysm-related deaths in the EVAR group. Second, after randomisation to the nonintervention group, 20% of patients subsequently underwent elective repair of their aneurysm in violation of the protocol. Amazingly, only one of these patients died as a result of their operation or an aneurysm complication during follow-up, indicating prescient selection of patients. Taken together, however, these effects bias the study against EVAR and reduce the power for a conclusive analysis. Nonetheless, the takehome message of EVAR-2 is clear and not surprising. Prophylactic operations designed to improve survival cannot be effective in patients with short lifeexpectancy. Thus selection of patients is critically important, because EVAR was much more costly than no intervention, without a survival benefit in high-risk patients. 2157
Comment
Returning to my earlier question, how should these results influence current practice? In a decision-analysis model, the key variables that determine the benefit of open repair versus EVAR are operative mortality and subsequent aneurysm-related mortality.10 Sensitivity analysis shows the interaction of these variables (figure). In this example, as in real practice, preoperative assessment of anatomical suitability for EVAR is a proxy for subsequent complications, re-intervention, and potential aneurysm-related mortality. Patients with low operative risk, who are usually younger with longer life-expectancy, are the best candidates for open repair and should not be considered for EVAR unless they have excellent anatomical suitability. Patients at higher operative risk are better candidates for EVAR, if anatomical suitability is adequate. However, there are many high-risk patients with marginal anatomical suitability for EVAR who have short life-expectancy and will not benefit from repair of their abdominal aortic aneurysm; they are best managed medically. Finally, there is still a large grey area where patients’ preference should influence the choice of EVAR versus open repair, given their similar outcomes. Current results from the EVAR-1 trial have shifted the choice point slightly toward the endovascular option, but ultimate clarity will await the long-term results of this trial. Furthermore, future subanalyses will provide details to assist individual selection of patients. Until then, patients are best advised to select well-informed surgeons with good results to assist their decision
making, such as the UK surgeons who designed and participated in these important trials. Jack L Cronenwett Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03755, USA [email protected] I declare that I have no conflict of interest. 1
Adriaensen ME, Bosch JL, Halpern EF, Myriam Hunink MG, Gazelle GS. Elective endovascular versus open surgical repair of abdominal aortic aneurysms: systematic review of short-term results. Radiology 2002; 224: 739–47. 2 Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364: 843–48. 3 Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351: 1607–18. 4 Anderson PL, Arons RR, Moskowitz AJ, et al. A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results. J Vasc Surg 2004; 39: 10–19. 5 Lee WA, Carter JW, Upchurch G, Seeger JM, Huber TS. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg 2004; 39: 491–96. 6 Hallett JW Jr, Marshall DM, Petterson TM, et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg 1997; 25: 277–84. 7 Harris PL, Vallabhaneni SR, Desgranges P, for the European Collaborators. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2000; 32: 739–49. 8 Harris PL, Buth J. An update on the important findings from the EUROSTAR EVAR registry. Vascular 2004; 12: 33–38. 9 Peppelenbosch N, Buth J, Harris PL, van Marrewijk C, Fransen G. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004; 39: 288–97. 10 Schermerhorn ML, Finlayson SR, Fillinger MF, Buth J, van Marrewijk C, Cronenwett JL. Life expectancy after endovascular versus open abdominal aortic aneurysm repair: results of a decision analysis model on the basis of data from EUROSTAR. J Vasc Surg 2002; 36: 1112–20.
Paternal postnatal depression: fathers emerge from the wings See Articles page 2201
2158
Although human beings have explored the moon and Mars, the development of infants, children, and adolescents remains a source of equal surprise and delight, filled with unexpected turns and new revelations. The paper in today’s Lancet by Paul Ramchandani and colleagues opens a new chapter on child-development research: the researchers have included fathers into the equation. But what is so new about fathers? Fathers have existed as long as there have been children. The concept is very simple: fathers and their well-being have an effect on their babies, even to the point that paternal depression is reflected in the babies’ development.
Research on maternal postpartum depression fills libraries. It is possibly one of the most researched areas in developmental psychopathology during the past 10 years. Clinical interventions usually focus on mothers and babies. Fathers, on the other hand, have been kept in the wings. Whether one considers developmental theories and research, health and social services, or organisation of child-care after birth, fathers’ roles have been defined as providing social and economic security to the family and emotional support for the mother during the infant period. At most, fathers have been seen as welcome playmates, but with only marginal effect on infants’ development. www.thelancet.com Vol 365 June 25, 2005