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ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES

(Embargoed Until: 3 P.M. (CT), Monday, April 11, 2005)

   IN YEARS PRECEDING MEDICARE ELIGIBILITY, MANY OLDER ADULTS AT RISK OF BEING UNINSURED

   LOCATION OF BODY FAT ASSOCIATED WITH CARDIOVASCULAR RISK IN OLDER MEN AND WOMEN EVEN AT NORMAL BODY WEIGHT

ARCHIVES OF NEUROLOGY NEWS RELEASES

(Embargoed Until: 3 P.M. (CT), Monday, April 11, 2005)

   DEEP BRAIN STIMULATION IN PARKINSON DISEASE REDUCES UNCONTROLLED MOVEMENTS

   RESTLESS LEGS SYNDROME HAS COMPLEX GENETIC INVOLVEMENT

ARCHIVES OF OPHTHALMOLOGY NEWS RELEASES

(Embargoed Until: 3 P.M. (CT), Monday, April 11, 2005)

   OLDER CHILDREN MAY BENEFIT FROM TREATMENT FOR LAZY EYE

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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 11, 2005
To contact David W. Baker, M.D., M.P.H., call Liz Crown 312-503-8928.

IN YEARS PRECEDING MEDICARE ELIGIBILITY, MANY OLDER ADULTS AT RISK OF BEING UNINSURED

CHICAGO—At least one-fourth of older U.S. adults will be uninsured at some point during the years preceding Medicare eligibility, according to an article in the April 11 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

"Uninsured individuals are less likely to have a regular source of care, to use preventive services, to obtain timely care for acute medical problems, and to take medications for chronic illnesses," according to background information in the article. As a result, uninsured patients have higher rates of illness and death. Because of their higher prevalence of chronic disease, uninsured individuals in late middle age may be especially vulnerable to the adverse consequences of being uninsured.

David W. Baker, M.D., M.P.H., from Northwestern University, Feinberg School of Medicine, Chicago, and Joseph J. Sudano, Ph.D., of Case Western Reserve University, Cleveland, analyzed data from the Health and Retirement Study (HRS) in order to assess the number of patients whose health is at risk from being uninsured. Study participants aged 51 to 57 years (n = 6,065) were interviewed every two years from 1992 to 2000. At the time of interview, insurance coverage was determined and classified as private, public, or uninsured.

Researchers found that at least 23.3 percent of participants were uninsured at least once during the eight-year study period. The percentage of uninsured individuals decreased throughout the study at the time of interviews in 1992, 1994, 1996, 1998, and 2000, with 14.3 percent, 10.8 percent, 9.7 percent, 8.8 percent, and 8.2 percent of people uninsured, respectively. Often, people shifted between having insurance and being uninsured. About 60 percent of patients were continuously enrolled in private insurance through all five interviews. Women, African American and Hispanic individuals, and those with low family incomes and/or low educational attainment in 1992 were more likely to be uninsured at least once. Older age, male sex, poor overall health, having one or more chronic illness, and being uninsured at the start of the study were all associated with higher risk of death.

"The proportion of U.S. adults in late middle age at risk from being uninsured over a ten-year follow-up period was two to three times higher than cross-sectional estimates. At least one-quarter of older adults will be uninsured at some point during the years preceding eligibility for Medicare," the authors write. "There is now substantial evidence that uninsured adults in their preretirement years are at greatly increased risk for adverse health outcomes, and urgent policy measures are needed to expand coverage for this group."
(Arch Intern Med. 2005;165:770-776. Available post-embargo at archinternmed.com)

Editor's Note: Supported by a grant from the Agency for Healthcare Research and Quality, Rockville, Md.

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.

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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 11, 2005
Media Advisory: To contact Bret H. Goodpaster, Ph.D., call Frank Raczkiewicz at 412-647-3555.

LOCATION OF BODY FAT ASSOCIATED WITH CARDIOVASCULAR RISK IN OLDER MEN AND WOMEN EVEN AT NORMAL BODY WEIGHT

CHICAGO—The distribution of body fat in older men and women is associated with metabolic syndrome, a risk factor for cardiovascular disease and diabetes, even in normal weight individuals, according to the April 11 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

Metabolic syndrome, a disorder that includes dyslipidemia (elevated blood lipid levels), insulin resistance and high blood pressure, affects 22 percent of adults in the U.S. and an even higher (42) percent of older men and women, according to background information in the article. In addition to overweight and obesity, patterns of fat distribution in middle-aged adults may confer additional risk for metabolic syndrome, but it is not known whether this is true for older individuals.

Bret H. Goodpaster, Ph.D., of the University of Pittsburgh Medical Center, and colleagues examined the association between the pattern of distribution of body fat and metabolic syndrome in 3,035 men and women aged 70 to 79. The distribution of body fat was determined using computed tomography (CT) scanning. Patients were examined and characterized as having metabolic syndrome if they met at least three of the following criteria: waist circumference greater than about 40.2 inches in men or 34.7 inches in women; elevated blood triglyceride levels; low high density lipoprotein (HDL) cholesterol levels; high blood pressure, treated or untreated; and elevated blood sugar level, treated or untreated. Individuals were classified as normal weight, overweight or obese based on the basis of body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) with a BMI of less than 25.0 considered normal weight, overweight was defined as a BMI of 25.0-29.9 and obese was defined by a BMI of greater than 29.9.

Visceral fat (fat found in the deeper tissues and around the body's organs rather than just under the skin) was associated with metabolic syndrome in older men and women whether they were normal weight, overweight or obese. Subcutaneous (under the skin) abdominal fat was associated with metabolic syndrome only in normal weight men. Intermuscular fat was associated with the syndrome in normal and overweight men, the researchers found. A surprising finding, according to the authors, was that subcutaneous thigh fat was inversely associated with metabolic syndrome in obese men and women. Having more of this type of fat made an individual less likely to have metabolic syndrome.

"In conclusion, excess accumulation of either visceral abdominal or muscle AT [adipose tissue or fat] is associated with a higher prevalence of metabolic syndrome in older adults, particularly in those who are of normal body weight," the authors write. "This suggests that practitioners should not discount the risk of metabolic syndrome in their older patients entirely on the basis of body weight or BMI. Indeed, generalized body composition, in terms of both BMI and the proportion of body fat, does not clearly distinguish older subjects with the metabolic syndrome."
(Arch Intern Med. 2005;165:777-783. Available post-embargo at archinternmed.com)

Editor's Note: This study was supported by grants from the National Institutes of Health, Bethesda, Md. Dr. Goodpaster was supported by a grant from the National Institute on Aging.

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.

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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 11, 2005
Media Advisory: To contact Valerie C. Anderson, Ph.D., call Jonathan Modie at 503-494-8231. To contact editorialist Michael S. Okun, M.D., call Tom Fortner at 352-392-2621.

DEEP BRAIN STIMULATION IN PARKINSON DISEASE REDUCES UNCONTROLLED MOVEMENTS

CHICAGO—Deep brain stimulation of two different areas of the brain appears to improve problems with uncontrolled movements (dyskinesia) in patients with Parkinson disease (PD), according to an article in the April issue of the Archives of Neurology, one of the JAMA/Archives journals.

Deep brain stimulation with electrical impulses delivered to structures deep within the brain is being intensively investigated for the management of advanced Parkinson disease, according to background information in the article. Although a number of studies have shown that stimulation of two different areas of the brain, the globus pallidus interna (GPi) and the subthalmic nucleus (STN), can be achieved safely and effectively, STN has been thought to be the preferred target. At the same time, the authors note, there does seem to be some evidence that the STN is more vulnerable during surgery and that STN patients may have more postoperative problems.

Valerie C. Anderson, Ph.D., of the Oregon Health and Science University, Portland, and colleagues compared 23 patients with Parkinson disease and problems with medication-induced uncontrolled movement who were randomly assigned to implantation of deep brain stimulators in either the GPi or the STN areas of the brain. Patients' Parkinson symptoms were evaluated with and without medication using a standard rating scale at three, six and 12 months after surgery.

"Off-medication Unified Parkinson's Disease Rating Scale motor scores were improved after 12 months of both GPi and STN stimulation (39 vs 48 percent)," the authors write. "Bradykinesia [extremely slow movement] tended to improve more with STN than GPi stimulation. No improvement in on-medication function was observed in either group. Levodopa [Parkinson medication] dose was reduced by 38 percent in STN stimulation patients compared with three percent in GPi stimulation patients. … Dyskinesia was reduced by stimulation at both GPi and STN ( 89 v 62 percent). Cognitive and behavioral complications were observed only in combination with STN stimulation."

"At this point, it appears that stimulation at either STN or GPi improves off-medication motor scores and levodopa-induced dyskinesia for at least one year, and there is no clear superiority of STN over GPi stimulation," the authors conclude. "Indeed, our comparison of GPi vs STN stimulation suggests that selection of a stimulation site should be influenced by symptom profile. Although GPi stimulation may be better for the patient with dose-limiting dyskinesia, STN stimulation may be better for the younger patient with prominent bradykinesia."
(Arch Neurol. 2005;62:554-560. Available post-embargo at archneurol.com)

Editor's Note: This study was supported in part by a grant from the Public Health Service.

EDITORIAL: WILL PALLIDAL DEEP BRAIN STIMULATION MAKE A TRIUMPHANT RETURN?

In an editorial accompanying this study, Michael S. Okun, M.D., and Kelly D. Foote, M.D., of the University of Florida, Gainesville, write, "Dyskinesia improves dramatically with both GPi and STN DBS [deep brain stimulation]. As suggested by the authors of this article and by others, the mechanism underlying this improvement may be different for each target. The majority of the anti-dyskinetic benefit of GPi DBS may be due to active stimulation, and the benefits in STN may be primarily a result of medication reduction. … the antidyskinetic effects of GPi DBS seem to be greater than those of STN DBS."

"One important and perhaps deciding factor in the rematch between GPi and STN DBS will be the incidence of surgical and postoperative complications," the authors suggest. "Assuming that the rates of the procedure-related and device complications are equal, then long-term cognitive, mood, and behavioral problems may lead to a victory of one target over the other."

"The unanswered questions regarding target selection will require several more head-to-head rematches between GPi and STN," the authors conclude. "Future improvements in implantation technique and in lead design may also enhance the benefit in each target. Studies may prove that STN is a better target than GPi or that there is no clear winner. Studies may also prove that STN is superior for certain features of the disease such as tremor, bradykinesia, and medication reduction. Alternatively, studies may show that GPi is equal to STN with regard to motor improvements, and is better antidyskinesia treatment, but has fewer cognitive, mood, and behavioral adverse effects. Whatever the outcome of these rematches, we should be open to changes in our current practices and recognize the possibility that we should match individual patient needs with the strengths and weaknesses of individual targets."
(Arch Neurol. 2005;62:533-536. Available post-embargo at archneurol.com)

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.

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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 11, 2005
Media Advisory: To contact corresponding author Guy A. Rouleau, M.D., Ph.D., call Marc Tulin at 514-343-7593.

RESTLESS LEGS SYNDROME HAS COMPLEX GENETIC INVOLVEMENT

CHICAGO—A new study confirmed that a gene associated with restless legs syndrome (RLS) susceptibility is located on chromosome 12q and and also suggests that at least one other gene may be involved in restless leg syndrome, according to an article in the April issue of the Archives of Neurology, one of the JAMA/Archives journals.

Restless legs syndrome is one of the leading causes of insomnia, affecting more than five to 10 percent of the white population, according to background information in the article. Genetic contributions to restless legs syndrome have been consistently supported by population, family and twin studies. To identify genetic risk factors, the current study used information from French Canadian families, where, according to the researchers, prevalence of restless legs syndrome is higher than in other populations.

Alex Desautels, Ph.D., of the University of Montreal, and colleagues examined the DNA of 19 multigenerational French Canadian families with four to nine individuals who were affected (or possibly affected) by restless legs syndrome. The researchers used statistical analysis of the genetic information to determine whether restless legs syndrome in each family was linked with markers on the same location on chromosome 12q that had previously been associated with restless legs syndrome.

Two-hundred-seventy-six individuals were included in the study, including 146 affected individuals, 39 possibly affected individuals and 91 unaffected family members. The researchers confirmed that the syndrome was consistent with linkage to chromosome 12q within five families. Linkage to that location was formally excluded for six other families. The researchers compared clinical features of the syndrome in affected individuals from the different families to see if those differences correlated with the differences in linkage. They found that one feature, periodic leg movements during sleep, was significantly greater for affected individuals from the linked families than for affected individuals from the unlinked families.

"These results further support the involvement of an RLS-susceptibility locus [gene location] on chromosome 12q in the FC [French Canadian] population and also provide evidence that there must be other loci involved in this common sleep disorder," the authors conclude. "Furthermore, our findings illustrate that extensive characterization of subclinical differences represents a major tool in the identification of susceptibility loci for complex diseases … Although the background of RLS is most likely complex, this finding may offer a new starting point for further dissecting the genetic cause of RLS."
(Arch Neurol. 2005;62:591-596. Available post-embargo at archneurol.com)

Editor's Note: This study was supported in part by research grants from the Canadian Institutes of Health Research (CIHR), Ottawa and from the National Institutes of Health, Bethesda, Md. Dr. Desautels is a recipient of the CIHR studentship.

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.

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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 11, 2005
Media Advisory: To contact corresponding author Mitchell M. Scheiman, O.D., call Ilena Ditoro at 215-780-1284. To contact editorialist David G. Hunter, M.D., Ph.D., call Susan Craig at 617-355-6420.

OLDER CHILDREN MAY BENEFIT FROM TREATMENT FOR LAZY EYE

CHICAGO—Some children aged seven to 17 who had previously been thought too old to benefit from treatment for amblyopia, commonly known as "lazy eye", showed improvement after treatment in a clinical trial reported in the April issue of the Archives of Ophthalmology, one of the JAMA/Archives journals.

Although it is widely agreed that amblyopia, a condition that involves poor vision and/or poor muscle control of one eye, can be effectively treated in children younger than six, it has generally been believed that older children were unlikely to benefit from treatment, according to background information in the article. The upper limit for successful treatment response has been believed to be six to seven or nine to ten years of age. The current study is designed to evaluate the effectiveness of treatment of amblyopia in children aged seven to 17 years.

Mitchell M. Scheiman, O.D., Richard W. Hertle, M.D., and colleagues in the Pediatric Eye Disease Investigator Group (PEDIG), conducted a randomized treatment trial of 507 older children with amblyopia at 49 clinical sites. All the patients were provided with optimal optical correction (children who already had glasses were given new ones). Children were then randomly assigned to receive treatment for amblyopia or to receive optical correction alone. Children aged seven to 12 in the treatment group were treated with two to six hours a day of patching over the sound eye combined with near visual activities such as playing with a GameBoy, homework, or reading, and one drop daily of atropine for the sound eye. Patients in the older treatment group (aged 13 to 17 years) were treated with patching and near visual activities alone.

Follow up visits occurred every six weeks for up to 24 weeks until the patients were classified as a responder or non-responder. A patient in the study was classified as a responder if the amblyopic eye acuity (sharpness of vision) was 10 or more letters (two lines on the eye chart) better than baseline. A patient was classified as a non-responder if amblyopic eye acuity had not improved 10 or more letters by the 24th week or if there was no improvement at all from a prior follow-up visit (or baseline).

Of the 404 seven- to 12-year-olds in the study, 53 percent (106 of 201) in the treatment group were responders compared with 25 percent in the optical correction group. Of the 13- to 17- year-olds, 25 percent of the treatment group (14 of 55) were responders compared with 23 percent of the optical correction group (11 of 48). However, of the13- to 17- year-olds who had not previously been treated for amblyopia, 47 percent (eight of 17) responded to treatment compared to 20 percent (four of 20) who did not.

"Although our results indicate that visual acuity can be improved by treating amblyopia in older children, it is not known whether the improvement will be sustained after treatment is discontinued," the authors write. "Therefore, a conclusion regarding the long-term benefit of treatment and the development of treatment recommendations for amblyopia in children seven years and older will need to await the results of a follow-up study we are conducting on the patients who responded to treatment."
(Arch Ophthalmol. 2005;123:437-447. Available post-embargo at archophthalmol.com)

EDITORIAL: TREATMENT OF AMBLYOPIA IN OLDER CHILDREN

In an editorial accompanying this study, David G. Hunter, M.D., Ph.D., of Harvard Medical School, Boston, writes that "The results indicate that visual acuity may improve modestly in some cases. Surprisingly, vision improved in many patients treated with optical correction alone…. The response could perhaps have been better, but the treatment chosen for older patients was minimal. Sixty-two percent of older patients in the treatment group were prescribed only two hours of patching, without atropine, despite a lack of published evidence that such limited treatment might be effective in severe amblyopia."

"Until we know the regression rate in these age groups (which may be very high) and the functional benefits of a two-line (10-letter) improvement in visual acuity at this age (which may be minimal), we will not know whether there is reason to treat older amblyopia patients," Hunter writes. "Until we know whether to treat, we will not know whether to screen populations for amblyopia at this age. Thus, although the study unearthed much new information about amblyopia in older children, the authors do not make any recommendations about treatment of these patients, nor should they until they obtain follow-up results."

"In this study, some older patients with amblyopia responded to treatment, but most did not," Hunter concludes. "Those who did respond were left with a residual visual acuity deficit. The take-home lesson is that considering how difficult it is to treat older children for amblyopia, it is vitally important to identify and treat amblyopia early in life, well before age seven years. This can be achieved by (1) increasing awareness (in parents and primary care providers) that amblyopia is a silent threat to vision, (2) improving our ability to screen children for amblyopia in the preschool years, and (3) ensuring that patients, once identified, will have access to care. If these goals can be achieved, the question of whether or how to treat older patients with severe amblyopia will become a strictly academic pursuit."
(Arch Ophthalmol. 2005;123:557-558. Available post-embargo at archophthalmol.com)

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.

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