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April 20, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases. THIS WEEK'S CONTENTS
ARCHIVES OF DERMATOLOGY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, April 20, 2009)
ARCHIVES OF OTOLARYNGOLOGY—HEAD & NECK SURGERY
(Embargoed Until: 3 P.M. (CT), Monday, April 20, 2009)
ARCHIVES OF SURGERY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, April 20, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Psoriasis Associated With Diabetes and High Blood Pressure in Women
CHICAGO—Women with psoriasis appear to have an increased risk for developing diabetes and hypertension (high blood pressure), according to a report in the April issue of Archives of Dermatology, one of the JAMA/Archives journals. Psoriasis, a chronic inflammatory skin disease, affects between 1 percent and 3 percent of the population, according to background information in the article. Recent studies indicate that psoriasis is associated with an increased risk of other illnesses and death. "Systemic inflammation in psoriasis and an increased prevalence of unhealthy lifestyle factors have been independently associated with obesity, insulin resistance and an unfavorable cardiovascular risk profile," the authors write. Abrar A. Qureshi, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues studied 78,061 women involved in the Nurses' Health Study II, a group of female nurses age 27 to 44 years in 1991. Participants—all of whom were free of diabetes and hypertension at the beginning of the study—responded to a survey which included a question about lifetime history of psoriasis in 2005 and were assessed for the development of diabetes or hypertension during the 14-year follow-up. Of the women, 1,813 (2.3 percent) reported a diagnosis of psoriasis. A total of 1,560 (2 percent) developed diabetes and 15,724 (20 percent) developed hypertension. Women with psoriasis were 63 percent more likely to develop diabetes and 17 percent more likely to develop hypertension than women without psoriasis. These associations remained strong even after the researchers considered age, body mass index and smoking status. Inflammation could be a biologically plausible explanation for the association between psoriasis and hypertension as well as that between psoriasis and diabetes, the authors note. Inflammation is a risk factor for high blood pressure and may also contribute to insulin resistance, a pre-diabetic stage where the body does not respond to the glucose-regulating hormone insulin. Alternatively, systemic steroid therapy or other treatments for psoriasis may promote development of diabetes or hypertension.
"These data illustrate the importance of considering psoriasis a systemic disorder rather than simply a skin disease," the authors conclude. "Further research is needed to better understand the mechanisms underlying these associations and to find out whether psoriasis therapy can reduce the risk for diabetes and hypertension."
Editor's Note: This work was partly supported by grants from the National Cancer Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Research Uncovers Effects of Diabetes Throughout the Body
The article is one of seven in this issue that relates to diabetes and its effects on the skin, write William H. Eaglstein, M.D., of Stiefel Laboratories Inc., and Jeffrey P. Callen, M.D., of University of Louisville, Ky., and associate editor of Archives of Dermatology, in an accompanying editorial. The issue is being published in conjunction with a JAMA theme issue on diabetes. The March issue of Archives of Ophthalmology and Archives of Neurology, along with the April issues of Archives of Pediatrics & Adolescent Medicine and Archives of Surgery, also feature research on diabetes, obesity and their related co-morbidities. "Although a link between diabetes mellitus and psoriasis was suggested as early as 1908, the article by Qureshi et al reporting on a study of 78,061 U.S. female nurses is the first to prospectively document the link between psoriasis and both diabetes mellitus and hypertension," Drs. Eaglstein and Callen write. Other reports in the issue address the following topics:
Dermatologists "should be certain that our patients are working with their primary care physicians or diabetes mellitus specialists to ensure the best glycemic control possible, thus bringing us back to the message inherent in the articles about diabetes mellitus and its comorbidities in this month's Archives Journals—that being that diabetes mellitus is a systemic disorder with protean manifestations through the entire body and thus its cutaneous [skin-related] manifestations cannot be adequately dealt with in isolation," they conclude.
Editor's Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Survey Identifies Factors Associated With Early Detection of Melanoma in Older Men
CHICAGO—Older men whose melanoma is detected by a physician are more likely to have thinner and therefore more treatable tumors at diagnosis, according to results of a survey published in the April issue of Archives of Dermatology, one of the JAMA/Archives journals. A second analysis of the same survey data finds that physician detection of thin melanoma is more common in those who are 65 or older, have cancers on their backs or who have a history of atypical moles. Melanoma is becoming more common and mortality rates from melanoma are steadily increasing among older men, according to background information in one of the articles. Tumor thickness at diagnosis strongly predicts the management and outcomes of melanoma, and the thickest tumors (4 millimeters or thicker) are increasingly common in white men age 60 and older. "Rigorous assessment of behavioral, social and medical access factors that differ between men 40 years or older with thinner vs. thicker melanomas may identify potential modifiable variables," the authors write. "A clearer understanding of these factors provides fundamental knowledge for additional studies and public health messages aimed at earlier melanoma detection in this high-risk subset of men." In one study, Susan M. Swetter, M.D., of Stanford University Medical Center, Calif., and colleagues surveyed 227 men age 40 and older between 2004 and 2006, within three months of their melanoma diagnosis. The men responded to questions about their previous melanoma awareness, skin examination practices, how their cancer was discovered and social and medical care factors. Of the 227 men, 57 (25.1 percent) had tumors thicker than 2 millimeters. These men were more likely to have less than a high school education, less likely to have a history of atypical nevi (moles) and their melanomas were more often discovered by the patient themselves or a friend or family member than by a physician. Men with thinner melanomas were more likely to have previous knowledge of melanoma, have paid attention to skin cancer detection information, be interested in health topics and be aware of the importance of physician skin examination. Tumor thickness was not associated with patients' age, whether or not they were married or lived with a partner, skin cancer history, sun sensitivity or the anatomic location of the cancer. Overall, few patients were aware of melanoma warning signs (less than 20 percent), practiced skin self-examination (less than 50 percent) or used the Internet (less than 14 percent) as a source of skin cancer information. "For men 40 years or older, who constitute more than half of all melanoma deaths in the United States, we have identified at least two key variables (physician skin examination and improved public awareness, particularly for patients in lower socioeconomic groups) as major targets for new interventions to promote earlier melanoma detection," the authors write. "Public education, in particular targeting less-educated, middle-aged and older men for improved self-examination and physician skin surveillance, should become an integral component of skin cancer risk reduction strategies promoted by cancer advocacy organizations." In another study, Alan C. Geller, M.P.H., R.N., of Boston University, and colleagues report a separate analysis of the same survey data. Patients whose melanomas were detected by a physician tended to be older—57 percent were 65 years or older, compared with 42 percent of patients who detected cancer themselves and 34 percent whose cancer was detected by another non-physician. This may be because older patients visit their physicians more frequently, providing more opportunities for skin examination, and they may rely more heavily on physician skin evaluation because they tend to have poorer eyesight and are less likely to have a partner. Forty-six percent of physician-detected melanomas, 16 percent of self-detected melanomas and 56 percent of melanomas detected by other means were on the patient's back; these back-of-the-body melanomas were smaller than 2 millimeters in 92 percent of physician-detected cases, 63 percent of self-detected cases and 76 percent of those detected by other means.
"Skin screenings of at-risk middle-aged and older American men can be integrated into the routine physical examination, with particular emphasis on hard-to-see areas, such as the back of the body," the authors conclude. "‘Watch your back' professional education campaigns should be promoted by skin cancer advocacy organizations and should incorporate the importance of physician screening and the benefit of spouse or partner assistance for early detection of melanoma, particularly in the high-risk population of middle-aged and older men."
Editor's Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Physicians Must Help Men Overcome Barriers to Care
"A growing body of sex-specific studies shows a trend among men, especially white middle-class men, of delaying seeking help when they become ill," writes June K. Robinson, M.D., of Northwestern University Feinberg School of Medicine, Chicago, and editor of Archives of Dermatology, and colleagues in an accompanying editorial. "By delaying seeking care, men present at a later stage of melanoma when it is no longer treatable." "The tasks associated with seeking help from physicians, such as relying on others, admitting a need for help or appearing vulnerable, may be in conflict with some individuals' societal and normative beliefs that men are self-reliant, physically tough, invincible and in control of their destiny. For example, some men may be thought of as the ‘strong, silent type'; thus, they are reluctant to make a fuss over a little mole or to admit their fear that something could be wrong, even to themselves."
"This latter issue leads to the question of how physicians can interact with their patients in a manner that overcomes some of these interpersonal and psychological barriers to improve treatment outcomes," the authors write. Building strong, trusting physician-patient relationships, using appropriate patient education materials, asking patients about their concerns and demonstrating empathy may improve the care of all patients with melanoma.
Editor's Note: This study was supported in part by a National Cancer Institute grant to Dr. Robinson. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Radiation Exposure Associated With More Aggressive Thyroid Cancer, Worse Outcomes
CHICAGO—Patients with thyroid cancer who have previously been exposed to radiation—for example, in the workplace, through environmental exposure or for treatment of acne or another condition—appear to have more aggressive disease and tend to have worse outcomes in the long term, according to a report in the April issue of Archives of Otolaryngology—Head & Neck Surgery, one of the JAMA/Archives journals. "Thyroid cancer is one of the well-known malignant neoplasms [tumors] associated with radiation exposure," the authors write as background information in the article. "It often induces characteristic histologic changes in thyroid tissue, and it is a well-established risk factor for both benign and malignant thyroid tumors. This is supported by epidemiologic studies in atomic bomb survivors and in children living in contaminated areas around Chernobyl, Ukraine, after the 1986 nuclear reactor accident." Raewyn M. Seaberg, M.D., Ph.D., and colleagues at Mount Sinai Hospital, Toronto, Ontario, Canada, studied 125 patients who had been exposed to radiation at least three years before surgical treatment for thyroid cancer. All the patients were treated at one academic teaching hospital between 1963 and 2007. Most (56 percent) had a history of direct radiation exposure to the head and neck, usually for the treatment of acne or another benign condition. Six percent had direct radiation exposure to other parts of the body; 23 percent had occupational or diagnostic exposures, such as radiographic technicians, dental assistants or patients exposed to repeated imaging procedures; 11 percent had environmental exposures, such as those in Chernobyl; and 4 percent had received radioactive iodine treatment. The average age at first exposure to radiation was 19.4 years, and cancers were diagnosed an average of 28.7 years later. Patients were followed for an average of 10.6 years. During this time, 16 percent experienced a recurrence of the disease in the thyroid and 9 percent had cancer that had metastasized (spread) to distant areas. At the last follow-up, 86 percent were alive and free of disease, 4 percent were alive with recurrent thyroid cancer, 4 percent were alive with distant metastases, 4 percent had died of the disease and 2 percent had died of unrelated causes. These patients were compared with a group of 574 patients of similar ages and sex distribution who also were treated for thyroid cancer but were not exposed to radiation beforehand. The radiation-exposed group was more likely to undergo total or near-total thyroidectomy (removal of the thyroid, 83 percent vs. 38 percent), require additional surgery (23 percent vs. 2 percent), have stage IV disease (16 percent vs. 5 percent), have distant metastases (9 percent vs. 2 percent), to have thyroid cancer at follow-up (8 percent vs. 3 percent) or to have died of the disease (4 percent vs. 1.5 percent).
"Therefore, this study suggests that patients who have been exposed to radiation have more aggressive disease and worse clinical outcome than other patients with thyroid cancer and, therefore, may require more aggressive treatment," they conclude.
Editor's Note: Dr. Freeman holds the Temmy Latner/Dynacure Chair in Head and Neck Oncology. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Robot-Assisted Surgery Appears Useful for Removal of Some Head and Neck Tumors
CHICAGO—Robot-assisted surgery appears feasible for treatment of selected head and neck cancers, according to a report in the April issue of Archives of Otolaryngology—Head & Neck Surgery, one of the JAMA/Archives journals. "Since the introduction of the surgical robot in 1999, robot-assisted cardiac, gynecologic and urologic procedures have become widely accepted throughout the country," the authors write as background information in the article. In these specialties, robotic procedures have been associated with less blood loss, fewer complications, shorter surgery durations and fewer days in the hospital or in intensive care compared with traditional open procedures. "Robotic surgery in the head and neck offers the possibility of limited surgical morbidity [illness], reduced hospital stay and improved lesion visualization over open approaches and traditional transoral [through the mouth] techniques." Bridget A. Boudreaux, M.D., and colleagues at the University of Alabama at Birmingham assessed the feasibility and safety of robot-assisted surgery in 36 patients with tumors involving the oral cavity, throat or larynx. Between March 2007 and May 2008, 29 (81 percent) of the patients underwent successful robotic resection, or removal of the diseased tissue. The operating room was arranged with the surgeon's console, from which he or she operated the robotic arms that held the surgical equipment, approximately eight feet from the head of the bed. Negative margins (when no cancer cells are found at the edge or border of the removed tissue) were obtained in all 29 patients who successfully completed surgery. Of those, 21 had breathing tubes that had been in place during surgery safely removed before leaving the operating room. The average operating time was 99 minutes, and the average hospital stay was 2.9 days. "The surgical robot has several advantages over traditional endoscopic and open approaches, including three-dimensional visualization, tremor filtration [steadying of any shaking in the surgeon's hands] and greater freedom of instrument movement," the authors write. "These advantages were appreciated in this study and offered good lesion visualization, short hospital stay and good functional preservation."
Patients who had smaller tumors and no teeth appeared more likely to have successful robot-assisted procedures. However, no clinical guidelines for robotic procedures in head and neck cancer patients yet exist, the authors note. "This clinical series demonstrates that robotic surgery can be utilized successfully in patients with T1 to T4 lesions located in the oral cavity, oropharynx [back of the mouth], hypopharynx [bottom part of throat] and larynx with good preservation of swallow function," they conclude. "This study does not confirm oncologic or functional superiority to any standard method of treatment. Further studies are needed to define the indications, advantages, limitations and outcomes of robotic surgery for head and neck applications."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Complication and Death Rate No Better at Bariatric Surgery Centers of Excellence than at Other Hospitals
CHICAGO—Patients who undergo bariatric surgery at hospitals designated as centers of excellence do not appear to have lower mortality rates or lower rates of complications than those whose procedures are performed at other hospitals, according to a report in the April issue of Archives of Surgery, one of the JAMA/Archives journals. Center of excellence designation is awarded to bariatric surgery centers by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery, according to background information in the article. The nearly identical guidelines require that centers perform at least 125 operations per year; employ a bariatric surgery coordinator and personnel to follow up patients long-term; and enter outcomes into proprietary databases, which requires trained staff and a subscription to a database. "These criteria make intuitive sense but lack an evidence base for their application," the author writes. In 2006, the Centers for Medicaid and Medicare Services began requiring that patients they insure undergo bariatric surgery at designated centers of excellence. Edward H. Livingston, M.D., of the University of Texas Southwestern School of Medicine and Department of Veterans Affairs, Dallas, analyzed data from the 2005 National Inpatient Survey for 19,363 patients who underwent bariatric surgery that year, including 5,420 (28 percent) whose procedures were performed at bariatric surgery centers of excellence. Overall, 0.1 percent of patients died in the hospital and 6.4 percent developed complications. More bariatric operations were performed at the 9.5 percent (24 of 253) of hospitals in the database designated as centers of excellence (an average of 226 procedures per year vs. 79 at other facilities). At centers of excellence, 0.17 percent of patients died and 6.3 percent developed complications, compared with a 0.09 death rate and 6.4 percent complication rate at other facilities. Patients spent an average of 2.6 days in the hospital both at centers of excellence and other facilities, but average costs per patient were higher at centers of excellence ($11,527 vs. $10,984). "It has been shown that the minimal annual procedure volume required to be designated as a center of excellence (125 cases per year) does not necessarily result in better outcomes and that the minimum volume requirement is not evidence based. Most important, this volume criterion significantly restricts access for bariatric surgery care," Dr. Livingston writes. "The number of bariatric operations performed each year was the most striking difference between bariatric surgery centers of excellence and hospitals that were not centers of excellence. Patient and facility characteristics were similar as were complication and death rates."
"Designation as a bariatric surgery center of excellence does not ensure better outcomes. Neither does high annual procedure volume," Dr. Livingston concludes. "Extra expenses associated with center of excellence designation may not be warranted."
Editor's Note: This study was funded by the Hudson-Penn endowment, grants from the National Institutes of Health and a grant from the Department of Veterans Affairs. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Online Reporting System Could Track Surgical Complications
CHICAGO—A Web-based reporting system may help clinicians track surgical complications and detect patterns of adverse events, identifying opportunities to improve the quality of care, according to a report in the April issue of Archives of Surgery, one of the JAMA/Archives journals. Complications and deaths during surgery are typically discussed by clinicians at a weekly surgical morbidity and mortality conference, according to background information in the article. "Individual cases are typically presented by a resident, and a discussion ensues addressing the issues in that single case," the authors write. "Recent efforts have attempted to make the discussion more evidence-based and less blame-oriented. However, the focus has remained on individual cases, residents and physicians rather than on the system and overall quality of patient care." In addition, the morbidity and mortality conference typically does not address near-misses, events that had the potential to result in an adverse outcome and can offer valuable learning opportunities. Karl Y. Bilimoria, M.D., M.S., of Feinberg School of Medicine, Northwestern University, Chicago and colleagues designed a Web-based system to track adverse and near-miss events and also established an automated method to identify patterns of these events. The system was implemented at a large metropolitan tertiary care center in September 2005. Residents entered data about adverse events used for the morbidity and mortality conference, and all clinicians in the surgery department were given a password to anonymously enter information about other adverse events and near misses. Through August 2007, 15,524 surgical patients were reported including 957 (6.2 percent) adverse events and 34 (0.2 percent) anonymous reports. "The automated pattern recognition system helped identify four event patterns from morbidity and mortality reports and three patterns from anonymous/near-miss reporting," the authors write. "After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues and/or intensive quality monitoring." For instance, recurring errors in chest tube placements and nurse-to-physician communications were detected and managed. The events entered into the online system also were compared with hospital databases to assess the completeness of reporting. Only 27.2 percent (264 of 970) of readmissions and 41.6 percent (89 of 214) of inpatient deaths were reported into the system; there was no change in monthly adverse reporting rate when the online system was initiated. "Though not surprising, this under-reporting was disappointing," the authors write. "During the study period, interventions aimed at increasing reporting had little effect." A presentation from the department chair regarding what constitutes an adverse event and the importance of tracking complications produced an initial spike in reporting that was short-lived.
"An electronic physician-reported event tracking system should be incorporated into all surgery departments irrespective of whether the department is associated with a residency program; however, this is just one component of what should be a larger quality improvement effort," the authors conclude. "An online event tracking system is a feasible, promising and potentially powerful initiative to improve surgical safety in the United States."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 20, 2009
Study Examines Outcomes of Gastric Bypass Surgery in Morbidly Obese and Superobese Patients
CHICAGO—Superobese gastric bypass patients appear to have improvements in quality of life and obesity-related co-existing conditions, and despite losing weight remain obese after surgery, according to a report in the April issue of Archives of Surgery, one of the JAMA/Archives journals. "The prevalence of overweight and obesity has increased markedly world-wide in past years. Obesity related comorbidities [co-existing diseases or conditions] are responsible for a shortened life expectancy and a reduced quality of life," the authors write as background information in the article. Though moderate weight loss has been shown to improve comorbidities in overweight or moderately obese patients, in morbidly obese patients "only bariatric surgery can provide substantial and maintained weight loss, which in turn results in improvement of obesity-related comorbidities and quality of life." Michel Suter, M.D., P.D., of Hôpital du Chablais, Aigle-Monthey, Lausanne, Switzerland, and colleagues compared weight loss, body mass index (BMI), comorbidities and quality of life in 492 morbidly obese (having a BMI of 40 to 49) patients and 133 superobese (having a BMI of 50 or higher) patients treated with primary laparoscopic gastric bypass patients (average age 39.8 and 40.4, respectively) between 1999 and 2006. Morbidly obese patients lost up to 15 BMI units (34.7 percent body weight) after two and a half years and maintained an average loss of 13 BMI (30.1 percent body weight) units six years after surgery. Superobese patients lost a maximum of 21 BMI units (37.3 percent body weight) after two and a half years and approximately 17 BMI units (30.7 percent body weight) after six years. Although superobese patients had a greater weight loss than morbidly obese patients, less than 50 percent of them had a BMI of less than 35 six years after surgery compared with more than 90 percent of morbidly obese patients. "Despite these differences, improvements in quality of life and comorbidities were impressive and similar in both groups," the authors note.
"Weight loss or residual BMI is not all that matters, and all aspects of the results of bariatric surgery must be evaluated to draw meaningful conclusions about the effectiveness of a given bariatric operation," the authors conclude. "Only large randomized studies comparing Roux-en-Y gastric bypass with other bariatric procedures and studying all aspects of weight loss surgery, with long-term follow-up, will be able to establish whether one procedure is superior to the others, especially in the superobese patient group."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. 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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