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May 11, 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 INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, May 11, 2009)
ARCHIVES OF OPHTHALMOLOGY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, May 11, 2009)
ARCHIVES OF NEUROLOGY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, May 11, 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, May 11, 2009
Real and Simulated Acupuncture Appear More Effective Than Usual Care for Back Pain
CHICAGO—Three types of acupuncture therapy—an individually tailored program, standard therapy and a simulation involving toothpicks at key acupuncture points—appear more effective than usual care for chronic low back pain, according to a report in the May 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Back pain costs Americans at least $37 billion annually, according to background information in the article. Many patients with this condition are unsatisfied with traditional medical care and seek help from complementary and alternative care providers, including acupuncturists. "Back pain is the leading reason for visits to licensed acupuncturists, and medical acupuncturists consider acupuncture an effective treatment for back pain," the authors write. Several recent studies have suggested that simulated acupuncture, or shallow needling on parts of the body not considered key acupuncture points, appear as effective as acupuncture involving penetrating the skin. To expand on these results, Daniel C. Cherkin, Ph.D., of Group Health Center for Health Studies, Seattle, and colleagues compared four different types of treatment in a randomized clinical trial involving 638 adults (average age 47) with chronic low back pain at Group Health in Seattle and Kaiser Permanente Northern California in Oakland. During the seven-week treatment period, 157 participants received 10 acupuncture treatments in a manner individually prescribed by a diagnostic acupuncturist; 158 underwent a standardized course of acupuncture treatments considered effective by experts for low back pain; 162 received 10 sessions of simulated acupuncture, in which practitioners used a toothpick inside of an acupuncture needle guide tube to mimic the insertion, stimulation and removal of needles; and 161 received usual care. Participants reported changes in their symptoms and in the amount of dysfunction caused by their back pain by phone after eight, 26 and 52 weeks. "Compared with usual care, individualized acupuncture, standardized acupuncture and simulated acupuncture had beneficial and persisting effects on chronic back pain," the authors write. At the eight-week follow-up, 60 percent of the participants receiving any type of acupuncture (individualized, standardized or simulated) experienced a clinically meaningful improvement in their level of functioning, compared with 39 percent of those receiving usual care. At the one-year follow-up, 59 percent to 65 percent of those in the acupuncture groups experienced an improvement in function compared with 50 percent of the usual care group. Several possible explanations exist for the effectiveness of simulated acupuncture, the authors note. Superficial stimulation of acupuncture points may directly stimulate physiological processes that result in reduced pain and improved function. Alternatively, the improvement may be due to another aspect of the treatment experience, such as interaction with the therapist or a belief that acupuncture will be helpful. "These findings raise questions about acupuncture's purported mechanisms of action," they write. "It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or non-specific effects."
"Our results have important implications for key stakeholders," they conclude. "For clinicians and patients seeking a relatively safe and effective treatment for a condition for which conventional treatments are often ineffective, various methods of acupuncture point stimulation appear to be reasonable options, even though the mechanism of action remains unclear. Furthermore, the reduction in long-term exposure to the potential adverse effects of medications is an important benefit that may enhance the safety of conventional medical care."
Editor's Note: This trial was funded through a National Institutes of Health Cooperative Agreement with the National Center for Complementary and Alternative Medicine. The sponsor (NIH), though its project officer, co-author Dr. Khalsa, was involved in the analysis and interpretation of data and review and approval of the manuscript. Lhasa OMS Inc., Weymouth, Mass., donated the Seirin acupuncture needles used in this study. 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, May 11, 2009
Small Promotional Items from Drug Companies May Influence Medical Students' Attitudes
CHICAGO—Exposure to small promotional items from pharmaceutical companies, such as clipboards and notepads, appears to influence medical students' unconscious attitudes toward the marketed product, according to a report in the May 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Students whose medical school restricts marketing practices had less favorable attitudes toward the product following exposure to the items, while those at a school with no such limitations responded more favorably. "Discussions about the influence of pharmaceutical promotion on physicians often focus on gifts and payments of relatively large economic value," the authors write as background information in the article. "The underlying assumption is that smaller gifts are unlikely to exert influence on prescribing decisions." However, marketing and psychological research suggests that even trivial items can sway attitudes and behaviors. David Grande, M.D., M.P.A., of the University of Pennsylvania, Philadelphia, and colleagues conducted a randomized controlled experiment involving 352 third- and fourth-year medical students. Of these, 154 were enrolled at the University of Pennsylvania School of Medicine (Penn), which has a policy prohibiting most gifts, meals and samples from drug companies. The other 198 attended the University of Miami Miller School of Medicine (Miami), which permits these marketing practices. One hundred and eighty-one of the participants were randomly assigned to be unknowingly exposed to small branded promotional items for the cholesterol-lowering medication Lipitor, including a clipboard and notepad used when they signed in to study appointments. The other 171 students received no such priming. All of the participants completed a test of implicit attitudes toward Lipitor (one of the most heavily promoted brand-name statins in the United States) and Zocor (which is available generically and considered to be equally effective). The test involved matching the brands to attributes of the brands (such as pleasant and unpleasant) in a computerized image- and word-association test. Differences in reaction times help reveal unconscious attitudes. The students also reported their explicit (conscious) attitudes toward both drugs by completing a questionnaire about safety, superiority, efficacy and convenience. "Overall, students in both class years and both schools demonstrated implicit attitudes favoring Lipitor over Zocor as reflected by the positive values even among control students," the authors write. "However, there were significant differences between the exposed and control groups among fourth-year medical students at Penn and Miami." Fourth-year students at Miami demonstrated stronger preferences toward Lipitor after exposure to promotional items, whereas fourth-year students at Penn exhibited the opposite response, with those in the exposure group showing weaker preferences toward Lipitor than the control group. There were no differences between the control and exposure groups among third-year students. This could be because fourth-year students have more clinical experience and have formed attitudes toward treatment options that can be primed with branded promotional items, the authors note.
"Our results provide evidence that subtle branding exposures are important and influential, as the psychology and marketing literature would suggest," they conclude. "Our findings are particularly notable because they are attributable to simple exposure to promotional items independent of other effects attributable to the social relationships associated with gifts. Our study also suggests that institutional policies, by way of their influence on student attitudes toward marketing, could lead to different responses to branded promotional items."
Editor's Note: Dr. Grande was supported by the Robert Wood Johnson Foundation Health & Society Scholars program at the time of this research. Co-author Dr. Frosch is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: The Time Has Come to Adopt Policies Restricting Drug Marketing
"The powerful influence by drug companies on physicians and medicine has drawn increasing public attention," writes Philip Greenland, M.D., of the Feinberg School of Medicine, Northwestern University, Chicago, in an accompanying editorial. "Grande et al in this issue of the Archives present interesting data on the effects of more restrictive institutional policies, such as those enforced at the University of Pennsylvania," Dr. Greenland writes. "The authors concluded that institutional policies can reverse the effects of drug marketing tactics, and the data suggest that adopting these more restrictive policies will reverse longstanding adverse trends on physicians' prescribing habits."
"As others have outlined, it is time to act and adopt restrictive policies," he concludes. "It is imperative that the profession police itself, or it is inevitable that government will step in and create a policing structure that will be punitive and require expensive oversight. Why are most of us still waiting? The evidence is clear, and the path is defined. It is time to act."
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, May 11, 2009
Women Who Follow Blood Pressure–Lowering Diet Have Reduced Risk for Heart Failure
CHICAGO—A diet designed to prevent and treat high blood pressure also may be associated with a lower risk of heart failure among women, according to a report in the May 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Dietary patterns have been associated with risk factors for heart failure, but little is known about whether food choices can prevent or delay the condition, according to background information in the article. "The Dietary Approaches to Stop Hypertension (DASH) diet may contribute to prevention of heart failure in some cases because it effectively reduced blood pressure and low-density lipoprotein [LDL, or "bad"] cholesterol levels in clinical trials," the authors write. "This diet features high intake of fruits, vegetables, low-fat dairy products and whole grains, resulting in high potassium, magnesium, calcium and fiber consumption, moderately high protein consumption and low total and saturated fat consumption." Emily B. Levitan, Sc.D., of Beth Israel Deaconess Medical Center, Boston, and colleagues analyzed data from 36,019 women ages 48 to 83 without heart failure who were participating in the Swedish Mammography Cohort. Participants completed a food frequency questionnaire at the beginning of the study, between 1997 and 1998, that was used to calculate a score indicating how closely their diets matched DASH guidelines. The women were followed up from 1998 through 2004 using Swedish databases of hospitalizations and deaths. During the seven-year follow-up, 443 women developed heart failure, including 415 who were hospitalized and 28 who died of the condition. Compared with the one-fourth of women with the lowest DASH diet scores, the one-fourth of women with the highest DASH diet scores had a 37 percent lower rate of heart failure after factors such as age, physical activity and smoking were considered. Women whose scores placed them in the top 10 percent had half the rate of heart failure compared with the one-fourth who had the lowest scores. Previous studies have shown that the DASH diet lowers systolic (top number) blood pressure by about 5.5 millimeters of mercury, a decrease that might be expected to reduce the rate of heart failure by about 12 percent, the authors note. Other mechanisms by which this eating pattern may influence heart failure risk include the reduction of LDL cholesterol, estrogen-like effects of some of the nutrients in the diet and a decrease in oxygen-related cell damage.
"In conclusion, greater consistency with the DASH diet as measured using food-frequency questionnaires was associated with lower rates of heart failure in middle-aged and elderly women living in Sweden," the authors write.
Editor's Note: Maintenance of the cohort was provided by grants from the Swedish Research Council/Committee for Infrastructure. This study was supported by a grant from the Swedish Foundation for International Cooperation in Research and Higher Education and by a grant from the National Institutes of Health. 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, May 11, 2009
Eating Fish, Nuts and Olive Oil May Be Associated With Reduced Risk of Age-Related Blindness
CHICAGO—Regularly eating fish, nuts, olive oil and other foods containing omega-three fatty acids and avoiding trans fats appears to be associated with a lower risk for the eye disease age-related macular degeneration, according to two reports in the May issue of Archives of Ophthalmology, one of the JAMA/Archives journals. By 2020, as many as 3 million Americans are expected to have late-stage age-related macular degeneration (AMD), according to background information in one of the articles. AMD is the leading cause of severe vision loss among individuals older than 65 in the developed world. Established risk factors include age, genetic markers and smoking (the only consistently reported modifiable risk factor). In one report, Jennifer S.L. Tan, M.B.B.S., B.E., of Westmead Hospital, University of Sydney, Australia, and colleagues studied 2,454 participants in the Blue Mountains Eye Study, which began in 1992 to 1994. At that time, participants completed a food frequency questionnaire that was analyzed to determine their intake of various fatty acids. Digital photographs of the retina were used to assess the development of AMD five and 10 years later. After adjusting for age, sex and smoking, eating one serving of fish per week was associated with a 31 percent lower risk of developing early AMD. The association was stronger among individuals with a lower intake of linoleic acid, an unsaturated omega-6 fatty acid found primarily in vegetable oils. Eating one to two servings of nuts per week was associated with a 35 percent lower risk of early AMD. "In conclusion, our findings support the hypothesis that increased intake of omega-three polyunsaturated fatty acids and regular consumption of fish and/or nuts in the diet may protect against the development of early AMD," the authors write. These fatty acids may protect the eyes by preventing the buildup of plaque in the arteries or reducing inflammation, blood vessel formation and oxygen-related cell damage in the retina. Joint effects of protection against AMD were suggested between the consumption of these foods and other factors, such as smoking, intake of unsaturated omega-6 fatty acids or beta carotene and the ratio of total blood cholesterol to HDL or "good" cholesterol. "These findings also suggest that an appropriate balance among various nutrients is essential for maximizing nutritional benefit," they continue. Further studies are needed to determine whether changing an individual's diet or recommending supplementation could prevent or delay the development of AMD. In the other report, Elaine W.-T. Chong, M.D., Ph.D., M.Epi., of the Centre for Eye Research Australia, and colleagues analyzed data from 6,734 individuals age 58 to 69. Between 1990 and 1994, participants' nutrient intakes were assessed from a food frequency questionnaire, and they were tracked for the development of AMD between 2003 and 2006. During the follow-up period, 2,872 cases of early AMD and 88 cases of late AMD developed. Individuals who consumed higher levels of trans-unsaturated fats—found in baked goods and processed foods—were more likely to have late AMD, whereas those who consumed the most omega-three fatty acids were less likely to have early AMD. "Olive oil intake (100 milliliters or more per week vs. less than 1 milliliter per week) was associated with decreased prevalence of late AMD," the authors write. "No significant associations with AMD were observed for intakes of fish, total fat, butter or margarine." Trans-unsaturated fatty acids have been shown to increase the risk of coronary heart disease through their effects on cholesterol levels and possibly through inflammation. In contrast, omega-three fatty acids are believed to protect against damage to the retina, thereby reducing risk for AMD. Although the primary fats found in olive oil (oleic acid and monounsaturated fatty acids) were not associated with AMD risk, olive oil contains other components that may have a protective effect, such as the antioxidants and anti-inflammatory compounds.
"Our findings suggest that people who follow a diet low in processed foods high in trans-unsaturated fatty acids and rich in omega-three fatty acids and olive oil might enjoy some protection from developing AMD," the authors conclude.
Editor's Note: Please see the articles 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, May 11, 2009
Age-Related Eye Disease May Be Associated With Cognitive Impairment
CHICAGO—Older adults with low scores on tests of cognitive function, including thinking, learning and memory appear more likely to have the early stages of the eye disease age-related macular degeneration, according to a report in the May issue of Archives of Ophthalmology, one of the JAMA/Archives journals. Age-related macular degeneration (AMD)—the leading cause of visual impairment in industrialized nations—has long been thought to share a common pathway with Alzheimer's disease, according to background information in the article. First, both conditions involve similar changes in the brain and eye, including the buildup of protein fragments known as beta-amyloid. "Second, clinical studies suggest that AMD and Alzheimer's disease share similar vascular risk factors, such as hypertension [high blood pressure] and cigarette smoking," the authors write. "Both AMD and Alzheimer's disease have been linked to an increased risk of stroke." Michelle L. Baker, M.D., of the University of Melbourne, Victoria, Australia, and colleagues assessed 2,088 individuals age 69 to 97. Participants underwent cognitive testing, retinal photography for the detection of AMD and an extensive assessment of artery disease and its risk factors (including blood pressure, smoking status and body mass index). After controlling for age, sex, race and the center at which they participated in the study, the one-fourth of individuals with the lowest scores on one cognitive test were twice as likely to have early-stage AMD as were individuals with higher scores. However, there was no association between AMD and scores on a second cognitive test, dementia or Alzheimer's disease.
"In conclusion, we found an association between low cognitive function and early AMD in this older population," the authors write. "These data, along with others, provide further support that AMD and cognitive impairment may share similar complex pathogenesis [development] and risk factors."
Editor's Note: The research reported in this article was supported by contracts from the National Heart, Lung and Blood Institute, with additional contributions from the National Institute of Neurological Disorders and Stroke. Additional support was provided by a grant from the National Heart, Lung and Blood Institute and by the National Heart Foundation. 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, May 11, 2009
Older Adults Often Inaccurately Report Their Own Stroke History
CHICAGO—The responses of older adults who are asked whether they had a stroke frequently do not agree with diagnoses obtained by magnetic resonance imaging (MRI) of the brain, according to a report posted online today that will appear in the July print issue of Archives of Neurology, one of the JAMA/Archives journals. Self-administered questionnaires are frequently used to obtain information about an individual's history of stroke, according to background information in the article. "In general, self-reports on medical conditions that are well defined and relatively easy to diagnose often have a high positive predictive value, in contrast to conditions characterized by complex symptoms," the authors write. "Stroke is associated with motor impairment but can also be accompanied by impairments in memory, sensation and speech or language, diminishing the ability of an individual to accurately report a history of stroke." Christiane Reitz, M.D., Ph.D., of Columbia University Medical Center, New York, and colleagues acquired MRIs for 717 Medicare recipients 65 years and older (average age 80.1) living in northern Manhattan. Participants underwent an in-person interview about general health and functioning, medical history, a physical and neurological examination and psychological testing. They or their caregivers also completed an eight-question survey about stroke history, including whether they had ever had symptoms of or been told by a physician they had a stroke. A total of 85 individuals (11.9 percent) reported a history of stroke. On the MRI, evidence of a stroke was observed in 225 participants (31.4 percent). The sensitivity of self-reported stroke—meaning number of individuals who reported having had a stroke divided by the total number of individuals with stroke detected on MRI—was 32.4 percent. The specificity, or the number of individuals who reported having no history of stroke divided by the total number of individuals who had no evidence of stroke on MRI, was 78.9 percent. "Lower-functioning memory, cognitive or language ability or presence of hypertension [high blood pressure] or myocardial infarction [heart attack] were associated with an increased frequency of false-negative reports," the authors write. In addition, younger individuals were more likely to accurately report their stroke history than older adults, and sensitivity was higher among African American than white or Hispanic individuals. Older adults may have more difficulty recalling prior events, contributing to lower sensitivity, the authors note. Rates of cerebrovascular disease are higher among African Americans, so individuals in this population may have an increased awareness of stroke signs and symptoms due to previous discussions with clinicians or contact with individuals who have had strokes.
"Our results indicate that sensitivity and specificity of stroke self-report are low when using MRI scans as validation," the authors conclude. "In stroke research, sensitive neuroimaging techniques rather than stroke self-report should be used to determine stroke history."
Editor's Note: This study was supported by grants from the National Institutes of Health. 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, May 11, 2009
Compounds in Spinal Fluid Associated With Faster Decline Among Individuals With Mild Dementia
CHICAGO—Levels of biomarkers in the cerebrospinal fluid of individuals with very mild dementia may be associated with the rate at which their thinking, learning and memory skills decline, according to a report in the May issue of Archives of Neurology, one of the JAMA/Archives journals. Finding effective treatments for Alzheimer's disease will likely depend on early identification of patients, according to background information in the article. "Because there is a growing emphasis on enrolling individuals with less cognitive impairment into clinical trials of putative anti–Alzheimer's disease agents, methods are needed that will identify individuals with very mild dementia of the Alzheimer's type who are more likely to exhibit measurable cognitive decline during the study," the authors write. Barbara J. Snider, M.D., Ph.D., and colleagues at Washington University School of Medicine, St. Louis, studied 49 individuals with a diagnosis of very mild dementia of the Alzheimer type. Participants underwent a lumbar puncture to obtain a sample of cerebrospinal fluid, which was tested for several biomarkers associated with Alzheimer's disease, including alpha-beta peptide 1-42 (Aβ42), tau and phosphorylated tau 181 (ptau 181). All the participants had at least one follow-up assessment an average of 3.5 years later. "The rate of dementia progression was significantly more rapid in individuals with lower baseline cerebrospinal fluid Aβ42 levels, higher tau or ptau 181 levels or high tau: Aβ42 ratios," the authors write. "Although the number of participants in this study was relatively small, the results suggest that CSF biomarkers might be useful as entry criteria for clinical trials of disease-modifying therapies for mild cognitive impairment and very mild dementia of the Alzheimer type," they continue. "Limiting enrollment to individuals with CSF Aβ 42 values below a certain cutoff point might ameliorate the difficulties caused by lack of disease progression in some individuals during the trial." For instance, if dementia progresses slowly among all patients in a trial, a larger number of participants would be needed to determine if the treatment was effective over a given time period.
"These findings are likely to have important implications for reducing the number of participants needed to show an effect in clinical trials for very mild dementia of the Alzheimer type and mild cognitive impairment and, ultimately, to assist in making treatment decisions as more invasive and potentially harmful disease-modifying treatments for Alzheimer's disease become available," they conclude.
Editor's Note: This study was supported by grants from the National Institutes of Health and by the Charles and Joanne Knight Alzheimer Research Initiative of the WU-ADRC. 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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