JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives 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 CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT Tuesday, February 17, 2009)
JAMA NEWS RELEASES
Study Indicates Some MRSA Infections in ICU Patients Have Been Decreasing in Recent Years
Persons Who Survive Cancer More Likely to be Unemployed
Type of Rheumatoid Arthritis Medication May be Associated With Increased Risk for Shingles
Genetic Identification of Marker in Lymph Nodes Appears Associated With Risk of Colorectal Cancer Recurrence
JAMA REPORT (VIDEO SCRIPT)
VIDEO: Windows Media | Quicktime
STUDY FINDS IMPRESSIVE DECLINE IN THE NUMBER OF CATHETER-RELATED BLOODSTREAM INFECTIONS CAUSED BY ‘MRSA’ IN ADULT INTENSIVE CARE UNITS
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.
TV Note: This week's JAMA Report video is on the incidence of MRSA infections in intensive care units. The report will be fed Tuesday, February 17, from 9:00 - 9:30 a.m. ET and 2:00 - 2:30 p.m. ET, on Galaxy 28 (C-Band), Transponder 19, downlink frequency: 4080 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, February 17, 2009
Media Advisory: To contact Deron C. Burton, M.D., J.D., M.P.H., call Nicole Coffin at 404-639-3286 or email ndc3{at}CDC.GOV. To contact editorial author Michael William Climo, M.D., call Darlene Edwards at 804-675-5242 or email darlene.edwards{at}va.gov.
Study Indicates Some MRSA Infections in ICU Patients Have Been Decreasing in Recent Years
CHICAGO—In contrast to the perception that methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections associated with use of a catheter is an increasing problem in intensive care unit (ICU) patients, the incidence of this type of infection decreased by nearly 50 percent from 1997 - 2007, according to a study in the February 18 issue of JAMA.
Staphylococcus aureus, a bacteria that is a cause of staph infections, is a common cause of potentially serious and costly health care–associated infections, appearing frequently in hospitals as central line–associated bloodstream infections (BSIs). Central line is defined as a catheter that is inserted into a large blood vessel in the body, with the tip of the catheter typically located at or close to the heart or in one of the great vessels (such as aorta or internal jugular vein). The emergence of MRSA in health care settings has drawn the attention of clinicians, public health agencies and the public, and has prompted calls for mandatory screening or reporting in efforts to reduce infections, according to background information in the article. Despite these concerns, there is a lack of recent data on the direction in which the problem of health care–associated MRSA infections is going in the U.S.
To provide information on the recent trend in the incidence of MRSA central line–associated BSIs in U.S. intensive care units, Deron C. Burton, M.D., J.D., M.P.H., of the Centers for Disease Control and Prevention (CDC), Atlanta, and colleagues analyzed national health care–associated infection surveillance data reported by hospitals to the CDC. These data, covering the period from 1997-2007, were used to calculate annual central line–associated BSI incidence rates for seven types of adult and pediatric ICUs.
From 1997 through 2007, 1,684 ICUs reported 33,587 central line–associated BSIs, of which 2,498 (7.4 percent) were MRSA and 1,590 (4.7 percent) were methicillin-susceptible Staphylococcus aureus (MSSA). The researchers found that although the overall percentage of S aureus central line–associated BSIs due to MRSA (called "percent MRSA") increased 25.8 percent from 1997 through 2007, the overall incidence rate of MRSA central line–associated BSIs declined 49.6 percent from 1997 through 2007. This overall decline occurred despite an initial increase in infection rate from 1997 through 2001, after which the rate steadily declined through 2007.
From 2001 through 2007, MRSA central line–associated BSI incidence declined significantly in all six adult ICU types and was stable in pediatric ICUs. Changes in MRSA central line–associated BSI incidence ranged from -51.5 percent in medical-surgical ICUs without a major teaching affiliation to -69.2 percent in surgical ICUs. In every ICU type, MSSA central line–associated BSI incidence declined continuously and significantly from 1997 through 2007, with estimated incidence changes ranging from -60.1 percent in surgical ICUs to -77.7 percent in medical ICUs.
The authors suggest that these decreases in incidence may be attributable to efforts by health care facilities to improve adherence to CDC's evidence-based prevention guidelines, the implementation of strategies designed to improve central line insertion and care practices, and increasing success in preventing MRSA transmission between patients by health care facilities.
"In summary, MRSA central line–associated BSI incidence has declined in recent years in all major adult ICU types and has remained stable in pediatric ICUs. The overall decline in incidence stands in sharp contrast to trends in percent MRSA, which give an incomplete picture of changes in the magnitude of the MRSA problem over time and may have led to a misperception that the MRSA central line–associated BSI problem in ICUs has been increasing," the authors write.
They add that large declines in incidence across all types of central line–associated BSIs, which included regular staph and drug-resistant staph (MRSA), in all major non-neonatal ICU types also suggest that general central line–associated BSI prevention efforts are succeeding and may have contributed to the declining MRSA trends. "Further study is needed to assess MRSA infection incidence in other patient populations and patient care areas and to determine the effect of specific prevention measures and of participation in national health care–associated infection surveillance on the observed trends."
(JAMA. 2009;301[7]:727-736. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Decreasing MRSA Infections — An End Met by Unclear Means
Michael William Climo, M.D., of the Hunter Holmes McGuire Veterans Affairs Medical Center, Infectious Disease, Richmond, Va., writes in an accompanying editorial that the report by Burton and colleagues provides important lessons for the new patient safety climate.
"Clearly, ICUs participating in National Nosocomial Infection Surveillance system (NNIS)/ National Healthcare Safety Network (NHSN) have made substantial progress at reducing hospital-acquired infections, suggesting that real change is being made. Despite this progress, most ICUs are far from the goal of zero infections and many have not implemented suggested prevention strategies. Better outcomes research is desirable as hospitals contemplate the variety of prevention strategies available to reduce infections. This type of research seems unlikely in an era of empiricism and as infection rates decrease, making meaningful research increasingly difficult due to the large size of comparative trials required. Despite the lack of specific recommendations from the trend analysis of NNIS/NHSN reported by Burton et al, hospitals should continue to implement well-researched prevention strategies with proven benefit."
(JAMA. 2009;301[7]:772-773. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, February 17, 2009
Media Advisory: To contact Angela G. E. M. de Boer, Ph.D., email a.g.deboer{at}amc.nl.
Persons Who Survive Cancer More Likely to be Unemployed
CHICAGO—An analysis of previous studies finds an association between being a cancer survivor and being unemployed, compared to healthy individuals, especially for survivors of breast and gastrointestinal cancers, according to an article in the February 18 issue of JAMA.
Long-term medical and psychological effects of cancer or its treatment may cause impairments that effect social functioning, including the obtainment or retention of employment. Almost half of all cancer survivors are younger than 65 years. "Many cancer survivors want and are able to return to work after diagnosis and treatment," the authors write. "Relatively few studies have assessed the association of cancer survivorship with unemployment." They add there are several factors that may promote unemployment after the diagnosis and treatment of cancer, including job discrimination, difficulty combining treatment with full-time work and physical or mental limitations.
Angela G. E. M. de Boer, Ph.D., of the Coronel Institute of Occupational Health, Academic Medical Center, Amsterdam, the Netherlands, and colleagues conducted a meta-analysis to determine the risk and factors associated with unemployment among adult cancer survivors compared with healthy control participants. After a search of various databases, the authors identified 26 articles reporting results from 36 studies meeting criteria for inclusion in the analysis. There were 16 studies from the United States, 15 from Europe and 5 from other countries. The 36 studies included 177,969 participants, with 20,366 cancer survivors and 157,603 healthy control participants.
The researchers found that overall, cancer survivors were 1.37 times more likely to be unemployed than healthy control participants (33.8 percent vs. 15.2 percent). Additional analysis by diagnosis showed an increased risk of unemployment for survivors of breast cancer (35.6 percent vs. 31.7 percent), gastrointestinal cancers (48.8 percent vs. 33.4 percent), and cancers of the female reproductive organs (49.1 percent vs. 38.3 percent). Higher risks of unemployment compared with healthy control participants were not shown among survivors of blood cancer, prostate cancer and testicular cancer.
In studies with a relatively low background unemployment rate, the risk for unemployment for cancer patients was lower compared with healthy control participants than in studies performed in countries with a relatively high background unemployment rate.
Seven studies reported unemployment because of disability, with analysis indicating a nearly 3 times higher risk for unemployment because of disability for cancer patients compared with control participants. "...the mechanism behind the higher unemployment rate among cancer survivors is likely to be a higher disability rate," the authors write.
They add that several studies indicated that cancer survivors were more likely than healthy controls to report that the reasons for unemployment included physical limitations, cancer-related symptoms, or both. "Furthermore, voluntary unemployment is not likely unless patients have other resources for income, which is not the case for most cancer survivors."
"Apart from the effects on employment, there are probably long-term effects of cancer on work ability, work capacity, and wage losses for a large group of survivors. Employment outcomes can be improved with innovations in treatment and with clinical and supportive services aimed at better management of symptoms, rehabilitation, and accommodation for disabilities. Moreover, workplace interventions are needed that are aimed at realizing workplace accommodations and paid sick leave during treatment. The development and evaluation of such interventions is urgently needed because they could mitigate the economic impact of surviving cancer and improve the quality of life for survivors," the researchers conclude.
(JAMA. 2009;301[7]:753-762. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, February 17, 2009
Media Advisory: To contact Anja Strangfeld, M.D., email strangfeld{at}drfz.de. To contact editorial co-author Richard J. Whitley, M.D., call Troy Goodman at 205-934-8938 or email tdgoodman{at}uab.edu.
Type of Rheumatoid Arthritis Medication May be Associated With Increased Risk for Shingles
CHICAGO—Use of certain medications known as monoclonal anti– tumor necrosis factor α (TNF-α) antibodies for the treatment of rheumatoid arthritis appears to be associated with an increased risk for herpes zoster (shingles), the painful infection characterized by blisters, according to a study in the February 18 issue of JAMA.
There has been evidence from some studies that patients treated with anti–TNF-α agents are at an increased risk of bacterial infections, but little is known about the risk of viral infections, such as herpes zoster, in patients with rheumatoid arthritis receiving these types of medications. Herpes zoster is one of the most common adverse events reported in clinical trials of anti–TNF-α agents, according to background information in the article. Patients with rheumatoid arthritis are at increased risk of herpes zoster compared with the general population.
Anja Strangfeld, M.D., of the German Rheumatism Research Center, Berlin, and colleagues investigated the association of various rheumatoid arthritis treatments, including anti–TNF-α therapy, with the risk of herpes zoster. The researchers analyzed data from patients who began treatment with adalimumab or infliximab (monoclonal anti–TNF-α antibodies), etanercept (a fusion protein), the monotherapeutic agent anakinra, or when patients changed conventional disease-modifying anti-rheumatic drug (DMARD). Treatment, clinical status and adverse events were assessed by rheumatologists at fixed points during follow-up (of up to three years). A total of 5,040 patients were included in the analysis.
There were 86 cases of herpes zoster among 82 patients. Thirty-nine occurrences could be attributed to treatment with anti–TNF-α antibodies (23 to etanercept, 24 to conventional DMARDs). The researchers found a significant association between herpes zoster and treatment with the monoclonal anti–TNF-α antibodies infliximab and adalimumab, although this risk was lower than the threshold for clinical significance. There was no significant association between herpes zoster and treatment with etanercept, or anti–TNF-α treatment as a class.
A significantly higher risk of developing herpes zoster was found for patients of older age and for treatment with glucocorticoids (steroid hormones that are widely used as anti-inflammatory medications).
"Based on our data, we recommend careful monitoring of patients treated with monoclonal anti–TNF-α antibodies for early signs and symptoms of herpes zoster," the authors conclude.
(JAMA. 2009;301[7]:737-744. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Herpes Zoster in the Age of Focused Immunosuppressive Therapy
In an accompanying editorial, Richard J. Whitley, M.D., and John W. Gnann Jr., M.D., of the University of Alabama at Birmingham, comment on the findings of this study.
"The TNF-α inhibitors provide tremendous benefit to a broad spectrum of patients with systemic inflammatory diseases. As with any therapy, time is required for all of the safety concerns related to these potent medications to become apparent. TNF-α inhibitors have revolutionized the management of a number of difficult diseases, especially inflammatory arthritis, but clinicians must continue to remain aware of the potential for serious infectious complications, which now include herpes zoster."
(JAMA. 2009;301[7]:774-775. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, February 17, 2009
Media Advisory: To contact Scott A. Waldman, M.D., Ph.D., call Emily Shafer at 215-955-5291 or email emily.shafer{at}jefferson.edu.
Genetic Identification of Marker in Lymph Nodes Appears Associated With Risk of Colorectal Cancer Recurrence
CHICAGO—A preliminary report suggests that genetic testing may help identify a marker in lymph nodes that is associated with an increased risk of colorectal cancer recurrence among patients in whom conventional testing indicates that those lymph nodes show no evidence of cancer spread, according to a study in the February 18 issue of JAMA.
Metastasis of tumor cells to regional lymph nodes is the single most important prognostic factor in patients with colorectal cancer. Recurrence rates increase from approximately 25 percent in patients with lymph nodes free of tumor cells as determined by biopsy (pN0 colorectal cancer) to approximately 50 percent in patients with four or more lymph nodes with metastases, according to background information in the article.
"Given the established relationship between lymph node metastasis and prognosis, recurrence in a substantial fraction of patients with pN0 colorectal cancer suggests the presence of occult [undetected] metastases (pN0 [mol+]) in regional lymph nodes that escape [biopsy] detection. Conversely, patients with pN0 colorectal cancer who are free of lymph node metastases may be at lowest risk for developing recurrent disease. Thus, a more accurate assessment of occult metastases in regional lymph nodes in patients with pN0 colorectal cancer could improve risk stratification in this clinically heterogeneous population," the authors write.
Research suggests that guanylyl cyclase C (GUCY2C), an intestinal tumor suppressing receptor, is a specific molecular marker for metastatic colorectal cancer that could reveal occult metastases in lymph nodes and better estimate recurrence risk.
Scott A. Waldman, M.D., Ph.D., of Thomas Jefferson University, Philadelphia, and colleagues examined the association of colorectal cancer recurrence with occult lymph node metastases detected by measuring GUCY2C messenger RNA, using the reverse transcriptase–polymerase chain reaction (RT-PCR; a highly sensitive technique for the detection and measurement of quantity of messenger RNA). The study included 257 patients with pN0 colorectal cancer who provided 2,570 lymph nodes for biopsy and GUCY2C messenger RNA analysis. Patients were followed up for a median (midpoint) of 24 months for disease recurrence or death.
"In this study, prospective detection of occult metastases by GUCY2C quantitative RT-PCR appeared to be an independent prognostic marker of risk. Molecular staging revealed that about 13 percent of patients with pN0 colorectal cancer were free of tumor cells, while about 87 percent had GUCY2C results that suggested occult metastases," the researchers write. "Future studies with greater numbers of patients should provide more precise estimates of the prognostic utility of GUCY2C quantitative RT-PCR."
"Molecular staging could overcome limitations in the detection of occult lymph node metastases by incorporating all available tissue into analyses and increasing detection sensitivity through quantifiable disease-specific molecular markers, which nominally identify a single cancer cell in 1 million normal cells."
The authors add that molecular staging represents one component of a comprehensive diagnostic, prognostic and predictive strategy to personalize management strategies for individual patients.
(JAMA. 2009;301[7]:745-752. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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JAMA REPORTS
VIDEO:
Windows Media |
Quicktime
STUDY FINDS IMPRESSIVE DECLINE IN THE NUMBER OF CATHETER-RELATED BLOODSTREAM INFECTIONS CAUSED BY 'MRSA' IN ADULT INTENSIVE CARE UNITS
INTRO:
There is a public perception that hospitals’ sickest patients – those in intensive care units – are also the ones at a high risk of contracting very serious infections. But a new study shows that efforts to reduce that risk may be paying off. Haley Weldon explains in this week's JAMA Report.
VIDEO:
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Nurses station
ICU signage
Patient in hospital bed
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IN HOSPITALS, THE ANTIBIOTIC-RESISTANT STRAIN OF BACTERIA KNOWN AS "MERSA" OR "M.R.S.A." CAN CAUSE SERIOUS AND COSTLY INFECTIONS. UNFORTUNATELY, DEVICES FREQUENTLY USED IN INTENSIVE CARE UNITS CAN PROVIDE MRSA WITH A DIRECT PATH INTO A PATIENT’S BLOODSTREAM.
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Deron C. Burton, M.D., J.D., M.P. H.
Centers for Disease Control and Prevention
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Doctors often use catheters inserted into major blood vessels both for treatment and monitoring. These catheters, which are sometimes called central lines, are vital for patient care, but they also can represent a potential source for infection of the bloodstream with M.R.S.A. or other microorganisms.
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John A. Jernigan, M.D.
Centers for Disease Control and Prevention
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One of the reasons that patients with central venous catheters are at such high risk for infection is because you’re placing a device through the patient’s skin into a sterile body space.
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GFX/JAMA Cover
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Dr. Burton in library
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OVER THE PAST DECADE, EFFORTS HAVE INTENSIFIED TO PREVENT SUCH INFECTIONS. IN A STUDY FEATURED THIS WEEK IN JAMA, THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, DR. DERON BURTON AND HIS COLLEAGUES AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION, ANALYZED DATA COLLECTED FROM ALMOST 600 HOSPITALS BETWEEN 1997 AND 2007 IN AN EFFORT TO SEE WHETHER THE RISK OF THESE INFECTIONS IN THIS HIGHLY VULNERABLE GROUP OF PATIENTS HAS GONE UP OR DOWN IN RECENT YEARS.
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Deron C. Burton, M.D., J.D., M.P. H.
Centers for Disease Control and Prevention
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From 1997 through 2001, in 4 of the 7 major ICU types that we studied, the risk was increasing. Since 2001 the risk of M.R.S.A. blood stream infections associated with the use of a central line in intensive care units has dramatically declined by roughly 50-70% in most types of ICUs.
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WHILE THE STUDY DID NOT DELVE INTO REASONS BEHIND THE NUMBERS, RESEARCHERS FOUND CLUES THAT PREVENTION METHODS MAY BE HAVING AN IMPACT.
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Deron C. Burton, M.D., J.D., M.P. H.
Centers for Disease Control and Prevention
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We know that there have been many ongoing efforts to improve the safety of central line use in hospitals around the country, particularly in intensive care units. We were thrilled to confirm that these efforts have been paying off and appear to be showing dramatic reductions in M.R.S.A. bloodstream infection risk.
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EXCELLENT NEWS FOR THE PATIENTS WHO JUST MAY NEED IT MOST. HALEY WELDON, THE JAMA, REPORT.
