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March 24, 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
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT Tuesday, March 24, 2009)
JAMA REPORT (VIDEO SCRIPT)
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. SAVE THE DATE: JAMA will present new research from a theme issue on Diabetes at a media briefing on Tuesday, April 14, from 10 a.m. – 12:15 p.m., at the National Press Club in Washington, D.C. To register, go to www.jamamedia.org and click on the Events tab, or call 312-464-JAMA. Program information will be included in a future email. TV Note: This week's JAMA Report video is on a program to help manage chronic pain. The report will be fed Tuesday, March 24, 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. 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), Tuesday, March 24, 2009
Program Helps Improve Management of Chronic Pain
CHICAGO—Patients with chronic pain who took part in a collaborative care intervention that included patient and clinician education and symptom monitoring and feedback to the primary care physician had improvements in pain-related disability and intensity, compared to usual care, according to a study in the March 25 issue of JAMA. Chronic noncancer pain is associated with considerable physical impairment, distress, depression and increased health care use and costs. Many primary care patients report chronic pain, according to background information in the article. Guidelines for chronic pain treatment have been developed, but implementation has been problematic. "Multifaceted, collaborative interventions can promote guideline-concordant care and improve outcomes for chronic conditions in primary care. These interventions, based on the chronic care model, attempt to optimize patient and clinician interactions via education and activation while providing system support, including care management and clinician feedback," the authors write. Steven K. Dobscha, M.D., of the Portland VA Medical Center, Portland, and colleagues assessed whether a collaborative care intervention would result in improvements in chronic pain–related outcomes, including depression, compared with treatment as usual among 401 patients treated at 5 primary care clinics. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians and facilitation of specialty care. The researchers found that, through the use of various measurement tools, intervention patients showed significantly greater improvements in pain-related disability and pain intensity compared with treatment as usual patients during a 12-month period. At 12 months, 21.9 percent of intervention patients vs. 14.0 percent of treatment as usual patients demonstrated 30 percent reductions in a measure of pain-related disability. Compared with treatment as usual patients with depression over 12 months, intervention patients with depression showed significantly greater improvements on a measurement of depression. Intervention patients also reported significantly improved ratings of impression of change at 6 months and 12 months compared with treatment as usual patients. "Process measures including greater use of adjunctive pain medications and long-term opioids suggest that the intervention contributed to delivery of guideline-concordant care," the researchers write.
"Overall, this study showed that a collaborative care intervention for chronic pain was significantly more effective than treatment as usual across a variety of outcome measures. Although many of the improvements were modest, they may be especially meaningful because patients in our sample were older, had long-standing pain, multiple medical problems, and reported high baseline rates of disability. Our results add to the growing body of literature suggesting that the collaborative care model is effective in improving clinical outcomes and adherence to treatment guidelines across a variety of chronic conditions. Patients in many health care systems and private group practices have limited access to specialty chronic pain services. A primary care–based intervention can have positive effects on pain disability and intensity, and on depressive symptoms," the authors conclude.
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), Tuesday, March 24, 2009
Use of Antibacterial Associated With Reduced Risk of Catheter-Related Infections
CHICAGO—For critically ill patients in intensive care units, use of a sponge containing the antimicrobial agent chlorhexidine gluconate as part of the dressing for catheters reduced the risk of major catheter-related infections, according to a study in the March 25 issue of JAMA. The researchers also found that reducing the frequency of changing unsoiled dressings from every three days to seven days appears to be safe. Patients admitted to the intensive care unit (ICU) usually require insertion of central venous catheters (CVCs). In the United States, approximately 80,000 CVC-related bloodstream infections are estimated to occur each year in ICU patients. The rate of death from CVC-related bloodstream infections ranges from 0 percent to 11.5 percent, and the additional ICU length of stay resulting from these infections is estimated at 9 to 12 days. "Consequently, efforts are required to decrease the incidence of these infections," the authors write. Most organisms responsible for CVC-related bloodstream infections originate from the insertion sites of short-term CVCs. Use of a chlorhexidine gluconate–impregnated sponge (CHGIS) as part of the dressing over the skin at the site of insertion of the intravascular catheter may reduce catheter-related infections (CRIs). It is also not certain whether changing catheter dressings every 3 days may be more frequent than necessary, according to background information in the article. Jean-François Timsit, M.D., Ph.D., of University Joseph Fourier, Albert Bonniot Institute, Grenoble, France, and colleagues evaluated the effects of using CHGIS dressings and increasing the time between dressing changes in adult ICU patients. The randomized controlled trial included 1,636 patients from seven intensive care units in three university and two general hospitals in France, who were expected to require an arterial catheter, central-vein catheter, or both, inserted for 48 hours or longer. The median (midpoint) duration of catheter insertion was 6 days. A chlorhexidine gluconate–impregnated sponge or standard dressing (control) was used for the patients. The scheduled change of unsoiled adherent dressings was every 3 or 7 days, with immediate change of any soiled or leaking dressings. Use of CHGIS dressings decreased the rates of major CRIs (catheter-related clinical sepsis without bloodstream infection or catheter-related bloodstream infection) by 61 percent (10/1,953 [0.5 percent] vs. 19/1,825 [1.1 percent]). Use of CHGIS dressings was estimated to prevent 1 major CRI for every 117 catheters left in place for an average duration of 10 days. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1,000 catheters). The rate of catheter colonization (the presence of bacteria on the catheter at the time of removal) was 7.8 percent in the 3-day group and 8.6 percent in the 7-day group, an average absolute difference of 0.8 percent. The median number of dressing changes per catheter was 4 in the 3-day group and 3 in the 7-day group.
"...the interval between dressing changes can be safely extended to more than 3 days but not exceeding 7 days, provided the dressings are closely monitored and changed immediately should separation or soiling be detected," the authors write.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Preventing Catheter-Related Bloodstream Infections - Thinking Outside the Checklist
In an accompanying editorial, Eli N. Perencevich, M.D., M.S., of the University of Maryland Medical Center and School of Medicine and VA Maryland Health Care System, Baltimore, and Didier Pittet, M.D., M.S., of the University of Geneva Hospitals and Faculty of Medicine and World Health Organization, Geneva, Switzerland, comment on the findings of Timsit and colleagues.
"Achieving the lowest possible rates of health care–associated infection is the ultimate goal, whether through mandate or individual hospital initiative. Even though the rates of catheter-related bloodstream infections have clearly declined during the past decade, efforts beyond the checklist are needed. Current guidelines suggest that the low rates achievable through optimized insertion practices and adherence to checklists might be sufficient. The study by Timsit et al has the potential to change the current clinical approach, given that rates of catheter-related bloodstream infection were driven even lower through the relatively simple use of a CHGIS dressing. Future advances in infection prevention will require similar investments in government-sponsored, high-quality randomized controlled trials."
Editor's Note: Please see the article for additional information, including 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), Tuesday, March 24, 2009
Recently Identified Rare Genetic Heart Disorder Progresses Rapidly, is Often Deadly For Young Patients
CHICAGO—A study that included young patients with a recently recognized rare type of cardiomyopathy (a disorder of the heart muscle) linked to a genetic mutation finds that progression of this disease may be rapid and often results in early death, according to a study in the March 25 issue of JAMA. Mutations in the lysosome-associated membrane protein gene (LAMP2; known as Danon disease) produce a cardiomyopathy in young patients that clinically is similar to severe hypertrophic cardiomyopathy (HCM; a condition in which the heart muscle becomes thick, making it harder for blood to leave the heart, forcing the heart to work harder to pump blood). However, the natural course of this disease is uncertain, according to background information in the article. Barry J. Maron, M.D., of the Minneapolis Heart Institute Foundation, Minneapolis, and colleagues assessed the natural history associated with LAMP2 cardiomyopathy and the outcomes of diagnostic and management strategies. The study included seven patients (6 boys) who were ages 7-17 years at the time of diagnosis with LAMP2 mutations. Clinical diagnosis in 6 patients occurred as a result of a heart murmur, family screening and findings on routine electrocardiogram (ECG) or by symptoms (chest pain or fainting) and, in 1 patient, by atrial fibrillation (abnormal heart rhythm). During the subsequent average time of 8.6 years after diagnosis, each of the 7 patients experienced serious adverse clinical consequences by 14 to 24 years of age (average, 21 years). Four patients died of acute or progressive heart failure, and 1 patient underwent heart transplantation. Clinical deterioration was often rapid, with the time interval from clinical stability with little or no symptoms to end-stage heart failure as brief as 6 months. Two other patients experienced sudden unexpected major arrhythmic events, with one patient dying suddenly (age 14 years) from ventricular fibrillation (very rapid, uncoordinated contractions of the ventricles) that was not responding to implantable cardioverter-defibrillator (ICD) therapy. All seven patients developed left ventricular systolic (contraction of the left ventricle) dysfunction. All patients had received ICDs, which ultimately failed to terminate lethal ventricular tachyarrhythmias (an excessively rapid heartbeat accompanied by an irregular heartbeat) in five patients. The most recent echocardiographic studies obtained of the patients demonstrated marked left ventricular hypertrophy (enlargement) in each. Postmortem examination of 2 hearts showed massive cardiac hypertrophy. "The clinical course of these 7 patients with LAMP2 mutations provides important insights regarding molecular diagnosis as well as the natural history, pathophysiology, and clinical implications of this recently recognized genetic cardiomyopathy. LAMP2 mutations cause a particularly profound and accelerated cardiac disease process characterized by clinical deterioration and early death, perhaps representing one of the most lethal cardiomyopathies in young and usually male patients. Such an outcome occurred in the patients in our study despite application of the most contemporary treatment strategies, including the ICD …" the authors write.
"The early experience with the distinctive natural history and prognosis of patients with LAMP2 mutations establishes the importance of molecular diagnosis and underscores the utility of genetic testing."
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.
JAMA REPORTS
VIDEO: Windows Media | Quicktime
STUDY FINDS THAT COLLABORATIVE CARE MAY RESULT IN IMPROVED OUTCOMES FOR THOSE WITH CHRONIC PAIN
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