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August 4, 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 — Theme Issue On Violence and Human Rights
(Embargoed for Release: 3 p.m. CT Tuesday, August 4, 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. TV Note: PLEASE NOTE, FEED TIMES ARE NOW 15 MINUTES. This week's JAMA Report video is on the development of new health problems years after prolonged exposure to the World Trade Center attack. The report will be fed Tuesday, August 4, from 9:00 - 9:15 a.m. ET and 2:00 - 2:15 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. The JAMA Report video is also now available on Pathfire every Tuesday. Please look for the JAMA Report "channel". Save the Date: The Sixth International Congress on Peer Review and Biomedical Publication will be held September 10-12 in Vancouver, Canada. New research will be presented on peer review and the other processes used to evaluate and disseminate medical information. The program and other information on the conference can be found at www.jama-peer.org. 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, August 4, 2009
Intense, Prolonged Exposure to World Trade Center Attack Associated With New Health Problems Several Years Later
CHICAGO—Large number of individuals, such as recovery and rescue workers, nearby residents and office workers, who experienced intense or prolonged exposure to the World Trade Center attack have reported new diagnoses of asthma or posttraumatic stress 5-6 years after the attack, according to a study in the August 5 issue of JAMA, a theme issue on violence and human rights. "The September 11, 2001, terrorist attack on the World Trade Center (WTC) killed thousands and exposed hundreds of thousands to horrific events and potentially harmful environmental conditions resulting from the collapsing towers and fires," according to background information in the article. Studies have documented adverse respiratory and mental health conditions associated with direct exposure within 1 to 3 years following the event, however, the longer-term impact on health has been unclear. Robert M. Brackbill, Ph.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues of the New York City Department of Health and Mental Hygiene, and Columbia University, New York, examined the incidence of two of the most commonly reported health outcomes: asthma and posttraumatic stress (PTS) symptoms indicative of probable posttraumatic stress disorder (PTSD) among adults 5 to 6 years after the attack. The researchers used data from the World Trade Center Health Registry, the largest postdisaster exposure registry in U.S. history, which prospectively follows a group that reported a range of WTC disaster–associated exposures on September 11 and during its immediate aftermath. Wave 1 of the study, conducted in 2003-2004, included enrollment of 71,437 adults in four groups: rescue/recovery workers, lower Manhattan residents, lower Manhattan office workers, and passersby; 46,322 adults (68 percent) completed a follow-up wave 2 survey in 2006-2007. The surveys included questions regarding symptoms of asthma following September 11 and event-related PTS symptoms indicative of probable PTSD, assessed using the PTSD Checklist (a self-report symptoms rating scale). The researchers found that overall postevent incidence among those without a prior history of asthma was 10.2 percent, with rescue/recovery workers having higher postevent asthma diagnosis rates than the next highest group, passersby on September 11 (12.2 percent vs. 8.6 percent). For all eligibility groups combined, intense dust cloud exposure was associated with postevent diagnoses of asthma (13.5 percent vs. 8.4 percent for no dust cloud exposure). Thirty-nine percent of all respondents reporting postevent diagnoses of asthma also reported intense dust cloud exposure. "These analyses confirm that intense dust cloud exposure was associated with new asthma diagnoses for each eligibility group, including the 1,913 passersby who only had exposure to the area air and dust on September 11," the authors write. Among rescue/recovery workers, risk for asthma was highest among those who worked on the pile on September 11, with risk diminishing with later start dates. Asthma risk also was independently associated with some damage to home or office, and risk was highest if there was a heavy coating of dust at home or at the office. Among residents, those who did not evacuate reported higher rates of asthma than those who did. Of the adults without a diagnosis of PTSD before September 11, 23.8 percent screened positive for PTS symptoms indicative of probable PTSD at either wave 1 (14.3 percent) or wave 2 (19.1 percent). At follow-up, the prevalence of PTS symptoms increased in every eligibility group, with the greatest increase occurring among rescue/recovery workers. At the wave 2 follow-up survey, passersby had the highest levels of symptoms (23.2 percent), while residents had the lowest (16.3 percent). Across eligibility groups, passersby had the highest prevalence of chronic PTS symptoms and office workers had the highest prevalence of resolved symptoms while rescue/recovery workers had the highest prevalence of late-onset symptoms. With regard to mental health diagnoses, 13.6 percent of all participants previously free of PTSD reported receiving a PTSD diagnosis from a mental health professional since September 11; 14.0 percent reported receiving a depression diagnosis; and 7.4 percent reported receiving both. Event-related loss of spouse or job was associated with PTS symptoms. Co-occurrence of postevent asthma and PTS symptoms was common in the follow-up survey. Among enrollees with postevent asthma, 36 percent had PTS symptoms; among enrollees with these symptoms at follow-up, 19 percent reported a new diagnosis of asthma after September 11. The researchers add that applying reported outcome rates from the follow-up survey results to the approximately 409,000 potentially exposed persons, roughly 25,500 adults are estimated to have experienced postevent asthma and 61,000 are estimated to have experienced symptoms indicative of probable PTSD.
"Our findings confirm that, after a terrorist attack, mental health conditions can persist if not identified and adequately treated and that a substantial number of exposed persons may develop late-onset symptoms. Our study highlights the need for surveillance, outreach, treatment, and evaluation of efforts for many years following a disaster to prevent and mitigate health consequences," 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, August 4, 2009
Elder Self-Neglect and Abuse Associated With Increased Risk of Death
CHICAGO—Elderly individuals who have a report of self-neglect or abuse submitted to a social service agency have an associated increased risk of death, according to a study in the August 5 issue of JAMA, a theme issue on violence and human rights. Elder self-neglect and abuse are serious, common and underrecognized public health issues in the U.S., and a 2000 survey from social service agencies suggests that these cases are increasing, according to background information in the article. But the association of either elder self-neglect or abuse with an increased risk of death has been unclear. XinQi Dong, M.D., of Rush University Medical Center, Chicago, and colleagues investigated the risk of death associated with reported elder self-neglect or abuse in a large and sociodemographically diverse group and across different levels of cognitive and physical function. The study included residents living in three adjacent neighborhoods in Chicago who were participating in the Chicago Healthy and Aging Project (CHAP; a population-based, epidemiological study of residents age 65 years or older). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies. The 9,318 CHAP participants had an average age of 73 years. About 40 percent were men, 63 percent were black, and the average education was 12.2 years. The 1,544 cases reported as elder self-neglect and the 113 cases reported as elder abuse tended to be older, female, black, and have a lower income and education. There were 4,306 deaths (46 percent) during the 14 years of follow-up. In the fully adjusted analysis, reported self-neglect was associated with a significantly increased risk of death within 1 year. The mortality risk for reported and confirmed cases after 1 year was lower, but remained increased (nearly twice the risk). White participants and men had a higher risk of death relative to others. "This mortality risk is especially alarming during the first year after the report of elder self-neglect. These findings may have direct implications for health care professionals and social services agencies to promote early identification of elder self-neglect and prompt interventions after the discovery of self-neglect," the authors write. Analysis also indicated that reported elder abuse was significantly associated with increased risk of overall mortality (about 40 percent). Confirmed elder abuse was associated with about a two times higher risk of death. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function. "... this study is the first, to our knowledge, to demonstrate increased mortality risk for reported and confirmed elder self-neglect across different levels of cognitive and physical function, challenging a belief that self-neglect and the potential for adverse health outcomes are confined to those with the most impaired cognitive and physical function. Rather, our findings suggest that even among those individuals with milder levels of cognitive and physical functional impairment, elder self-neglect is associated with substantially increased risk of death."
"These results may be useful not only in informing future research efforts into elder self-neglect and abuse, but also to inform relevant clinical, social, and policy guidelines developed to treat and prevent elder self-neglect and abuse on a national level," the researchers conclude.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Elder Self-neglect — Medical Emergency or Marker of Extreme Vulnerability?
Thomas M. Gill, M.D., of Yale University School of Medicine, New Haven, Conn., writes in an accompanying editorial that elder self-neglect poses significant challenges to the health care system and social service agencies.
"The number of cases of reported self-neglect has been increasing and will likely continue to increase with the graying of the baby boom generation," Dr. Gill writes. "Assuming that the mortality related to elder self-neglect and abuse is causal, it could be interpreted as a failure of society and the health care system to adequately protect the most vulnerable older adults. To better address the complex needs of this burgeoning population, a stronger work force well prepared to care for older adults will be needed, as highlighted in a recent Institute of Medicine report. While awaiting evidence-based answers to the myriad unanswered questions regarding the epidemiology and management of elder self-neglect and abuse, health care professionals caring for older adults should act to renew the social contract with older individuals in the United States by supporting and expanding model programs for these potentially devastating disorders."
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, August 4, 2009
Universal Screening for Intimate Partner Violence in Health Care Settings Shows No Significant Reductions in Recurrent Interpersonal Violence Episodes
CHICAGO—New research suggests that universal intimate partner violence (IPV) screening in health care settings does not result in significant changes in subsequent reports of IPV or quality of life, according to a study in the August 5 issue of JAMA, a theme issue on violence and human rights. There is a lack of consensus on the issue of screening women for IPV in health care settings. Proponents support screening because of the high prevalence of IPV and associated impairment and the availability of feasible screening techniques. But organizations such as the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care have concluded that insufficient evidence exists to recommend for or against universal screening – mainly due to lack of interventions that have been proven effective for women exposed to violence and referred from health care settings. "Nevertheless, clinicians and health care organizations are being encouraged to implement IPV screening. Numerous professional societies recommend routine IPV evaluation, assessment, and/or screening as a part of standard patient care, and the standards of the Joint Commission require that hospitals have objective criteria for identifying and assessing possible victims of abuse and neglect," the authors write. Harriet L. MacMillan, M.D., M.Sc., F.R.C.P.C., of McMaster University, Hamilton, Ontario, Canada, and colleagues examined the effectiveness of IPV screening and communication of a positive screening result to clinicians in health care settings, compared with no screening, in reducing subsequent violence and improving quality of life. The randomized controlled trial was conducted in 11 emergency departments, 12 family practices, and 3 obstetrics/gynecology clinics in Ontario, Canada, among 6,743 female patients, age 18 to 64 years. Women in the screened group (n = 3,271; 347 positive for abuse) self-completed the Woman Abuse Screening Tool (WAST); if a woman screened positive, this information was given to her clinician before the health care visit. Subsequent discussions and/or referrals were at the discretion of the treating clinician. The nonscreened group (n = 3,472; 360 positive for abuse) self-completed the WAST and other measures after their visit. Women who disclosed past-year IPV were interviewed at the start of the study and every 6 months until 18 months regarding subsequent incidents of IPV and quality of life, as well as several health outcomes and potential harms of screening. The number of women who did not complete the study was high: 43 percent of screened women, and 41 percent of nonscreened women, and data analysis accounted for these losses. The study found that:
The authors suggest that one possible explanation for the lack of effectiveness of screening was "If it is true that study participation conferred benefits, the fact that both groups were interviewed using the same methods at the same intervals would have reduced the likelihood of detecting differences between groups. Screening itself—asking about IPV exposure—may have offered little benefit." They add that even though screening may provide some small benefits on some outcomes, "It is critical to balance the number and magnitude of potential benefits of universal screening with the human, opportunity, and resource costs required." In this trial, trained research assistants conducted the screening in each health care setting and clinicians were only notified when a screen was positive. All sites consented to participate, and training regarding IPV was provided to them.
"We conclude, although sample attrition urges cautious interpretation, that these results do not provide sufficient evidence to support universal IPV screening in health care settings in the absence of an effective intervention to prevent or reduce IPV, especially in the context of the resources required to conduct screening and to deal with the number of women identified by the screening tool," the authors write. "Further research is essential to determine whether these findings are replicated in other settings and samples." They add that evidence regarding effective interventions to assist women who disclose abuse in health care settings is urgently required.
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 Intimate Partner Violence — Screening Is Not Enough
In an accompanying editorial, Kathryn E. Moracco, Ph.D., M.P.H., and Thomas B. Cole, M.D., M.P.H., of the University of North Carolina at Chapel Hill, (Dr. Cole is also a Contributing Editor, JAMA), comment on the findings of the study by MacMillan and colleagues.
"... there continues to be a lack of evidence that universal screening alone improves health outcomes for IPV survivors. It is certainly understandable that clinicians and health care facilities have implemented universal screening programs, given the prevalence and potential severity of IPV. However, the results of the study by MacMillan et al should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships. Specific interventions to prevent the recurrence of abuse for women at risk of violence should be implemented and rigorously tested, preferably in randomized trials, without further delay."
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, August 4, 2009
Khmer Rouge Trials May Affect Posttraumatic Stress Disorder Symptoms Among Cambodian Survivors
CHICAGO—The so-called "Khmer Rouge trials" now underway are likely to have an impact on the mental health of many Cambodians, according to a new study published in the August 5 issue of JAMA, a theme issue on violence and human rights. "Millions of Cambodians suffered profound trauma during the Khmer Rouge era (1975 to 1979)," according to background information provided by the authors. "It is estimated that between one million and two million people (approximately 20 percent of the Cambodian population) died during that epoch, and millions of survivors were forced into slave labor under harsh conditions." The authors note that many previous studies suggest that the psychological effects among the population include a high prevalence of posttraumatic stress disorder (PTSD) and other mental and physical disabilities. A joint United Nations-Cambodian tribunal (the "Khmer Rouge trials") began hearings earlier this year to try the senior leadership of the Khmer Rouge. Jeffrey Sonis, M.D., M.P.H., from the School of Medicine at the University of North Carolina at Chapel Hill, and colleagues analyzed data from face-to-face interviews of a national probability sample of 1,017 adult Cambodians to determine the prevalence of PTSD symptoms and disability and associations with perceived justice, desire for revenge and knowledge of and attitudes toward the trials. The population sample included 813 adults older than 35 years who had lived through the Khmer Rouge era and 204 adults ages 18 to 35 years who had not been exposed to the regime. A substantial percentage of the older adults reported being exposed to trauma during the Khmer Rouge era with about half (50.1 percent or 391) telling the interviewers that they had been close to death during that time and 243 respondents (31.4 percent) reported physical or mental torture. The interviews were conducted before the Khmer Rouge trials began. "The prevalence of current probable PTSD was 11.2 percent overall and 7.9 percent among the younger group and 14.2 percent in the older group," the researchers report. That figure (11.2 percent) is almost five times higher than a current estimated PTSD prevalence figure of 2.3 percent in the United States, according to the researchers. "Probable PTSD was significantly associated with mental disability (40.2 percent vs. 7.9 percent) and physical disability (39.6 percent vs. 20.1 percent)." More of the respondents in the older group were aware of the Khmer Rouge trials than those in the younger group. "Although Cambodians were hopeful that the trials would promote justice, 87.2 percent (681) of those older than 35 years believed that the trials would create painful memories for them." The researchers also found that respondents with high levels of perceived justice for violations during the Khmer Rouge era were less likely to have probable PTSD.
"The crucial question is whether the Khmer Rouge trials will reduce symptoms of PTSD by increasing feelings of justice or increase PTSD symptoms by reviving traumatic memories of survivors without providing an opportunity to process and reframe these memories." In conclusion the researchers write, "... longitudinal research is needed to determine the impact of the trials on Cambodians' mental health."
Editor's Note: This study was supported by a grant from the United States Institute of Peace. 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
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HEALTH CONSEQUENCES OF 9-11 TERRORIST ATTACKS CONTINUE FOR PEOPLE DIRECTLY EXPOSED
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