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October 27, 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, October 27, 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: This week's JAMA Report video is on access to burn care in the U.S. by ground and air transport. The report will be fed Tuesday, October 27, from 9:00 - 9:15 a.m. ET and 2:00 - 2:15 p.m. ET, on Galaxy 28 (C-Band), Transponder 15, downlink frequency: 4000 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, in VNF Provider A. Please look for the JAMA Report tab. 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, October 27, 2009
Use of Antipsychotic Medications by Children and Adolescents Associated With Significant Weight Gain
CHICAGO—Many pediatric and adolescent patients who received second-generation antipsychotic medications experienced significant weight gain, along with varied adverse effects on cholesterol and triglyceride levels and other metabolic measures, according to a study in the October 28 issue of JAMA. Treatment for psychotic disorders, bipolar disorder, and nonpsychotic mental disorders for children and adolescents in the United States often includes second-generation antipsychotic medications. "Increasingly, the cardiometabolic effects of second-generation antipsychotic medications have raised concern. Cardiometabolic adverse effects, such as age-inappropriate weight gain, obesity, hypertension, and lipid and glucose abnormalities, are particularly problematic during development because they predict adult obesity, the metabolic syndrome, cardiovascular morbidity, and malignancy," the authors write. The cardiometabolic effects of these medications have not been sufficiently studied in children and adolescent patients who have not previously received them, according to background information in the article. Christoph U. Correll, M.D., of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, and The Feinstein Institute for Medical Research, Manhasset, New York, and colleagues conducted a study of weight and metabolic changes in a group of 272 pediatric patients (ages 4 to 19 years) who had not previously received antipsychotic medication. Patients had mood spectrum (47.8 percent), schizophrenia spectrum (30.1 percent), and disruptive or aggressive behavior spectrum (22.1 percent) disorders. Fifteen patients who refused participation or were nonadherent to medications served as a comparison group. Patients were treated with the antipsychotic medications aripiprazole, olanzapine, quetiapine, or risperidone for 12 weeks. After a median (midpoint) of 10.8 weeks of treatment, weight increased by an average of 18.7 lbs. with olanzapine (n = 45), by 13.4 lbs. with quetiapine (n = 36), by 11.7 lbs. with risperidone (n = 135), and by 9.7 lbs. with aripiprazole (n = 41) compared with minimal weight change of 0.4 lbs. in the untreated comparison group (n = 15). "Each antipsychotic medication was associated with significantly increased fat mass and waist circumference," the authors write. "Altogether, 10 percent to 36 percent of patients transitioned to overweight or obese status within 11 weeks." The researchers also found that adverse changes during the study period reached statistical significance for olanzapine and quetiapine for total cholesterol, triglycerides, non-HDL cholesterol, and ratio of triglycerides to HDL cholesterol. "With risperidone, levels of triglycerides increased significantly. Metabolic baseline-to-end-point changes were not significant with aripiprazole or in the untreated comparison group. Patients receiving quetiapine had modestly higher incidence rates of hyperglycemia and the metabolic syndrome and patients receiving olanzapine experienced the highest incidence rates." The authors note that these results are concerning because they include fat mass and waist circumference, which are associated with the metabolic syndrome in adults treated with antipsychotic medications and heart disease in the general population. "Moreover, abnormal childhood weight and metabolic status adversely affect adult cardiovascular outcomes via continuation of these risk factors or independent or accelerated mechanisms."
"Our results, together with data from first-episode studies, suggest that guidelines for antipsychotic medication exposure for vulnerable pediatric and adolescent patients naive to antipsychotic medication should consider more frequent (e.g., biannual) cardiometabolic monitoring after the first 3 months of treatment. Finally, in view of poor physical health outcomes and suboptimal metabolic monitoring in the severely mentally ill, the benefits of second-generation antipsychotic medications must be balanced against their cardiometabolic risks through a careful assessment of the indications for their use, consideration of lower-risk alternatives, and proactive adverse effect monitoring and management," 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. Editorial: Implications of Marked Weight Gain Associated With Atypical Antipsychotic Medications in Children and Adolescents
Christopher K. Varley, M.D., and Jon McClellan, M.D., of Seattle Children's Hospital, write in an accompanying editorial that these findings indicate there are other factors to consider regarding the use of atypical antipsychotic medications in children and adolescents.
"These medications can be lifesaving for youth with serious psychiatric illnesses such as schizophrenia, classically defined bipolar disorder, or severe aggression associated with autism. However, given the risk for weight gain and long-term risk for cardiovascular and metabolic problems, the widespread and increasing use of atypical antipsychotic medications in children and adolescents should be reconsidered."
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, October 27, 2009
Alternative to Pap Test Does Not Appear To Be Better For Detecting Cervical Cancer
CHICAGO—A Dutch study that included nearly 90,000 women finds that liquid-based cytology, a commonly used alternative to conventional Pap tests, is not superior to Pap tests for the detection of cervical cancer precursors or cancer, according to a study in the October 28 issue of JAMA. Due to false-negative and false-positive test results, the papanicolaou (Pap) test is considered suboptimal. For the liquid-based cytology (use of cells), the cervical cells are collected with a traditional sampling device and rinsed into a vial with preservation solution rather than being smeared on a slide, according to background information in the article. Despite numerous studies, some uncertainty remains about its diagnostic accuracy. Albertus G. Siebers, M.Sc., of Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands, and colleagues compared the screening performance of Pap tests and liquid-based cytology in terms of test positivity rates, histological detection rates and positive predictive values (PPVs). The randomized controlled trial involved 89,784 women ages 30 to 60 years who participated in a Dutch cervical screening program at 246 family practices. One hundred twenty-two practices were assigned to use liquid-based cytology and screened 49,222 patients and 124 practices were assigned to use the conventional PAP test and screened 40,562 patients. Patients were screened for cervical intraepithelial neoplasia (CIN) and were followed up for 18 months, through January 2008. The researchers found that the adjusted detection rate ratios for CIN grade 1+ was 1.01; for CIN grade 2+, 1.00; for CIN grade 3+, 1.05; and for carcinoma, 1.69. "The adjusted positive predictive value ratios, considered at several cytological cutoffs and for various outcomes of CIN did not differ significantly from unity." "Because of randomization, it can plausibly be assumed that the prevalence of CIN was equal in both study groups. Therefore, the lack of difference in detection rates and PPV in this trial demonstrates that liquid-based cytology is neither more sensitive nor more specific in detecting cervical cancer precursors than the conventional Pap smear."
"As shown in a previous publication, no differences were found in the cytological test positivity rates between methods. Nevertheless, these cytological findings contribute insufficient evidence to claim equal diagnostic accuracy. Both the intention-to-treat and per protocol analyses demonstrated that liquid-based cytology was not superior to Pap test regarding detection rates of histologically confirmed outcomes. The same was found for the PPVs. Altogether, these findings provide strong evidence that the performance of liquid-based cytology is not superior to that of the conventional Pap test when applied within a well-organized and quality-controlled cervical screening program," 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: Screening and Prevention Methods for Cervical Cancer
In an accompanying editorial, Mark Schiffman M.D., M.P.H., and Diane Solomon, M.D., of the National Cancer Institute, Bethesda, Md., comment on the findings of this study.
"It is a challenging time to be a clinician or health planner dedicated to cervical cancer prevention. Even though an increasingly powerful set of prevention tools is available, no combination of vaccination, cytology, HPV testing, colposcopy, and novel methods will be suitable for all settings. Even in the most wealthy regions, using vaccination, cytology, and HPV testing without careful planning would invite waste and, more importantly, overtreatment. For those designing rational cervical cancer prevention programs, Siebers et al have convincingly simplified one aspect of a complex health policy puzzle. Physicians and other health professionals can choose either liquid-based cytology or conventional Pap smear as they discuss how cytology fits into the larger picture."
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, October 27, 2009
Significant Regional Variations Exist Regarding Proximity to Burn Centers
CHICAGO—Although nearly 80 percent of the U.S. population lives within 2 hours by ground or helicopter transport to a verified burn center, there is substantial state and regional variation in geographic access to these centers, according to a study in the October 28 issue of JAMA. More than 500,000 burn injuries occur in the United States each year, causing approximately 4,000 burn-related deaths, according to the American Burn Association. In addition, more than 40,000 patients are admitted to hospitals each year for treatment of burn injury. The authors write that the delivery of optimal burn care to these patients is a resource-intensive endeavor requiring specialized equipment and experienced personnel, and that these resources are typically available only at dedicated burn centers. They add that timely access to a burn center may benefit patients. The current distribution of burn centers relative to geographic area and population is unknown, according to background information in the article. Matthew B. Klein, M.D., M.S., of the University of Washington, Seattle, and colleagues conducted a study to estimate the proportion of the U.S. population living within 1 and 2 hours by ground or helicopter transport of a burn care facility, evaluating state, regional, and national access. The researchers compiled and analyzed information from the 2000 U.S. census, road and speed limit data, the Atlas and Database of Air Medical Services database, and the 2008 American Burn Association Directory. The researchers found that in the U.S. in 2008, there were 128 self-reported burn centers, including 51 verified burn centers (verified by the American Burn Association, in which the quality of burn care provided at a center is assessed and confirmed). A total of 782 helipads and 804 helicopters served these centers. Nationally, about 25 percent of the U.S. population lived within 1 hour by ground transport of a verified center; 46.3 percent lived within 2 hours; and 67.7 percent lived within 4 hours by ground transport of a verified burn center. "By air transport [helicopter], 53.9 percent and 79.0 percent of the population lived within 1 and 2 hours, respectively, of a verified center, and 75.3 percent lived within 1 hour and more than 96.4 percent lived within 2 hours of any self-reported center," the authors write. They add that one-third of the U.S. population must be transported by air to reach a verified burn care center within 2 hours. The researchers also found that there was significant regional variation in access to verified burn centers by both ground and rotary air transport. "The greatest proportion of the population with access was highest in the northeast region and lowest in the southern United States," they write. "The variation in baseline geographic access rates found in this study may be an influential predictor of optimal regionalization strategy. For states and regions with a relatively high baseline rate of access, the best strategy for improving access and reducing time to definitive care may involve optimization of air and ground emergency medical service systems. For states and regions with a relatively low baseline rate of access, the best strategy may involve construction or verification of new regional burn care facilities."
"While the optimal distribution of burn centers relative to population and area remains to be determined, these data provide important information about population access that may be used to guide resource allocation in burn care," 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, October 27, 2009
Patients Starting Dialysis Have Increased Risk of Death
CHICAGO—Compared to the general population, patients starting dialysis have an increased risk of death that is not attributable to a higher rate of death from cardiovascular causes, as previously thought, according to a study in the October 28 issue of JAMA. Several studies have shown that cardiovascular disease accounts for 40 percent to 50 percent of deaths in patients with end-stage kidney disease, according to background information in the article. "It is believed that the life span of patients receiving dialysis is reduced mainly as a consequence of premature cardiovascular death," the authors write. Dinanda J. de Jager, M.Sc., of the Leiden University Medical Center, Leiden, the Netherlands, and colleagues estimated cardiovascular and noncardiovascular rates of death in a large group of European patients receiving dialysis (n = 123,407) and compared these estimates with mortality data from the general European population, using data from between January 1994 and January 2007. The researchers found that among the patients receiving dialysis, noncardiovascular death was the most prevalent cause of death (50.8 percent), and 39.1 percent died because of cardiovascular disease. The most common causes of noncardiovascular death were infections and malignancies. In the general population, 10,183,322 persons (58.4 percent) died from noncardiovascular causes, 7,041,747 (40.4 percent) from cardiovascular causes, and 201,050 (1.2 percent) from unknown causes. Analysis indicated that the overall all-cause mortality rate was higher in patients starting dialysis than in the general population. "In particular, noncardiovascular mortality rates were higher than cardiovascular mortality rates in patients starting dialysis," the authors write. "These results suggest that excess mortality in patients receiving dialysis is not specifically the result of increased cardiovascular deaths."
"In summary, the present study shows that cardiovascular and noncardiovascular mortality are equally increased during the first 3 years of dialysis, compared with the general population. This implies that the importance of noncardiovascular mortality in patients receiving dialysis has generally been underestimated. Therefore, research should focus more on methods to prevent noncardiovascular mortality," 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. 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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SPECIALIZED BURN CARE NOT EASILY ACCESSIBLE IN SOME PARTS OF THE U.S.
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