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August 16, 2010 — Embargoed ContentJAMA 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. ARCHIVES OF SURGERY NEWS RELEASES
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ARCHIVES OF DERMATOLOGY NEWS RELEASES
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ARCHIVES OF OTOLARYNGOLOGY—HEAD & NECK SURGERY
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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, August 16, 2010
Patients With Diabetes May Need Fewer Medications After Bariatric Surgery
CHICAGO—Bariatric surgery appears to be associated with reduced use of medications and lower health care costs among patients with type 2 diabetes, according to a report in the August issue of Archives of Surgery, one of the JAMA/Archives journals. "The rapidly growing epidemics of obesity and diabetes threaten to overburden the world's health care systems," the authors write as background information in the article. "From an epidemiological standpoint, once these diseases develop they are rarely reversed. Dietary, pharmaceutical and behavior treatments for obesity are associated with high failure rates, and medical management of diabetes is also often unsuccessful. Despite many efforts to improve the control of glucose levels in diabetes, including clinical guidelines and patient and provider education, less than half of all patients with type 2 diabetes mellitus achieve the American Diabetes Association recommendation of a hemoglobin A1C level of less than 7 percent." The use of bariatric surgery—that results in long-term weight loss, improved lifestyle and decreased risk of death—has tripled in the past five years, the authors note. Martin A. Makary, M.D., M.P.H., and colleagues at the Johns Hopkins Bloomberg School of Public Health and The Johns Hopkins University School of Medicine, Baltimore, studied 2,235 U.S. adults (average age 48.4) with type 2 diabetes who underwent bariatric surgery during a four-year period, from 2002 to 2005. They used claims data to measure the use of diabetes medications before and after surgery, along with health care costs per year. Of the 2,235 patients, 1,918 (85.8 percent) were taking at least one diabetes medication before surgery, with an average of 4.4 medications per patient. Six months after surgery, 1,669 of 2,235 patients (74.7 percent) had eliminated their diabetes medications. Of the 1,847 patients with available data one year after surgery, 1,489 (80.6 percent) had eliminated medications; after two years, 906 of 1,072 (84.5 percent) had done so. This reduction was observed in all classes of diabetes medications. "We observed that independence from diabetes medication was almost immediate within the initial months after surgery and did not correlate with the gradual weight loss expected," the authors write. "This supports the theory that the resolution of diabetes is not due to weight loss alone but is also mediated by gastric hormones, with the three most implicated being peptide YY, glucagonlike peptide and pancreatic polypeptide. As a known mediator of insulin regulation, glucagonlike peptide levels have been noted to increase immediately after bariatric surgery and may explain why surgeons have noted complete resolution of diabetes in some cases within days after surgery." Health care costs averaged $6,376 per year in the two years before surgery, and the median or midpoint cost of the surgery and hospitalization was $29,959. Total annual health care costs increased by 9.7 percent ($616) in the year following the procedure, but decreased by 34.2 percent ($2,179) in year two and by 70.5 percent ($4,498) in year three.
"Based on these data, we have identified several important implications for health care delivery and public policy," the authors conclude. "Foremost, eligible obese patients should be properly informed of the risks and benefits of bariatric surgery compared with non-surgical health management. Health care providers should consider discussing bariatric surgery in the treatment of obese patients with type 2 diabetes. Health insurers, private and public, should pay for bariatric surgery for appropriate candidates, recognizing a potential annualized cost savings in addition to the benefit to health."
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), Monday, August 16, 2010
Surgery Can Be Safely Performed in Settings With Limited Resources
CHICAGO—The humanitarian organization Médecins Sans Frontières performed close to 20,000 procedures in resource-limited settings between 2001 and 2008 with an operative death rate of only 0.2 percent, suggesting surgical care can be provided safely in these circumstances with appropriate minimum standards and protocols, according to a report in the August issue of Archives of Surgery, one of the JAMA/Archives journals. Of the 230 million major surgical procedures performed worldwide each year, an estimated 4 percent or less are done in poor-income countries, according to background information in the article. "The fact that the latter bear the greatest burden of injury, violence and maternal mortality indicates a substantial unmet need for surgical care, although few data exist about the burden of unmet surgical disease in the developing world," the authors write. In developed countries, surgical practices typically subscribe to quality control programs to monitor and improve safety that do not yet exist in resource-limited countries. Reportedly high rates of operative death in these nations have prompted a re-examination of the safety of international surgical care. Kathryn M. Chu, M.D., M.P.H., of Johns Hopkins Medical Institutions, Baltimore, and Médecins Sans Frontières (MSF), Johannesburg, South Africa, conducted a retrospective study of 17 surgical programs from 13 countries performed by MSF, an international medical organization that provides surgical care in response to humanitarian crises. Between 2001 and 2008, surgeons involved with MSF performed 19,643 procedures on 18,653 patients. Among these, 8,329 (42 percent) were emergency procedures, 7,933 (40 percent) were for obstetric-related problems and 2,767 (14 percent) were trauma-related. Eight of the 13 programs reported no deaths, the highest death rate was 0.9 percent and the overall death rate was 0.2 percent. A higher rate of death was associated with programs in conflict settings, procedures performed under emergency conditions, complex procedures (including abdominal surgeries and hysterectomies) and those done in patients given a higher score under the American Society of Anesthesiologists classification of severity. "As a large provider of surgical care in developing countries, assuring quality is paramount for MSF," the authors write. "Our low operative mortality, even in a variety of emergencies, was partly the result of strict protocols for all essential aspects of surgical care. In most humanitarian contexts outcome data are difficult to collect, which means that structural and process indicators are even more important, as are minimum standards for essential items such as water, a blood bank, electricity, sterilization equipment and a postanesthesia care unit."
A wide range of additional organizations, including governments, non-governmental organization and missionary groups, provide surgical care in similar settings, the authors note. "Quality improvement programs are needed to regulate the enormous body of surgical providers in resource-limited settings," they conclude. "In this respect, the World Health Organization's Safe Surgery Saves Lives checklist is an important first step in a process of establishing global minimum standards in surgical care for humanitarian contexts. Operational research is needed to ensure such standardized approaches developed in relatively well-resourced settings are adapted to the complexities and constraints of humanitarian emergencies."
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), Monday, August 16, 2010
Hair Color, Socioeconomic Status Among Risk Factors for Recurring Basal Cell Carcinoma
CHICAGO—Patients who receive a diagnosis of the skin cancer basal cell carcinoma at a younger age—along with those who have red hair, a higher socioeconomic status and a cancerous lesion on their upper extremities—appear to be at higher risk of developing multiple cancers and require closer follow-up, according to a report in the August issue of Archives of Dermatology, one of the JAMA/Archives journals. "Basal cell carcinoma is the most common type of cancer in people with European ancestry, and its incidence continues to increase steeply," the authors write as background information in the article. "Although basal cell carcinoma therapy is relatively straightforward and basal cell carcinoma mortality rates are extremely low, the high incidence of basal cell carcinoma and the high risk of developing multiple lesions put a major burden on limited health care resources, placing basal cell carcinoma in fifth place on the list of most expensive cancers to treat in the United States." Risk factors for the disease include older age, being male, race and genetic predisposition, which may interact with UV light exposure or other environmental hazards. To investigate the incidence of and risk factors for single vs. multiple basal cell carcinoma lesions, Ville Kiiski, M.D., and colleagues at Erasmus Medical Center, Rotterdam, the Netherlands, studied two cohorts of 10,994 Dutch adults 55 or older, one in 1990 and one in 1999. Patients with basal cell carcinoma lesions were identified from Dutch national records and potential risk factors—including sex, age, hair color, eye color, educational level and other demographic and health characteristics—were determined when individuals entered the study. A total of 524 (4.8 percent) individuals in both cohorts had basal cell carcinoma, of whom 361 had single lesions and 163 (31.1 percent) had multiple lesions. Individuals who developed their first lesion after age 75 were significantly less likely to develop multiple lesions, whereas red hair and a first lesion located on the upper extremities was associated with a significantly increased risk of developing multiple lesions. "In contrast to developing a first lesion, high educational level was significantly positively associated with developing multiple lesions," the authors write. "This finding may be explained by the probability that people with higher levels of education (which correlates strongly with socioeconomic status) have different lifestyles (e.g., more frequent exposure to UV rays for intermittent periods)." It may also be that these individuals were more likely to develop cancer in places other than the face and neck, or because they tend to live longer and thus have more time to develop lesions, the authors note.
Known risk factors for basal cell carcinoma, including having blue eyes and fair or blond hair, were not associated with the risk for additional lesions. "The observed discrepancy among risk factor profiles of developing single or multiple basal cell carcinoma lesions may suggest that once cumulative environmental-genetic interaction has surpassed a certain threshold and resulted in a lesion, the phenotypic characteristics of patients seem less important. The clinical relevance of this finding is that physicians' risk assessment efforts should differentiate between patients at risk for a first lesion and those who have a history of basal cell carcinoma."
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), Monday, August 16, 2010
UV-B Treatment May Improve Psoriasis and Vitamin D Levels
CHICAGO—Treatment with narrow-band UV-B rays may increase serum levels of vitamin D in the wintertime while clearing psoriasis, according to a report in the August issue of Archives of Dermatology, one of the JAMA/Archives journals. Psoriasis affects 1.5 percent to 3 percent of the population, according to background information in the article. Abnormalities in vitamin D metabolism may be partly responsible for the development and worsening of this skin condition. "Most vitamin D is obtained by skin production following exposure to solar UV-B, while less than 15 percent is obtained from dietary sources such as oily fish and fortified foods," the authors write. Narrowband UV-B treatment has become the standard light therapy for psoriasis. Caitriona Ryan, M.B., B.Ch., B.A.O., then of St. Vincent's University Hospital, Dublin, and now of Baylor Research Institute, Dallas, and colleagues assessed 30 consecutive patients with psoriasis who were treated with narrowband UV-B three times per week until their psoriasis cleared between October 2008 and February 2009. Their serum vitamin D levels—measured before the study, after four weeks of treatment and after completing treatment—were compared with those of 30 control patients who also had psoriasis but did not undergo UV-B therapy. Psoriasis severity and dermatology-related quality of life were also assessed before and after treatment. Levels of serum 25-hydroxyvitamin D [25(OH)D]—the most accurate measurement of vitamin D levels in the body—increased significantly among individuals receiving UV-B therapy, from a media (midpoint) of 23 nanograms per milliliter to 59 nanograms per milliliter at the end of treatment. There was no change in the control group. "At the end of the study, all patients in the treatment group were vitamin D sufficient, but 75 percent of the control group had vitamin D insufficiency [serum 25(OH)D level of less than 20 nanograms per milliliter]," the authors write. In addition, psoriasis severity scores decreased in the UV-B group, from a median of 7.1 at the beginning of the study to 0.5 after treatment. Median scores did not change in the control group. Among those treated with UV-B, change in vitamin D level was associated with the number of exposures and the cumulative dose of UV-B, but not with whether psoriasis responded to the treatment. "In fact, those who required a greater number of exposures to clear had a significantly higher serum 25(OH)D level, most likely produced by more prolonged exposure to narrowband UV-B," the authors write. "We cannot conclude, therefore, that narrowband UV-B mediates its therapeutic effects by increasing vitamin D levels. This suggests that the improvement in both vitamin D status and psoriasis are contemporaneous, but unrelated, consequences of narrowband UV-B, or that there is another explanation for the causal relationship."
The results also highlight the significant rate of vitamin D insufficiency in Irish patients with psoriasis who are not being treated with UV-B, suggesting that additional supplements may be needed to prevent harmful effects of this deficiency, the authors note.
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), Monday, August 16, 2010
Skin Condition Associated With Depression, Anxiety and Suicidal Feelings
CHICAGO—Individuals with psoriasis appear to have an increased risk of depression, anxiety and suicidality, according to a report in the August issue of Archives of Dermatology, one of the JAMA/Archives journals. Psoriasis affects 1 percent to 3 percent of the general population, and estimates suggest 0.4 percent to 2.3 percent of adults have the condition but have not been diagnosed. "Psoriasis has long been recognized to be associated with potentially adverse effects on mental health," the authors write. "In the 1960s, a popular ad campaign labeled the emotional burden of this skin disease as the 'heartbreak of psoriasis.' However, there have been relatively few studies evaluating psychological outcomes in patients with psoriasis." Shanu Kohli Kurd, M.D., M.S.C.E, M.H.S., and colleagues at the University of Pennsylvania, Philadelphia, studied data from electronic medical records in the United Kingdom from 1987 to 2002. The analyses included 146,042 patients with mild psoriasis, 3,956 patients with severe psoriasis and 766,950 patients without psoriasis (five control patients for each patient with psoriasis, selected from the same practice and similar entry dates). Patients were defined as having new-onset depression, anxiety or suicidality if corresponding diagnostic codes appeared in their records after follow-up began. Of patients with mild or severe psoriasis, 25.9 per 1,000 individuals per year were diagnosed with depression, 20.9 per 1,000 per year with anxiety and 0.9 per 1,000 per year with suicidality. The rate of these cases attributable to psoriasis was 11.8 per 1,000 individuals per year for depression, 8.1 per 1,000 per year for anxiety and 0.4 per 1,000 per year for suicidality. "Stated another way, the excess risk attributable to psoriasis is one case of depression for every 39 patients with severe psoriasis per year (or per 87 patients in patients with mild psoriasis per year)," the authors write. "The excess risks associated with psoriasis for anxiety and suicidality correspond to one case per 123 and 2,500 patients with psoriasis per year, respectively." Considering this data and the prevalence of psoriasis in the U.K., the authors estimate that there are more than 10,400 diagnoses of depression, 7,100 of anxiety and 350 of suicidality related to psoriasis each year.
"It is important to identify these psychiatric disorders because they represent substantial morbidity that can be improved with a variety of pharmacological and non-pharmacological approaches," the authors conclude. "Recent data suggest that psychiatric co-morbidity may negative affect response to certain psoriasis treatments (e.g., photochemotherapy), while other studies suggest that control of psoriasis is associated with improvements in psychological symptoms. Future studies are necessary to determine the mechanisms by which psoriasis is associated with depression, anxiety and suicidality as well as approaches to prevent such adverse outcomes in patients with psoriasis."
Editor's Note: This study was supported in part by a National Research Service Award grant from the National Institutes of Health, the Doris Duke Foundation, University of Pennsylvania Center for Clinical Epidemiology and Biostatistics pharmacoepidemiology training grant and a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. 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, August 16, 2010
Women Who Drink Beer More Likely to Develop Psoriasis
CHICAGO—Regular beer—but not light beer or other types of alcohol—appears to be associated with an increased risk of developing psoriasis, according to a report posted online today that will be published in the December print issue of Archives of Dermatology, one of the JAMA/Archives journals. "Psoriasis is a common immune-mediated skin disease," the authors write as background information in the article. "The association between alcohol consumption and increased risk of psoriasis onset and psoriasis worsening has long been suspected. For example, individuals with psoriasis drink more alcohol than individuals without psoriasis, and alcohol intake may exacerbate psoriasis severity." For other diseases, type of alcoholic beverage has been shown to influence risk—for instance, beer confers a larger risk for gout than wine or spirits. To evaluate the association between different types of alcohol and psoriasis risk, Abrar A. Qureshi, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, assessed data from 82,869 women who were age 27 to 44 years in 1991. The women, participants in the Nurses' Health Study II, reported the amount and type of alcohol they consumed on biennial questionnaires. They also reported whether they had received a diagnosis of psoriasis. Through 2005, 1,150 cases of psoriasis developed, 1,069 of which were used for analysis. Compared with women who did not drink alcohol, the risk of psoriasis was 72 percent greater among women who had an average of 2.3 drinks per week or more. When beverages were assessed by type, there was an association between non-light beer drinking and psoriasis, such that women who drank five or more beers per week had a risk for the condition that was 1.8 times higher. Light beer, red wine, white wine and liquor were not associated with psoriasis risk. When only confirmed psoriasis cases—those in which women provided more details about their condition on a seven-item self-assessment—were considered, the risk for psoriasis was 2.3 times higher for women who drank five or more beers per week than women who did not drink beer. "Non-light beer was the only alcoholic beverage that increased the risk for psoriasis, suggesting that certain non-alcoholic components of beer, which are not found in wine or liquor, may play an important role in new-onset psoriasis," the authors write. "One of these components may be the starch source used in making beer. Beer is one of the few non-distilled alcoholic beverages that use a starch source for fermentation, which is commonly barley." Barley and other starches contain gluten, to which some individuals with psoriasis show a sensitivity. Lower amounts of grain are used to make light beer as compared with non-light beer, potentially explaining why light beer was not associated with psoriasis risk, they note.
"Women with a high risk of psoriasis may consider avoiding higher intake of non-light beer," the authors conclude. "We suggest conducting further investigations into the potential mechanisms of non-light beer inducing new-onset psoriasis."
Editor's Note: This study was supported by grants from the National Institutes of Health/National Cancer Institute. Dr. Qureshi has served as a consultant to Amgen and Genentech. 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, August 16, 2010
Difficulty Swallowing a Sign of Poor Prognosis Among Hospitalized Patients
CHICAGO—Dysphagia, or difficulty swallowing, is associated with longer hospital stays among patients with any diagnosis, is increasingly prevalent with older age and is an indicator of a poor prognosis, according to a report in the August issue of Archives of Otolaryngology—Head & Neck Surgery, one of the JAMA/Archives journals. "The consequences of dysphagia can be profound. Although it is appreciated that nutrition, hydration, quality of life issues and social isolation may arise, aspiration (especially if not immediately recognized) may be the pivotal factor that precipitates a significant decline in a patient's outcome," the authors write as background information in the article. The harmful effects of dysphagia on patients with stroke, heart disease and pneumonia have been recognized. Kenneth W. Altman, M.D., Ph.D., of The Mount Sinai School of Medicine, New York, and colleagues analyzed data from the 2005 to 2006 National Hospital Discharge Survey to evaluate the presence of dysphagia and the most common co-occurring medical conditions. Demographics, associated diseases, length of hospital stay, illness and death were assessed. During the time period studied, more than 77 million hospital admissions were recorded, of which 271,983 were associated with dysphagia. "Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection and congestive heart failure," the authors write. Being older than age 75 was associated with double the risk of dysphagia. The median (midpoint) number of days in the hospital was 4.04 among patients with dysphagia, compared with 2.4 among patients without, a 40-percent increase in length of stay. Patients undergoing rehabilitation had a greater than 13-fold increased risk of death during their hospitalization if they had dysphagia; the condition was also associated with increased risk of death among patients with intervertebral disk disorders and heart disease. "While dysphagia occurs in only a small portion of hospitalized patients, the impact on hospital resources is substantial," the authors conclude. "We recommend early identification of dysphagia in hospitalized patients, particularly in those with high-risk co-morbid conditions such as older age, stroke, dehydration, malnutrition, neurodegenerative disease, pneumonia, cardiac disease and the need for rehabilitation. The plan of care in these patients should include proper assessment, early intervention using appropriate therapy and aspiration precautions and consideration of enteral feeding or supplementation options in the high-risk population."
"Further clinical research to address clinical pathways and outcomes in these populations could help to mitigate both the clinical and economic ill effects of this potentially devastating condition."
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. |
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