EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 17, 2015

Media Advisory: To contact Ahmedin Jemal, D.V.M., Ph.D., email David Sampson at david.sampson@cancer.org. To contact Jesse D. Sammon, D.O., call Tammy Battaglia at 248-881-0809 or email Tammy.Battaglia@hfhs.org. To contact editorial author David F. Penson, M.D., M.P.H., call Craig Boerner at 615-322-4747 or email craig.boerner@vanderbilt.edu.

To place an electronic embedded link to this study and editorial in your story This link to the 1^st study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.14905 This link to the 2^nd study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.7273 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13775

Two studies in the November 17 issue of JAMA examine the change in prostate-specific antigen (PSA) screening and prostate cancer incidence before and after the 2012 U.S. Preventive Services Task Force (USPSTF) screening recommendations.

Ahmedin Jemal, D.V.M., Ph.D., of the American Cancer Society, Atlanta, and colleagues examined trends in stage-specific prostate cancer incidence and PSA-based screening for men 50 years and older subsequent to the 2008 and 2012 USPSTF recommendations using the most recent population-based incidence and nationally representative screening data. Prostate cancer incidence in men 75 years and older substantially decreased following the 2008 USPSTF recommendation against PSA-based screening for this age group. It has been unknown whether incidence has changed since the USPSTF recommendation against screening for all men in May 2012.

The researchers determined prostate cancer incidence (newly diagnosed cases/100,000 men 50 years of age and older) by stage from 2005 through 2012 using data from 18 population-based Surveillance, Epidemiology, and End Results (SEER) registries. The PSA screening rate was determined for men 50 years and older without a history of prostate cancer who responded to the 2005 (n = 4,580), 2008 (n = 3,476), 2010 (n = 4,157), and 2013 (n = 6,172) National Health Interview Survey.

The researchers found that prostate cancer incidence per 100,000 in men 50 years and older (n = 446,009 in SEER areas) was 535 in 2005, 541 in 2008, 505 in 2010, and 416 in 2012; rates began decreasing in 2008 and the largest decrease occurred between 2011 and 2012, from 498 to 416. The number of men 50 years and older diagnosed with prostate cancer nationwide declined by 33,519, from 213,562 in 2011 to 180,043 in 2012. The decreases in incidence were evident in both non-Hispanic white and non-Hispanic black individuals and across regions.

The percentage of men 50 years and older reporting PSA screening in the past 12 months was 37 percent in 2005, 41 percent in 2008, 38 percent in 2010, and 31 percent in 2013. In relative terms, screening rates increased by 10 percent between 2005 and 2008 and then decreased by 18 percent between 2010 and 2013. Similar screening patterns were found in age subgroups 50 to 74 years and 75 years and older.

“Using the most recent population-based incidence and nationally representative self-reported PSA screening data, we report reductions in early-stage prostate cancer incidence and PSA-based screening rates in men 50 years and older, coinciding with the 2012 USPSTF recommendation against PSA-based screening,” the authors write. “Longer follow-up is needed to see whether these decreases are associated with trends in mortality.”

(doi:10.1001/jama.2015.14905; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This project was supported by the Intramural Research Department of the American Cancer Society. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

In another study, Jesse D. Sammon, D.O., of Brigham and Women’s Hospital, Boston, and colleagues examined PSA screening data from the 2000, 2005, 2010, and 2013 National Health Interview Survey to determine the prevalence and determinants of screening before and after the 2012 USPSTF recommendations (draft released October 2011), as well as the association between the new USPSTF recommendations and the prevalence of screening.

The final study population included 20,757 men. The prevalence of PSA screening was 34 percent in 2000 and 2005. Between 2010 and 2013, the prevalence decreased from 36 percent to 31 percent overall. In a pooled analysis, survey year 2013 (vs 2010) was associated with lower odds of PSA screening. However, declines were seen only in men younger than 75 years vs men 75 and older. The largest declines were seen among men age 50-54 years (from 23 percent to 18 percent) and among men 60-64 years of age (from 45 percent to 35 percent). After adjusting for patient factors, there were significant reductions in PSA screening associated with the 2012 USPSTF recommendations.

“The 2008 USPSTF recommendations against PSA screening in men aged 75 years or older have not been associated with changes in screening practices. However, we found a decrease in the prevalence of PSA screening following the 2012 recommendations, particularly in men younger than 75 years,” the authors write.

“These findings using nationally representative data suggest that younger men may be altering health care behavior at a higher rate than older men following the new USPSTF recommendations, changes in clinician PSA screening practices have occurred in response to the policy change, or both. Alternatively, the findings may reflect the broad effects of the economic recession on health care use or a delayed response to the 2008 guidelines.”

(doi:10.1001/jama.2015.7273; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: The Pendulum of Prostate Cancer Screening

“There is reason to be concerned about the decline in prostate cancer screening and prostate cancer incidence reported by Sammon et al and Jemal et al,” writes David F. Penson, M.D., M.P.H., of Vanderbilt University, Nashville, in an accompanying editorial.

“Certainly, physicians have been overly aggressive in their approach to prostate cancer screening and treatment during the past 2 decades, but the pendulum may be swinging back the other way. It is time to accept that prostate cancer screening is not an ‘all­or-none’ proposition and to accelerate development of personalized screening strategies that are tailored to a man’s individual risk and preferences. By doing this, it should be possible to reach some consensus around this vexing problem and ultimately help men by stopping the swinging pendulum somewhere in the middle.”

(doi:10.1001/jama.2015.13775; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 17, 2015

Media Advisory: To contact Leonard B. Bacharier, M.D., call Judy Martin at 314-286-0105 or email Martinju@wustl.edu. To contact editorial co-author Robyn T. Cohen, M.D., M.P.H., call Elissa Snook at 617- 638-6823 or email Elissa.Snook@bmc.org.

To place an electronic embedded link to this study and editorial in your story This link to the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13896 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.14953

Among young children with histories of recurrent severe lower respiratory tract illness (LRTI), the use of azithromycin early during an apparent RTI compared with placebo significantly reduced the risk of experiencing progression to severe LRTI, according to a study in the November 17 issue of JAMA.

Acute episodes of severe LRTI are common among preschoolers, and up to 14 percent to 26 percent of preschoolers present with recurrent wheezing during the first 6 years of life. These severe episodes are often associated with substantial illness, and may result in visits to urgent care and emergency departments. Although viral infections are often present, bacteria may also contribute to illness development. Identification of treatment approaches that lessen the severity of these recurrent episodes would provide substantial benefit to preschool children with recurrent severe LRTI, according to background information in the article.

Leonard B. Bacharier, M.D., of the Washington University in St. Louis School of Medicine, and colleagues randomly assigned 607 children (age 12 months through 71 months) with histories of recurrent, severe LRTIs to receive the antibiotic azithromycin (for 5 days; n = 307) or matching placebo (n = 300), started early during each predefined RTI (child’s signs or symptoms prior to development of LRTI), based on individualized action plans. The trial was conducted across 9 academic U.S. medical centers in the National Heart, Lung, and Blood Institute’s AsthmaNet network.

A total of 937 treated RTIs (azithromycin group, 473; placebo group, 464) were experienced by 443 children (azithromycin group, 223; placebo group, 220), including 92 severe LRTIs (azithromycin group, 35; placebo group, 57). The azithromycin group experienced a significantly lower risk of progressing to severe LRTI than the placebo group. Adverse events were infrequently observed.

Although limited to 86 participants at a single study site, the researchers found numerically higher rates of acquisition of azithromycin-resistant organisms in oropharyngeal samples in participants receiving azithromycin and those who did not, along with evidence of acquisition of azithromycin-resistant organisms even in participants not treated with azithromycin. “Real-world rates of development of azithromycin-resistant organisms may be greater, potentially due to failure to complete the full duration of therapy often seen in clinical practice. Given the small sample size, further studies are needed to assess the potential increased risk of antibiotic resistance vs the comparative effectiveness of azithromycin with respect to other asthma medications to prevent severe LRTI,” the authors write.

“In children with the phenotype of wheezing studied herein, clinicians may consider a therapeutic trial of azithromycin early in the course of RTIs based on a parent-initiated individualized plan. Children who demonstrate an azithromycin response, as reflected by less-severe episodes of RTI, may benefit from repeating such therapy with subsequent illnesses.”

“Studies replicating the findings reported herein would provide further support to this conclusion, and future studies comparing the relative benefits of early azithromycin therapy with either daily or intermittent high-dose inhaled corticosteroids may help determine the relative efficacies of these treatment strategies.”

(doi:10.1001/jama.2015.13896; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Individual Benefit vs Societal Effect of Antibiotic Prescribing for Preschool Children With Recurrent Wheeze

“Limiting children’s loss of days from school (or parents’ days from work) and relieving the anxiety that an RTI that may progress to a hospitalization is almost certainly to be of benefit to children and families,” write Robyn T. Cohen, M.D., M.P.H., and Stephen I. Pelton, M.D., of the Boston University School of Medicine, in an accompanying editorial

“The question is how to determine (through studies incorporating biomarkers, airway endotyping, or genetics) which children are most likely to obtain the largest benefit from early initiation of azithromycin. Until a higher-risk population can be prospectively identified (rather than all children with intermittent wheezing associated with viral RTI) for progression to severe LRTI, the consequences of widespread use of azithromycin, both known and hypothesized, outweigh the benefit for most children.”

(doi:10.1001/jama.2015.14953; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 17, 2015

Media Advisory: To contact Cunlin Wang, M.D., Ph.D., call Sarah Peddicord at 301-796-2805 or email sarah.peddicord@fda.hhs.gov.

To place an electronic embedded link to this study in your story This link for the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.15572

Cunlin Wang, M.D., Ph.D., of the U.S. Food and Drug Administration, Silver Spring, Md., and colleagues studied recipients of intravenous (IV) iron (n = 688,183) enrolled in the fee-for-service Medicare program from January 2003 to December 2013. The study appears in the November 17 issue of JAMA.

In 2010, anemia affected one third of the global population, and iron deficiency was the most common cause. Oral iron replacement is the primary treatment strategy for iron deficiency anemia but may be inadequate for some patients due to intolerance, impaired absorption, significant ongoing bleeding, or nonadherence. For these patients, intravenous iron may be indicated. As of June 2013, there were 5 IV iron products marketed in the United States. While their efficacy is established, the most important safety concern relates to the risk of serious and fatal anaphylaxis (an allergic reaction to a substance), which may occur at both first and subsequent exposures. The comparative safety of each product has not been well established, according to background information in the article.

This study examined administrations of IV iron dextran, gluconate, sucrose, or ferumoxytol. A total of 274 anaphylaxis cases were identified at first exposure, with an additional 170 cases identified during subsequent IV iron administrations. The researchers found that iron dextran was associated with increased anaphylaxis risk compared with nondextran formulations at first administration. Among the nondextran products, the risk of anaphylaxis at first administration was higher with both iron gluconate and ferumoxytol than with iron sucrose.

Because each IV iron product has a specific recommended dose and schedule of administration, the cumulative risk of anaphylaxis was also calculated based on both the number of administrations and clinically relevant repletion level of iron (1000 mg) achieved within 12 weeks. Both analyses showed iron dextran was associated with the highest cumulative risk of anaphylaxis and iron sucrose with the lowest risk.

The authors note that the mechanism of anaphylactic reaction after IV iron remains unknown.

(doi:10.1001/jama.2015.15572; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 5:50 P.M. (ET) FRIDAY, NOVEMBER 13, 2015

Media Advisory: To contact Lee M. Jampol, M.D., DRCR Network Chair, email l-jampol@northwestern.edu; to contact Adam R. Glassman, M.S., Director DRCR.net Coordinating Center, email aglassman@jaeb.org. To contact editorial author Timothy W. Olsen, M.D., call Joy Bell at 404-778-3711 or email JBELL@emory.edu.

Video and Audio Content: There will be a video and audio report for this study, posted under embargo by 1 p.m. ET Wednesday, November 11 at https://media.jamanetwork.com/. This will include broadcast-quality downloadable video and audio files, B-roll, scripts, and other images.

To place an electronic embedded link to this study and editorial in your story This link to the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.15217 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.15409
Among patients with proliferative diabetic retinopathy, treatment with an injection in the eye of the drug ranibizumab resulted in visual acuity that was not worse than panretinal photocoagulation at 2 years, according to a study appearing in JAMA. This study is being released to coincide with its presentation at the American Academy of Ophthalmology annual meeting.

Proliferative diabetic retinopathy (PDR; a more advanced form of the disease) is a leading cause of vision loss in patients with diabetes mellitus, resulting in 12,000 to 24,000 new cases of blindness each year in the United States. Panretinal photocoagulation (PRP; procedure that involves use of a laser) is the standard treatment for reducing severe visual loss from PDR. However, PRP can cause permanent peripheral visual field loss and decreased night vision and may exacerbate diabetic macular edema (DME; swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula), which makes alternative treatments desirable, according to background information in the article.

When used as treatment of DME, intravitreous (in the vitreous, the fluid behind the lens in the eye) anti-vascular endothelial growth factor (VEGF) agents reduce the risk of diabetic retinopathy worsening and increase the chance of improvement, making these agents a potentially viable PDR treatment. Adam R. Glassman, M.S., of Jaeb Center for Health Research, Tampa, Fla., and the Writing Committee for the Diabetic Retinopathy Clinical Research Network, and colleagues conducted a study that included 305 adults with PDR; both eyes were enrolled for 89 participants (1 eye to each study group), with a total of 394 study eyes. Individual eyes were randomly assigned to receive PRP treatment, completed in 1 to 3 visits (n = 203 eyes), or the anti-VEGF agent ranibizumab, by intravitreous injection at study entry and as frequently as every 4 weeks based on a structured retreatment protocol (n = 191 eyes). Eyes in both treatment groups could receive ranibizumab for DME. The trial was conducted at 55 U.S. sites.

The researchers found that intravitreous ranibizumab met a prespecified noninferiority (not worse than) outcome of visual acuity change at 2 years than in the PRP group. There was no statistically significant visual acuity difference between the groups at 2 years, with the authors noting that 53 percent of the PRP group received ranibizumab injections for DME.

More peripheral visual field loss occurred, more vitrectomies (removal of the gel [vitreous] from within the eyeball) were performed, and DME development was more frequent in the PRP group compared with the ranibizumab group. No systemic safety concerns with ranibizumab were identified in the prespecified major safety outcomes.

“Although longer-term follow-up is needed, ranibizumab may be a reasonable treatment alternative at least through 2 years for patients with PDR,” the authors write.

(doi:10.1001/jama.2015.15217; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Anti-VEGF Pharmacotherapy as an Alternative to Panretinal Laser Photocoagulation for Proliferative Diabetic Retinopathy

“In summary, this important study by the Diabetic Retinopathy Clinical Research [DRCR].net investigators represents a major step forward for patients with PDR by providing the ophthalmologists who manage their retinal disease with new options,” writes Timothy W. Olsen, M.D., of Emory University, Atlanta, in an accompanying editorial.

“The short-term role (2 years) for using anti-VEGF agents seems to represent a viable alternative therapy for adherent patients with high-risk PDR. Nevertheless, PRP represents the standard of care for PDR and may represent the best long-term treatment option for high-risk PDR. It is certainly not time to abandon PRP in favor of exclusively treating patients with PDR using only intravitreal anti­VEGF injections. Clinical judgment and timing of initiation of either therapy are viable options, and the findings reported by the DRCR.net researchers provide clinicians with evidence to support the alternative option of anti-VEGF pharmacotherapy for high-risk PDR. Further advances in pharmacologic management and sustained delivery systems will help expand this alternative therapy for PDR.”

(doi:10.1001/jama.2015.15409; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This work was supported by an unrestricted departmental grant from Research to Prevent Blindness, New York, NY. Please see the article for additional information, including financial disclosures, etc.

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EMBARGOED FOR RELEASE: 3:45 P.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact Mihai Gheorghiade, M.D., email Marla Paul at marla-paul@northwestern.edu.

To place an electronic embedded link to this study in your story This link for the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.15734

Mihai Gheorghiade, M.D., of the Northwestern University Feinberg School of Medicine, Chicago, and colleagues randomly assigned 456 patients with worsening chronic HF and reduced left ventricular ejection fraction (a measure of how well the left ventricle of the heart pumps with each beat) to receive placebo or 1 of 4 daily target doses of the medication vericiguat for 12 weeks. This JAMA study is being released to coincide with its presentation at the American Heart Association’s Scientific Sessions 2015.

More than 1 million hospitalizations for heart failure (HF) occur annually in the United States alone, and more than 80 percent of these hospitalized patients have worsening chronic HF. Despite an often rapid and substantial in-hospital improvement in HF signs and symptoms with standard therapy, approximately 25 percent of patients are rehospitalized within 30 days and 30 percent of patients may die within 1 year.

This phase 2 study, which included patients from across Europe, North America, and Asia, was conducted to determine the optimal dose and tolerability of the drug vericiguat to reduce elevated natriuretic peptide levels. Natriuretic peptides are produced by the heart in response to high pressures inside the heart, which is typical in heart failure. Elevated levels are seen in the setting of worsening heart failure and correlate with severity of symptoms and risk of death.

Overall, 351 patients (77 percent) completed treatment with the study drug with valid 12-week N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and no major protocol deviation. In the primary analysis, change in NT-proBNP levels from baseline to week 12 was not significantly different between the pooled vericiguat group and placebo. The secondary analysis suggested a dose-response relationship, such that higher vericiguat doses were associated with greater reductions in NT-proBNP level. Rates of any adverse event were 77 percent and 71 percent among the placebo and 10-mg vericiguat groups, respectively.

“Among patients with worsening chronic HF and reduced LVEF, compared with placebo, vericiguat did not have a statistically significant effect on change in NT-proBNP level at 12 weeks but was well-tolerated. Further clinical trials of vericiguat based on the dose-response relationship in this study are needed to determine the potential role of this drug for patients with worsening chronic HF,” the authors write.

(doi:10.1001/jama.2015.15734; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study was funded by affiliates of Bayer and Merck, Sharp & Dohme, a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 4:00 P.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact Anna Svatikova, M.D., Ph.D., call Traci Klein at 507-990-1182 or email Klein.Traci@mayo.edu.

To place an electronic embedded link to this study in your story This link for the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13744

Anna Svatikova, M.D., Ph.D., of the Mayo Clinic, Rochester, Minn., and colleagues randomly assigned 25 healthy volunteers (age 18 years or older) to consume a can (480 mL; 16 fl. oz.) of a commercially available energy drink (Rockstar; Rockstar Inc) and placebo drink within 5 minutes, in random order on 2 separate days, maximum 2 weeks apart. The placebo drink, selected to match the nutritional constituents of the energy drink, was similar in taste, texture, and color but lacked caffeine and other stimulants of the energy drink (240 mg of caffeine, 2,000 mg of taurine, and extracts of guarana seed, ginseng root, and milk thistle). This JAMA study is being released to coincide with its presentation at the American Heart Association’s Scientific Sessions 2015.

Energy drink consumption has been associated with serious cardiovascular events, possibly related to caffeine and other stimulants. The researchers examined the effect of energy drink consumption on hemodynamic changes, such as blood pressure and heart rate. Participants were fasting and abstained from caffeine and alcohol 24 hours prior to each study day. Serum levels of caffeine, plasma glucose, and norepinephrine (noradrenaline) were measured and blood pressure and heart rate were obtained at baseline and 30 minutes after drink ingestion.

Caffeine levels remained unchanged after the placebo drink, but increased significantly after energy drink consumption. Consumption of the energy drink elicited a 6.2 percent increase in systolic blood pressure; diastolic blood pressure increased by 6.8 percent; average blood pressure increased after consumption of the energy drink by 6.4 percent. There was no significant difference in heart rate increase between the 2 groups. The average norepinephrine level increased from 150 pg/mL to 250 pg/mL after consumption of the energy drink and from 140 pg/mL to 179 pg/mL after placebo (change rate: 74 percent vs 31 percent, respectively).

“These acute hemodynamic and adrenergic changes may predispose to increased cardiovascular risk,” the authors write. “Further research in larger studies is needed to assess whether the observed acute changes are likely to increase cardiovascular risk.”

(doi:10.1001/jama.2015.13744; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This research was supported by a grant from the Mayo Foundation and the National Center for Advancing Translational Sciences, National Institutes of Health. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 9:00 A.M. (ET) MONDAY, NOVEMBER 9, 2015

Media Advisory: To contact Nihar R. Desai, M.D., M.P.H., call Karen Peart at 203-432-1326 or email karen.peart@yale.edu. To contact editorial author Robert A. Harrington, M.D., email Tracie White at traciew@stanford.edu.

To place an electronic embedded link to this study and editorial in your story This link to the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13764 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13764

Nihar R. Desai, M.D., M.P.H., of the Yale School of Medicine, New Haven, Conn., and colleagues examined trends in percutaneous coronary intervention use, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. This JAMA study is being released to coincide with its presentation at the American Heart Association’s Scientific Sessions 2015.

In 2009, the American College of Cardiology and the American Heart Association, along with other professional societies, released Appropriate Use Criteria for Coronary Revascularization to critically examine and improve patient selection for percutaneous coronary intervention (PCI; commonly known as coronary angioplasty, a non-surgical procedure used to open narrow or blocked coronary arteries) as well as address concerns about potential overuse. Prior studies demonstrated that 1 in 6 nonacute PCIs were classified as inappropriate, indicating that the benefits of the procedure were unlikely to outweigh the risks. National trends in the appropriateness of PCI have not been examined since the introduction of the Appropriate Use Criteria, according to background information in the article.

This analysis included patients undergoing PCI between July 2009 and December 2014 at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period. The researchers determined the proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for coronary revascularization.

A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period, but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. The proportion of nonacute PCIs classified as inappropriate decreased from 26 percent to 13 percent, and the absolute number of inappropriate PCIs decreased from 21,781to 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 13 percent in 2014).

Among patients undergoing nonacute PCI, there were significant increases in angina severity, use of antianginal medications prior to PCI, and high-risk findings on noninvasive testing, but only modest increases in multivessel coronary artery disease.

“This analysis provides details about changes in the clinical profiles of patients undergoing PCI and suggests that the observed reductions in inappropriate PCI in part reflect improvements in patient selection and clinical decision making as well as better documentation of the key elements used to determine procedural appropriateness,” the authors write. “These findings may indicate that clinicians are doing a better job of identifying and limiting nonacute PCI procedures to those patients most likely to benefit from revascularization.”

“Collectively, these findings suggest that the practice of interventional cardiology has evolved since the introduction of Appropriate Use Criteria in 2009.”

(doi:10.1001/jama.2015.13764; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Appropriate Use Criteria for Coronary Revascularization and the Learning Health System

“As reported by Desai et al, the use of the National Cardiovascular Data Registry has allowed temporal review of the PCI appropriate use criteria,” writes Robert A. Harrington, M.D., of Stanford University, Stanford, Calif., in an accompanying editorial.

“However, these data analyses are retrospective. What is needed is a national system that allows immediate real-time decision support for clinical activities fully integrated with clinical research capabilities that use constantly accumulating data and sophisticated data analytics, including randomization when appropriate. Only at that point will the continuously learning health care system be a reality.”

(doi:10.1001/jama.2015.13764; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 9:00 A.M. (ET) MONDAY, NOVEMBER 9, 2015

Media Advisory: To contact Josep Rodes-Cabau, M.D., email Josep.Rodes@criucpq.ulaval.ca.

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Josep Rodes-Cabau, M.D., of Laval University, Quebec City, Canada, and colleagues randomly assigned 171 patients with an indication for atrial septal defect (ASD) closure and no history of migraine to receive dual antiplatelet therapy (aspirin + clopidogrel [the clopidogrel group], n = 84) or single antiplatelet therapy (aspirin + placebo [the placebo group], n = 87) for 3 months following transcatheter ASD closure. This JAMA study is being released to coincide with its presentation at the American Heart Association’s Scientific Sessions 2015.

An atrial septal defect is a hole in the part of the septum (wall) that separates the upper chambers of the heart. Occurrence of new-onset migraine attacks has been reported in approximately 15 percent of patients following transcatheter ASD closure, with the majority of initial episodes occurring within the days to weeks following the procedure. Aspirin is often prescribed for 6 months following the procedure. Preliminary studies have suggested an association with a lower incidence and severity of migraine headaches following ASD closure when ticlopidine or clopidogrel is added to aspirin treatment.

The researchers found that patients in the clopidogrel group had a reduced average number of monthly migraine days within the 3 months following the procedure (0.4 days) vs the placebo group (1.4 days) and a lower incidence of migraine attacks (9.5 percent for the clopidogrel group vs 22 percent for the placebo group). Among patients with migraines, those in the clopidogrel group had less-severe migraine attacks (zero patients with moderately or severely disabling migraine attacks vs 37 percent [7 patients] in the placebo group). No significant increase in adverse events was observed with the use of dual vs single antiplatelet therapy.

“Further studies are needed to assess generalizability and durability of this effect,” the authors write.

(doi:10.1001/jama.2015.13919; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study was funded by unrestricted grants from Sanofi and St. Jude Medical and a grant from the Foundation of the Quebec Heart and Lung Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 10:45 A.M. (ET) TUESDAY, NOVEMBER 10, 2015

Media Advisory: To contact Myeong-Ki Hong, M.D., Ph.D., email mkhong61@yuhs.ac.

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Myeong-Ki Hong, M.D., Ph.D., of the Yonsei University College of Medicine, Seoul, Korea and colleagues randomly assigned 1,400 patients with long coronary lesions to receive intravascular ultrasound-guided (n = 700) or angiography-guided (n = 700) everolimus-eluting stent implantation. This JAMA study is being released to coincide with its presentation at the American Heart Association’s Scientific Sessions 2015.

Even though recent guidelines recommend the use of intravascular ultrasound (IVUS) to optimize stent implantation for select patients, the effect of IVUS-guided drug-eluting (releasing) stent implantation on clinical outcomes remains uncertain because of the limited number of properly powered randomized trials.

For this trial, one-year follow-up was complete in 1,323 patients (94.5 percent). Major adverse cardiac events (including cardiac death, target lesion-related heart attack, or ischemia-driven target lesion revascularization) at 1 year occurred in 39 patients (5.8 percent) undergoing angiography-guided and in 19 patients (2.9 percent) undergoing IVUS-guided stent implantation (a 2.9 percent absolute reduction and 48 percent relative reduction). The difference was driven by a lower risk of ischemia-driven target lesion revascularization in patients undergoing IVUS-guided (17 [2.5 percent]) compared with angiography-guided (33 [5 percent]) stent implantation.

Cardiac death and target lesion-related heart attack were not significantly different between the 2 groups. For cardiac death, there were 3 patients (0.4 percent) in the IVUS-guided group and 5 patients (0.7 percent) in the angiography-guided group. Target lesion-related heart attack occurred in 1 patient in the angiography-guided stent implantation group.

“Our findings suggest better clinical outcomes for major adverse cardiac events with IVUS-guided stent implantation compared with angiography-guided stent implantation, particularly for diffuse long lesions,” the authors write.

(doi:10.1001/jama.2015.15454; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study was supported by the Cardiovascular Research Center (Seoul, Korea) and funded by Abbott Vascular Inc. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact Kevin G. Volpp, M.D., Ph.D., call Katie Delach at 215-349-5964 or email Katharine.Delach@uphs.upenn.edu.

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In a study examining the effect of financial incentives to improve lipid levels among patients in primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a modest reduction of low-density lipoprotein cholesterol (LDL-C) levels after 12 months, according to a study in the November 10 issue of JAMA. This issue, a cardiovascular disease theme issue, coincides with the American Heart Association’s Scientific Sessions 2015.

Cardiovascular disease is the leading cause of death in the United States, and studies indicate that taking statins to lower cholesterol reduces the risk of heart attack by about 30 percent. Despite proven benefits, the relatively low cost, once-a-day dosing, and few adverse effects, the population effectiveness of statins is limited for several reasons, including physicians underprescribing statins or failing to intensify treatment when indicated, and poor medication adherence among patients. Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established, according to background information in the article.

David A. Asch, M.D., and Kevin G. Volpp, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, and colleagues conducted a study in which primary care physicians were randomly assigned to one of four groups: control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1,024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation.

The clinical trial was conducted in 3 health care delivery systems in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1,503 were enrolled.

After 12 months, the average reduction in LDL-C levels for patients was:

25.1 mg/dL for patients in the control group;

25.1 mg/dL for patients in the patient incentives group;

27.9 mg/dL for patients in the physician incentives group;

33.6 mg/dL for patients in the shared physician-patient incentives group.

Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (difference of 8.5 mg/dl). “This outcome is supported by the finding that 49 percent of the patients in the shared patient and physician incentive group achieved the LDL-C goal in comparison with 36 percent to 40 percent in the other 3 groups. The superiority of a shared approach makes sense because success at LDL-C reduction is likely to be driven by both provision of medication by physicians and patient adherence to that medication. Consistent with this hypothesis, patients in the shared group were more likely to receive medication intensification and to adhere to medication use than patients in other groups.”

The author note that the reduction in LDL-C levels achieved by the patients in the shared physician-patient incentives group were modest, and that further information is needed to understand whether this approach represents good value.

(doi:10.1001/jama.2015.14850; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study received support from the National Institute on Aging. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact David A. Bluemke, M.D., Ph.D., email Molly Freimuth at molly.freimuth@nih.gov.

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In a multiethnic, middle-aged and older study population, the prevalence of myocardial scars (evidence of a heart attack) was nearly 8 percent, of which nearly 80 percent were unrecognized by electrocardiography or clinical evaluation, according to a study in the November 10 issue of JAMA. This issue, a cardiovascular disease theme issue, coincides with the American Heart Association’s Scientific Sessions 2015.

Ischemic heart disease is an important public health concern, but a considerable proportion of myocardial infarctions (MIs; heart attacks) are clinically unrecognized. Given the aging of the U.S. population, it is important to understand the prevalence, risk factors, and prognosis of unrecognized MI. In patients who survive a heart attack, normal contractile (having the property of contracting) tissue is replaced by noncontractile fibrosis (formation of excess fibrous connective tissue in a reparative process) (scar). Myocardial scarring leads to abnormal heart function and poor prognosis. The prevalence of and factors associated with unrecognized MI and scar have not been previously defined using contemporary methods in a multiethnic U.S. population, according to information in the article.

David A. Bluemke, M.D., Ph.D., of the National Institute of Biomedical Imaging and Bioengineering, Bethesda, Md., and colleagues examined the prevalence of myocardial scar using cardiac magnetic resonance (CMR; considered a standard of reference for defining the presence of myocardial scar). Participants were multiethnic, 45 through 84 years of age and free of clinical cardiovascular disease (CVD) at study entry in 2000-2002. In the 10th year examination (2010-2012), 1,840 participants (average age, 68 years; 52 percent men) underwent CMR imaging with gadolinium to detect myocardial scar. Cardiovascular disease risk factors and coronary artery calcium (CAC) scores were measured at study entry and year 10.

The overall prevalence of myocardial scar by CMR was 7.9 percent (146 of 1,840). The prevalence of previously unrecognized myocardial scar was 6.2 percent, whereas 1.7 percent had clinically recognized MI. Thus, 78 percent (114 of 146) of myocardial scars were unrecognized by clinical or electrocardiography (ECG) evaluation. Men had a higher prevalence of myocardial scar than women (12.9 percent vs 2.5 percent).

Of individual risk factors, age, male sex, CAC score, body mass index, current smoking, and use of antihypertensive medications at study entry were associated with higher odds of myocardial scar.

“The clinical significance of unrecognized myocardial scar remains to be defined, although prior myocardial scar has been noted pathologically in more than 70 percent of patients with sudden cardiac death but without prior known coronary artery disease,” the authors write. “Further studies are needed to understand the clinical consequences of these undetected scars.”

(doi:10.1001/jama.2015.14849; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact Adrian F. Hernandez, M.D., M.H.S., call Sarah Avery at 919-660-1306 or email sarah.avery@duke.edu.

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Although frequent laboratory monitoring of patients with heart failure following initiation of mineralocorticoid receptor antagonists is supported by the results of large clinical trials and recommended in guidelines, there appears to be low rates of monitoring in clinical practice, according to a study in the November 10 issue of JAMA. This issue, a cardiovascular disease theme issue, coincides with the American Heart Association’s Scientific Sessions 2015.

Mineralocorticoid receptor antagonists (MRAs) are a cornerstone of heart failure therapy but carry a risk of hyperkalemia (elevated potassium in the blood). Clinical guidelines recommend close monitoring of kidney function and electrolyte (including potassium) levels throughout the course of therapy. No large studies have examined whether laboratory monitoring occurs routinely in community practice. Adrian F. Hernandez, M.D., M.H.S., of the Duke University School of Medicine, Durham, N.C., and colleagues analyzed a group of patients (10,443 Medicare beneficiaries) with heart failure who had initiated MRA therapy (eplerenone or spironolactone). The researchers examined the frequency of measurement of serum creatinine and potassium levels before and after MRA initiation.

The researchers found that combined, 756 patients (7 percent) received appropriate testing before and after MRA initiation. After initiation of MRA therapy, 13 percent and 30 percent of patients received appropriate testing in early and extended follow-up, respectively. In contrast, 55 percent and 22 percent received no testing in early or extended follow-up, respectively. Atrial fibrillation, anemia, chronic kidney disease, chronic obstructive pulmonary disease, hypothyroidism, osteoporosis, and use of diuretics were associated with a greater likelihood of appropriate laboratory testing during all periods.

“The landmark trials of MRAs in heart failure showed MRAs significantly reduced mortality and cardiovascular readmission compared with placebo. However, an analysis of community practice found similar outcomes among patients treated or not treated with an MRA. One possible explanation may be less rigorous monitoring outside clinical trial settings, which may increase risks of adverse events associated with MRAs,” the authors write.

“Closing the gap between the efficacy and effectiveness of MRAs in heart failure will require clinicians to address this issue. Quality improvement initiatives to improve appropriate laboratory monitoring are needed.”

(doi:10.1001/jama.2015.11904; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This project was supported in part by a grant from the Agency for Healthcare Research and Quality. Dr. Cooper was supported by a grant from the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) SUNDAY, NOVEMBER 8, 2015

Media Advisory: To contact M.G. Myriam Hunink, M.D., Ph.D., email m.hunink@erasmusmc.nl. To contact editorial author Mary McGrae McDermott, M.D., email Marla Paul at marla-paul@northwestern.edu.

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Among patients with peripheral artery disease and intermittent claudication (cramping pain in the legs due to poor circulation in the arteries, aggravated by walking), a combination therapy of endovascular revascularization (an invasive procedure to improve blood flow in an artery) followed by supervised exercise resulted in greater improvement in walking distances and health-related quality-of-life measures at one year compared with supervised exercise only, according to a study in the November 10 issue of JAMA. This issue, a cardiovascular disease theme issue, coincides with the American Heart Association’s Scientific Sessions 2015.

Intermittent claudication is the classic symptomatic form of peripheral artery disease (PAD), affecting approximately 20 to 40 million people worldwide and increasing rapidly with the aging world population. Patients with claudication experience significant functional disability often resulting in a sedentary lifestyle and reduced quality of life. Supervised exercise is recommended as a first-line treatment. A combination therapy of endovascular revascularization plus supervised exercise may be beneficial, but few data comparing the two therapies are available, according to background information in the article.

M.G. Myriam Hunink, M.D., Ph.D., of the Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues randomly assigned 212 patients with PAD and intermittent claudication to endovascular revascularization plus supervised exercise (n = 106) or supervised exercise only (n = 106). The primary measured outcome for the study was the difference in maximum treadmill walking distance at 12 months between the groups.

The researchers found that endovascular revascularization plus supervised exercise (combination therapy) was associated with greater improvement in maximum walking distance compared with the supervised exercise only group, and in pain-free walking distance. Also, the combination therapy group demonstrated significantly greater improvement in health-related quality-of-life.

“The present study reopens the debate for revascularization in patients with claudication, in particular in terms of an approach using endovascular revascularization first. By improving lower extremity blood flow, early percutaneous revascularization of the target lesion gives an impulse to patient mobility and quality of life in the short-term. This, in turn, facilitates subsequent exercising and allows the patient to profit from the long-term benefits of an additional supervised exercise program,” the authors write.

(doi:10.1001/jama.2015.14851; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: All study funding was provided by the Netherlands Organisation for Health Research and Development. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Editorial: Erasing Disability in Peripheral Artery Disease

The results of this trial (ERASE) underscore once again the benefits of supervised treadmill exercise for patients with peripheral artery disease, writes Mary McGrae McDermott, M.D., of the Northwestern University Feinberg School of Medicine, Chicago, and Senior Editor, JAMA, in an accompanying editorial.

“Randomized trial evidence already convincingly demonstrates that supervised treadmill exercise improves walking performance compared with no exercise. The ERASE trial newly demonstrates that supervised exercise also improves lower extremity outcomes after endovascular revascularization. Current reimbursement strategies in the United States provide significant incentives for clinicians to offer endovascular revascularizations to patients with peripheral artery disease, whereas supervised exercise remains expensive and inaccessible to patients. Reducing disability from peripheral artery disease in the 21st century requires strategies to ensure that effective exercise programs are accessible for all patients with peripheral artery disease.”

(doi:10.1001/jama.2015.15116; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 3, 2015

Media Advisory: To contact Elizabeth D. Kantor, Ph.D., M.P.H., call Nicole McNamara at 646-227-3633 or email mcnamarn@mskcc.org.

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Between 1999-2012, overall prescription drug use increased among U.S. adults, with this increase seen for the majority of but not all drug classes, according to a study in the November 3 issue of JAMA.

Use of prescription drugs represents a major expenditure in the United States, and research suggests that use of prescription drugs is increasing. Yet much of the information about prescription use is derived from pharmacy databases or expenditure data, neither of which directly captures use at the population level. It is important to document patterns of prescription drug use to inform both clinical practice and research, according to background information in the article.

Elizabeth D. Kantor, Ph.D., M.P.H., formerly of the Harvard T.H. Chan School of Public Health, Boston, and colleagues evaluated trends in prescription drug use using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Participants included 37,959 U.S. adults, age 20 years and older. Seven NHANES cycles were included (1999-2000 to 2011-2012), and the sample size per cycle ranged from 4,861 to 6,212. Within each NHANES cycle, use of prescription drugs in the prior 30 days was assessed overall and by drug class.

The researchers found that the prevalence of prescription drug use increased from 51 percent in 1999-2000 to 59 percent in 2011-2012, while the prevalence of polypharmacy (use of five or more prescription drugs) increased from 8 percent to 15 percent. Use of medications for hypertension increased (20 percent-27 percent), as did medications to treat hyperlipidemia, a trend largely driven by statins (7 percent-17 percent). Use of antidepressants also increased (7 percent-13 percent). Among the 18 drug classes used by more than 2.5 percent of the population at any point over the study period, the prevalence of use increased in 11 drug classes.

Prescription drug use increased significantly among persons 40 to 64 years of age and also among those 65 years and older, but not among adults 20 to 39 years old.

The most commonly used individual drug in 2011-2012 was simvastatin (7.9 percent), increasing from 2.0 percent in 1999-2000. The remaining top 10 drugs included lisinopril, levothyroxine, metoprolol, metformin, hydrochlorothiazide, omeprazole, amlodipine, atorvastatin, and albuterol; all of the top 10 most commonly used drugs increased over the study period except atorvastatin.

“Eight of the 10 most commonly used drugs in 2011-2012 are used to treat components of the cardiometabolic syndrome, including hypertension, diabetes, and dyslipidemia. Another is a proton-pump inhibitor used for gastroesophageal reflux, a condition more prevalent among individuals who are overweight or obese. Thus, the increase in use of some agents may reflect the growing need for treatment of complications associated with the increase in overweight and obesity,” the authors write.

(doi:10.1001/jama.2015.13766; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Elizabeth D. Kantor, Ph.D., M.P.H., is now with the Memorial Sloan Kettering Cancer Center, New York. 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: 11 A.M. (ET) TUESDAY, NOVEMBER 3, 2015

Media Advisory: To contact Saleh A. Almenawer, M.D., call Veronica McGuire at 905-525-9140, ext. 22169 or email vmcguir@mcmaster.ca. To contact editorial co-author Joanna M. Wardlaw, M.D., F.R.C.R., email joanna.wardlaw@ed.ac.uk.

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In a meta-analysis of randomized clinical trials for the treatment of acute ischemic stroke, an endovascular intervention (such as use of a very small catheter to remove a blood clot) compared to standard medical care (administration of a clot dissolving agent) was associated with improved functional outcomes and higher rates of functional independence at 90 days, but no significant difference in symptomatic intracranial hemorrhage (bleeding in the brain) or all-cause mortality, according to a study in the November 3 issue of JAMA.

The current standard therapy for acute ischemic stroke is intravenous administration of tissue plasminogen activator (tPA). Although intravenous tPA improves survival and functional outcomes when administered as early as possible after onset of ischemic stroke, its use is limited by the narrow therapeutic time window (<4.5 hours), and by several contraindications. As few as 10 percent of patients presenting with ischemic stroke can be eligible for treatment with intravenous tPA. The limitations of its use have led to interest in endovascular therapy for acute ischemic stroke. Endovascular intervention improves blood flow but clinical studies examining this therapy have yielded variable results, warranting further examination, according to background information in the article.

Saleh A. Almenawer, M.D., of McMaster University, Hamilton, Ontario, Canada, and colleagues conducted a meta-analysis that included data from 8 trials involving 2,423 patients with acute ischemic stroke (average age, 67 years; 47 percent women), including 1,313 who underwent endovascular thrombectomy and 1,110 who received standard medical care with tPA. For this analysis, endovascular therapy was defined as the intra-arterial use of a microcatheter or other device for mechanical thrombectomy (clot removal), with or without the use of a chemical thrombolytic (clot busting) agent.

The researchers found that endovascular therapy was associated with a significant treatment benefit across measures of functional outcomes. Functional independence at 90 days occurred among 45 percent of the patients in the endovascular therapy group vs 32 percent of the patients in the standard medical care group. Compared with standard medical care, endovascular thrombectomy was associated with significantly higher rates of angiographic revascularization at 24 hours but no significant difference in rates of symptomatic intracranial hemorrhage (5.7 percent vs 5.1 percent) or all-cause mortality at 90 days (218 deaths [16 percent] vs 201 deaths [18 percent]).

“This meta-analysis synthesizes evidence from multicenter randomized clinical trials, and may help inform the design and execution of future studies examining the efficacy of endovascular therapy for acute ischemic stroke. Additional trials are needed to systematically study the relationship of patient-, disease-, and treatment-related variables with outcomes following mechanical thrombectomy, and to identify the ideal patient to undergo endovascular therapy.”

(doi:10.1001/jama.2015.13767; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: Thrombectomy for Acute Ischemic Stroke

“Thrombectomy appears to improve functional outcome for selected patients with internal carotid artery or middle cerebral artery main stem thrombus who have limited comorbidities and who are younger than 80 years. For these patients, intravenous recombinant tissue plasminogen activator should be initiated quickly (if the patient has no contraindications) while rapidly preparing for thrombectomy. Perfusion imaging is not essential,” write Joanna M. Wardlaw, M.D., F.R.C.R., and Martin S. Dennis, M.D., F.R.C.P., of the University of Edinburgh, United Kingdom, in an accompanying editorial.

“However, clinicians should realize that thrombectomy is not necessarily safer than standard medical care, with similar risks of symptomatic intracranial hemorrhage and all-cause mortality reported by Badhiwala et al, along with potential procedural risks.”

“Additional rigorous trials would help to define which additional patients might benefit from thrombectomy and, by how much, including consideration of the effects of comorbidities, advanced age, limits of extractable thrombus location or extent and the latest time window (probably >6 hours). Studies also are needed to determine how to implement thrombectomy in routine practice, including testing the thorny question of who should perform the procedure, and whether the balance of benefit, cost, and service efficiency favor treating just those patients who individually will gain most or treating all patients with a reasonable chance of some worthwhile benefit.”

(doi:10.1001/jama.2015.14674; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 3, 2015

Media Advisory: To contact Robert D. Kirkcaldy, M.D., M.P.H., email Brian Katzowitz at wxq5@cdc.gov.

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Although gonorrhea susceptibility to the antibiotic cefixime has been improving in recent years, suggesting a halt of a drift towards antibiotic resistance, data for 2014 indicates a worsening of susceptibility, according to a study in the November 3 issue of JAMA.

Gonorrhea is a common sexually transmitted disease that, if untreated, can cause a number of reproductive and general health complications. Treatments for gonorrhea have been repeatedly jeopardized by antimicrobial resistance. To ensure effective treatment, the U.S. Centers for Disease Control and Prevention (CDC) periodically updates guidelines based on resistance trends. Following declining cephalosporin susceptibility in several countries, the CDC updated its treatment recommendation in 2010 from single-dose cephalosporin (injectable ceftriaxone or oral cefixime) to a higher dose of ceftriaxone or cefixime plus a second antimicrobial. In 2012, the CDC again updated treatment guidelines and recommended ceftriaxone-based combination therapy as the single recommended therapy.

Robert D. Kirkcaldy, M.D., M.P.H., of the CDC, Atlanta, and colleagues examined recent gonorrhea susceptibility trends (when antibiotics are effective at killing or stopping the growth of a certain bacteria in the laboratory, the bacteria is known as susceptible to antibiotics) to third generation cephalosporin antibiotics (injectable ceftriaxone or oral cefixime). The researchers analyzed data from the CDC’s Gonococcal Isolate Surveillance Project, a system that monitors antimicrobial susceptibility in urethral (opening through which urine is discharged) isolates from men with gonorrhea treated at U.S. public clinics for sexually transmitted disease.

During 2006-2014, 51,144 isolates were collected in 34 cities. The percentage of participants treated with 250 mg of ceftriaxone intramuscularly increased from 8.7 percent in 2006 to 96.6 percent in 2014. The percentage of isolates with reduced cefixime susceptibility increased from 0.1 percent in 2006 to 1.4 percent in 2011, and then declined to 0.4 percent in 2013. In 2014, the percentage of resistant isolates increased to 0.8 percent.

“Although this improvement in susceptibility appears temporally correlated with treatment guideline changes, we cannot establish a causal relationship,” the authors write. “The 2014 data, however, suggest that improvements in susceptibility may be short-lived.”

“The increased prevalence of reduced cefixime susceptibility in 2014 highlights the need to maintain surveillance, search for new therapeutics, and ensure that gonorrhea is treated according to the CDC’s guidelines.”

(doi:10.1001/jama.2015.10347; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The Gonococcal Isolate Surveillance Project is funded by the CDC. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 3, 2015

Media Advisory: To contact Morten Olsen, M.D., Ph.D., email mo@clin.au.dk

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Although the absolute risk was low, researchers found an increased risk of childhood-onset epilepsy among children in Denmark who had a hospital-diagnosed pertussis infection, compared with the general population, according to a study in the November 3 issue of JAMA.

Pertussis, an acute respiratory tract infection, is among the most common vaccine-preventable childhood diseases in developed countries. Worldwide, an estimated 16 million cases occur each year; almost 50,000 pertussis cases were reported in the United States in 2012. Pertussis is characterized by spasms of coughing and a protracted course. During the acute phase, pertussis is associated with seizures in infants, but the likelihood of developing epilepsy has not been known. Epilepsy is the most common neurologic childhood disorder, and its cause is poorly understood, according to background information in the article.

Morten Olsen, M.D., Ph.D., of the Aarhus University Hospital, Aarhus N, Denmark, and colleagues used population-based medical registries covering all Danish hospitals to identify all patients with pertussis born between 1978 and 2011, followed up through 2011. A database was used to identify 10 individuals from the general population for each patient with pertussis, matched on sex and year of birth.

The researchers identified 4,700 patients with pertussis (48 percent male), of whom 53 percent were diagnosed before age 6 months. In the pertussis cohort, 90 children were diagnosed with epilepsy, compared with 511 children in the comparison cohort. The cumulative incidence of epilepsy at age 10 years was 1.7 percent for patients in the pertussis cohort and 0.9 percent for members of the comparison cohort. Patients older than 3 years when diagnosed with pertussis were not at increased risk of epilepsy compared with the general population.

The authors write that potential mechanisms underlying the observed association include hypoxic brain damage from coughing, perhaps via increased intrathoracic and intra-abdominal pressure and central nervous system hemorrhages.

(doi:10.1001/jama.2015.13971; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The study was supported by grants from the Program for Clinical Research Infrastructure established by the Lundbeck Foundation and the Novo Nordisk Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, NOVEMBER 3, 2015

Media Advisory: To contact Louise Kuhn, Ph.D., call Stephanie Berger at 212-305-4372 or email sb2247@columbia.edu. To contact editorial author Ram Yogev, M.D., call Julie Pesch at 312-227-4261 or email jpesch@luriechildrens.org.

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Louise Kuhn, Ph.D., of Columbia University, New York, and colleagues evaluated whether HIV-infected children in South Africa who had achieved viral suppression with one treatment could transition to efavirenz-based therapy without risk of viral failure. The study appears in the November 3 issue of JAMA.

Implementation of pediatric antiretroviral treatment (ART) programs in sub-Saharan Africa has resulted in significant reductions in morbidity and mortality among children infected with human immunodeficiency virus (HIV), changing a rapidly fatal disease into a chronic condition. For infants and young children, ritonavir-boosted lopinavir-based therapy is recommended as first-line ART. In adults and older children, efavirenz is recommended as part of first-line ART. Advantages of this regimen include once-daily dosing, simplification of co-treatment for tuberculosis, preservation of ritonavir-boosted lopinavir for second-line treatment, and alignment of adult and pediatric treatment regimens. However, there have been concerns about possible reduced viral efficacy of efavirenz in children exposed to nevirapine for prevention of mother-to-child transmission.

This study, conducted at a hospital in Johannesburg, South Africa, included HIV-infected children 3 years of age or older exposed to nevirapine for prevention of mother-to-child transmission and who had plasma HIV RNA of less than 50 copies/ml during ritonavir-boosted lopinavir-based therapy. Participants were randomly assigned to switch to efavirenz-based therapy (n = 150) or continue ritonavir-boosted lopinavir-based therapy (n = 148). The children were followed up to 48 weeks after randomization.

The researchers found that switching to efavirenz-based therapy compared with continuing ritonavir-boosted lopinavir-based therapy did not result in significantly higher rates of viral rebound (i.e., HIV RNA >50 copies/mL) or viral failure (i.e., confirmed HIV RNA >1000 copies/mL). “This therapeutic approach may offer advantages in children such as these.”

“There is little guidance available as to what clinicians ought to do when confronted with a child older than 3 years who has begun treatment with ritonavir-boosted lopinavir. As a result, it has been left to individual interpretation, and there are anecdotal reports of clinicians switching to efavirenz in the absence of data to support such a practice. This study provides evidence to support the safety and efficacy of switching to efavirenz, the recommended drug for children older than 3 years, among children with viral suppression,” the authors write.

(doi:10.1001/jama.2015.13631; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: Antiretroviral Therapy for Nevirapine-Exposed Children With HIV Infection

Ram Yogev, M.D., of Lurie Children’s Hospital, Chicago, comments on the findings of this study in an accompanying editorial.

“The study by Coovadia et al is an important contribution in the evolving science of how to treat perinatally HIV­infected children. Even when combination ART controls the viral load, HIV-related complications remain (e.g., cardiovascular disease), and strategies to improve patient outcomes are needed that include early treatment and chemoprophylaxis as well as research on vaccines and an effective cure.”

(doi:10.1001/jama.2015.13763; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 27, 2015

Media Advisory: To contact Jiemin Ma, Ph.D., M.H.S., email David Sampson at david.sampson@cancer.org. To contact editorial author J. Michael McGinnis, M.D., M.P.P., email Jennifer Walsh at jwalsh@nas.edu.

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An analysis of deaths in the United States between 1969 and 2013 finds an overall decreasing trend in the age-standardized death rate for all causes combined and for heart disease, cancer, stroke, unintentional injuries, and diabetes, although the rate of decrease appears to have slowed for heart disease, stroke, and diabetes, according to a study in the October 27 issue of JAMA.

A comprehensive examination of long-term trends in mortality is important for health planning and priority setting and for identifying modifiable factors that may contribute to the trends. Jiemin Ma, Ph.D., M.H.S., of the American Cancer Society, Atlanta, and colleagues analyzed U.S. national vital statistics data from 1969 through 2013 to determine total and annual percent change in age-standardized death rates and years of potential life lost before age 75 years for all causes combined and for the leading causes.

Between 1969 and 2013, the age-standardized death rate for all causes combined decreased from 1,279 per 100,000 population to 730 (43 percent reduction) – an average annual decrease of 1.3 percent. Five of the six leading causes of death experienced an overall decline in death rates during this time period. The rate of death (per 100,000) decreased for stroke by 77 percent; for heart disease, by 68 percent; for unintentional injuries, by 40 percent; for cancer, by 18 percent; and for diabetes, by 17 percent. The death rate for chronic obstructive pulmonary disease (COPD) increased by 101 percent during this period. However, during the last time segment in the analysis, the death rate for COPD in men began to decrease and the declines in rates slowed for heart disease, stroke, and diabetes. For example, the annual decline for heart disease slowed from 3.9 percent during the 2000-2010 period to 1.4 percent during the 2010-2013 period.

Between 1969 and 2013, age-standardized years of potential life lost per 1,000 decreased from 1.9 to 1.6 for diabetes (14.5 percent reduction); a 41 percent reduction for cancer; 48 percent for unintentional injuries; 68 percent for heart disease; and 75 percent for stroke. For COPD, the rate for years of potential life lost did not decrease over this time interval.

The researchers write that the progress against heart disease and stroke is attributed to improvements in control of hypertension and hyperlipidemia, smoking cessation, and medical treatment. “The reduction in cancer deaths since the early 1990s is also an outcome of tobacco control efforts, as well as advances in early detection and treatment. Notably, the years-of-potential-life lost rate from cancer has been decreasing since 1969, preceding the decline in cancer death rates by about 20 years. This may reflect the importance of smoking cessation in substantially reducing premature mortality. The overall decrease in the death rate for unintentional injuries has been largely attributed to continuous declines in motor vehicle–related deaths.”

The authors note that the observed recent slowing of the decline in death rates for obesity-related diseases (e.g., heart disease, stroke, and diabetes) may reflect the lagged consequences of increased obesity prevalence since the 1980s.

“Further disease-specific studies are needed to investigate these trends. Regardless of the changes in death rates, the increasing numbers of old persons in the United States and growth of the U.S. population will pose a considerable challenge for health care delivery in the coming decades, in view of the shortage of primary care physicians and geriatricians, increasing cost of health care, and the lag between healthy life and life expectancies.”

(doi:10.1001/jama.2015.12319; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This work was supported by the Intramural Research Department of the American Cancer Society. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: Mortality Trends and Signs of Health Progress in the United States

“Death rate may have at one time served as a sufficient measure of health system performance, but assessment now requires more textured insights, including those that reflect the improving capacity to measure health status, risk prevalence, and service access, effectiveness, and affordability,” writes J. Michael McGinnis, M.D., M.P.P., of the National Academy of Medicine, Washington D.C., in an accompanying editorial.

“What is needed is a set of national vital health indicators that is broader than mortality, but still a limited number, tightly constructed, standardized, and reliably available at all levels from local to national. Earlier this year, an Institute of Medicine Committee on Core Metrics for Better Health at Lower Cost, released its report, Vital Signs: Core Metrics for Health and Health Care Progress. The Committee recommended 15 core measures across 4 domains—healthy people, quality care, affordable care, and engaged people—which could be assembled from a manageable set of standardized measures to be collected system-wide. Whether through adoption of this or some other expanded notion of what should constitute the nation’s truly vital signs, the time has arrived to match the capacity with the potential and the need.”

(doi:10.1001/jama.2015.12391; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 27, 2015

Media Advisory: To contact corresponding author Elliot Israel, M.D., call Lori Schroth at 617-525-6374 or email ljschroth@partners.org.

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Among black adults with asthma treated with an inhaled corticosteroid, adding a long-acting beta-agonist did not improve the time to an asthma exacerbation compared with adding the anticholinergic tiotropium, according to a study in the October 27 issue of JAMA.

National treatment recommendations suggest increasing inhaled corticosteroid (ICS) dose or adding a long-acting beta-agonist (LABA) to asthma patients with poor asthma control on low-dose ICS. However, asthma experts and the U.S. Food and Drug Administration have questioned the safety of LABA therapy, noting possible increases in serious events, including hospitalizations and death. Data suggest that LABA risks, if they exist, may disproportionately affect black populations and that black individuals may not benefit from LABAs to the same degree as individuals of other races. Investigations in predominantly white populations have attempted to determine if long-acting anticholinergics (a class of drugs that inhibit the transmission of certain nerve impulses, reducing spasms of smooth muscles, such as in the lungs) can substitute for LABAs in asthma, according to background information in the article.

Michael E. Wechsler, M.D., M.Sc., of National Jewish Health, Denver, and Elliot Israel, M.D., of Brigham and Women’s Hospital, Boston, and colleagues randomly assigned black adults with moderate to severe asthma to receive ICS plus either once-daily tiotropium (n = 532) or twice-daily LABAs (n = 538). Patients completed monthly questionnaires and were followed up for up to 18 months. Patients also underwent genetic testing. Some studies have suggested that a genetic variation may be associated with increased rates of adverse outcomes when LABAs are used for asthma, especially among black patients.

The researchers found that the primary outcome, time to first exacerbation, did not differ significantly between groups. In addition, LABA + ICS was not superior to tiotropium + ICS for secondary outcomes that addressed additional dimensions of asthma control, such as patient-reported outcomes (quality of life, asthma control, symptom index, symptom-free days), spirometry (a test of the air capacity of the lungs), rescue medication use, and asthma deteriorations.

Genetic variants were not associated with differential responses to therapy.

“These findings do not support the superiority of LABA + ICS compared with tiotropium + ICS for black patients with asthma,” the authors write.

“Although we could not detect a difference in exacerbations between either combination therapy, we found that, despite combination therapy, this population experienced a high rate of exacerbations. Additional targeted interventions and further study are needed to reduce the rate of asthma exacerbations in this population.”

(doi:10.1001/jama.2015.13277; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This project was supported by a grant from the Agency for Healthcare Research and Quality. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 27, 2015

Media Advisory: To contact co-author Benjamin D. Sommers, M.D., Ph.D., call Todd Datz at 617-432-8413 or email tdatz@hsph.harvard.edu.

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In a study of federal marketplace insurance plans, nearly 15 percent completely lacked in-network physicians for at least 1 specialty, a practice found among multiple states and issuers, raising concerns regarding patient access to specialty care, according to a study in the October 27 issue of JAMA.

Nearly 12 million individuals have enrolled in coverage through the Affordable Care Act’s insurance marketplaces. The U.S. Department of Health and Human Services regulates plans, applying a “reasonable access” standard to ensure access to “a sufficient number and type of providers.” Concerns remain about network adequacy, according to background information in the article.

Stephen C. Dorner, M.Sc., of the Harvard T. H. Chan School of Public Health, Boston, and colleagues examined physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment; this analysis included 135 plans. Using plans’ online directories, the authors searched for in-network specialist physicians for various specialties.

Using a 100 mile and 50 mile search radius, 18 (13 percent) and 19 (14 percent), respectively, of 135 plans were specialist-deficient plans (plans without a specialist physician). Endocrinology, rheumatology, and psychiatry were most commonly excluded, and an additional 7-14 plans had fewer than 5 in-network physicians in those specialties. There was no significant difference in the proportion of specialist­ deficient plans across insurance plan premium levels. Nine of 34 states (24 percent) had at least 1 specialist-deficient plan. Twelve different insurers had at least 1 specialist-deficient plan.

Beneficiaries of specialist-deficient plans had high out-of-network costs; 5 of 19 (26 percent) plans did not cover out-of-network services, whereas 11 of the remaining 14 plans (79 percent) required cost-sharing of 50 percent or more. Nine of 19 (47 percent) did not cover medications prescribed by out-of-network physicians. There was no significant difference in premiums between specialist-deficient plans and other plans.

Regarding plans that lack in-network physicians for at least 1 specialty, “this likely violates network adequacy requirements, raising concerns regarding patient access to specialty care,” the authors write. “Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.”

(doi:10.1001/jama.2015.9375; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Sommers reported currently serving part-time as a senior advisor to the U.S. Department of Health and Human Services. No other disclosures were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) MONDAY, OCTOBER 26, 2015

Media Advisory: To contact Bridget K. Ambrose, Ph.D., M.P.H., call Michael Felberbaum at 240-402-9548 or email michael.felberbaum@fda.hhs.gov.

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JAMA

Among a survey of youth 12 to 17 years of age, the majority who self-reported ever experimenting with tobacco started with a flavored product, and most current tobacco users reported use of flavored products, according to a study published by JAMA.

Most tobacco use begins during youth and young adulthood. Recent declines in prevalence of cigarette smoking among youth have coincided with increased use of e-cigarettes and hookahs. Although flavors other than menthol are prohibited in cigarettes in the United States, flavored noncigarette tobacco products are widely available and may appeal to youth, according to background information in the article.

Bridget K. Ambrose, Ph.D., M.P.H., of the Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Md., and colleagues examined flavored tobacco use among U.S. youth using data from the Population Assessment of Tobacco and Health Study, a household-based, nationally representative study of 45,971 adults and youth (12-17 years) in the United States. Youth responded to questions about ever and past 30-day use of tobacco products including cigarettes, e-cigarettes, hookahs, cigars, pipe tobacco, all types of smokeless tobacco, dissolvable tobacco, bidis, and kreteks. For each product ever used, youth answered whether the first product they used was flavored (e.g., “Was the first e-cigarette you used flavored to taste like menthol, mint, clove, spice, candy, fruit, chocolate, alcohol [such as wine or cognac], or other sweets?”).

Of the 13,651 youth enrolled and included in this analysis, 51 percent were male, 55 percent non-Hispanic white, 14 percent non-Hispanic black, and 23 percent Hispanic; average age was 14.5 years. The majority of youth ever-users reported that the first product they had used was flavored, including 89 percent of ever hookah users, 81 percent of ever e-cigarette users, 65 percent of ever users of any cigar type, and 50 percent of ever cigarette smokers. For past 30-day youth tobacco use, the overall proportion of flavored product use was 80 percent among users of any product and 89 percent among hookah users, 85 percent among e-cigarette users, 72 percent among users of any cigar type, and 60 percent among cigarette smokers. Youth consistently reported product flavoring as a reason for use across all product types, including e-cigarettes, hookahs, cigars, smokeless tobacco, and snus pouches.

“Consistent with national school-based estimates, this study confirms widespread appeal of flavored products among youth tobacco users. In addition to continued proven tobacco control and prevention strategies, efforts to decrease use of flavored tobacco products among youth should be considered,” the authors write.

(doi:10.1001/jama.2015.13802; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Funded by the National Institute on Drug Abuse, National Institutes of Health, and the U.S. FDA, Department of Health and Human Services. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 20, 2015

Media Advisory: To contact corresponding author Robert A. Smith, Ph.D., of the American Cancer Society, email David Sampson at david.sampson@cancer.org. To contact editorial co-author Nancy L. Keating, M.D., M.P.H., email David Cameron at David_Cameron@hms.harvard.edu.

To place an electronic embedded link to this study and editorial in your story This link to the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.12783 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.13086

Among the changes in the American Cancer Society’s updated breast cancer screening guideline is that women with an average risk of breast cancer should undergo regular, annual screening mammography beginning at age 45 years, with women having an opportunity to choose to begin annual screening as early as age 40; women 55 years and older should transition to screening every other year (vs annual), but still have the opportunity to continue with annual screening; and routine screening clinical breast examination is no longer recommended, according to an article in the October 20 issue of JAMA.

Breast cancer is the most common cancer in women worldwide. In the United States, it is estimated that approximately 230,000 women will be diagnosed with breast cancer in 2015. Breast cancer continues to rank second, after lung cancer, as a cause of cancer death in women in the U.S., and is a leading cause of premature mortality for women. Even though death from breast cancer has declined steadily since 1990, largely due to improvements in early detection and treatment, an estimated 40,300 women in the U.S. will die of breast cancer in 2015. Early detection is associated with reduced breast cancer illness and death, according to background information in the article.

Since the last American Cancer Society (ACS) breast cancer screening update for average-risk women was published in 2003, new evidence has accumulated from long-term follow-up of randomized controlled trials and observational studies of organized, population-based screening programs. Evan R. Myers, M.D., M.P.H., of the Duke Evidence Synthesis Group, Duke Clinical Research Institute, Durham, N.C., and colleagues conducted a systematic review of the breast cancer screening literature to update the American Cancer Society 2003 breast cancer screening guideline for women at average risk for breast cancer (this study appears in JAMA); Diana L. Miglioretti, Ph.D., of the University of California Davis School of Medicine, and colleagues performed an analysis of Breast Cancer Surveillance Consortium mammography registry data to address questions related to screening intervals (this study appears in JAMA Oncology). Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms.

The 2015 recommendations for breast cancer screening for women at average risk:

Women should undergo regular screening mammography starting at age 45.

Women 45 to 54 years of age should be screened annually.

Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually.

Women should have the opportunity to begin annual screening between the ages of 40 and 44 years.

Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.

Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age.

“The ACS endorses beginning annual screening mammography at age 45 years and transitioning to biennial screening at age 55 years, while retaining the option to continue annual screening, which some women may elect based on personal preference, clinical guidance, or both,” the authors write. “After careful examination of the burden of disease among women aged 40 to 54 years, the guideline development group (GDG) concluded that the lesser, but not insignificant, burden of disease for women aged 40 to 44 years and the higher cumulative risk of adverse outcomes no longer warranted a direct recommendation to begin screening at age 40 years.”

Regarding no longer recommending periodic clinical breast examination (CBE), the researchers write that “the absence of clear evidence that CBE contributed significantly to breast cancer detection prior to or after age 40 years led the GDG to conclude that it could no longer be recommended for average-risk women at any age.”

“This guideline is intended to provide guidance to the public and clinicians, and it is especially designed for use in the context of a clinical encounter. Women should be encouraged to be aware of and to discuss their family history and medical history with a clinician, who should periodically ascertain whether a woman’s risk factor profile has changed. If the woman has an average risk of developing breast cancer, the ACS encourages a discussion of screening around the age of 40 years. The ACS also recommends that women be provided with information about risk factors, risk reduction, and the benefits, limitations, and harms associated with mammography screening.”

“In conclusion, the ACS recommendations are made in the context of maximizing reductions in breast cancer mortality and reducing years of life lost while minimizing the associated harms among the population of women in the United States. The ACS recognizes that the balance of benefits and harms will be close in some instances and that the spectrum of women’s values and preferences will lead to varying decisions. The intention of this new guideline is to provide both guidance and flexibility for women about when to start and stop screening mammography and how frequently to be screened for breast cancer.”

(doi:10.1001/jama.2015.12783; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The American Cancer Society supported the development of this guideline through the use of general funds. Dr. Oeffinger was supported in part through a Cancer Center Support Grant from the National Institutes of Health/National Cancer Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Editorial: New Guidelines for Breast Cancer Screening in U.S. Women

“Will the new ACS guideline make it easier for clinicians and women to make decisions about screening mammography? In some ways, the messages from ACS and the U.S. Preventive Services Task Force (USPSTF), 2 major guidelines, are now more consistent. Both guidelines agree that for average-risk women younger than 45 years, the harms of mammography screening likely outweigh the benefits,” write Nancy L. Keating, M.D., M.P.H., of Harvard Medical School, Boston, and Lydia E. Pace, M.D., M.P.H., of Brigham and Women’s Hospital, Boston, in an accompanying editorial.

“For women older than 55 years, biennial mammography is likely to provide the best balance of benefits to harms. The new ACS recommendation to stop screening older women with life expectancies of less than 10 years is practical and consistent with the increasing emphasis on functional vs chronologic age. The more challenging decisions are for women aged 45 to 54 years, for whom ACS recommends annual screening, but for whom the USPSTF recommends no routine screening (age 45-49 years) or biennial screening (age 50-54 years). In communicating with patients, clinicians will have to balance the ACS’ recommendation for more frequent screening against the fact that younger women experience a lower absolute benefit from screening mammography.”

(doi:10.1001/jama.2015.13086; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

Note: The video below is a helpful summary of the updated breast cancer screening recommendations.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 20, 2015

Media Advisory: To contact Benjamin W. Friedman, M.D., M.S., call Helene Guss at 718-920-4712 or email hguss@montefiore.org.

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Among patients with acute, low back pain presenting to an emergency department, neither the nonsteroidal anti-inflammatory drug (NSAID) naproxen combined with oxycodone/acetaminophen or the muscle relaxant cyclobenzaprine provided better pain relief or improvement in functional outcomes than naproxen combined with placebo, according to a study in the October 20 issue of JAMA.

Low back pain (LBP) is responsible for 2.4 percent of visits to U.S. emergency departments, resulting in more than 2.5 million visits annually. These patients are usually treated with NSAIDs, acetaminophen, opioids, or skeletal muscle relaxants, often in combination. Pain outcomes for these patients are generally poor.

Benjamin W. Friedman, M.D., M.S., of the Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y., and colleagues randomly assigned 323 patients who presented to an emergency department with nontraumatic, nonradicular LBP of 2 weeks’ duration or less to receive a 10-day course of naproxen + placebo (n = 107); naproxen + cyclobenzaprine (5 mg) (n = 108); or naproxen + oxycodone, 5 mg/acetaminophen, 325 mg (n = 108). Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP; naproxen, 500 mg, was to be taken twice a day. Patients also received a standardized 10-minute LBP educational session prior to discharge.

The researchers found that neither naproxen combined with oxycodone/acetaminophen nor naproxen combined with cyclobenzaprine provided better pain relief or better improvement in functional outcomes than naproxen combined with placebo. Measures of pain, functional impairment, and use of health care resources were not different between the study groups at 7 days or at 3 months after the emergency department visit.

Regardless of allocation, nearly two-thirds of patients demonstrated clinically significant improvement in LBP and function 1 week later. However, 40 percent of the cohort reported moderate or severe pain, half reported functionally impairing LBP, and nearly 60 percent were still using medication for their LBP 1 week later. By 3-month follow-up, nearly one-fourth of the cohort reported moderate or severe pain and use of medications for LBP. Three months after the emergency department visit, regardless of study group, opioid use for LBP was uncommon, with fewer than 3 percent of patients reporting use of an opioid within the previous 72 hours.

“These findings do not support the use of these additional medications in this setting,” the authors write.

(doi:10.1001/jama.2015.13043; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) TUESDAY, OCTOBER 20, 2015

Media Advisory: To contact Nathalie Auger, M.D., M.Sc., F.R.C.P.C., email William Raillant-Clark at w.raillant-clark@umontreal.ca.

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An analysis of more than 1.9 million mother and infant pairs finds that preeclampsia was significantly associated with noncritical heart defects in offspring, and preeclampsia with onset before 34 weeks was associated with critical heart defects; however, the absolute risk of congenital heart defects was low, according to a study in the October 20 issue of JAMA.

Congenital heart defects are the most common anomalies in infants, affecting every 8 births per 1,000, and are a major cause of infant illness and death, despite significant advancements in medical care. The causes and risk factors for congenital heart defects are mostly unknown. Some studies have shown that the pathology of preeclampsia (a disorder of pregnancy characterized by high blood pressure and excess protein in the urine) begins early and possibly even at the start of pregnancy, around the time of fetal heart morphogenesis. Despite the plausible link, evidence that preeclampsia is associated with congenital heart defects has largely been absent, according to background information in the article.

Nathalie Auger, M.D., M.Sc., F.R.C.P.C., of the University of Montreal, Quebec, Canada and colleagues conducted an analysis of live births before discharge (1989-2012) for the entire province of Quebec, comprising a quarter of Canada’s population. All women who delivered an infant with or without heart defects in any Quebec hospital were included (n = 1,942,072 neonates). The researchers examined the presence of any critical or noncritical congenital heart defect detected in infants at birth, comparing prevalence in those exposed and not exposed to preeclampsia. In general, critical heart defects lead to significant mortality and morbidity if not diagnosed promptly after birth; for noncritical defects, mortality and morbidity are much lower.
The overall prevalence of heart defects was 8.9 per 1,000 infants. Prevalence was higher for infants of women with preeclampsia than without preeclampsia (16.7 vs 8.6 per 1,000). Risk was elevated for defects affecting all general structures of the heart, including the aorta, pulmonary artery, valves, ventricles, and septa. Infants of women with preeclampsia had no increased prevalence of critical heart defects but did have an increased prevalence of noncritical heart defects compared with infants of non-preeclamptic women. Compared with infants of women with late-onset preeclampsia, those with early onset (<34 weeks) had greater prevalence of critical and noncritical heart defects. The absolute risk of congenital heart defects was low.

“Our results help advance the current understanding of the pathophysiology of preeclampsia and congenital heart defects. The relationship between them supports the notion that these disorders share common risk factors and etiology, beginning very early in pregnancy and involving a long cascade of events affecting the development of fetal heart structures throughout gestation,” the authors write.

“Prevention of both preeclampsia and heart defects may well depend on the ability to elucidate these pathways more clearly in future research. Until then, clinicians should be alert to the possibility that preeclampsia may increase the risk of heart defects in fetuses, although more research is needed in other settings to confirm our findings before modification of clinical practice.”

(doi:10.1001/jama.2015.12505; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) TUESDAY, OCTOBER 20, 2015

Media Advisory: To contact Lakshmi Sukumaran, M.D., M.P.H., call Melissa Brower at 404-639-4718 or email mbrower@cdc.gov.

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Among women who received the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine during pregnancy, there was no increased risk of adverse events in the mothers or adverse birth outcomes in newborns for women who had received a tetanus-containing vaccine in the previous 5 years, according to a study in the October 20 issue of JAMA.

Pertussis (whooping cough) is a vaccine-preventable illness that has been increasing in incidence over the past decade in the United States. Neonates (a baby from birth to four weeks) and infants are at increased risk of pertussis-related hospitalization and death compared with older children and adults. The Advisory Committee on Immunization Practices recommends the Tdap vaccine for pregnant women during each pregnancy, regardless of prior immunization status. However, safety data on repeated Tdap vaccination in pregnancy has been lacking, according to background information in the article.

Lakshmi Sukumaran, M.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted a study that included 29,155 pregnant women, ages 14 through 49 years, using data from 2007 to 2013 from 7 Vaccine Safety Datalink sites in California, Colorado, Minnesota, Oregon, Washington, and Wisconsin. The authors examined outcomes for women who received Tdap in pregnancy following a prior tetanus-containing vaccine less than 2 years before, 2 to 5 years before, and more than 5 years before.

The researchers found no significant differences in rates of acute adverse events in the mothers (fever, allergy, and local reactions) or adverse birth outcomes in neonates (small for gestational age, preterm delivery, and low birth weight) when comparing women who were vaccinated with Tdap during pregnancy regardless of the length of time since a prior tetanus-containing vaccine.

“Our findings should reassure patients and clinicians who might be hesitant to give Tdap vaccine to pregnant women who recently received a Tdap or other tetanus-containing vaccination,” the authors write.

The researchers add that future studies are needed to determine if there are differences in other important adverse pregnancy outcomes, such as stillbirth and spontaneous abortion, when Tdap is given in pregnancy in close intervals from prior tetanus-containing vaccines.

(doi:10.1001/jama.2015.12790; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This work was supported by the Centers for Disease Control and Prevention and a grant from the National Institute of Allergy and Infectious Diseases. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 20, 2015

Media Advisory: To contact Ulrik Sartipy, M.D., Ph.D., email ulrik.sartipy@karolinska.se.

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Although some studies have suggested that transfusion of stored red blood cell (RBC) concentrates may be harmful, as blood undergoes several physiological changes during storage, an analysis of patients who underwent cardiac surgery in Sweden over a 16-year period found no association between duration of RBC storage and risk of death or serious complications, according to a study in the October 20 issue of JAMA.

Ulrik Sartipy, M.D., Ph.D., of Karolinska University Hospital, Stockholm, Sweden and colleagues identified all patients in Sweden who underwent coronary artery bypass graft surgery, heart valve surgery, or both between 1997 and 2012. Transfusion data were obtained from a nationwide register of blood transfusions. Linkage with national health data registers provided vital status and adverse outcomes. Blood services in Sweden are part of the public health care system and follow national guidelines, whereby the oldest available blood unit of the appropriate blood type is allocated first.

During the study period, 47,071 patients were transfused in connection with cardiac surgery in 9 Swedish hospitals. Of these patients, 37 percent exclusively received RBCs stored less than 14 days; 27 percent, RBCs stored 14-27 days; 9 percent, RBCs stored 28-42 days; and 28 percent, RBCs of mixed age. Compared with recipients of RBCs stored for less than 14 days, there was no association between transfusion of RBCs stored 14-27 days or 28-42 days and 30-day, 2-year and 10-year mortality. There was no association with risk of selected serious complications.

“These results complement recent randomized trials in providing further reassurance of the safety of current blood storage practices,” the authors write.

(doi:10.1001/jama.2015.8690; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) TUESDAY, OCTOBER 13, 2015

Media Advisory: To contact Beth Han, M.D., Ph.D., M.P.H., call Bradford Stone at 240-276-2140 or email Bradford.Stone@SAMHSA.hhs.gov. To contact editorial co-author Lewis S. Nelson, M.D., call Rob Magyar at 212-404-3591 or email Robert.magyar@nyumc.org.

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From 2003 to 2013, the percentage of nonmedical use of prescription opioids decreased among adults in the U.S., while the prevalence of prescription opioid use disorders, frequency of use, and related deaths increased, according to a study in the October 13 issue of JAMA.

Since 1999, the United States has experienced increases in illness and death associated with nonmedical use of prescription opioids, which is being called a U.S. epidemic. During this period, emergency department visits and drug overdose deaths involving these drugs have increased rapidly. To fully understand the current status of the epidemic and who is currently most affected, an examination of nationally representative U.S. surveillance data is needed.

Beth Han, M.D., Ph.D., M.P.H., of the Substance Abuse and Mental Health Services Administration, Rockville, Md., and colleagues examined the prevalence of nonmedical use and use disorders (dependence on or abuse of alcohol, marijuana, cocaine, hallucinogens, heroin, inhalants, or nonmedical use of prescription pain relievers, sedatives, or stimulants) and related risk factors with data from 472,200 persons who participated in the 2003-2013 National Surveys on Drug Use and Health. Mortality was based on the 2003-2013 National Vital Statistics System’s Multiple Cause of Death Files.

Among adults age 18 through 64 years, the prevalence of nonmedical use of prescription opioids decreased from 5.4 percent in 2003 to 4.9 percent in 2013, but the prevalence of prescription opioid use disorders increased from 0.6 percent in 2003 to 0.9 percent in 2013. The 12-month prevalence of high-frequency use (200 days or more) also increased from 0.3 percent in 2003 to 0.4 percent in 2013.

Mortality assessed by drug overdose death rates involving prescription opioids increased from 4.5 per 100,000 in 2003 to 7.8 per 100,000 in 2013. The average number of days of nonmedical use of prescription opioids increased from 2.1 in 2003 to 2.6 in 2013. The prevalence of having prescription opioid use disorders among nonmedical users increased to 15.7 percent in 2010, 16.1 percent in 2011, 17 percent in 2012, and 16.9 percent in 2013, from 12.7 percent in 2003.

“We found a significant decrease in the percentage of nonmedical use of prescription opioids, as well as significant increases in the prevalence of prescription opioid use disorders, high-frequency use, and related mortality among adults aged 18 through 64 years in the United States over the past decade. Furthermore, the increases identified in this study occurred in the context of increasing heroin use and heroin-related overdose deaths in the United States, supporting a need to address nonmedical use of prescription opioid and heroin abuse in a coordinated and comprehensive manner,” the authors write.

“Receiving treatment for substance use disorders is particularly critical. Most adults with prescription opioid use disorders or other substance use disorders neither receive treatment nor perceive a need for treatment. In 2013, more than three-fourths of adults aged 18 through 64 years who had prescription opioid use disorders did not receive any substance use treatment. Particularly, policy and societal barriers prevent broad dissemination, access, and adoption of highly effective medication-assisted therapies for people with prescription opioid use disorders.”

(doi:10.1001/jama.2015.11859; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Addressing the Opioid Epidemic

“If the observed decrease in rates of new opioid users reported by Han et al is sustained, understanding the reasons behind this change is important. These are likely multifactorial and may include the use of prescribing guidelines for chronic pain, rationalizing expectations of physicians and patients for pain control and functional outcome, media attention on the consequences of addiction, and regulatory and legal efforts. It is encouraging that the culture around prescription opioids is starting to change, especially when considering the marketing of a plethora of new opioids for the treatment of chronic pain, none of which has been shown to be safe and effective over the long term,” writes Lewis S. Nelson, M.D., of the New York University School of Medicine, and colleagues.

“The chronic, relapsing nature of opioid addiction means most patients are never ‘cured,’ and the best outcome is long-term recovery. The lifelong implications of this disease far outweigh the limited benefits of opioids in the treatment of chronic pain, and in many cases the risks inherent in the treatment of acute pain with opioids. The encouraging finding of declining opioid initiation rates should be tempered by the increasing rates of nonmedical opioid use disorders and the limited utilization of treatment programs. Although multifaceted approaches are needed to successfully address the opioid epidemic, an important step is to start at the beginning and keep opioid-naive patients opioid naive.”

(doi:10.1001/jama.2015.12397; Available pre-embargo to the media at http:/media.jamanetwork.com)

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 13, 2015

Media Advisory: To contact Brendan Saloner, Ph.D., call Stephanie Desmon at 410-955-7619 or email sdesmon1@jhu.edu.

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During the decade from 2004 to 2013, use of treatment remained low for individuals with opioid use disorders, according to a study in the October 13 issue of JAMA.

During the last decade, nonmedical use of opioid analgesics and heroin increased substantially in the United States. In the early 2000s, less than one-sixth of individuals with opioid use disorders (OUDs) received any treatment, and use of office-based treatment was rare. It is unknown whether treatment patterns have changed in recent years. Brendan Saloner, Ph.D., and Shankar Karthikeyan, M.P.P., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, used data from the 2004-2013 rounds of the National Survey of Drug Use and Health, a nationally representative annual survey of individuals age 12 years or older, to identify individuals with opioid abuse or dependence symptoms and if they received treatment for OUD in the prior 12 months. The sample was divided into two 5-year periods (2004-2008 vs 2009-2013) to provide reliable estimates.

In the combined sample, the researchers identified 6,770 respondents with OUDs. The adjusted rates for the percentage of individuals with OUDs receiving treatment were similar (18.8 percent in 2004-2008 vs 19.7 percent in 2009-2013).

The average number of treatment settings visited increased during the study period. The most common setting in both periods was self-help groups. More than half of individuals receiving treatment during both periods also visited outpatient treatment. Use of inpatient treatment increased from 37.5 percent in 2004-2008 to 52 percent in 2009-2013, and office-based treatment increased from 25 percent to 35 percent.

“Individuals in treatment received care in more settings, with the greatest increases in inpatient treatment and at physician’s offices. Although physician’s offices may provide access to buprenorphine, medication-assisted treatments are often unavailable in inpatient settings, which could hinder patient recovery,” the authors write.

(doi:10.1001/jama.2015.10345; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) TUESDAY, OCTOBER 13, 2015

Media Advisory: To contact Julie M. Fritz, Ph.D., P.T., call Julie Kiefer at 801-587-1293 or email julie.kiefer@utah.edu.

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Early physical therapy for recent-onset low back pain resulted in statistically significant improvement in disability compared to usual care, but the improvement was modest and did not achieve a difference considered clinically important at the individual patient level, according to a study in the October 13 issue of JAMA.

Lifetime prevalence of low back pain (LBP) is about 70 percent and accounts for 2 percent to 5 percent of all physician visits. The effect of early physical therapy for LBP is unclear. Guidelines advise delaying referral to physical therapy or other specialists for a few weeks to permit spontaneous recovery. Findings from recent observational studies suggest that some patients may benefit from early physical therapy.

Julie M. Fritz, Ph.D., P.T., of the University of Utah, Salt Lake City, and colleagues randomly assigned 220 patients with recent-onset LBP to early physical therapy (n = 108; consisted of 4 physical therapy sessions [manipulation and exercise]), or usual care (n = 112; no additional interventions during the first 4 weeks). All participants received back pain related education. One-year follow-up was completed by 207 participants (94 percent).

For the primary study outcome, early physical therapy showed improvement compared to usual care on a measure of disability after 3 months. A significant difference was not found for disability between groups at 1-year follow-up. There was no improvement in pain intensity at 4-week, 3-month, or 1-year follow-up. Most differences between groups were modest. There were no differences in health care utilization at any point.

“We found that patients in both groups improved rapidly. Rapid and substantial improvement by most patients with acute LBP limits treatment effects in early intervention studies. We detected a modest difference favoring early physical therapy that was better than the natural history of acute LBP for the primary outcome at 3-month follow-up. However, the between-group difference did not achieve the threshold for minimum clinically important difference. Furthermore, differences were mostly undetectable by 1 year,” the authors write.

(doi:10.1001/jama.2015.11648; Available pre-embargo to the media at http:/media.jamanetwork.com)

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: 11 A.M. (ET) THURSDAY, OCTOBER 8, 2015

Media Advisory: To contact Joshua D. Schiffman, M.D., call Linda Aagard at 801-587-7639 or email linda.aagard@hci.utah.edu. To contact editorial author Mel Greaves, Ph.D., email Mel.Greaves@icr.ac.uk.

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Multiple copies of a cancer-suppression gene may play a role in why elephants have a lower-than-expected rate of cancer, findings that have the potential to provide a better understanding of the mechanisms related to cancer suppression, including in humans, according to a study published online by JAMA.

The mechanisms that prevent accumulation of genetic damage and subsequent uncontrolled proliferation of somatic cells (any cell in the body that is not involved in reproduction) remain poorly understood. Understanding the cellular mechanism of cancer suppression in animals could benefit humans at high risk of cancer. Joshua D. Schiffman, M.D., of the University of Utah School of Medicine, Salt Lake City, and colleagues investigated the cancer rate in different mammals, including elephants, identified potential molecular mechanisms of cancer resistance, and compared response to DNA damage in elephants with that in healthy human controls and patients with Li-Fraumeni syndrome (LFS; a genetic syndrome with a high lifetime risk of cancer).

A comprehensive survey of necropsy data (information on disease and cause of death) was performed across 36 mammalian species to validate cancer resistance in large and long-lived organisms, including elephants (n = 644). The African and Asian elephant genomes were analyzed for potential mechanisms of cancer resistance. Peripheral blood lymphocytes (a type of white blood cell that plays a role in immunity and defending the body against disease) from elephants, healthy human controls, and patients with LFS were tested in vitro in the laboratory for DNA damage response. The study included African and Asian elephants (n = 8), patients with LFS (n = 10), and age-matched human controls (n = 11).

The authors write that a greater number of cells and cell divisions increases the chance of accumulating mutations resulting in malignant transformation. If all mammalian cells are equally susceptible to oncogenic mutations, then cancer risk should increase with body size (number of cells) and species life span (number of cell divisions), although it has been observed that cancer incidence across animals does not appear to increase as theoretically expected for larger body size and life span.

For this study, the researchers found that across mammals, cancer mortality did not increase with body size and/or maximum life span (e.g., for rock hyrax, 1 percent; African wild dog, 8 percent; lion, 2 percent). Despite their large body size and long life span, elephants remain cancer resistant, with an estimated cancer mortality of 4.8 percent, compared with humans, who have 11 percent to 25 percent cancer mortality.

While humans have 1 copy (2 alleles [one of a pair of alternative forms of a gene]) of TP53 (a crucial tumor suppressor gene, mutated in the majority of human cancers), African elephants have at least 20 copies (40 alleles). Patients with LFS inherit only 1 functioning TP53 allele and may have a lifetime risk of cancer approaching 90 percent to 100 percent. TP53 plays a central role in response to DNA damage through apoptosis (a form of cell death) and cell cycle arrest. In response to DNA damage, elephant lymphocytes underwent p53-mediated apoptosis at higher rates than human lymphocytes proportional to TP53 status. The multiple copies of TP53 and the enhanced p53-mediated apoptosis observed in elephants may have evolved to offer such cancer protection.

“Compared with other mammalian species, elephants appeared to have a lower-than-expected rate of cancer, potentially related to multiple copies of TP53. Compared with human cells, elephant cells demonstrated increased apoptotic response following DNA damage. These findings, if replicated, could represent an evolutionary-based approach for understanding mechanisms related to cancer suppression,” the authors write.

(doi:10.1001/jama.2015.13134; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Evolutionary Adaptations to Cancer Risk

“It is not clear what lessons the study of elephants by Abegglen and colleagues has for informing cancer risk in humans. Perhaps the main message from this innovative investigation is to bring into focus the question of why humans appear to be so ill-adapted to cancer, given the average size and life span? The human genome is replete with footprints of positive selection in the not too distant historical past. Humans may have acquired, in one particular respect, an extra cancer suppressor gene variant early on in evolutionary history approximately 1.8 million years ago,” writes Mel Greaves, Ph.D., of the Institute of Cancer Research, London, in an accompanying editorial.

“However, in other respects, as aging occurs, modern humans appear to be exceptionally vulnerable to cancer, especially in more developed societies. The explanation for this dilemma may involve other factors that greatly increase cancer risk. For instance, most human cancers (approximately 75 percent – 90 percent) are associated with lifestyles that are not found among animals, such as smoking, reproductive, dietary, and sun­soaking habits. These behaviors are relatively recently acquired by humans, over a few hundred years, and the risks they impart far exceed prior and otherwise effective cancer suppressor mechanisms that were inherited from primate ancestors. Contrariwise, humans have inadvertently become maladapted via mismatches between current lifestyles and inherent genetics that was adaptively forged in a very different ancestral environment.”

(doi:10.1001/jama.2015.13153; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The author’s research is supported by a grant from the Wellcome Trust. The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 8 A.M. (ET) WEDNESDAY, OCTOBER 7, 2015

Media Advisory: To contact Elie Azoulay, M.D., Ph.D., email elie.azoulay@sls.aphp.fr. To contact editorial co-author John P. Kress, M.D., email John Easton at John.Easton@uchospitals.edu.

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Among immunocompromised patients admitted to the intensive care unit with hypoxemic (inadequate oxygenation of the blood) acute respiratory failure, early noninvasive ventilation compared with oxygen therapy alone did not reduce the risk of death at 28 days, according to a study appearing in JAMA. The study is being released to coincide with its presentation at the 28th annual congress of the European Society of Intensive Care Medicine.

The number of patients living with immune deficiencies is increasing steadily. These patients are at high risk for life-threatening complications, including acute respiratory failure warranting admission to the intensive care unit (ICU). Mortality in this situation has ranged from 40 percent to 90 percent and remains high, despite improvements in recent years. Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure. However, its effectiveness has been unclear, according to background information in the article.

Elie Azoulay, M.D., Ph.D., of Saint-Louis University Hospital, Paris, and colleagues had 374 critically ill immunocompromised patients randomly assigned to early noninvasive ventilation (n = 191) or oxygen therapy alone (n = 183). Of these patients, 317 (85 percent) were receiving treatment for hematologic malignancies or solid tumors. The trial was conducted at 28 ICUs in France and Belgium.

On day 28 after randomization, 46 deaths (24 percent) had occurred in the noninvasive ventilation group vs 50 (27 percent) in the oxygen group. Oxygenation failure occurred in 155 patients overall (41 percent), 38 percent in the noninvasive ventilation group and 45 percent in the oxygen group. There were no significant differences in ICU-acquired infections, duration of mechanical ventilation, or lengths of ICU or hospital stays.

“In this multicenter randomized trial enrolling critically ill immunocompromised patients with acute respiratory failure, early noninvasive ventilation, compared with oxygen therapy alone, did not reduce the primary outcome of day-28 all-cause mortality, either overall or in any of the prespecified subgroups,” the authors write. “However, study power was limited.”

(doi:10.1001/jama.2015.12402; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The study was sponsored by 2 grants from the nonprofit organizations Legs Poix (Chancellerie des Universites de Paris) and the OUTCOMEREA study group. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: The Changing Landscape of Noninvasive Ventilation in the Intensive Care Unit

Bhakti K. Patel, M.D., and John P. Kress, M.D., of the University of Chicago, comment on this subject in an accompanying editorial.

“With additional efforts to continue to reduce the percentage of critically ill patients who require invasive mechanical ventilation, alternative strategies for noninvasive ventilation that minimize face mask leak, improve oxygenation, and decrease work of breathing with alternative interfaces such as high-flow nasal cannula will need further investigation.”

(doi:10.1001/jama.2015.12401; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 8 A.M. (ET) WEDNESDAY, OCTOBER 7, 2015

Media Advisory: To contact Paul Young, F.C.I.C.M., email paul.young@ccdhb.org.nz. To contact editorial co-author John A. Kellum, M.D., email Anita Srikameswaran at srikamav@upmc.edu.

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There was no significant difference in the incidence of acute kidney injury or failure for intensive care unit (ICU) patients who received a buffered crystalloid or saline for fluid therapy, according to a study appearing in JAMA. The study is being released to coincide with its presentation at the 28th annual congress of the European Society of Intensive Care Medicine.

The administration of intravenous fluids to increase intravascular volume or maintain hydration is a frequent intervention in the ICU, although the choice of fluid remains controversial. Globally, 0.9 percent sodium chloride (saline) is the most commonly used resuscitation fluid. However, despite its widespread use, emerging data provide uncertainty about the safety of saline in patients who are critically ill, with a concern that the high chloride content may contribute to the development of acute kidney injury (AKI), according to background information in the article.

One alternative to saline is a buffered crystalloid solution with an electrolyte composition that more closely resembles that of plasma, such as the prototype compound sodium lactate solutions or proprietary “buffered” or “balanced” crystalloid solutions. Observational data suggest that buffered crystalloids may be associated with a decreased risk of AKI and of death compared with saline. Paul Young, F.C.I.C.M., of the Medical Research Institute of New Zealand, Wellington, and colleagues studied 2,278 patients who were receiving treatment in 4 ICUs in New Zealand and requiring crystalloid fluid therapy. Of these patients, 1,152 of 1,162 patients (99 percent) receiving buffered crystalloid and 1,110 of 1,116 patients (99.5 percent) receiving saline were analyzed.

In the buffered crystalloid group, 102 of 1,067 patients (9.6 percent) developed AKI within 90 days after enrollment compared with 94 of 1,025 patients (9.2 percent) in the saline group. In the buffered crystalloid group, renal replacement therapy (dialysis) was used in 38 of 1,152 patients (3.3 percent) compared with 38 of 1,110 patients (3.4 percent) in the saline group. Overall, 7.6 percent of patients in the buffered crystalloid group and 8.6 percent of patients in the saline group died in the hospital.

“Further large randomized clinical trials are needed to assess efficacy in higher-risk populations and to measure clinical outcomes such as mortality,” the authors write.

(doi:10.1001/jama.2015.12334; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study was funded by the Health Research Council of New Zealand through a Research Partnership for Health Delivery grant and by Baxter Healthcare Corporation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Editorial: Assessing Toxicity of Intravenous Crystalloids in Critically Ill Patients

In an accompanying editorial, John A. Kellum, M.D., of the University of Pittsburgh, and Andrew D. Shaw, M.B., F.R.C.A., of the Vanderbilt University School of Medicine, Nashville, comment on the findings of this study.

“The results of the trial by Young et al provide reassurance that neither 0.9 percent saline nor a low-chloride electrolyte solution appears to be particularly hazardous when the total dose used in patients at low to moderate risk is about 2 L. This is an important contribution to the care of patients in the ICU. However, the large body of ‘circumstantial’ evidence that points to a harm signal for saline—with scant, if any, evidence of comparative benefit—should behoove intensivists and other clinicians to proceed with caution when ordering intravenous fluids.”

(doi:10.1001/jama.2015.12390; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) MONDAY, OCTOBER 5, 2015

Media Advisory: To contact Carlos G. Grijalva, M.D., M.P.H., call Craig Boerner at 615-322-4747 or email craig.boerner@vanderbilt.edu.

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Among children and adults hospitalized with community-acquired pneumonia, those with influenza-associated pneumonia, compared with those with pneumonia not associated with influenza, had lower odds of having received an influenza vaccination, according to a study published online by JAMA.

In the United States, seasonal influenza epidemics are responsible for an estimated average of 226,000 hospitalizations and between 3,000 and 49,000 deaths each year. Pneumonia, the leading infectious cause of hospitalization and death in the United States, is a relatively common and serious complication of influenza. Whether influenza vaccines can decrease the risk of influenza-associated hospitalizations for community acquired pneumonia remains unclear, according to background information in the article.

In an observational multicenter study of hospitalizations for community-acquired pneumonia conducted from January 2010 through June 2012 at 4 U.S. sites, Carlos G. Grijalva, M.D., M.P.H., of the Vanderbilt University School of Medicine, Nashville, Tenn., and colleagues used data from patients 6 months or older with laboratory-confirmed influenza infection and verified vaccination status during the influenza seasons. Odds ratios were calculated, comparing the odds of vaccination between influenza-positive (case) and influenza-negative (control) patients with pneumonia, controlling for various factors.

Overall, 2,767 patients hospitalized for pneumonia were eligible for the study; 162 (5.9 percent) had laboratory-confirmed influenza. Twenty-eight of 162 cases (17 percent) with influenza-associated pneumonia and 766 of 2,605 controls (29 percent) with influenza-negative pneumonia had been vaccinated. The estimated vaccine effectiveness was 57 percent, meaning that the odds of influenza vaccination among cases hospitalized with influenza-associated pneumonia was 57 percent lower than among noninfluenza pneumonia controls.

The authors note that the estimated odds ratio of vaccination between cases and controls, and derived vaccine effectiveness from this study, could be used to inform subsequent estimations of the national number of hospitalizations for pneumonia averted by influenza vaccination.

(doi:10.1001/jama.2015.12160; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This study was funded by the Influenza Division in the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) MONDAY, OCTOBER 5, 2015

Media Advisory: To contact Alexander J. Kallen, M.D., M.P.H., call Melissa Brower at 404-639-4718 or email mbrower@cdc.gov. To contact editorial author Mary K. Hayden, M.D., call Charlie Jolie at 312-217-1864 or email Charles_L_Jolie@rush.edu.

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The overall incidence in 2012-2013 was relatively low of a serious, highly drug-resistant group of bacteria (Carbapenem-resistant Enterobacteriaceae [CRE]) that are an important cause for health-care associated infections, according to a study published online by JAMA. Most CRE cases were associated with prior hospitalizations and discharge to long-term care settings.

Carbapenem-resistant Enterobacteriaceae are a worldwide clinical and public health problem. These multidrug-resistant organisms cause infections associated with high mortality and limited treatment options. Assessment of the U.S. epidemiology of CRE is needed to inform national prevention efforts, according to background information in the article.

Alexander J. Kallen, M.D., M.P.H., of the U.S. Centers for Disease Control and Prevention, Atlanta, and colleagues conducted a population- and laboratory-based active surveillance of CRE in 2012-2013 among individuals living in 1 of 7 U.S. metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. Cases of CRE were defined as carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobocter cloacae complex, Klebsiella pneumoniae, or Klebsiella oxytoca that were recovered from sterile-site or urine cultures during 2012-2013.

Among 599 CRE cases in 481 individuals, 520 (87 percent) were isolated from urine and 68 (11 percent) from blood. The median age was 66 years. The overall annual CRE incidence rate per 100,000 population was 2.93. The authors note that this estimate is substantially lower than the incidence of infections due to other pathogens traditionally associated with health care exposures, including methicillin-resistant Staphylococcus aureus (25.1 per 100,000 population), invasive candidiasis (13.3-26.2 per 100,000), and Clostridium difficile (147.2 per 100,000).

Most cases occurred in individuals with prior hospitalizations (75 percent) or indwelling devices (73 percent; such as urinary catheter, central venous catheter); 56 percent of admitted cases resulted in a discharge to a long-term care setting. Death occurred in 51 cases (9 percent), including in 27.5 percent of cases with CRE isolated from normally sterile sites.

The CRE standardized incidence ratio was significantly higher than predicted for the sites in Georgia (1.65), Maryland (1.44), and New York (1.42), and significantly lower than predicted for the sites in Colorado (0.53), New Mexico (0.41), and Oregon (0.28).

“The fact that heterogeneity exists (with respect to the incidence and the types of CRE found in these different surveillance areas) further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States. The frequency with which individuals with CRE are transferred between facilities emphasizes the need for regional control efforts in all the facilities,” the authors write.

“In summary, the results of this investigation further inform local efforts to prevent CRE transmission. The low CRE incidence in the catchment areas, compared with other more established resistant organisms, highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect.”

(doi:10.1001/jama.2015.12480; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: This work was supported by the Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases at the U.S. Centers for Disease Control and Prevention. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: Measuring Carbapenem-Resistant Enterobacteriaceae in the United States

“The study by Guh et al represents an important step forward for CRE control in the United States,” writes Mary K. Hayden, M.D., of Rush University Medical Center, Chicago.

“Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts. Whether the resources needed for this work will be made available is unclear.”

“In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative [used for this study] and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.”

(doi:10.1001/jama.2015.11629; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Hayden reported receiving grants from the U.S. Centers for Disease Control and Prevention.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 6, 2015

Media Advisory: To contact James Fleshman, M.D., call Craig Civale at 214-820-6251 or email Craig.Civale@baylorhealth.edu. To contact Andrew R. L. Stevenson, M.B.B.S., F.R.A.C.S., email admin@ausces.com. To contact editorial co-author Scott A. Strong, M.D., call Pat Tremmel at 847-491-4892 or email p-tremmel@northwestern.edu.

To place an electronic embedded link to these studies and editorial in your story This link to the 1^st study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.10529 This link to the 2^nd study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.12009 This will be the link to the editorial: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.11454

Compared to open resection (surgical removal) for rectal cancer, minimally invasive laparoscopic-assisted resection did not provide better cancer outcomes, according to two studies in the October 6 issue of JAMA.

Treatment of curable, locally advanced (stage II or III) rectal cancer relies on surgical resection as the core feature of a treatment process. Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease. There are concerns that not all the cancer can be removed with minimally invasive techniques. James Fleshman, M.D., of Baylor University Medical Center, Dallas, and colleagues conducted a trial in which 486 patients with clinical stage II or Ill rectal cancer were randomly assigned to laparoscopic or open resection to examine whether laparoscopic resection is noninferior (not worse than) to open resection, as determined by several measures of the adequacy of cancer removal. A 6 percent noninferiority margin was chosen as being a clinically important difference. . The trial was conducted at 35 institutions in the United States and Canada and sponsored by the American College of Surgeons and the National Cancer Institute.

Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis. They underwent surgery by surgeons with experience and proven expertise in the operations they were performing. Pre-determined measures of overall surgical success occurred in 82 percent of laparoscopic resection cases and 87 percent of open resection cases. “Laparoscopic resection failed to meet the criterion for noninferiority for pathologic outcomes compared with open resection and was thus potentially inferior,” the authors write. In terms of cancer control, the laparoscopic procedure was not shown to be as good as the traditional, open operation.

Operative time was significantly longer for laparoscopic resection. Hospital length of stay, readmission within 30 days, and severe complications were not significantly different.

The researchers write that one explanation for their findings is that proctectomy (resection of the rectum) is challenging, and it can be even more difficult to work in the deep pelvis with in-line rigid instruments used in laparoscopic surgery. Access to this very difficult area of the body might be better with the open procedure. .

“Pending clinical oncologic outcomes [such as survival or cancer recurrence rates], the findings do not support the use of laparoscopic resection in these patients.”

(doi:10.1001/jama.2015.10529; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In another study using the same design as the Fleshman study, Andrew R. L. Stevenson, M.B.B.S., F.R.A.C.S., of the University of Queensland, Brisbane, Australia, and colleagues conducted a phase 3 trial that included 475 patients with T1-T3 rectal cancer who were randomized to open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238) at 24 sites in Australia and New Zealand.

Proponents of the laparoscopic technique suggest that a similar tumor resection with better short-term outcomes can be achieved with minimal access surgery. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection, according to background information in the article.

For this trial, the primary outcome of a successful resection (a composite of oncological factors, with a noninferiority margin of 8 percent) was achieved in 194 patients (82 percent) in the laparoscopic surgery group and in 208 patients (89 percent) in the open surgery group and was the same as that of the Fleshman study. Non inferiority was not shown for the laparoscopic resection, meaning that it was not shown to be as good as the open operation for rectal cancer. In fact, a post hoc test for superiority suggested that open surgery was better. Additional analysis with adjustment for baseline prognostic factors, including pathological grade, did not significantly change the overall treatment effect.

There were no differences between the two groups in hospital length of stay, intensive care unit stay or analgesic requirement.

“We were unable to establish noninferiority of laparoscopic rectal cancer surgery in this large randomized trial,” the authors write. “Even though our trial was not designed to demonstrate whether one method of rectal dissection was superior to the other, the inability to establish noninferiority suggests that surgeons should be cautious when considering the suitability of a laparoscopic approach for a patient with rectal cancer.”

(doi:10.1001/jama.2015.12009; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: The study was supported by grants from the Colorectal Surgical Society of Australia and New Zealand Foundation and the National Health and Medical Research Council. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: Minimally Invasive Approaches to Rectal Cancer and Diverticulitis

The large, randomized, multicenter trials reported in this issue of JAMA substantiate recent findings from similar randomized trials that a laparoscopic resection may not be oncologically justified in many patients requiring proctectomy for rectal cancer, write Scott A. Strong, M.D., and Nathaniel J. Soper, M.D., of the Northwestern University Feinberg School of Medicine, Chicago.

“The studies do not signal a moratorium on these approaches, but surgeons must proceed in a judicious manner to ensure that patients are informed about the benefits and risks associated with minimally invasive and open operations.”

“Although the surgical management of patients with rectal cancer and diverticulitis has greatly improved, many questions persist and new ones continually arise that can be answered only with well-designed, rigorously conducted clinical trials. The utility of less intrusive strategies and minimally invasive approaches will undoubtedly expand as technologies evolve, but they must be responsibly incorporated into surgical practice based on evidence rather than subjective reasons.”

(doi:10.1001/jama.2015.11454; Available pre-embargo to the media at http:/media.jamanetwork.com)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, OCTOBER 6, 2015

Media Advisory: To contact Anne M. Moseley, Ph.D., email amoseley@georgeinstitute.org.au.

To place an electronic embedded link to this study in your story This link for the study will be live at the embargo time: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.12180

A supervised exercise program and self-management advice, like those commonly given with physical therapy, did not improve activity limitation or quality of life compared with advice alone after removal of immobilization for patients with an uncomplicated ankle fracture, according to a study in the October 6 issue of JAMA.

Ankle fracture is a common injury and is treated with reduction (realignment), sometimes with surgical fixation, followed by a period of immobilization while the fracture heals. The benefits of rehabilitation after immobilization for ankle fracture has been unclear, according to background information in the article.

Anne M. Moseley, Ph.D., of the University of Sydney, Australia, and colleagues randomly allocated 214 patients with isolated ankle fracture presenting to fracture clinics in 7 Australian hospitals to rehabilitation (n = 106) or advice alone (n = 108), following removal of their immobilization cast. Rehabilitation consisted of a supervised exercise program (individually tailored, prescribed, monitored, and progressed by a physical therapist) and advice about self-management. Participants in the advice group were provided with a single session of self-management advice about exercise and return to activity.

There was follow-up for 170 patients (79 percent) at 6 months. Activity limitation and quality of life were assessed at study entry and at 1, 3 and 6 months. At study entry, participants had significant activity limitation and low quality of life. The researchers found that the rehabilitation program and self-management advice did not improve activity limitation or quality of life compared with advice alone. The treatment effects were not associated with fracture severity, age or sex.

“We have previously shown that recovery of activity limitation after ankle fracture is rapid in the first 6 months and that adding passive stretch or manual therapy to a supervised exercise program did not enhance the benefits of exercise alone,” the authors write. “It is possible that the lack of treatment effect we observed in this trial is attributable to the fact that rehabilitation cannot accelerate this rapid recovery. These findings and the findings of the present trial suggest that routine care for patients after isolated ankle fracture should include self-management advice at the time of removal of immobilization but not a supervised exercise program [like those typically provided in a physical therapy program].”

(doi:10.1001/jama.2015.12180 Available pre-embargo to the media at http:/media.jamanetwork.com)

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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