Mary Ann Moon

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.

The benefits of aspirin therapy for primary prevention of cardiovascular disease outweigh the risks in patients who have coronary artery calcification scores of 100 or more, while the opposite is true in those who have scores of 0, according to a subanalysis of the MESA study published online in Circulation: Cardiovascular Quality and Outcomes.

In addition, the coronary artery calcium (CAC) score, a highly specific marker of the atherosclerotic plaque burden in the coronary arteries that is obtained via chest CT, predicts the risk/benefit ratio of aspirin therapy independently of traditional risk factors. These findings indicate that it can be used to guide aspirin therapy regardless of whether patients "qualify" for it according to AHA guidelines, said Dr. Michael D. Miedema of the Minneapolis Heart Institute and his associates.

Dr. Miedema and his colleagues assessed whether CAC could be used to fine-tune risk assessment and thus allow treatment of more patients, preventing more cardiovascular events while avoiding unnecessary exposure of patients in whom risk truly exceeds benefit. At present, aspirin therapy for primary prevention is recommended only for patients at elevated risk for a cardiovascular event because its risks, particularly that of bleeding, are considered to outweigh the benefits. This means aspirin prevention is withheld from lower-risk patients "who represent the majority of the primary prevention population and in whom a large proportion of CVD events occur."

They analyzed data from the Multi-Ethnic Study of Atherosclerosis, a longitudinal epidemiologic study involving 6,814 men and women aged 45-84 years at baseline in 2000 who were followed at six U.S. medical centers for a median of 7.6 years.

For their study, Dr. Miedema and his associates included 4,229 of these individuals in whom CAC scores were obtained at enrollment, none of whom had clinical CVD or diabetes at that time. A total of 56% had a CAC score of 0, 18% had a CAC score of 100 or more, and the remaining 26% had intermediate CAC scores of 1-99.

Compared with patients who had a CAC score of 0, those with CAC scores of 100 or higher had more than a ninefold higher risk (hazard ratio, 9.03) for a coronary heart disease event, defined as nonfatal MI, resuscitated cardiac arrest, or CHD death; and more than a sixfold higher risk (HR, 6.57) for a CVD event, defined as a CHD event or stroke, during follow-up. This difference remained robust after the data were adjusted to account for traditional risk factors, in both men and women, and regardless of patient age (Circ. Cardiovasc. Qual. Outcomes 2014 May 6 [doi:10.1161/circoutcomes.113.000690]).

The findings indicate that CAC score can be used to guide aspirin therapy, at least in the 74% of patients whose scores fall at the extreme ends of the spectrum rather than in the intermediate range, the researchers noted.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Miedema and his associates reported no financial conflicts of interest.

The benefits of aspirin therapy for primary prevention of cardiovascular disease outweigh the risks in patients who have coronary artery calcification scores of 100 or more, while the opposite is true in those who have scores of 0, according to a subanalysis of the MESA study published online in Circulation: Cardiovascular Quality and Outcomes.

In addition, the coronary artery calcium (CAC) score, a highly specific marker of the atherosclerotic plaque burden in the coronary arteries that is obtained via chest CT, predicts the risk/benefit ratio of aspirin therapy independently of traditional risk factors. These findings indicate that it can be used to guide aspirin therapy regardless of whether patients "qualify" for it according to AHA guidelines, said Dr. Michael D. Miedema of the Minneapolis Heart Institute and his associates.

Dr. Miedema and his colleagues assessed whether CAC could be used to fine-tune risk assessment and thus allow treatment of more patients, preventing more cardiovascular events while avoiding unnecessary exposure of patients in whom risk truly exceeds benefit. At present, aspirin therapy for primary prevention is recommended only for patients at elevated risk for a cardiovascular event because its risks, particularly that of bleeding, are considered to outweigh the benefits. This means aspirin prevention is withheld from lower-risk patients "who represent the majority of the primary prevention population and in whom a large proportion of CVD events occur."

They analyzed data from the Multi-Ethnic Study of Atherosclerosis, a longitudinal epidemiologic study involving 6,814 men and women aged 45-84 years at baseline in 2000 who were followed at six U.S. medical centers for a median of 7.6 years.

For their study, Dr. Miedema and his associates included 4,229 of these individuals in whom CAC scores were obtained at enrollment, none of whom had clinical CVD or diabetes at that time. A total of 56% had a CAC score of 0, 18% had a CAC score of 100 or more, and the remaining 26% had intermediate CAC scores of 1-99.

Compared with patients who had a CAC score of 0, those with CAC scores of 100 or higher had more than a ninefold higher risk (hazard ratio, 9.03) for a coronary heart disease event, defined as nonfatal MI, resuscitated cardiac arrest, or CHD death; and more than a sixfold higher risk (HR, 6.57) for a CVD event, defined as a CHD event or stroke, during follow-up. This difference remained robust after the data were adjusted to account for traditional risk factors, in both men and women, and regardless of patient age (Circ. Cardiovasc. Qual. Outcomes 2014 May 6 [doi:10.1161/circoutcomes.113.000690]).

The findings indicate that CAC score can be used to guide aspirin therapy, at least in the 74% of patients whose scores fall at the extreme ends of the spectrum rather than in the intermediate range, the researchers noted.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Miedema and his associates reported no financial conflicts of interest.

The benefits of aspirin therapy for primary prevention of cardiovascular disease outweigh the risks in patients who have coronary artery calcification scores of 100 or more, while the opposite is true in those who have scores of 0, according to a subanalysis of the MESA study published online in Circulation: Cardiovascular Quality and Outcomes.

In addition, the coronary artery calcium (CAC) score, a highly specific marker of the atherosclerotic plaque burden in the coronary arteries that is obtained via chest CT, predicts the risk/benefit ratio of aspirin therapy independently of traditional risk factors. These findings indicate that it can be used to guide aspirin therapy regardless of whether patients "qualify" for it according to AHA guidelines, said Dr. Michael D. Miedema of the Minneapolis Heart Institute and his associates.

Dr. Miedema and his colleagues assessed whether CAC could be used to fine-tune risk assessment and thus allow treatment of more patients, preventing more cardiovascular events while avoiding unnecessary exposure of patients in whom risk truly exceeds benefit. At present, aspirin therapy for primary prevention is recommended only for patients at elevated risk for a cardiovascular event because its risks, particularly that of bleeding, are considered to outweigh the benefits. This means aspirin prevention is withheld from lower-risk patients "who represent the majority of the primary prevention population and in whom a large proportion of CVD events occur."

They analyzed data from the Multi-Ethnic Study of Atherosclerosis, a longitudinal epidemiologic study involving 6,814 men and women aged 45-84 years at baseline in 2000 who were followed at six U.S. medical centers for a median of 7.6 years.

For their study, Dr. Miedema and his associates included 4,229 of these individuals in whom CAC scores were obtained at enrollment, none of whom had clinical CVD or diabetes at that time. A total of 56% had a CAC score of 0, 18% had a CAC score of 100 or more, and the remaining 26% had intermediate CAC scores of 1-99.

Compared with patients who had a CAC score of 0, those with CAC scores of 100 or higher had more than a ninefold higher risk (hazard ratio, 9.03) for a coronary heart disease event, defined as nonfatal MI, resuscitated cardiac arrest, or CHD death; and more than a sixfold higher risk (HR, 6.57) for a CVD event, defined as a CHD event or stroke, during follow-up. This difference remained robust after the data were adjusted to account for traditional risk factors, in both men and women, and regardless of patient age (Circ. Cardiovasc. Qual. Outcomes 2014 May 6 [doi:10.1161/circoutcomes.113.000690]).

The findings indicate that CAC score can be used to guide aspirin therapy, at least in the 74% of patients whose scores fall at the extreme ends of the spectrum rather than in the intermediate range, the researchers noted.

This study was supported by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Miedema and his associates reported no financial conflicts of interest.

Group cognitive-behavioral therapy, often recommended as first-line therapy for social anxiety disorder, is effective even when patients have comorbid major depressive or anxiety disorders, a recent report shows.

Few previous studies have examined whether coexisting depression or anxiety influence the outcome of psychological treatment for social anxiety, and their findings have been conflicting. In this study, researchers assessed pre- and posttreatment results on the Social Phobia Inventory and the Depression Anxiety Stress Scales for 163 adults treated with group CBT at a single community hospital outpatient clinic over a 10-year period. Forty-one of these participants had social anxiety disorder with no comorbid diagnoses, 76 had comorbid major depressive disorder, 19 had comorbid bipolar disorder, and 27 had additional comorbid anxiety disorders.

The average age of onset of social anxiety disorder was 12 years in the 77 men and 86 women. A total of 85% were white, said Katie Fracalanza, a doctoral student in the department of psychology, Ryerson University, Toronto, and her associates.

All patients showed significant improvement in social anxiety symptoms after treatment, regardless of their comorbidities. Also, small to moderate improvements were found in depressive symptoms, the investigators reported (J. Affect. Disord. 2014;162:61-6).

Patients with comorbid disorders presented with more severe symptoms than did those who only had social anxiety disorder, and they completed treatment with greater residual symptoms, though still significantly improved. Additional sessions might be helpful for further symptom remission in such patients, Ms. Fracalanza and her associates said.

Limitations of the study include the self-report nature of social anxiety and depressive symptoms, and the relatively small sample size. Nevertheless, these findings are in line with those of previous studies reporting that depressive symptoms "do not hinder the effectiveness of CBT for social anxiety disorder" and might improve even though they are not specifically targeted by the treatment, the investigators noted.

Group cognitive-behavioral therapy, often recommended as first-line therapy for social anxiety disorder, is effective even when patients have comorbid major depressive or anxiety disorders, a recent report shows.

Few previous studies have examined whether coexisting depression or anxiety influence the outcome of psychological treatment for social anxiety, and their findings have been conflicting. In this study, researchers assessed pre- and posttreatment results on the Social Phobia Inventory and the Depression Anxiety Stress Scales for 163 adults treated with group CBT at a single community hospital outpatient clinic over a 10-year period. Forty-one of these participants had social anxiety disorder with no comorbid diagnoses, 76 had comorbid major depressive disorder, 19 had comorbid bipolar disorder, and 27 had additional comorbid anxiety disorders.

The average age of onset of social anxiety disorder was 12 years in the 77 men and 86 women. A total of 85% were white, said Katie Fracalanza, a doctoral student in the department of psychology, Ryerson University, Toronto, and her associates.

All patients showed significant improvement in social anxiety symptoms after treatment, regardless of their comorbidities. Also, small to moderate improvements were found in depressive symptoms, the investigators reported (J. Affect. Disord. 2014;162:61-6).

Patients with comorbid disorders presented with more severe symptoms than did those who only had social anxiety disorder, and they completed treatment with greater residual symptoms, though still significantly improved. Additional sessions might be helpful for further symptom remission in such patients, Ms. Fracalanza and her associates said.

Limitations of the study include the self-report nature of social anxiety and depressive symptoms, and the relatively small sample size. Nevertheless, these findings are in line with those of previous studies reporting that depressive symptoms "do not hinder the effectiveness of CBT for social anxiety disorder" and might improve even though they are not specifically targeted by the treatment, the investigators noted.

Group cognitive-behavioral therapy, often recommended as first-line therapy for social anxiety disorder, is effective even when patients have comorbid major depressive or anxiety disorders, a recent report shows.

Few previous studies have examined whether coexisting depression or anxiety influence the outcome of psychological treatment for social anxiety, and their findings have been conflicting. In this study, researchers assessed pre- and posttreatment results on the Social Phobia Inventory and the Depression Anxiety Stress Scales for 163 adults treated with group CBT at a single community hospital outpatient clinic over a 10-year period. Forty-one of these participants had social anxiety disorder with no comorbid diagnoses, 76 had comorbid major depressive disorder, 19 had comorbid bipolar disorder, and 27 had additional comorbid anxiety disorders.

The average age of onset of social anxiety disorder was 12 years in the 77 men and 86 women. A total of 85% were white, said Katie Fracalanza, a doctoral student in the department of psychology, Ryerson University, Toronto, and her associates.

All patients showed significant improvement in social anxiety symptoms after treatment, regardless of their comorbidities. Also, small to moderate improvements were found in depressive symptoms, the investigators reported (J. Affect. Disord. 2014;162:61-6).

Patients with comorbid disorders presented with more severe symptoms than did those who only had social anxiety disorder, and they completed treatment with greater residual symptoms, though still significantly improved. Additional sessions might be helpful for further symptom remission in such patients, Ms. Fracalanza and her associates said.

Limitations of the study include the self-report nature of social anxiety and depressive symptoms, and the relatively small sample size. Nevertheless, these findings are in line with those of previous studies reporting that depressive symptoms "do not hinder the effectiveness of CBT for social anxiety disorder" and might improve even though they are not specifically targeted by the treatment, the investigators noted.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

"Actionable" oncogenic drivers—genetic mutations that are critical to the development and maintenance of a cancer and that are susceptible to targeted therapy—were identified in 64% of tumor samples from 733 patients with lung adenocarcinoma in a proof-of-concept study aimed at determining the frequency of such mutations that was reported online May 20 in JAMA.

The researchers used multiplexed genetic testing to screen tumor samples for 10 possible oncogenic drivers simultaneously. In some cases, the results allowed clinicians to individually tailor cancer treatment, and patients who received this targeted therapy showed longer survival times than those who received conventional therapy.

Thus, this study established that it is feasible to incorporate genomic testing into clinical care for treatment stratification, and that multiplex testing is useful for guiding treatment in the majority of patients with lung adenocarcinoma, said Dr. Mark G. Kris of Memorial Sloan Kettering Cancer Center, New York, and his associates.

Since this study wasn’t designed to assess patient survival, further randomized trials are needed to definitively determine whether selecting therapy based on this method of identifying oncogenic drivers improves survival in the real-word setting, they noted.

The study involved patients with stage IV or recurrent lung adenocarcinoma treated at 14 medical centers across the country during a 3-year period. Each site performed multiplex genotyping on tumor samples using one of three available methods, to search for any of 10 oncogenic drivers: mutations in the EGFR gene (which are known to respond to tyrosine kinase inhibitors such as gefitinib and erlotinib), the ALK gene (known to respond to crizotinib), and the KRAS, NRAS, BRAF, ERBB2 (formerly known as HER-2), PIK3CA, MEK1, and AKT1 genes, as well as amplification of the met protooncogene (MET).

These participants’ treating physicians decided whether or not to recommend a targeted therapy to patients found to have tumors harboring one of these oncogenic drivers.

A total of 1,007 patients had at least 1 gene assessed for oncogenic drivers, and 733 patients were fully genotyped. The main reason why full genotyping couldn’t be done in all the study subjects was that insufficient tissue had been obtained in some tumor samples. (When this trial began in 2009, tumor sampling was only done to establish a diagnosis. Since then, genotyping has become an essential step in choosing therapy, so larger tissue samples are now obtained routinely.)

Of the 733 specimens tested for all 10 onocogenic drivers, 466 (64%) were found to harbor them; 442 specimens had 1 oncogenic driver and 24 had 2 of them. KRAS mutations were the most frequent, found in 25% of tumors; sensitizing EGFR mutations were found in 17%, other EGFR mutations in 4%, and ALK rearrangements in 8%. Each of the other mutations were found in less than 1%-3% of tumors, Dr. Kris and his associates said (JAMA 2014 May 20 [doi:10.1001/jama.2014.3741]).

A total of 260 of these patients received targeted therapy directed at the oncogenic driver(s) found in their tumors, and their median survival was 3.5 years. In contrast, 318 patients who were found to have at least one oncogenic driver did not receive targeted therapy, and their median survival was 2.4 years. And the 360 patients with no oncogenic driver identified in their tumors had a median survival of 2.1 years.

This study was supported by the National Cancer Institute. Dr. Kris reported ties to Ariad, AstraZeneca, Bind Biosciences, Boehringer Ingelheim, Chugai, Clovis, Covidien, Daiichi Sankyo, Esanex, Exelixis, Genentech, Pfizer, PUMA, Novartis, Millenium, and Roche, and his associates reported ties to numerous industry sources.

"Actionable" oncogenic drivers—genetic mutations that are critical to the development and maintenance of a cancer and that are susceptible to targeted therapy—were identified in 64% of tumor samples from 733 patients with lung adenocarcinoma in a proof-of-concept study aimed at determining the frequency of such mutations that was reported online May 20 in JAMA.

The researchers used multiplexed genetic testing to screen tumor samples for 10 possible oncogenic drivers simultaneously. In some cases, the results allowed clinicians to individually tailor cancer treatment, and patients who received this targeted therapy showed longer survival times than those who received conventional therapy.

Thus, this study established that it is feasible to incorporate genomic testing into clinical care for treatment stratification, and that multiplex testing is useful for guiding treatment in the majority of patients with lung adenocarcinoma, said Dr. Mark G. Kris of Memorial Sloan Kettering Cancer Center, New York, and his associates.

Since this study wasn’t designed to assess patient survival, further randomized trials are needed to definitively determine whether selecting therapy based on this method of identifying oncogenic drivers improves survival in the real-word setting, they noted.

The study involved patients with stage IV or recurrent lung adenocarcinoma treated at 14 medical centers across the country during a 3-year period. Each site performed multiplex genotyping on tumor samples using one of three available methods, to search for any of 10 oncogenic drivers: mutations in the EGFR gene (which are known to respond to tyrosine kinase inhibitors such as gefitinib and erlotinib), the ALK gene (known to respond to crizotinib), and the KRAS, NRAS, BRAF, ERBB2 (formerly known as HER-2), PIK3CA, MEK1, and AKT1 genes, as well as amplification of the met protooncogene (MET).

These participants’ treating physicians decided whether or not to recommend a targeted therapy to patients found to have tumors harboring one of these oncogenic drivers.

A total of 1,007 patients had at least 1 gene assessed for oncogenic drivers, and 733 patients were fully genotyped. The main reason why full genotyping couldn’t be done in all the study subjects was that insufficient tissue had been obtained in some tumor samples. (When this trial began in 2009, tumor sampling was only done to establish a diagnosis. Since then, genotyping has become an essential step in choosing therapy, so larger tissue samples are now obtained routinely.)

Of the 733 specimens tested for all 10 onocogenic drivers, 466 (64%) were found to harbor them; 442 specimens had 1 oncogenic driver and 24 had 2 of them. KRAS mutations were the most frequent, found in 25% of tumors; sensitizing EGFR mutations were found in 17%, other EGFR mutations in 4%, and ALK rearrangements in 8%. Each of the other mutations were found in less than 1%-3% of tumors, Dr. Kris and his associates said (JAMA 2014 May 20 [doi:10.1001/jama.2014.3741]).

A total of 260 of these patients received targeted therapy directed at the oncogenic driver(s) found in their tumors, and their median survival was 3.5 years. In contrast, 318 patients who were found to have at least one oncogenic driver did not receive targeted therapy, and their median survival was 2.4 years. And the 360 patients with no oncogenic driver identified in their tumors had a median survival of 2.1 years.

This study was supported by the National Cancer Institute. Dr. Kris reported ties to Ariad, AstraZeneca, Bind Biosciences, Boehringer Ingelheim, Chugai, Clovis, Covidien, Daiichi Sankyo, Esanex, Exelixis, Genentech, Pfizer, PUMA, Novartis, Millenium, and Roche, and his associates reported ties to numerous industry sources.

"Actionable" oncogenic drivers—genetic mutations that are critical to the development and maintenance of a cancer and that are susceptible to targeted therapy—were identified in 64% of tumor samples from 733 patients with lung adenocarcinoma in a proof-of-concept study aimed at determining the frequency of such mutations that was reported online May 20 in JAMA.

The researchers used multiplexed genetic testing to screen tumor samples for 10 possible oncogenic drivers simultaneously. In some cases, the results allowed clinicians to individually tailor cancer treatment, and patients who received this targeted therapy showed longer survival times than those who received conventional therapy.

Thus, this study established that it is feasible to incorporate genomic testing into clinical care for treatment stratification, and that multiplex testing is useful for guiding treatment in the majority of patients with lung adenocarcinoma, said Dr. Mark G. Kris of Memorial Sloan Kettering Cancer Center, New York, and his associates.

Since this study wasn’t designed to assess patient survival, further randomized trials are needed to definitively determine whether selecting therapy based on this method of identifying oncogenic drivers improves survival in the real-word setting, they noted.

The study involved patients with stage IV or recurrent lung adenocarcinoma treated at 14 medical centers across the country during a 3-year period. Each site performed multiplex genotyping on tumor samples using one of three available methods, to search for any of 10 oncogenic drivers: mutations in the EGFR gene (which are known to respond to tyrosine kinase inhibitors such as gefitinib and erlotinib), the ALK gene (known to respond to crizotinib), and the KRAS, NRAS, BRAF, ERBB2 (formerly known as HER-2), PIK3CA, MEK1, and AKT1 genes, as well as amplification of the met protooncogene (MET).

These participants’ treating physicians decided whether or not to recommend a targeted therapy to patients found to have tumors harboring one of these oncogenic drivers.

A total of 1,007 patients had at least 1 gene assessed for oncogenic drivers, and 733 patients were fully genotyped. The main reason why full genotyping couldn’t be done in all the study subjects was that insufficient tissue had been obtained in some tumor samples. (When this trial began in 2009, tumor sampling was only done to establish a diagnosis. Since then, genotyping has become an essential step in choosing therapy, so larger tissue samples are now obtained routinely.)

Of the 733 specimens tested for all 10 onocogenic drivers, 466 (64%) were found to harbor them; 442 specimens had 1 oncogenic driver and 24 had 2 of them. KRAS mutations were the most frequent, found in 25% of tumors; sensitizing EGFR mutations were found in 17%, other EGFR mutations in 4%, and ALK rearrangements in 8%. Each of the other mutations were found in less than 1%-3% of tumors, Dr. Kris and his associates said (JAMA 2014 May 20 [doi:10.1001/jama.2014.3741]).

A total of 260 of these patients received targeted therapy directed at the oncogenic driver(s) found in their tumors, and their median survival was 3.5 years. In contrast, 318 patients who were found to have at least one oncogenic driver did not receive targeted therapy, and their median survival was 2.4 years. And the 360 patients with no oncogenic driver identified in their tumors had a median survival of 2.1 years.

This study was supported by the National Cancer Institute. Dr. Kris reported ties to Ariad, AstraZeneca, Bind Biosciences, Boehringer Ingelheim, Chugai, Clovis, Covidien, Daiichi Sankyo, Esanex, Exelixis, Genentech, Pfizer, PUMA, Novartis, Millenium, and Roche, and his associates reported ties to numerous industry sources.

Long-acting paliperidone palmitate injections were no better than long-acting haloperidol decanoate injections at preventing relapse in patients with schizophrenia or schizoaffective disorder in the first randomized head-to-head comparison of the two drugs, which was published online May 20 in JAMA.

Contrary to expectations, injectable paliperidone also was no better than injectable haloperidol with regard to several adverse effects: the incidence and severity of abnormal involuntary movements, parkinsonism, and tardive dyskinesia. Paliperidone caused more weight gain and greater increases in serum prolactin, while haloperidol caused a higher incidence of akathisia, reported Dr. Joseph P. McEvoy, of the department of psychiatry and health behavior, Georgia Regents University, Augusta, and his associates in the ACLAIMS (A Comparison of Long-Acting Injectable Medications for Schizophrenia) trial.

These findings "are consistent with previous research that has not found large differences in the effectiveness of newer and older antipsychotic medications," they noted.

The ACLAIMS study was a double-blind clinical trial performed at 22 U.S. medical centers affiliated with the Schizophrenia Trials Network, which is supported by the National Institute of Mental Health. It involved 290 patients with schizophrenia or schizoaffective disorder aged 18-65 years (mean age, 44 years) who were at risk for "efficacy failure" because of their history of medication noncompliance, significant comorbid substance abuse, or both.

The participants were randomly assigned in equal numbers to receive either paliperidone palmitate or haloperidol decanoate by intramuscular injection every month, and were followed for as long as 2 years. The mean follow-up was 488 days.

The primary outcome was efficacy failure, defined as a need for crisis stabilization or psychiatric hospitalization, a clinically meaningful increase in the frequency of outpatient visits, a clinician’s decision to discontinue the long-acting injections because of inadequate therapeutic benefit, or an ongoing or repeated need for adjunctive oral antipsychotic drugs. The rate of this outcome was not significantly different between paliperidone (33.8%) and haloperidol (32.4%).

"Results of all preplanned sensitivity and supporting analyses led to similar conclusions," the investigators reported (JAMA 2014;311:1978-86).

However, because the confidence intervals for the primary efficacy finding were very broad, these results "cannot rule out a clinically meaningful difference favoring one of the drugs," they added.

There were no significant differences between the two study groups with regard to the incidence and severity of abnormal involuntary movements, probable tardive dyskinesia, or parkinsonism; and the rates of treatment discontinuation for any cause were similar. Paliperidone raised prolactin levels to a greater degree than haloperidol did, but measures of sexual dysfunction were not significantly different between the two study groups among either men or women.

Patients who received paliperidone gained weight progressively, and the mean weight change at 6 months was an increase of 2.17 kg. In contrast, participants receiving haloperidol lost weight, and the mean weight change at 6 months was a decrease of 0.96 kg. Seven participants taking paliperidone (4.8%) discontinued the drug because of weight gain, compared with only two participants taking haloperidol (1.4%).

One study limitation is that neither subjective measures of patient satisfaction nor global well-being were assessed. Also, the cost differences between the two drugs were never addressed. Such cost differences may be "substantial, as paliperidone palmitate is still on patent while haloperidol decanoate is available as a generic drug," the authors wrote.

This study was supported by the National Institute of Mental Health. Dr. McEvoy reported ties to Alkermes, EnVivo, and other companies; his associates reported ties to numerous industry sources.

Long-acting paliperidone palmitate injections were no better than long-acting haloperidol decanoate injections at preventing relapse in patients with schizophrenia or schizoaffective disorder in the first randomized head-to-head comparison of the two drugs, which was published online May 20 in JAMA.

Contrary to expectations, injectable paliperidone also was no better than injectable haloperidol with regard to several adverse effects: the incidence and severity of abnormal involuntary movements, parkinsonism, and tardive dyskinesia. Paliperidone caused more weight gain and greater increases in serum prolactin, while haloperidol caused a higher incidence of akathisia, reported Dr. Joseph P. McEvoy, of the department of psychiatry and health behavior, Georgia Regents University, Augusta, and his associates in the ACLAIMS (A Comparison of Long-Acting Injectable Medications for Schizophrenia) trial.

These findings "are consistent with previous research that has not found large differences in the effectiveness of newer and older antipsychotic medications," they noted.

The ACLAIMS study was a double-blind clinical trial performed at 22 U.S. medical centers affiliated with the Schizophrenia Trials Network, which is supported by the National Institute of Mental Health. It involved 290 patients with schizophrenia or schizoaffective disorder aged 18-65 years (mean age, 44 years) who were at risk for "efficacy failure" because of their history of medication noncompliance, significant comorbid substance abuse, or both.

The participants were randomly assigned in equal numbers to receive either paliperidone palmitate or haloperidol decanoate by intramuscular injection every month, and were followed for as long as 2 years. The mean follow-up was 488 days.

The primary outcome was efficacy failure, defined as a need for crisis stabilization or psychiatric hospitalization, a clinically meaningful increase in the frequency of outpatient visits, a clinician’s decision to discontinue the long-acting injections because of inadequate therapeutic benefit, or an ongoing or repeated need for adjunctive oral antipsychotic drugs. The rate of this outcome was not significantly different between paliperidone (33.8%) and haloperidol (32.4%).

"Results of all preplanned sensitivity and supporting analyses led to similar conclusions," the investigators reported (JAMA 2014;311:1978-86).

However, because the confidence intervals for the primary efficacy finding were very broad, these results "cannot rule out a clinically meaningful difference favoring one of the drugs," they added.

There were no significant differences between the two study groups with regard to the incidence and severity of abnormal involuntary movements, probable tardive dyskinesia, or parkinsonism; and the rates of treatment discontinuation for any cause were similar. Paliperidone raised prolactin levels to a greater degree than haloperidol did, but measures of sexual dysfunction were not significantly different between the two study groups among either men or women.

Patients who received paliperidone gained weight progressively, and the mean weight change at 6 months was an increase of 2.17 kg. In contrast, participants receiving haloperidol lost weight, and the mean weight change at 6 months was a decrease of 0.96 kg. Seven participants taking paliperidone (4.8%) discontinued the drug because of weight gain, compared with only two participants taking haloperidol (1.4%).

One study limitation is that neither subjective measures of patient satisfaction nor global well-being were assessed. Also, the cost differences between the two drugs were never addressed. Such cost differences may be "substantial, as paliperidone palmitate is still on patent while haloperidol decanoate is available as a generic drug," the authors wrote.

This study was supported by the National Institute of Mental Health. Dr. McEvoy reported ties to Alkermes, EnVivo, and other companies; his associates reported ties to numerous industry sources.

Long-acting paliperidone palmitate injections were no better than long-acting haloperidol decanoate injections at preventing relapse in patients with schizophrenia or schizoaffective disorder in the first randomized head-to-head comparison of the two drugs, which was published online May 20 in JAMA.

Contrary to expectations, injectable paliperidone also was no better than injectable haloperidol with regard to several adverse effects: the incidence and severity of abnormal involuntary movements, parkinsonism, and tardive dyskinesia. Paliperidone caused more weight gain and greater increases in serum prolactin, while haloperidol caused a higher incidence of akathisia, reported Dr. Joseph P. McEvoy, of the department of psychiatry and health behavior, Georgia Regents University, Augusta, and his associates in the ACLAIMS (A Comparison of Long-Acting Injectable Medications for Schizophrenia) trial.

These findings "are consistent with previous research that has not found large differences in the effectiveness of newer and older antipsychotic medications," they noted.

The ACLAIMS study was a double-blind clinical trial performed at 22 U.S. medical centers affiliated with the Schizophrenia Trials Network, which is supported by the National Institute of Mental Health. It involved 290 patients with schizophrenia or schizoaffective disorder aged 18-65 years (mean age, 44 years) who were at risk for "efficacy failure" because of their history of medication noncompliance, significant comorbid substance abuse, or both.

The participants were randomly assigned in equal numbers to receive either paliperidone palmitate or haloperidol decanoate by intramuscular injection every month, and were followed for as long as 2 years. The mean follow-up was 488 days.

The primary outcome was efficacy failure, defined as a need for crisis stabilization or psychiatric hospitalization, a clinically meaningful increase in the frequency of outpatient visits, a clinician’s decision to discontinue the long-acting injections because of inadequate therapeutic benefit, or an ongoing or repeated need for adjunctive oral antipsychotic drugs. The rate of this outcome was not significantly different between paliperidone (33.8%) and haloperidol (32.4%).

"Results of all preplanned sensitivity and supporting analyses led to similar conclusions," the investigators reported (JAMA 2014;311:1978-86).

However, because the confidence intervals for the primary efficacy finding were very broad, these results "cannot rule out a clinically meaningful difference favoring one of the drugs," they added.

There were no significant differences between the two study groups with regard to the incidence and severity of abnormal involuntary movements, probable tardive dyskinesia, or parkinsonism; and the rates of treatment discontinuation for any cause were similar. Paliperidone raised prolactin levels to a greater degree than haloperidol did, but measures of sexual dysfunction were not significantly different between the two study groups among either men or women.

Patients who received paliperidone gained weight progressively, and the mean weight change at 6 months was an increase of 2.17 kg. In contrast, participants receiving haloperidol lost weight, and the mean weight change at 6 months was a decrease of 0.96 kg. Seven participants taking paliperidone (4.8%) discontinued the drug because of weight gain, compared with only two participants taking haloperidol (1.4%).

One study limitation is that neither subjective measures of patient satisfaction nor global well-being were assessed. Also, the cost differences between the two drugs were never addressed. Such cost differences may be "substantial, as paliperidone palmitate is still on patent while haloperidol decanoate is available as a generic drug," the authors wrote.

This study was supported by the National Institute of Mental Health. Dr. McEvoy reported ties to Alkermes, EnVivo, and other companies; his associates reported ties to numerous industry sources.

Primary care physicians are not advised to screen general patients for suicide risk at present, because evidence remains insufficient to properly assess the benefits and harms of suicide screening in this setting, according to a clinical guideline updated by the U.S. Preventive Services Task Force and published May 19 online.

Suicide was the 10th leading cause of death in the United States in 2010, and it ranks among the top 5 causes of death in adolescents and young adults. Nevertheless, currently "there is insufficient evidence to conclude that screening adolescents, adults, and older adults in primary care adequately identifies patients at risk for suicide who would not otherwise be identified on the basis of an existing mental health disorder, emotional distress, or previous suicide attempt," said Dr. Michael L. LeFevre, chair of the USPSTF and professor of family and community medicine at the University of Missouri–Columbia, and his associates (Ann. Intern. Med. 2014;160:719-26).

They emphasized that screening the general population for depression is a separate issue. Depression screening by primary physicians is recommended for all age groups.

The USPSTF first issued a clinical guideline regarding suicide screening in 2004, when research indicated that 38% of adults – and 50%-70% of adults over age 65 – who committed suicide had visited their primary care provider within 1 month of taking their lives. Later research also showed that nearly 90% of adolescents and children who committed suicide had seen their primary care provider during the preceding year. It was reasoned that primary caregivers might be in a position to intervene and prevent some of these deaths.

At the time of the 2004 Clinical Guideline, the USPSTF concluded that there was insufficient evidence to recommend either for or against clinicians conducting routine screening to detect suicide risk in the general population. After reviewing new data from studies conducted since the last review, the USPSTF again has reached the same conclusion. (The American Academy of Family Physicians published a similar recommendation in January of this year, Dr. LeFevre and his colleagues noted.)

Since the 2004 recommendations, only four studies have assessed the accuracy of screening instruments, and all of them were considered to be only of fair quality. Only one study involved primary care patients of all ages. Two studies involved only adolescents, one involved only the elderly, and one involved depressed patients receiving outpatient mental health services.

Similarly, no studies since the 2004 recommendations have directly assessed whether screening and subsequent referral for treatment improved health outcomes. Few studies have examined treatment efficacy, particularly that of medication; those that have done so were of only fair quality, with small sample sizes, high attrition rates, and extremely low incidences of suicide. The treatments found most effective at reducing the risk of suicide attempts include psychotherapy, specifically cognitive-behavioral therapy and related approaches, Dr. LeFevre wrote. "Although most of these treatments are not customarily administered by primary care providers in the office, patients can be referred to behavioral health providers for them. The primary care provider can play a continued role in the care of these patients by monitoring them during the process, providing follow-up, and coordinating with other care providers," the investigators wrote.

Few studies have assessed the potential harms of screening the general population for suicide, and at this time the possibility cannot be ruled out that a primary caregiver’s inquiring about suicide might actually increase a patient’s distress.

In contrast to the general patient population, certain subsets of patients are at risk for suicide attempts. Primary caregivers "should consider identifying patients with [these] risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation," the USPSTF said.

Risk factors for suicide include:

• Mental health disorders. These include depression, schizophrenia, posttraumatic stress disorder (PTSD), and substance use disorders. "About 87% of patients who die by suicide meet the criteria for one or more mental health disorders." In addition, "depression is probably present in 50%-79% of youths attempting suicide, although it may not always be recognized," the investigators said.

• Older age. Suicide risk begins to rise in both men and women in their 50s and 60s, compared with those in their 30s and 40s, and continues to rise with increasing age. Social isolation, unemployment, grief over a spouse’s death, physical illness or disability, and functional impairment all add to this risk.

• Ethnicity. American Indians and Alaskan natives of all ages have higher-than-average rates of death by suicide. Among adolescents, Hispanic girls are at higher risk than girls of other ethnicities.

• Military service. Veterans who have sustained traumatic brain injury, have separated from the service within the past year, or have PTSD are at particularly high risk of suicide.

"Other important risk factors for suicide attempt include serious adverse childhood events; family history of suicide; prejudice or discrimination associated with being gay, bisexual, or transgender; access to lethal means; and possibly a history of being bullied, sleep disturbances, and such chronic medical conditions as epilepsy and chronic pain. In males, socioeconomic factors such as low income, occupation, and unemployment also are related to suicide risk," Dr. LeFevre and his associates said.

Reprints of the recommendation statement are available here. In addition, resources regarding suicide prevention are available at the Suicide Prevention Resource Center, which is supported by the Substance Abuse and Mental Health Services Administration.

The USPSTF is an independent, voluntary group supported by the U.S. Agency for Healthcare Research and mandated by Congress to make recommendations about the effectiveness of specific preventive care services for patients. Dr. LeFevre and his associates reported no financial conflicts of interest.

Primary care physicians are not advised to screen general patients for suicide risk at present, because evidence remains insufficient to properly assess the benefits and harms of suicide screening in this setting, according to a clinical guideline updated by the U.S. Preventive Services Task Force and published May 19 online.

Suicide was the 10th leading cause of death in the United States in 2010, and it ranks among the top 5 causes of death in adolescents and young adults. Nevertheless, currently "there is insufficient evidence to conclude that screening adolescents, adults, and older adults in primary care adequately identifies patients at risk for suicide who would not otherwise be identified on the basis of an existing mental health disorder, emotional distress, or previous suicide attempt," said Dr. Michael L. LeFevre, chair of the USPSTF and professor of family and community medicine at the University of Missouri–Columbia, and his associates (Ann. Intern. Med. 2014;160:719-26).

They emphasized that screening the general population for depression is a separate issue. Depression screening by primary physicians is recommended for all age groups.

The USPSTF first issued a clinical guideline regarding suicide screening in 2004, when research indicated that 38% of adults – and 50%-70% of adults over age 65 – who committed suicide had visited their primary care provider within 1 month of taking their lives. Later research also showed that nearly 90% of adolescents and children who committed suicide had seen their primary care provider during the preceding year. It was reasoned that primary caregivers might be in a position to intervene and prevent some of these deaths.

At the time of the 2004 Clinical Guideline, the USPSTF concluded that there was insufficient evidence to recommend either for or against clinicians conducting routine screening to detect suicide risk in the general population. After reviewing new data from studies conducted since the last review, the USPSTF again has reached the same conclusion. (The American Academy of Family Physicians published a similar recommendation in January of this year, Dr. LeFevre and his colleagues noted.)

Since the 2004 recommendations, only four studies have assessed the accuracy of screening instruments, and all of them were considered to be only of fair quality. Only one study involved primary care patients of all ages. Two studies involved only adolescents, one involved only the elderly, and one involved depressed patients receiving outpatient mental health services.

Similarly, no studies since the 2004 recommendations have directly assessed whether screening and subsequent referral for treatment improved health outcomes. Few studies have examined treatment efficacy, particularly that of medication; those that have done so were of only fair quality, with small sample sizes, high attrition rates, and extremely low incidences of suicide. The treatments found most effective at reducing the risk of suicide attempts include psychotherapy, specifically cognitive-behavioral therapy and related approaches, Dr. LeFevre wrote. "Although most of these treatments are not customarily administered by primary care providers in the office, patients can be referred to behavioral health providers for them. The primary care provider can play a continued role in the care of these patients by monitoring them during the process, providing follow-up, and coordinating with other care providers," the investigators wrote.

Few studies have assessed the potential harms of screening the general population for suicide, and at this time the possibility cannot be ruled out that a primary caregiver’s inquiring about suicide might actually increase a patient’s distress.

In contrast to the general patient population, certain subsets of patients are at risk for suicide attempts. Primary caregivers "should consider identifying patients with [these] risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation," the USPSTF said.

Risk factors for suicide include:

• Mental health disorders. These include depression, schizophrenia, posttraumatic stress disorder (PTSD), and substance use disorders. "About 87% of patients who die by suicide meet the criteria for one or more mental health disorders." In addition, "depression is probably present in 50%-79% of youths attempting suicide, although it may not always be recognized," the investigators said.

• Older age. Suicide risk begins to rise in both men and women in their 50s and 60s, compared with those in their 30s and 40s, and continues to rise with increasing age. Social isolation, unemployment, grief over a spouse’s death, physical illness or disability, and functional impairment all add to this risk.

• Ethnicity. American Indians and Alaskan natives of all ages have higher-than-average rates of death by suicide. Among adolescents, Hispanic girls are at higher risk than girls of other ethnicities.

• Military service. Veterans who have sustained traumatic brain injury, have separated from the service within the past year, or have PTSD are at particularly high risk of suicide.

"Other important risk factors for suicide attempt include serious adverse childhood events; family history of suicide; prejudice or discrimination associated with being gay, bisexual, or transgender; access to lethal means; and possibly a history of being bullied, sleep disturbances, and such chronic medical conditions as epilepsy and chronic pain. In males, socioeconomic factors such as low income, occupation, and unemployment also are related to suicide risk," Dr. LeFevre and his associates said.

Reprints of the recommendation statement are available here. In addition, resources regarding suicide prevention are available at the Suicide Prevention Resource Center, which is supported by the Substance Abuse and Mental Health Services Administration.

The USPSTF is an independent, voluntary group supported by the U.S. Agency for Healthcare Research and mandated by Congress to make recommendations about the effectiveness of specific preventive care services for patients. Dr. LeFevre and his associates reported no financial conflicts of interest.

Primary care physicians are not advised to screen general patients for suicide risk at present, because evidence remains insufficient to properly assess the benefits and harms of suicide screening in this setting, according to a clinical guideline updated by the U.S. Preventive Services Task Force and published May 19 online.

Suicide was the 10th leading cause of death in the United States in 2010, and it ranks among the top 5 causes of death in adolescents and young adults. Nevertheless, currently "there is insufficient evidence to conclude that screening adolescents, adults, and older adults in primary care adequately identifies patients at risk for suicide who would not otherwise be identified on the basis of an existing mental health disorder, emotional distress, or previous suicide attempt," said Dr. Michael L. LeFevre, chair of the USPSTF and professor of family and community medicine at the University of Missouri–Columbia, and his associates (Ann. Intern. Med. 2014;160:719-26).

They emphasized that screening the general population for depression is a separate issue. Depression screening by primary physicians is recommended for all age groups.

The USPSTF first issued a clinical guideline regarding suicide screening in 2004, when research indicated that 38% of adults – and 50%-70% of adults over age 65 – who committed suicide had visited their primary care provider within 1 month of taking their lives. Later research also showed that nearly 90% of adolescents and children who committed suicide had seen their primary care provider during the preceding year. It was reasoned that primary caregivers might be in a position to intervene and prevent some of these deaths.

At the time of the 2004 Clinical Guideline, the USPSTF concluded that there was insufficient evidence to recommend either for or against clinicians conducting routine screening to detect suicide risk in the general population. After reviewing new data from studies conducted since the last review, the USPSTF again has reached the same conclusion. (The American Academy of Family Physicians published a similar recommendation in January of this year, Dr. LeFevre and his colleagues noted.)

Since the 2004 recommendations, only four studies have assessed the accuracy of screening instruments, and all of them were considered to be only of fair quality. Only one study involved primary care patients of all ages. Two studies involved only adolescents, one involved only the elderly, and one involved depressed patients receiving outpatient mental health services.

Similarly, no studies since the 2004 recommendations have directly assessed whether screening and subsequent referral for treatment improved health outcomes. Few studies have examined treatment efficacy, particularly that of medication; those that have done so were of only fair quality, with small sample sizes, high attrition rates, and extremely low incidences of suicide. The treatments found most effective at reducing the risk of suicide attempts include psychotherapy, specifically cognitive-behavioral therapy and related approaches, Dr. LeFevre wrote. "Although most of these treatments are not customarily administered by primary care providers in the office, patients can be referred to behavioral health providers for them. The primary care provider can play a continued role in the care of these patients by monitoring them during the process, providing follow-up, and coordinating with other care providers," the investigators wrote.

Few studies have assessed the potential harms of screening the general population for suicide, and at this time the possibility cannot be ruled out that a primary caregiver’s inquiring about suicide might actually increase a patient’s distress.

In contrast to the general patient population, certain subsets of patients are at risk for suicide attempts. Primary caregivers "should consider identifying patients with [these] risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation," the USPSTF said.

Risk factors for suicide include:

• Mental health disorders. These include depression, schizophrenia, posttraumatic stress disorder (PTSD), and substance use disorders. "About 87% of patients who die by suicide meet the criteria for one or more mental health disorders." In addition, "depression is probably present in 50%-79% of youths attempting suicide, although it may not always be recognized," the investigators said.

• Older age. Suicide risk begins to rise in both men and women in their 50s and 60s, compared with those in their 30s and 40s, and continues to rise with increasing age. Social isolation, unemployment, grief over a spouse’s death, physical illness or disability, and functional impairment all add to this risk.

• Ethnicity. American Indians and Alaskan natives of all ages have higher-than-average rates of death by suicide. Among adolescents, Hispanic girls are at higher risk than girls of other ethnicities.

• Military service. Veterans who have sustained traumatic brain injury, have separated from the service within the past year, or have PTSD are at particularly high risk of suicide.

"Other important risk factors for suicide attempt include serious adverse childhood events; family history of suicide; prejudice or discrimination associated with being gay, bisexual, or transgender; access to lethal means; and possibly a history of being bullied, sleep disturbances, and such chronic medical conditions as epilepsy and chronic pain. In males, socioeconomic factors such as low income, occupation, and unemployment also are related to suicide risk," Dr. LeFevre and his associates said.

Reprints of the recommendation statement are available here. In addition, resources regarding suicide prevention are available at the Suicide Prevention Resource Center, which is supported by the Substance Abuse and Mental Health Services Administration.

The USPSTF is an independent, voluntary group supported by the U.S. Agency for Healthcare Research and mandated by Congress to make recommendations about the effectiveness of specific preventive care services for patients. Dr. LeFevre and his associates reported no financial conflicts of interest.

The ergosterol-synthesis inhibitor posaconazole proved ineffective at eliminating Trypanosoma cruzi DNA from the blood of patients with chronic Chagas’ disease, according to a report published online May 14 in the New England Journal of Medicine.

"Posaconazole has shown considerable activity in murine models of acute and chronic Chagas’ disease, and this effect was expected to be reproducible in humans; unfortunately, however, only suppressive activity was shown," said Dr. Israel Molina of the infectious disease department, Vall d’Hebron Teaching Hospital, Barcelona, and his associates.

They assessed two oral doses of posaconazole against standard-dose benznidazole in an open-label clinical trial involving 78 treatment-naive patients with chronic Chagas’ disease, which is also known as American trypanosomiasis. At present, there are only two agents available for treating the chronic form of the disorder – benznidazole and nifurtimox – and both have daunting toxicity profiles. Up to 30% of patients withdraw from these drugs because of adverse events, and their cure rates are unsatisfactory at only 15%-35%.

Like other ergosterol-synthesis inhibitors, posaconazole was particularly promising because it showed antiprotozoal activity. It also has been used to treat invasive fungal infections and has an established safety profile in humans.

Chagas’ disease is endemic in Latin America but was rare in North America and Europe until recently, when population shifts caused the incidence in some countries, including the United States and Spain, to eclipse that in many endemic areas.

Dr. Molina and his colleagues performed the clinical trial at three public health centers in Spain. Seventy-five of the 78 patients were originally from Bolivia. There were 47 women and 31 men, and the mean age was 39.9 years. A total of 22% had cardiac involvement, 6% had gastrointestinal involvement, and 6% had involvement of multiple organ systems.

These participants were randomly assigned in equal numbers to receive 100-mg posaconazole twice daily, 400-mg posaconazole twice daily, or 150-mg benznidazole twice daily for 60 days. They were followed for 40 weeks after the conclusion of treatment.

All patients responded to all the drugs during active treatment, showing negative results on assays to detect T. cruzi DNA from serial blood samples by day 14. However, parasitic DNA began to be detected in many participants after treatment ended, by day 60, and continued to be found throughout follow-up.

The primary end point of the study was consistently negative results on the T. cruzi DNA assays throughout follow-up. This was achieved by only 2 of 26 patients receiving low-dose posaconazole and only 5 of 26 receiving high-dose posaconazole. In comparison, the primary end point was achieved by 16 of 26 patients receiving benznidazole, the investigators said (N. Engl. J. Med. 2014 May 14 [doi:10.1056/NEJMoa1313122]).

In an intention-to-treat analysis, 92% of patients in the low-dose posaconazole group and 81% in the high-dose posaconazole group tested positive for T. cruzi DNA during follow-up, compared with only 38% of the benznidazole group.

Serious adverse effects forced the withdrawal of treatment in five patients, all of whom were receiving benznidazole. These included severe allergic dermatitis (with anaphylaxis in one patient), other cutaneous reactions, dysgeusia, and leukopenia.

Despite these disappointing results, with posaconazole failing to eliminate T. cruzi DNA in the blood, the drug did show suppressive activity, even at the low dose, throughout the active treatment period. So "it is possible that ergosterol inhibitors could be useful as a partner drug in future combination therapies," the researchers said.

This study was supported by the Ministry of Health, Spain. Dr. Molina and his associates reported no potential conflicts of interest.

The ergosterol-synthesis inhibitor posaconazole proved ineffective at eliminating Trypanosoma cruzi DNA from the blood of patients with chronic Chagas’ disease, according to a report published online May 14 in the New England Journal of Medicine.

"Posaconazole has shown considerable activity in murine models of acute and chronic Chagas’ disease, and this effect was expected to be reproducible in humans; unfortunately, however, only suppressive activity was shown," said Dr. Israel Molina of the infectious disease department, Vall d’Hebron Teaching Hospital, Barcelona, and his associates.

They assessed two oral doses of posaconazole against standard-dose benznidazole in an open-label clinical trial involving 78 treatment-naive patients with chronic Chagas’ disease, which is also known as American trypanosomiasis. At present, there are only two agents available for treating the chronic form of the disorder – benznidazole and nifurtimox – and both have daunting toxicity profiles. Up to 30% of patients withdraw from these drugs because of adverse events, and their cure rates are unsatisfactory at only 15%-35%.

Like other ergosterol-synthesis inhibitors, posaconazole was particularly promising because it showed antiprotozoal activity. It also has been used to treat invasive fungal infections and has an established safety profile in humans.

Chagas’ disease is endemic in Latin America but was rare in North America and Europe until recently, when population shifts caused the incidence in some countries, including the United States and Spain, to eclipse that in many endemic areas.

Dr. Molina and his colleagues performed the clinical trial at three public health centers in Spain. Seventy-five of the 78 patients were originally from Bolivia. There were 47 women and 31 men, and the mean age was 39.9 years. A total of 22% had cardiac involvement, 6% had gastrointestinal involvement, and 6% had involvement of multiple organ systems.

These participants were randomly assigned in equal numbers to receive 100-mg posaconazole twice daily, 400-mg posaconazole twice daily, or 150-mg benznidazole twice daily for 60 days. They were followed for 40 weeks after the conclusion of treatment.

All patients responded to all the drugs during active treatment, showing negative results on assays to detect T. cruzi DNA from serial blood samples by day 14. However, parasitic DNA began to be detected in many participants after treatment ended, by day 60, and continued to be found throughout follow-up.

The primary end point of the study was consistently negative results on the T. cruzi DNA assays throughout follow-up. This was achieved by only 2 of 26 patients receiving low-dose posaconazole and only 5 of 26 receiving high-dose posaconazole. In comparison, the primary end point was achieved by 16 of 26 patients receiving benznidazole, the investigators said (N. Engl. J. Med. 2014 May 14 [doi:10.1056/NEJMoa1313122]).

In an intention-to-treat analysis, 92% of patients in the low-dose posaconazole group and 81% in the high-dose posaconazole group tested positive for T. cruzi DNA during follow-up, compared with only 38% of the benznidazole group.

Serious adverse effects forced the withdrawal of treatment in five patients, all of whom were receiving benznidazole. These included severe allergic dermatitis (with anaphylaxis in one patient), other cutaneous reactions, dysgeusia, and leukopenia.

Despite these disappointing results, with posaconazole failing to eliminate T. cruzi DNA in the blood, the drug did show suppressive activity, even at the low dose, throughout the active treatment period. So "it is possible that ergosterol inhibitors could be useful as a partner drug in future combination therapies," the researchers said.

This study was supported by the Ministry of Health, Spain. Dr. Molina and his associates reported no potential conflicts of interest.

The ergosterol-synthesis inhibitor posaconazole proved ineffective at eliminating Trypanosoma cruzi DNA from the blood of patients with chronic Chagas’ disease, according to a report published online May 14 in the New England Journal of Medicine.

"Posaconazole has shown considerable activity in murine models of acute and chronic Chagas’ disease, and this effect was expected to be reproducible in humans; unfortunately, however, only suppressive activity was shown," said Dr. Israel Molina of the infectious disease department, Vall d’Hebron Teaching Hospital, Barcelona, and his associates.

They assessed two oral doses of posaconazole against standard-dose benznidazole in an open-label clinical trial involving 78 treatment-naive patients with chronic Chagas’ disease, which is also known as American trypanosomiasis. At present, there are only two agents available for treating the chronic form of the disorder – benznidazole and nifurtimox – and both have daunting toxicity profiles. Up to 30% of patients withdraw from these drugs because of adverse events, and their cure rates are unsatisfactory at only 15%-35%.

Like other ergosterol-synthesis inhibitors, posaconazole was particularly promising because it showed antiprotozoal activity. It also has been used to treat invasive fungal infections and has an established safety profile in humans.

Chagas’ disease is endemic in Latin America but was rare in North America and Europe until recently, when population shifts caused the incidence in some countries, including the United States and Spain, to eclipse that in many endemic areas.

Dr. Molina and his colleagues performed the clinical trial at three public health centers in Spain. Seventy-five of the 78 patients were originally from Bolivia. There were 47 women and 31 men, and the mean age was 39.9 years. A total of 22% had cardiac involvement, 6% had gastrointestinal involvement, and 6% had involvement of multiple organ systems.

These participants were randomly assigned in equal numbers to receive 100-mg posaconazole twice daily, 400-mg posaconazole twice daily, or 150-mg benznidazole twice daily for 60 days. They were followed for 40 weeks after the conclusion of treatment.

All patients responded to all the drugs during active treatment, showing negative results on assays to detect T. cruzi DNA from serial blood samples by day 14. However, parasitic DNA began to be detected in many participants after treatment ended, by day 60, and continued to be found throughout follow-up.

The primary end point of the study was consistently negative results on the T. cruzi DNA assays throughout follow-up. This was achieved by only 2 of 26 patients receiving low-dose posaconazole and only 5 of 26 receiving high-dose posaconazole. In comparison, the primary end point was achieved by 16 of 26 patients receiving benznidazole, the investigators said (N. Engl. J. Med. 2014 May 14 [doi:10.1056/NEJMoa1313122]).

In an intention-to-treat analysis, 92% of patients in the low-dose posaconazole group and 81% in the high-dose posaconazole group tested positive for T. cruzi DNA during follow-up, compared with only 38% of the benznidazole group.

Serious adverse effects forced the withdrawal of treatment in five patients, all of whom were receiving benznidazole. These included severe allergic dermatitis (with anaphylaxis in one patient), other cutaneous reactions, dysgeusia, and leukopenia.

Despite these disappointing results, with posaconazole failing to eliminate T. cruzi DNA in the blood, the drug did show suppressive activity, even at the low dose, throughout the active treatment period. So "it is possible that ergosterol inhibitors could be useful as a partner drug in future combination therapies," the researchers said.

This study was supported by the Ministry of Health, Spain. Dr. Molina and his associates reported no potential conflicts of interest.

Both acamprosate and oral naltrexone are helpful for curbing alcohol use disorders, with no apparent difference in effectiveness, according to a comprehensive review of the literature and meta-analysis funded by the Agency for Healthcare Research and Quality and published online May 13.

When added to psychosocial interventions, acamprosate and naltrexone were helpful in preventing patients from returning to any alcohol drinking and to heavy drinking, reducing the number of days of drinking, and decreasing the number of drinks per day. Importantly, both drugs were equally beneficial for real-world health outcomes such as reducing motor vehicle crashes, decreasing all types of injuries, reducing mortality, and improving quality of life, reported Dr. Daniel E. Jonas, of the University of North Carolina at Chapel Hill, and his associates.

In contrast, disulfiram did not consistently reduce any measure of alcohol consumption or improve any alcohol-related health outcome. Clinicians might be more familiar with disulfiram "because of its long-standing availability," but the best available evidence does not support its efficacy for most patients with alcohol use disorders, the investigators said.

Dr. Jonas and his associates undertook their comprehensive report on medications for alcohol use disorders because despite their known efficacy, less than one-third of such patients receive any treatment, and less than 10% receive medication to assist in reducing alcohol consumption.

The researchers reviewed the literature and identified 151 articles examining 122 double-blind, randomized, controlled trials and 1 prospective cohort study of 12-52 weeks’ duration comparing these three Food and Drug Administration–approved medications or 23 off-label medications in outpatient settings. There were 22,803 total participants, with sample sizes ranging from 21 to 1,383 subjects.

Acamprosate and oral naltrexone were comparably effective at reducing several measures of alcohol consumption. To prevent 1 patient from resuming any drinking, the number-needed-to-treat was only 12 with acamprosate and only 20 for oral naltrexone. (Injectable naltrexone was not as effective.) Head-to-head comparisons of these two drugs showed no statistically significant differences between them.

Clinicians and patients therefore should use factors other than effectiveness to choose between acamprosate and oral naltrexone, such as the local availability of the drug, convenience of dosing, cost, adverse-event profile, and contraindications, Dr. Jonas and his colleagues said.

In contrast, "evidence from well-controlled trials of disulfiram does not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes," the investigators said (JAMA 2014;311:1889-1900).

And for most of the off-label medications, "evidence was either insufficient to determine whether they are associated with reduced consumption or evidence suggested that they are not." The exceptions were topiramate, which reduced the number of drinking days, the number of heavy drinking days, and the number of drinks per day; nalmefene, which reduced the number of drinking days per month and drinks per day; and valproic acid.

Very few of the 123 studies reviewed for this meta-analysis reported on health outcomes. However, epidemiologic studies consistently reported that reducing alcohol consumption decreases patients’ risks for several cancers, liver cirrhosis, pancreatitis, stroke, depression, suicide, injuries, violence, and cognitive impairment, the researchers added.

No financial conflicts of interest were reported.

Both acamprosate and oral naltrexone are helpful for curbing alcohol use disorders, with no apparent difference in effectiveness, according to a comprehensive review of the literature and meta-analysis funded by the Agency for Healthcare Research and Quality and published online May 13.

When added to psychosocial interventions, acamprosate and naltrexone were helpful in preventing patients from returning to any alcohol drinking and to heavy drinking, reducing the number of days of drinking, and decreasing the number of drinks per day. Importantly, both drugs were equally beneficial for real-world health outcomes such as reducing motor vehicle crashes, decreasing all types of injuries, reducing mortality, and improving quality of life, reported Dr. Daniel E. Jonas, of the University of North Carolina at Chapel Hill, and his associates.

In contrast, disulfiram did not consistently reduce any measure of alcohol consumption or improve any alcohol-related health outcome. Clinicians might be more familiar with disulfiram "because of its long-standing availability," but the best available evidence does not support its efficacy for most patients with alcohol use disorders, the investigators said.

Dr. Jonas and his associates undertook their comprehensive report on medications for alcohol use disorders because despite their known efficacy, less than one-third of such patients receive any treatment, and less than 10% receive medication to assist in reducing alcohol consumption.

The researchers reviewed the literature and identified 151 articles examining 122 double-blind, randomized, controlled trials and 1 prospective cohort study of 12-52 weeks’ duration comparing these three Food and Drug Administration–approved medications or 23 off-label medications in outpatient settings. There were 22,803 total participants, with sample sizes ranging from 21 to 1,383 subjects.

Acamprosate and oral naltrexone were comparably effective at reducing several measures of alcohol consumption. To prevent 1 patient from resuming any drinking, the number-needed-to-treat was only 12 with acamprosate and only 20 for oral naltrexone. (Injectable naltrexone was not as effective.) Head-to-head comparisons of these two drugs showed no statistically significant differences between them.

Clinicians and patients therefore should use factors other than effectiveness to choose between acamprosate and oral naltrexone, such as the local availability of the drug, convenience of dosing, cost, adverse-event profile, and contraindications, Dr. Jonas and his colleagues said.

In contrast, "evidence from well-controlled trials of disulfiram does not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes," the investigators said (JAMA 2014;311:1889-1900).

And for most of the off-label medications, "evidence was either insufficient to determine whether they are associated with reduced consumption or evidence suggested that they are not." The exceptions were topiramate, which reduced the number of drinking days, the number of heavy drinking days, and the number of drinks per day; nalmefene, which reduced the number of drinking days per month and drinks per day; and valproic acid.

Very few of the 123 studies reviewed for this meta-analysis reported on health outcomes. However, epidemiologic studies consistently reported that reducing alcohol consumption decreases patients’ risks for several cancers, liver cirrhosis, pancreatitis, stroke, depression, suicide, injuries, violence, and cognitive impairment, the researchers added.

No financial conflicts of interest were reported.

Both acamprosate and oral naltrexone are helpful for curbing alcohol use disorders, with no apparent difference in effectiveness, according to a comprehensive review of the literature and meta-analysis funded by the Agency for Healthcare Research and Quality and published online May 13.

When added to psychosocial interventions, acamprosate and naltrexone were helpful in preventing patients from returning to any alcohol drinking and to heavy drinking, reducing the number of days of drinking, and decreasing the number of drinks per day. Importantly, both drugs were equally beneficial for real-world health outcomes such as reducing motor vehicle crashes, decreasing all types of injuries, reducing mortality, and improving quality of life, reported Dr. Daniel E. Jonas, of the University of North Carolina at Chapel Hill, and his associates.

In contrast, disulfiram did not consistently reduce any measure of alcohol consumption or improve any alcohol-related health outcome. Clinicians might be more familiar with disulfiram "because of its long-standing availability," but the best available evidence does not support its efficacy for most patients with alcohol use disorders, the investigators said.

Dr. Jonas and his associates undertook their comprehensive report on medications for alcohol use disorders because despite their known efficacy, less than one-third of such patients receive any treatment, and less than 10% receive medication to assist in reducing alcohol consumption.

The researchers reviewed the literature and identified 151 articles examining 122 double-blind, randomized, controlled trials and 1 prospective cohort study of 12-52 weeks’ duration comparing these three Food and Drug Administration–approved medications or 23 off-label medications in outpatient settings. There were 22,803 total participants, with sample sizes ranging from 21 to 1,383 subjects.

Acamprosate and oral naltrexone were comparably effective at reducing several measures of alcohol consumption. To prevent 1 patient from resuming any drinking, the number-needed-to-treat was only 12 with acamprosate and only 20 for oral naltrexone. (Injectable naltrexone was not as effective.) Head-to-head comparisons of these two drugs showed no statistically significant differences between them.

Clinicians and patients therefore should use factors other than effectiveness to choose between acamprosate and oral naltrexone, such as the local availability of the drug, convenience of dosing, cost, adverse-event profile, and contraindications, Dr. Jonas and his colleagues said.

In contrast, "evidence from well-controlled trials of disulfiram does not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes," the investigators said (JAMA 2014;311:1889-1900).

And for most of the off-label medications, "evidence was either insufficient to determine whether they are associated with reduced consumption or evidence suggested that they are not." The exceptions were topiramate, which reduced the number of drinking days, the number of heavy drinking days, and the number of drinks per day; nalmefene, which reduced the number of drinking days per month and drinks per day; and valproic acid.

Very few of the 123 studies reviewed for this meta-analysis reported on health outcomes. However, epidemiologic studies consistently reported that reducing alcohol consumption decreases patients’ risks for several cancers, liver cirrhosis, pancreatitis, stroke, depression, suicide, injuries, violence, and cognitive impairment, the researchers added.

No financial conflicts of interest were reported.