EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 13, 2004
To contact John D. Piette, Ph.D., call Kara Gavin at 734/764-2220. To contact editorialist Alex D. Federman, M.D., M.P.H., call Debra Kaplan at 212/659-9045.

MANY PATIENTS NEVER TELL THEIR HEALTH CARE CLINICIANS THEY UNDERUSE MEDICATIONS BECAUSE OF PRESCRIPTION COSTS

CHICAGO—About one-third of chronically ill adults who underuse medications because of the costs associated with buying the drugs, never tell their health care practitioners, according to an article in the September 13 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

Patients concerned with out-of-pocket medication costs often limit their prescription drug use, according to background information in the article. Because chronically ill patients often take multiple medications, they are especially vulnerable to the strain from drug costs, the article states. The underuse of essential medications, including cholesterol-lowering medications, heart medications, asthma medications and antipsychotics, has been associated with increased emergency department visits, nursing home admissions, acute psychiatric hospitalizations, and a decrease in self-reported health status, according to the article.

John D. Piette, Ph.D., from the University of Michigan, Ann Arbor, and colleagues surveyed 660 chronically ill adults (average age, 62.6 years) nationwide who had reported underusing medication the year before due to cost. Of those surveyed, 16 percent were nonwhite, 64 percent had at most a high school education, and 30 percent had an annual household income of $20,000 or less.

Of those surveyed, two thirds never told a clinician (doctor or nurse) in advance that they intended to underuse their medication due to cost, and 35 percent of respondents never discussed the subject at all. Of respondents who did not tell a clinician, 66 percent reported that they had not been asked about their ability to pay for prescriptions. Seventy two percent of patients who talked with their clinicians about medication costs found the conversations to be helpful. However, 31 percent said their medications were never changed to a generic or less expensive replacement. Also, only 30 percent of patients were informed of programs that help pay drug costs, and fewer people were told where to purchase less expensive medication (28 percent).

"This study suggests that most patients who fail to alert clinicians about their medication cost problems are not asked about their ability to pay for their medication, and many perceive that clinicians are unwilling or unable to help them with this problem," the authors write.

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To contact Peter U. Heuschmann, M.D., M.P.H., e-mail: heuschma{at}uni-muenster.de.

STUDY IDENTIFIES MEDICAL AND NEUROLOGICAL COMPLICATIONS THAT INCREASE RISK OF DYING IN THE HOSPITAL AFTER STROKE

CHICAGO—Patients who experience medical or neurological complications following stroke, such as pneumonia or brain swelling, are at a greater risk of dying in the hospital, according to an article in the September 13 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

According to information in the article, stroke will be the second leading cause of death and disability in the developed world in 2020. However, there is little information on factors that may be associated with dying in the hospital and the impact of neurological complications on early outcomes for patients with stroke.

Peter U. Heuschmann, M.D., M.P.H., of the University of Muenster, Germany, and colleagues studied stroke patients who were admitted to German hospitals between January 1, 2000 and December 31, 2000 to determine factors that may predict risk of death after ischemic stroke (when a blood clot prevents blood from getting to the brain). A total of 13,440 ischemic stroke patients were included in the study.

The researchers found that overall, 4.9 percent of the stroke patients died in the hospital. In women, higher age, severity of stroke, and atrial fibrillation (heart rhythm disorder) were independent predictors for dying in the hospital. In men, diabetes and previous stroke had a significant negative influence on early outcomes after stroke in addition to the factors identified for women. Increased intracranial pressure (a building of pressure inside the skull, often due to swelling of the brain) accounted for 94 percent of deaths for patients with this complication. Pneumonia was the complication that caused the most deaths among the stroke patients, accounting for 31.2 percent of all deaths. The researchers also found that more than half of all in-hospital deaths were caused by serious medical or neurological complications.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 13, 2004
To contact Brennan M. R. Spiegel, M.D., M.S.H.S., call Rachel Champeau at 310/794-0777.

MANY FACTORS INFLUENCE QUALITY OF LIFE FOR PATIENTS WITH IRRITABLE BOWEL SYNDROME

CHICAGO—The quality of life for patients with irritable bowel syndrome is as related to non-gastrointestinal (GI) symptoms, including tiring easily and feeling tense, as it is to GI symptoms associated with the disorder, according to an article in the September 13 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

Irritable bowel syndrome (IBS) is a chronic disorder of the gastrointestinal tract characterized by frequent abdominal pain and abnormal bowel habits. IBS affects 15 percent of the general adult population, results in 3.6 million physician visits annually, and costs more than $8 billion per year. Patients with IBS have worse health-related quality of life (HRQOL) than patients with diabetes or severe kidney disease, the article states. However, data suggest that many physicians do not adequately assess the impact of IBS symptoms and non-disease-related symptoms on their patients' lives and health status.

Brennan M. R. Spiegel, M.D., M.S.H.S., of The David Geffen School of Medicine at the University of California, Los Angeles, and colleagues identified several factors that play a role in the HRQOL in patients with IBS.

The researchers examined 770 patients, 18 years and older (69.1 percent female), with IBS at a university-based referral center. Participants completed a 90-item questionnaire on their symptoms, and a 36-item health survey.

The researchers found seven factors were related to patients' HRQOL: making more than five physician visits per year, tiring easily, low energy, severe symptoms, predominantly painful symptoms, feeling that there is "something seriously wrong with my body," and symptom flares lasting longer than 24 hours. The researchers found that eight factors were related to mental HRQOL: feeling tense, feeling nervous, feeling hopeless, difficulty sleeping, tiring easily, low sexual interest, IBS symptoms interfering with sexual function, and low energy.

"... we have identified specific clinical predictors of mental and physical HRQOL that may facilitate efficient assessment and targeted treatment in patients with IBS," the researchers write. "Whereas physical HRQOL is associated with symptom severity, symptom periodicity, and pain, mental HRQOL is associated with abnormalities in sexuality, mood, and anxiety."

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 13, 2004
To contact Eliot L. Berson, M.D., call Mary Leach at 617/573-4170.

USE OF OMEGA-3 FATTY ACID THERAPY DOES NOT SLOW THE PROGRESSION OF RETINITIS PIGMENTOSA IN PATIENTS RECEIVING VITAMIN A TREATMENT

CHICAGO—Patients with retinitis pigmentosa, a progressive eye disease that can cause vision loss, who were treated with vitamin A and docosahexaenoic acid (DHA), a kind of omega-3 fatty acid, did not experience slowing of the progression of their disease, according to two articles in the Archives of Ophthalmology, one of the JAMA/Archives journals.

Retinitis pigmentosa is a disorder of the light-collecting cells on the retina-the layer at the back of the eye that collects light-and can cause vision loss. According to the article, retinitis pigmentosa affects about one in 4,000 people worldwide. Previous studies have shown that patients treated with vitamin A have a slower decline in retinal function and vision loss compared to patients who do not take vitamin A. Other studies have found that patients with retinitis pigmentosa tend to have lower blood levels of docosahexaenoic acid (DHA), an omega-3 fatty acid found in the photoreceptor cells.

Eliot L. Berson, M.D., of the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, and colleagues investigated whether giving oral DHA to patients already receiving vitamin A treatment could halt or slow the course of their retinitis pigmentosa.

The researchers studied 221 patients with retinitis pigmentosa aged 18 to 55 years who were followed over a four year period. Patients were given either 1,200 milligrams per day of DHA or control capsules (placebo), and all were given 15,000 IU/d (international units per day) of vitamin A.

The researchers write that "No significant differences in decline in ocular function were found between the docosahexaenoic acid plus vitamin A (DHA+A) group and control plus vitamin A (control + A) group over a four-year interval."

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 13, 2004
To contact corresponding author James C. Tsai, M.D., call Elizabeth Streich at 212/305-6535.

CORNEAL THICKNESS MAY INFLUENCE DECISION REGARDING TREATMENT OPTIONS FOR PATIENTS WITH GLAUCOMA

CHICAGO—Thickness of the cornea, the thin, transparent layer covering the eye, may be an important factor in considering treatment options for patients with glaucoma, according to an article appearing in the September issue of the Archives of Ophthalmology, one of the JAMA/Archives journals.

According to information in the article, central corneal thickness (CTT) can effect the accuracy of intraocular pressure (IOP) measurements. Elevated intraocular pressure (pressure inside the eyeball) is a strong indicator of glaucoma, a disease of the optic nerve that can cause vision loss. Patients with decreased CCT measurements are at an increased risk for developing glaucoma, the article states.

Carolyn Y. Shih, M.D., of the Edward S. Harkness Eye Institute, Columbia University, New York, and colleagues evaluated the effect of CCT measurements on decisions regarding clinical management of 188 patients with glaucoma or suspected glaucoma.

The researchers measured CCT and IOP for each participant. Using an algorithm, the researchers adjusted the IOP measurements based on their findings from the CCT measurements. Adjustments in therapy-use of eye drops, or addition or cancellation of laser therapy or surgery-were recorded for patients whose IOP was adjusted by 1.5 mm Hg (millimeters of mercury, the unit of measurement for pressure inside the eye) or more based on the CCT findings (referred to in the paper as "measurement-significant adjustment").

Of 188 patients, 105 (55.9 percent) had a measurement-significant adjustment in their IOP measurements, with 67 patients (35.6 percent) having adjustments between 1.5 and 3.0 mm Hg, with 38 patients (20.2 percent) having an outcomes-significant IOP adjustment. Sixteen patients (8.5 percent) had a change in eye drop therapy, four (2.1 percent) had a change regarding laser therapy, and six (3.2 percent) had a decision change regarding glaucoma surgery. "Although some authors have reported that patients may be misdiagnosed because of the absence of CCT determination or the subsequent adjustment of IOP, we are not aware of any studies that have assessed the effect of CCT-associated IOP adjustments on glaucoma clinical management," write the researchers.

"Based on our analysis, there appears to be clinical usefulness in the IOP corrections, as approximately 8 percent to 10 percent of the patients had a change in their medication therapy, about 2 percent had a change in the recommendation (or deferment) of laser procedures, and about 3 percent had a change in the recommendation (or deferment) of glaucoma incisional surgery," write the authors.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 13, 2004
To contact Perminder Sachdev, M.D., Ph.D., F.R.A.N.Z.C.P., e-mail: p.sachdev{at}unsw.edu.au.

ELEVATED HOMOCYSTEINE LEVELS MAY BE RELATED TO CHANGES IN DEEP BRAIN TISSUE

CHICAGO—Higher blood levels of homocysteine (HCY), an amino acid in the body, may be associated with changes in deep brain tissue in middle-aged men, according to an article in the September issue of the Archives of Neurology, one of the JAMA/Archives journals.

According to the article, high HCY levels have been associated with an increased risk for vascular diseases, and some studies have suggested that HCY may also increase the risk for brain atrophy and Alzheimer disease. Other studies have shown an inverse relationship between elevated HCY levels and cognitive functioning, the article states.

Perminder Sachdev, M.D., Ph.D., F.R.A.N.Z.C.P., of the University of New South Wales, Sydney, Australia, and colleagues examined the relationship between HCY levels and findings from brain magnetic resonance imaging (MRI) and cognitive function among healthy individuals aged 60 to 64 years old. There were 196 men and 189 women included in the study.

Blood samples from each participant were used to measure HCY levels. Participants also had MRI of their brains and underwent a battery of cognitive tests administered within three months of the MRI and blood examinations.

The researchers found that HCY levels did not have a significant relationship with brain atrophy, but high HCY levels in men were related to changes in deep white matter hyperintensities in the brain, which appeared on the MRI.

"Total HCY level is independently related to leukoaraiosis [deep white matter hyperintensities] in middle-aged men, and this may be functionally relevant in the form of mild cognitive impairment," write the authors.