JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENTS
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, February 25, 2008)
STUDY EXAMINES ANTIBIOTIC USE AMONG NURSING HOME PATIENTS WITH ADVANCED DEMENTIA WHO ARE NEAR THE END OF LIFE
HORMONE THERAPY INCREASES FREQUENCY OF ABNORMAL MAMMOGRAMS, BREAST BIOPSIES
STUDY EXAMINES LONG-TERM OUTCOMES FOLLOWING BLOOD CLOTS
MORE ELDERLY AMERICANS ARE LIVING WITH HEART FAILURE
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 25, 2008
Media Advisory: To contact Erika D’Agata, M.D., M.P.H., call Bonnie Prescott at 617-667-7306. To contact corresponding editorialist Yehuda Carmeli, M.D., M.P.H., e-mail: yehudac{at}tasmc.health.gov.il.
STUDY EXAMINES ANTIBIOTIC USE AMONG NURSING HOME PATIENTS WITH ADVANCED DEMENTIA WHO ARE NEAR THE END OF LIFE
CHICAGO—Antibiotics appear to be frequently prescribed to individuals with advanced dementia in nursing homes, especially in the two weeks before death, according to a report in the February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
More than 5 million Americans have dementia, according to background information in the article. About 70 percent of them will live in nursing homes at the end of their lives. Recurrent infections and fever are common among these patients, who may receive antibiotics to treat these conditions.
Erika D’Agata, M.D., M.P.H., of Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, and colleagues studied 214 residents (average age 85.2) with advanced dementia living in 21 area nursing homes. The participants underwent an initial assessment between 2003 and 2006 and then were examined every three months for a maximum of 18 months. At each evaluation, the number of courses of antibiotic therapy prescribed since the prior visit was obtained from facility records.
During an average of 322 days of follow-up, 142 (66.4 percent) participants received at least one course of antibiotics and the overall average was four courses. Of the 99 (46.3 percent) residents who died, 42 (42.4 percent) received antibiotics during the two weeks before their death. “The proportion of residents taking antimicrobials was seven times greater in the last two weeks of life compared with six to eight weeks before death,” the authors write. Thirty of the 72 courses (41.7 percent) in the last two weeks of life were administered intravenously rather than by mouth, a method that may be uncomfortable for patients with advanced dementia.
“This extensive use of antimicrobials and pattern of antimicrobial management in advanced dementia raises concerns not only with respect to individual treatment burden near the end of life but also with respect to the development and spread of antimicrobial resistance in the nursing home setting,” the authors write. The results support “the development of programs and guidelines designed to reduce the use of antimicrobial agents in advanced dementia.”
(Arch Intern Med. 2008;168[4]:357-362. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This study was supported by a grant from the National Institute on Aging, National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: ANTIBIOTICS RAISE ETHICAL DILEMMAS THAT MUST BE SOLVED INDIVIDUALLY
“The findings in this study require the medical community to ask whether the extensive use of antibiotics in this particular patient population is appropriate, taking two factors into consideration: the benefit to the patient treated and the risk imposed on other patients,” write Mitchell J. Schwaber, M.D., M.Sc., and Yehuda Carmeli, M.D., M.P.H., of the Tel Aviv Medical Center, Israel, in an accompanying editorial.
“The solution is not to categorically deny antibiotics to the severely demented elderly, or even to impose limits on their use or their spectrum as a matter of policy,” they continue. “We must, however, begin to consider every decision to use antibiotics in this population as we would decisions regarding other treatment modalities, including resuscitation and major surgery. That is, we must ask whether the interests of the patient are being served by using antibiotics. We must further ask whether the use of antibiotics in each specific patient justifies the risk placed on others by their use.”
“All such decisions must ultimately be made individually, based on the medical situation and the expressed wishes of the patient and family, as well as on the physician’s judgment of the benefits and risks entailed in treating vs. not treating,” they conclude.
(Arch Intern Med. 2008;168[4]:349-350. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 25, 2008
Media Advisory: To contact Rowan T. Chlebowski, M.D., Ph.D., call Laura Mecoy at 310-546-5860.
HORMONE THERAPY INCREASES FREQUENCY OF ABNORMAL MAMMOGRAMS, BREAST BIOPSIES
CHICAGO—Combined hormone therapy appears to increase the risk that women will have abnormal mammograms and breast biopsies and may decrease the effectiveness of both methods for detecting breast cancer, according to a report in the February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Hormone therapy use remains common among women beginning menopause, according to background information in the article. “For women with a uterus considering combined estrogen plus progestin use, identified breast cancer issues represent a concern,” the authors write.
Rowan T. Chlebowski, M.D., Ph.D., of the Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, and colleagues studied 16,608 post-menopausal women who participated in the Women’s Health Initiative (WHI) clinical trial, beginning in 1993 through 1998. A total of 8,506 women were randomly assigned to receive a combination of estrogen (0.625 milligrams of conjugated equine estrogens per day) plus progesterone (2.5 milligrams of medroxyprogesterone acetate per day), while 8,102 took a placebo. Each woman received a mammogram and breast examination yearly, with biopsies performed based on physicians’ clinical judgment.
During the 5.6 years of the study, 199 women in the combined hormone group and 150 women in the placebo group developed breast cancer. Mammograms with abnormal results were more common among women taking hormones than among women taking placebo (35 percent vs. 23 percent); women taking hormones had a 4 percent greater risk of having a mammogram with abnormalities after one year and an 11 percent greater risk after five years.
Breast biopsies also were more common among women taking hormones than among those assigned to placebo (10 percent vs. 6.1 percent). “Although breast cancers were significantly increased and were diagnosed at higher stages in the combined hormone group, biopsies in that group less frequently diagnosed cancer (14.8 percent vs. 19.6 percent),” the authors write.
“After discontinuation of combined hormone therapy, its adverse effect on mammograms modulated but remained significantly different from that of placebo for at least 12 months,” they continue.
Use of combined hormones increases breast density, which increases the risk of breast cancer and may also delay diagnosis, the authors note. However, breast density was not measured in the current study.
“Use of conjugated equine estrogens plus medroxyprogesterone acetate for approximately five years resulted in more than one in 10 and one in 25 women having otherwise avoidable mammogram abnormalities and breast biopsies, respectively, and compromised the diagnostic performance of both,” the authors conclude. “This adverse effect on breast cancer detection should be incorporated into risk-benefit discussions with women considering even short-term combined hormone therapy.”
(Arch Intern Med. 2008;168[4]:370-377. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: The WHI program is funded by the National Heart, Lung, and Blood Institute, U.S. Department of Health and Human Services. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 25, 2008
Media Advisory: To contact Frederick A. Spencer, M.D., call Veronica McGuire at 905-525-9140 ext. 22169.
STUDY EXAMINES LONG-TERM OUTCOMES FOLLOWING BLOOD CLOTS
CHICAGO—Patients who develop a blood clot in their legs (deep vein thrombosis) or lungs (pulmonary embolism) are at risk for experiencing another blood clot within three years, and patients with pulmonary embolism have a higher risk of death, according to a report in the February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Deep vein thrombosis and pulmonary embolism are considered different manifestations of the same disease process, according to background information in the article. The medical management of both conditions, known collectively as venous thromboembolism, has improved in the past decade, the authors note.
Frederick A. Spencer, M.D., of McMaster University Medical Center, Hamilton, Ontario, Canada, and colleagues analyzed the medical records of 1,691 Worcester, Mass., residents (54 percent women, average age 65) who were diagnosed with venous thromboembolism in 1999, 2001 or 2003. Of those, 549 had pulmonary embolism and 1,142 had isolated deep vein thrombosis.
Over the three-year study, among the 549 patients who presented with pulmonary embolism, 31 (5.7 percent) had a recurrent clot in the lung, 75 (13.7 percent) had a recurrence of either type of venous thromboembolism and 82 (14.9 percent) experienced a major bleeding episode (i.e., so severe they required a transfusion). Among the 1,142 patients who presented with isolated deep vein thrombosis over the same period, 64 (5.6 percent) developed a pulmonary embolism, 217 (19 percent) had recurrent venous thromboembolism and 146 (12.8 percent) had a major bleeding episode.
Individuals with pulmonary embolism were more likely to die after one month (13 percent vs. 5.4 percent), one year (26 percent vs. 20.3 percent) and three years (35.3 percent vs. 29.6 percent) than those with deep vein thrombosis. “Patients whose course was complicated by major bleeding were more likely to experience recurrent venous thromboembolism or to die at three years than those without these complications,” the authors write.
“Patients who presented with pulmonary embolism had similar rates of subsequent pulmonary embolism or recurrent venous thrombosis compared with patients with isolated deep vein thrombosis,” the authors conclude. “However, rates of recurrent venous thromboembolism and major bleeding after deep vein thrombosis and pulmonary embolism remain unacceptably high in the community setting. Efforts are needed to identify patients most at risk for venous thrombosis–associated complications and to develop better anticoagulation strategies conducive to long-term use in the community setting.”
(Arch Intern Med. 2008;168[4]:425-430. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This study was supported by a grant from the National Heart, Lung and Blood Institute. Dr. Spencer has also received a Career Investigator Award from the Heart and Stroke Foundation of Canada. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 25, 2008
Media Advisory: To contact Lesley H. Curtis, Ph.D., call Michelle Gailiun at 919-660-1306.
MORE ELDERLY AMERICANS ARE LIVING WITH HEART FAILURE
CHICAGO—The number of elderly individuals newly diagnosed with heart failure has declined during the past ten years, but the number of those living with the condition has increased, according to a report in the February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
“Heart failure affects nearly 5 million people in the United States, and more than 300,000 die each year as a result of the disease. Heart failure is primarily a disease of elderly persons and, consequently, places a significant and growing economic burden on the Medicare program,” according to background information in the article. The number of people age 65 or older hospitalized for heart failure from 1984 to 2002 rose by more than 30 percent. “Estimates of the incidence [rate of new cases] and prevalence [percentage of the population affected] of heart failure in elderly persons translate directly into projections of resource use for the Medicare program, so accurate estimates are essential.”
Lesley H. Curtis, Ph.D., of the Duke University School of Medicine, Durham, N.C., and colleagues analyzed information obtained from the files of 622,789 Medicare patients age 65 or older who were diagnosed with heart failure between 1994 and 2003. The rate of new heart failure occurrences and the number of people living with heart failure were measured.
The yearly occurrence of heart failure decreased from 32 per 1,000 person-years (years of observation time during which each person is at risk to develop the disease) in 1994 to 29 per 1,000 person-years in 2003. A sharper decline was seen in Medicare patients age 80 to 84 (from 57.5 to 48.4 per 1,000 person-years), while a slight increase was seen in those age 65 to 69 (from 17.5 to 19.3 per 1,000 person-years).
The number of patients living with the condition increased steadily from about 140,000 to approximately 200,000 with more men living with the disease than women each year. “The proportion of beneficiaries with a heart failure diagnosis grew from 90 per 1,000 in 1994 to 120 per 1,000 in 2000, and remained at about 120 per 1,000 through 2003,” the authors write.
“Although the incidence of heart failure has declined somewhat during the past decade, modest survival gains have resulted in an increase in the number of patients living with heart failure,” the authors conclude. “Identifying optimal strategies for the treatment and management of heart failure will become increasingly important as the size of the Medicare population grows.”
(Arch Intern Med. 2008;168[4]:418-424. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This study was supported in part by a grant from the National Institute on Aging; a grant from the National Heart, Lung and Blood Institute; a grant from the Agency for Healthcare Research and Quality and a research agreement between Medtronic and Duke University. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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