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, October 27, 2008)
STATINS ASSOCIATED WITH LOWER RISK OF DEATH FROM PNEUMONIA
DIABETES TREATMENT BECOMES MORE COMPLEX, COSTLY
END-OF-LIFE PREFERENCES APPEAR TO REMAIN STABLE AS HEALTH DECLINES
CAREGIVING MAY BE ASSOCIATED WITH POORER HEALTH IN CERTAIN GROUPS
META-ANALYSIS EXAMINES CARDIOVASCULAR EFFECTS OF DIABETES MEDICATIONS
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, October 27, 2008
Media Advisory: To contact Reimar W. Thomsen, M.D., Ph.D., e-mail r.thomsen@rn.dk. To contact editorialist Kasturi Haldar, Ph.D., call William G. Gilroy at 574-631-4127.
STATINS ASSOCIATED WITH LOWER RISK OF DEATH FROM PNEUMONIA
CHICAGO—Individuals who take cholesterol-lowering statins before being hospitalized with pneumonia appear less likely to die within 90 days afterward, according to a report in the October 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
In the United States and Europe, pneumonia hospitalization rates have increased 20 percent to 50 percent over the past decade, according to background information in the article. About 10 percent to 15 percent of those with pneumonia die from the disease. A recent review article indicated that statins may benefit patients with sepsis (infection of the bloodstream) or bacteremia (presence of bacteria in the bloodstream), possibly due to the medications' anti-clotting, anti-inflammatory or immune-modifying properties.
Reimar W. Thomsen, M.D., Ph.D., of Aarhus University and Aalborg Hospital, Aalborg, Denmark, and colleagues reviewed data from 29,900 adults hospitalized with pneumonia between 1997 and 2004. Of these, 1,371 (4.6 percent) were taking statins at the time.
"Mortality [death] among statin users was lower than among non-users: 10.3 percent vs. 15.7 percent after 30 days and 16.8 percent vs. 22.4 percent after 90 days," the authors write. The lowest relative death rate associated with statins was observed in patients older than 80 and those with bacteremia. "The differences became apparent during the first few weeks of hospitalization, a period associated with a high number of pneumonia-related deaths, and they increased only minimally between 30 and 90 days after admission, which suggests that statin use is beneficial primarily in the early phase of infection."
Previous statin use, or the use of any other preventive medication for cardiovascular health, was not associated with a reduced death rate from pneumonia.
"Several biological mechanisms may explain our results," the authors write. Statins change the immune response, beneficially affect processes associated with blood clotting and inflammation and inhibit dysfunction in blood vessels. These effects may especially benefit patients with sepsis and bacteremia, which are associated with early death from pneumonia.
"Our study adds to the accumulating evidence that statin use is associated with improved prognosis after severe infections," the authors write. "The decrease in mortality associated with statin use seems to be substantial in patients with pneumonia requiring hospital admission. Randomized trials are needed to examine causality of the associations found in observational studies. Given the availability of statins, with their relatively low cost and mild adverse effects, positive results of statin therapy trials in patients with pneumonia would have substantial clinical and public health implications."
(Arch Intern Med. 2008;168[19]:2081-2087. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This study was supported by the Western Danish Research Forum for Health Sciences and by the Clinical Epidemiological Research Foundation at Aarhus University Hospital, Aarhus, Denmark. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: COMBINING STATINS AND ANTIBIOTICS MAY PROVE EFFECTIVE AGAINST INFECTION
"These data suggest a substantial decrease in mortality with statin use," writes Kasturi Haldar, Ph.D., of the University of Notre Dame, South Bend., Ind., in an accompanying editorial.
The resulting data "raises the question of whether statins should be used to improve anti-infective therapy. They are not optimal for treating acute infection because it takes days to achieve the desirable concentrations in plasma," Dr. Haldar continues.
"However, because statins target the host, drug resistance, a major problem in treating bacterial infections, is not likely to develop. Thus, it may be useful to consider clinical research testing of combinations of statins with existing antibiotic agents to evaluate whether it is possible to develop optimized combination therapies effective against both acute and persistent infections."
(Arch Intern Med. 2008;168[19]:2067-2068. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: This editorial was supported by a Department of Veterans Affairs Merit Award, Great Lakes Research Center of Excellence and by the National Institutes of Health. 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, October 27, 2008
Media Advisory: To contact G. Caleb Alexander, M.D., M.S., call John Easton at 773-702-6241.
DIABETES TREATMENT BECOMES MORE COMPLEX, COSTLY
CHICAGO—A progressively more complex and expensive array of treatments for type 2 diabetes is being prescribed to an increasing number of adults, according to a report in the October 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
In 2000, more than 11 million Americans had been diagnosed with diabetes, according to background information in the article. "By 2050, the number of Americans with diabetes is expected to soar to 29 million, a prevalence of 7 percent," the authors write. "The annual economic burden of diabetes is estimated at $132 billion and increasing. In 2002, more than one-tenth of U.S. health care expenditures were attributable to diabetes." As costs and prevalence increase, managing diabetes also has become increasingly complex, as physicians prescribe more medications to each patient and combine drugs from different therapeutic classes.
To evaluate these trends, G. Caleb Alexander, M.D., M.S., of the University of Chicago Hospitals, and colleagues gathered diabetes prescription information and costs from national databases. The researchers analyzed prescription data from U.S. patients age 35 and older with type 2 diabetes who visited a physician's office between 1994 and 2007. Information about medication costs was available from 2001 to 2007.
The analysis revealed that, between 1994 and 2007:
- The estimated number of yearly patient visits to treat diabetes increased from 25 million to 36 million
- The average number of medications prescribed per treated patient increased from 1.14 to 1.63
- Among visits in which any treatment was given, the number in which only one drug was prescribed decreased from 82 percent to 47 percent
- Insulin use decreased from 38 percent in 1994 to a low of 25 percent in 2000, and then increased again to 28 percent
- The types of medications prescribed shifted—the use of sulfonylurea drugs decreased from 67 percent to 34 percent of treatment visits, while use of newer drugs such as biguanides and glitazones increased, so that by 2007 these agents were prescribed at 54 percent and 28 percent of treatment visits, respectively
The increasing use of glitazones—along with other new treatments, including new forms of insulin and other new classes of drugs—accounted for increases in average cost per prescription (from $56 in 2001 to $76 in 2007) and in overall medication expenditures for those with diabetes (from $6.7 billion in 2001 to $12.5 billion in 2007).
"We document large shifts in patterns of diabetes treatment and pharmaceutical expenditures across treatment classes," the authors conclude. "Whether increased treatment costs are balanced by improved outcomes associated with these changes cannot be evaluated in the absence of data comparing effectiveness and cost-effectiveness across treatment classes. Our findings suggest the importance of generating new comparative data and coupling this information with clinical and formulary guidelines that contribute to constraining costs, maximizing glycemic control and minimizing diabetes-related morbidity and mortality."
(Arch Intern Med. 2008;168[19]:2088-2094. Available to the media pre-embargo at www.jamamedia.org)
Editor's Note: Dr. Alexander is a Robert Wood Johnson Faculty Scholar and is also supported by a career development award from the Agency for Healthcare Research and Quality. Senior author Dr. Stafford was supported by a Mid-Career Mentoring Award from the National Heart, Lung, and Blood Institute. 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, October 27, 2008
Media Advisory: To contact Marsha N. Wittink, M.D., M.B.E., call Marc Kaplan at 215-349-5660.
END-OF-LIFE PREFERENCES APPEAR TO REMAIN STABLE AS HEALTH DECLINES
CHICAGO—Most individuals' preferences regarding life-sustaining treatment do not appear to change over a three-year period, regardless of declines in physical and mental health, according to a report in the October 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Individuals who say they want aggressive care and those without advance directives are most likely to change their end-of-life wishes over time.
"Efforts to improve the experience of patients and families at the end of life must incorporate patient perspectives," the authors write as background information in the article. "Advance directives are one strategy through which patient preferences can be elicited and recorded, to be invoked at a time when the patient may not be able to make decisions directing care." However, they note, preferences for life-sustaining treatment given in one state of health may not reflect the choices patients would make if their health status changed.
Marsha N. Wittink, M.D., M.B.E., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues assessed end-of-life preferences in 818 physicians (average age 69) who graduated from medical school at Johns Hopkins University between 1948 and 1964. Participants completed questionnaires about their health status and their end-of-life preferences in 1999 and again in 2002. They were asked to consider what treatments they would want in the event of brain death that left them unable to speak or recognize people. They reported how likely they were to desire each of 10 interventions, including cardiopulmonary resuscitation, major surgery, a feeding tube and dialysis.
The physicians were divided into three clusters based on their preferences: those who would want most of the interventions were classified as preferring aggressive care (12 percent in 1999 and 14 percent in 2002), those who would want intravenous fluids and antibiotics as the primary interventions as preferring intermediate care (26 percent in 1999 and 26 percent in 2002) and those who would decline most interventions as desiring least aggressive care (62 percent in 1999 and 60 percent in 2002).
"In general, procedures that were declined in 1999 were likely also to be declined in 2002," the authors write. "Nevertheless, a substantial proportion of persons who desired an intervention in 1999 declined the treatment in 2002." A total of 41 percent of those who said they desired aggressive care in 1999 remained in that category in 2002. In addition, physicians who did not have a living will or durable power of attorney were twice as likely to transition to the most aggressive category as those without advance directives. Age and declines in mental and physical health were not associated with transitions to either more or less aggressive care.
"We believe that the results of this study suggest that although physician-respondents were relatively stable in their preferences, persons without advance directives and who desired the most aggressive treatment at baseline exhibited the most changeable preferences," the authors write. "Persons who express a desire for aggressive treatment and those who have not communicated their wishes with a more formal written document (advance directives) may require frequent clinical re-evaluation to assess whether wishes have changed."
(Arch Intern Med. 2008;168[19]:2125-2130. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: Dr. Wittink was supported by Mentored Patient-Oriented Research Career Development Award from the National Institute of Mental Health. The Johns Hopkins Precursors Study was supported by grants from the National Institutes of Health. 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, October 27, 2008
Media Advisory: To contact Lisa Fredman, Ph.D., call Lisa Chedekel at 617-414-1401.
CAREGIVING MAY BE ASSOCIATED WITH POORER HEALTH IN CERTAIN GROUPS
CHICAGO—Older white caregivers (those who provide regular care or assistance for a child or a disabled or sick adult) appear to have poorer health outcomes than black female caregivers, according to a report in the October 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Although past studies have found that caregivers have poorer immune status than non-caregivers, there has not been any consistent evidence stating that caregiving increases disease occurrence or death, according to background information in the article. "These inconsistent results suggest the need to examine factors that may influence the association between caregiving and health decline in older adults, particularly race, sex and overall level of physical activity of caregivers and non-caregivers," the authors write. Since physical activity is associated with lower stress and depressive symptoms, and protects against heart disease, death and mobility disability, including it in studies of caregiving "may provide a more accurate description of how caregiving affects physical health."
Lisa Fredman, Ph.D., of the Boston University School of Public Health, and colleagues assessed the physical activity (including daily routine, exercise and caregiving activity) and health of 3,075 healthy adults (ages 70 to 79) from 1997 to 1998. Of these, 680 (about 22 percent) were caregivers. Demographic information such as race and sex were also noted. Participants were clinically examined or interviewed every year for eight years and short telephone interviews were conducted six months between each annual interview.
"Black women were most likely to be caregivers (28.8 percent) and to spend the most time caregiving," the authors write. "Nineteen percent of black women spent eight or more hours a week performing caregiving activities, whereas white men were least likely to be caregivers (18.2 percent) and less involved in caregiving activities than other race-sex groups."
Approximately 20 percent of caregivers died and 50.9 percent developed mobility limitations (difficulty walking one-quarter mile or climbing 10 steps at two consecutive semiannual follow-ups), while 22 percent of non-caregivers died and 48.9 percent developed mobility limitations. "Associations differed by race and sex. Mortality [death] and mobility limitation rates were 1.5 times higher in white caregivers but not for black female caregivers vs. non-caregivers," the authors write. Caregivers who took care of someone for 24 hours or more per week had higher rates of health decline when physical activity was taken into consideration but lower rates of health decline when physical activity was not considered.
"Given the increasing number of elderly caregivers in the United States, these results underscore the potential toll of caregiving on physical health and the need for services to reduce caregivers' stress and maintain their health and ability to provide optimal care for their family members," the authors conclude.
(Arch Intern Med. 2008;168[19]:2154-2162. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This research was supported in part by the Intramural Research Program of the National Institutes of Health (NIH), National Institute on Aging (NIA), by NIA contracts and by a grant from the NIH, NIA. 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, October 27, 2008
Media Advisory: To contact Elizabeth Selvin, Ph.D., M.P.H., call Tim Parsons at 410-955-7619. To contact editorialist David M. Nathan, M.D., call Sue McGreevey at 617-724-2764.
META-ANALYSIS EXAMINES CARDIOVASCULAR EFFECTS OF DIABETES MEDICATIONS
CHICAGO—The diabetes medication metformin may be associated with a lower risk of death from cardiovascular disease, according to a meta-analysis of previously published studies in the October 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. No associations were found between other diabetes medications and beneficial or harmful cardiovascular effects, in part because of insufficient data, the authors note.
"A wide variety of oral diabetes medications are currently available for the treatment of type 2 diabetes mellitus," they write as background information in the article. "With the addition of newer oral therapies to the market in the late 1990s (e.g., thiazolidinediones and meglitinides), it is critical to evaluate how these agents compare with older medications. This is particularly important in light of the expense of many of the newer therapies." The specific effects of these medications on cardiovascular health remains unclear, and recent controversy has surrounded possible cardiac risks associated with one newer drug, rosiglitazone.
Elizabeth Selvin, Ph.D., M.P.H., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues performed a meta-analysis of data from 40 clinical trials published on or before Jan. 19, 2006. All the trials assessed the benefits or harms of oral diabetes medications approved for use in the United States, including combinations of therapies commonly prescribed by physicians, and included information about heart attack, stroke or other cardiovascular events. The average age of participants ranged from 52 to 69 and 27 of the studies (68 percent) were less than one year in duration.
"Treatment with metformin hydrochloride was associated with a decreased risk of cardiovascular morality [death] compared with any other oral diabetes agent or placebo; the results for cardiovascular morbidity [illness] and all-cause mortality were similar but not statistically significant," the authors write. "No other significant associations of oral diabetes agents with fatal or non-fatal cardiovascular disease or all-cause mortality were observed. When compared with any other agent or placebo, rosiglitazone was the only diabetes agent associated with an increased risk of cardiovascular morbidity and mortality, but this result was not statistically significant."
Poor quality and inconsistent reporting of cardiovascular data, along with the lack of long-term studies, make it difficult to draw firm conclusions, the authors note. "Our study demonstrates that there have been few trials of oral diabetes therapies that have lasted longer than six months and that reporting of adverse events for cardiovascular disease is poor," they continue.
"There is a critical need for studies of oral diabetes medications with long-term outcomes. The relatively modest differences in blood pressure, cholesterol levels and weight observed after treatment with oral diabetes medications in short-term trials may not translate to changes in long-term cardiovascular risk. Only long-term trials can provide definitive conclusions regarding the comparative efficacy of oral diabetes medications and long-term risks."
(Arch Intern Med. 2008;168[19]:2070-2080. Available to the media pre-embargo at www.jamamedia.org).
Editor's Note: This article is based on research conducted by the Johns Hopkins Evidence-Based Practice Center under a contract with the Agency for Healthcare Research and Quality. This study was also supported by grants from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: INNOVATIVE APPROACHES NEEDED TO ENSURE SAFETY OF DIABETES MEDICATIONS
"Selvin et al noted that, when it comes to choosing the safest oral agents, the quality of the data are problematic," writes David M. Nathan, M.D., of Massachusetts General Hospital, Boston, in an accompanying editorial.
"The current approach to assessing the relatively rare but clinically important adverse effects of diabetes management is unsatisfactory," he continues. "The vagaries of meta-analyses make them unreliable. On the other hand, increasing the size and duration of controlled clinical trials to provide adequate statistical power to detect relatively infrequent events would potentially bankrupt the pharmaceutical industry that supports most of the trials and delay the development of new drugs."
New approaches are needed to ensure the safety of drugs without slowing development, Dr. Nathan concludes. "For example, the phased introduction of new medications with uniform, standardized collection of adverse outcome data might identify relatively rare complications before the drugs are used by millions. Similarly, the use of clinical databases may provide an early alert regarding adverse outcomes," he writes. "In the meantime, there are well-established and safe treatments that, if used aggressively, can improve the long-term health of patients with type 2 diabetes."
(Arch Intern Med. 2008;168[19]:2064-2066. 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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