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 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 CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3:00 p.m. CT, Tuesday, October 7, 2008)
JAMA NEWS RELEASES
SIMPLER DIAGNOSTIC METHOD MAY BE AS EFFECTIVE AT DETECTING BLOOD CLOT IN THE LEG
END-OF-LIFE DISCUSSIONS WITH PHYSICIANS MAY HAVE BENEFITS FOR PATIENTS AND CAREGIVERS
USE OF MEDICATION FOR ENLARGED PROSTATE NOT ASSOCIATED WITH INCREASED RISK OF HIP FRACTURE
CIRCUMCISION NOT ASSOCIATED WITH REDUCED RISK OF HIV FOR MEN WHO HAVE SEX WITH MEN
JAMA REPORT (VIDEO SCRIPT)
VIDEO: Windows Media | Quicktime
STUDY FINDS BETTER QUALITY OF LIFE FOR TERMINALLY ILL PATIENTS WHO REPORTED HAVING END-OF-LIFE DISCUSSIONS WITH THEIR DOCTOR
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TV Note: This week's JAMA Report video is on the benefits of end-of-life discussions between physicians and patients. The report will be fed Tuesday, October 7, from 9:00 - 9:30 a.m. ET and 2:00 - 2:30 p.m. ET, on Galaxy 28 (C-Band), Transponder 19, downlink frequency: 4080 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, October 7, 2008
Media Advisory: To contact Enrico Bernardi, M.D., Ph.D., email: enrico.bernardi{at}ulss7.it. To contact editorial author C. Seth Landefeld, M.D., call Lauren Hammit at 415-476-2557.
SIMPLER DIAGNOSTIC METHOD MAY BE AS EFFECTIVE AT DETECTING BLOOD CLOT IN THE LEG
CHICAGO—A comparison of two diagnostic methods used to detect deep vein thrombosis (DVT; a blood clot in a deep vein in the leg or thigh) of the lower extremities indicates that a simpler method, with wider availability, has rates of DVT detection that are equivalent to a more complex method, according to a study in the October 8 issue JAMA.
The imaging technique, compression ultrasonography, is a highly accurate method for the detection of DVT and has replaced other diagnostic methods in common practice. Two ultrasonography diagnostic methods often used are 2-point and whole-leg. With 2-point ultrasonography, compression is applied to two veins, and benefits include simplicity, reproducibility and broad availability (may be performed with virtually all ultrasound scanners, irrespective of age or model). "Its major limitation is the need to repeat the test once within 1 week in patients with normal findings at presentation to detect calf DVT extending to the proximal [near the point of origin] veins. Repeat testing may be safely avoided in patients with a normal D-dimer test [blood test used to help rule out active blood clot formation] at presentation," the authors write.
The advantages of whole-leg ultrasonography include the ability to exclude isolated calf DVT, allowing for 1-day treatment of all patients, without additional testing. Conversely, it needs top-quality ultrasound equipment and experienced operators; therefore, it is often unobtainable after hours and during the weekends. Despite the lack of definite evidence, whole-leg ultrasonography is thought to be better than serial 2-point ultrasonography, and as a consequence, many patients with suspected DVT need to wait hours or even days before whole-leg ultrasonography is obtained and are frequently (unnecessarily) administered anticoagulants in the meantime, according to background information in the article.
Enrico Bernardi, M.D., Ph.D., of the Civic Hospital, Conegliano, Italy, and colleagues conducted a study to determine if the two diagnostic strategies are equivalent for the treatment of patients with suspected DVT of the lower extremities. The randomized, multicenter study included 2,098 outpatients with a first episode of suspected DVT of the lower extremities who were randomized to undergo 2-point (n = 1,045) or whole-leg (n = 1,053) ultrasonography.
Of patients in the 2-point strategy group, the incidence of confirmed symptomatic venous thromboembolism (VTE; blood clots in the deep veins of the legs or in the lungs) during the 3-month follow-up period was 0.9 percent (7 of 801 patients). Of patients randomized to the whole-leg ultrasonography method, the incidence of confirmed symptomatic VTE during the follow-up period was 1.2 percent (9 of 763 patients).
"The observed difference between the 2 groups in terms of symptomatic VTE at the end of the 3-month follow-up period was 0.3 percent, which is within the chosen equivalence limit" the authors write. "Either strategy may be chosen based on the clinical context, on the patients’ needs, and on the available resources. [Two-point ultrasonography plus D-dimer] is simple, convenient, and widely available but requires repeat testing in one-fourth of the patients. [Whole-leg ultrasonography] offers a 1-day answer, desirable for patients with severe calf complaints, for travelers, and for those living far from the diagnostic service, but is cumbersome, possibly more expensive, and may expose patients to the risk of (unnecessary) anticoagulation."
(JAMA. 2008;300[14]:1653-1659. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: NONINVASIVE DIAGNOSIS OF DEEP VEIN THROMBOSIS
In an accompanying editorial, C. Seth Landefeld, M.D., of the University of California, San Francisco, San Francisco Veterans Affairs Medical Center, and Stanford University, Stanford, Calif., comments on the findings of Bernardi and colleagues.
"How should clinicians approach patients with a possible first episode of DVT? Based on the available evidence, it would be reasonable to choose 2 tests initially—a clinical prediction rule and D-dimer test, a clinical prediction rule and 2-point ultrasonography, or 2-point ultrasonography and a D-dimer test. If both tests are negative, DVT is effectively ruled out and anticoagulation can be withheld safely."
"If DVT is not ruled out, 2-point ultrasonography should be performed if not already performed. If DVT has neither been ruled out nor diagnosed by ultrasound, a second ultrasound should be performed 1 week later; if that ultrasound is negative for DVT, no further testing is indicated. The results of the trial by Bernardi et al show that whole-leg ultrasonography has little advantage, unless a course of anticoagulant therapy for isolated calf DVT is preferable to repeating 2-point ultrasonography a week later."
(JAMA. 2008;300[14]:1696-1697. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, October 7, 2008
Media Advisory: To contact Alexi A. Wright, M.D., call Bill Schaller at 617-632-5357.
END-OF-LIFE DISCUSSIONS WITH PHYSICIANS MAY HAVE BENEFITS FOR PATIENTS AND CAREGIVERS
CHICAGO—Terminally ill patients who had end-of-life discussions with physicians were not more likely to experience emotional distress, received less aggressive medical care in their final week of life and had a better quality of life near death, compared to patients who did not have these discussions, according to a study in the October 8 issue of JAMA.
End-of-life discussions offer patients the opportunity to define their goals and expectations for the medical care that they want to receive near death. "But these discussions also mean confronting the limitations of medical treatments and the reality that life is finite, both of which may cause psychological distress. Studies suggest that physicians and patients are ambivalent about talking about death and often avoid these conversations. To date, however, research has not examined whether these discussions are associated with patients’ psychological distress or medical care near death. Without this information physicians cannot weigh the risks and benefits of end-of-life discussions," the authors write.
Alexi A. Wright, M.D., of the Dana-Farber Cancer Institute, Boston, and colleagues examined the associations between end-of-life discussions with physicians and the medical care that terminally ill patients receive near death. The study included patients with advanced cancer and their informal caregivers (n = 332 pairs). Patients were followed-up from enrollment to death, a median (midpoint) of 4.4 months later. Bereaved caregivers’ psychiatric illness and quality of life was assessed a median of 6.5 months later. One hundred twenty-three of 332 (37.0 percent) patients reported having end-of-life discussions with their physicians.
The researchers found that such discussions were not associated with higher rates of major depressive disorder or more worry, but these patients received significantly fewer aggressive medical interventions near death: lower rates of ventilation (1.6 percent vs. 11.0 percent), resuscitation (0.8 percent vs. 6.7 percent), and ICU admission (4.1 percent vs. 12.4 percent). Patients who had end-of-life discussions had earlier hospice enrollment (65.6 percent vs. 44.5 percent), and longer hospice stays were associated with better patient quality of life, while more aggressive medical care was associated with worse patient quality of life.
Patients who reported engaging in these conversations were significantly more likely to accept that their illness was terminal, prefer medical treatment focused on relieving pain and discomfort over life-extending therapies, and have complete a do-not-resuscitate order.
Caregivers of patients who received any aggressive care were at higher risk for developing a major depressive disorder, experiencing regret and feeling unprepared for the patient’s death, compared with caregivers of patients who did not receive aggressive care. They also had worse quality of life outcomes, including overall quality of life, self-reported health and increased role limitations. Better patient quality of life was associated with better caregiver quality of life at follow-up.
"Our results suggest that end-of-life discussions may have cascading benefits for patients and their caregivers. Despite physicians’ concerns that patients may experience psychological harm due to end-of-life discussions, we found no evidence that they were significantly associated with increased emotional distress or psychiatric disorders. Instead, the worst outcomes were seen in patients who did not report having these conversations." the authors write.
"Given the adverse outcomes associated with not having end-of-life discussions, there appears to be a need to increase the frequency of these conversations. By acknowledging that death is near, patients, caregivers, and physicians can focus on clarifying patients’ priorities and improving pain and symptom management."
(JAMA. 2008;300[14]:1665-1673. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, October 7, 2008
Media Advisory: To contact Steven J. Jacobsen, M.D., Ph.D., call Jim Anderson at 626-405-5157.
USE OF MEDICATION FOR ENLARGED PROSTATE NOT ASSOCIATED WITH INCREASED RISK OF HIP FRACTURE
CHICAGO—Use of a class of medications for treating an enlarged prostate, known as 5-α reductase inhibitors, are not associated with an increased hip fracture risk, according to a study in the October 8 issue of JAMA.
Benign prostatic hyperplasia (BPH; an enlarged prostate) is a common condition in aging men. It has been estimated that more than 8 million U.S. men age 50 to 79 years will meet current guidelines for considering treatment options for BPH by 2010, according to background information in the article. Treatments for BPH include surgical procedures, minimally invasive procedures and medications. Most often the first-line therapy is pharmacological, using either α-blockers, or 5-α reductase inhibitors (such as finasteride or dutasteride), which work through hormonal mechanisms. It is not clear how 5-α reductase inhibition affects long-term bone health.
Steven J. Jacobsen, M.D., Ph.D., of Kaiser Permanente Southern California, Pasadena, Calif., and colleagues examined the association between use of 5-α reductase inhibitors for BPH and occurrence of hip fracture. The study included 7,076 men, 45 years and older, who experienced a hip fracture between 1997-2006. Control patients were 7,076 men without a hip fracture during the study period. Electronic information on pharmaceutical use was used to identify use of finasteride from 1991 forward. During this period (1991 to 2006), finasteride was the only 5-α reductase inhibitor dispensed to study patients, and 109 case patients (1.5 percent) and 141 control patients (2 percent) had a history of any exposure to these compounds.
The researchers found that there was no dose-response relationship between exposure to 5-α reductase inhibitors when the exposure was stratified into levels of total exposure. Of the patients in the study, 2,547 (36 percent of the men with hip fracture) and 2,488 (35 percent of the men without hip fracture) had a prior diagnosis of BPH. The use of α-blockers was slightly greater in men with hip fracture (32 percent) compared with those without hip fracture (30 percent).
"These data suggest that 5-α reductase inhibitors do not confer a negative risk for bone health and in fact may lower the risk of hip fracture. While presumably this lower risk is related to hormonal mechanisms, further understanding of the biological mechanisms underlying this phenomenon may lead to new insights that can be exploited for preventive measures. The increased risk of fracture associated with recent receipt of an α-blocker highlights the need for careful [use] of these agents," the authors conclude.
(JAMA. 2008;300[14]:1660-1664. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, October 7, 2008
Media Advisory: To contact Gregorio A. Millett, M.P.H., call the news office of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at 404-639-8895. To contact editorial co-author Sten H. Vermund, M.D., Ph.D., call Craig Boerner at 615-322-4747.
CIRCUMCISION NOT ASSOCIATED WITH REDUCED RISK OF HIV FOR MEN WHO HAVE SEX WITH MEN
CHICAGO—An analysis of previous research indicates there is a lack of sufficient evidence that circumcision reduces the risk of human immunodeficiency virus (HIV) infection or other sexually transmitted infections among men who have sex with men, according to an article in the October 8 issue of JAMA.
Randomized controlled trials (RCTs) conducted with men in Africa have shown that male circumcision reduces the likelihood of female-to-male transmission of HIV infection by 50 percent to 60 percent. Studies also suggest that male circumcision may protect heterosexual men against other sexually transmitted infections (STI), such as syphilis or chlamydial infection, according to background information in the article. Less is known about whether circumcision provides protection against HIV infection among men who have sex with men (MSM).
Gregorio A. Millett, M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues performed a meta-analysis of 15 studies to examine the association of circumcision status with HIV infection and other STIs among MSM. The studies included a total of 53,567 MSM participants (52 percent of whom were circumcised).
The researchers found that the odds of being HIV-positive were nonsignificantly lower among MSM who were circumcised than uncircumcised. In contrast, a statistically significant protective association of circumcision with HIV infection was found for MSM studies conducted prior to the introduction of highly active antiretroviral therapy (HAART) in 1996. Of studies conducted after HAART, the association of circumcision and HIV infection was not statistically significant.
"A possible explanation for [these differences] may be related to an increase in the sexual risk behaviors of MSM after HAART. It has been well documented that beliefs that HAART limits HIV transmissibility are associated with increases in sexual risk behavior among MSM, and that the era since the advent of HAART has been defined by higher rates of sexual risk behaviors among MSM, outbreaks of STIs, and increasing rates of HIV infection," the authors write.
Among MSM who primarily engaged in insertive anal sex, the association between male circumcision and HIV was protective but not statistically significant. The STI analyses similarly revealed no statistically significant association by circumcision status among MSM.
"Taken together, these findings indicate insufficient evidence among available observational studies conducted with MSM of an association between circumcision and HIV infection or other STIs," the researchers write. "Additional studies are necessary to elucidate further the relationship between circumcision status and HIV infection or STIs among MSM."
(JAMA. 2008;300[14]:1674-1684. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
EDITORIAL: CIRCUMCISION AND HIV PREVENTION AMONG MEN WHO HAVE SEX WITH MEN - NO FINAL WORD
In an accompanying editorial, Sten H. Vermund, M.D., Ph.D., and Han-Zhu Qian, M.D., Ph.D., of Vanderbilt University School of Medicine, Nashville, Tenn., write that only future research can answer whether MSM should be circumcised to reduce their HIV risk.
"The meta-analysis by Millett et al is likely to be used by both advocates and detractors of clinical trial investment; some will argue the benefit is likely to be too modest to justify a multimillion dollar clinical trial while others will argue that only a clinical trial will answer this important HIV prevention question. Barriers to circumcision among heterosexual men include human rights issues, ethical and legal issues, high cost, fear of pain, safety concerns, availability of surgery services, and sexual risk compensation if men overrate their degree of protection and ongoing risk. As in other HIV prevention trials, circumcision would likely be insufficiently efficient to be universally effective in reducing HIV risk, and will have to be combined with other prevention modalities to have a substantial and sustained prevention effect."
(JAMA. 2008;300[14]:1698-1700. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
VIDEO:
Windows Media |
Quicktime
STUDY FINDS BETTER QUALITY OF LIFE FOR TERMINALLY ILL PATIENTS WHO REPORTED HAVING END-OF-LIFE DISCUSSIONS WITH THEIR DOCTOR
INTRO:
Talking about death can be difficult. But for people with terminal illness, it may be critically important. A new study finds that people with terminal cancer -who reported having what’s called an "end-of-life" discussion with their doctor - benefitted from those conversations. Alissa Krinsky explains in this week’s JAMA Report.
VIDEO:
B-ROLL
Robyn walking into office, sitting down
Family photo photo
AUDIO:
ROBYN FARRELL LOST HER HUSBAND, BOB, TO CANCER IN 2007. THE PARENTS OF THREE CHILDREN, THEY WERE MARRIED FOR SIXTEEN YEARS.
VIDEO:
SOT/FULL
Super @ :10
Robyn Farrell
Husband Died of Cancer
Runs: 07
AUDIO:
"He was my best friend. He was everything. And so there’s a huge void in our family."
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B-ROLL
Family photo
AUDIO:
SHE IS COMFORTED KNOWING BOB’S LAST DAYS WERE SPENT WITH FAMILY AT HOME – NOT AT A HOSPITAL – A DECISION MADE AFTER WHAT ARE CALLED "END-OF-LIFE" CONVERSATIONS.
VIDEO:
B-ROLL
Doctor looking at study
Close-up of study pages
AUDIO:
DR. ALEXI WRIGHT IS A MEDICAL ONCOLOGY FELLOW AT BOSTON’S DANA-FARBER CANCER INSTITUTE. SHE AND HER COLLEAGUES STUDIED 332 TERMINALLY ILL CANCER PATIENTS TO LEARN MORE ABOUT SUCH "END-OF-LIFE" DISCUSSIONS.
VIDEO:
SOT/FULL
Super @ :41
Alexi Wright, M.D.
Dana-Farber Cancer Institute
Runs :12
AUDIO:
"An end-of-life conversation is when a patient and doctor talk about how long the patient has to live, what their options are, and what kind of care they want to receive in their final week of life."
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B-ROLL
Doctor’s office exam room
AUDIO:
AT ISSUE: WHETHER A PATIENT WANTS DOCTORS TO USE LIFE-SAVING MEASURES DURING HIS LAST DAYS.
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SOT/FULL
Alexi Wright, M.D.
Dana-Farber Cancer Institute
Runs :11
AUDIO:
"Whether people want to be on breathing machines, whether they want to undergo a resuscitation if their heart would stop, whether they want to receive artificial nutrition or antibiotics..."
VIDEO:
B-ROLL
GFX/JAMA COVER
GFX:
Patients Who Reported Having "End-of-Life" Discussions
GFX:
In Their Last Week of Life
- 3x Less Likely: ICU
- 4x Less Likely: Breathing Machine
- 6x Less Likely: Resuscitation
AUDIO:
THE STUDY APPEARS THIS WEEK IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. IT COMPARED PATIENTS WHO DID – AND DID NOT – REPORT HAVING "END-OF-LIFE" DISCUSSIONS. IN THEIR LAST WEEK OF LIFE, THE PATIENTS WHO DID, WERE: THREE TIMES LESS LIKELY TO BE ADMITTED TO THE INTENSIVE CARE UNIT…FOUR TIMES LESS LIKELY TO BE PUT ON A BREATHING MACHINE…AND SIX TIMES LESS LIKELY TO BE RESUSCITATED.
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Alexi Wright, M.D.
Dana-Farber Cancer Institute
Runs :03
AUDIO:
"And their quality of life was significantly better."
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B-ROLL
Family photo
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A BETTER QUALITY OF LIFE, DURING THE LAST DAYS OF LIFE.
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Robyn Farrell
Husband Died of Cancer
Runs: 11
AUDIO:
"And we remember that as a peaceful time. And I don’t think my kids remember it – and they don’t talk about it – as being a stressful time. It was a very comfortable time. It was kind of like the way that it should be."
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B-ROLL
Family photo
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"END-OF-LIFE" DISCUSSIONS MAY NOT BE EASY, BUT THEY CAN MAKE A BIG DIFFERENCE FOR PATIENTS AND THEIR LOVED ONES. ALISSA KRINSKY, THE JAMA REPORT.
TAG:
The five-year study, called "Coping With Cancer," also found that patients’ loved ones benefitted from those "end-of-life" discussions, with a better quality of life six months after a patient’s death. For more information about this study you can log on to www.jama.com.
