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 p.m. CT Tuesday, November 25, 2008)
JAMA NEWS RELEASES
UNDER NEW LIVER TRANSPLANTATION ALLOCATION SYSTEM, IMPROVEMENT SEEN REGARDING DISPARITIES FOR BLACK PATIENTS, BUT NOT FOR WOMEN
RECEIPT OF HEART ASSIST PUMPS BY MEDICARE PATIENTS ASSOCIATED WITH POOR OUTCOMES, HIGH COSTS
ASSOCIATION BETWEEN DEPRESSION, INCREASED RISK OF CARDIOVASCULAR EVENTS APPEARS TO BE LARGELY EXPLAINED BY CHANGE IN HEALTH BEHAVIORS
USE OF INHALED CORTICOSTEROIDS FOR COPD DOES NOT APPEAR TO IMPROVE SURVIVAL, BUT MAY INCREASE RISK FOR PNEUMONIA
GENE VARIATION FOR PERSONS WITH DIABETES ASSOCIATED WITH INCREASED RISK OF CORONARY ARTERY DISEASE
JAMA REPORT (VIDEO SCRIPT)
VIDEO: Windows Media | Quicktime
STUDY FINDS RACIAL DISPARITY NO LONGER ASSOCIATED WITH NATION'S CURRENT LIVER TRANSPLANTATION ALLOCATION SYSTEM,BUT GENDER DISPARITY REMAINS
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.
Please Note: This week's JAMA Report video is on disparities in liver transplantation before and after the start of a new allocation system for donated livers. The report will be fed Tuesday, November 25, 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, November 25, 2008
Media Advisory: To contact Cynthia A. Moylan, M.D., call Michelle Gailiun at 919-724-5343. To contact editorial co-author David A. Axelrod, M.D., M.B.A., call Jason Aldous at 603-653-1913.
UNDER NEW LIVER TRANSPLANTATION ALLOCATION SYSTEM, IMPROVEMENT SEEN REGARDING DISPARITIES FOR BLACK PATIENTS, BUT NOT FOR WOMEN
CHICAGO—Following introduction of a new system in 2002 to determine the allocation of donated livers, black patients no longer are less likely to receive a liver transplant, but disparities for women remain, according to a study in the November 26 issue of JAMA.
The Model for End-Stage Liver Disease (MELD) score has been used by the Organ Procurement and Transplantation Network (OPTN) since February 2002 as the basis for allocation of deceased donor livers for transplantation among adults in the United States. The MELD score predicts the risk of death within 3 months and is based on objective laboratory variables: bilirubin (pigment in the bile that forms as a product of hemoglobin), creatinine (an end-product of protein metabolism found in the blood and urine), and a ratio for the prothrombin time (a clotting test). "In the current system, patients with higher MELD scores receive greater priority for organ allocation regardless of the amount of time spent on the waiting list," the authors write.
Cynthia A. Moylan, M.D., of Duke University Medical Center, Durham, N.C., and colleagues used a national database to determine whether racial or sex-based disparities exist in access to liver transplantation since the MELD system has been implemented. The study included adult black and white patients registered on the United Network for Organ Sharing liver transplantation waiting list between January 1996 and December 2000 (pre-MELD group, n = 21,895) and between February 2002 and March 2006 (post-MELD group, n = 23,793). Black patients, compared with white patients, were younger (average, 49.2 vs. 52.4 years) and sicker (MELD score at listing: median [midpoint], 16 vs. 14).
Analysis indicated that the odds of death or becoming too sick for liver transplantation within 3 years of listing were higher in black vs. white patients in the pre-MELD cohort (27.0 percent vs. 21.7 percent), but not in the post-MELD group (26.5 percent vs. 22.0 percent). The researchers also found that black patients were less likely than white patients to receive liver transplantation within 3 years of listing in the pre-MELD cohort but not in the post-MELD cohort.
"This elimination in racial disparity in the post-MELD cohort likely reflects the fact that the MELD score now accounts for the severity of a patient's disease when listed," the authors write.
Sex was significantly associated with death and liver transplantation after adjusting for race despite the use of the MELD score. Women were more likely to die or become too sick for liver transplantation within 3 years of listing in the post-MELD group (23.7 percent of women vs. 21.4 percent of men) but not in the pre-MELD group (22.4 percent of women vs. 21.9 percent of men). Women were also less likely to receive a liver transplant within 3 years of listing in both the pre-MELD and post-MELD groups.
"Sex differences persist despite the use of MELD. Whether these differences result from true anatomic differences or represent a problem not addressed by the use of the MELD score mandates further investigation," they write.
"The use of the MELD score allocation system appears to have reduced at least racial disparity in liver transplantation. We hope that ongoing investigations and refinements of MELD can provide even greater equity in the allocation of this precious resource."
(JAMA. 2008;300[20]:2371-2378. 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: RACE AND SEX DISPARITIES IN LIVER TRANSPLANTATION — PROGRESS TOWARD ACHIEVING EQUAL ACCESS?
The MELD system has helped decrease disparities regarding the allocation of donated livers, writes David A. Axelrod, M.D., M.B.A., of Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and Elizabeth A. Pomfret, M.D., Ph.D., of Lahey Clinic Medical Center, Burlington, Mass., in an accompanying editorial.
"When compared with the system before 2002, the current MELD system is clearly a step toward achieving the goal of an equitable, efficient, and transparent organ allocation system. The MELD system appears to have reduced, but likely not eliminated, differential access based on race and ethnicity. However, modest differences based on sex persist, but could be addressed by revisions in the organ allocation policy to ensure that MELD scores are comparable across sexes."
"The sex disparity is likely a reflection of several factors, including a limitation in the MELD calculation, body and organ size considerations, and potentially differences in the etiology of the underlying liver disease."
(JAMA. 2008;300[20]:2425-2427. 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.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, November 25, 2008
Media Advisory: To contact Adrian F. Hernandez, M.D., M.H.S., call Michelle Gailiun at 919-724-5343.
RECEIPT OF HEART ASSIST PUMPS BY MEDICARE PATIENTS ASSOCIATED WITH POOR OUTCOMES, HIGH COSTS
CHICAGO—Medicare patients who receive ventricular assist devices (a type of heart pump) have high rates of death, illness, prolonged hospital stays, with resulting high costs of care, according to a study in the November 26 issue of JAMA.
A ventricular assist device consists of a mechanical pump that takes over the function of a damaged ventricle of the heart and helps restore normal blood flow. These devices are used primarily in patients with end-stage heart failure who are awaiting heart transplantation, as "destination," or permanent therapy for patients who are not candidates for transplantation, or as a rescue procedure for patients with shock after open-heart surgery that is not responding to treatment, according to background information in the article. In 2003, Medicare expanded coverage of ventricular assist devices as permanent therapy for end-stage heart failure. Little is known about the long-term outcomes and costs associated with these devices.
Adrian F. Hernandez, M.D., M.H.S., of Duke University School of Medicine, Durham, N.C., and colleagues analyzed trends in use, outcomes and costs of ventricular assist devices for all Medicare fee-for-service beneficiaries from February 2000 through June 2006 by examining inpatient claims from the Centers for Medicare & Medicaid Services for this period. This study included beneficiaries who received a ventricular assist device as primary therapy (primary device group; n = 1,476) or after cardiotomy (heart surgery, such as coronary bypass surgery or valve replacement surgery) in the previous 30 days (postcardiotomy group; n = 1,467).
The researchers found that overall 1-year survival, regardless of subsequent heart transplantation or device removal, was 51.6 percent (n = 669) in the primary device group and 30.8 percent (n = 424) in the postcardiotomy group. Of the 815 patients in the primary device group who were discharged alive with a device, 55.6 percent were readmitted within 6 months. On average, these patients spent 29.8 days in the hospital during the subsequent 2 years; survival was 64.7 percent at 2 years. Among patients in the postcardiotomy group who were discharged alive with a device (n = 493), 48.3 percent were readmitted within 6 months. These patients spent an average of 16.7 days in the hospital during the subsequent 2 years; survival was 69.4 percent at 2 years.
For patients in the 2000 through 2005 groups, the average Medicare payment to hospitals for inpatient care in the first year after implantation of a ventricular assist device was $144,298 per patient. One-year Medicare payments for inpatient care of primary device patients totaled approximately $228 million, and was about $151 million for inpatient care of postcardiotomy patients.
"Ventricular assist devices are an evolving technology with modest adoption in the Medicare population. Mortality, morbidity, and costs remain high, so periodic surveillance using Medicare claims may complement other postmarketing surveillance efforts," they write. "Improving outcomes will require a focus on the high perioperative [around the time of surgery] mortality found in this and other studies. Identifying patients who are likely to benefit from ventricular assist devices and excluding those whose likelihood of survival is low is warranted."
(JAMA. 2008;300[20]:2398-2406. 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.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, November 25, 2008
Media Advisory: To contact Mary A. Whooley, M.D., call Steve Tokar at 415-221-4810, ext. 5202.
ASSOCIATION BETWEEN DEPRESSION, INCREASED RISK OF CARDIOVASCULAR EVENTS APPEARS TO BE LARGELY EXPLAINED BY CHANGE IN HEALTH BEHAVIORS
CHICAGO—The increased risk of cardiovascular events for patients with coronary heart disease and symptoms of depression appears to be largely explained by a change in health behaviors, especially a lack of physical activity, according to a study in the November 26 issue of JAMA.
Depression has long been recognized as a risk factor for the development of cardiovascular disease in healthy patients and for recurrent events in patients with established cardiovascular disease. Despite the substantial body of evidence demonstrating a strong link between depression and cardiovascular disease, the explanation for this association remains unclear, according to background information in the article. "Understanding how depression leads to cardiovascular events is necessary for developing interventions to decrease the excess cardiovascular morbidity [illness] and mortality [death] associated with depression," the authors write.
Mary A. Whooley, M.D., of the VA Medical Center, San Francisco, and colleagues conducted a study to determine why depressive symptoms are associated with an increased risk of cardiovascular events. The study included 1,017 outpatients with stable coronary heart disease followed-up for an average of 4.8 years. Symptoms of depression were measured with a questionnaire, and various models were used to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, heart attack, stroke, transient ischemic attack [a temporary cessation or reduction of blood supply to part of the brain], or death) were explained by disease severity at the beginning of the study and potential biological or behavioral factors.
The researchers found that participants with depressive symptoms had a 50 percent greater risk of cardiovascular events: the age-adjusted annual rate of cardiovascular events was 10.0 percent among the 199 participants with depressive symptoms and 6.7 percent among the 818 participants without depressive symptoms. Adjustment for physical activity was associated with a reduction in the strength of association between depressive symptoms and cardiovascular events.
When adjusted for other existing conditions and cardiac disease severity, depressive symptoms remained associated with a 31 percent higher rate of cardiovascular events. After further adjustment for certain health behaviors, including physical inactivity, there was no longer a significant association between depressive symptoms and cardiovascular events. Physical inactivity was associated with a 44 percent greater rate of cardiovascular events, after adjusting for various factors.
The researchers note that patients with depressive symptoms are less likely to adhere to dietary, exercise, and medication recommendations, and poor health behaviors can lead to cardiovascular events.
"These findings raise the hypothesis that the increased risk of cardiovascular events associated with depression could potentially be preventable with behavior modification, especially exercise. Given the relatively modest effects of traditional therapies on depressive symptoms in patients with heart disease, there is increasing urgency to identify interventions that not only reduce depressive symptoms but also directly target the mechanisms by which depression leads to cardiovascular events."
(JAMA. 2008;300[20]:2379-2388. 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.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, November 25, 2008
Media Advisory: To contact corresponding author Eddy Fan, M.D., call David March at 410-955-1534.
USE OF INHALED CORTICOSTEROIDS FOR COPD DOES NOT APPEAR TO IMPROVE SURVIVAL, BUT MAY INCREASE RISK FOR PNEUMONIA
CHICAGO—An analysis of randomized trials indicates that use of inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease (COPD) does not improve the rate of survival after one year, but is associated with an increased risk of pneumonia, according to an article in the November 26 issue of JAMA.
COPD, a lung disease characterized by recurrent episodes of coughing and breathlessness, represents a substantial public health burden, affecting 10-15 million persons in the United States. COPD is currently the fourth leading cause of death in the United States, accounting for 120,000 deaths annually, and is expected to be the third leading cause of death by 2020, according to background information in the article. No pharmacotherapy and few interventions, other than smoking cessation and supplemental oxygen, have been shown to improve the rate of death in patients with COPD. Recent studies regarding the use of inhaled corticosteroid (ICS) therapy for managing stable COPD have yielded conflicting results regarding survival and risk of adverse events.
M. Bradley Drummond, M.D., M.H.S., of Johns Hopkins University, Baltimore, and colleagues conducted a review and meta-analysis of 11 randomized controlled trials (14,426 participants) to determine associations of ICS use of 6 or more months' duration with all-cause death and risk of pneumonia in patients with stable COPD.
All-cause mortality at 1-year follow-up was reported in five studies (9,233 patients), and analysis indicated that ICS therapy was not associated with a decreased risk of death after one year. There were 128 deaths among 4,636 individuals in the treatment group, and 148 deaths among 4,597 individuals in the control group.
Seven studies (10,776 patients) reported pneumonia outcomes, and indicated that patients receiving ICS had a 34 percent higher incidence of pneumonia. These studies included 777 events among 5,405 individuals in the treatment group and 561 events among 5,371 individuals in the control group.
"The association of ICS therapy with increased rates of pneumonia reported in our meta-analysis should be considered by clinicians and guideline developers when evaluating the role of ICS therapy in the management of stable COPD. This finding must be balanced with those of other reports describing beneficial effects of ICS therapy," the authors write.
Subgroup analyses indicated an increased risk of pneumonia in the following groups: highest ICS dose, shorter duration of ICS use, lowest baseline forced expiratory volume in the first second of expiration (a measure of lung function) and combined ICS and bronchodilator therapy.
"Recognizing the adverse events associated with ICS use is especially important, since clinicians may increase ICS therapy from moderate to high doses in patients who are not responding. Our data suggest that increasing to higher ICS doses may place patients at greater risk for pneumonia. While the results of our subgroup analysis suggest the existence of subpopulations of patients with COPD who might be at higher risk for pneumonia, our evidence is not conclusive and is only hypothesis-generating. Analysis of existing observational studies and future clinical trials may help physicians determine an optimal ICS dose that balances the potential risks and benefits of this therapy. Until studies can confirm an unequivocal benefit of ICS therapy in a group of patients with COPD, patients should receive the lowest effective ICS dose to minimize potential adverse effects," the authors write.
(JAMA. 2008;300[20]:2407-2416. 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.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, November 25, 2008
Media Advisory: To contact Alessandro Doria, M.D., Ph.D., M.P.H., call Margaret Bonilla at 603-548-0693.
GENE VARIATION FOR PERSONS WITH DIABETES ASSOCIATED WITH INCREASED RISK OF CORONARY ARTERY DISEASE
CHICAGO—Patients with type 2 diabetes who have poor glycemic control and a certain genetic variation have an increased risk of coronary artery disease, according to a study in the November 26 issue of JAMA.
Among the known risk factors for cardiovascular disease, diabetes mellitus ranks as one of the most potent. It increases the lifetime risk of a major cardiac event by 2 to 4 times, relative to individuals without diabetes, according to background information in the article. A substantial proportion of cardiovascular risk is under the control of genetic factors.
Genetic variation on chromosome 9p21 has been associated with increased risk of coronary artery disease (CAD) in the general population. Alessandro Doria, M.D., Ph.D., M.P.H., of the Joslin Diabetes Center, Harvard Medical School, Boston, and colleagues examined the association of this genetic variant with coronary artery disease in individuals with type 2 diabetes and whether the association is affected by poor glycemic control. The researchers conducted two studies, with one including 734 type 2 diabetes patients (322 with angiographically diagnosed CAD and 412 with no evidence of CAD), who were recruited between 2001 and 2006; the other study included 475 type 2 diabetes patients whose survival status was monitored from their recruitment between 1993 and 1996 until December 31, 2004.
Participants for both studies were tested for a representative single-nucleotide polymorphism (gene variation) of chromosome 9p21 (rs2383206) and characterized for their long-term glycemic control by averaging measurements of hemoglobin A1c (HbA1c) taken in the years before study entry.
The researchers found that relative to the CAD risk for patients with neither a 9p21 risk gene variant nor poor glycemic control, the odds for CAD among participants having two risk gene variants but not poor glycemic control was increased 2-fold, whereas the odds for CAD among study participants with the same genotype but poor glycemic control was increased 4-fold. The interaction was stronger when a measure of long-term glycemic control (7-year average rather than most recent HbA1c) was used for participants having two risk gene variants and a history of poor glycemia and for participants with the same genotype but not long-term poor glycemia.
A similar interaction between the 9p21 variant and poor glycemic control was observed with respect to the rate of death after 10 years.
"In conclusion, 9p21 [variant] and poor glycemic control interact in determining the odds of CAD in type 2 diabetes. This finding may have implications for our understanding of atherogenesis [the process of plaque forming in arteries] in diabetes and for the design of more effective prevention strategies. More broadly, it illustrates the complex etiology of multifactorial disorders and highlights the importance of accounting for gene-environment and gene-gene interactions in the quest for genetic factors contributing to these conditions," the authors write.
(JAMA. 2008;300[20]:2389-2397. 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.
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JAMA REPORTS
VIDEO:
Windows Media |
Quicktime
STUDY FINDS RACIAL DISPARITY NO LONGER ASSOCIATED WITH NATION'S CURRENT LIVER TRANSPLANTATION ALLOCATION SYSTEM, BUT GENDER DISPARITY REMAINS
INTRO:
Tens of thousands of Americans are on the nation's organ transplant waiting list. Many of them need a new liver. Now, a new study looks at whether there are disparities in liver allocation due to race and gender. Alissa Krinsky explains in this week's JAMA Report.
VIDEO:
B-ROLL
Alice with dog
AUDIO:
ALICE JONES MAYER (May'-ur) REMEMBERS THE DAY SHE FOUND OUT SHE HAD LIVER FAILURE AND NEEDED A TRANSPLANT.
VIDEO:
SOT/FULL
Super @ :09
Alice Jones Mayer
Liver Transplant Recipient
Runs :09
AUDIO:
"My initial question was, ‘Well, how long do you think I'll have to wait,' and ‘Do you think I'll live long enough to get a liver.'"
VIDEO:
B-ROLL
Alice reading book
Doctor sits down at computer
Close-up of keyboard/typing
Back of head/computer screen
AUDIO:
SHE GOT A NEW LIVER IN TEN WEEKS…BUT WHEN SHE NEEDED A SECOND LIVER YEARS LATER… SHE HAD TO WAIT – GETTING SICKER EVERY DAY – FOR MORE THAN A YEAR AND A HALF. DOCTOR CYNTHIA MOYLAN OF DUKE UNIVERSITY MEDICAL CENTER – AND HER COLLEAGUES – DECIDED TO LOOK AT THE NATION'S LIVER TRANSPLANT ALLOCATION SYSTEM, RETOOLED IN 2002 TO ELIMINATE SUBJECTIVITY FROM THE PROCESS – A PROBLEM IN THE OLD SYSTEM.
VIDEO:
SOT/FULL
Super @ :40
Cynthia Moylan, M.D.
Duke University Medical Center
Runs :09
AUDIO:
"Many times we found that the process was biased by different physicians assessing a patient's liver disease differently."
VIDEO:
B-ROLL
Doctors in Operating Room
AUDIO:
AT ISSUE: HAS THE CURRENT, MORE OBJECTIVE METHODOLOGY ELIMINATED RACE AND GENDER DISPARITIES IN LIVER ALLOCATION? PREVIOUSLY, BLACK AND FEMALE PATIENTS WERE DISADVANTAGED IN THE PROCESS.
VIDEO:
SOT/FULL
Super @ :
Cynthia Moylan, M.D.
Duke University Medical Center
Runs :08
AUDIO:
"...waiting longer and dying more quickly before receiving a liver organ offer."
VIDEO:
B-ROLL
GXF/JAMA COVER
GFX:
MELD SCORE SYSTEM
Model for End Stage Liver Disease
AUDIO:
THE STUDY APPEARS THIS WEEK IN JAMA, JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. IT EXAMINED THE EFFECTS OF THE MELD SCORE SYSTEM – "MODEL FOR END-STAGE LIVER DISEASE".
VIDEO:
SOT/FULL
Cynthia Moylan, M.D.
Duke University Medical Center
Runs :07
AUDIO:
"With the use of the MELD score allocation system, we found that that racial inequity has been greatly reduced."
VIDEO:
B-ROLL
Doctor walking down hallway
AUDIO:
PROGRESS THERE, BUT NOT WITH GENDER DISPARITY. WOMEN STILL ARE LESS LIKELY TO RECEIVE A TRANSPLANT AND MORE LIKELY TO DIE THAN MEN.
VIDEO:
SOT/FULL
Cynthia Moylan, M.D.
Duke University Medical Center
Tape 1 / 01:19:51-:20:02
Runs :11
AUDIO:
"It is important that we make sure that these livers are allocated fairly, and that we're using the correct and best, most equitable system to do that"
VIDEO:
B-ROLL
Alice with photo album.
AUDIO:
BECAUSE A NEW LIVER CAN MEAN A NEW LIFE.
VIDEO:
SOT/FULL
Super @
Alice Jones Mayer
Liver Transplant Recipient
Runs :09
AUDIO:
"I actually feel great. I feel that I've crossed some threshold and I feel like I have an opportunity to live a full life."
VIDEO:
B-ROLL
Alice looking at photos
AUDIO:
A FULL LIFE BECAUSE SHE GOT THE LIVER SHE NEEDED. ALISSA KRINSKY, THE JAMA REPORT.
TAG:
This is the first study to look at racial and gender disparities since the implementation of the MELD score system. Dr. Moylan says there are several reasons for the racial disparity that once existed in liver allocation, but that it is also difficult to explain why gender disparity exists today. For more information about this study you can log on to www.jama.com.
