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March 9, 2009JAMA 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 NEUROLOGY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, March 9, 2009)
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, March 9, 2009)
ARCHIVES OF OPHTHALMOLOGY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, March 9, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Metabolic and Neurological Disorders May Share Common Risk Factors
Archives of Neurology theme issue examines relationships between obesity, diabetes and dementia CHICAGO—Metabolic disorders such as obesity and diabetes appear to share risk factors with and may influence the development of Alzheimer's disease and other forms of dementia, according to several reports published in the March issue of Archives of Neurology, one of the JAMA/Archives journals. The issue—a theme issue on neurological disorders related to metabolic diseases—is being published in conjunction with a JAMA theme issue on diabetes, obesity and their comorbidities. The March issue of Archives of Ophthalmology, along with the April issues of Archives of Pediatrics & Adolescent Medicine, Archives of Dermatology and Archives of Surgery, will also feature research on this theme. Studies featured in this issue include the following: Women With More Components of Metabolic Syndrome More Likely to Develop Cognitive Impairment
Women with the cluster of cardiovascular risk factors known collectively as the metabolic syndrome appear likely to develop cognitive impairment over a four-year period. Kristine Yaffe, M.D., of the University of California, San Francisco, and the San Francisco Veterans' Affairs Medical Center, and colleagues assessed 4,895 older women (average age 66.2) who did not have cognitive impairment at the beginning of the study. Of the 497 (10.2 percent) women who had the metabolic syndrome 7.2 percent (36) developed cognitive impairment during a four-year period, compared with 4.1 percent (181 of 4,398) of those who did not have the metabolic syndrome. Each additional component of the syndrome—such as abdominal obesity, high blood pressure and low HDL cholesterol levels—was associated with a 23 percent increase in risk of cognitive impairment.
"As the obesity and sedentary lifestyle epidemic escalates throughout the world, identification of the role of these modifiable behaviors in increasing risk for development of deleterious outcomes, such as cognitive impairment, is critical," the authors conclude. "Future research should assess whether identification of cognitive impairment among patients with the metabolic syndrome or more aggressive clinical control of the factors that compose the metabolic syndrome might lessen the risk of developing cognitive impairment in elderly people."
Obesity Associated With Worsening Cognitive Function in Older Men
Older men with higher levels of fat appear more likely to experience declines in cognitive function over seven years, but the same association does not appear to occur in older women. Alka M. Kanaya, M.D., of the University of California–San Francisco, and colleagues studied 3,054 elderly individuals enrolled in the Health ABC Study. Participants' adiposity (fat level) was assessed by body mass index, waist circumference, sagittal diameter (distance between the back and the highest point of the abdomen), total fat mass and subcutaneous (beneath the skin) and visceral fat (fat between the internal organs) measured by computed tomography. Men whose measurements were higher were more likely to experience declines in scores on a cognitive functioning test administered at the beginning of the study and again after three, five and eight years. However, no association was observed in women.
"Women show trends toward inverse associations, with higher levels of adiposity being associated with less cognitive change," the authors write. "Traditional metabolic factors, adipocytokines [compounds produced by fat tissue] and sex hormones do not explain this sex difference. Future studies should confirm these longitudinal associations with adiposity and cognitive change and investigate why adiposity has inverse associations in men and women."
Obese Middle-Aged Adults and Underweight Older Adults Appear to Have Increased Risk for Dementia
Midlife obesity may be associated with risk for dementia, but after age 65, the relationship between body mass index and dementia appears to reverse so that underweight individuals are at higher risk. Annette L. Fitzpatrick, Ph.D., of the University of Washington, Seattle, and colleagues analyzed data from 2,798 adults (average age 74.7) without dementia. Participants reported their weight at age 50 (midlife) and had their height and weight measured at age 65 or older (late life). Over an average of 5.4 years of follow-up, 480 individuals developed dementia, including 245 with Alzheimer's disease and 213 with vascular dementia. In evaluations of midlife obesity, individuals with a body mass index (BMI) of higher than 30—classified as obese—were more likely than those of a normal weight to develop dementia. However, those who were underweight (BMI of lower than 20) in late life had an increased risk of dementia, whereas being overweight in late life was not associated with dementia and being obese appeared to have a protective effect.
"The greatest dementia risk was found in underweight individuals at older ages. These findings suggest the predictive ability of BMI changes across time," the authors write. "These results help explain the ‘obesity paradox' as differences in dementia risk across time are consistent with physical changes in the trajectory toward disability."
Heart Disease Risk Factors Associated With Faster Cognitive Decline
Individuals with higher total and low-density lipoprotein (LDL, or "bad") cholesterol levels and a history of diabetes appear to experience a more rapid cognitive decline after developing Alzheimer's disease. Elizabeth P. Helzner, Ph.D, and colleagues at the Columbia University Medical Center, New York, studied 156 patients who were diagnosed with Alzheimer's disease at an average age of 83. During an average of 3.5 years of follow-up, those who had higher LDL and total cholesterol levels before diagnosis experienced a more rapid decline on cognitive test scores than those whose cholesterol levels were in the normal range, as did those with a history of diabetes when compared with those without diabetes.
The study "provides further evidence for the role of vascular risk factors in the course of Alzheimer's disease," the authors conclude. "Prevention or treatment of these conditions can potentially slow the course of Alzheimer's disease."
Review: Insulin Resistance May Links Metabolic and Cognitive Disorders
Insulin resistance, when tissues in the body lose sensitivity to the hormone that regulates glucose, may underlie both dementia and metabolic disorders such as obesity and diabetes. In a review article, Suzanne Craft, Ph.D., of Veterans Administration Puget Sound Health Care System and University of Washington School of Medicine, Seattle, writes that "considerable progress has been made in establishing relationships among metabolic disorders and late-life dementing illnesses," including through the common foundation of insulin resistance.
"A number of challenges must be addressed as we move forward to determine the key mechanisms underlying these associations," Dr. Craft concludes, including establishing clear definitions of both metabolic and neurological conditions. "Future research aimed at identifying mechanisms that underlie comorbid associations will not only provide important insights into the causes and interdependencies of late-life dementias, but will also inspire novel strategies for treating and preventing these disorders."
Editor's Note: Please see the March issue of Archives of Neurology 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.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Parkinson Disease Treatment Strategies Appear to Have Similar Long-Term Effects on Disability
CHICAGO—Patients with early Parkinson disease appear to have similar overall levels of disability and quality of life six years after beginning treatment with either levodopa or a dopamine agonist, according to a report posted online today that will appear in the May print issue of Archives of Neurology, one of the JAMA/Archives journals. However, persistent differences are seen in some effects of these medications, including motor symptoms, fluid build-up and sleepiness. Individuals with Parkinson disease are believed to have a depleted natural supply of the neurotransmitter dopamine. Background information in the article cites previous research indicating that patients with early Parkinson disease who begin therapy with levodopa, a medication processed into dopamine by the body, experience greater improvement in symptoms than those taking other medications. Over time, the effects of levodopa begin wearing off and patients develop more frequent motor problems, including dyskinesias (impairments in the ability to control movement). This has led some to argue in favor of initial treatment with a dopamine agonist, a drug that stimulates dopamine receptors in the brain but is not processed into dopamine by the body. In the paper, the Parkinson Study Group CALM Cohort Investigators report on the long-term outcomes of the Comparison of the Agonist Pramipexole With Levodopa on Motor Complications of Parkinson's Disease (CALM-PD trial). Between 1996 and 1997, 301 participants with early Parkinson disease (less than seven years since diagnosis) were randomly assigned to take either levodopa or the dopamine agonist pramipexole. Clinicians involved in the study were permitted to add levodopa or other medications to the patients' therapy if disability emerged or persisted. Between June and August 2001, treatment groups were revealed to the patients and subsequent care was left to the discretion of their neurologists. A total of 222 patients (108 in the pramipexole group and 114 in the levodopa group were followed until August 2003. After an average of six years of follow-up, most patients were taking combination therapy regardless of their initial treatment assignment, with more than 90 percent taking levodopa. Of those who started on pramipexole, more than 80 percent were still taking a dopamine agonist, with 84.1 percent of those remaining on pramipexole. Self-reported scores on scales measuring disability, quality of life and total disease severity were similar between the group initially taking pramipexole and the group that began on levodopa. Motor complications were significantly more common in the levodopa group than in the pramipexole group (68.4 percent vs. 50 percent), but disabling dyskinesias were uncommon in both groups. Patients in the pramipexole group reported more severe somnolence (sleepiness) and were more likely to experience edema (swelling from excess fluid) than those in the levodopa group.
"The differences seen in favor of pramipexole (fewer dopaminergic events) or levodopa (less somnolence and edema) argue for an individualized approach," the authors write. "Over the long term, there is no strong evidence favoring either of these initial treatment strategies over the other."
Editor's Note: This study was supported by Pharmacia Corp. and Boehringer Ingelheim. 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.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Studies Investigate Health Care at the End of Life
CHICAGO—Patients with advanced cancer who discuss end-of-life care with their physicians appear to have lower health care costs in the final week of life than those who do not, according to a report in the March 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. A second report finds that black and Hispanic patients tend to have higher health care costs at the end of life than white patients, despite dying of similar causes. Two other articles in the same issue examine dying patients’ feelings of abandonment by physicians and reasons that patients request physician aid in dying in Oregon. A disproportionate share of medical costs occur at the end of life, according to background information in the first article. Almost one-third of Medicare expenditures are attributable to the 5 percent of beneficiaries who die each year, and about one-third of expenses in the last year of life are spent in the final month. Previous studies suggest that most of these costs result from life-sustaining care, including resuscitation and mechanical ventilation. Baohui Zhang, M.S., of the Dana-Farber Cancer Institute, Boston, and colleagues studied 603 patients who were part of the Coping With Cancer study, funded by the National Institute of Mental Health and the National Cancer Institute. At the beginning of the study—between 2002 and 2007—188 (31.2 percent) reported discussing their wishes about end-of-life care with their physicians. They were then followed up through death. In the final week of life, patients who reported having end-of-life discussions with their physicians had average aggregate health care costs of $1,876, compared with $2,917 for patients who did not. Formal and informal caregivers who were interviewed after patients' deaths reported that those with higher costs also had a worse quality of death in their final week. In the second article about end-of-life costs, Amresh Hanchate, Ph.D., of Boston University School of Medicine, and colleagues report on an analysis of data from 158,780 Medicare beneficiaries who died in 2001. In the last six months of life, costs varied significantly by racial and ethnic background—costs for whites averaged $20,166, compared with $26,704 for blacks and $31,702 for Hispanics. "Although 40 percent to 60 percent of these excess differences are associated with geography, i.e., living in high–medical-expenditure areas, substantial differences remain, even after adjustment for many patient characteristics in addition to geographic variables," the authors write. "Strikingly higher rates of use of intensive end-of-life treatments such as ICU [intensive care unit] and ventilators account for most of these residual differences."
"Therefore, at life's end, minorities often receive more expensive but not necessarily life-enhancing care," they conclude. "It is unclear how much of this was actively sought, or the extent to which racial and ethnic differences are principally driven by how choices are presented or how they are ‘heard.' These would be fruitful questions for future research."
Patients and Families Report Feeling Abandoned by Physicians at the End of Life
Patients who are dying and their families report that feelings of abandonment by their physicians at the end of life have two components: a loss of continuity of care before death and a lack of closure near death or afterward. In another article in the March 9 issue, Anthony L. Back, M.D., of Fred Hutchinson Cancer Research Center and University of Washington, Seattle, and colleagues identified 55 patients with incurable cancer or advanced lung disease who were expected to live a year or less. These patients, along with 31 physicians, 36 family caregivers and 25 nurses involved in their care, were interviewed at enrollment and again at four to six months and at 12 months. "Early on, patients and family caregivers fear that their physician, whose expertise and caring they have come to depend on, will become unavailable," the authors write. "Physicians are aware of this fear and attempt to address it with reassurance or continuity strategies. Yet, as death approaches, some patients and families may feel abandoned nonetheless because they lose the continuity of their physician's expertise or their relationship with that physician."
"Near death or afterward, they may also experience a lack of closure of that relationship. Most of these physicians are not consciously aware of having abandoned their patients. Instead, they report lack of closure or a feeling of unfinished business." The findings could help physicians structure care to maintain the professional value of non-abandonment, including use of non-hospice palliative care or closure-promoting communication strategies involving nurses and other members of the health care team.
Oregonians Interested in Physician Aid in Dying Appear Motivated by Fear of Future Events
Individuals exploring physician aid in dying in Oregon appear to be motivated by worries about future pain and loss of autonomy rather than current symptoms, according to another report in the same issue. Linda Ganzini, M.D., M.P.H., and colleagues at Portland Veterans’ Affairs Medical Center and Oregon Health and Science University, Portland, surveyed 56 individuals who either requested physician aid in dying or contacted a related advocacy organization. Participants were asked to rate the importance of 29 reasons for seeking this option on a scale of one (least important) to five (most important). The most important reasons—with median (midpoint) scores of five—were wanting to die at home and control the surrounding circumstances of death; loss of independence; and concerns about future pain, poor quality of life and inability to care for one's self. All current physical symptoms were rated as unimportant (one).
"Our data suggest that when patients first request physician aid in dying, they do so not because of physical symptoms or quality of life at the time of the request but in anticipation of future suffering that they perceive as intolerable. Their desire to die is not strong, and they do not believe that their life is poor in quality, meaningless or worthless. Rather, they appear to be protecting against the risk of future experience they do not believe they can endure," the authors write. "When confronted with a request for physician aid in dying, health care providers should first work to bolster the patient's sense of control and to educate and reassure the patient regarding management of future symptoms."
Editor's Note: Please see the articles 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.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Insomnia Often Appears to Be a Persistent Condition
CHICAGO—About three-fourths of individuals with insomnia report experiencing the condition for at least one year and almost half experience it for three years, according to a report in the March 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Insomnia is the inability to fall asleep or stay asleep. "Approximately 30 percent of adults report symptoms of insomnia and 6 percent to 10 percent meet diagnostic criteria for an insomnia disorder," the authors write as background information in the article. Several factors such as being female, increasing age, having anxiety or depression and experiencing pain from medical conditions have been associated with insomnia. The condition has been linked to higher health care costs, work absenteeism, disability and higher risk of hypertension and depression. Charles M. Morin, Ph.D., of Université Laval and Centre de recherche Université Laval—Robert Giffard, Québec, Canada, and colleagues evaluated insomnia persistence, remission and relapse in 388 adults (average age 44.8) over a course of three years. Individuals with an insomnia syndrome (insomnia symptoms at least three nights per week for at least one month causing substantial distress or daytime impairment) at the beginning of the study (n=119) were compared to those with insomnia symptoms (n=269) to examine the course of initial severe sleep difficulties. "Of the study sample, 74 percent reported insomnia for at least one year and 46 percent reported insomnia persisting over the entire three-year study," the authors write. The group with initial insomnia syndrome had a higher persistence rate than the group with symptoms of insomnia (66.1 percent vs. 37.2 percent), respectively. About fifty-four percent of participants went into insomnia remission; however, 26.7 percent of them eventually experienced relapse. "Individuals with subsyndromal insomnia [insomnia symptoms] at baseline were three times more likely to remit than worsen to syndrome status, although persistence was the most frequent course in that group as well," the authors note. Of the 269 individuals with baseline symptoms of insomnia, after one year 38.4 percent were classified as good sleepers, 48.7 percent still had insomnia symptoms and 12.9 percent had insomnia syndrome. Results were similar after the second and third year of follow-up. Of the 119 participants with insomnia syndrome at the beginning of the study, 17 percent were good sleepers after one year, while 37 percent had symptoms of insomnia and 46 percent remained in the insomnia syndrome group.
"This study provides preliminary evidence to better understand the natural course of insomnia. Additional studies are needed, however, to identify moderating and mediating factors of persistence, remission and relapse," the authors conclude. "Improved understanding of the long-term course of persistent insomnia would be helpful to guide the development of effective public health prevention and intervention programs to avert long-term negative outcomes."
Editor's Note: This study was supported by a grant from the Canadian Institutes of Health Research. 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.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Vitamin C Intake Associated With Lower Risk of Gout in Men
CHICAGO—Men with higher vitamin C intake appear less likely to develop gout, a painful type of arthritis, according to a report in the March 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "Gout is the most common type of inflammatory arthritis in men," the authors write as background information in the article. "Epidemiologic studies suggest that the overall disease burden of gout is substantial and growing. The identification of the risk factors for gout that are modifiable with available measures is an important first step in the prevention and management of this common and excruciatingly painful condition." Hyon K. Choi, M.D., Dr.P.H., then of University of British Columbia, Vancouver, and now of Boston University School of Medicine, and colleagues examined the relationship between vitamin C intake and gout in 46,994 men between 1986 and 2006. Every four years, the men completed a dietary questionnaire, and their vitamin C intake through food and supplements was computed. Every two years, participants reported whether they had been diagnosed with or developed symptoms of gout. During 20 years of follow-up, 1,317 men developed gout. Compared with men who had a vitamin C intake of less than 250 milligrams per day, the relative risk of gout was 17 percent lower for those with a daily intake of 500 to 999 milligrams, 34 percent lower for those with an intake of 1,000 to 1,499 milligrams per day and 45 percent lower for those with an intake of 1,500 milligrams per day or higher. For every 500-milligram increase in their vitamin C intake, men's risk for gout appeared to decrease by 17 percent. Compared with men who did not take vitamin C supplements, those who took 1,000 to 1,499 supplemental milligrams per day had a 34 percent lower risk of gout and those who took 1,500 supplemental milligrams per day had a 45 percent lower risk. Vitamin C appears to reduce levels of uric acid in the blood, the authors note; a buildup of this naturally occurring compound can form crystal deposits in and around joints, leading to the pain, inflammation and swelling associated with gout. Vitamin C may affect reabsorption of uric acid by the kidneys, increase the speed at which the kidneys work or protect against inflammation, all of which may reduce gout risk, the authors note.
"Given the general safety profile associated with vitamin C intake, particularly in the generally consumed ranges as in the present study (e.g., tolerable upper intake level of vitamin C of less than 2,000 milligrams in adults according to the Food and Nutrition Board, Institute of Medicine), vitamin C intake may provide a useful option in the prevention of gout," they conclude.
Editor's Note: This work was supported in part by grants from the National Institutes of Health and by TAP Pharmaceuticals. 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.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Health Insurance Status Associated With Frequency of Eye Care Visits
CHICAGO—Individuals with no or inconsistent health care coverage appear less likely to regularly seek eye care, even if they are visually impaired, according to a report in the March issue of Archives of Ophthalmology, one of the JAMA/Archives journals. Eye disorders have an estimated economic impact of $51 billion annually in the United States, according to background information in the article. "Recommendations for periodic eye examinations vary across ocular and medical organizations, but most recommend one- to two-year screening intervals depending on age and ocular risk factors," the authors write. David J. Lee, Ph.D., of University of Miami Miller School of Medicine, and colleagues analyzed data from almost 290,000 individuals who participated in the National Health Interview Survey from 1997 through 2005. These adults age 18 and older reported whether they were visually impaired and whether they had seen an eye care professional in the previous year, along with sociodemographic information such as age, sex, education level, family income and insurance status. In an analysis pooling all the years of data, 58.3 percent of individuals who were severely visually impaired, 49.6 percent of those with some visual impairment and 33.7 percent of those with no visual impairment reporting seeking eye care in the previous year. Rates of eye care use for individuals without health insurance were 35.9 percent among severely visually impaired, 23.8 percent among those with some visual impairment and 14.3 percent for those without visual impairment. Low rates of eye care utilization were associated with no visual impairment, lack of health insurance, male sex and low education. The lowest rates were reported among individuals who were without health insurance for 12 months or longer: in this group, 11.3 percent of those with no visual impairment, 20.5 percent of those with some visual impairment and 33.5 percent of those with severe visual impairment accessed eye care.
"Interventions designed to increase eye care utilization rates in select sociodemographic subgroups are needed," the authors conclude. "Overall utilization rates may also be enhanced if progress is made toward dramatically increasing the number of Americans with health insurance."
Editor's Note: This study was supported by a grant from the National Eye Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Alternate Solutions to Universal Coverage Also Must Be Considered
The authors of the paper "assert that providing universal vision care coverage would insure that financial resources are no longer a barrier for those seeking access to a vision care provider," write Steven M. Kymes, Ph.D., M.H.A., and Kevin D. Frick, Ph.D., of Washington University School of Medicine, St. Louis, in an accompanying editorial. "However, we must also consider whether this would indeed be the most effective method to achieve the social goal of increased use of vision care services," they continue.
"Lee and his colleagues have made an important contribution to this growing literature by examining barriers to vision care. However, the principles of scientific inquiry should not be shortchanged simply because we are debating a policy question rather than a biochemical one. The vision care community has an obligation to fully consider alternative solutions and their consequences in seeking way to remove barriers to vision care."
Editor's Note: This Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, March 9, 2009
Ophthalmologists Should Join Forces With Other Clinicians in Battle With Diabetes, Obesity and Related Diseases
CHICAGO—The prevalence of diabetes has doubled in the past decade, and the resulting increases in diabetes-related eye disease pose a new challenge to eye specialists, according to an editorial in the March issue of Archives of Ophthalmology, one of the JAMA/Archives journals. Two editorials and a research article in the issue focus on ophthalmologic implications of metabolic diseases, and are being published in conjunction with a JAMA theme issue on diabetes, obesity and their comorbidities. The March issue of Archives of Neurology, along with the April issues of Archives of Pediatrics & Adolescent Medicine, Archives of Dermatology and Archives of Surgery, will also focus on this theme. "By 2050, the number of Americans with diabetic retinopathy [affecting blood vessels in the retina] is projected to triple from 5.5 million to 16 million, and the number of those with vision-threatening retinopathy will increase from 1.2 million to 3.4 million," write Thomas W. Gardner, M.D., M.S., and Robert A. Gabbay, M.D., Ph.D., of the Penn State College of Medicine, Hershey, Pa., in the first editorial. "The number of cataracts will increase by 235 percent and glaucoma among elderly Hispanic individuals with diabetes will increase 12-fold."
To effectively treat these conditions, ophthalmologists must go beyond surgically treating late-stage eye disease and work with other clinicians to help patients control their diabetes before eye complications worsen, Dr. Gardner and Dr. Gabbay note. "Ophthalmologists have a unique opportunity to influence patient behavior because vision loss is one of the most feared complications of diabetes. Helping patients make the connection between their eye disease and the ABCs of diabetes (A1C, blood pressure and cholesterol) can motivate them to improve their health."
Editor's Note: This work was supported by grants from the Juvenile Diabetes Research Foundation, American Diabetes Association and the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Gardner is a Jack and Nancy Turner Professor and Dr. Gabbay is a Laurence M. Demers Career Development Professor. Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc. Steroid Treatment Shows No Long-Term Benefit For Diabetes-Related Eye Disease
The steroid triamcinolone does not appear to offer a long-term benefit in the treatment of diabetic macular edema (swelling of the retina due to excess fluid build-up), and patients who take the drug are likely to require cataract surgery, according to a report in the same issue. Authors writing on behalf of the Diabetic Retinopathy Clinical Research Network report the three-year outcomes of a clinical trial in which 306 eyes of patients with diabetic macular edema were randomly assigned to receive either photocoagulation (laser treatments to stop fluid leakage), 1 milligram of intravitreal (administered through the eye) triamcinolone or 4 milligrams of intravitreal triamcinolone.
"Our three-year results, analyzed from a subset of the randomized subjects, are consistent with the previously published results after two years of follow-up," the authors write. "There was no long-term benefit of intravitreal triamcinolone relative to focal/grid photocoagulation [laser treatment] for patients with diabetes macular edema receiving treatment as performed in this clinical trial. Rather, visual acuity outcomes slightly favored the laser group over either of the two triamcinolone groups. It appears that most eyes receiving this 4-milligram triamcinolone preparation will require cataract surgery, though only a few will develop glaucoma that will require surgery."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Recent Study Results Validate Long-Term Value of Blood Glucose Control
Results of the Epidemiology of Diabetes Interventions and Complications (EDIC) study, published in the December 2008 issue of the Archives, provide more proof that tight blood glucose control after diagnosis with diabetes significantly reduces the risk of diabetic retinopathy at least 10 years later. Previous investigators coined the term metabolic memory to describe the lasting reduction of diabetes complications following initial efforts to reduce blood glucose levels, writes Robert N. Frank, M.D., of the Wayne State University School of Medicine in a second editorial in the March issue.
"The present results of the EDIC study dramatically show the long-term benefit of initial tight glycemic control through the phenomenon of metabolic memory," he concludes. "But the presence of metabolic memory also sets a critical parameter that any proposed mechanism through which prolonged hyperglycemia [high blood glucose] leads to the complications of diabetes must fulfill to be biologically plausible."
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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