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July 27, 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 INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, July 27, 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, July 27, 2009
Delays in Defibrillation Not Explained by Traditional Hospital Factors
CHICAGO—Traditional hospital factors - such as case volume and academic status - do not appear to predict whether patients with cardiac arrest at that facility are likely to experience delays in receiving defibrillation, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The American Heart Association recommends that defibrillation be performed within two minutes of cardiac arrest, according to background information in the article. Longer delays to defibrillation are associated with lower survival rates following cardiac arrest in the hospital. Previous studies have found that factors associated with individual patients, such as being admitted to the hospital for a non-cardiac diagnosis and experiencing cardiac arrest on evenings and weekends, predicted delayed defibrillation. However, less is known about whether differences between hospitals are associated with these delays. Paul S. Chan, M.D., M.Sc., of the Saint Luke's Mid-America Hospital Institute, Kansas City, Mo., and colleagues analyzed records from 7,479 adult inpatients with cardiac arrest (average age 67 years) at 200 hospitals included in the National Registry of Cardiopulmonary Resuscitation (NRCPR). Hospitals participating in the NRCPR in 2006 were asked to complete a detailed survey, including information about location, hospital teaching status, number of patient beds and the availability of automatic external defibrillators. Rates of delayed defibrillation - defined as longer than the two-minute standard - varied substantially among hospitals and ranged from 2.4 percent to 50.9 percent. Differences between hospitals accounted for a significant amount of the variation between patients; for instance, patients with identical characteristics had 46 percent greater odds of experiencing a defibrillation delay at one randomly selected hospital compared with another. "However, many of the individual hospital characteristics that we explored - such as volume, academic status and hospital-wide mortality rate - were unrelated to hospital performance in defibrillation time," the authors write. Only the number of beds and the location of the cardiac arrest (for example, in or out of the intensive care unit) were associated with the rate of defibrillation delays, whereas there was no association between delays and geographical location, rate of cardiac arrest per 1,000 patient admissions, existence of an automatic external defibrillator program or most other hospital-related factors assessed. "This lack of correlation between 'conventional' hospital-level factors and defibrillation time suggests that other unmeasured characteristics are responsible for certain institutions achieving extremely low rates of delayed defibrillation." Patients at hospitals with fewer defibrillation delays were less likely to die in the hospital - the odds of survival were 41 percent higher in the one-fourth of hospitals with the fewest defibrillation delays than in the one-fourth of hospitals with the most delays.
"Given extensive differences in defibrillation time across institutions and the recognized impact of delayed defibrillation on survival, new approaches to improve hospital performance in defibrillation time could represent a critical area for quality improvement," the authors conclude.
Editor's Note: The American Heart Association provides operational funding for the NRCPR. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Efforts Needed to Close Gap in Care
"In the early 1990s, the American Heart Association identified early defibrillation as the single most important predictor of survival in patients who experience cardiac arrest," write P. Michael Ho, M.D., Ph.D., of the University of Colorado Denver and Denver VA, and Steven M. Bradley, M.D., in an accompanying editorial. "Each minute delay between onset of cardiac arrest and defibrillation is associated with a 7 percent to 10 percent lower likelihood of survival." "In this issue of the Archives, Chan et al extend their prior work by demonstrating wide variation in the frequency of delayed hospital defibrillation among 200 hospitals participating in the National Registry of Cardiopulmonary Resuscitation (NRCPR)," they continue. "Although this article is important in highlighting the gap in care, it is now time to move beyond demonstrating the gap to closing it."
Lessons can be learned from previous efforts to improve heart attack treatment times, Dr. Ho and Dr. Bradley note. "In particular, involving senior leadership, providing prompt data feedback and using a multidisciplinary team-based approach are likely to improve performance. Identification of the practices of NRCPR participant hospitals that have been successful at providing timely defibrillation is also likely to lead to strategies for shortening times to defibrillation. Research testing different approaches to improve timely defibrillation times is needed as well. Once effective strategies have been developed and tested, individual hospitals can implement and adapt those strategies that are feasible within their local environment."
Editor's Note: Dr. Ho serves as a consultant for Wellpoint Inc. 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, July 27, 2009
Adult Cancer Survivors at Increased Risk of Psychological Distress
CHICAGO—Long-term survivors of cancer that developed in adulthood are at increased risk of experiencing serious psychological distress, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The estimated 12 million cancer survivors in the United States represent approximately 4 percent of the population, according to background information in the article. "The number of cancer survivors has steadily increased over the last three decades and is expected to continue to increase with the implementation of improved cancer screening, the adoption of more efficacious cancer treatment and the aging of the population," the authors write. "As more individuals survive cancer, it is important to understand how cancer and cancer therapies affect long-term quality of life and psychological adjustment." Karen E. Hoffman, M.D., M.H.Sc., of Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, and colleagues studied participants in the National Health Interview Survey, a cross-sectional in-person survey conducted annually by the U.S. Census Bureau. Participants in the 2002 to 2006 surveys were asked questions about their history of cancer and assessed using a scale of serious psychological distress. The researchers compared the responses of 4,636 individuals who had survived five years or longer following the diagnosis of an adult-onset cancer with those of 122,220 individuals who had never had cancer. A total of 5.6 percent of cancer survivors screened positive for severe psychological distress within the previous 30 days, compared with 3 percent of those without cancer. "After adjustment for other clinical and sociodemographic variables, long-term survivors who were younger, were unmarried, had less than a high school education, were uninsured, had more comorbidities or had difficulty performing instrumental activities of daily living were more likely to experience serious psychological distress," the authors write. A history of cancer may affect current mental health in several ways, the authors note. "Cancer diagnosis and treatment can produce delayed detrimental effects on physical health and functioning such as secondary cancers, cardiac dysfunction, lung dysfunction, infertility, neurological complications and neurocognitive dysfunction," they write. "A cancer history can also affect social adaptation, employment opportunities and insurance coverage. Adjusting to these functional and life limitations may create long-term psychological stress." A total of 9 percent of long-term cancer survivors and 6 percent of individuals without cancer reported seeing or talking to a mental health professional within the previous 12 months. One-third of survivors with serious psychological distress reported using mental health services, whereas 18 percent said they could not afford mental health care during the previous year.
"Because long-term survivors may not be seen by oncologists as frequently as they were during treatment, or at all, the increased risk of serious psychological distress and the need to screen for serious psychological distress should be communicated to primary care physicians and other care providers," the authors conclude. "Given that cancer survivors with more chronic medical conditions tended to be those most at risk for psychological distress in this study, the findings also underscore the need to integrate medical and behavioral health care for survivors. Specifically, cancer survivorship clinics may benefit from having mental health providers on staff for a multidisciplinary approach to the care of these patients."
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 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, July 27, 2009
Antipsychotic Drugs Associated With High Blood Sugar in Older Adults With Diabetes
CHICAGO—Older patients with diabetes who take antipsychotic medications appear to have an increased risk of hospitalization for hyperglycemia (elevated blood glucose level), especially soon after beginning treatment, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. An increasing number of older adults are being prescribed antipsychotic drugs for dementia and other conditions, according to background information in the article. However, these medications may be associated with adverse effects - including Parkinson's disease symptoms, stroke and diabetes - in the older population. "The risk of diabetes may be partly related to chronic effects of the weight gain associated with antipsychotic agents," the authors write. "However, case reports of acute hyperglycemia after the initiation of therapy with these drugs suggest that they may also be associated with acute glycemic [blood glucose level] changes." Lorraine L. Lipscombe, M.D., M.Sc., of the Institute for Clinical Evaluative Sciences, University of Toronto and Women’s College Research Institute at Women’s College Hospital, Ontario, Canada, and colleagues studied 13,817 individuals age 66 and older (average age 78) with diabetes who began treatment with antipsychotics between April 1, 2002, and March 31, 2006. Each patient who was hospitalized for hyperglycemia during the observation period - through March 31, 2007, an average of two years of follow-up - was considered a case and was matched with up to 10 control patients who were the same age and sex but were not hospitalized over the same time period. The researchers then compared the likelihood of hyperglycemia among those who were currently taking antipsychotic medications to those who had discontinued antipsychotic medications for more than 180 days. Of the total group of 13,817 patients, 1,515 (11 percent) were hospitalized for hyperglycemia. Those who were currently taking antipsychotic drugs had a higher risk of hospitalization than those who had stopped the medications more than 180 days ago. The risk was highest among those who were just starting antipsychotic drug treatment. "Our study indicates that the initiation of antipsychotic therapy represents a critical period during which seniors with diabetes are particularly vulnerable to metabolic decompensation [failure of the metabolic system to function adequately]," the authors write. "The new use of both atypical [newer] and typical antipsychotic drugs was associated with a significant increase in hospitalizations for hyperglycemia, which appeared independent of baseline diabetes treatment and was strikingly high during the initial period of antipsychotic therapy."
Some previous evidence suggests that the neurotransmitter dopamine has a role in regulating blood glucose levels; first-time antipsychotic users may experience an acute disruption in this system, leading to hyperglycemic episodes, the authors note. However, further studies are needed to confirm a causal effect and identify the mechanisms involved. "In the meantime, other options to manage behavioral symptoms of dementia should be considered among older persons with diabetes," they conclude. "Patients and their families should be alerted to observe for signs of glycemic decompensation when treatment with an antipsychotic agent is initiated, and enhanced glucose monitoring is recommended for all patients for whom an antipsychotic drug is prescribed, particularly after treatment initiation."
Editor's Note: This work was supported by a Team Grant from the Canadian Institutes of Health Research (CIHR) and by a CIHR Interdisciplinary Capacity Enhancement Grant. 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, July 27, 2009
Study Examines Modern-Day Course of Type 1 Diabetes
CHICAGO—The rates of serious complications among individuals with type 1 diabetes appear lower than reported historically, especially when patients are treated intensively, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "The clinical course of type 1 diabetes mellitus, including its treatment, metabolic outcomes and long-term clinical complications, has changed dramatically in the past 20 years," the authors write as background information in the article. Treatment innovations, including insulin pumps and analogues, along with the improved treatment of co-occurring illnesses such as high blood pressure and abnormal cholesterol have contributed to changes in the management of type 1 diabetes. In addition, clinical trials such as the Diabetes Control and Complications Trial (DCCT) - a study conducted between 1983 and 1993 comparing the then-current standard of care with more intensive therapy - and its long-term observational follow-up, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, have shown the benefits of more careful control of blood glucose levels. The DCCT/EDIC Research Group analyzed the incidence of long-term complications among participants in those studies, including both patients who were originally assigned to intensive therapy and those who received standard therapy until the DCCT clinical trial ended in 1993 and all patients were offered intensive therapy. In addition, they assessed complication rates among participants in the Pittsburgh Epidemiology of Diabetes Complications study, an observational study in which researchers have collected data on patients who were diagnosed with type 1 diabetes between 1950 and 1980. "After 30 years of diabetes, the cumulative incidences of proliferative retinopathy [an eye disease associated with diabetes], nephropathy [kidney disease] and cardiovascular disease were 50 percent, 25 percent and 14 percent, respectively, in the DCCT conventional treatment group, and 47 percent, 17 percent and 14 percent, respectively, in the Pittsburgh Epidemiology of Diabetes Complications cohort," the authors write. "The DCCT intensive therapy group had substantially lower cumulative incidences (21 percent, 9 percent and 9 percent) and fewer than 1 percent became blind, required kidney replacement or had an amputation because of diabetes during that time." Differing methods of ascertaining and defining complications make exact historical comparisons difficult. However, the rates of retinopathy (30 percent) and nephropathy (12 percent) in DCCT/EDIC participants after 25 years compare favorably to rates in studies of individuals who developed diabetes 10 to 20 years prior (40 percent to 53 percent for retinopathy and approximately 35 percent for nephropathy). Rates of functional impairment, such as vision loss and the need for kidney transplant, are also difficult to compare but were low in the overall DCCT/EDIC cohort, with only three of 1,441 patients becoming legally blind and 18 requiring kidney replacement therapy after an average of 25 years.
"While the results of the DCCT/EDIC conventional therapy and of the Pittsburgh Epidemiology of Diabetes Complications study supply clinicians with a realistic description of clinical outcomes that they can discuss with their patients who have had their type 1 diabetes mellitus in the past 25 years, the intensive treatment group results provide a view of what patients with type 1 diabetes mellitus can expect in the future. Intensive therapy, now the standard of care, should result in more than 50 percent reduction in the rates of complications over time, with implementation early in the course of diabetes providing the most powerful salutary effect."
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 JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. |
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