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September 15, 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
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT Tuesday, September 15, 2009)
JAMA REPORT (VIDEO SCRIPT)
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. TV Note: PLEASE NOTE, FEED TIMES ARE NOW 15 MINUTES. This week's JAMA Report video is on the racial differences in survival after experiencing an in-hospital cardiac arrest. The report will be fed Tuesday, September 15, from 9:00 - 9:15 a.m. ET and 2:00 - 2:15 p.m. ET, on Galaxy 28 (C-Band), Transponder 15, downlink frequency: 4000 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA. The JAMA Report video is also now available on Pathfire every Tuesday, in VNF Provider A. Please look for the JAMA Report tab. 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), Tuesday, September 15, 2009
Outcomes Appear to Be Improving For Conservative Management of Localized Prostate Cancer
CHICAGO—A comparison of outcomes of different eras of conservative treatment for localized prostate cancer indicates that overall and prostate cancer-specific survival rates are higher for men diagnosed from 1992 through 2002 compared to men diagnosed in the 1970s and 1980s, according to a study in the September 16 issue of JAMA. "Among men, prostate cancer is the most common nonskin cancer and the second most common cause of cancer death in the United States. When diagnosed, prostate cancer is contained within the prostate in approximately 85 percent of cases, and standard treatment options usually include surgery, radiation, or conservative management (active surveillance or deferral of treatment until necessitated by disease signs or symptoms)," according to background information in the article. "Despite its potential as a reasonable treatment choice, however, conservative management has been used in only about 10 percent of patients, perhaps because of a limited understanding of and contemporary data on the anticipated course and outcomes of this approach." The authors add that this lack of reliable contemporary information makes it difficult for patients and their physicians to anticipate outcomes and make informed treatment decisions. Grace L. Lu-Yao, M.P.H., Ph.D., of the Cancer Institute of New Jersey and UMDNJ-Robert Wood Johnson Medical School, Piscataway, N.J., and colleagues analyzed data for men with localized T1 or T2 prostate cancer to evaluate the outcomes of conservatively managed localized prostate cancer diagnosed in the contemporary prostate-specific antigen (PSA) era. The population-based cohort study included 14,516 men age 65 years or older when they were diagnosed (1992-2002) with stage T1 or T2 prostate cancer and whose cases were managed without surgery or radiation for 6 months after diagnosis. Living in areas covered by the Surveillance, Epidemiology, and End Results (SEER) program, the men were followed up for a median (midpoint) of 8.3 years (through December 2007). The median age at diagnosis was 78 years. The researchers found that ten-year prostate cancer–specific mortality was 8.3 percent for men with well-differentiated tumors, 9.1 percent for moderately differentiated, and 25.6 percent for those with poorly differentiated tumors. The corresponding 10-year risks of dying of causes other than prostate cancer were 59.8 percent, 57.2 percent, and 56.5 percent for each respective group. Ten-year disease-specific mortality for men age 66 to 74 years diagnosed with moderately differentiated disease was 60 percent to 74 percent lower than earlier studies. "Survival results in our contemporary PSA era study cohort were more favorable than results previously reported. For example, in the current study, 10-year prostate cancer–specific mortality was 6 percent in the contemporary PSA era (1992-2002) compared with results of previous studies (15 percent-23 percent) in earlier eras (1949-1992) for men aged 65 to 74 years diagnosed with moderately differentiated disease. Improvement in survival among men with older age or poorly differentiated disease was also observed," the authors write. "The substantial improvement in survival that we observed in our study compared with previous reports might be explained, in part, by additional lead time, overdiagnosis related to PSA testing, or grade migration, among other factors. Prostate-specific antigen testing identifies disease 6 to 13 years before it presents clinically. Contemporary patients identified through such testing would be expected to live at least 6 to 13 years longer because of this lead time. In addition, previously documented systematic upgrading of modern tumors compared with earlier eras makes more recently graded tumors appear to have a more benign course, resulting in longer survivals. Finally, it is also possible that advancements in medical care might have led to improved outcomes."
"The net overall effect is that outcomes following conservative management are now significantly better than those reported in previous eras; therefore, physicians and their patients may need to reconsider this management option, particularly in light of randomized trial data from the pre-PSA era suggesting little if any benefit to more aggressive intervention."
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), Tuesday, September 15, 2009
Study Finds Increased Risk of Death For Patients With Celiac Disease-Related Disorders
CHICAGO—New research indicates that patients with lesser degrees of celiac disease-related symptoms, such as intestinal inflammation or latent celiac disease, have a modestly increased risk of death, according to a study in the September 16 issue of JAMA. "Celiac disease is an immune-mediated disorder that is triggered by gluten exposure in genetically sensitive individuals, occurring in about 1 percent of the Western population," according to background information in the article. It causes impaired digestion of nutrients through the small intestine, with symptoms including frequent diarrhea and weight loss. While most research has shown an increased risk of death in celiac disease, less is known about the long-term consequences of nonspecific small-intestinal inflammation without villous atrophy (abnormality of the small intestinal mucosa [the innermost membrane of the intestinal wall], resulting in flattening of the mucosa). "Research on other inflammatory disorders suggests that inflammation may be associated with increased mortality, but this has not been investigated for nonspecific inflammation in the small intestine." Jonas F. Ludvigsson, M.D., Ph.D., of Örebro University Hospital, Örebro, Sweden, and colleagues used nationwide histopathology (diseased tissue studied at a microscopic level) data collected from biopsies taken between July 1969 and February 2008 in Sweden to examine the overall risk of death in individuals with celiac disease and inflammation. Data from the biopsies was divided into three groups: celiac disease (Marsh stage 3 [a classification of the stage of the disease]: villous atrophy; n = 29,096 individuals); inflammation (Marsh stage 1-2; n = 13,306); and individuals with latent celiac disease, (n = 3,719). Latent celiac disease was defined as positive celiac disease serology in individuals with normal intestinal mucosa. Through linkage with the Swedish Total Population Register, the researchers estimated the risk of death through August 2008, compared with age- and sex-matched controls from the general population. The data indicated there were 3,049 deaths among patients with celiac disease, 2,967 deaths in patients with inflammation, and 183 deaths with latent celiac disease. The researchers found that the risk of death was increased in all 3 groups, with patients with inflammation having a 72 percent increased risk of death; patients with celiac disease, a 39 percent increased risk; and patients with latent celiac disease having a 35 percent increased risk of death. The risk of death was highest in the first year of follow-up, with celiac disease associated with a 2.8-fold increased risk of death, inflammation with a 4.7-fold increase, and latent celiac disease with a 1.8-fold increase. After the first year of follow-up, these figures decreased. The risk of death also decreased with age at diagnosis, with risk being higher for those diagnosed before age 20.
"In conclusion, we found increased [risks] for death in individuals with biopsy-verified celiac disease, inflammation, and latent celiac disease, although absolute risks were small. Individuals undergoing small-intestinal biopsy in childhood had increased [risks] for death. Cardiovascular disease and malignancy were the main causes of death in celiac disease," the authors write.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Mortality in Celiac Disease, Intestinal Inflammation, and Gluten Sensitivity
Peter H. R. Green, M.D., of Columbia University College of Physicians and Surgeons, New York, writes in an accompanying editorial that this study provides important information on the risks associated with celiac disease.
"Until recently, gluten sensitivity has received little attention in the traditional medical literature, although there is increasing evidence for its presence in patients with various neurological disorders and psychiatric problems. The study by Ludvigsson and colleagues reinforces the importance of celiac disease as a diagnosis that should be sought by physicians. It also suggests that more attention should be given to the lesser degrees of intestinal inflammation and gluten sensitivity."
Editor's Note: Please see the article for additional information, including other 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), Tuesday, September 15, 2009
Black Patients Have Lower Rate of Survival After In-Hospital Cardiac Arrest
CHICAGO—Compared with white patients, black patients who have an in-hospital cardiac arrest are significantly less likely to survive to hospital discharge, having lower rates of successful resuscitation and postresuscitation survival, although much of this survival difference was associated with the hospital in which black patients received care, according to a study in the September 16 issue of JAMA. "Survival following in-hospital cardiac arrest represents a unique opportunity to examine racial disparities in medical care and outcomes. In-hospital cardiac arrest is an emergency condition tightly linked to processes of care and for which there is little debate regarding clinical appropriateness of treatment in eligible patients," according to background information in the article. "Racial differences in survival have not been previously studied after in-hospital cardiac arrest, an event for which access to care is not likely to influence treatment." Paul S. Chan, M.D., M.Sc., of Saint Luke's Mid America Heart Institute, Kansas City, Mo., and colleagues used data from the National Registry of Cardiopulmonary Resuscitation (NRCPR) to examine whether racial differences exist in survival for patients with in-hospital cardiac arrest. The study included 10,011 patients from 274 hospitals who underwent defibrillation for a cardiac arrest. The average age in the study population was 67 years, 6,021 were men (60.1 percent), and 1,883 were black (18.8 percent). Several patient and hospital factors differed by race, including white cardiac arrest patients being older and more likely to be male; black patients were more likely to have ventricular fibrillation as their initial presenting arrest rhythm, were sicker at the time of cardiac arrest (higher rates of renal insufficiency, diabetes mellitus, central nervous system depression, acute stroke, pneumonia, sepsis, major trauma, and requirement for hemodialysis), and were more likely to be admitted to a hospital unit not monitored, to a hospital with greater than 500 beds, and in the southeastern United States. The researchers found that black patients had a 27 percent lower overall rate, and a 12 percent lower absolute rate, of survival to hospital discharge, compared with white patients. "These unadjusted survival differences by race were, in large part, attributable to black patients being more likely to receive treatment at hospitals with worse outcomes." These differences narrowed after adjusting for patient characteristics and for the hospital to which the patient was admitted. "However, further adjustment for hospital process variables did not meaningfully [diminish] residual differences, and black patients remained 10 percent less likely to survive to hospital discharge," the authors note. "Lower rates of survival to discharge for blacks reflected lower rates of both successful resuscitation (55.8 percent vs. 67.4 percent for whites) and postresuscitation survival (45.2 percent vs. 55.5 percent for whites)," they write. "The racial difference in postresuscitation survival was eliminated after multivariable adjustment, and was largely explained by the hospital site at which patients received postresuscitation care."
"Collectively, these findings suggest that strategies to eliminate racial disparities in survival after in-hospital cardiac arrest are not likely to succeed unless they are accompanied by successful identification and implementation of interventions that improve resuscitation survival in those poorly performing hospitals in which black patients are more likely to receive care."
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), Tuesday, September 15, 2009
Experiencing In-Hospital Kidney Injury Requiring Dialysis Associated With Increased Risk of Chronic Dialysis, But Not Death
CHICAGO—Hospitalized patients who experience acute kidney problems that require dialysis are at increased risk of receiving chronic dialysis once discharged, but do not have an increased risk of death, according to a study in the September 16 issue of JAMA. "Acute kidney injury, which leads to a sudden decline in kidney function, is a common and serious complication of hospitalization in the adult population. Many patients with severe acute kidney injury require initiation of hemodialysis or hemofiltration [dialysis], and their in-hospital mortality rate ranges from 45 percent to 70 percent. Among those who survive, as many as 15 percent require dialysis at the time of discharge," according to background information in the article. The authors note that little is known about the long-term outcomes of patients with an acute kidney injury that requires in-hospital dialysis, especially once they leave the hospital and recover enough kidney function to be free of dialysis in the short term. Ron Wald, M.D.C.M., M.P.H., F.R.C.P.C., of St Michael's Hospital, Toronto, and the University of Toronto, and colleagues evaluated the long-term risk of chronic dialysis and death among hospitalized patients in Ontario, Canada, who sustained an acute kidney injury while hospitalized, required dialysis and survived free of dialysis for at least 30 days after discharge. These individuals (n = 3,769) were matched with patients without acute kidney injury or dialysis during their hospitalization (n = 13,598). Patients were followed up until March 2007. The average age of the enrolled participants was 62 years, and approximately 40 percent were women. After a median (midpoint) follow-up of 3 years, the researchers "found that survivors of a hospitalization complicated by acute kidney injury requiring dialysis were approximately 3 times more likely to require chronic dialysis compared with those without acute kidney injury. However, no difference was observed between these groups for long-term mortality."
"Our findings expand on prior knowledge to provide clinicians with new information about the long-term effect of acute kidney injury that arises during a hospitalization. First, if affected patients survive to hospital discharge, then they remain at high risk of needing dialysis over the next 3 to 5 years. Patients who survive a hospitalization complicated by acute kidney injury requiring dialysis may benefit from specialized care to address complications of chronic kidney disease, and also from concerted efforts to prevent progression to chronic dialysis. At the same time, their high mortality rate is similar to hospitalized patients without acute kidney injury or need for dialysis. Hence, an episode of acute kidney injury requiring in-hospital dialysis may not be an independent contributing factor to long-term survival," the authors conclude.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Chronic on Acute Renal Failure — Long-term Implications of Severe Acute Kidney Injury
In an accompanying editorial, Sushrut S. Waikar, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and Wolfgang C. Winkelmayer, M.D., M.P.H., Sc.D., of Stanford University School of Medicine, Palo Alto, Calif., write on the importance of preventing and treating kidney disease and injury.
"Based on the available evidence from administrative and laboratory-based databases, severe acute kidney injury seems to increase the risk of progressive chronic kidney disease and may increase the risk of death. Given the extraordinarily high rates of morbidity and mortality observed in chronic kidney disease patients and acute kidney injury patients, the complex interconnection between them, and increasing incidence of both, kidney disease prevention and treatment should be a major public health priority."
Editor's Note: Please see the article for additional information, including 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), Tuesday, September 15, 2009
Treatment with Insulin or Metformin Does Not Reduce Inflammatory Biomarkers for Patients With Diabetes
CHICAGO—In patients with recent onset type-2 diabetes, treatment with insulin or the diabetes drug metformin did not reduce inflammatory biomarkers, such as high-sensitivity C-reactive protein, although the treatment did improve glucose control, according to a study in the September 16 issue of JAMA. As diabetes is in part an inflammatory condition, a possible therapeutic target for patients is subclinical inflammation, a modifiable risk factor, according to background information in the article. "Proinflammatory mechanisms have been linked to the core metabolic defects of beta-cell insufficiency and insulin resistance, and elevations in levels of inflammatory biomarkers, including high-sensitivity C-reactive protein (hsCRP), IL-6, and soluble tumor necrosis factor receptor 2 (sTNFr2), predict incident type 2 diabetes among apparently healthy individuals," the authors write. Evidence is limited on whether improvement in glycemic control, insulin resistance, or both with antidiabetic agents such as insulin and metformin may beneficially change inflammation. Aruna D. Pradhan, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues conducted a study to determine whether insulin alone or combined with metformin lowers levels of hsCRP, IL-6, and sTNFr2 in patients with recent-onset type 2 diabetes mellitus. The study included 500 adults (median [midpoint] time from diabetes diagnosis, 2.0 years), with suboptimal glycemic control and elevated hsCRP levels. Participants were randomized to 1 of 4 treatments: placebo metformin only; placebo metformin and insulin; active metformin only; or active metformin and insulin. The researchers noted the change in the measurement of the inflammatory biomarkers from the beginning of the trial to 14 weeks. The authors write that "no consistent association was found between glucose reduction and improvement in inflammatory status ascertained by change in levels of hsCRP, IL-6, or sTNFr2. Despite substantially improving glucose control, neither insulin nor metformin reduced inflammatory biomarker levels for the main effects evaluated or in comparisons between the individual treatment groups. An interaction between interventions was observed such that, compared with no pharmacologic intervention, those allocated to insulin alone had a significant attenuation of inflammation reduction, an effect not observed among those allocated to metformin and insulin or to metformin alone."
"From a clinical perspective, until other end-point trial data become available, these data underscore the need to improve adherence with therapies that do reduce cardiovascular events among diabetic patients, including exercise; weight management; smoking cessation; blood pressure control; and, in appropriate patients, antiplatelet and statin therapy," the authors conclude.
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.
JAMA REPORTS
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SURVIVAL RATES FOUND TO DIFFER BY RACE AFTER IN-HOSPITAL CARDIAC ARREST
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