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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2013;173(16):1485-1487. doi:10.1001/jamainternmed.2013.6313.
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Comparing survival rates in patients with prosthetic valve endocarditis (PVE) who undergo valve replacement surgery vs medical therapy is challenging owing to treatment selection and survivor bias. Lalani and coauthors use a prospective multinational cohort of 1025 patients with definite PVE to evaluate in-hospital and 1-year mortality rates. They found that early surgery was associated with a mortality benefit in the overall cohort in the unadjusted analysis and after controlling for treatment selection bias, but this benefit was neutralized after controlling for survival bias. Early valve replacement was not associated with improved survival compared with medical therapy in the overall cohort. In an Invited Commentary, Bolger considers the challenges of treating PVE.

Little is known about the likelihood of older people becoming disabled in the basic activities required for independent living. Smith and coauthors use a nationally representative dataset of 8232 older adults who died between 1995 and 2010 to examine the prevalence of disability during the last 2 years of life, defining disability as requiring assistance with dressing, bathing, eating, transferring, walking across the room, or toileting. Disability rose from 28% two years before death to 56% in the last month of life, and subjects who lived to the oldest ages were more likely to be disabled in the last 2 years of life compared with subjects who died at a younger age. Independent of age, women were more likely to be disabled than men.

Less Is More

Although the symptomatic benefits of spinal augmentation for the treatment of osteoporotic compression fractures are controversial, recent population-based studies suggest that these procedures may offer a significant long-term mortality improvement over conservative therapy. McCullough and coauthors use preprocedure outcomes and propensity score analysis to reexamine this question in the Medicare population, with special attention to the role of selection bias in medical billing claims. They demonstrate underlying selection bias favoring the augmented group despite standard covariate adjustments. After better accounting for this bias, mortality was no better with augmentation compared with controls, and health care utilization was worse. Bauer addresses the relative merits of treatment options in an Invited Commentary, and Grady explains the study’s Less Is More designation in an Editor’s Note.

The factors affecting the health of kidney transplant patients as they transition from adolescence to adulthood are not well understood. Using the Organ Procurement Transplantation Network database of more than 100 000 kidney transplant recipients from 1987 to 2010, Andreoni and coauthors found that adolescent recipients aged 14 to 16 years had the highest risk of graft loss of any age group, with greater risk among African Americans. Across all age groups, the government insurance recipients had a greater risk of graft failure compared with those with private coverage. In an Editor’s Note, Katz considers the findings in the context of the national conversation about health care reform.

Freedom from symptoms is an important determinant of a good death, but little is known about symptom occurrence during the last year of life. In a prospective cohort study of 491 community-dwelling older persons, Chaudhry and coauthors assess symptoms leading to restrictions in daily activities every month in the year before death. They found that the monthly occurrence of restricting symptoms was fairly constant until 5 months prior to death, when it began to increase rapidly, reaching 57.2% in the month prior to death. In multivariable analysis, age younger than 85 years, multimorbidity, and proximity to time of death were significantly associated with the monthly occurrence of restricting symptoms, and participants who died of cancer had a higher monthly symptom occurrence compared with participants who died of sudden death. In an Invited Commentary, Ritchie proposes changes to common methods of research on symptom burden in older adults in order to improve care.





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