Michele G. Sullivan

BERLIN – A population-based screening project for type 2 diabetes did not improve 10-year mortality, a very large British study has determined.

When compared to best-practice identification of individual diabetes patients, general screening offered no benefits in all-cause mortality or in the specific outcomes of cardiovascular, cancer, or diabetes-related deaths Dr. Rebecca K. Simmons reported Oct. 4 at the annual meeting of the European Association for the Study of Diabetes (EASD).

But the study did show that individuals at risk for the disease who refused the screening were significantly more likely to die over the follow-up period, said Dr. Simmons of the University of Cambridge (England).

"The take-home message here is that the benefits of population-based screening have been overestimated and are probably restricted to those who are at risk, who attend the screen, and who receive earlier treatment because of it," she said.

The ADDITION-Cambridge study involved 32 general medical practices in England and more than 20,000 patients who were at risk of developing type 2 diabetes. The practices were randomized to conduct either large-scale screening of all at-risk patients (27) or to no screening (5). The control practices continued to diagnose patients according to best practices.

Practices in the intervention group sent invitations to those who had been identified as high risk. The stepwise process included capillary blood glucose and hemoglobin A_1c tests, and a confirmatory oral glucose tolerance test. Those who had the OGTT also had a cardiovascular risk factor assessment that included body mass index, waist circumference, blood pressure, and lipids. Those who did not attend the screen after a reminder were considered to be nonattenders.

Patients diagnosed in either practice group were managed according to a national consensus guideline of lifestyle education and modification, medical management, and blood pressure and cholesterol control.

All participants – whether screened or not – were followed for 10 years in the National Office of Statistics. The study accumulated 184,000 person-years of follow-up data.

Of the 16,000 screen-eligible patients, 15,000 were invited for screening and 11,737 (73%) attended the first stage. There were 466 new diagnoses of type 2 diabetes (3% of the screen-eligible group). There were 4,137 patients in the no-screening group, who served as controls.

Patients had a mean age of 58 years; most (64%) were male. The mean BMI was 30.5 kg/m². About half were taking an antihypertensive, and a small number (4%-5%) were taking steroids.

At 10 years, there were 1,532 deaths in the screening group (10.5 per 1,000 person-years), and 377 in the control group (9.9 per 1,000 person-years) – a difference that was not significant.

The screening group had 482 cardiovascular deaths (3.3 per 1,000 person-years), compared with 124 in the control group (3.3 per 1,000 person-years). Cancer was the cause of death in 697 patients in the screening group and in 169 in the control group (4.8 and 4.4 per 1,000 person-years, respectively). Diabetes-related deaths occurred in 75 of the screening group and in 16 of the control group (0.5 and 0.4 per 1,000 person-years).

Deaths due to other causes occurred in 353 patients in the screening group (2.4 per 1,000 person-years) and 84 in the control group (2.2 per 1,000 person-years).

None of these findings were statistically significant, Dr. Simmons said.

However, a significant difference did emerge when the invited group was broken down into attenders and nonattenders. In this analysis, those who refused screening were 62% more likely to die within 10 years, and those who attended were 17% less likely to die, than were the control patients.

Most of those who refused screening were younger, obese men, who were less likely to be taking antihypertensive medications. Considered along with the significant increase in the risk of death in this group, targeted screening makes more sense than a general approach, Dr. Simmons suggested.

The results of ADDITION-Cambridge were published online to coincide with the EASD meeting (Lancet 2012 Oct. 4 [doi: 10.1016/S0140-6736(12)61422-6]).

"It’s probably best to focus on identifying those who have diagnosable disease and treating them according to our best practices," she said.

The study was funded by the Wellcome Trust, the Medical Research Council, the National Health Service, and the National Institute for Health Research. Dr. Simmons had no financial disclosures.

BERLIN – A population-based screening project for type 2 diabetes did not improve 10-year mortality, a very large British study has determined.

When compared to best-practice identification of individual diabetes patients, general screening offered no benefits in all-cause mortality or in the specific outcomes of cardiovascular, cancer, or diabetes-related deaths Dr. Rebecca K. Simmons reported Oct. 4 at the annual meeting of the European Association for the Study of Diabetes (EASD).

But the study did show that individuals at risk for the disease who refused the screening were significantly more likely to die over the follow-up period, said Dr. Simmons of the University of Cambridge (England).

"The take-home message here is that the benefits of population-based screening have been overestimated and are probably restricted to those who are at risk, who attend the screen, and who receive earlier treatment because of it," she said.

The ADDITION-Cambridge study involved 32 general medical practices in England and more than 20,000 patients who were at risk of developing type 2 diabetes. The practices were randomized to conduct either large-scale screening of all at-risk patients (27) or to no screening (5). The control practices continued to diagnose patients according to best practices.

Practices in the intervention group sent invitations to those who had been identified as high risk. The stepwise process included capillary blood glucose and hemoglobin A_1c tests, and a confirmatory oral glucose tolerance test. Those who had the OGTT also had a cardiovascular risk factor assessment that included body mass index, waist circumference, blood pressure, and lipids. Those who did not attend the screen after a reminder were considered to be nonattenders.

Patients diagnosed in either practice group were managed according to a national consensus guideline of lifestyle education and modification, medical management, and blood pressure and cholesterol control.

All participants – whether screened or not – were followed for 10 years in the National Office of Statistics. The study accumulated 184,000 person-years of follow-up data.

Of the 16,000 screen-eligible patients, 15,000 were invited for screening and 11,737 (73%) attended the first stage. There were 466 new diagnoses of type 2 diabetes (3% of the screen-eligible group). There were 4,137 patients in the no-screening group, who served as controls.

Patients had a mean age of 58 years; most (64%) were male. The mean BMI was 30.5 kg/m². About half were taking an antihypertensive, and a small number (4%-5%) were taking steroids.

At 10 years, there were 1,532 deaths in the screening group (10.5 per 1,000 person-years), and 377 in the control group (9.9 per 1,000 person-years) – a difference that was not significant.

The screening group had 482 cardiovascular deaths (3.3 per 1,000 person-years), compared with 124 in the control group (3.3 per 1,000 person-years). Cancer was the cause of death in 697 patients in the screening group and in 169 in the control group (4.8 and 4.4 per 1,000 person-years, respectively). Diabetes-related deaths occurred in 75 of the screening group and in 16 of the control group (0.5 and 0.4 per 1,000 person-years).

Deaths due to other causes occurred in 353 patients in the screening group (2.4 per 1,000 person-years) and 84 in the control group (2.2 per 1,000 person-years).

None of these findings were statistically significant, Dr. Simmons said.

However, a significant difference did emerge when the invited group was broken down into attenders and nonattenders. In this analysis, those who refused screening were 62% more likely to die within 10 years, and those who attended were 17% less likely to die, than were the control patients.

Most of those who refused screening were younger, obese men, who were less likely to be taking antihypertensive medications. Considered along with the significant increase in the risk of death in this group, targeted screening makes more sense than a general approach, Dr. Simmons suggested.

The results of ADDITION-Cambridge were published online to coincide with the EASD meeting (Lancet 2012 Oct. 4 [doi: 10.1016/S0140-6736(12)61422-6]).

"It’s probably best to focus on identifying those who have diagnosable disease and treating them according to our best practices," she said.

The study was funded by the Wellcome Trust, the Medical Research Council, the National Health Service, and the National Institute for Health Research. Dr. Simmons had no financial disclosures.

BERLIN – A population-based screening project for type 2 diabetes did not improve 10-year mortality, a very large British study has determined.

When compared to best-practice identification of individual diabetes patients, general screening offered no benefits in all-cause mortality or in the specific outcomes of cardiovascular, cancer, or diabetes-related deaths Dr. Rebecca K. Simmons reported Oct. 4 at the annual meeting of the European Association for the Study of Diabetes (EASD).

But the study did show that individuals at risk for the disease who refused the screening were significantly more likely to die over the follow-up period, said Dr. Simmons of the University of Cambridge (England).

"The take-home message here is that the benefits of population-based screening have been overestimated and are probably restricted to those who are at risk, who attend the screen, and who receive earlier treatment because of it," she said.

The ADDITION-Cambridge study involved 32 general medical practices in England and more than 20,000 patients who were at risk of developing type 2 diabetes. The practices were randomized to conduct either large-scale screening of all at-risk patients (27) or to no screening (5). The control practices continued to diagnose patients according to best practices.

Practices in the intervention group sent invitations to those who had been identified as high risk. The stepwise process included capillary blood glucose and hemoglobin A_1c tests, and a confirmatory oral glucose tolerance test. Those who had the OGTT also had a cardiovascular risk factor assessment that included body mass index, waist circumference, blood pressure, and lipids. Those who did not attend the screen after a reminder were considered to be nonattenders.

Patients diagnosed in either practice group were managed according to a national consensus guideline of lifestyle education and modification, medical management, and blood pressure and cholesterol control.

All participants – whether screened or not – were followed for 10 years in the National Office of Statistics. The study accumulated 184,000 person-years of follow-up data.

Of the 16,000 screen-eligible patients, 15,000 were invited for screening and 11,737 (73%) attended the first stage. There were 466 new diagnoses of type 2 diabetes (3% of the screen-eligible group). There were 4,137 patients in the no-screening group, who served as controls.

Patients had a mean age of 58 years; most (64%) were male. The mean BMI was 30.5 kg/m². About half were taking an antihypertensive, and a small number (4%-5%) were taking steroids.

At 10 years, there were 1,532 deaths in the screening group (10.5 per 1,000 person-years), and 377 in the control group (9.9 per 1,000 person-years) – a difference that was not significant.

The screening group had 482 cardiovascular deaths (3.3 per 1,000 person-years), compared with 124 in the control group (3.3 per 1,000 person-years). Cancer was the cause of death in 697 patients in the screening group and in 169 in the control group (4.8 and 4.4 per 1,000 person-years, respectively). Diabetes-related deaths occurred in 75 of the screening group and in 16 of the control group (0.5 and 0.4 per 1,000 person-years).

Deaths due to other causes occurred in 353 patients in the screening group (2.4 per 1,000 person-years) and 84 in the control group (2.2 per 1,000 person-years).

None of these findings were statistically significant, Dr. Simmons said.

However, a significant difference did emerge when the invited group was broken down into attenders and nonattenders. In this analysis, those who refused screening were 62% more likely to die within 10 years, and those who attended were 17% less likely to die, than were the control patients.

Most of those who refused screening were younger, obese men, who were less likely to be taking antihypertensive medications. Considered along with the significant increase in the risk of death in this group, targeted screening makes more sense than a general approach, Dr. Simmons suggested.

The results of ADDITION-Cambridge were published online to coincide with the EASD meeting (Lancet 2012 Oct. 4 [doi: 10.1016/S0140-6736(12)61422-6]).

"It’s probably best to focus on identifying those who have diagnosable disease and treating them according to our best practices," she said.

The study was funded by the Wellcome Trust, the Medical Research Council, the National Health Service, and the National Institute for Health Research. Dr. Simmons had no financial disclosures.

BERLIN – Women who are diagnosed with diabetes at the time of an acute myocardial infarction are three times more likely to die over the next 3 years as are similar women without diabetes.

In contrast, men whose diabetes was diagnosed during their hospitalization for acute MI had twice the risk of death after 3 years compared with men without diabetes, based on the latest results of the SWEETHEART registry, a prospective study of 2,767 patients with ST- or non-ST-elevation myocardial infarction.

Michele G. Sullivan/IMNG Medical Media

The double-whammy of diabetes and coronary artery disease is "extraordinarily dangerous" for women, said Dr. Diethelm Tschoepe of the Heart and Diabetes Center, Bad Oeynhausen, Germany. Women with a new diagnosis of diabetes "have a much, much worse prognostic gradient" than do men with newly diagnosed diabetes, and men and women without diabetes.

Dr. Tschoepe said the findings suggest there is a large population of women with longstanding, undiagnosed diabetes that goes unrecognized until a cardiovascular event. "The vigilance of women and their treatment physicians seems to be insufficient" to detect their diabetes.

Additionally, testing for diabetes needs to occur in all patients who experience a cardiovascular event, despite the logistic difficulty this might present, Dr. Tschoepe said. "I am working in a place where endocrinologists, cardiac surgeons, and cardiologists work together, but it is still a tough fight to get every patient tested."

Among women in the study, the 3-year mortality rate was 30% for those with known diabetes and 30.5% for those with newly diagnosed diabetes – significantly higher than the rates for those without diabetes and those with impaired glucose regulation (11% and 13% respectively).

Among men, the mortality rate was highest among those with known diabetes (35%), followed by those with newly diagnosed disease (22%). Both groups had significantly higher mortality than that seen in those without diabetes and those with impaired glucose regulation (11% each).

In the overall multivariate adjusted model, patients with known diabetes were 77% more likely to die and 68% more likely to experience a major cardiovascular or cerebrovascular event than were those without diabetes. Those with newly diagnosed diabetes were 43% more likely to die and 18% more likely to have a significant adverse event than were those without diabetes, Dr. Tschoepe reported at the annual meeting of the European Association for the Study of Diabetes.

At the time of their coronary events, some level of glycemic dysregulation affected 68% of the women and 60% of the men in the study.

At admission, 30% of women and 23% of men had diabetes. Testing identified diabetes in an additional 20% of women and 15% of men. Another 18% of women and 23% of men had impaired glucose tolerance or impaired fasting glucose.

There was a "striking difference" in diabetes treatment between the groups at discharge, Dr. Tschoepe said, with 47% of women and 37% of men on some form of therapy. Oral treatment was prescribed for 27% of the women and 37% of the men, while 39% of the women and 27% of the men were discharged on insulin; both of these differences were significant. Exactly the same number of men and women were discharged on the combination of insulin and oral therapy (6.2%).

Men were more likely to be discharged on dietary treatment alone (42% vs. 39%), but this was not a significant difference. Dr. Tschoepe added.

Patients were enrolled in the trial within 24 hours of treatment and followed for 3 years. In addition to cardiovascular treatment, all patients underwent an oral glucose tolerance test as recommended in 2007 by the European Society of Cardiology and the European Association for the Study of Diabetes.

There were 706 women in the cohort. The women were older than the men, average age 71 and 64 years, respectively; were less likely to have a prior MI, 13% vs. 19%; had fewer prior percutaneous coronary interventions, 12% vs. 18%; had more hypertension, 80% vs. 69%; were less likely to smoke, 25% vs. 40%; and were more likely to have a known history of diabetes, 30% vs. 23%.

The mean blood glucose value at admission was significantly higher in women than in men, 137 mg/dL vs. 127 mg/dL. Women also had a significantly higher HbA_1c, 6.1% vs. 5.8%. STEMI and NSTEMI were equally distributed in men and women.

Almost all of the patients underwent a coronary angiogram (95% of women, 97% of men). One-, two-, and three-vessel disease were equally distributed in both genders. Cardiovascular drug therapy did not significantly differ at discharge, with the vast majority receiving aspirin, clopidogrel, beta-blockers and ACE inhibitors as appropriate with guideline recommendations.

The SWEETHEART registry is funded by Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, Sanofi, and Novartis. Dr. Tschoepe Tschoepe has received consultancy and speaker remuneration from Astra Zeneca, Bristol-Myers, Squibb, Servier, Sanofi, and Novartis.

BERLIN – Women who are diagnosed with diabetes at the time of an acute myocardial infarction are three times more likely to die over the next 3 years as are similar women without diabetes.

In contrast, men whose diabetes was diagnosed during their hospitalization for acute MI had twice the risk of death after 3 years compared with men without diabetes, based on the latest results of the SWEETHEART registry, a prospective study of 2,767 patients with ST- or non-ST-elevation myocardial infarction.

Michele G. Sullivan/IMNG Medical Media

The double-whammy of diabetes and coronary artery disease is "extraordinarily dangerous" for women, said Dr. Diethelm Tschoepe of the Heart and Diabetes Center, Bad Oeynhausen, Germany. Women with a new diagnosis of diabetes "have a much, much worse prognostic gradient" than do men with newly diagnosed diabetes, and men and women without diabetes.

Dr. Tschoepe said the findings suggest there is a large population of women with longstanding, undiagnosed diabetes that goes unrecognized until a cardiovascular event. "The vigilance of women and their treatment physicians seems to be insufficient" to detect their diabetes.

Additionally, testing for diabetes needs to occur in all patients who experience a cardiovascular event, despite the logistic difficulty this might present, Dr. Tschoepe said. "I am working in a place where endocrinologists, cardiac surgeons, and cardiologists work together, but it is still a tough fight to get every patient tested."

Among women in the study, the 3-year mortality rate was 30% for those with known diabetes and 30.5% for those with newly diagnosed diabetes – significantly higher than the rates for those without diabetes and those with impaired glucose regulation (11% and 13% respectively).

Among men, the mortality rate was highest among those with known diabetes (35%), followed by those with newly diagnosed disease (22%). Both groups had significantly higher mortality than that seen in those without diabetes and those with impaired glucose regulation (11% each).

In the overall multivariate adjusted model, patients with known diabetes were 77% more likely to die and 68% more likely to experience a major cardiovascular or cerebrovascular event than were those without diabetes. Those with newly diagnosed diabetes were 43% more likely to die and 18% more likely to have a significant adverse event than were those without diabetes, Dr. Tschoepe reported at the annual meeting of the European Association for the Study of Diabetes.

At the time of their coronary events, some level of glycemic dysregulation affected 68% of the women and 60% of the men in the study.

At admission, 30% of women and 23% of men had diabetes. Testing identified diabetes in an additional 20% of women and 15% of men. Another 18% of women and 23% of men had impaired glucose tolerance or impaired fasting glucose.

There was a "striking difference" in diabetes treatment between the groups at discharge, Dr. Tschoepe said, with 47% of women and 37% of men on some form of therapy. Oral treatment was prescribed for 27% of the women and 37% of the men, while 39% of the women and 27% of the men were discharged on insulin; both of these differences were significant. Exactly the same number of men and women were discharged on the combination of insulin and oral therapy (6.2%).

Men were more likely to be discharged on dietary treatment alone (42% vs. 39%), but this was not a significant difference. Dr. Tschoepe added.

Patients were enrolled in the trial within 24 hours of treatment and followed for 3 years. In addition to cardiovascular treatment, all patients underwent an oral glucose tolerance test as recommended in 2007 by the European Society of Cardiology and the European Association for the Study of Diabetes.

There were 706 women in the cohort. The women were older than the men, average age 71 and 64 years, respectively; were less likely to have a prior MI, 13% vs. 19%; had fewer prior percutaneous coronary interventions, 12% vs. 18%; had more hypertension, 80% vs. 69%; were less likely to smoke, 25% vs. 40%; and were more likely to have a known history of diabetes, 30% vs. 23%.

The mean blood glucose value at admission was significantly higher in women than in men, 137 mg/dL vs. 127 mg/dL. Women also had a significantly higher HbA_1c, 6.1% vs. 5.8%. STEMI and NSTEMI were equally distributed in men and women.

Almost all of the patients underwent a coronary angiogram (95% of women, 97% of men). One-, two-, and three-vessel disease were equally distributed in both genders. Cardiovascular drug therapy did not significantly differ at discharge, with the vast majority receiving aspirin, clopidogrel, beta-blockers and ACE inhibitors as appropriate with guideline recommendations.

The SWEETHEART registry is funded by Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, Sanofi, and Novartis. Dr. Tschoepe Tschoepe has received consultancy and speaker remuneration from Astra Zeneca, Bristol-Myers, Squibb, Servier, Sanofi, and Novartis.

BERLIN – Women who are diagnosed with diabetes at the time of an acute myocardial infarction are three times more likely to die over the next 3 years as are similar women without diabetes.

In contrast, men whose diabetes was diagnosed during their hospitalization for acute MI had twice the risk of death after 3 years compared with men without diabetes, based on the latest results of the SWEETHEART registry, a prospective study of 2,767 patients with ST- or non-ST-elevation myocardial infarction.

Michele G. Sullivan/IMNG Medical Media

The double-whammy of diabetes and coronary artery disease is "extraordinarily dangerous" for women, said Dr. Diethelm Tschoepe of the Heart and Diabetes Center, Bad Oeynhausen, Germany. Women with a new diagnosis of diabetes "have a much, much worse prognostic gradient" than do men with newly diagnosed diabetes, and men and women without diabetes.

Dr. Tschoepe said the findings suggest there is a large population of women with longstanding, undiagnosed diabetes that goes unrecognized until a cardiovascular event. "The vigilance of women and their treatment physicians seems to be insufficient" to detect their diabetes.

Additionally, testing for diabetes needs to occur in all patients who experience a cardiovascular event, despite the logistic difficulty this might present, Dr. Tschoepe said. "I am working in a place where endocrinologists, cardiac surgeons, and cardiologists work together, but it is still a tough fight to get every patient tested."

Among women in the study, the 3-year mortality rate was 30% for those with known diabetes and 30.5% for those with newly diagnosed diabetes – significantly higher than the rates for those without diabetes and those with impaired glucose regulation (11% and 13% respectively).

Among men, the mortality rate was highest among those with known diabetes (35%), followed by those with newly diagnosed disease (22%). Both groups had significantly higher mortality than that seen in those without diabetes and those with impaired glucose regulation (11% each).

In the overall multivariate adjusted model, patients with known diabetes were 77% more likely to die and 68% more likely to experience a major cardiovascular or cerebrovascular event than were those without diabetes. Those with newly diagnosed diabetes were 43% more likely to die and 18% more likely to have a significant adverse event than were those without diabetes, Dr. Tschoepe reported at the annual meeting of the European Association for the Study of Diabetes.

At the time of their coronary events, some level of glycemic dysregulation affected 68% of the women and 60% of the men in the study.

At admission, 30% of women and 23% of men had diabetes. Testing identified diabetes in an additional 20% of women and 15% of men. Another 18% of women and 23% of men had impaired glucose tolerance or impaired fasting glucose.

There was a "striking difference" in diabetes treatment between the groups at discharge, Dr. Tschoepe said, with 47% of women and 37% of men on some form of therapy. Oral treatment was prescribed for 27% of the women and 37% of the men, while 39% of the women and 27% of the men were discharged on insulin; both of these differences were significant. Exactly the same number of men and women were discharged on the combination of insulin and oral therapy (6.2%).

Men were more likely to be discharged on dietary treatment alone (42% vs. 39%), but this was not a significant difference. Dr. Tschoepe added.

Patients were enrolled in the trial within 24 hours of treatment and followed for 3 years. In addition to cardiovascular treatment, all patients underwent an oral glucose tolerance test as recommended in 2007 by the European Society of Cardiology and the European Association for the Study of Diabetes.

There were 706 women in the cohort. The women were older than the men, average age 71 and 64 years, respectively; were less likely to have a prior MI, 13% vs. 19%; had fewer prior percutaneous coronary interventions, 12% vs. 18%; had more hypertension, 80% vs. 69%; were less likely to smoke, 25% vs. 40%; and were more likely to have a known history of diabetes, 30% vs. 23%.

The mean blood glucose value at admission was significantly higher in women than in men, 137 mg/dL vs. 127 mg/dL. Women also had a significantly higher HbA_1c, 6.1% vs. 5.8%. STEMI and NSTEMI were equally distributed in men and women.

Almost all of the patients underwent a coronary angiogram (95% of women, 97% of men). One-, two-, and three-vessel disease were equally distributed in both genders. Cardiovascular drug therapy did not significantly differ at discharge, with the vast majority receiving aspirin, clopidogrel, beta-blockers and ACE inhibitors as appropriate with guideline recommendations.

The SWEETHEART registry is funded by Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, Sanofi, and Novartis. Dr. Tschoepe Tschoepe has received consultancy and speaker remuneration from Astra Zeneca, Bristol-Myers, Squibb, Servier, Sanofi, and Novartis.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

Physicians in five countries agree: Those who diagnose and treat patients with Alzheimer’s disease need more – and better – tools to handle the job.

Nearly half of those who took part in an international survey said that Alzheimer’s is often misdiagnosed, eating away at the window when early treatment could temporarily slow disease progression. Lack of a definitive diagnostic tool is the biggest barrier to getting patients the help they need as quickly as possible, and, just as importantly, preparing for the challenges that lie ahead.

"This is a surprising, but understandable, problem, given the complexity of Alzheimer’s," said Graeme Leiser, a market research analyst for Eli Lilly and Company’s Alzheimer’s Disease Team, during a Sept. 19 teleconference to announce the survey results. Patients and families contribute to the problem because they’re afraid to admit Alzheimer’s might be a possibility and because it’s tough to communicate effectively at such a stressful moment in their lives.

"Nearly half of those interviewed in the U.S. indicated that patients and caregivers are not completely forthcoming with information about their symptoms," Mr. Leiser said. "There is a very strong emotional reaction when this diagnosis is delivered, and a stigma associated with it that’s very difficult to face."

Eli Lilly funded the survey, collaborating with Alzheimer’s Disease International (ADI), the umbrella group that works to strength and support Alzheimer’s associations around the world. The survey polled almost 1,000 physicians in five countries – the United States, United Kingdom, France, Italy, and Japan – about the biggest barriers they face in diagnosing and caring for patients with the disease. The survey cohort included primary care physicians, neurologists, psychiatrists, and geriatricians who care for patients on a regular basis.

The survey identified three common barriers to making a formal diagnosis of Alzheimer’s: the lack of definitive tests; communication problems between physician, patients, and their families; and patient denial of symptoms, Mr. Leiser said.

Lack of a definitive diagnostic tool leads to many problems, the survey found.

"We saw that nearly half of all the physicians believed that Alzheimer’s is often misdiagnosed, and nearly half said it was often or always diagnosed too late to intervene in any meaningful way."

Early intervention doesn’t just mean prescribing drugs that may slow progression. "This is an important point because some symptoms are due to other dementias, some of which are curable," Mr. Leiser said. "And all of these dementias require different management, which may also be different from the way Alzheimer’s is treated."

Timely recognition of Alzheimer’s also helps patients and families prepare for the years ahead. More than half of U.S. physicians said it helps them educate families and manage their expectations.

But early diagnosis comes with its own problems, the survey found. Most physicians (61%) said patients and families receive an enormous emotional shock when they get the news, which forces them to confront the social and personal stigma associated with Alzheimer’s.

"In the U.S., physicians said the loss of freedom was the most important stigma" – significantly different than the opinions in other countries. Physicians in the United Kingdom, for example, said their patients’ and families’ biggest problem was dealing with the negative social opinion of Alzheimer’s.

These perceptions are a huge contributor to the barriers to care seen all over the world, said Marc Woortman, executive director of ADI.

"This survey uncovered many insights that will not only help families and physicians work together for the patient, but also add to the effort to change the way people perceive Alzheimer’s disease."

In fact, ADI’s 2012 global report on Alzheimer’s issues focuses strongly on stigma and suggests ways the international community can begin to breach them.

"By destigmatizing this illness, we can pave the way for earlier and more effective communication. This will help ease the burden of patients, and improve how society looks at the disease."

Physicians in five countries agree: Those who diagnose and treat patients with Alzheimer’s disease need more – and better – tools to handle the job.

Nearly half of those who took part in an international survey said that Alzheimer’s is often misdiagnosed, eating away at the window when early treatment could temporarily slow disease progression. Lack of a definitive diagnostic tool is the biggest barrier to getting patients the help they need as quickly as possible, and, just as importantly, preparing for the challenges that lie ahead.

"This is a surprising, but understandable, problem, given the complexity of Alzheimer’s," said Graeme Leiser, a market research analyst for Eli Lilly and Company’s Alzheimer’s Disease Team, during a Sept. 19 teleconference to announce the survey results. Patients and families contribute to the problem because they’re afraid to admit Alzheimer’s might be a possibility and because it’s tough to communicate effectively at such a stressful moment in their lives.

"Nearly half of those interviewed in the U.S. indicated that patients and caregivers are not completely forthcoming with information about their symptoms," Mr. Leiser said. "There is a very strong emotional reaction when this diagnosis is delivered, and a stigma associated with it that’s very difficult to face."

Eli Lilly funded the survey, collaborating with Alzheimer’s Disease International (ADI), the umbrella group that works to strength and support Alzheimer’s associations around the world. The survey polled almost 1,000 physicians in five countries – the United States, United Kingdom, France, Italy, and Japan – about the biggest barriers they face in diagnosing and caring for patients with the disease. The survey cohort included primary care physicians, neurologists, psychiatrists, and geriatricians who care for patients on a regular basis.

The survey identified three common barriers to making a formal diagnosis of Alzheimer’s: the lack of definitive tests; communication problems between physician, patients, and their families; and patient denial of symptoms, Mr. Leiser said.

Lack of a definitive diagnostic tool leads to many problems, the survey found.

"We saw that nearly half of all the physicians believed that Alzheimer’s is often misdiagnosed, and nearly half said it was often or always diagnosed too late to intervene in any meaningful way."

Early intervention doesn’t just mean prescribing drugs that may slow progression. "This is an important point because some symptoms are due to other dementias, some of which are curable," Mr. Leiser said. "And all of these dementias require different management, which may also be different from the way Alzheimer’s is treated."

Timely recognition of Alzheimer’s also helps patients and families prepare for the years ahead. More than half of U.S. physicians said it helps them educate families and manage their expectations.

But early diagnosis comes with its own problems, the survey found. Most physicians (61%) said patients and families receive an enormous emotional shock when they get the news, which forces them to confront the social and personal stigma associated with Alzheimer’s.

"In the U.S., physicians said the loss of freedom was the most important stigma" – significantly different than the opinions in other countries. Physicians in the United Kingdom, for example, said their patients’ and families’ biggest problem was dealing with the negative social opinion of Alzheimer’s.

These perceptions are a huge contributor to the barriers to care seen all over the world, said Marc Woortman, executive director of ADI.

"This survey uncovered many insights that will not only help families and physicians work together for the patient, but also add to the effort to change the way people perceive Alzheimer’s disease."

In fact, ADI’s 2012 global report on Alzheimer’s issues focuses strongly on stigma and suggests ways the international community can begin to breach them.

"By destigmatizing this illness, we can pave the way for earlier and more effective communication. This will help ease the burden of patients, and improve how society looks at the disease."

Physicians in five countries agree: Those who diagnose and treat patients with Alzheimer’s disease need more – and better – tools to handle the job.

Nearly half of those who took part in an international survey said that Alzheimer’s is often misdiagnosed, eating away at the window when early treatment could temporarily slow disease progression. Lack of a definitive diagnostic tool is the biggest barrier to getting patients the help they need as quickly as possible, and, just as importantly, preparing for the challenges that lie ahead.

"This is a surprising, but understandable, problem, given the complexity of Alzheimer’s," said Graeme Leiser, a market research analyst for Eli Lilly and Company’s Alzheimer’s Disease Team, during a Sept. 19 teleconference to announce the survey results. Patients and families contribute to the problem because they’re afraid to admit Alzheimer’s might be a possibility and because it’s tough to communicate effectively at such a stressful moment in their lives.

"Nearly half of those interviewed in the U.S. indicated that patients and caregivers are not completely forthcoming with information about their symptoms," Mr. Leiser said. "There is a very strong emotional reaction when this diagnosis is delivered, and a stigma associated with it that’s very difficult to face."

Eli Lilly funded the survey, collaborating with Alzheimer’s Disease International (ADI), the umbrella group that works to strength and support Alzheimer’s associations around the world. The survey polled almost 1,000 physicians in five countries – the United States, United Kingdom, France, Italy, and Japan – about the biggest barriers they face in diagnosing and caring for patients with the disease. The survey cohort included primary care physicians, neurologists, psychiatrists, and geriatricians who care for patients on a regular basis.

The survey identified three common barriers to making a formal diagnosis of Alzheimer’s: the lack of definitive tests; communication problems between physician, patients, and their families; and patient denial of symptoms, Mr. Leiser said.

Lack of a definitive diagnostic tool leads to many problems, the survey found.

"We saw that nearly half of all the physicians believed that Alzheimer’s is often misdiagnosed, and nearly half said it was often or always diagnosed too late to intervene in any meaningful way."

Early intervention doesn’t just mean prescribing drugs that may slow progression. "This is an important point because some symptoms are due to other dementias, some of which are curable," Mr. Leiser said. "And all of these dementias require different management, which may also be different from the way Alzheimer’s is treated."

Timely recognition of Alzheimer’s also helps patients and families prepare for the years ahead. More than half of U.S. physicians said it helps them educate families and manage their expectations.

But early diagnosis comes with its own problems, the survey found. Most physicians (61%) said patients and families receive an enormous emotional shock when they get the news, which forces them to confront the social and personal stigma associated with Alzheimer’s.

"In the U.S., physicians said the loss of freedom was the most important stigma" – significantly different than the opinions in other countries. Physicians in the United Kingdom, for example, said their patients’ and families’ biggest problem was dealing with the negative social opinion of Alzheimer’s.

These perceptions are a huge contributor to the barriers to care seen all over the world, said Marc Woortman, executive director of ADI.

"This survey uncovered many insights that will not only help families and physicians work together for the patient, but also add to the effort to change the way people perceive Alzheimer’s disease."

In fact, ADI’s 2012 global report on Alzheimer’s issues focuses strongly on stigma and suggests ways the international community can begin to breach them.

"By destigmatizing this illness, we can pave the way for earlier and more effective communication. This will help ease the burden of patients, and improve how society looks at the disease."

Social stigma associated with dementia and Alzheimer’s disease places burdens on patients and their families that may interfere with early diagnosis and treatment, negatively affect social support and care at home or in a facility, and even undermine research efforts.

The World Alzheimer’s Report here found that 75% of people with dementia and 64% of caregivers believe that negative associations exist, and many have experienced at least one.

"One of our most basic key findings is that people with dementia wanted to be treated as human," Nicole Batsch, the report’s primary author, said in a teleconference announcing the report. "These people are not being treated with dignity and they sense that. They are marginalized, excluded from society, and not respected for the wisdom and experience they have accumulated over the years."

Alzheimer's Disease International, an umbrella group that supports Alzheimer’s associations around the world, commissioned the survey, which included responses from more than 2,500 people affected by the disease, including 2,068 to the English-speaking version of the survey. There were 127 responses to the English-speaking survey from Alzheimer’s patients.

"We think this is the largest, and maybe even the only, online survey with [patients] participating," Ms. Batsch, a doctoral candidate at King’s College, London, said during a teleconference. "Most of those who did take part are already connected with some kind of support program, so the results don’t necessarily reflect the experiences of those who are not. But we think those people may be more stigmatized."

The survey was available in 54 countries and was translated into four languages: English, Spanish, Chinese, and Greek. About half of the entire survey population had completed college or obtained a graduate degree, indicating that the cohort represented a "select group."

Most of the respondents (59%) said they had concealed the diagnosis from other people, citing a fear of social stigma as their reason for silence. A number had withheld the information because they feared losing their jobs, while others were concerned about being judged by their community and family. Half also said they had experienced such reactions after revealing the diagnosis, with 60% saying they had been treated differently because of it.

Both patients and caregivers described a number of reactions to the condition. A frequent complaint of patients was being ignored as others spoke to their companions instead of directly to them. A Spanish-speaking man said his family changed his given name to a diminutive form, revealing that they no longer thought of him as a competent adult.

Some Chinese respondents said that physicians seemed to give up on them or their loved one because "treatment is only a waste of money."

Many physicians do, in fact, engage in stigmatizing behavior, Ms. Batsch wrote.

"Physicians are reluctant to discuss cognitive symptoms with their patients because of the stigma associated with it and the sense that ‘nothing can be done.’ ... Moreover, stigmatic beliefs of primary care physicians and therapeutic nihilism lead them to avoid evaluating cognitive function until the illness is so apparent that it cannot be ignored."

Some have a more altruistic reason for avoiding the discussion, she said. "This attitude is shared by many health care professionals, who are reluctant [because they fear] to give their patients a stigmatizing label."

A 2010 literature review found a number of themes running through physicians’ problems with discussing dementia, she noted. Dr. Tamar Koch, a senior clinical researcher at University College, London, found 11 studies addressing the issue (BMC Fam. Pract. 2010;11:52).

"The main themes from the qualitative studies were found to be lack of support, time constraints, financial constraints, stigma, diagnostic uncertainty, and disclosing the diagnosis," Dr. Koch wrote. Physicians demonstrated divergent levels of disease knowledge, support services, time constraints, and confidence in their ability to discuss the issue.

The survey highlights an important problem for primary care physicians, who are on the front lines of Alzheimer’s diagnosis and treatment, Ms. Batsch wrote. "There is an urgent need for better training of primary health care physicians, who are often involved in making a diagnosis of dementia and need appropriate training to do so effectively. Health care providers need to adopt specific dementia care philosophies that support independence and are centered on the person with dementia."

Important lessons can be drawn from the stigma attached to HIV/AIDS, which hamstrung research for years, perhaps unnecessarily setting back treatment progress, Dr. Baron Peter Piot wrote in the report. For decades, the global community failed to focus on the disease, dismissing it as a "gay plague," wrote Dr. Piot, director of the London School of Hygiene and Tropical Medicine, and a professor of global health.

"Much time and effort were spent trying to overcome bureaucracy and official denial – and stigma attached to AIDS victims. ... Although virologists rapidly elucidated the nature and workings of HIV, and developed anti-retrovirals, it required a massive international effort to slow the spread of HIV and make treatment available to those who most need it."

"Stigmatization leads to a socially sanctioned ignorance and unwillingness to engage with real issues. This is not only unjust, but often gets in the way of efforts to understand and tackle epidemics and other health issues."

Social stigma associated with dementia and Alzheimer’s disease places burdens on patients and their families that may interfere with early diagnosis and treatment, negatively affect social support and care at home or in a facility, and even undermine research efforts.

The World Alzheimer’s Report here found that 75% of people with dementia and 64% of caregivers believe that negative associations exist, and many have experienced at least one.

"One of our most basic key findings is that people with dementia wanted to be treated as human," Nicole Batsch, the report’s primary author, said in a teleconference announcing the report. "These people are not being treated with dignity and they sense that. They are marginalized, excluded from society, and not respected for the wisdom and experience they have accumulated over the years."

Alzheimer's Disease International, an umbrella group that supports Alzheimer’s associations around the world, commissioned the survey, which included responses from more than 2,500 people affected by the disease, including 2,068 to the English-speaking version of the survey. There were 127 responses to the English-speaking survey from Alzheimer’s patients.

"We think this is the largest, and maybe even the only, online survey with [patients] participating," Ms. Batsch, a doctoral candidate at King’s College, London, said during a teleconference. "Most of those who did take part are already connected with some kind of support program, so the results don’t necessarily reflect the experiences of those who are not. But we think those people may be more stigmatized."

The survey was available in 54 countries and was translated into four languages: English, Spanish, Chinese, and Greek. About half of the entire survey population had completed college or obtained a graduate degree, indicating that the cohort represented a "select group."

Most of the respondents (59%) said they had concealed the diagnosis from other people, citing a fear of social stigma as their reason for silence. A number had withheld the information because they feared losing their jobs, while others were concerned about being judged by their community and family. Half also said they had experienced such reactions after revealing the diagnosis, with 60% saying they had been treated differently because of it.

Both patients and caregivers described a number of reactions to the condition. A frequent complaint of patients was being ignored as others spoke to their companions instead of directly to them. A Spanish-speaking man said his family changed his given name to a diminutive form, revealing that they no longer thought of him as a competent adult.

Some Chinese respondents said that physicians seemed to give up on them or their loved one because "treatment is only a waste of money."

Many physicians do, in fact, engage in stigmatizing behavior, Ms. Batsch wrote.

"Physicians are reluctant to discuss cognitive symptoms with their patients because of the stigma associated with it and the sense that ‘nothing can be done.’ ... Moreover, stigmatic beliefs of primary care physicians and therapeutic nihilism lead them to avoid evaluating cognitive function until the illness is so apparent that it cannot be ignored."

Some have a more altruistic reason for avoiding the discussion, she said. "This attitude is shared by many health care professionals, who are reluctant [because they fear] to give their patients a stigmatizing label."

A 2010 literature review found a number of themes running through physicians’ problems with discussing dementia, she noted. Dr. Tamar Koch, a senior clinical researcher at University College, London, found 11 studies addressing the issue (BMC Fam. Pract. 2010;11:52).

"The main themes from the qualitative studies were found to be lack of support, time constraints, financial constraints, stigma, diagnostic uncertainty, and disclosing the diagnosis," Dr. Koch wrote. Physicians demonstrated divergent levels of disease knowledge, support services, time constraints, and confidence in their ability to discuss the issue.

The survey highlights an important problem for primary care physicians, who are on the front lines of Alzheimer’s diagnosis and treatment, Ms. Batsch wrote. "There is an urgent need for better training of primary health care physicians, who are often involved in making a diagnosis of dementia and need appropriate training to do so effectively. Health care providers need to adopt specific dementia care philosophies that support independence and are centered on the person with dementia."

Important lessons can be drawn from the stigma attached to HIV/AIDS, which hamstrung research for years, perhaps unnecessarily setting back treatment progress, Dr. Baron Peter Piot wrote in the report. For decades, the global community failed to focus on the disease, dismissing it as a "gay plague," wrote Dr. Piot, director of the London School of Hygiene and Tropical Medicine, and a professor of global health.

"Much time and effort were spent trying to overcome bureaucracy and official denial – and stigma attached to AIDS victims. ... Although virologists rapidly elucidated the nature and workings of HIV, and developed anti-retrovirals, it required a massive international effort to slow the spread of HIV and make treatment available to those who most need it."

"Stigmatization leads to a socially sanctioned ignorance and unwillingness to engage with real issues. This is not only unjust, but often gets in the way of efforts to understand and tackle epidemics and other health issues."

Social stigma associated with dementia and Alzheimer’s disease places burdens on patients and their families that may interfere with early diagnosis and treatment, negatively affect social support and care at home or in a facility, and even undermine research efforts.

The World Alzheimer’s Report here found that 75% of people with dementia and 64% of caregivers believe that negative associations exist, and many have experienced at least one.

"One of our most basic key findings is that people with dementia wanted to be treated as human," Nicole Batsch, the report’s primary author, said in a teleconference announcing the report. "These people are not being treated with dignity and they sense that. They are marginalized, excluded from society, and not respected for the wisdom and experience they have accumulated over the years."

Alzheimer's Disease International, an umbrella group that supports Alzheimer’s associations around the world, commissioned the survey, which included responses from more than 2,500 people affected by the disease, including 2,068 to the English-speaking version of the survey. There were 127 responses to the English-speaking survey from Alzheimer’s patients.

"We think this is the largest, and maybe even the only, online survey with [patients] participating," Ms. Batsch, a doctoral candidate at King’s College, London, said during a teleconference. "Most of those who did take part are already connected with some kind of support program, so the results don’t necessarily reflect the experiences of those who are not. But we think those people may be more stigmatized."

The survey was available in 54 countries and was translated into four languages: English, Spanish, Chinese, and Greek. About half of the entire survey population had completed college or obtained a graduate degree, indicating that the cohort represented a "select group."

Most of the respondents (59%) said they had concealed the diagnosis from other people, citing a fear of social stigma as their reason for silence. A number had withheld the information because they feared losing their jobs, while others were concerned about being judged by their community and family. Half also said they had experienced such reactions after revealing the diagnosis, with 60% saying they had been treated differently because of it.

Both patients and caregivers described a number of reactions to the condition. A frequent complaint of patients was being ignored as others spoke to their companions instead of directly to them. A Spanish-speaking man said his family changed his given name to a diminutive form, revealing that they no longer thought of him as a competent adult.

Some Chinese respondents said that physicians seemed to give up on them or their loved one because "treatment is only a waste of money."

Many physicians do, in fact, engage in stigmatizing behavior, Ms. Batsch wrote.

"Physicians are reluctant to discuss cognitive symptoms with their patients because of the stigma associated with it and the sense that ‘nothing can be done.’ ... Moreover, stigmatic beliefs of primary care physicians and therapeutic nihilism lead them to avoid evaluating cognitive function until the illness is so apparent that it cannot be ignored."

Some have a more altruistic reason for avoiding the discussion, she said. "This attitude is shared by many health care professionals, who are reluctant [because they fear] to give their patients a stigmatizing label."

A 2010 literature review found a number of themes running through physicians’ problems with discussing dementia, she noted. Dr. Tamar Koch, a senior clinical researcher at University College, London, found 11 studies addressing the issue (BMC Fam. Pract. 2010;11:52).

"The main themes from the qualitative studies were found to be lack of support, time constraints, financial constraints, stigma, diagnostic uncertainty, and disclosing the diagnosis," Dr. Koch wrote. Physicians demonstrated divergent levels of disease knowledge, support services, time constraints, and confidence in their ability to discuss the issue.

The survey highlights an important problem for primary care physicians, who are on the front lines of Alzheimer’s diagnosis and treatment, Ms. Batsch wrote. "There is an urgent need for better training of primary health care physicians, who are often involved in making a diagnosis of dementia and need appropriate training to do so effectively. Health care providers need to adopt specific dementia care philosophies that support independence and are centered on the person with dementia."

Important lessons can be drawn from the stigma attached to HIV/AIDS, which hamstrung research for years, perhaps unnecessarily setting back treatment progress, Dr. Baron Peter Piot wrote in the report. For decades, the global community failed to focus on the disease, dismissing it as a "gay plague," wrote Dr. Piot, director of the London School of Hygiene and Tropical Medicine, and a professor of global health.

"Much time and effort were spent trying to overcome bureaucracy and official denial – and stigma attached to AIDS victims. ... Although virologists rapidly elucidated the nature and workings of HIV, and developed anti-retrovirals, it required a massive international effort to slow the spread of HIV and make treatment available to those who most need it."

"Stigmatization leads to a socially sanctioned ignorance and unwillingness to engage with real issues. This is not only unjust, but often gets in the way of efforts to understand and tackle epidemics and other health issues."

The death toll associated with West Nile virus now stands at 118 – with more undoubtedly to come, federal health officials said Sept. 12.

"Deaths are likely to go up because they are a lagging indicator" of severe disease, Dr. Lyle Petersen said during a Centers for Disease Control and Prevention press briefing. "Someone with severe disease may die a week, a month, or even 6 months after becoming infected. Even if transmission stopped tomorrow – which it won’t – we would expect the death rate to continue to rise across the country."

Photo credit: CDC

Dallas County, Tex., and surrounding counties continue to bear the brunt of the disease, which has occurred in five other states as well (Michigan, Mississippi, Louisiana, Oklahoma, and South Dakota). In Texas alone, a total of 50 people have died during this outbreak, which includes 10 deaths since the Sept. 4 case update.

"The number of deaths in those counties reflects the high number of neuroinvasive disease" cases, Dr. Petersen said. "There have been a tremendous number of cases of severe disease in that area. We know that 8%-10% of people who develop neuroinvasive West Nile will eventually succumb to the infection."

The overall mortality is the highest reported through the second week of September in any West Nile outbreak since the disease first appeared here in 1999, said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

So far this summer, there have been 2,636 human cases, 1,405 of which (53%) have been the serious, neuroinvasive form.

The new numbers represent a significant increase since the last update, when there were 1,993 reported cases, 1,069 neuroinvasive cases, and 87 deaths – marking 2012 as the worst West Nile outbreak ever recorded in this country.

The season, however, may be nearing its close, Dr. Petersen said. "Based on historical data, we think we have turned the corner on this epidemic. West Nile outbreaks tend to peak in mid to late August and we are hopeful that the worst is behind us."

The 2012 epidemic "has raised a number of challenging questions," he said, adding that the CDC will release a full report sometime next spring. In addition to finalized numbers, Dr. Petersen said that the report will examine environmental factors that seem to have exacerbated the outbreak and examine the virus’s genetic proclivity for virulence.

The marked increase in the number of neuroinvasive cases this year has prompted concerns about a mutation that could be making West Nile more dangerous.

"We have no reason to think the virus has become" more virulent, but a genetic comparison with prior strains is the only way to allay that fear, he said.

The 2013 report also will look at how heat and rain may have interacted to promote a higher viral load in mosquitoes and more efficient transmission to birds, animals, and humans.

"Temperature and rainfall affect a lot of things related to outbreaks," including the number and lifespan of mosquitoes, the number of birds, the way those hosts interact, and even the rate of viral growth within the mosquito and the ease of transmission into humans and animals.

National Weather Service data are being analyzed to see if it’s possible to predict where and when an outbreak might occur, Dr. Petersen said. Such models have so far failed because of the complex interplay of environmental factors. "It may take years of observation to tease this entire thing out. I’m not too optimistic that we will ever be able to say, ‘This was the cause of this year’s outbreak.’ "

There will be no more public presentations on the outbreak, Dr. Petersen added, although the CDC will continue to update case counts every Wednesday through the end of October.

The death toll associated with West Nile virus now stands at 118 – with more undoubtedly to come, federal health officials said Sept. 12.

"Deaths are likely to go up because they are a lagging indicator" of severe disease, Dr. Lyle Petersen said during a Centers for Disease Control and Prevention press briefing. "Someone with severe disease may die a week, a month, or even 6 months after becoming infected. Even if transmission stopped tomorrow – which it won’t – we would expect the death rate to continue to rise across the country."

Photo credit: CDC

Dallas County, Tex., and surrounding counties continue to bear the brunt of the disease, which has occurred in five other states as well (Michigan, Mississippi, Louisiana, Oklahoma, and South Dakota). In Texas alone, a total of 50 people have died during this outbreak, which includes 10 deaths since the Sept. 4 case update.

"The number of deaths in those counties reflects the high number of neuroinvasive disease" cases, Dr. Petersen said. "There have been a tremendous number of cases of severe disease in that area. We know that 8%-10% of people who develop neuroinvasive West Nile will eventually succumb to the infection."

The overall mortality is the highest reported through the second week of September in any West Nile outbreak since the disease first appeared here in 1999, said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

So far this summer, there have been 2,636 human cases, 1,405 of which (53%) have been the serious, neuroinvasive form.

The new numbers represent a significant increase since the last update, when there were 1,993 reported cases, 1,069 neuroinvasive cases, and 87 deaths – marking 2012 as the worst West Nile outbreak ever recorded in this country.

The season, however, may be nearing its close, Dr. Petersen said. "Based on historical data, we think we have turned the corner on this epidemic. West Nile outbreaks tend to peak in mid to late August and we are hopeful that the worst is behind us."

The 2012 epidemic "has raised a number of challenging questions," he said, adding that the CDC will release a full report sometime next spring. In addition to finalized numbers, Dr. Petersen said that the report will examine environmental factors that seem to have exacerbated the outbreak and examine the virus’s genetic proclivity for virulence.

The marked increase in the number of neuroinvasive cases this year has prompted concerns about a mutation that could be making West Nile more dangerous.

"We have no reason to think the virus has become" more virulent, but a genetic comparison with prior strains is the only way to allay that fear, he said.

The 2013 report also will look at how heat and rain may have interacted to promote a higher viral load in mosquitoes and more efficient transmission to birds, animals, and humans.

"Temperature and rainfall affect a lot of things related to outbreaks," including the number and lifespan of mosquitoes, the number of birds, the way those hosts interact, and even the rate of viral growth within the mosquito and the ease of transmission into humans and animals.

National Weather Service data are being analyzed to see if it’s possible to predict where and when an outbreak might occur, Dr. Petersen said. Such models have so far failed because of the complex interplay of environmental factors. "It may take years of observation to tease this entire thing out. I’m not too optimistic that we will ever be able to say, ‘This was the cause of this year’s outbreak.’ "

There will be no more public presentations on the outbreak, Dr. Petersen added, although the CDC will continue to update case counts every Wednesday through the end of October.

The death toll associated with West Nile virus now stands at 118 – with more undoubtedly to come, federal health officials said Sept. 12.

"Deaths are likely to go up because they are a lagging indicator" of severe disease, Dr. Lyle Petersen said during a Centers for Disease Control and Prevention press briefing. "Someone with severe disease may die a week, a month, or even 6 months after becoming infected. Even if transmission stopped tomorrow – which it won’t – we would expect the death rate to continue to rise across the country."

Photo credit: CDC

Dallas County, Tex., and surrounding counties continue to bear the brunt of the disease, which has occurred in five other states as well (Michigan, Mississippi, Louisiana, Oklahoma, and South Dakota). In Texas alone, a total of 50 people have died during this outbreak, which includes 10 deaths since the Sept. 4 case update.

"The number of deaths in those counties reflects the high number of neuroinvasive disease" cases, Dr. Petersen said. "There have been a tremendous number of cases of severe disease in that area. We know that 8%-10% of people who develop neuroinvasive West Nile will eventually succumb to the infection."

The overall mortality is the highest reported through the second week of September in any West Nile outbreak since the disease first appeared here in 1999, said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

So far this summer, there have been 2,636 human cases, 1,405 of which (53%) have been the serious, neuroinvasive form.

The new numbers represent a significant increase since the last update, when there were 1,993 reported cases, 1,069 neuroinvasive cases, and 87 deaths – marking 2012 as the worst West Nile outbreak ever recorded in this country.

The season, however, may be nearing its close, Dr. Petersen said. "Based on historical data, we think we have turned the corner on this epidemic. West Nile outbreaks tend to peak in mid to late August and we are hopeful that the worst is behind us."

The 2012 epidemic "has raised a number of challenging questions," he said, adding that the CDC will release a full report sometime next spring. In addition to finalized numbers, Dr. Petersen said that the report will examine environmental factors that seem to have exacerbated the outbreak and examine the virus’s genetic proclivity for virulence.

The marked increase in the number of neuroinvasive cases this year has prompted concerns about a mutation that could be making West Nile more dangerous.

"We have no reason to think the virus has become" more virulent, but a genetic comparison with prior strains is the only way to allay that fear, he said.

The 2013 report also will look at how heat and rain may have interacted to promote a higher viral load in mosquitoes and more efficient transmission to birds, animals, and humans.

"Temperature and rainfall affect a lot of things related to outbreaks," including the number and lifespan of mosquitoes, the number of birds, the way those hosts interact, and even the rate of viral growth within the mosquito and the ease of transmission into humans and animals.

National Weather Service data are being analyzed to see if it’s possible to predict where and when an outbreak might occur, Dr. Petersen said. Such models have so far failed because of the complex interplay of environmental factors. "It may take years of observation to tease this entire thing out. I’m not too optimistic that we will ever be able to say, ‘This was the cause of this year’s outbreak.’ "

There will be no more public presentations on the outbreak, Dr. Petersen added, although the CDC will continue to update case counts every Wednesday through the end of October.

The reoperation rate for hernia repair probably underestimates the rate of recurrence by four to five times, according to results from a large Danish study.

In the cohort study of almost 1,000 hernia patients, 165 had a recurrence, but only 46 underwent a second repair, Dr. Frederik Helgstrand and his colleagues reported in the August issue of Annals of Surgery.

Recurrences were more common among patients who had an incisional repair than in those who had an umbilical or epigastric repair, wrote Dr. Helgstrand of the University of Copenhagen and his coauthors. Because the Danish hernia repair recommendations are different from other countries’, the investigators suggested that their observations could even further underestimate recurrence in some regions.

"Our results are based on a general Danish population, where the recommendation is to repair primary small (less than 2 cm) umbilical hernias with nonabsorbable sutures using open technique and to repair recurrences and all incisional hernias with a mesh, either laparoscopically or by open technique. The gap between reoperation and clinical recurrence might be different in other cultures and even wider in more narrowly defined populations with comorbidity such as obesity" (Ann. Surg. 2012 August [doi: 10.1097/SLA.0b013e318254f5b9]).

The study group comprised 902 patients who had hernia repair in 2007; they were all recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry. In 2010, they all received a questionnaire inquiring about recurrence. Another hernia operation was considered a definite recurrence. Patients who suspected that their hernia recurred or were told by a physician that it had, came in for a clinical evaluation.

The patients’ mean ages were 51 years in the laparoscopic group and 61 years in the incisional group; the median postoperative follow-up was 41 months. There were 646 laparoscopic repairs and 256 incisional repairs. Overall, there were 119 clinical recurrences.

In the laparoscopic group, there were 87 recurrences (13%); of these, 27 were reoperations and 60 were clinically diagnosed. In the incisional group, there were 78 recurrences (30%); of these, 19 were reoperations and 59 were clinically diagnosed.

"Consequently," the authors wrote, "the overall recurrences after [laparoscopic] and incisional hernia repair exceeded the reoperations for recurrence by factors of four and five, respectively."

Most patients who did not have a reoperation said they had only minor symptoms or that the recurrence was asymptomatic (85% of the laparoscopic group and 58% of the incisional group). A number said their surgeon or general physician had recommended against another repair (10% of the laparoscopic group and 34% of the incisional group).

None of the authors had any financial disclosures.

The reoperation rate for hernia repair probably underestimates the rate of recurrence by four to five times, according to results from a large Danish study.

In the cohort study of almost 1,000 hernia patients, 165 had a recurrence, but only 46 underwent a second repair, Dr. Frederik Helgstrand and his colleagues reported in the August issue of Annals of Surgery.

Recurrences were more common among patients who had an incisional repair than in those who had an umbilical or epigastric repair, wrote Dr. Helgstrand of the University of Copenhagen and his coauthors. Because the Danish hernia repair recommendations are different from other countries’, the investigators suggested that their observations could even further underestimate recurrence in some regions.

"Our results are based on a general Danish population, where the recommendation is to repair primary small (less than 2 cm) umbilical hernias with nonabsorbable sutures using open technique and to repair recurrences and all incisional hernias with a mesh, either laparoscopically or by open technique. The gap between reoperation and clinical recurrence might be different in other cultures and even wider in more narrowly defined populations with comorbidity such as obesity" (Ann. Surg. 2012 August [doi: 10.1097/SLA.0b013e318254f5b9]).

The study group comprised 902 patients who had hernia repair in 2007; they were all recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry. In 2010, they all received a questionnaire inquiring about recurrence. Another hernia operation was considered a definite recurrence. Patients who suspected that their hernia recurred or were told by a physician that it had, came in for a clinical evaluation.

The patients’ mean ages were 51 years in the laparoscopic group and 61 years in the incisional group; the median postoperative follow-up was 41 months. There were 646 laparoscopic repairs and 256 incisional repairs. Overall, there were 119 clinical recurrences.

In the laparoscopic group, there were 87 recurrences (13%); of these, 27 were reoperations and 60 were clinically diagnosed. In the incisional group, there were 78 recurrences (30%); of these, 19 were reoperations and 59 were clinically diagnosed.

"Consequently," the authors wrote, "the overall recurrences after [laparoscopic] and incisional hernia repair exceeded the reoperations for recurrence by factors of four and five, respectively."

Most patients who did not have a reoperation said they had only minor symptoms or that the recurrence was asymptomatic (85% of the laparoscopic group and 58% of the incisional group). A number said their surgeon or general physician had recommended against another repair (10% of the laparoscopic group and 34% of the incisional group).

None of the authors had any financial disclosures.

The reoperation rate for hernia repair probably underestimates the rate of recurrence by four to five times, according to results from a large Danish study.

In the cohort study of almost 1,000 hernia patients, 165 had a recurrence, but only 46 underwent a second repair, Dr. Frederik Helgstrand and his colleagues reported in the August issue of Annals of Surgery.

Recurrences were more common among patients who had an incisional repair than in those who had an umbilical or epigastric repair, wrote Dr. Helgstrand of the University of Copenhagen and his coauthors. Because the Danish hernia repair recommendations are different from other countries’, the investigators suggested that their observations could even further underestimate recurrence in some regions.

"Our results are based on a general Danish population, where the recommendation is to repair primary small (less than 2 cm) umbilical hernias with nonabsorbable sutures using open technique and to repair recurrences and all incisional hernias with a mesh, either laparoscopically or by open technique. The gap between reoperation and clinical recurrence might be different in other cultures and even wider in more narrowly defined populations with comorbidity such as obesity" (Ann. Surg. 2012 August [doi: 10.1097/SLA.0b013e318254f5b9]).

The study group comprised 902 patients who had hernia repair in 2007; they were all recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry. In 2010, they all received a questionnaire inquiring about recurrence. Another hernia operation was considered a definite recurrence. Patients who suspected that their hernia recurred or were told by a physician that it had, came in for a clinical evaluation.

The patients’ mean ages were 51 years in the laparoscopic group and 61 years in the incisional group; the median postoperative follow-up was 41 months. There were 646 laparoscopic repairs and 256 incisional repairs. Overall, there were 119 clinical recurrences.

In the laparoscopic group, there were 87 recurrences (13%); of these, 27 were reoperations and 60 were clinically diagnosed. In the incisional group, there were 78 recurrences (30%); of these, 19 were reoperations and 59 were clinically diagnosed.

"Consequently," the authors wrote, "the overall recurrences after [laparoscopic] and incisional hernia repair exceeded the reoperations for recurrence by factors of four and five, respectively."

Most patients who did not have a reoperation said they had only minor symptoms or that the recurrence was asymptomatic (85% of the laparoscopic group and 58% of the incisional group). A number said their surgeon or general physician had recommended against another repair (10% of the laparoscopic group and 34% of the incisional group).

None of the authors had any financial disclosures.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

A total of 87 people have now died from West Nile disease – an additional 22 fatalities since the last national update on Aug. 28.

The overall number of infections also continues to increase, with 403 new cases reported as of Sept. 4. The total case count now stands at 1,993, Dr. Lyle Petersen reported during a Centers for Disease Control and Prevention press briefing.

Of these, 1,069 (54%) have been classified as neuroinvasive disease and 924 (46%) as nonneuroinvasive disease said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

(c) Cynthia Goldsmith/CDC

Only two states – Alaska and Hawaii – have not reported the virus, Dr. Petersen said. Every other state has reported infections in mosquitoes, birds, or people.

"The cases reported thus far in 2012 are the highest number of West Nile virus disease cases ever reported to CDC through the first week in September, since the disease was first detected in the U.S. since 1999," he said. More than 70% of the cases are in six states (Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan), with nearly half in Texas alone.

The disease continues to ravage that state, according to Dr. David Lakey, commissioner of the Texas Department of State Health Services. Since Aug. 28, Texas has reported an additional 230 cases, bringing that state’s total to 1,013. There also were 69 more cases of neuroinvasive disease, for a total of 485.

Nine more people died in Texas, he added during the briefing. The total death count in Texas now stands at 40. It’s the worst outbreak of West Nile since 2003, when 40 people died from the disease during the entire event.

"When we look at data, a quarter of the deaths were reported in last week alone. Unfortunately that count will continue to go up. There will be more cases of neuroinvasive disease and more deaths."

Some relief may be in sight, he said. "There are some indicators that the disease in the northern part of the state may have peaked."

Aerial spraying in some areas decreased the numbers of mosquitoes significantly Dr. Lakey said. In northern Texas, recent mosquito pool sampling showed that just 6% of the insects carried the virus – a significant decrease from the 93% infection rate in the last pool samplings.

"In other parts of the state, however, a large number of pools are still infected," he said, including a 28% rate in the area of Austin and Travis County.

A total of 87 people have now died from West Nile disease – an additional 22 fatalities since the last national update on Aug. 28.

The overall number of infections also continues to increase, with 403 new cases reported as of Sept. 4. The total case count now stands at 1,993, Dr. Lyle Petersen reported during a Centers for Disease Control and Prevention press briefing.

Of these, 1,069 (54%) have been classified as neuroinvasive disease and 924 (46%) as nonneuroinvasive disease said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

(c) Cynthia Goldsmith/CDC

Only two states – Alaska and Hawaii – have not reported the virus, Dr. Petersen said. Every other state has reported infections in mosquitoes, birds, or people.

"The cases reported thus far in 2012 are the highest number of West Nile virus disease cases ever reported to CDC through the first week in September, since the disease was first detected in the U.S. since 1999," he said. More than 70% of the cases are in six states (Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan), with nearly half in Texas alone.

The disease continues to ravage that state, according to Dr. David Lakey, commissioner of the Texas Department of State Health Services. Since Aug. 28, Texas has reported an additional 230 cases, bringing that state’s total to 1,013. There also were 69 more cases of neuroinvasive disease, for a total of 485.

Nine more people died in Texas, he added during the briefing. The total death count in Texas now stands at 40. It’s the worst outbreak of West Nile since 2003, when 40 people died from the disease during the entire event.

"When we look at data, a quarter of the deaths were reported in last week alone. Unfortunately that count will continue to go up. There will be more cases of neuroinvasive disease and more deaths."

Some relief may be in sight, he said. "There are some indicators that the disease in the northern part of the state may have peaked."

Aerial spraying in some areas decreased the numbers of mosquitoes significantly Dr. Lakey said. In northern Texas, recent mosquito pool sampling showed that just 6% of the insects carried the virus – a significant decrease from the 93% infection rate in the last pool samplings.

"In other parts of the state, however, a large number of pools are still infected," he said, including a 28% rate in the area of Austin and Travis County.

A total of 87 people have now died from West Nile disease – an additional 22 fatalities since the last national update on Aug. 28.

The overall number of infections also continues to increase, with 403 new cases reported as of Sept. 4. The total case count now stands at 1,993, Dr. Lyle Petersen reported during a Centers for Disease Control and Prevention press briefing.

Of these, 1,069 (54%) have been classified as neuroinvasive disease and 924 (46%) as nonneuroinvasive disease said Dr. Petersen, director of CDC’s Division of Vector-Borne Infectious Disease.

(c) Cynthia Goldsmith/CDC

Only two states – Alaska and Hawaii – have not reported the virus, Dr. Petersen said. Every other state has reported infections in mosquitoes, birds, or people.

"The cases reported thus far in 2012 are the highest number of West Nile virus disease cases ever reported to CDC through the first week in September, since the disease was first detected in the U.S. since 1999," he said. More than 70% of the cases are in six states (Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan), with nearly half in Texas alone.

The disease continues to ravage that state, according to Dr. David Lakey, commissioner of the Texas Department of State Health Services. Since Aug. 28, Texas has reported an additional 230 cases, bringing that state’s total to 1,013. There also were 69 more cases of neuroinvasive disease, for a total of 485.

Nine more people died in Texas, he added during the briefing. The total death count in Texas now stands at 40. It’s the worst outbreak of West Nile since 2003, when 40 people died from the disease during the entire event.

"When we look at data, a quarter of the deaths were reported in last week alone. Unfortunately that count will continue to go up. There will be more cases of neuroinvasive disease and more deaths."

Some relief may be in sight, he said. "There are some indicators that the disease in the northern part of the state may have peaked."

Aerial spraying in some areas decreased the numbers of mosquitoes significantly Dr. Lakey said. In northern Texas, recent mosquito pool sampling showed that just 6% of the insects carried the virus – a significant decrease from the 93% infection rate in the last pool samplings.

"In other parts of the state, however, a large number of pools are still infected," he said, including a 28% rate in the area of Austin and Travis County.

Long-term use of inhaled budesonide is associated not only with slowed growth in prepubertal children, but with reduced final adult height as well.

An 8-year observational study found that children who had used budesonide during an asthma treatment trial were more than 1 cm shorter than those who used nedocromil or placebo. The findings suggest that glucocorticoid-related growth impairment has a lasting effect on potential adult height, H. William Kelly, Pharm.D., and his colleagues wrote in the Sept. 3 issue of the New England Journal of Medicine (2012;367:904-12 [doi: 10.1056/NEJMoa1203229]).

The prospective study followed 943 children who had participated in the Childhood Asthma Management Program (CAMP) trial. CAMP randomized children with asthma aged 5-13 years to placebo, 400 mcg/day budesonide, or 16 mg/day nedocromil.

Comstock/thinkstockphotos.com

Initial follow-up averaged 4.3 years, with height measured once or twice a year for the subsequent 8 years. Final height was measured at a mean age of 25 years.

The mean adult height in the budesonide group was 171.1 cm – significantly shorter than the 172.3 cm in the placebo group. Mean adult height in the nedocromil group was almost the same as in the placebo group (172.1 cm).

Women in the budesonide group were particularly affected; they were a mean of 1.8 cm shorter than women in the placebo group. Men who took budesonide were a mean of 0.8 cm shorter than men who took placebo as children.

During the first 2 years of the CAMP trial, growth had already slowed, showing a 1.3-cm difference between the budesonide and placebo groups. At the end of that trial, the difference was 1.2 cm, a deficit that did not change as the patients entered young adulthood.

Final height was related to daily dosage during the randomized trial, with a decrement of 0.1 cm for each microgram per kilogram of budesonide. Several baseline characteristics were also significantly related to lower adult height, including Hispanic ethnicity and being female, or having a higher Tanner stage, greater body mass index, longer duration of asthma, and low vitamin D levels.

Since the CAMP trial concluded, research has shown that 200 mcg/day budesonide in a dry-powder inhaler is sufficient to control mild to moderate asthma and prevent exacerbations in children. "Even at this lower dose, there was a reported mean reduction of 1.0 cm in height during the first 2 years of therapy," the investigators noted. "Although the systemic effects of inhaled glucocorticoids are dose dependent, they are also dependent on the therapeutic index of the specific inhaled glucocorticoid and the delivery device used. Thus, it seems prudent to select inhaled glucocorticoids and devices with higher therapeutic indexes, and to use them in the lowest effective doses in children with persistent asthma."

Ultimately, they concluded, parents and physicians must work together to decide the risk-benefit ratio that is most appropriate and acceptable for each individual patient.

"In the information about inhaled glucocorticoids and their side effects that is provided to parents, the potential effect on adult height must be balanced against the large and well-established benefits of these drugs in controlling persistent asthma," concluded Dr. Kelly of the University of New Mexico, Albuquerque, and his coauthors.

The CAMP trial and its observational study were funded by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Kelly serves on steering committees for and has received consulting fees from AstraZeneca, GlaxoSmithKline, and other companies. His coauthors also reported multiple financial relationships with pharmaceutical companies.

Long-term use of inhaled budesonide is associated not only with slowed growth in prepubertal children, but with reduced final adult height as well.

An 8-year observational study found that children who had used budesonide during an asthma treatment trial were more than 1 cm shorter than those who used nedocromil or placebo. The findings suggest that glucocorticoid-related growth impairment has a lasting effect on potential adult height, H. William Kelly, Pharm.D., and his colleagues wrote in the Sept. 3 issue of the New England Journal of Medicine (2012;367:904-12 [doi: 10.1056/NEJMoa1203229]).

The prospective study followed 943 children who had participated in the Childhood Asthma Management Program (CAMP) trial. CAMP randomized children with asthma aged 5-13 years to placebo, 400 mcg/day budesonide, or 16 mg/day nedocromil.

Comstock/thinkstockphotos.com

Initial follow-up averaged 4.3 years, with height measured once or twice a year for the subsequent 8 years. Final height was measured at a mean age of 25 years.

The mean adult height in the budesonide group was 171.1 cm – significantly shorter than the 172.3 cm in the placebo group. Mean adult height in the nedocromil group was almost the same as in the placebo group (172.1 cm).

Women in the budesonide group were particularly affected; they were a mean of 1.8 cm shorter than women in the placebo group. Men who took budesonide were a mean of 0.8 cm shorter than men who took placebo as children.

During the first 2 years of the CAMP trial, growth had already slowed, showing a 1.3-cm difference between the budesonide and placebo groups. At the end of that trial, the difference was 1.2 cm, a deficit that did not change as the patients entered young adulthood.

Final height was related to daily dosage during the randomized trial, with a decrement of 0.1 cm for each microgram per kilogram of budesonide. Several baseline characteristics were also significantly related to lower adult height, including Hispanic ethnicity and being female, or having a higher Tanner stage, greater body mass index, longer duration of asthma, and low vitamin D levels.

Since the CAMP trial concluded, research has shown that 200 mcg/day budesonide in a dry-powder inhaler is sufficient to control mild to moderate asthma and prevent exacerbations in children. "Even at this lower dose, there was a reported mean reduction of 1.0 cm in height during the first 2 years of therapy," the investigators noted. "Although the systemic effects of inhaled glucocorticoids are dose dependent, they are also dependent on the therapeutic index of the specific inhaled glucocorticoid and the delivery device used. Thus, it seems prudent to select inhaled glucocorticoids and devices with higher therapeutic indexes, and to use them in the lowest effective doses in children with persistent asthma."

Ultimately, they concluded, parents and physicians must work together to decide the risk-benefit ratio that is most appropriate and acceptable for each individual patient.

"In the information about inhaled glucocorticoids and their side effects that is provided to parents, the potential effect on adult height must be balanced against the large and well-established benefits of these drugs in controlling persistent asthma," concluded Dr. Kelly of the University of New Mexico, Albuquerque, and his coauthors.

The CAMP trial and its observational study were funded by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Kelly serves on steering committees for and has received consulting fees from AstraZeneca, GlaxoSmithKline, and other companies. His coauthors also reported multiple financial relationships with pharmaceutical companies.

Long-term use of inhaled budesonide is associated not only with slowed growth in prepubertal children, but with reduced final adult height as well.

An 8-year observational study found that children who had used budesonide during an asthma treatment trial were more than 1 cm shorter than those who used nedocromil or placebo. The findings suggest that glucocorticoid-related growth impairment has a lasting effect on potential adult height, H. William Kelly, Pharm.D., and his colleagues wrote in the Sept. 3 issue of the New England Journal of Medicine (2012;367:904-12 [doi: 10.1056/NEJMoa1203229]).

The prospective study followed 943 children who had participated in the Childhood Asthma Management Program (CAMP) trial. CAMP randomized children with asthma aged 5-13 years to placebo, 400 mcg/day budesonide, or 16 mg/day nedocromil.

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Initial follow-up averaged 4.3 years, with height measured once or twice a year for the subsequent 8 years. Final height was measured at a mean age of 25 years.

The mean adult height in the budesonide group was 171.1 cm – significantly shorter than the 172.3 cm in the placebo group. Mean adult height in the nedocromil group was almost the same as in the placebo group (172.1 cm).

Women in the budesonide group were particularly affected; they were a mean of 1.8 cm shorter than women in the placebo group. Men who took budesonide were a mean of 0.8 cm shorter than men who took placebo as children.

During the first 2 years of the CAMP trial, growth had already slowed, showing a 1.3-cm difference between the budesonide and placebo groups. At the end of that trial, the difference was 1.2 cm, a deficit that did not change as the patients entered young adulthood.

Final height was related to daily dosage during the randomized trial, with a decrement of 0.1 cm for each microgram per kilogram of budesonide. Several baseline characteristics were also significantly related to lower adult height, including Hispanic ethnicity and being female, or having a higher Tanner stage, greater body mass index, longer duration of asthma, and low vitamin D levels.

Since the CAMP trial concluded, research has shown that 200 mcg/day budesonide in a dry-powder inhaler is sufficient to control mild to moderate asthma and prevent exacerbations in children. "Even at this lower dose, there was a reported mean reduction of 1.0 cm in height during the first 2 years of therapy," the investigators noted. "Although the systemic effects of inhaled glucocorticoids are dose dependent, they are also dependent on the therapeutic index of the specific inhaled glucocorticoid and the delivery device used. Thus, it seems prudent to select inhaled glucocorticoids and devices with higher therapeutic indexes, and to use them in the lowest effective doses in children with persistent asthma."

Ultimately, they concluded, parents and physicians must work together to decide the risk-benefit ratio that is most appropriate and acceptable for each individual patient.

"In the information about inhaled glucocorticoids and their side effects that is provided to parents, the potential effect on adult height must be balanced against the large and well-established benefits of these drugs in controlling persistent asthma," concluded Dr. Kelly of the University of New Mexico, Albuquerque, and his coauthors.

The CAMP trial and its observational study were funded by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr. Kelly serves on steering committees for and has received consulting fees from AstraZeneca, GlaxoSmithKline, and other companies. His coauthors also reported multiple financial relationships with pharmaceutical companies.