Monday, June 30, 2008

Alzheimer's Drug Shows Early Promise

By Amanda Gardner
30 june 2008---- Long-anticipated results from a trial on an experimental Alzheimer's therapy look promising, at least in a certain group of patients.
Findings that are slated to be presented Sunday at the International Conference on Alzheimer's Disease in Chicago suggest that while the drug, bapineuzumab, showed only a modest trend towards a benefit in patients with the ApoE4 gene, there were more notable improvements in the degree of cognitive decline in individuals lacking the gene.
Patients who lack the ApoE4 gene have a predisposition to developing Alzheimer's, especially earlier in life.
"This is the first study of adequate size and duration that suggests the immunotherapy beta-amyloid model works," said Dr. Anton Porsteinsson, an associate professor of psychiatry at the University of Rochester School of Medicine who was one of the investigators for the study. "Immunotherapy is a huge front in the development of treatments."
Many experts are hoping the results will usher in a new era in Alzheimer's treatment and research. "If it had failed, it would have significant reverberations," Porsteinsson. "It allows this and multiple other studies to move forward. It's a big relief, but it also turns into considerable excitement."
"The recently announced bapineuzumab results were encouraging enough to keep moving forward, but yet not definitive enough to be certain of any effect," added Dr. Sam Gandy, chairman of the Alzheimer's Association National Medical and Scientific Advisory Council and an Alzheimer's expert with Mount Sinai in New York City. " The best care for any Alzheimer's patient is in the setting of a clinical trial, if possible, with bapineuzumab or any of a number of agents. Our most promising drugs are in trials and not yet approved."
Gandy serves as a safety monitor on another Wyeth/Elan vaccine trial. Wyeth and Elan also sponsored the current trial.
Immunotherapy, an emerging frontier for a variety of different diseases, involves stimulating the body's own immune system to fight various conditions, including cancer.
Porsteinsson estimated that some one-half to two-thirds of the research push in Alzheimer's is aimed at amyloid therapy and especially immunotherapy.
Bapineuzumab is a humanized monoclonal antibody which binds to and might be able to eliminate beta amyloid peptide, which accumulate as plaques in the brains of people with Alzheimer's. The drug delivers antibodies to beta amyloid.
Most experts in the field of Alzheimer's believe that the build-up of beta-amyloid proteins in the brain are responsible for the disease.
But clinical gains in the area of Alzheimer's, not to mention advancement in a basic understanding of the disease, have been hard to come by.
This phase 2 trial involved both men and women with mild to moderate Alzheimer's at more than 30 sites in the United States, Finland and the United Kingdom. All participants received bapineuzumab.
Researchers noted statistically significant improvements in patients without the ApoE4 gene. The therapy did not appear to have a statistically significant benefit in patients with the gene, although there was some benefit.
A large, phase 3 study is currently underway, although even if all goes well, the drug could take almost four years to reach the market, Porsteinsson said.
Obesity may interfere with prostate cancer screen

30 june 2008--The test commonly used to screen men for prostate cancer may be more likely to miss tumors in obese men, a new study suggests.
In a study of 535 men in a free prostate cancer screening program, researchers found that obese men were more likely to have relatively low levels of prostate specific antigen (PSA), even when their prostate findings were abnormal.
PSA levels in the blood typically rise when a man has prostate cancer, so PSA testing is often used to screen for the disease. Men with a high PSA level can then have further testing to get a definitive diagnosis.
The new findings, published in the journal Urology, suggest that because obese men's PSA levels tend to be relatively low in general, some cancers may be missed or not detected promptly.
The generally lower PSA values in heavy men may be the result of a "dilution" effect, according to Dr. Stephen J. Freedland, of Duke University School of Medicine in Durham, North Carolina.
"Obese men have lower PSA values likely due to excess blood volume," Freedland, the senior investigator on the study, told Reuters Health.
"Thus, when interpreting a PSA value in an obese man," Freedland said, "we should adjust the value we call 'abnormal' downwards to reflect this diluted PSA measurement. If we do not, we may be missing cancers in obese men."
Of the men in his team's study, 73 percent were overweight or obese. Compared with their normal-weight counterparts, overweight men had 5 percent lower PSA value, on average. For mildly obese men the difference was 14 percent, and in moderately and severely obese men, the values were 29 percent lower.
"The current data," the researchers conclude, "suggest that the PSA cut-points used to recommend biopsy need to be adjusted for the degree of obesity."
SOURCE: Urology, May 2008.
Accidental fungus leads to promising cancer drug

By Maggie Fox
30 june 2008--A drug developed using nanotechnology and a fungus that contaminated a lab experiment may be broadly effective against a range of cancers, U.S. researchers reported on Sunday.
The drug, called lodamin, was improved in one of the last experiments overseen by Dr. Judah Folkman, a cancer researcher who died in January. Folkman pioneered the idea of angiogenesis therapy -- starving tumors by preventing them from growing blood supplies.
Lodamin is an angiogenesis inhibitor that Folkman's team has been working to perfect for 20 years. Writing in the journal Nature Biotechnology, his colleagues say they developed a formulation that works as a pill, without side-effects.
They have licensed it to SynDevRx, Inc, a privately held Cambridge, Massachusetts biotechnology company that has recruited several prominent cancer experts to its board.
Tests in mice showed it worked against a range of tumors, including breast cancer, neuroblastoma, ovarian cancer, prostate cancer, brain tumors known as glioblastomas and uterine tumors.
It helped stop so-called primary tumors and also prevented their spread, Ofra Benny of Children's Hospital Boston and Harvard Medical School and colleagues reported.
"Using the oral route of administration, it first reaches the liver, making it especially efficient in preventing the development of liver metastasis in mice," they wrote in their report. "Liver metastasis is very common in many tumor types and is often associated with a poor prognosis and survival rate," they added.
"When I looked at the livers of the mice, the treated group was almost clean," Benny said in a statement. "In the control group you couldn't recognize the livers -- they were a mass of tumors."
The drug was known experimentally as TNP-470, and was originally isolated from a fungus called Aspergillus fumigatus fresenius.
Harvards's Donald Ingber discovered the fungus by accident while trying to grow endothelial cells -- the cells that line blood vessels. The mold affected the cells in a way known to prevent the growth of tiny blood vessels known as capillaries.
Ingber and Folkman developed TNP-470 with the help of Takeda Chemical Industries in Japan in 1990.
But the drug affected the brain, causing depression, dizziness and other side-effects. It also did not stay in the body long and required constant infusions. The lab dropped it.
Efforts to improve it did not work well. Then Benny and colleagues tried nanotechnology, attaching two "pom-pom"-shaped polymers to TNP-470, protecting it from stomach acid.
In mice, the altered drug, now named lodamin, went straight to tumor cells and helped suppress melanoma and lung cancer, with no apparent side effects, Benny said.
All untreated mice had fluid in the abdominal cavity, and enlarged livers covered with tumors. Mice treated with lodamin had normal-looking livers and spleens, the researchers said.
Twenty days after being injected with cancer cells, four out of seven untreated mice had died, while all treated mice were still alive, Benny's team reported.
"I had never expected such a strong effect on these aggressive tumor models," she said. The researchers believe lodamin may also be useful in other diseases marked by abnormal blood vessel growth, such as age-related macular degeneration.
Stress Test

30 june 2008--For weeks before a store down the street from where I live in Berkeley opened, it was unclear what it would sell — materially, anyway. Rather than having a sign describing the merchandise, the windows were papered over with foot-high aphorisms in punchy red and white type. “Friends are more important than money.” “Jealousy works the opposite way you want it to.” True enough, I suppose. But the one that caught my attention was this: “Stress is related to 99 percent of all illness.”
I tried to imagine how that claim made it past the copywriters and project managers who must have approved it. It was hardly as benign as the suggestions that people should floss daily or drink lots of water. Or was it? Somewhere along the line, maybe when yoga studios began to outnumber Starbucks outlets, the notion, at once modern and primitive, of the mind’s irrefutable power over the flesh became the conventional wisdom.
It’s not that I think the mind-body connection is a total sham. But even where it would seem most established, say in the relationship between stress and heart disease, the mechanism is unclear. Is stress an independent risk factor or does it merely influence others, raising blood pressure or encouraging over-eating? Either way, popular mythology both simplifies and generalizes the potential harm, applying it to everything that ails us. After all, it feels true: I’m more at peace with my frenetic life after a few rounds of sun salutations. Yet, what does that prove?
Admittedly, I’m a tad touchy about this. Eleven years (and, as of this writing, 6 months, 2 days, 19 hours and 30 minutes) ago I found out I had breast cancer. I later endured years of multiple miscarriages and failed infertility treatments before conceiving a child. So I’ve fielded my share of intimations that stress, or some other self-inflicted wrong thinking, could be the source of my troubles: I should relax, take a vacation, express my anger. I do my best. In a nod to that latter advice, I yelled at the screen during “Sex and the City” when Charlotte, who has an adopted Chinese daughter, becomes unexpectedly pregnant and explains: “People always say that when you stop trying it can happen. My doctor says that she knows other couples who’ve adopted, and then they get pregnant.”
The idea that easing up on the pressure kick-starts women’s fertility intuitively seems sound. Everyone knows someone (or someone who knows someone) who gave birth after adopting. From the 1930s through 1950s, according to “The Empty Cradle,” a history of infertility, medical literature actually promoted adoption as a “cure,” claiming it resulted in pregnancy “more often than not.” Freudians, too, counseled that infertility was psychological, the result of maternal ambivalence; resolve those feeling through adoption, and fecundity would follow.
Except — leaving aside the insinuations that adoption is a means to an end rather than its own joyous experience, and that women who become easily pregnant are never ambivalent — it’s not true. As early as 1949, a study of adoptive parents co-written by the infertility pioneer John Rock showed they conceived at the same rate as nonadopting infertile couples: around 10 percent. (Subsequent research has put the likelihood as low as 3 percent.) What’s more, according to a 2005 study of women undergoing in vitro fertilization, published in the journal Human Reproduction, stress had no impact on pregnancy rates. The fretful conceived as readily as the chill.
I suspect women today may be particularly vulnerable to placing the locus of illness in their heads rather than their bodies. In part that’s because the causes of the ailments we’re prone to — reproductive cancers, arthritis, fibromyalgia — are often mysterious in origin. But it may also be an artifact of our rapid and successful social progress. We of the postfeminist generation grew up being told we could do anything, be anything, if we just put our minds to it. Yet, if we have the power to create our own fates, wouldn’t the corollary be that we’re also responsible for our own misfortunes? And, in a kind of double magical thinking, shouldn’t we be able to cure ourselves using the same indefatigable will? No surprise then, that in a 2001 Canadian study of 200 ovarian-cancer survivors, almost two-thirds believed that stress caused their disease and more than 80 percent attributed their survival to a positive attitude. A related study of women who had breast cancer produced similar results — fewer than 5 percent chalked up their survival to any medical treatment. Or (as I do) to just plain good luck. Meanwhile, a Danish study of 6,689 women, published in 2005, found those who were highly stressed were 40 percent less likely than others to get breast cancer.
Susan Sontag noted that a culture’s maladies are apparent in the emotional causes it attributes to illness. In the Victorian period, cancer was “caused” by excessive family obligations or hyper-emotionalism. In the 1970s it was “caused” by isolation and suppressed anger. So the assertion that stress underlies 99 percent of illness may indicate more about the healthy than the sick. Stress is our burden, our bogyman, and reducing it is the latest all-purpose talisman against adversity’s randomness. And maybe it helps. Maybe meditating and letting go of my anger at people who drive for miles with their left-turn signal flashing would improve the quality of my life, if not its length. Or maybe it would be more the equivalent of forcing a New Yorker to live in rural Maine.
As for the new store down the street from me, it turns out that it sells “yoga-inspired apparel.” At first I refused to patronize it, but eventually I broke down. They do free hemming. And that saves me a lot of time — and stress.
E. Coli and You

30 june 2008--From Victorian England to contemporary America, creationists have often denied that we are related to other primates. But the hard truth of our genealogy does even greater damage to human pride. We are cousins of every living thing, including the billions of E. coli bacteria in our intestines. This kinship may not be flattering, but it is useful. By studying these tiny creatures, we learn about other organisms, including ourselves. As the French biologist Jacques Monod once said, “What is true for E. coli is true for the elephant.”
Carl Zimmer effectively applies this principle in his engrossing new book, “Microcosm,” relating the study of these microbes to larger developments in biology and thoughtfully discussing the social implications of science. If you must limit yourself to only one title on bacteria this year, “Microcosm” is a good pick.
As Zimmer explains, a number of landmark discoveries have involved E. coli, including experiments confirming the universality of biochemistry and revealing how genes function. Studying the many strains of E. coli (most are innocuous) suggests something further: the divergent behavior of genetically identical bacteria, Zimmer writes, is “a warning to those who would put human nature down to any sort of simple genetic determinism.”
Along with some more familiar material, Zimmer vividly describes the unfamiliar microscopic world of E. coli and their tightly packed, rod-shaped bodies: “If you prick us, we bleed, but if you prick E. coli, it blasts.” And unlike mammals, bacteria often swap genetic material, placing limits on Monod’s dictum. However, species large and small absorb DNA from viruses. For E. coli and humans alike, Zimmer emphasizes, “there are no fixed essences in life.”
“Microcosm” also examines E. coli’s contentious public life. Creationists claim its tail-like, propulsive flagellum is proof of someone’s intentional design. But at the 2005 trial over the teaching of “intelligent design” in Dover, Pa., scientists showed that the flagellum is not inexplicably complex. The resistance some E. coli have developed to antibiotics (whose limits are given their own slightly disquieting chapter) provides yet more evidence for evolution.
In the 1970s, tinkering with E. coli helped scientists learn to manipulate genes, making the bacterium, Zimmer says, “the monster and the mule” of bioscience — a symbol of fears about genetic experimentation, as well as a workhorse used to make drugs. Here, he calmly finds a middle ground. While these initial concerns have remained largely unrealized, “genetic engineering has fallen far short of the more extravagant promises” about the eradication of major diseases that were offered 30 years ago.
Broadly, Zimmer sees public tolerance for genetic engineering increasing as science further reveals our patchwork genomic cloth. “New research on human evolution,” he writes, “makes it impossible to believe that a thing either is or is not a whole human being,” as some conservative opponents of biomedical inventions have argued. If our attempts to define a uniquely human core are arbitrary, however, they help us decide how to live. Zimmer thus hopes a debate over genetic engineering will produce a “deeper understanding of what it means to be human: not as an inviolable essence but as a complex cloud of genes, traits, environmental influences and cultural forces.”
Desirable as this discussion sounds, is it likely? As Zimmer notes, a bit too briefly, the emergence of biotechnology as an economic force dampened this debate three decades ago. Still, some public advocacy groups remain wary of bioscience, and coming innovations could revive opposition from cultural conservatives, rights-based interest groups and liberals upset at the uneven distribution of these goods. Genetic engineering and new forms of biomedicine could therefore engender a worthy civic dialogue or aggravate old political fractures. Or biotechnology may simply roll on. In any case, Zimmer adroitly links the common heritage we share with E. coli and the emerging horizons of science: “Through E. coli we can see the history of life, and we can see its future as well.”

Sunday, June 29, 2008

Weighing the Costs of a CT Scan’s Look Inside the Heart

29 june 2008--A group of cardiologists recently had a proposition for Dr. Andrew Rosenblatt, who runs a busy heart clinic in San Francisco: Would he join them in buying a CT scanner, a $1 million machine that produces detailed images of the heart?
The scanner would give Dr. Rosenblatt a new way to look inside patients’ arteries, enable his clinic to market itself as having the latest medical technology and provide extra revenue.
Although tempted, Dr. Rosenblatt was reluctant. CT scans, which are typically billed at $500 to $1,500, have never been proved in large medical studies to be better than older or cheaper tests. And they expose patients to large doses of radiation, equivalent to at least several hundred X-rays, creating a small but real cancer risk.
Dr. Rosenblatt worried that he and other doctors in his clinic would feel pressure to give scans to people who might not need them in order to pay for the equipment, which uses a series of X-rays to produce a composite picture of a beating heart.
“If you have ownership of the machine,” he later recalled, “you’re going to want to utilize the machine.” He said no to the offer.
And yet, more than 1,000 other cardiologists and hospitals have installed CT scanners like the one Dr. Rosenblatt turned down. Many are promoting heart scans to patients with radio, Internet and newspaper ads. Time magazine and Oprah Winfrey have also extolled the scans, which were given to more than 150,000 people in this country last year at a cost exceeding $100 million. Their use is expected to soar through the next decade. But there is scant evidence that the scans benefit most patients.
Increasing use of the scans, formally known as CT angiograms, is part of a much larger trend in American medicine. A faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques. Patient advocacy groups and some doctors are clamoring for such evidence. But the story of the CT angiogram is a sobering reminder of the forces that overwhelm such efforts, making it very difficult to rein in a new technology long enough to determine whether its benefits are worth its costs.
Some medical experts say the American devotion to the newest, most expensive technology is an important reason that the United States spends much more on health care than other industrialized nations — more than $2.2 trillion in 2007, an estimated $7,500 a person, about twice the average in other countries — without providing better care.
No one knows exactly how much money is spent on unnecessary care. But a Rand Corporation study estimated that one-third or more of the care that patients in this country receive could be of little value. If that is so, hundreds of billions of dollars each year are being wasted on superfluous treatments.
At a time when Americans are being forced to pay a growing share of their medical bills and when access to medical care has become a major political issue for states, Congress and the presidential candidates, health care experts say it will be far harder to hold down premiums and expand insurance coverage unless money is spent more wisely.
The problem is not that newer treatments never work. It is that once they become available, they are often used indiscriminately, in the absence of studies to determine which patients they will benefit.
Some new treatments, like the cancer drug Gleevec and implantable heart defibrillators, undoubtedly save lives, contributing to the United States’ reputation for medical breakthroughs. But others — like artificial spinal disks, which can cost tens of thousands of dollars to implant but have not been shown to reduce back pain in many patients, and Vytorin, a new cholesterol drug that costs 20 times as much as older medicines but has not been proved superior — have been criticized for not justifying their costs.
And sometimes, the new technologies prove harmful. Physicians were stunned, for example, when clinical trials showed last year that expensive anemia medicines might actually hasten death in kidney and cancer patients. Such drugs are used more widely in the United States than elsewhere.
“We have too many situations where we thought we knew what the answer was and it didn’t turn out like everyone thought,” said Dr. Mark Hlatky, a cardiologist and professor of health research and policy at Stanford University.
A Tool of Dubious Value
The problem of inadequate study is especially serious for medical devices and imaging equipment like scanners, which typically are not as strictly regulated as prescription drugs. Under Food and Drug Administration regulations, the makers of CT scanners — CT is short for computed tomography — do not have to conduct studies to prove that their products benefit patients, as drug makers do. The manufacturers must certify only that the scanners are safe and provide accurate images.
Once the F.D.A. approves a test or device, Medicare rarely demands evidence that it benefits patients before agreeing to pay for it. But last year, Medicare officials raised questions about the benefits of CT heart scans and said they would demand more studies before paying for them. But after heavy lobbying by cardiologists, Medicare backed down. Private insurers, while initially reluctant to pay for the tests, are also covering them.
Physicians in this country have a free hand in deciding when to use new technology like CT angiography. Some are conservative. But others, especially doctors in private practice who own their scanners, use the tests aggressively.
Douglas Ring, a 63-year-old Los Angeles real estate developer, said he received a CT heart scan in October 2005, on the advice of Dr. Ronald P. Karlsberg, a Beverly Hills cardiologist. “Ron has been my physician for 15 or 20 years, and he got this new toy in his office, and he said I should try it,” Mr. Ring said. He took the test despite having no symptoms of heart disease, like shortness of breath and chest pain. He was already taking cholesterol medicine, and a different test had shown no problems with his heart.
The CT heart scan by Dr. Karlsberg found a moderate buildup of plaque in one of Mr. Ring’s coronary arteries. The doctor increased Mr. Ring’s cholesterol medicines and encouraged him to diet and exercise.
Dr. Karlsberg said he considered the information from Mr. Ring’s CT scan extremely valuable. “Here’s a case of near-serious coronary disease that required medical management,” said Dr. Karlsberg, a partner at the Cardiovascular Medical Group of Southern California, which conducted about 1,400 CT heart scans last year.
Many other cardiologists, though, say patients like Mr. Ring do not benefit from CT scans. And by the time they are 50, most people will have plaque visible on a CT scan, so the findings of Mr. Ring’s scan were not surprising.
Arteries narrowed by plaque are not necessarily a threat, said Dr. Eric Topol, a practicing cardiologist and director of the Scripps Translational Science Institute in La Jolla, Calif. The danger arises when bits of plaque break and produce a clot that blocks blood to the heart. But CT angiograms cannot tell whether a particular blockage is likely to rupture or, except in extreme cases, is keeping the heart from receiving enough blood.
If doctors do choose to treat blockages, they can insert stents — small metal scaffolds that prop open arteries. But while stents have been proved to reduce chest pain, they have not been shown to prolong patients’ lives or help them avoid heart attacks. Patients with the most severe blockages can receive bypass surgery, which when necessary can be a lifesaving procedure.
And so patients who do not have chest pain, like Mr. Ring, should not receive CT heart scans, said Dr. Rita Redberg, a cardiologist and researcher at the University of California, San Francisco, who is a leading critic of the scans.
“No data suggests that there’s any reason for anyone asymptomatic to have a test,” she said. “There certainly is this idea that having a test can help you prevent a heart attack, and I don’t know where it came from.”
Further, each scan creates an additional lifetime risk of cancer that is somewhere between 1 in 200 and 1 in 5,000, said Dr. David J. Brenner, director of the Center for Radiological Research at Columbia University. Younger patients and women are at higher risk.
Dr. Karlsberg and other cardiologists who support widespread use of CT heart scans argue that they can reduce the need for other tests — like conventional angiograms, which can find plaque but require a catheter to be threaded through the arteries. Conventional angiograms are more expensive than CT scans and carry their own risks.
If a CT heart scan finds plaque that a doctor intends to treat with a stent, a conventional angiogram will still be necessary to determine where and how to implant the stent. So a CT scan does not always eliminate the need for a conventional angiogram.
The most valuable use of a CT angiogram may be when a patient comes to an emergency room complaining of chest pains but has few other symptoms of a heart attack. The test can quickly rule out heart trouble. But such patients represent a minority of those receiving CT heart scans.
Dr. Karlsberg also pointed to the case of a seemingly healthy 68-year-old patient whom he scanned in his office in 2006. To the shock of both doctor and patient, the scan revealed a 95 percent blockage of the patient’s main coronary artery. The patient had immediate bypass surgery to relieve the blockage, an operation that may have saved his life, Dr. Karlsberg said. The man, who cited privacy concerns in asking that his name not be used, confirmed the doctor’s account.
Cardiologists who oppose wide use of the scans agree that they can sometimes find dangerous blockages that require immediate surgery in asymptomatic patients. But they said such cases are extremely rare — not common enough to justify using the scans routinely, given their cost and radiation risks.
For too many people, the scans are simply inappropriate, said Dr. Howard C. Herrmann, director of interventional cardiology at the University of Pennsylvania. “I find many patients have CT angiograms who shouldn’t be getting CT angiograms.”
As more than 13,000 heart doctors gathered in Chicago in late March for the annual American College of Cardiology conference, the biggest and best-located booths belonged to General Electric, Philips Electronics, Siemens and Toshiba, the leading makers of the machines used for CT angiograms.
Cardiologists hired by the companies offered short briefings on ways to reduce radiation doses, while sales representatives in business suits quietly talked up the benefits of the scans and the clarity of the images. The sales atmosphere was low key, more art gallery than “Glengarry Glen Ross.”
A hard sell is unnecessary because the manufacturers are finding a receptive audience. Many cardiologists have been eager for a new tool that lets them see inside the heart with unprecedented clarity — while also providing a new source of revenue.
Use of CT scans accelerated after 2004, when manufacturers introduced a new generation called 64-slice scanners, which are fast enough to capture images of a beating heart. The scanners fire X-rays in a series of rotations around the torso, generating thousands of narrow vertical images. Sophisticated software then combines data from the X-rays into a single image.
The Financial Incentives
Already, more than 1,000 hospitals and an estimated 100 private cardiology practices own or lease the $1 million CT scanners, which can be used for the angiograms and for other imaging procedures. Once they have made that investment, doctors and hospitals have every incentive to use the machines as often as feasible. To pay off a scanner, doctors need to conduct about 3,000 tests, industry consultants say.
Fees from imaging have become a significant part of cardiologists’ income — accounting for half or more of the $400,000 or so that cardiologists typically make in this country, said Jean M. Mitchell, an economist at Georgetown University who studies the way financial incentives influence doctors.
Besides generating profits themselves, the scans enable cardiologists to find blockages in patients who have no symptoms of heart problems. Doctors can then place stents in patients who would not otherwise have received them, generating additional revenue of $7,500 to $20,000 per patient.
While clinical trials have not shown that stents benefit patients with no symptoms of heart disease, they are still routinely inserted in such patients when tests find significant blockages. Cardiologists joke that the phenomenon is “ocular stenosis” — blockages that can be seen are stented.
“You find a lot of asymptomatic disease,” said John O. Goodman, a business consultant to cardiologists. “It will put more patients in the cath lab” — medical shorthand for a cardiac catheterization laboratory, where conventional angiograms and stenting procedures take place.
Ms. Mitchell said cardiologists simply practice medicine the way the health system rewards them to. Given the opportunity to recommend a test for which they will make money, the doctors will.
“This is not greed,” she said. “This is normal economic behavior.”
Doctors who perform a lot of CT heart scans tend to be evangelists for the technology. Dr. John A. Osborne, a cardiologist in solo practice in Grapevine, Tex., just outside Dallas, argues that CT angiograms catch heart disease at its earliest stages. His Web site,, states the proposition in stark terms: “Half of Americans have died of heart attacks and strokes. Which one are you?”
Supported by a staff of about 20 people, Dr. Osborne estimates that he does 15 CT angiograms a day. Arterial plaque is “cancer of the coronaries,” he tells patients. “Do you have it or not?”
Before their plaque creates symptoms, Dr. Osborne asserts, patients should be aggressively treated, urged to diet and exercise and given cholesterol-lowering and other drugs.
Scans ‘Sell Themselves’
Like many cardiologists who perform CT scans, Dr. Osborne relies on primary-care doctors to send him candidates. He frequently gives lectures to primary-care doctors on the technology’s benefits. When doctors see the images, he said, “they become true believers.”
Two years ago, Dr. Osborne persuaded a family practice doctor, Dr. Michael Dotti, to have his own CT angiogram at no cost. Dr. Dotti was amazed at the scan’s ability to spot early signs of disease. “It’s nice to know I have clear arteries at 51,” he said. “The scans sort of sell themselves.”
The technology has been covered in the news media, including a September 2005 Time magazine cover on CT angiograms, “How New Heart-Scanning Technology Could Save Your Life.” The following month, Oprah Winfrey devoted a segment of her television program to women’s heart disease and recommended that her viewers consider taking the test. Representatives for Time and Ms. Winfrey declined to comment on their coverage of the technology.
Even cardiologists who think the CT scans are overused say they may one day prove valuable. If manufacturers can produce scanners that can determine which plaques are stable and which are likely to rupture, the machines could revolutionize the treatment of heart disease. Patients found to be at low risk might be able to avoid taking medicine entirely, while others would be given intensive treatment.
But for now, doctors cannot use the images that way. Finding out whether the heart is actually short of blood and at high risk for an attack requires tests other than a CT scan — most likely, a nuclear stress test, which uses radioactive dye to track blood flow through the coronary arteries.
The CT angiogram is “a great technology searching for a great application,” said Dr. Charanjit S. Rihal, the director of the cardiac catheterization laboratory at the Mayo Clinic in Rochester, Minn., who sees little diagnostic value in the current generation of heart scanners.
CareCore National, a Bluffton, S.C., company that reviews treatment and test requests for health insurers, has found that when doctors request a CT angiogram for a patient, they also frequently ask for a nuclear stress test.
“We’re seeing layering of tests on top of each other,” said Dr. Russell Amico, a CareCore executive. His company denies as many as 70 percent of the CT scans requested, a much higher rate of rejection than for other kinds of tests his company reviews.
Impatient Patients
Sometimes, it is not the doctor but the patient who is eager for the scan. On a recent Wednesday morning on the Upper East Side of Manhattan, Dr. Harvey Hecht at Lenox Hill Hospital watched from a lead-shielded control room as a 59-year-old patient, Robert Franks, underwent a CT angiogram.
Mr. Franks has a family history of cardiac disease, and his father and two uncles died of heart attacks. But Mr. Franks, director of corporate security for Time Inc., is in excellent shape. He works out daily and takes two cholesterol-lowering medicines. The drugs have reduced his LDL, or bad, cholesterol to 60, a remarkably low level.
Nonetheless, in February, Mr. Franks took a test called a calcium score, which measures the amount of calcified plaque in the arteries. The test, a less extensive form of scanning, revealed a moderate buildup of calcium in his arteries, a potential sign of heart disease.
So he decided to have a nuclear stress test. When that test showed no problem, the cardiologist who conducted it said he did not need more testing.
But Mr. Franks was still not satisfied. “I’m someone who wants to know,” he said.
After doing research on the Internet, he found Dr. Hecht, who recommended a CT angiogram. Dr. Hecht acknowledged that Mr. Franks probably did not have severe heart disease. But he said the scan would be valuable anyway because it might reassure him. And his insurance would cover the cost.
A CT scanner is 8 feet high by 8 feet wide and 2 feet deep, with a doughnut-shaped hole at its center. Wearing a hospital gown, Mr. Franks lay on a table attached to the machine and was injected with a drug to lower his heart rate, along with a contrast dye to improve the quality of the images from the test. (Mr. Franks later compared the warmth he felt after the injection of the dye to “the first sip of a well-blended martini.”)
In the control room, Salvatore Fevola, the manager of the CT scanning equipment at Lenox Hill, instructed Mr. Franks, who was raising his hands over his head, to hold his breath as the table moved through the machine.
Twelve seconds later, the test was complete, and the machine’s software began to assemble information from thousands of images into a single coherent picture of Mr. Franks’s heart.
A few minutes later, Dr. Hecht studied the results. As he had expected, the angiogram revealed that Mr. Franks’s arteries were healthy. In some places, plaque had blocked 25 percent of their blood flow, but in general, cardiologists do not consider blockages clinically relevant until they reduce blood flow at least 70 percent.
After Mr. Franks finished dressing, he joined Dr. Hecht, who went over the results, explaining that his heart appeared healthy and that he would not need a stent. Still, Dr. Hecht recommended that Mr. Franks have another CT angiogram next year to check that the plaque was not thickening. Mr. Franks agreed, pronounced himself satisfied and left.
For Mr. Franks, the test was quick and painless. But it subjected him to a significant dose of radiation.
Based on a reporter’s notes about the duration of the scan and the power output reported by the scanner, Dr. Brenner of the Center for Radiological Research estimated that Mr. Franks had received 21 millisieverts of radiation — even more than a typical test, equal to about 1,050 conventional chest X-rays.
Given the radiation risks, Dr. Ralph Brindis, another cardiologist, said Dr. Hecht had erred. Because Mr. Franks had already taken a nuclear stress test with normal results, he did not need a CT angiogram, said Dr. Brindis, vice president of the American College of Cardiology. And particularly because the scan’s results were benign, he said, Dr. Hecht should not have recommended a follow-up test.
“The biggest problem we have with radiation is that the doses are cumulative and additive,” Dr. Brindis said. “So the concept of doing serial CT testing on asymptomatic patients, I think, is abhorrent. I cannot justify that.”
Dr. Hecht said he sharply disagreed with Dr. Brindis. The scan was appropriate for Mr. Franks, despite his normal results from the nuclear stress test, because of Mr. Franks’s other risk factors for heart disease, including his higher-than-average calcium score, Dr. Hecht said. And he said he recommended a follow-up scan next year so he could see how quickly the plaque in Mr. Franks’s arteries was thickening.
Otherwise, “how do we know that our therapy is effective?” Dr. Hecht said. He acknowledged that many cardiologists do not favor repeat scans but said long-term radiation risks were a relatively minor issue for patients 60 and older.
Cardiologists like Dr. Brindis hurt their patients by being overly conservative and setting unrealistic standards for the use of new technology, Dr. Hecht said.
“It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”
Medicare’s Scrutiny
The Centers for Medicare and Medicaid Services had decided to push back.
The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients.
Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value.
The plan met with fierce resistance, particularly from a relatively new organization of specialists, the Society of Cardiovascular Computed Tomography. The society has 4,700 physician members and one purpose — to promote CT angiograms.
“For the CT society, this was life or death,” said Dr. Daniel S. Berman, the group’s president-elect. “This decision could essentially put them out of business.”
Galvanized, at a meeting in November in Chicago, the CT specialists vowed to overturn any possible Medicare proposal.
“We didn’t need to be talking about registries and the research,” Dr. Berman said. “We needed to be questioning the wisdom of the Medicare decision itself.”
The next month, Medicare issued the draft of its proposal, saying that it would pay for the scans only if a large-scale study were conducted. The CT society, along with other prominent medical groups whose members performed scans, set to work lobbying the agency and members of Congress.
One group marshaled the evidence the doctors would take to Medicare, arguing that the agency had ignored some studies, including those of the new 64-slice CT scans. Another group visited Congressional offices. Defenders of the technology argued that Medicare had agreed to pay for other tests, like mammograms, without requiring proof that they improved patient care. Breakthrough technologies, they said, need time to prove themselves.
Medicare “set the bar so high, no new technology would be able to survive,” said Dr. Michael Poon, a New York cardiologist who is the CT society’s current president.
Cardiologists met with Representative Carolyn McCarthy, a New York Democrat. In March, she and other members of Congress wrote to Medicare, urging it to reconsider its plan. Eventually, a dozen or so senators and 79 representatives lined up to support the society’s efforts.
And Medicare gave way.
“There are a lot of technologies, services and treatments that have not been unequivocally shown to improve health outcomes in a definitive manner,” Dr. Barry Straube, Medicare’s chief medical officer, explained when announcing that the agency would keep covering the tests.
In other words, the lack of evidence that the CT scans provide measurable medical benefit would not stop Medicare from paying for them.
Heavy lobbying makes it virtually impossible for the agency to insist on more evidence before agreeing to pay for a new technology, said Dr. James Adamson, chief medical officer for Arkansas Blue Cross and Blue Shield. “Medicare,” he said, “does not make a lot of really hard decisions.”
In a subsequent interview, Marcel Salive, a Medicare official, said the agency still hoped for large-scale studies to demonstrate the value of CT scans.
The technology’s proponents say they understand the need to prove its value. “It’s incumbent on us to do more work,” said Gene Saragnese, vice president for molecular imaging and CT at General Electric.
Doctors are also discussing the creation of registries to track patients who have had CT angiograms. But now that Medicare has backed down, skeptics say it is unlikely that anyone will conduct a major clinical trial to determine if patients who receive CT heart scans have better medical outcomes than those who do not.
“It’s clearly going to be much more difficult, given the Medicare decision,” said Dr. Sean Tunis, a former Medicare official who directs the Center for Medical Technology Policy, a nonprofit group.
Industry consultants say that now that Medicare has agreed to pay for the tests, resistance among commercial insurers is likely to disappear. “I believe the holdouts will be paying within 12 months,” said Michelle Boston, the chief executive of Partners Imaging, a Dallas company that works with doctors to offer CT scans.
And so CT angiograms seem destined to continue, in ever greater numbers. “Once the train leaves the station, once the technology gets on the marketplace, we don’t get the evidence,” said Dr. Redberg, the University of California, San Francisco, cardiologist. “We’re spending a lot of money on technology of unclear benefit and risk.”
Key Facts About Avian Influenza (Bird Flu) and Avian Influenza A (H5N1) Virus

29 june 2008--Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. These influenza viruses occur naturally among birds. Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. However, avian influenza is very contagious among birds and can make some domesticated birds, including chickens, ducks, and turkeys, very sick and kill them.
Infected birds shed influenza virus in their saliva, nasal secretions, and feces. Susceptible birds become infected when they have contact with contaminated secretions or excretions or with surfaces that are contaminated with secretions or excretions from infected birds. Domesticated birds may become infected with avian influenza virus through direct contact with infected waterfowl or other infected poultry, or through contact with surfaces (such as dirt or cages) or materials (such as water or feed) that have been contaminated with the virus.
Infection with avian influenza viruses in domestic poultry causes two main forms of disease that are distinguished by low and high extremes of virulence. The “low pathogenic” form may go undetected and usually causes only mild symptoms (such as ruffled feathers and a drop in egg production). However, the highly pathogenic form spreads more rapidly through flocks of poultry. This form may cause disease that affects multiple internal organs and has a mortality rate that can reach 90-100% often within 48 hours.
Human infection with avian influenza viruses
There are many different subtypes of type A influenza viruses. These subtypes differ because of changes in certain proteins on the surface of the influenza A virus (hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA subtypes and 9 known NA subtypes of influenza A viruses. Many different combinations of HA and NA proteins are possible. Each combination represents a different subtype. All known subtypes of influenza A viruses can be found in birds.
Usually, “avian influenza virus” refers to influenza A viruses found chiefly in birds, but infections with these viruses can occur in humans. The risk from avian influenza is generally low to most people, because the viruses do not usually infect humans. However, confirmed cases of human infection from several subtypes of avian influenza infection have been reported since 1997. Most cases of avian influenza infection in humans have resulted from contact with infected poultry (e.g., domesticated chicken, ducks, and turkeys) or surfaces contaminated with secretion/excretions from infected birds. The spread of avian influenza viruses from one ill person to another has been reported very rarely, and has been limited, inefficient and unsustained.
“Human influenza virus” usually refers to those subtypes that spread widely among humans. There are only three known A subtypes of influenza viruses (H1N1, H1N2, and H3N2) currently circulating among humans. It is likely that some genetic parts of current human influenza A viruses came from birds originally. Influenza A viruses are constantly changing, and they might adapt over time to infect and spread among humans.
During an outbreak of avian influenza among poultry, there is a possible risk to people who have contact with infected birds or surfaces that have been contaminated with secretions or excretions from infected birds.
Symptoms of avian influenza in humans have ranged from typical human influenza-like symptoms (e.g., fever, cough, sore throat, and muscle aches) to eye infections, pneumonia, severe respiratory diseases (such as acute respiratory distress), and other severe and life-threatening complications. The symptoms of avian influenza may depend on which virus caused the infection.Studies done in laboratories suggest that some of the prescription medicines approved in the United States for human influenza viruses should work in treating avian influenza infection in humans. However, influenza viruses can become resistant to these drugs, so these medications may not always work. Additional studies are needed to demonstrate the effectiveness of these medicines.
Avian Influenza A (H5N1)
Influenza A (H5N1) virus – also called “H5N1 virus” – is an influenza A virus subtype that occurs mainly in birds, is highly contagious among birds, and can be deadly to them. H5N1 virus does not usually infect people, but infections with these viruses have occurred in humans. Most of these cases have resulted from people having direct or close contact with H5N1-infected poultry or H5N1-contaminated surfaces.
Avian influenza A (H5N1) outbreaks
For current information about avian influenza A (H5N1) outbreaks, see our Outbreaks page.
Human health risks during the H5N1 outbreak
Of the few avian influenza viruses that have crossed the species barrier to infect humans, H5N1 has caused the largest number of detected cases of severe disease and death in humans. However, it is possible that those cases in the most severely ill people are more likely to be diagnosed and reported, while milder cases go unreported. For the most current information about avian influenza and cumulative case numbers, see the World Health Organization (WHO) avian influenza website.
Of the human cases associated with the ongoing H5N1 outbreaks in poultry and wild birds in Asia and parts of Europe, the Near East and Africa, more than half of those people reported infected with the virus have died. Most cases have occurred in previously healthy children and young adults and have resulted from direct or close contact with H5N1-infected poultry or H5N1-contaminated surfaces. In general, H5N1 remains a very rare disease in people. The H5N1 virus does not infect humans easily, and if a person is infected, it is very difficult for the virus to spread to another person.
While there has been some human-to-human spread of H5N1, it has been limited, inefficient and unsustained. For example, in 2004 in Thailand, probable human-to-human spread in a family resulting from prolonged and very close contact between an ill child and her mother was reported. In June 2006, WHO reported evidence of human-to-human spread in Indonesia. In this situation, 8 people in one family were infected. The first family member is thought to have become ill through contact with infected poultry. This person then infected six family members. One of those six people (a child) then infected another family member (his father). No further spread outside of the exposed family was documented or suspected.
Nonetheless, because all influenza viruses have the ability to change, scientists are concerned that H5N1 virus one day could be able to infect humans and spread easily from one person to another. Because these viruses do not commonly infect humans, there is little or no immune protection against them in the human population. If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. For more information about influenza pandemics, see
No one can predict when a pandemic might occur. However, experts from around the world are watching the H5N1 situation in Asia and Europe very closely and are preparing for the possibility that the virus may begin to spread more easily and widely from person to person.
Treatment and vaccination for H5N1 virus in humans
The H5N1 virus that has caused human illness and death in Asia is resistant to amantadine and rimantadine, two antiviral medications commonly used for influenza. Two other antiviral medications, oseltamivir and zanamivir, would probably work to treat influenza caused by H5N1 virus, but additional studies still need to be done to demonstrate their effectiveness.For information about H5N1 vaccines, visit
Doctors Say Medication Is Overused in Dementia

29 june 2008--Ramona Lamascola thought she was losing her 88-year-old mother to dementia. Instead, she was losing her to overmedication.
Last fall her mother, Theresa Lamascola, of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor — the younger Ms. Lamascola’s own physician — who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.
Theresa Lamascola was moved to a nursing home to get these problems under control. But things only got worse. “My mother was screaming and out of it, drooling on herself and twitching,” said Ms. Lamascola, a pediatric nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.
“I knew the drugs were doing this to her,” her daughter said. “I told him to stop the medications and stay away from Mom.”
Not until yet another doctor took Mrs. Lamascola off the drugs did she begin to improve.
The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.
Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.
The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.
In 2005, the Food and Drug Administration ordered that the newer drugs carry a “black box” label warning of an increased risk of death. Last week, the F.D.A. required a similar warning on the labels of older antipsychotics.
The agency has not approved marketing of these drugs for older people with dementia, but they are commonly prescribed to these patients “off label.” Several states are suing the top sellers of antipsychotics on charges of false and misleading marketing.
Ambre Morley, a spokeswoman for Janssen, the division of Johnson & Johnson that manufactures Risperdal, would not comment on the suits, but said: “As with any medication, the prescribing of a medication is up to a physician. We only promote our products for F.D.A.-approved indications.”
Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”
Dr. William D. Smucker, a member of the American Medical Directors Association, a group of health professionals who work in nursing homes, agreed. Though the group encourages doctors to conduct a thorough assessment and prescribe antipsychotics only as a last resort, he said, “Many physicians are absent without leave in the nursing home and don’t take an active role in the assessment of the patient.”
Some nursing homes are trying a different approach, so-called environmental intervention. The strategies include reducing boredom, providing intellectual and physical stimulation, exercise, calming music, bringing in pets for therapy and improving how the staff approaches and talks to dementia patients.
At the Margaret Teitz Nursing and Rehabilitation Center in Queens, social workers do life reviews of patients to understand their interests, lifestyle and former occupations.
“I had a patient who used to be in fashion,” said Nancy Goldwasser, the director of social services. “So we got her fabric samples. And she’d sit and look through the books, touch the fabric, and it would calm her.”
But such approaches are time consuming, they do not help all patients, they can be prohibitively expensive and they will be more difficult to provide as Alzheimer’s continues to increase.
“Our health care system isn’t set up to address the mental, emotional and behavioral problems of the elderly,” said Dr. Gary S. Moak, president of the American Association for Geriatric Psychiatry.
Nursing homes are short staffed, and insurers do not generally pay for the attentive medical care and hands-on psychosocial therapy that advocates recommend. It is much easier to use sedatives and antipsychotics, despite their side effects.
The first generation of antipsychotics, like Haldol, carry a significant risk of repetitive movement disorders and sedation. Second-generation antipsychotics, also called atypicals, are more commonly prescribed because the risk of movement disorders is lower. But they, too, can cause sedation, and they contribute to weight gain and diabetes.
Used correctly, the drugs do have a role in treating some seriously demented patients, who may be incapacitated by paranoia or are self-destructive or violent. Taking the edge off the behavior can keep them safe and living at home, rather than in a nursing home.
If patients are prescribed an antipsychotic, it should be a very low dose for the shortest period necessary, said Dr. Dillip V. Jeste, a professor of psychiatry and neuroscience at the University of California, San Diego.
It may take a few weeks or months to control behavior. In many cases, the patient can then be weaned off of the drugs or kept at a very low dose.
Some experts say another group of medications — antidementia drugs like Aricept, Exelon and Namenda — are underused. Research shows that 10 to 20 percent of Alzheimer’s patients had noticeable positive responses to the drugs, and 40 percent more showed some cognitive improvement, even if it was not noticeable to an observer.
“Sometimes, it’s enough to take the edge off the behavioral problems, so the family and patient can live with it and you don’t expose people to much risk,” said Dr. Gary J. Kennedy, director of geriatric psychiatry at the Montefiore Medical Center in the Bronx.
Other experts cite a lack of research backing these drugs for behavioral problems.
If patients begin showing behavioral symptoms of dementia, doctors said, they should have complete medical and psychiatric workups first, especially if symptoms develop suddenly.
“Just because someone is 95 does not mean one should not do a workup, especially if she’s been healthy,” Dr. Kennedy said.
Common causes of the symptoms include ministrokes, reparable brain hemorrhage from a mild bump on the head, hypothyroidism, dehydration, malnourishment, depression and sleep disorders.
Some doctors point out that simply paying attention to a nursing home patient can ease dementia symptoms. They note that in randomized trials of antipsychotic drugs for dementia, 30 to 60 percent of patients in the placebo groups improved.
“That’s mind boggling,” Dr. Jeste said. “These severely demented patients are not responding to the power of suggestion. They’re responding to the attention they get when they participate in a clinical trial.
“They receive both T.L.C. and good general medical and humane care, which they did not receive until now. That’s a sad commentary on the way we treat dementia patients.”
To family members looking at a nursing home for an aging parent, experts recommend seeking out homes with low staff turnover, a high ratio of staff members to patients, and programs with psychosocial components.
The Medicare Web site has basic information on individual homes at The National Citizens’ Coalition for Nursing Home Reform, at, offers a consumer guide to choosing a nursing home.
If medications are necessary, a family member should communicate with the prescribing doctor, learn the goal of each medication and be involved in making the decision.
Dr. Moak, of the psychiatry association, emphasized seeking out the doctor. Family members, he said, “often speak through the nursing staff, and that’s a huge mistake.”
Family members who are not convinced that a relative is receiving the best care should get a second opinion, as Ramona Lamascola did.
The physician she consulted, Dr. Kennedy of Montefiore, stopped her mother’s antipsychotics and sedatives and prescribed Aricept.
“It’s not clear whether it was getting her hypothyroid and other medical issues finally under control or getting rid of the offending medications,” he said. “But she had a miraculous turnaround.”
Theresa Lamascola still has dementia, but she went from confinement in a wheelchair — unable to sit still and screaming out in fear — to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversations and even make jokes.
Or, as her daughter put it, “I got my mother back.”
Number of People with Diabetes Increases to 24 Million

29 june 2008--Diabetes now affects nearly 24 million people in the United States, an increase of more than 3 million in approximately two years, according to new 2007 prevalence data estimates released today by the Centers for Disease Control and Prevention (CDC). This means that nearly 8 percent of the U.S. population has diabetes.
In addition to the 24 million with diabetes, another 57 million people are estimated to have pre-diabetes, a condition that puts people at increased risk for diabetes. Among people with diabetes, those who do not know they have the disease decreased from 30 percent to 25 percent over a two-year period.
“These new estimates have both good news and bad news,” said Dr. Ann Albright, director of the CDC Division of Diabetes Translation. “It is concerning to know that we have more people developing diabetes, and these data are a reminder of the importance of increasing awareness of this condition, especially among people who are at high risk. On the other hand, it is good to see that more people are aware that they have diabetes. That is an indication that our efforts to increase awareness are working, and more importantly, that more people are better prepared to manage this disease and its complications.”
Diabetes is a disease associated with high levels of blood glucose resulting from defects in insulin production that causes sugar to build up in the body. It is the seventh leading cause of death in the country and can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations.
Among adults, diabetes increased in both men and women and in all age groups, but still disproportionately affects the elderly. Almost 25 percent of the population 60 years and older had diabetes in 2007. And, as in previous years, disparities exist among ethnic groups and minority populations including Native Americans, blacks and Hispanics. After adjusting for population age differences between the groups, the rate of diagnosed diabetes was highest among Native Americans and Alaska Natives (16.5 percent). This was followed by blacks (11.8 percent) and Hispanics (10.4 percent), which includes rates for Puerto Ricans (12.6 percent), Mexican Americans (11.9 percent), and Cubans (8.2 percent). By comparison, the rate for Asian Americans was 7.5 percent with whites at 6.6 percent.
The data are an update of diabetes prevalence estimates last reported two years ago and now published in the 2007 National Diabetes Fact Sheet developed by CDC in collaboration with multiple agencies under the U.S. Department of Health and Human Services and other federal agencies.
CDC also is releasing estimates of diagnosed diabetes for all counties in the United States. Derived from the agency's Behavioral Risk Factor Surveillance Survey (BRFSS) and census data, the estimates provide a clearer picture of areas within states that have higher diabetes rates. Nationally, the data indicate increased diabetes rates in areas of the Southeast and Appalachia that have traditionally been recognized as being at higher risk for many chronic diseases, including heart disease and stroke.
“These data are an important step in identifying the places in a state that have the greatest number of people affected by diabetes,” said Dr.Albright. “If states know which communities or areas have more people with diabetes, they can use that information to target their efforts or tailor them to meet the needs of specific communities.”
CDC, through its Division of Diabetes Translation, funds diabetes prevention and control programs in all 50 states, as well as the District of Columbia and eight U.S. territories and island jurisdictions. The National Diabetes Education Program, co-sponsored by CDC and the National Institutes of Health (NIH), provides diabetes education to improve the treatment and outcomes for people with diabetes, promote early diagnosis, and prevent or delay the onset of diabetes.
For more information on diabetes, please visit To access the National Diabetes Fact Sheet and county-level estimates of diagnosed diabetes, click on the "data and trends" link at the left.

Saturday, June 28, 2008

Diabetes linked to cognitive decline in seniors

28 june 2008--Older adults with type 2 diabetes may have a steeper mental decline as they age, a large study suggests.
Diabetes is known to raise the risk of a number of major health problems, including heart disease and kidney failure. More recently, studies have also linked diabetes to speedier mental decline and dementia in older adults.
These latest findings, published in the Journal of the American Geriatric Society, confirm those earlier reports -- and suggest that the longer a person has had diabetes, the more substantial the cognitive decline over time.
For the study, researchers led by Dr. Olivia Okereke, of Harvard Medical School in Boston, examined data from the Physicians' Health Study and the Women's Health Study -- two long-term projects looking at the health of thousands of U.S. men and women.
The researchers looked at the association between diabetes and late-life cognitive impairment in 5,907 men and 6,326 women. Participants were in their early 70s, on average, when they were first assessed for memory, thinking and other cognitive abilities; they were tested again roughly two years later, and women had a third test around the four-year mark.
In general, Okereke and her colleagues found, men and women with diabetes performed more poorly on the initial cognitive tests, then showed a more marked decline on subsequent tests.
In addition, participants with longer-standing diabetes tended to be in worse cognitive shape at the outset, and show a steeper decline over time.
There are several plausible reasons why diabetes might fuel age-related mental decline, according to the researchers.
One is that diabetes can damage the blood vessels that supply the brain, diminishing blood flow and thereby contributing to cognitive problems.
In addition, people with diabetes typically have chronically high levels of the blood-sugar-regulating hormone insulin. And some research suggests that elevated insulin concentrations may boost the body's levels of amyloid-beta protein, which build up to form the "plaques" seen in the brains of people with Alzheimer's disease.
More studies are now needed to find out precisely how diabetes affects older adults' mental function, Okereke and her colleagues conclude.

SOURCE: Journal of the American Geriatrics Society, June 2008.
Staying Social May Keep Dementia at Bay

By Kathleen Doheny
28 june 2008-- The key to a healthy mind in old age may lie in an active social life, a new study suggests.
"If you are socially engaged, you are at lower risk of dementia," said Dr. Valerie C. Crooks, a researcher at the Department of Research and Evaluation, Kaiser Permanente Southern California.
During her study, which followed more than 2,200 women ages 78 and older for four years, those with large social networks reduced their risk of getting dementia by 26 percent, she said.
Previous studies about the association between social engagement with family and friends and cognitive functioning in old age have yielded mixed results, Crooks noted. For example, "there were studies that said being married is helpful, and studies that said being married is not so helpful," she said.
In recent studies, social contact has been generally found to be protective of cognitive functioning, however, she said.
For this new study, published in the July issue of the American Journal of Public Health, Crooks and her colleagues conducted telephone interviews with the women, all of who were members of the Kaiser Permanente HMO. The women were free of dementia when the study started in 2001.
The team tested each woman's cognitive status by phone and reviewed her medical records to help assess it, as well. They also asked about social interactions with a spouse and/or other family and friends, including how many people they interacted with and how often.
Crooks' team also asked the women how many people they felt they could rely on if they needed help and whether they had a person or persons they could talk to about personal issues.
At the end of the follow-up, 268 of the women had been diagnosed with dementia.
Those with larger social networks also showed a reduced risk for dement ia, whose most common form is Alzheimer's disease.
"In this study, we found marriage didn't make a difference in terms of dementia risk," she said. In other words, it was the social network that was protective, regardless of whether the woman was married or not.
"Those with daily contact or more had a lower risk of dementia," she said. The contact didn't have to be face-to-face -- e-mail and telephone interaction counted, Crooks added.
It's impossible to say how many friends and family makes up a big enough social circle to be protective, the researcher said. "Two or fewer is probably not a sufficient amount. You could have three really close friends [or family] and be fine," Crooks speculated.
"We can't tell you what the magic number is," she said.
And she emphasized that her team found only an association between social networks and reduced risk of dementia, which doesn't point to a cause-and-effect relationship, necessarily.
"There could be a person with one person [in his or her social network] who is doing perfectly fine," she said.
While more study is needed to zero in on exactly which aspects of social support are linked with a decrease in dementia risk, Crooks said the findings make perfect sense, neurologically speaking. "The more interaction, the more you challenge your brain."
Dr. William Thies, vice president of medical and scientific relations at the Alzheimer's Association, said the finding "fits with a large body of evidence that being isolated is bad for you."
But he added, the finding is merely an association, not cause and effect.
"You don't know whether the bigger network prevents Alzheimer's or [whether] people who don't get Alzheimer's maintain bigger networks," he said.
Sudden Deafness Linked to Increased Risk of Stroke

By Todd Neale
TAIPEI, Taiwan,28 june 2008-- Sudden sensorineural hearing loss may signal an increased risk of a stroke within five years, researchers here found In a national healthcare database, those who were hospitalized with the condition were 1.64-fold more likely to have a stroke in the next five years compared with the general population (HR 1.64, 95% CI 1.31 to 2.07, P<0.001), Herng-Ching Lin, Ph.D., of Taipei Medical University, and colleagues reported online in Stroke: Journal of the American Heart Association. Those with sudden sensorineural hearing loss "should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future," they said.
Possible underlying causes of the sudden deafness include vascular occlusion, viral or bacterial infection, ruptured inner ear membrane, autoimmune diseases, and acoustic tumors, the researchers said.
Although some investigators had suggested that sudden sensorineural hearing loss may be an early sign of stroke, they said, no studies had examined the link between the two.
Using Taiwan's National Health Insurance Research Database, Dr. Lin and colleagues identified 1,423 patients who were hospitalized with sudden sensorineural hearing loss. For a control group representative of the general population, they selected 5,692 patients who had an appendectomy. All patients were followed for five years.
Patients with hearing loss were significantly more likely than the controls to have hypertension (P<0.001), diabetes (P<0.001), or hyperlipidemia (P=0.007) at the time of hospitalization.
They were also more likely to have a higher income and to live in the most urbanized areas and in the northern part of Taiwan (P<0.001 for all).
Overall, 621 (8.7%) patients had a stroke during follow-up -- 180 (12.7%) of those with hearing loss and 441 (7.8%) who had an appendectomy.
The researchers noted that almost half (49.4%) of the strokes in patients with hearing loss occurred more than two years after hospitalization. "This suggests that efforts to prevent the development of stroke should last for several years after an episode of sudden deafness."
The patients with hearing loss had a significantly lower five-year stroke-free survival than appendectomy patients (P<0.001).
After adjusting for cardiovascular risk factors, age, gender, level of urbanization, geographical location, and income, patients with hearing loss were 1.64-fold more likely to have a stroke within five years of hospitalization (P<0.001) than the controls.
As expected, all patients with hypertension, diabetes, and hyperlipidemia were at an increased risk of stroke (P<0.001 for all).
"Our finding supports a vascular origin in the pathogenesis of [sudden sensorineural hearing loss], at least in some patients," the researchers said, although the mechanism remains unclear.
They speculated that sudden sensorineural hearing loss shares an etiology with stroke because recent studies have shown that patients with the condition have significantly higher plasma fibrinogen and cholesterol levels than the general population.
One study speculated that the association between hearing loss and stroke "could be explained by the particular vulnerability of the cochlea to ischemia," a result of the high energy requirement of the inner ear and the lack of adequate collateral blood supply, they said.
The authors acknowledged that the study was limited because the database from which the patients were selected did not use a universal definition for sudden sensorineural hearing loss.
In addition, they said, the database did not contain information on the severity of hearing loss, extent of hearing recovery, tobacco use, body mass index, or medical history of cardiovascular disease and atrial fibrillation.
The authors made no financial disclosures.
Primary source: Stroke: Journal of the American Heart AssociationSource reference:Lin H-C, et al "Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study" Stroke 2008; DOI: 10.1161/STROKEAHA.108.519090.
EOH: Physical Activity May Alter Diabetes Link to Breast Cancer in Hispanic Women

By Charles Bankhead
BALTIMORE, 28 june 2008 -- Physical activity may help counter the adverse effect diabetes seems to have on breast cancer risk in Hispanic women, data presented here suggested.
In a case-control study among Hispanic women, physically active breast cancer survivors were 60% less likely to have diabetes compared with a physically inactive control group, Maureen Sanderson, Ph.D., of the University of Texas-Houston School of Public Health at Brownsville, reported at the Department of Defense Era of Hope meeting.
In contrast to previous studies, however, diabetes was not associated with breast cancer among physically inactive women. In fact, the breast cancer patients had a slightly lower prevalence of diabetes compared with the control group.
"The negative association between diabetes and breast cancer was unexpected, since a recent meta-analysis reported a significant positive association," said Dr. Sanderson. "Potential mechanisms that warrant exploration are related to hormone levels and the severity and treatment of diabetes."
Several studies have shown that diabetes increases the risk of breast cancer, whereas the data suggested that physical activity reduces breast cancer risk. Hispanic women, in contrast to white women, have lower rates of breast cancer and physical activity but a higher prevalence of diabetes.
Dr. Sanderson and colleagues undertook a study to evaluate potential interactions among diabetes, physical activity, and breast cancer. They also wanted to determine whether physical activity modified the effect of diabetes on breast cancer risk in Hispanic women.
Investigators interviewed 176 Hispanic women diagnosed with breast cancer from 2004 to 2008. The patients were compared with 464 Hispanic women who had a mammography at the center where the patients' breast cancer was diagnosed.
Diabetes status (including overt and borderline diabetes) and leisure-time physical activity were self-reported. Patients and controls were grouped according to level of physical activity.
Consistent with previous studies, physical activity was associated with a decreased risk of breast cancer. Dr. Sanderson said 61.4% of the breast cancer patients reported no leisure-time activity, whereas patients reporting the most physical activity accounted for 13.1% of the group (OR 0.6, 95% CI 0.3 to 0.9). In the control group, 48% of the women reported no physical activity, and 17% fell into the highest category of physical activity.
Unexpectedly, the researchers said, there was a lower prevalence of diabetes among the breast cancer survivors than in the control group, although the difference was not statistically significant (27.4% versus 33%, OR 0.7, 95% CI 0.5 to 1.1).
Moreover, physical activity had a mixed influence on diabetes' association with breast cancer. Physically inactive breast cancer patients had a 33.6% prevalence of diabetes compared with a 37.1% prevalence among physically inactive controls (OR 0.9, 95% CI 0.6 to 1.6).
However, physically active breast cancer patients had a diabetes prevalence of 17.7%, which was significantly lower than in the control group (29.3%, OR 0.4, 95% CI 0.2 to 0.9).
The researchers noted the need for larger studies to confirm their results. With such confirmation, they said, "the reduction in risk among diabetic women, especially those that exercise, may help explain the lower rate of breast cancer among Hispanic women relative to whites."
The study was supported by the Department of Defense. Dr. Sanderson reported no disclosures.
Primary source: Department of Defense Era of Hope MeetingSource reference:Sanderson M, et al "Diabetes, physical activity, and berast cancer among Hispanic women" Department of Defense Breast Cancer Research Program Era of Hope Meeting 2008.
HIV Life Expectancy Approaching Normal

By Michael Smith
NEW YORK, 28 june 2008-- In the early days of the HIV pandemic, patients could expect only a few years between diagnosis and a final fatal AIDS-associated illness. Now, people with HIV in the developed world are living long enough that other causes of death -- such as cardiovascular disease -- are starting to assume an ever-greater importance.Indeed, some physicians counsel new patients that they can expect an essentially normal lifespan -- as long as they keep taking their HIV medication and don't drop dead of something else.
At the 2006 World AIDS Conference in Toronto, for instance, Stefano Vella, M.D., a former president of the International AIDS Society, told reporters: "Today, I can tell my patients with HIV that they can have a normal life expectancy."
The most recent analyses show that Dr. Vella is wrong -- but not by much.
A computer simulation, using data from U.S. sources, calculated the median lifespan of an adult entering HIV care to be 24.2 years, according to Bruce Schackman, Ph.D., of Weill Medical College of Cornell University, and colleagues. The study appeared in Medical Care in November 2006.
In the study, the median age for entering care was 39, which yields a potential lifespan of 63 years, Dr. Schackman said. On the other hand, a 39-year-old without HIV can probably expect to live well into his or her 70s, he said.
In fact, according to the CDC's national Vital Statistics Report, issued June 11, a 40-year-old American can expect to live another 40.2 years.
"There's still a gap," Dr. Schackman said, but it's a far cry from 1993, when one study estimated a lifespan of just 6.4 years for an HIV patient entering care with a CD4 T cell count of about 500 cells per microliter of plasma.
The major difference is highly active antiretroviral therapy (HAART). Its use began in 1996 and it caused an immediate and precipitous decline in HIV/AIDS mortality, Dr. Schackman said.
But even compared with the first years of HAART, that 24.2 years is a huge jump: a 1997 analysis suggested that the early HAART regimens would add only four years of life expectancy.
By 2006, however, the number of drugs available had expanded and their ease of use -- often a barrier -- had increased, to the point where some patients are able to suppress HIV replication with just one pill a day.
Indeed, Dr. Schackman said, the available drugs and drug regimens "have only gotten better since then."
In an analysis that took a different tack, researchers in British Columbia looked at the life expectancy of a 20-year-old starting HAART in one of three periods -- 1996 through 1999, 2000 through 2002, and from 2003 through 2005.
Rather than using a simulated cohort, as Dr. Schackman and colleagues did, Robert Hogg, M.D., of the University of British Columbia and colleagues looked at more than 26,000 people who started HAART in those periods.
As might be expected, they found that the years of life available to their standardized 20-year-old increased over time -- from 24.3 years in the earliest period to 27.1 in 2000-2002 and 33.2 in 2003-2005.
Living to your early 50s is a far cry from a normal life span, but it is a far cry from not making it out of your 20s.
Dr. Hogg and colleagues reported their findings at the 2007 Conference in Retroviruses and Opportunistic Infections, held a few months after Dr. Schackman and colleagues published their analysis.
Although the exact figures aren't identical to those of Dr. Schackman -- and the starting point of care is different -- they're in the same ballpark.
But even the 24 years suggested by the computer simulation is probably an underestimate, if you consider only medication issues, Dr. Schackman said.
"We were being overly conservative by not considering the fact that innovation will continue in the future," he said. "We could only focus on the technology that existed in 2006, but 24 years from now, there will probably be many new ideas."
In another analysis by Dr. Schackman and colleagues, antiretroviral medications accounted for 70% of the lifetime costs of HIV medical care.
On the other hand, Dr. Schackman said, the researchers also did not consider some of the implications of a long life with HIV -- such as the increased risk of cardiovascular disease.
Indeed attendees at the 2006 AIDS meeting were told that 9% of HIV patients now die from heart disease, 15% from liver disease, and 8% from cancer.
The interaction between HIV, the medications, and the human body is still not well understood and it will require years of study on large numbers of patients to work out the details, Dr. Schackman said.
"There may be things about HIV disease itself that affect the risk of other chronic diseases," he said, and what those are will only emerge with time.
Luckily, for people with HIV who have access to HAART, time is what they have.
The study was supported by the National Institute of Allergy and Infectious Diseases, the National Institute on Drug Abuse, and the Agency for Healthcare Research and Quality. Dr. Schackman did not report any conflicts.
Primary source: Medical CareSource reference:Schackman BR, et al "The lifetime cost of current human immunodeficiency virus care in the United States" Med Care 2006; 44: 990-997. Additional source: CROI 2007Source reference: Hogg R, at al "Life expectancy of persons at the time of initiating cART in high-income countries" 14th Conference on Retroviruses and Opportunistic Infections 2007; Abstract 972.