Tag Archives: epidemic

Influenza Toys with the Human Race

The current U.S. influenza seasonal epidemic, the mildest in years, is in its death throes, based on infection trends over the past several weeks, including the most recent data released on May 11 by the Centers for Disease Control and Prevention.

During the week that ended on May 5, 13.7% of U.S. respiratory surveillance specimens tested positive for influenza, continuing the clear downhill slope of U.S, flu cases since this season’s U.S. epidemic peaked at 30% positive during the week of March 11-17. The CDC hasn’t yet declared the current, 2011-2012 flu-season’s epidemic, which started in late February, officially over—it can’t until the influenza-positive rate falls back below 10%–but the epidemic curve’s steep downward track (see graphic) is as well defined as the far side of L’Alpe d’Huez.

graphic courtesy of the CDC

With the current influenza epidemic nearly ended, the season’s numbers paint a decidedly benign picture. So far, 22 children have died from influenza; if that figure continues to grow as it has so far it will top out as the lowest since the CDC began collecting these data in 2004.

Other markers of how mild the 2011-2012 season has been include the number of U.S. patients hospitalized for influenza, which sits below past seasons, and the proportion of deaths attributable to pneumonia or influenza has hovered below the epidemic threshold for that measure all season.

During a winter and spring where the influenza world focused on mammalian-transmissible H5N1 flu, strains dubbed by some the “doomsday” virus, having such a mild seasonal flu season tossed at us can’t help but be seen as some ironic, natural-world prank. On a purely rationale basis, year-to-year variations in seasonal flu have nothing whatsoever to do with the looming danger from H5N1 flu, but with this infectious-disease juxtaposition I can’t help but imagine that somewhere, off in the distance, I hear a quiet, cosmic chortle.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Blognosis, IMNG, Infectious Diseases, Internal Medicine, Internal Medicine News

Obesity, Diabetes are the Epidemics; Is Bariatric Surgery the Cure?

The quick answer to this question is yes, at least for many (as opposed to all) patients, and at least according to the bariatric surgeons I heard and spoke with at their society meeting in mid-June. My take from that meeting was that bariatric surgery is working wonders these days–of course for obesity, but for type 2 diabetes too. It’s remarkably safe, yet way underused. Will that change soon? Is a golden age of bariatric surgery dawning, and will the big, two-headed medical epidemic now rampaging get tamed as a result?

Roux-en-Y gastric bypass; courtesy NIDDK, Wikimedia Commons

It’s a tall order, but my bet is on bariatric surgery, and there are hints that its long-standing status as the wallflower of surgical interventions may be shifting.

Last March, the International Diabetes Federation issued a position statement on bariatric surgery saying that it should be “considered earlier in the treatment of eligible patients.” The statement called bariatric surgery “an accepted option in people who have type 2 diabetes and a body mass index of 35 kg/m2 or more.” And for patients with a BMI of 30-35 kg/m2 the statement said that bariatric surgery “should be considered an alternative treatment option” for patients inadequately controlled by optimal medical therapy, especially when they also have major cardiovascular disease risk factors.

To someone like me, previously unfamiliar with where bariatric surgery stood these days, some of the facts I gleaned at the meeting were eye-opening. The perioperative mortality rate for laparoscopic gastric bypass surgery (Roux-en-Y), the type of bariatric surgery considered most practical and effective for treating types 2 diabetes by most surgeons I ran into, fell to a rate of 6/10,000 patients treated in 2009 at about 360 U.S. academic medical centers and affiliated hospitals. The non-fatal complication rates and need for repeat hospitalization was also low, placing the risk from bariatric surgery these days squarely in the ranks of many “routine” surgeries, such as hip replacement, appendectomy,  and gallbladder removal for stones. Gastric band placement is safer still, though not as effective for resolving type 2 diabetes.

The diabetes effect from gastric bypass is also impressive. One recent study compared 46 patients with diabetes who underwent laparoscopic gastric bypass at the Gundersen Lutheran Health System in La Crosse, Wis., with 41 matched patients with type 2 diabetes who remained on their standard medical treatment during 2001-2005.  One year after surgery, the average hemoglobin A1c in the surgery patients stood at a normal 5.8%, compared with their average baseline value of 7.4%. Twenty-seven of these 46 (59%) were in full diabetes remission, meaning they were off all diabetes medications and their HbA1c was below 6.0%. In contrast, just 2 of the 41 conventional-treatment patients (5%) went into remission a year after their baseline.

“If there was a pill that achieved remission rates like this and had a safety profile like this and you didn’t offer it to your patients it would be unethical,” said Dr. Shanu N. Kothari, director of the minimally invasive bariatric surgery center at Gundersen and lead author of this study.

Yet bariatric surgery is neglected by most patients–be they just obese or obese with type 2 diabetes–and by their physicians. At the meeting I heard that about 200,000 U.S. bariatric surgeries are done annually now, a scope dwarfed by the number of patients who are candidates.

Why the neglect? Several surgeons at the meeting noted the disconnect between acceptance in the medical community of bariatric surgery relative to just about every other type of medically driven surgery out there.

What’s also striking is that bariatric surgery’s success contrasts with the problems that medical weight loss and maintenance has faced recently. During the past year or so, the Food and Drug Administration has shot down lorcaserin (Lorqess), the combination of phentermine and topiramate (Qnexa) , and another combination, bupropion and naltrexone (Contrave), all because of concerns that these agents might cause cardiovascular adverse events. In contrast, a report at the bariatric surgery meeting showed that all forms of bariatric surgery actually led to significant reductions in cardiovascular disease events as well as increased patient survival.

With medical management of obesity in sorry shape, and lots of evidence building for surgery’s safety and efficacy, the ascendance of a surgical solution to obesity and diabetes may have begun.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Blognosis, Cardiovascular Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Practice Trends, Primary care, Surgery