Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

This article has been revised to reflect the following correction:

Correction: November 29, 2012

An earlier version of this article misstated the number of traits included in the proposed criteria for narcissistic personality disorder.   The final proposal relies on two personality traits, not four.

Read More..

Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

This article has been revised to reflect the following correction:

Correction: November 29, 2012

An earlier version of this article misstated the number of traits included in the proposed criteria for narcissistic personality disorder.   The final proposal relies on two personality traits, not four.

Read More..

State of the Art: Tablets Are Hot Holiday Gifts, but Which One to Buy? — Review

From left: J. Emilio Flores for The New York Times, Jim Wilson/The New York Times, Everett Kennedy Brown/European Pressphoto Agency

From left, the Kindle PaperWhite, the iPad Mini and the  Nexus 7.

The other day, I joined NPR for a segment about high-tech holiday gifts. I was ready for the calls from listeners. I’d brushed up on cameras, phones, laptops, music players and game consoles. I was prepared to talk about limiting screen time, digital addiction, cyberbullying. I knew where to get the best deals.

But all six callers had the same question: “What tablet should I get?”

There were variations, of course. “ — for my kid?” “ — for my elderly father?” “ — just for reading?” “ — for not much money?” But in general, it was clear: the gadget most likely to be found under the tree this year is thin, battery-powered and flat.

No wonder people are confused. The marketplace has gone tablet-crazy. There’s practically a different model for every man, woman and child.

There’s the venerable iPad, of course. And now the iPad Mini. There are new tablets from Google, also in small and large. There are Samsung’s Note tablets in a variety of sizes, with styluses. There are $200 touch-screen color e-book/video players. There’s a new crop of black-and-white e-book readers. There are stunningly cheap plastic models you’ve never heard of. There are tablets for children (and I don’t mean baby aspirin).

So how are you, the confused consumer, supposed to keep tabs on all these tablets? By taking this handy tour through the jungle of tablets 2012. Keep hands and feet inside the tram at all times.

DIRT-CHEAP KNOCKOFFS You can find no-name tablets for $100 or even less. You can also find mystery-brand Chinese tablets in toy stores, marketed to children.

Don’t buy them. They don’t have the apps, the features, the polish or the pleasure of the nicer ones. The junk drawer is already calling their names.

E-BOOK READERS The smallest, lightest, least expensive, easiest to read tablets are the black-and-white e-book readers. If the goal is simply reading — and not, say, watching movies or playing games — these babies are pure joy.

Don’t bother with the lesser brands; if you’re going to get locked into one company’s proprietary, copy-protected book format, you’ll reduce your chances of library obsolescence if you stick with Amazon or Barnes & Noble.

Each company offers a whole bunch of models. But on the latest models, the page background lights up softly, so that you can read in the dark without a flashlight. (These black-and-white models also look fantastic in direct sun — now you get the best of both lighting conditions.)

The one you want is the Kindle PaperWhite ($120), whose illumination is more even and pleasant than the equivalent Nook’s.

Of course, plain, no-touch, no-light Kindles, with ads on the screen saver, start as low as $70. But the light and the touch-screen are really worth having.

COLOR E-READERS/PLAYERS Amazon and B.& N. each sell a seven-inch tablet that, functionally, lands somewhere between an e-book reader and an iPad. They have beautiful, high-definition touch-screens. They play music, TV shows, movies and e-books. They can surf the Web. They even run a few handpicked Android apps like Netflix and Angry Birds.

They’re nowhere near as capable as full-blown, computerlike tablets of the iPad/Nexus ilk, mainly because there are so few apps, accessories and add-ons. But they cost $200; you’re paying only a fraction of the price.

The big two here are, once again, Amazon and B.& N. If you’re not already locked in to one of those companies’ books and videos because you owned a previous model, the Nook HD is the one to get. It’s much smaller and lighter than the Kindle Fire HD. It has a much sharper screen. And the $200 price includes a wall charger (the Fire doesn’t) and no ads (the Fire does). Or get the classy Google Nexus 7, also $200. Although its book/music/movie catalog is far smaller, its Android app catalog is far larger (but see “iPad versus Android,” below).

BIG COLOR READERS/PLAYERS This year, both Amazon and B.& N. have introduced jumbo-screen (9-inch) versions of their HD tablets. Here again, B.& N. offers a better value than its 9-inch Kindle Fire HD rival. For $270, the Nook HD+ offers a sharper screen, lighter weight, no ads, a memory-card slot and a wall charger.

E-mail: pogue@nytimes.com

Read More..

General Assembly Grants Palestine Upgraded Status in U.N.

Chang W. Lee/The New York Times

President Mahmoud Abbas of the Palestinian Authority spoke at the United Nations before the General Assembly voted on Palestine's status as a “nonmember observer state” on Thursday.

UNITED NATIONS — More than 130 countries voted on Thursday to grant Palestine the upgraded status of nonmember observer state in the United Nations, a stinging defeat for Israel and the United States and a boost for President Mahmoud Abbas of the Palestinian Authority, who was weakened by the recent eight days of fighting in Gaza.

The new ranking could make it easier for the Palestinians to pursue Israel in international legal forums, but it remained unclear what effect it would have on attaining what both sides say they want — a two-state solution.

Still, the vote offered a showcase for an extraordinary international lineup of support for the Palestinians and constituted a deeply symbolic achievement for their cause, made even weightier by arriving on the 65th anniversary of the General Assembly vote that divided the former British Mandate of Palestine into two states, one Jewish and the other Arab — a vote that Israel considers the international seal of approval for its birth.

In the West Bank city of Ramallah, about 2,000 Palestinians gathered to celebrate in a central square named after the late Palestinian leader Yasser Arafat. Security forces fired into the air and people applauded, danced in the streets and honked car horns when the results were broadcast to the crowd.

“We are witnessing exceptional moments after 65 years of injustice, suffering and pain,” said Jibril Rajoub, the member of Fatah Central Committee. “We are going to witness an Israeli American efforts to keep this resolution ink on paper.”

The tally, in which 138 members voted yes, 9 voted no and 41 abstained, took place after a speech by Mr. Abbas to the General Assembly, in which he called the moment a “last chance” to save the two-state solution amid a narrowing window of opportunity.

“The General Assembly is called upon today to issue a birth certificate of the reality of the state of Palestine,” he said before the vote.

But in the run-up to the vote, he and Ron Prosor, the Israeli ambassador to the United Nations, blamed the other side for not doing enough to pursue peace.

”We have not heard one word from any Israeli official expressing any sincere concern to save the peace process,” Mr. Abbas said.

“On the contrary, our people have witnessed, and continue to witness, an unprecedented intensification of military assaults, the blockade, settlement activities and ethnic cleansing, particularly in occupied East Jerusalem, and mass arrests, attacks by settlers and other practices by which this Israeli occupation is becoming synonymous with an apartheid system of colonial occupation, which institutionalizes the plague of racism and entrenches hatred and incitement.”

“The moment has arrived for the world to say clearly: enough of aggression, settlements and occupation,” he said.

Mr. Prosor, speaking after Mr. Abbas but before the vote was taken, said the United Nations resolution would do nothing to advance the process.

“Today the Palestinians are turning their back on peace,” he said. “Don’t let history record that today the U.N. helped them along on their march of folly.”

As expected, the vote won backing from a number of European countries, and was a rebuff to intense American and Israeli diplomacy. In an indication of the bitterness of the blow to the Israelis, the office of Prime Minister Benjamin Netanyahu released a statement calling Mr. Abbas’s speech “defamatory and venomous” that was “full of mendacious propaganda against the IDF and the citizens of Israel.”

“Someone who wants peace does not talk in such a manner," the statement continued.

Among the countries that had forecast their yes votes were France, Spain and Switzerland. Germany and the United Kingdom were among the countries that abstained, and a few countries joined Israel and the United States in voting no.

After the vote, Susan E. Rice, the American ambassador to the United Nations, explained the American vote as a reaction to an “unfortunate and counterproductive” resolution that placed “further obstacles in the path to peace.”

Reporting was contributed by Michael R. Gordon and Mark Landler from Washington, Isabel Kershner from Jerusalem, Khaled Abu Aker from Ramallah, and Nicholas Kulish from Berlin.

Read More..

Chamber Competes to Be Heard in Fiscal Debate

WASHINGTON — After months of sparring with President Obama in the heat of the campaign season, Chamber of Commerce executives came to the White House this week with a far more conciliatory tone, offering up suggestions to avert large budget cuts without having to raise taxes.

Jim Young/Reuters

Tom Donahue, the president of the Chamber of Commerce, with President Obama last year. The two have been involved in a showdown on the federal budget deficit.

But Mr. Obama’s top advisers were not budging. There would be no deal on the federal budget deficit, they told chamber executives, without higher taxes, participants said. If there were doubts about the White House’s resolve, Mr. Obama met the chamber’s chief executive afterward for an unscheduled Oval Office chat about the showdown.

For the United States Chamber of Commerce, long the leading business voice in Washington, this month’s negotiations over the nation’s debt will be a key test of whether it can retain its influence and swagger in the capital even after a string of bruising political losses.

Many business leaders are looking to the chamber as a bulwark against the White House’s push for higher taxes, but it is unclear if the century-old association has the clout it once did. Other business groups seen as more open to tax increases have become players in the negotiations, exposing rifts in the private sector.

The Chamber of Commerce, in the biggest voter mobilization effort in its history, spent tens of millions of dollars in support of pro-business candidates, usually Republicans, in the Nov. 6 elections. But the results were disastrous: out of 48 House and Senate candidates that it spent money to try to either elect or defeat, the outcome went the chamber’s way only seven times, according to data from the Center for Responsive Politics, a Washington research group that tracks political spending.

If the chamber was an 800-pound gorilla before the elections, “now they’re a wounded 500-pound gorilla,” said Cyrus Mehri, a Washington lawyer for U.S. Chamber Watch, a union-backed group that is critical of the chamber’s political practices.

“But they’re still a major force to be reckoned with,” he added.

As the White House looks to work out a deal with Congress to avert hundreds of billions of dollars in automatic budget cuts at the end of the year, Mr. Obama and his top economic advisers have been meeting through the week with business leaders to push their plan for raising taxes on the wealthiest Americans.

Mr. Obama met Wednesday with chief executives from Goldman Sachs, Coca-Cola, Yahoo and other prominent firms, and he met a day earlier with small-business representatives.

The president’s advisers also met with officials from the Campaign to Fix the Debt, a centrist group that has become influential in pushing for a combination of tax increases and spending cuts. It is led by Erskine B. Bowles, a former Clinton administration official, and Alan K. Simpson, a former Republican senator from Wyoming.

When Mr. Obama met two weeks ago with a dozen corporate leaders but did not invite the Chamber of Commerce, it was widely seen as a snub of the group over its political attacks during the presidential campaign. But the chamber got its turn Monday.

Jack Lew, the White House chief of staff, and other senior economic advisers listened as chamber executives, including Thomas J. Donohue, the group’s president, and Bruce Josten, its top lobbyist, laid out their ideas for raising significant revenue without necessarily raising taxes by expanding energy development.

“They wrote it down, but where that goes, I don’t know,” Mr. Josten said in an interview.

But Mr. Josten said that the White House advisers stressed that any debt deal would have to include increased taxes at the highest brackets and that if an agreement could not be reached, they were willing to risk the automatic spending cuts — the so-called fiscal cliff option — at the end of the year.

“They reiterated that they want the higher rates, and they’ll go over the cliff if they need to,” Mr. Josten said.

Read More..

Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

Read More..

Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

Read More..

Peter Swire Named Mediator in Internet ‘Do Not Track’ Effort

Over the last few months, an international effort to give consumers more control over the collection of their online data has devolved into acrimonious discussions, name-calling and witch hunts.

Andrew Spear for The New York Times

Peter Swire, a law professor and former White House privacy official, will be the new co-chairman of an international consortium's Tracking Protection working group.

The idea was to work out a global standard for “Do Not Track,” a computer browser setting that would allow Internet users to signal Web sites, advertising networks and data brokers that they did not want their browsing activities tracked for marketing purposes.

But some industry executives involved in the negotiations have questioned the agenda of privacy advocates, saying their efforts threaten to undermine an advertising ecosystem that fuels free online products and services. At the same time, some technology experts and privacy advocates have accused industry executives of stalling and acting in bad faith.

Into this rancorous battle steps a new mediator, Peter Swire, a professor of law at Ohio State University and a former White House privacy official during the Clinton administration. On Wednesday, the World Wide Web Consortium, or W3C, the international consortium that has been trying to develop technical Do Not Track standards, said that Mr. Swire would take over as co-chairman of its Tracking Protection Working Group.

While parties on both sides welcomed the move, many said they were doubtful that Mr. Swire could bring opponents to agreement, especially at a time when some industry groups are questioning whether the W3C is an appropriate forum.

On one hand, industry executives have an interest in protecting “behavioral” ads, marketing pitches that use data about an individual’s online activities to tailor ads to that person. On the other hand, consumer advocates argue that Internet users should be able to limit that kind of online surveillance.

Mr. Swire, a former chief counselor for privacy at the Office of Management and Budget, said he hoped to strike a balance that was palatable to both sides. He said he viewed a Do Not Track system as a kind of digital equivalent to the Do Not Call list, a national registry in the United States through which consumers may opt out of phone solicitations.

“People can choose not to have telemarketers call them during dinner. The simple idea is that users should have a choice over how their Internet browsing works as well,” Mr. Swire said in a phone interview. But he added: “The overarching theme is how to give users choice about their Internet experience while also funding a useful Internet.”

Still, Mr. Swire may not be able to overcome the bitterness that remains among the negotiating parties after months of public accusations, personal attacks and recriminations.

Earlier this year at an event at the White House, industry representatives publicly committed to incorporating and honoring a browser-based Do Not Track system under certain conditions. The conditions included a requirement that individual users would actively choose to turn on a don’t-track-me setting. Industry groups also said any system should still permit companies to collect information about users’ browsing activities for market research and product development purposes.

But after months of wrangling with consumer advocates, industry representatives now say the W3C is not an appropriate forum for them to work out policy details, arguing that the group’s expertise is more technical than practical.

In an online discussion forum for the working group, for example, senior industry executives have suggested that respected technology experts are out of touch with commercial reality.

“The advocacy side of the group tends to lean toward absolutist terms and solutions,” Shane Wiley, the vice president for privacy and data governance at Yahoo, wrote in a message in September to Ed Felten, a professor of computer science and public affairs at Princeton University. “The real world isn’t that easy even if it feels that way in a classroom or a small lab.”

Then there are the technologists who say industry executives are playing down the privacy risks of online data-mining.

“For want of a better metaphor: you are the climate change skeptic of computer privacy,” Jonathan Mayer, a graduate student in computer science and law at Stanford University, wrote last month to Yahoo’s Mr. Wiley. “Unlike some of the more patient members of the group, I long ago ceased pretending you’re negotiating in good faith.”

Now the industry has begun an effort to distance itself from the W3C process and promote its own self-regulatory program that allows consumers to decline targeted advertising by installing opt-out buttons from dozens of member companies.

“We’ve seen the W3C falter,” said Mike Zaneis, the general counsel for the Interactive Advertising Bureau, an industry trade group. “So industry is redoubling its efforts to come up with a meaningful standard for browser controls.”

As the debate rages on, newer iterations of popular browsers like Microsoft’s Internet Explorer and Google’s Chrome have already installed Do Not Track settings for their users. But in the absence of accepted global standards for these systems, ad networks and data brokers are not yet honoring the don’t-track-me browser flags. Even Microsoft’s and Google’s own ad services don’t respond to such signals coming from their own browsers.

Although Mr. Swire said he hoped to spur progress, for the moment Do Not Track browser settings have no more significance than emoticons.

“Do Not Track is a work in progress,” Mr. Swire said. “So is the Internet.”

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As Opposition Coalition Meets in Cairo, More Violence Kills Dozens in Syria

Francisco Leong/Agence France-Presse — Getty Images

Rebels celebrated on top of a downed Syrian jet in Daret Azzeh, 20 miles west of Aleppo, on Wednesday.

In its first major effort to show that it can be a viable political force, the newly formed Syrian opposition coalition started talks in Egypt on Wednesday aimed at forming an alternative to the government of President Bashar al-Assad and paving the way for more international acceptance and aid.

The coalition, whose official name is the National Coalition of Syrian Revolutionary and Opposition Forces, was formed at a meeting in Qatar this month and has been recognized by Britain, France, Turkey and the Gulf Cooperation Council. To win further support from foreign capitals, it must tackle the broader problems of uniting the many opposition groups in exile and the rebels on the ground in Syria.

Delegates were expected to hold their second day of talks in a Cairo hotel on Thursday against the backdrop of a 20-month civil war in which about 40,000 people have been killed in clashes between armed rebels and jihadist fighters on one side and Mr. Assad’s forces on the other. The rebels appear to be gaining in their strategy to challenge the air supremacy of Mr. Assad’s military.

There were reports on Wednesday that for the second successive day, insurgents had shot down a government aircraft. Video posted on the Internet by rebels showed an airplane tail assembly jutting out of debris. Such videos are difficult to verify, but the episode on Wednesday seemed to be confirmed by other witnesses.

“We watched a Syrian plane being shot down as it was flying low to drop bombs” on the town of Daret Azzeh, 20 miles west of Aleppo and close to the Turkish border, said Ugur Cuneydioglu, who said he saw the aircraft being downed from a Turkish border village in southern Hatay Province. “It slowly went down in flames before it hit the ground. It was quite a scene,” Mr. Cuneydioglu said.

The video said the plane had been brought down by “the free men of Daret Azzeh soldiers of God brigade.”

On Tuesday, Syrian rebels said they shot down a military helicopter with a surface-to-air missile outside Aleppo.

The violence on Wednesday also included car bombs in a Damascus suburb that killed dozens of people.

In their first meeting since their umbrella organization was created in Doha, Qatar, on Nov. 11, coalition delegates confronted the realities of the political terrain. Disagreements emerged over the coalition’s composition when one member, the Syrian National Council, tried to increase the number of its representatives.

“Nothing will proceed until we work this out,” said one council member who spoke on condition of anonymity, according to Reuters.

The focus also seemed to be more on deciding how leadership candidates should be chosen rather than on who they might be. “I don’t think we’ll be discussing the election of a transitional government during the meeting today,” said Khaled Khoja, a coalition member. “We’re still discussing whether to have a government or to have committees instead.”

While the group, and the talks, are in their infancy, members appeared to recognize that world supporters were watching for results. Mr. Khoja said that while the group was discussing the coalition’s structure, it wanted to “see the outcome of the meeting in Morocco before deciding on the government.”

He was referring to a meeting planned for next month in Morocco of the so-called Friends of Syria group of nations, which includes the United States. At a meeting in New York City in September that included foreign ministers and Syrian opposition leaders, the group offered modest pledges of support for opponents of the Assad government. The opposition had unified under international pressure to give provinces better representation, and ideally, to oversee the disparate rebel factions while also providing a counterweight to the well-armed jihadist groups in the country.

The conflict has also flared along Syria’s borders with Lebanon, Israel, Turkey and Jordan.

In Turkey, which was once an ally of the Assad government, a team of NATO inspectors visited sites on Wednesday where the alliance might install batteries of Patriot antiaircraft missiles.

Another video on Wednesday showed a rebel fighter holding what appeared to be a complete SA-16 heat-seeking, shoulder-fired missile.

The man claimed to have shot down both the airplane and the helicopter, and said the missiles had been captured by rebels when they overran Base 46 outside Aleppo earlier this month.

High-profile tactical successes in the war have often been followed by videotaped claims of responsibility, and in part are seen as fund-raising opportunities for the fighters. Many claims, including those by the rebel fighters, are impossible to verify immediately.

But it was significant. The SA-16 is more modern and capable than the more commonly seen SA-7. It flies at a faster speed, can be used against aircraft at much wider range of attack angles, has a longer range and is promoted by its Russian exporters as being more resistant to an aircraft’s efforts to thwart it.

Its presence suggested that the rebels have been acquiring more weapons and could be mounting a more meaningful challenge to the Syrian Air Force.

State news media said on Wednesday that two car bombings struck Jaramana, a suburb of Damascus that is populated by members of the Christian and Druse minorities.

The SANA news agency said the death toll was at least 34. An activist group based in Britain, the Syrian Observatory for Human Rights, said 47 people were killed.

Christine Hauser reported from New York, and Hala Droubi from Dubai, United Arab Emirates. Reporting was contributed by Alan Cowell from London; Sebnem Arsu from Istanbul; Hania Mourtada from Beirut, Lebanon; and C. J. Chivers from the United States.

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United Is Struggling Two Years After Its Merger With Continental

Nam Y. Huh/Associated Press

A United 787 Dreamliner at O’Hare International Airport in Chicago. United lost $103 million through the third quarter of 2012.

CHICAGO — It was supposed to be a moment for celebration: United Airlines observing the delivery of its second Boeing 787 Dreamliner with a flight from Seattle to Chicago earlier this month for a select group of employees, while senior officers, including Jeffery A. Smisek, United’s hard-charging chief executive, served Champagne and took lunch orders.

Jad Mouawad/The New York Times

Jeff Smisek, the chief of United Airlines, served champagne on a flight to celebrate delivery of a Boeing 787 on Nov. 15.

But before the flight took off that morning, a computer glitch in one of the airline’s computer systems delayed 250 flights around the world for two hours.

So it goes at United these days. The world’s biggest airline, created after United merged with Continental Airlines in 2010, promised an unparalleled global network, with eight major hubs and 5,500 daily flights serving nearly 400 destinations. As an added benefit, the new airline would be led by Mr. Smisek of Continental, which was known for its attention to customer service.

But two years on, United still grapples with a myriad problems in integrating the two airlines. The result has been hobbled operations, angry passengers and soured relations with employees.

The list of United’s troubles this year has been long. Its reservation system failed twice, shutting its Web site, disabling airport kiosks and stranding passengers as flights were delayed or canceled. The day of the 787 flight, another system, which records the aircraft’s weight once passengers and bags are loaded, shut down because of a programming error.

United has the worst operational record among the nation’s top 15 airlines. Its on-time arrival rate in the 12 months through September was just 77.5 percent — six percentage points below the industry average and 10 percentage points lower than Delta Air Lines. It had the highest rate of regularly delayed flights this summer, and generated more customer complaints than all other airlines combined in July, according to the Transportation Department.

The airline even angered the mayor of Houston, Continental’s longtime home and still the carrier’s biggest hub, when it unsuccessfully sought to block Southwest Airlines’ bid to bring international flights to the city’s smaller airport, Hobby. 

The United-Continental merger is weighing on the company’s finances. It took a $60 million charge in the third quarter for merger-related expenses, including repainting planes. It also took a $454 million charge to cover a future cash payment to pilots under a tentative deal reached in August.

While most large airlines reported profits this year, United has lost $103 million in the first three quarters of 2012, with revenue up just 1 percent to $28.5 billion. Its shares are up 7 percent this year compared with a 12 percent gain for the Standard & Poor’s 500-stock index and a 24 percent gain for Delta.

“United remains at a challenging point,” analysts from Barclays wrote last month, and they forecast that the carrier would not begin to see the benefits of its merger until late in 2013 and into 2014. Still, while airlines initially struggle, mergers increase revenue eventually, as the example of Delta’s acquisition of Northwest Airlines demonstrated two years ago.

Mr. Smisek, taking a break from serving coffee halfway through the maiden 787 flight, acknowledged that things were not going as fast as expected, particularly given the aggressive targets he set two years ago. Back then, Mr. Smisek said the merger would be wrapped up in 12 to 18 months. He has since learned to be patient, he said.

“It is still a work in progress,” he said. “The integration of two airlines takes years. It’s very complex. If you look at where we were two years ago, we’ve come a long way.”

Admittedly, the process is complicated. Airline mergers mean combining different technologies, often old computer systems, as well as thousands of procedures used by pilots and flight dispatchers, gate agents, flight attendants and ground crew.

Setbacks are common. Like United, US Airways experienced a breakdown in its booking technology after its combination with America West in 2005. Delta’s on-time performance fell sharply in the year after its purchase of Northwest.

But today, Delta is a leader among big airlines in on-time performance. US Airways had a record third-quarter profit even though it still lacks common work rules for its pilots seven years after its merger.

United has completed many of its merger tasks, particularly as far as passengers are concerned. It has received its single operating certificate from the Federal Aviation Administration, allowing it to run a combined fleet. Despite all the problems this summer, it claims to have finally merged the reservation and technology systems.

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