Apr 26, 2013

A $5.5 Billion Road Map To Banish Polio Forever

by Jason Beaubien, NPR

April 26, 2013

Polio isn't going easily into the dustbin of history.
The world needs to push it in, throw down the lid and then keep an eye out to make sure it doesn't escape.
That's the gist of a new plan released Thursday by the World Health Organization and other foundations at a vaccine meeting in Abu Dhabi, United Arab Emirates.
It's a six-year, $5.5 billion program, and its goal is to wipe out polio for good.
The plan calls for attacking the remaining pockets of polio in the last endemic countries — Afghanistan, Pakistan and Nigeria — with mass immunization campaigns. It would boost polio surveillance globally and set up systems to respond rapidly in case outbreaks do occur.
At the same time, the new Polio Eradication and Endgame Strategic Plan lays out a strategy to switch to an injectable vaccine instead of the ubiquitous oral vaccine. The latter is cheap and easy, but it contains a live virus, which in very rare instances can cause polio.
The road map also looks at how to contain existing samples of the virus in laboratories and how to secure stockpiles of the vaccine in case polio somehow comes back.
Global health leaders who have been going after polio for decades believe they're finally on the verge of crushing it.
In 2011, there were 650 polio cases reported worldwide. Last year that number dropped down to 223. This year, so far there have been fewer than 20.
This trajectory is good news, says Dr. Walter Orenstein at Emory University, who has been working on polio eradication for years.
But the job isn't finished, he says. "The last cases are the hardest," Orenstein tells Shots. "Obviously if they were easy, we would have gotten rid of those reservoirs a long time ago."
Orenstein says the period in between what appears to be the last human case and "the end of polio" is a precarious one.
He points out that the world has appeared close to eradicating polio before. "In 2010, Tajikistan, which had been free of polio for many years, had an introduction of polio from India and had 460 cases," he says, "a massive outbreak."
Less than six months ago, Egyptian health officials found live polio virus circulating in the Cairo sewage system, despite the fact that Egypt hasn't recorded a single case of polio-induced paralysis since 2004.
"I think the information from Cairo points out that as long as we have reservoir countries, polio can travel," Orenstein says. Health workers traced the virus in


"I think the information from Cairo points out that as long as we have reservoir countries, polio can travel," Orenstein says. Health workers traced the virus in Cairo back to Pakistan.
"There's no evidence that polio has been re-established in Egypt, but it's clear that Egypt got exposed because of someone from Pakistan coming there," he says. "All the more reason we need to focus on the reservoir countries as we continue to maintain surveillance everywhere else to make sure it isn't being transmitted in other countries."
India launched a massive campaign to eliminate polio in the late 1990s and seems to have succeeded. There hasn't been a single case recorded in India in more than two years.
But there's a constant fear there that polio could get re-imported and come roaring back, says Deepak Kapur, who heads up Rotary International's efforts to eliminate polio from India.
"We in India have been guilty of exporting polio virus to almost every part of the world," Kapur tells Shots. "And by the same channels by which it went, the virus could well come back into India."
Kapur and others involved in the polio endgame say one of the biggest challenges now and in the coming years is keeping people focused on the final goal until it's clear that polio is really, truly gone.
To see more, visit http://www.npr.org/.Broadcast Dates Morning Edition, April 26, 2013

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Apr 23, 2013

TOTAL JOINT REPLACEMENT IN POST- POLIO

by Marny Eulberg, M.D.
Educational meeting, September, 1992, Mercy Medical Center
Colorado Post-Polio Connections
  

My qualifications are that first I am a physician, a family practice physician not an orthopedic surgeon, so I'll give you the generalities of the surgery not the nitty-gritty of how many parts there are or where the screws go. Secondly I am a polio survivor and had a total joint replacement done in March of this year (1992).
The primary reason for a total joint replacement, in fact pretty much the only reason is severe arthritis of the affected joint. Occasionally the same procedure is used for a severe fracture that cannot be fixed any other way. Several joints can be replaced the most common are hip, knee and finger. There are some physicians woh are doing replacements of wrists, shoulders and ankles. The technology for the last three is still being developed so physicians have not had as much experience but it is a possibility.
There are limitations about total joint replacement in folks who've had polio; when a joint is removed, part of the bones and ligaments holding the bones together are removed and replaced with plastic or metal parts. It now depends on your muscles to hold the joint in place and keep it from dislocating. So it is not generally appropriate nor will it be as useful and work for you if you have a joint replacement in a polio affected extremity, unless you have fairly decent muscles around that joint. If you have a very weak leg and you have arthritis in that knee or hip a total joint replacement may not be a good choice.

Fortunately joints that have not carried much weight do not get arthritis nearly as often, patriculary the wear and tear of degenerative arthritis. Total joint replacement can be useful for folks who had polio if it is in their good leg, a joint that's wearing out from doing work for two legs all these years. It's not the total answer, it's not without problems and risks. We don't know how long the parts last. They have been doing total hips for 25 years, total knees for 15-20 years before they wear out. We're not exactly sure how many times it can be redone...each time some bone is removed so there's probably some limit as to how many times a joint can be replaced. In general orthopedic surgeons are going to want you to wait as long as possible, be as old as possible and still be in good health in order to survive the surgery and recover from it well. Surgeons are reluctant to do surgery on anyone less than 40 or 50 because we don't know how long the parts will last.
After the surgery intensive physical therapy is required to learn how to use the joint and to strengthen the muscles around the joint to get the range of motion back.

There are risks as it is a big surgery: 1) 50% chance of getting blood clots, so anticoagulants are used to thin the blood; 2) there is a chance of infection and if we get infection where we have replacement hardware it is difficult to get rid of and sometimes to get rid of the infection we have to take all the parts out then wait six months to a year before another total joint replacement can be done. Surgeons do use antibiotics before and after surgery, they wear all kinds of fancy headgear, the air is recirculated through special filters in the room. 3) Joint replacement surgery is a bloody surgery so surgeons have their patients donate two or three pints of their own blood before surgery. 4) Also parts can loosen, they are put in with glue but over time normal bones around the glue tend to loosen so over the years there is a 10-15% chance of parts loosening.
It's not all bad. Obviously if you're hurting a lot, getting so you can't do the things you want to do, have restriction of motion so you can't bend down to get things anymore or sit comfortably anymore, or get in and out of the car comfortably anymore. If the surgery is successful, which it is 90 to 99% of the time, you lose the pain and gain more mobility. But you lose the ligaments that were there for stability so it's not quite the same. It's going to feel and be a little more wobbly, it's more likely it may give out in extreme positions. You also lose proprioception [which] is in a joint and also the muscles where you have nerves that tell you where you are in space; tell you whether that joint is straight or bent or partially bent. You can relearn to use some of the other sensors in your muscles but you'll probably feel a little more unsteady on that leg. That can be a problem if that's been your good leg, the one you've always depended on.
Unlike some of you who had orthopedic surgery when you were children or younger, 30 or 40 years ago you were put in a cast for six weeks to six months to heal; now orthopedic surgeons are aware of how important motion is and how joints get stiff.
 Now, shortly after surgery, there are machines called CPM's continuous passive motion, that will start bending your knee up and down continuously for several hours a day; there also are CPM machines for shoulders and other kinds of joints.
Some of the parts of joint replacement are put in with cement, some are cementless. There are advantages and disadvantages of both. Cemented, the joint is weight bearing much more quickly because it's pretty solid within a few days after surgery. Cementless, the bone has to grow into the metal parts and takes the same amount of time to weight on it as a bad break - three to six months before it's full weight bearing.
As smart as we think we are, we are not as good at doing anything as the Creator was when he made the parts in the first place. None of the things we do work as well. We try to duplicate a joint, we try to get close, but the original parts were designed best.

QUESTION: Why don't they do as many wrist replacements?
ANSWER: A wrist is not a weight bearing joint so if it is affected with arthritis it's usually rheumatoid which can affect the whole hand. A wrist is a more complicated joint unlike the hip, which is a ball and socket joint. A knee is actually a lot harder than the hip because a knee is not just bending and straightening when you step on it each time, you also turn it in a little bit and out a little bit so it's been hard to duplicate that internal and external rotation. With a wrist you go up and down, sideways and all sorts of combinations of those movements. In the forearm there are two bones; in your wrist there are six so to duplicate that has been a difficulty.
QUESTION: Is anyone doing any joint replacements in the spine?
ANSWER: No, not that I know of.
QUESTION: What are some of the consequences of knee joint replacement surgery?
ANSWER: The major consequences despite weakened muscles, is the knee may be a little more likely to dislocate, may pop apart and not line up right. But, in three to six months after the surgery you're going to know that. You'll probably do okay unless you get into a real extreme situation where you start falling and putting unusual forces around your knee that might dislocate somebody's normal knee too.
QUESTION: Will total joint replacement eliminate all the pain in the joint?
ANSWER: In a joint replacement you'll lose the bone and nerve fibers in the bone, but you still have nerve fibers in the skin and muscle around that joint. So you may not get total pain relief. One of the signs if the joint is loosening up is pain.
QUESTION: Sometimes surgeons use ground bone graft in re-replacement of the joint. Why don't they use ground bone instead of cement in the first place?
ANSWER: It takes longer to heal. The cement hardens fast, within a day or two and allows the joint to be weight bearing quicker. The ground bone has to heal just like a broken bone so it takes longer before it can bear weight. If you had polio you're going to have to be hopping on your weak leg or trying to walk with crutches or a walker, so you need to have that leg fairly functional as soon as possible.
QUESTION: What are antibiotic marbles?
ANSWER: Antibiotic marbles are just another way of getting the antibiotic right into the joint rather than trying to give it in the vein where it has to go all through the body and hope it gets the right concentration into the right joint. Antibiotic marbles are a way of slowly releasing the antibiotic over a period of time.
QUESTION: How soon can you expect relief from pain after surgery?
ANSWER: In hip surgery it's usually much faster than knee surgery. Sometimes after hip replacement the pain is gone immediately. In knee replacement it will probably take three to six months before you can say, "Ahh, yes, that's better. I'm glad I did it."Source: Colorado Post-Polio Connection, Winter 1992


Apr 21, 2013

The Costs of Excess Weight on Joint Replacement Surgery

Complication rates don’t go up, but hospital costs do.


04/11/2013 | By Jennifer Davis

How does a patient’s weight impact total knee replacement surgery? That was the focus of two studies presented recently at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). While one study, out of Singapore, found that surgical outcomes were not so different between obese and normal-weight patients, a second study, out of the United States, found that the costs were.

Obese patients have long been told to lose weight before undergoing joint replacement surgery in the hopes of reducing complications, achieving faster recoveries and producing better outcomes. But researchers from Singapore didn’t find that to be the case.
The researcher followed 77 obese patients and 224 normal/overweight patients for two years, starting right before surgery. Obese was defined as having a body mass index (BMI) greater than 30. They found that obesity alone did not significantly raise the risk of surgical complications and  – after taking into account age, gender and other health conditions – obese patients overall had outcomes as good as those of normal-weight patients.
“Despite some studies highlighting the increased propensity for wound complications, deep infections and thromboembolism among the obese, these possible complications did not translate to poor clinical outcome in [our study’s] obese group in the short term follow-up of two years,” explains lead study authors Chin Tat Lim, MD, from the University Orthopaedic Hand and Reconstructive Microsurgery Cluster at the National University Health System in Singapore.
Dr. Lim says that because his team’s results don’t indicate that weight has a large effect on the outcome of a knee replacement, perhaps it’s not necessary for doctors to insist that patients lose weight before getting a total joint replacement. “Physicians should not withhold knee replacement therapy from obese patients. Obese patients do seem to benefit in similar ways from knee replacement surgery compared to non-obese patients,” Dr. Lim says.
But others are not convinced. Andrew Urquhart, MD, an associate professor of orthopaedic surgery at the University of Michigan Health System in Ann Arbor, is concerned that Dr. Lim’s study results are based on a relatively small number of participants. More importantly, he says, the researchers didn’t stratify obese patients. He says there can be complications following joint replacement surgery in those with a BMI greater than 35 – and the risks go up even more when BMI tops 40.
“If they chose a BMI cutoff of 35 or 40 I think they would have had a much different outcome,” Dr. Urquhart says. “I think they lumped in so many good performing, slightly obese patients with a BMI just above 30 with the morbidly obese – it skewed their data.”
For a person who is five foot six inches, a BMI of 30 works out to 185 pounds; by contrast, that same person with a BMI of 40 would weigh 247 pounds – and that patient would be different from a surgical perspective. “To me, someone who is five foot six at 250 pounds is a much different patient and different risk profile than someone who is five foot six and 185 pounds,” he says, noting that in the US, a person with a BMI of 30 may not necessarily be viewed as obese. “Our cutoff [at the University of Michigan] for elective arthroplasty surgery at five foot six is 247 pounds.”
In the second study, researchers from the Mayo Clinic in Rochester, Minn., analyzed 8,129 patients who had 6,475 primary total knee replacements and 1,654 revision knee replacements at a large U.S. medical center between January 2000 and September 2008. The patients were stratified into eight groups based on BMI and – after taking into account age, general health and type of surgery – costs associated with their surgeries were compared.
As with the first study, increasing BMI was not associated with a higher risk of complications (in this case, within 90 days). But it was associated with significantly longer hospitals stays. Patients with a BMI less than 35 had the shortest hospital stays and lowest costs associated with the procedure. And irrespective of comorbidities or complications, increasing BMI caused longer hospital stays and higher hospitalization costs. Every five-unit increase in BMI over 30 caused hospital costs to rise about $250 to $300 for patients getting their first joint replacement and $600 to $650 for those getting a revision surgery.
“What this paper is saying is you don’t need to be super obese to have higher costs. There are costs associated with obesity even among less obese people. It’s a continuum,” says lead author Hilal Maradit-Kremers, MD, an associate professor of epidemiology at the Mayo Clinic. “The cost is there – hidden in many other things like operating room cost and room and board and the type of devices and prostheses they use.”
Dr. Maradit-Kremers says, because total knee replacements are one of the most common elective surgical procedures in the U.S., this study highlights the hidden cost of obesity for the nation’s healthcare system. Even “small” cost increases at the individual level translate to big increases in costs at the population level.
The same researchers also presented a poster at the AAOS conference on a separate but related study of nearly 9,000 patients who had primary and revision hip replacements. It shows obesity causes costs to jump during hip replacement procedures as well – even more than the jump in cost related to knee surgery – in part due to higher baseline costs. Every 5-unit increase in BMI above 30 costs $500 more in hospital costs and $900 more in 90-day costs for patients getting their first hip replacement. For patients having a revision hip replacement, every 5-unit increase in BMI above 30 costs $800 more in hospital costs and $1,500 more for 90-day costs.
Dr. Urquhart calls these studies impressive, because they take into account different degrees of obesity. “It’s nice that they were able to prove what we anecdotally have seen: the bigger the patient is, the more staff assistance you need to get them out of bed, the longer the surgery,” he says.
Dr. Urquhart says he believes the bottom line is that anyone considered obese will improve their general health and surgical outcomes by losing weight before undergoing an elective procedure. And even if patients haven’t previously been able to lose weight on their own, he says they are often able to do it if joint replacement surgery is their goal.
“It’s a really tough conversation but it’s a conversation that has to happen,” Dr. Urquhart says, noting that there is a lot of interplay between obesity and arthritis.

25 Treatments for Arthritis Hip and Knee Pain

Guidelines recommend combining drugs with non-medicinal remedies.

When it comes to treating osteoarthritis in your knees and hips, you may have more options than you realize. In February 2008, the Osteoarthritis Research Society International (OARSI), a nonprofit organization dedicated to promoting osteoarthritis research and treatment, published its first evidence-based recommendations for treatment of osteoarthritis of the hip and knee. The goal was to eliminate inconsistent treatment approaches by creating simple guidelines that would enable health care providers to determine which therapies would be most useful for an individual patient.
The committee took the scientifically proven commonalities it found in the international literature, evaluated the level of scientific evidence, proposed a strength of recommendation for each modality, and then condensed them into a comprehensive “playbook” of 25 treatment recommendations. The first of the 25 recommendations is to combine drug and non-drug treatments for optimal results. The remaining 24 fall into three categories: non-drug, drug and surgical. Following are the 25 recommendations with updates and links to further reading by Arthritis Today.
1. Drug and non-drug treatments. The optimal osteoarthritis (OA) treatment program should consist of both medications and non-drug treatments.
Non-drug treatments
2. Education and self-management. The initial focus of treatment should be on what patients can do for themselves, rather than on passive therapies delivered by a health professional.  
3. Regular telephone contact.  The best evidence for the benefit of phone contact came from a study of 439 OA patients in which monthly phone calls from lay personnel promoting self-care were associated with improvements in joint pain and physical function for up to a year.
4. Physical therapy. Studies consistently support the usefulness of an evaluation by a physical therapist and instruction in appropriate exercise to reduce pain and improve function. Physical therapists can also provide assistive devices to make daily tasks easier.
5. Aerobic, muscle-strengthening and water-based exercises. A roundedexercise program can promote muscle strength, improve range of motion, increase mobility and ease pain. 
6. Weight loss. Maintaining your recommended weight or losing weight if you are overweight can lessen your pain by reducing stress on your affected joints. Weight loss specifically helps ease pressure on weight-bearing joints such as the hips and knees. 
7. Walking aids. Canes and crutches can reduce pain in hip and knee or OA. If both hips and/or knees are affected wheeled walkers may be preferable.
8. Footwear and insoles. If osteoarthritis affects the knee, special footwear and insoles can reduce pain and improve walking.
9. Knee braces. For osteoarthritis with associated knee instability, a knee brace can reduce pain, improve stability and reduce the risk of falling. 
10. Heat and cold. Many people find the heat of a warm bath, heat pack or paraffin bath eases OA pain. Others find relief in cold packs. Still others prefer alternating the two. 
11. Transcutaneous electrical nerve stimulation (TENS).  A technique in which a weak electric current is administered through electrodes placed on the skin, TENS is believed to stop messages from pain receptors from reaching the brain. It has been shown to help with short-term pain control in some patients with knee or hip arthritis.
12. Acupuncture. A form of traditional Chinese medicine involving the insertion of thin, sharp needles at specific points on the body, acupuncture has been touted as a treatment for osteoarthritis pain. A recent trial of 352 patients with knee osteoarthritis showed small but statistically significant improvement in pain intensity two and four weeks after a course of acupuncture.

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