Overuse of Antibiotic Use In The Southeastern US

New research suggests a pattern of outpatient antibiotic overuse in parts of the United States-- particularly in the Southeast --a problem that could accelerate the rate at which these powerful drugs are rendered useless, according to Extending the Cure, a project of the Center for Disease Dynamics, Economics & Policy.

These findings come out just as the Centers for Disease Control and Prevention (CDC) kicked off an annual effort to reduce overuse of antibiotics called "Get Smart: Know When Antibiotics Work." The campaign, which lasts throughout the week, urges Americans to use antibiotics wisely. The CDC estimates that $1.1 billion is spent annually on unnecessary antibiotic prescriptions for adult upper respiratory infections alone. These prescriptions also speed the development of resistance to important antibiotic therapies.

Also, on Monday of this week, Extending the Cure introduced a new tool that allows non-experts to track changes in antibiotic effectiveness over time. The new Drug Resistance Index (DRI) is similar in concept to the Consumer Price Index and is described in a paper in the British Medical Journal Open.

Trends in Antibiotic Use Paint a Troubling Picture

Interactive maps released by Extending the Cure track antibiotic use in the United States from 1999 to 2007 and show how overall antibiotic dispensing has decreased; consumption fell by about 12% over this time period. However, they also highlight alarmingly high antibiotic use across the Southeast compared to states in the Pacific Northwest. For example, residents of West Virginia and Kentucky, where antibiotic use rates are highest, take about twice as many antibiotics per capita as people living in Oregon and Alaska.

Additional key findings include: 

• The five states with the highest antibiotic use in the nation are West Virginia, Kentucky, Tennessee, Louisiana and Alabama. However, the maps show higher than average use of antibiotics in other regions of the country as well. Check your state's antibiotics use at ResistanceMap.
• Prescribing rates for a powerful class of antibiotics known as fluoroquinolones shot up by 49 percent from 1999 to 2007. At the same time, antibiotic resistance is increasing: these drugs are now seven times less likely to work against Escherichia coli, the most frequent cause of bacterial infections, than they were in 1999.
• Penicillins remain the most popular antibiotics -- accounting for nearly one out of three prescriptions filled in the United States. At the same time, the market share of these standard drugs has declined by 28 percent as physicians increasingly turn to more powerful antibiotics.

High per capita antibiotic use rates could reflect an environment in which consumers mistakenly demand antibiotics – and physicians prescribe them -- when they have a cold or the flu, which are caused by viruses and cannot be treated with these drugs. However, additional research must be done to better understand the driving factors behind antibiotic use.

The data was released today as part of Extending the Cure's ResistanceMap, an interactive web-based tool that tracks drug resistance.

Novel Way to Track Resistance: Drug Resistance Index (DRI)

In a report published this week in the British Medical Journal Open, Ramanan Laxminarayan, Director of Extending the Cure, and Keith P. Klugman, Professor of Global Health at Emory University, describe a first-of-its-kind index for tracking resistance. Like a Consumer Price Index (CPI) for drug resistance, the tool aggregates information about resistance trends and antibiotic use into a single measure of antibiotic resistance over time.

Hospitals can use the DRI to track resistance levels in their facility and to measure the success of interventions including antibiotic stewardship and infection control programs. The tool also offers decision makers a convenient way of communicating progress and pitfalls in the fight against resistance, according to the study authors. The index is designed to be applicable at any level, from local hospitals to national healthcare system surveillance.

In this paper, researchers explain how the index can be used by assessing trends in resistance associated with two disease-causing micro-organisms: Escherichia coli and Acinetobacter baumannii. The index can also illuminate how physicians adapt to trends in resistance. For example, in this analysis, the index showed how physicians were able to use other drugs to treat infections caused by resistant strains of E. coli but had very few options left for treating Acinetobacter, a superbug that increasingly is resistant to all available antibiotics.

"Mapping the geography of antibiotic use and summarizing their effectiveness with a Drug Resistance Index bring us one step closer to the solutions we urgently need in order to curtail this public health crisis," Laxminarayan said. "If we do nothing, resistance will continue to develop and our most valuable antibiotics ultimately will fail."

Extending the Cure research suggests that policymakers must address the broader problem of antibiotic resistance by putting comprehensive solutions in place, including better infection control and surveillance as well as stepping up efforts to curtail overuse of antibiotics, a solution that would help preserve the power of the drugs we have left on the shelf.

Provided by Burness Communications

Be Careful With Your Pain Meds

Patients who are dependent on opioids (narcotic pain relievers) for pain management before knee replacement surgery have much more difficulty recovering, a study recently published in the Journal of Bone and Joint Surgery (JBJS) has found. These patients tend to have longer hospital stays, more post-surgical pain, a higher rate of complications, and are more likely to need additional procedures, than patients who are not opioid-dependent.

"We expected to find that the opioid-dependent patients have worse outcomes," says orthopaedic surgeon Michael A. Mont, M.D., the principal investigator and Director of the Center for Joint Preservation and Reconstruction at the Rubin Institute for Advanced Orthopaedics at Sinai Hospital of Baltimore. "But the differences between the two groups of patients were even greater than we thought they would be. The chronic narcotics users did significantly worse in every category."

Study Findings:

Patients included in the study were matched according to age, sex, body-mass index, insurance type, as well as a variety of medical factors. When those factors were accounted for, the study still found that chronic opioid users: 

• had to remain in the hospital longer after surgery
• were more likely to need referrals for pain management
• were more likely to suffer unexplained pain or stiffness
• had lower function and less motion in the replaced knee

"This doesn't mean that opioid users shouldn't have the surgery," Mont says. "But those patients and their physicians should know that their results may not be as optimal. It might be possible that we can work with these patients to improve theirsurgical outcomes."

Dr. Mont and his co-authors outline several strategies to help improve patient outcomes; including: 

• weaning patients off strong opioid medications prior to surgery
• prescribing alternate, non-opioid pain medications
• considering non-pharmaceutical pain management strategies

The study's authors acknowledge that some patients who become dependent on opioids before surgery may have lower pain thresholds than those who do not. In addition, those patients may be less compliant with rehabilitation plans and other post-surgical treatments. However, the results of this study are important enough to warrant attention to this issue.

"Previous studies have found that patients who use opioids are more dissatisfied after surgery," Mont says. "But these are more powerful findings since patients require additional surgeries. This is a topic our orthopaedic community and other care providers need to address together."

Provided by American Academy of Orthopaedic Surgeons (news : web)

I found this study to be a bit alarming because I have used Tramadol since 1998 to control my pain and I have had total knee replacement with absolutely no complications.  As a matter of fact, my therapist and doctor were amazed at my recovery.  I was a month ahead on my rehab then everyone else who had the surgery the same day I did.

Opioid Painkillers for Abdominal Pain More Than Doubled

Across U.S. outpatient clinics between 1997 and 2008, opioid prescriptions for chronic abdominal pain more than doubled, according to a new study in Clinical Gastroenterology and Hepatology, the official journal of the American Gastroenterological Association.

Chronic abdominal pain is a common symptom and a frequent reason for health-care visits. Because it is often incurable, clinicians often find it challenging to help their patients manage their abdominal pain over time.

"Opioid use for persistent abdominal pain highlights the growing challenges clinicians face trying to manage chronic illness without the time, infrastructure and incentives needed to take the integrated approach that experts suggest," said Spencer D. Dorn, MD, MPH, of the University of North Carolina and lead author of the study. "Writing a prescription for a pain killer may be the path of least resistance; doing so may satisfy the patient's demand for relief and mitigate the clinician's possible feelings of inadequacy."

The researchers concluded that the dramatic nationwide rise in opioid use to treat chronic abdominal pain is concerning for several reasons. First, using opioids to treat non-cancer chronic pain is supported by very limited evidence. Second, opioids are frequently misused and sometimes abused. Finally, when used over long periods of time, opioids may trigger other gastrointestinal symptoms, such as constipation, nausea and vomiting, and may even paradoxically worsen abdominal pain.

The researchers speculate that the growth in opioid use has likely been driven by numerous factors, including a tendency to generalize recommendations for the use of opioids in treating pain, campaigns to recognize pain as the "fifth vital sign," and widespread direct-to-consumer advertising, which, in the case of OxyContin, was considered misleading and illegal.

Provided by American Gastroenterological Association (news : web)

Lipitor Is Going Generic

Lipitor came on the market in 1997, and has raked in some $100 billion for Pfizer even in a crowded market that includes various other cholesterol-lowering statins, many of which have already gone generic.

In the United States, anti-cholesterol drugs account for 255 million prescriptions a year, and about nine million people are taking Lipitor.

India's pharmaceutical giant Ranbaxy won US approval to make the first generic version of Lipitor, known as atorvastatin, from its New Jersey lab, after the company had faced delays from US authorities due to problems with quality control at some of of its Indian factories.

US-based Watson Pharmaceuticals also announced a deal to distribute a generic version made by Pfizer, whereby Pfizer manufactures the drug and Watson sells it, sharing net sales with Pfizer until 2016.

"There should be a price war in that first six months," as more companies elbow for market share of the cheaper generic version of Lipitor, said Morningstar analyst Damien Conover.

Meanwhile, Pfizer is left hunting for new sources of revenue to replace the cash flow from its longtime star, which made up 15 percent of annual sales.

Pfizer has not released its projected losses due to the patent expiration, but its company forecasts call for sales in 2012 of $63-63.5 billion, versus $67.8 billion in 2010.

Lipitor global sales were over $10 billion last year, according to earnings reports. Conover estimated a sales figure of $3.8 billion in 2012.

Pfizer already lost exclusive rights on the product in Canada, Spain, Mexico and Brazil last year, but it continues to earn revenue in developing countries.

In the United States, Pfizer is aiming to defend its territory and undercut its competitors in the generic market.

By forming alliances with pharmacies and health insurance companies, Pfizer will continue to offer Lipitor "at or below generic cost" during the next 180 days, company spokesman MacKay Jimeson told AFP in an email.

"In this 180-day period, typically payers do not receive a significant cost-savings by utilizing a generic," he added.

Lipitor currently costs about $120 per month, a price that should drop 30 percent in December, slightly more than the typical 10-20 percent that a drug price typically falls after a patent expires.

Pfizer has made a deal with Diplomat Specialty Pharmacy in the northern state of Michigan to create the program "Lipitor For You," so customers can sign up online to continue to get the drug in their pharmacy or home-delivered.

It is too early to know if this approach will continue beyond six months. Pfizer could decide to continue to compete with other generic makers but it would have to lower prices even more, which may not prove profitable.

Pfizer is counting on licensing deals that will continue to generate revenue from Lipitor, such as one signed with the French pharmaceutical giant Sanofi-Aventis which will make and market its generic version in France starting in May 2012.

"I don't think they'll be able, in the short term, to compensate, but they have a lot of products in pipeline," said Conover, referring to Pfizer.

Among them are an anti-clotting drug known as Eliquis, and another against rheumatoid arthritis known as tofacitinib, which together could make up a billion dollars in annual sales.

Ratings agency Standard and Poor's said it views the New York-based drug giant as well-placed to survive the expiration of the patent on Lipitor.

"Over the next two years, the company will be able to weather the upcoming storm of patent expirations and associated revenue loss while maintaining its excellent business risk profile and a solidly minimal financial risk profile."

A two-year study released earlier this month showed that maximum doses of Lipitor and its competitor Crestor, made by AstraZeneca, were similarly effective and safe in cutting down plaque in the arteries. Side effects may include liver and muscle problems.

With Lipitor now generic, Crestor will be left as the sole major brand-name statin on the market.

"The market for Crestor will go close to zero," said Cam Patterson, chief of cardiology at the University of North Carolina-Chapel Hill.

(c) 2011 AFP

Coming Soon: Cartilage Replacement!!!!!

Self-assembling sheets of mesenchymal stem cells permeated with tiny beads filled with growth factor formed thicker, stiffer cartilage than previous tissue engineering methods, researchers at Case Western Reserve University have found. A description of the research is published in the Journal of Controlled Release.

"We think that the capacity to drive cartilage formation using the patient's own stem cells and the potential to use this approach without lengthy culture time prior to implantation makes this technology attractive," said Eben Alsberg, associate professor in the departments of Biomedical Engineering and Orthopaedic Surgery, and senior author of the paper.

Alsberg teamed with biomedical engineering graduate students Loran D. Solorio and Phuong N. Dang, undergraduate student Chirag D. Dhami, and Eran L. Vieregge, a student at Case Western Reserve School of Medicine.

The team put transforming growth factor beta-1 in biodegradable gelatinmicrospheres distributed throughout the sheet of stem cells rather than soak the sheet in growth factor.

The process showed a host of advantages, Alsberg said.

The microspheres provide structure, similar to scaffolds, creating space between cells that is maintained after the beads degrade. The spacing results in betterwater retention – a key to resiliency.

The gelatin beads degrade at a controllable rate due to exposure to chemicals released by the cells. As the beads degrade, growth factor is released to cells at the interior and exterior of the sheet, providing more uniform cell differentiation into neocartilage.

The rate of microsphere degradation and, therefore, cell differentiation, can be tailored by the degree to which the microsphere are cross-linked. Within the microspheres, the polymer is connected by a varying number of threads. The more of these connections, or cross-links, the longer it takes for enzymes the cell secretes to enter and break down the material.

The researchers made five kinds of sheets. Those filled with: sparsely cross-linked microspheres containing growth factor, highly cross-linked microspheres containing growth factor, sparsely cross-linked microspheres with no growth factor, highly cross-linked microspheres with no growth factor, and a control with no microspheres. The last three were grown in baths containing growth factor.

After three weeks in a petri dish, all sheets containing microspheres were thicker and more resilient than the control sheet. The sheet with sparsely crosslinked microspheres grew into the thickest and most resilient neocartilage.

The results indicate that the sparsely cross-linked microspheres, which degraded more rapidly by cell-secreted enzymes, provided a continuous supply of growth factor throughout the sheets that enhanced the uniformity, extent, and rate of stem cell differentiation into cartilage cells, or chondrocytes.

The tissue appeared grossly similar to articular cartilage, the tough cartilage found in the knee: rounded cells surrounded by large amounts of a matrix containing glycosaminoglycans. Called GAG for short, the carbohydrate locks water ions in the tissue, which makes the tissue pressure-resistant.

Testing also showed that this sheet had the highest amount of type II collagen – the main protein component of articular cartilage.

Although the sheet was significantly stiffer than control sheets, the mechanics still fell short of native cartilage. Alsberg's team is now working on a variety of ways to optimize the process and make replacement cartilage tough enough for the wear and tear of daily life.

One major advantage of this system is that it may avoid the troubles and expense of growing the cartilage fully in the lab over a long period of time, and instead permit implantation of a cartilage sheet into a patient more rapidly.

Because the sheets containing microspheres are strong enough to be handled early during culturing, the researchers believe sheets just a week or two old could be used clinically. The mechanical environment within the body could further enhance cartilage formation and increase strength and resiliency of the tissue, completing maturation.

Provided by Case Western Reserve University (news : web)

Baby Boomers Feed The Need For Joint Replacements

US baby boomers are fueling a wave of joint replacement surgeries, hoping to use new artificial knees and hips to stay active as they get older.

With 76 million baby boomers still kicking, many are rejecting the sedentary lifestyle of their parents' generation, and are using advances in technology and surgical techniques to keep on running, cycling, skiing and engaging in other sports.

The 45-64 age group accounted for more than 40 percent of the more than 906,000 total knee or total hip replacement surgeries in 2009, the last year for which figures were available from the American Academy of Orthopedic Surgeons.

Boomers will account for a majority of these joint replacements in 2011, according to projections by Drexel University specialist Steven Kurtz.

The study projects the 45-64 age group will account for a 17-fold increase in knee replacements alone to 994,000 by 2030. Active boomers often accelerate the arthritis which wears down their joints, and obesity is another factor.

"We are still doing patients 65 years and up, but the volume is increasing dramatically among 45-64 year-old patients," said Douglas Dennis, a Colorado orthopedist who has performed some 5,000 knee replacements and 4,000 hip replacements over his career.

Decades earlier, most replacements were in elderly patients unable to walk. But Dennis said, "We are now performing them in younger age patients. We have made great strides in our ability to revise them should they fail."

A number of his patients are avid skiers who have had several attempts to repairknee injuries, but want to keep active.

"We encourage the patients to be active," he said. "But I don't favor things like racquet sports, soccer or basketball" which can put extra strain on joints.

Some patients are drawing hope from new technology, such as a so-called 30-year knee from British-based Smith & Nephew, endorsed by former tennis star Billie Jean King.

"I feel like I'm 20 again, and I'm back on the courts playing tennis," King says in her endorsement after double knee replacement surgery. But some physicians say people these claims may not be realistic.

"That knee has been designed in the last five years, so how can you say it is going to last 30 years?" says Dennis.

"It is disingenuous marketing... It is harmful rather than helpful. If I had 20 years of data on young patients playing racquet sports, and it showed good survivorship, I would change my opinion. But we don't have that data."

Still, some boomers persist.

Dick Beardsley, an avid distance runner who came within two seconds of winning the Boston Marathon in 1982, said he is determined to show he can come back from two knee replacements.

"I've been a runner all my life," Beardsely told AFP from his home in Austin, Texas, a year after he had replacement surgery for his left knee.

"For a while I thought I might become a cyclist. But I had to give this a try."

Beardsley, 55, is back to running 70-80 miles a week to prepare for the April marathon in Boston, without any problem for his left knee replaced in 2010 or his right knee replaced three years ago.

"The first six to eight weeks (after surgery) are brutal," he said.

"But I would keep at it, run a mile... eventually I got back to running the same pace I was before the knee surgery."

Beardsley, who works as a motivational speaker and operates running camps for adults, said he knows he is flying in the face of medical advice.

When he told his doctor about his training, "He told me, 'I'm not going to tell you to keep running, but I'm not going to tell you to stop.'"

His exams have shown no excess wear on the joints, and believes this is in part due to his small frame and a technique he uses -- "midfoot, forefoot" without striking his heels.

Allen Beale, a 62-year-old computer consultant in Durham, North Carolina, said he is extremely satisfied with the hip replacement he received two years ago, when he was barely able to walk.

Now, he is back at golf, motorcycling and other activities.

Before the surgery, he said, "it had gotten to the point where I couldn't stand up and move... Now it feels so good I don't even know it's there."

Among celebrities getting surgery are former Olympic gymnast Mary Lou Retton (hip), singer Billy Joel (double hip) and actress and workout guru Jane Fonda (knee).

Even if the new joints work as promised, it remains unclear whether supply will be able to keep up with demand, and if the costs will become overwhelming.

A study appearing the journal Health Affairs suggests the costs may reach $50 billion for the government Medicare program alone by 2030 if current trends continue.

And with government reimbursement reduced, and private insurance following suit, the incentives for doctors are declining.

A separate study co-authored by Thomas Fehring showed that if current trends continue, by 2016, 46 percent of needed hip replacements and 72 percent of needed knee replacements will not be able to be completed.

"I was somewhat shocked at the shortfall that we predicted," said Fehring, an orthopedic surgeon in Charlotte, North Carolina.

"The number of people getting joint replacements is going up, the number of young surgeons is going down," said Dennis.

"There are fewer people going into this specialty."

If boomers can't wait, technology may come up with alternatives which may avert the need for radical surgery.

Kurtz notes in his study that he did not account for the "potential for future alternative technologies, such as cartilage regeneration or tissue engineering, or drug therapies that limit progression of joint diseases, which may preempt the need" for joint replacement.

(c) 2011 AFP