In this month’s issue:

Philadelphia - "Whether it be in the areas of cardiology, oncology or community care, Philadelphia International Medicine (PIM) hospitals are leading the world in new treatment and training techniques," said Andrew Wigglesworth, president of PIM. Below are just some examples of exciting medical advances and new residency training programs of interest to international patients and physicians.

Jefferson Program using radiation seeds helps prevent restenosis

A new procedure recently approved by the FDA, using a tiny radiation catheter to help reopen blocked coronary arteries, in part because of testing done at Thomas Jefferson University, is now being performed at the hospital and is available to international patients as part of the Philadelphia International Medicine network. The procedure, known as brachytherapy, offers hope for people with restenosis, a condition where scar tissue grows in coronary arteries that were previously opened by balloon angioplasty and stents. It is estimated that every year, more than 700,000 patients in the United States undergo the procedure during which a balloon at the tip of a catheter is inflated to widen the blocked coronary artery and thus improve blood flow. Small coils called stents are usually implanted into the artery at the time of balloon angioplasty to keep it propped open. However, in 20 to 30 percent of patients, scar-like plaque forms causing restenosis within the stent. "Restenosis inside a stent can be really frustrating," said Michael Savage, MD, associate professor of Medicine, Jefferson Medical College of Thomas Jefferson University and director, Cardiac Catheterization Laboratory at Thomas Jefferson University Hospital. "We can reopen the blockage with balloons, lasers and rotablators but then the artery tends to close up again within six months. Once the brachytherapy procedure was approved, we began to use it to help our patients because it is dramatically effective in keeping the arteries open." Jefferson was among the first hospitals in the world to perform brachytherapy and was one of 30 centers in the START (Stents and Radiation Therapy) trial to test the effectiveness of this new procedure. The trial compared balloon angioplasty with radiation to angioplasty alone on patients with recurrent blockages after stent placement. Restenosis inside the stent occurred in only 14 percent of patients treated with the radiation catheter compared to 41 percent of patient who did not receive radiation. "Restenosis often requires a patient to undergo another angioplasty procedure or bypass surgery within six months after the original angioplasty," says David Fischman, MD, director of Jefferson's Core Angiography Laboratory in the Division of Cardiology, which is responsible for analyzing the results of a major coronary radiation trial involving 1,455 patients. According to Dr. Fischman, who is also associate professor of Medicine, Jefferson Medical College of Thomas Jefferson University, two factors cause restenosis. Treated arteries tend to shrink or collapse over time. In addition, the balloons used in the angioplasty stretch and injure the artery as they clear it, triggering a healing response that causes scar tissue to build up and obstruct blood flow. With this new coronary procedure, Jefferson physicians are temporarily placing tiny radioactive "seeds" inside the coronary artery immediately after the angioplasty procedure and providing low-dose radiation therapy. All of the radiation remains in a catheter during the procedure, and does not touch the patient or the physician. Jefferson physicians are using a system called the Beta-Cath TM System made by Novoste in Atlanta, Ga. Richard Valicenti, MD, assistant professor of Radiation Oncology at Jefferson Medical College, who also participates in the procedure, says the new system "will become a standard of care quickly for people who have had restenosis. "The fact that the radioactive seeds remain in the catheter is very important," he says. It allows localized radiation exposure to the treated area, which permits the physician to stay in the same room as the patient during the procedure. "This way, the doctor can speak with the patient throughout the procedure," Dr. Fischman adds, "to learn if there is any discomfort that can then be alleviated."

Penn study finds partial removal of larynx can be effective for cancer patients while preserving organ

Researchers at the University of Pennsylvania Cancer Center, a member of the Philadelphia International Medicine network, have completed a study assessing both the oncologic outcome and quality of life implications following a novel surgical technique to partially remove the larynx ("voice box") of patients with cancer of the larynx, as opposed to a total removal of the larynx (TL). This organ preservation surgical procedure is known as the supracricoid partial laryngectomy (SCPL). The study that was published in the February issue of Laryngoscope, demonstrates that the SCPL procedure provides excellent local control of the cancer, significantly improves a patient's quality of life vis-a-vis the TL procedure, and suggests that many patients who underwent total voice box removal in the past could have been reasonable candidates for this partial removal procedure to save their voice box. The treatment of larynx cancer, the most common form of head and neck cancer, can have a major impact on many aspects of the quality of life of patients, including their ability to swallow and speak, as well as their ability to breathe normally. Depending on the size and extent of the cancer, several surgical and non-surgical procedures are available as treatment options. Historically, a total removal of the larynx has been the most common treatment method in cases where the cancer was very extensive and when non-surgical interventions such as chemotherapy and/or radiation have failed, resulting in a recurrence of the cancer. The main problem encountered after total removal of the voice box is that the patient no longer breathes through their nose and mouth, and must breathe through a "stoma", or breathing hole in the neck. Total laryngectomy impacts on quality of life in numerous ways including: one's self-image because of the cosmetic impact of a breathing hole in the neck, by causing swallowing dysfunction, and other problems such as a marked decrease in smell and taste because of lack of breathing through the nose. This still remains the case today in most such situations. However, the SCPL, now provides a new option for both intermediate as well as advanced size cancers, resulting in improved breathing and swallowing without the need for a permanent breathing hole in the neck, which significantly improves quality of life in these patients. While the SCPL procedure first originated in Europe in 1959 and has been performed extensively there for years, it was not initially available to patients in the United States and was not first performed here until 1989, 30 years after it's European introduction. Gregory S. Weinstein, MD, Associate Director of the Center for Head and Neck Cancer at Penn's Cancer Center, the first surgeon to perform this procedure in the United States, serves as the primary instructor of this procedure in the nation. "Informing the public of this option is crucial" said Weinstein. In many situations, this procedure can provide much less hardship to the patient, lessen the negative impact on the patient's quality of life, with just as much oncologic success and excellent local control. A patient with larynx cancer should no longer be unaware of the availability and clinical effectiveness of this procedure which has been shown to be less drastic and less debilitating" notes Weinstein. The primary indications for the SCPL are selected cancers with intermediate to advanced stage larynx cancers in which the only other surgical option is total removal of the voice box. A second important indication of the SCPL is as an alternative to non-surgical approaches such as radiation or chemotherapy and radiation when the risk for treatment failure may be high. The final indication is for patients who already underwent radiation therapy for very early cancers of the voice box and then had the cancer recur. Unfortunately, if a patient undergoes radiation or chemotherapy and radiation for an intermediate or advanced cancer and then has a recurrence in the voice box, they are almost never a candidate for a SCPL at that point. The cure rate in the voice box following SCPL, however, is consistently in the 90% range. Quality of post-operative life is a key concern for surgeons and patients alike. All medical treatments have some degree of acute and chronic side effects. The expected outcome after SCPL is temporary difficulty swallowing, a temporary breathing tube in the windpipe ("tracheostomy") and some degree of permanent hoarseness. In addition, post-surgical voice box swelling occurs. Although this swelling is temporary, a temporary tracheostomy tube is put into the windpipe, but typically removed after two weeks. Speech after total removal of the voice box is frequently facilitated by either an implanted or hand-held prosthetic device. The SCPL patient, who will have some degree of permanent hoarseness, is able to speak without the need for a permanent breathing hole in the neck and without the need for using prosthetic tone/voice generators. Evidence suggests that the absence of such prosthetic devices has a significant positive effect on the patient's physical functioning, general health, vitality and emotional state. Generally, three months after the SCPL procedure, treatment and rehabilitation have ended, the patients' quality of life issues such as eating, breathing, speaking and other activities of life far exceed his or her initial expectations. What the SCPL procedure now allows for is the local control of cancer, while preserving enough of the larynx to allow for speech and swallowing without the need for a permanent tracheostomy, concludes Weinstein. Also contributing to this study performed at the University of Pennsylvania and to this article were Mohamed Mahmoud El-Sawy, MD and Mostafa Mohamed El-Sayed, MD of the Al-Ashar University, Cairo, Egypt, Cesar Ruiz, MA, Patricia Dooley, MA, and Ara Chalian, MD, University of Pennsylvania and Andrew Goldberg, MD, University of San Francisco.

Temple Physicians inject skeletal muscle cells into a patient's heart

Physicians at Temple University Hospital transplanted a patient's own skeletal muscle cells directly into damaged areas of the heart for the first time, a technique that could be used to treat heart disease. "Our long-term goal is to perhaps be able to reconstruct the heart with cells from arm or leg muscles of patients," says Dr. Howard Eisen, medical director of Temple's heart and lung transplantation program. Eisen and Dr. Satoshi Furukawa, surgical director of Temple's heart and lung transplantation programs, are co-principal investigators of the trial. "There are two goals of this Phase I trial: 1) to test the feasibility and safety of transplanting these cells into patients' hearts and 2) to gain preliminary information on the cell's survival and the potential for improvement of cardiac function that might be associated with the cell transplantation. The study, which is being run in collaboration with, and is funded by, Diacrin Inc., is "primarily a safety study to see if the graft takes," says E. Michael Egan, vice president for corporate development at the Boston-based company. "The ideal solution, which would be years away, is that a patient who has a heart attack would have muscle cells grafted to the heart to prevent further damage and even avert the need for a transplant," says Egan. In pre-clinical animal studies, skeletal muscle cells survived in the heart and were detected at various time intervals up to 12 weeks after transplantation. These studies involving rats suggest that the transplanted muscle tissue may repair damaged heart muscle and strengthen heart contractions.

Crozer pediatric residency programs brings physicians into the community

Physicians must know and understand their patient's cultural, social and economic backgrounds to effectively meet both their physical and psychological healthcare needs. Understanding nuances of the community is also essential to provide the best quality care. In order to prepare pediatric residents to take an active role in the communities where they plan to establish their practices, the Crozer-Chester Medical Center Pediatric Residency Program, offers unique training that demonstrates the importance of one-on-one experiences with their young patients and parents within the community setting. Crozer-Keystone Health System is part of Philadelphia International Medicine, and its continuing education and residency programs are available through PIM's Institute for Education. With funding from a three-year federal grant, the residency program recently established the Pediatric Education to Deliver Community Integrated Care (PEDCIC) program. The program goals are to provide residents with the knowledge and tools to access available community resources to assist children and their caregivers. It also provides residents of the community with an opportunity to interact with their children's healthcare providers and community service workers in an interactive setting. "Teaching our pediatric residents the importance of knowing their patients and the various resources available throughout the community is an important part of their overall education," said Kathleen Reeves, MD, director of Crozer-Chester Medical Center's Pediatric Residency Program. "To effectively care for their patients, pediatricians must understand the obstacles that children and their parents must face. In some instances, physicians can help eliminate these obstacles by providing resources to help parents care for their children." Reeves, instrumental in receiving the PEDCIC grant, said, "It is imperative that pediatricians learn to work with other community care providers to provide a more comprehensive care plan. This also leads to pre-screenings and understandings with families related to issues of poverty, literacy and transportation, etc." Crozer pediatric residents serve a unique month-long training within the community at schools, courts, shelters, community agencies, day care centers, and ChesPenn Health Services, a federally-funded community health center that provides primary care to area children and adults. This experience provides an accurate picture of what life is like in the community they serve. Residents develop unified care plans for families that they see in conjunction with every community service provider. Children at high risk-those who fail to thrive, appear isolated or are suspected of experiencing physical or psychological abuse--are identified. Sometimes it can be as simple as supplying parents with phone numbers of area resources, or checking to make certain that they comply with physician's advice. Other times, family problems may be multi-faceted and take more intense management under the supervisor of social service agencies and others.

Philadelphia International Medicine is an organization that provides medical and patient support services to international patients. It also provides continuing medical education and health care training and education to international physicians, administrators and other practitioners. As the international department of several Philadelphia-area hospitals, international patients gain access to physicians and hospitals rated among the best in the world through one telephone call to PIM. You can reach PIM by calling 1-215-735-3575; fax, 1-215-790-1267; or e-mail, physicians@philadelphiamedicine.com. You can find out more about PIM through its Website at www.philadelphiamedicine.com.

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