In this month’s issue:

Philadelphia -- Hospitals in the Philadelphia International Medicine (PIM) network continue to make the news with groundbreaking advances in medical research. This month's newsletter provides information on new guidelines developed to manage pain for cancer patients; a fundamental change in the way chemotherapy doses are prescribed for some cancer patients; and a project that applies pressure to neurons in order to help them grow that holds major implications for treatment of some diseases of the nervous system.
"With top hospitals and the newest in available treatment, Philadelphia International Medicine is growing as the choice for international patients looking for the very best in medical care," said Andrew Wigglesworth, president and chief executive officer. International patients or their doctors seeking an appointment with any PIM physician should call 215-735-3575 for more information.

Fox Chase helps develop understandable guidelines for pain management

For the first time ever, treatment guidelines used by oncology professionals to manage cancer pain have been translated into specific, reliable and easy-to-understand language for patients and their families -- Cancer Pain Treatment Guidelines for Patients (available at www.nccn.org). The cancer pain guidelines are based on the review of published research on cancer pain by an interdisciplinary panel of experts from the 19 member institutions of the National Comprehensive Cancer Center (NCCN) including Fox Chase Cancer Center, a founding member of Philadelphia International Medicine. The treatment options are presented as flow charts, which were developed by oncologists from different disciplines. The guidelines illustrate several appropriate options for care based on the results of scientific evidence, clinical experience, medical judgment and a patient's personal preference. The booklet also explains what pain is, its causes, obstacles to cancer pain relief, pain assessment tools and offers patient and family education. The ACS/NCCN patient guidelines empower patients and their families by helping them ask the right questions, understand their treatment options, and participate fully in their care. With these guidelines at their fingertips, patients and their families can follow the same guidelines that their doctors are using. Pain can affect a patient in many ways. It can cause a reduction in activity, prevent sleep, and inhibit eating. Pain can also make a patient feel afraid and depressed. About one-third of the cancer patients in the U.S. suffer from significant pain. More than two-thirds of patients with advanced cancer have pain. "Not all patients realize that there are options in managing side effects of cancer and its treatment including pain," said Michael Levy, MD, PhD, vice-chairman of the Medical Oncology Department at Fox Chase Cancer Center and director of its Supportive Oncology Program. "Many times, patients believe pain is simply something they have to live with and not question. That's not so. We hope that these guidelines will encourage patients and their families to talk to their nurse or physician right away about relieving pain before it becomes severe."

Jefferson research finds less may be more in chemotherapy doses

Radiation oncologists at Thomas Jefferson University Hospital are rethinking how to give chemotherapy, taking advantage of its unique properties. They are giving chemotherapy more frequently than usual and in tinier doses, targeting the process by which a new blood supply is created feeding tumor growth, called angiogenesis. Traditionally, most cancer therapies are used in the highest possible doses, says Adam Dicker, MD, PhD, assistant professor of radiation oncology at Jefferson Medical College of Thomas Jefferson University in Philadelphia and at Jefferson's Kimmel Cancer Center. But anti-angiogenesis drugs have caused people to rethink chemotherapy. "Instead of targeting the tumor, perhaps you can target the tumor-associated blood supply," he says. Dr. Dicker and his Jefferson co-workers studied the chemotherapy drug docitaxel (Taxotere) in the laboratory in lower-than-usual doses, about one-tenth the clinical dose. They wanted to see the effects of radiation and the drug, which makes cancer cells more vulnerable to radiation, on endothelial cells, which are involved in angiogenesis. They found the lower doses of drug affect different parameters of angiogenesis and can increase the effects with radiation. "This is a unique approach in combination therapy, targeting the vasculature," Dr. Dicker said. Dr. Dicker presented the group's findings March 27 at the annual meeting of the American Association for Cancer Research meeting in New Orleans. "What's unique about this is that we've used a common chemotherapy agent in an antiangiogenic manner and potentiated that," Dr. Dicker says. "This area is particularly interesting because these drugs, which are FDA approved, can have antiangiogenic effects. "It's a totally new way of thinking; it's completely changed the paradigm," says Dr. Dicker. "With all the interest in anti-angiogenesis, you can rethink how you give chemotherapy and radiation." According to Dr. Dicker, recent research has shown dramatic effects with conventional chemotherapy, but used in a different way. Instead of using large doses infrequently, every three weeks or so, for example, giving the time the body needs to recover from chemotherapy, preclinical studies have been using lower doses more frequently, maybe twice a week. They next plan to take this approach, using low-dose docetaxel and radiation therapy, in a study in lung cancer together with colleague Maria Werner-Wasik, MD, assistant professor of radiation oncology at Jefferson Medical College.

Penn Researchers Discover That Stretching Neurons Induces Growth; Scientists Foresee Bridging Nerve Damage with Grafts

They say that tension is bad for the nerves, but it turns out that a little applied tension might be good for nerve cells. Researchers at the University of Pennsylvania Medical Center have been able to grow nerve cells, or neurons, by stretching them - offering a new means of bridging damaged areas of the nervous system. Using a motorized device to slowly pull connected neurons away from each other, the Penn researchers have discovered that the connecting nerve fibers, called axons, grow longer in response to the strain. In addition, the researchers have grown these elongated nerve fibers directly on a dissolvable membrane, ready-made for transplant. Their discovery is published in the April edition of Tissue Engineering. "Most studies have examined axon growth in terms of how axons sprout from one neuron and connect to another. But there is an equally important form of axon growth that has been overlooked, the growth of axons in terms of the growth of the entire organism," said Douglas Smith, MD, lead researcher on the project and associate professor in the Penn Department of Neurosurgery. "In a way, stretching is akin to how nerve cells grow in developing children - as they get taller their axons get longer." These findings, which have evolved from Smith's ongoing research into how neurons respond to their environment, also represent a departure from other methods of restoring neural pathways in spinal cord injuries by bridging over damaged tissue. One approach has been to transplant a synthetic scaffolding across the injured area and then use a trail of attractive chemicals to entice axons to grow out from one end of the lesion and connect with viable nervous tissue on the other side. While these attempts have had limited success in the laboratory, they have been hampered in live subjects by, among other things, the body's innate desire to stop neuron outgrowth. "Once somebody's nervous system is already formed, further outgrowth could cause mass confusion, so the body actively produces chemicals that stop axon growth," said Smith. But it was the inherent ability of axons that were already connected to grow during natural development that gave the researchers the idea to stretch axons in culture. Smith and his colleagues began with a group of neurons grown in a culture across two membranes. Using a motor that could function in precise increments, they separated the two membranes by a few thousandths of a centimeter every few minutes: A small distance on a human level, but a remarkably large distance on the cellular level. Eventually, as they describe in Tissue Engineering, they were able to stretch the neurons an entire centimeter. Smith, however, could find no hysiological reason why they could not be stretched even further. "We believe that, as we put pressure on the axons from either end, the axon begins to add a little to its own internal skeleton in response," said Smith. During these experiments, Smith noticed another curious phenomena. "We began to see that the stretch-grown neurons could actually organize themselves into bundles, nerve fibers composed of thousands of axons," said Smith, "and these bundles gradually consolidated into even larger tracts." Accordingly, these large tracts could serve as the bridge across damaged tissue, connecting either side and allowing the nerve signal to cross. In fact, researchers would likely not have to modify the stretched neurons before transplanting - the body easily absorbs the membranes used in the stretching process. As with all strategies to bridge nerve damage, Smith hopes that the neuron's own innate ability to connect will allow transplantable axon bridge to rewire damaged nervous tissue. In addition to spinal cord repair, Smith conceives of using the elongated axon cultures as a bridge for other types of neural injuries affecting long axon tracts, including optic nerve damage and peripheral nerve damage. "The idea itself may seem like a stretch," said Smith, "but we are only at the beginning of learning what we can do with this concept."

Brazilian professionals tour Magee; some of the international dignitaries who visit Philadelphia International Medicine's hospitals

A contingent of Brazilian professionals visited and toured Magee Rehabilitation April 26, another in a group of international visitors who frequently are hosted by PIM hospitals. The five-person team was part of an international group study exchange. While in America, the contingent of Brazilian dentists, teachers, architects, and nurses stayed with host families. The group learned about teaching methods and nursing practices in the United States. In addition to touring Magee Rehabilitation, during their week-long stay in the area, the Brazilians visited Philadelphia cultural institutions including the Philadelphia Art Museum, the Franklin Institute and the Academy of Natural Science. Another influential delegation from Brazil will be visiting Philadelphia in June in a Reverse Trade Mission coordinated by Philadelphia International Medicine. Key health care decision makers from Brazil will be in Philadelphia June 10 to 14, when they will tour each of the PIM hospitals, attend clinical and administrative lectures and participate in one-on-one meetings with their Philadelphia counterparts. Sponsors for the event so far include the Greater Philadelphia Visitors and Convention Bureau and Temple University Hospital. PIM also expects to be visited by dignitaries from Qatar in July, and hospital administrators from Riyadh in July. PIM's Institute of Education has also arranged for continuing medical education experiences for a physical therapist from Jeddah, Saudi Arabia in May; and medical students from Philadelphia who will travel to Latin America in the summer months. For more information about visiting Philadelphia International Medicine hospitals, or to arrange attendance at continuing education or advanced training seminars, or to arrange a visiting physician to travel from Philadelphia abroad, please contact Lucia Rosenberg at the Institute, 215-735-3269, lrosenberg@philadelphiamedicine.com. 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.

- 30 -