PHILADELPHIA INTERNATIONAL MEDICINE NEWS BUREAU
Contact: Leonard N. Karp
lkarp@philadelphiamedicine.com
215-735-3989
May 29, 2002

For Immediate Release:

1. Children's Hospital Work Can Lay Groundwork for Controlled Trial of Fetal Study for Spina Bifida

2. Temple University Hospital Establishes Aortic Surgery Center

3. Outcomes at Crozer's Burn Center Enhanced by Team Approach; One of First To Gain Accreditation

Philadelphia -- Philadelphia International Medicine (PIM) hospitals are making the news with new research, new services and great outcomes. Below are three examples of how the hospitals of PIM are working hard to maintain their status as among the best health care organizations in the world. For more information, contact PIM at 215-735-3575.

Children's Hospital Work Can Lay Groundwork for Controlled Trial of Fetal Study for Spina Bifida

Researchers at The Children's Hospital of Philadelphia, a member of the Philadelphia International Medicine network, have completed the first study comparing the location on the spine of the birth defect spina bifida with the rate of shunting - the surgical placement of a drainage tube. The research showed that infants with spina bifida are more likely to require a shunt when the birth defect is located higher on the spine. The shunt carries excess spinal fluid away from the child's brain to prevent a life-threatening buildup of pressure.

The researchers, led by Leslie N. Sutton, MD, director of Neurosurgery at Children's Hospital, reported on 297 children at Children's Hospital who received surgery shortly after birth to close spina bifida lesions. Overall, 81 percent of the infants required shunts. "Our study confirmed the previous widespread impression of neurosurgeons that spina bifida defects closer to the head correspond to a higher incidence of shunting," said Dr. Sutton. The research is published in the March issue of Pediatrics.

In spina bifida, the most common birth defect of the central nervous system, a developmental failure early in pregnancy leaves an opening in part of the bone and tissue covering the fetus's spinal cord. Depending on the severity of the defect, the newborn may suffer paralysis, bowel and bladder problems, and fluid pressure on the brain.

Surgery performed on newborns with open spina bifida lesions requires closing tissue over the defect to protect the spinal tissue. However, previous studies have suggested that neurological injury may occur before or during birth. To prevent that injury, physicians at The Center for Fetal Diagnosis and Treatment at The Children's Hospital of Philadelphia have performed surgery for spina bifida on the fetus prior to birth.

In a previously published study, Dr. Sutton and his colleagues showed that only one of nine surviving patients who underwent fetal spina bifida surgery required a shunt within 6 months of surgery. In contrast, 81 percent of the 297 infants followed in the current study, all of whom had surgery after birth, required shunts. "Our current study provides outcome data that will be important for comparison purposes when a clinical trial evaluates the effectiveness of fetal surgery for spina bifida," said Dr. Sutton.

In addition to correlating shunt incidence with the level of the spinal defect, the current study also compared the infants' functional level - their degree of paralysis, with their bony level -- the location of the missing vertebra as viewed on X-ray images. The researchers found the two types of measurements generally corresponded with each other except at the lowest level of the spine, the sacral vertebrae, which are at hip level. In these cases, children were more likely to have shunts when lesions were identified by bony level rather than by functional level.

"In addition to helping design a future trial of fetal surgery, our findings provide physicians more information with which to counsel parents of infants with spina bifida about their child's prognosis," said Dr. Sutton.

Co-authors of the study with Dr. Sutton, all from Children's Hospital, are Natalie E. Rintoul, MD; Anne M. Hubbard, MD; Brian Cohen, Ph.D.; Jeanne Melchionni, R.N.; Patrick S. Pasquariello, MD; and N. Scott Adzick, MD.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked today as the best pediatric hospital in the nation by a comprehensive Child magazine survey. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefitted children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 381-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19.

Temple University Hospital Establishes Aortic Surgery Center

Physicians from three clinical departments at Temple University Hospital have jointly established a multi-disciplinary Aortic Surgery Center that offers comprehensive surgical and medical treatment of aortic dissections, aneurysms, traumatic ruptures and aortic occlusions.

The Center's staff includes thoracic and vascular surgeons, interventional cardiologists and radiologists working in collaboration to offer state-of-the-art surgical procedures, including stent graft repair, and diagnostic tools such as ECHO, CT and angiogram. The particular focus of the Aortic Surgery Center is the high-risk patient who requires complex surgical treatment.

The Aortic Surgery Center focuses on treatment of abdominal aortic aneurysms, acute aortic dissection, thoracic aortic aneurysms, traumatic aortic injuries and aortic occlusions. Abdominal aortic aneurysms are abnormal enlargements in the abdominal portion of the aorta. Classically, patients with abdominal aortic aneurysm are also predisposed to coronary artery disease. Temple's expertise in managing severe heart disease and vascular disease provides the Center with state-of-the-art capabilities for patients with both problems.

Acute aortic dissection is caused by separation of walls of the aorta, with blood dissecting between the layers of the intima and the media. Type A dissections, involving the entire aorta or the ascending aorta alone, are always treated surgically, while type B dissections, involving the descending thoracic and/or thoracoabdominal aorta, are usually managed with antihypertensive therapy. Etiologies of acute aortic dissection include hypertension, atherosclerotic aortic disease, cystic medial necrosis and Marfan's syndrome.

Thoracic aortic aneurysms are usually located in the ascending and descending thoracic regions but can also be found in the transverse arch and thoracoabdominal locations. Operative repair is generally indicated with aneurysms greater than or equal to 5 cm in diameter, since the risk of rupture is directly correlated with the diameter of the aneurysm.

The most common cause of aneurysm is atherosclerotic degeneration of the aorta. Indeed, particularly in Caucasians, lifestyle factors that lead to occlusive heart disease can also cause aneurysmal disease. Other causes include chronic aortic dissection, Marfan's syndrome, cystic medial necrosis, or aortitis secondary to syphilis or granuloma.

Aortic ruptures occur from traumatic injury or as an aneurysm enlarges. Most acute ruptures occur in patients whose aneurysm has not been diagnosed and have a relatively poor prognosis, with thoracic ruptures more serious than abdominal ruptures. Specialized centers like the Temple Aortic Surgery Center are uniquely equipped to treat these high-risk cases.

Occlusive disease of the aorta is a problem frequently treated in the Aortic Surgery Center. Occlusive disease in the abdominal aorta leads to poor circulation in the lower extremities. Uncontrolled hypertension and renal dysfunction are sequelae of renal artery involvement; intestinal angina (post-prandial abdominal pain) and intestinal infarction (in advanced cases) reflect compromised circulation to the intestines when the mesenteric arteries are occluded. Occlusion of the lower branches of the aorta leads to occlusion of the total aorta.

Treatment is usually surgical, with graft replacement if a large segment of the aorta is involved, and balloon dilation and stenting if the lesions are focal. "In the appropriate patient, the cooperative relationships between all subspecialties often allow emphasis on less invasive therapy, often negating the need for surgery," says Gary Cohen, MD, section chief of interventional radiology.

"We are focusing on high risk abdominal and thoracic cases, due to either the complicated nature of the patient's overall condition or the complexity of the required surgery," says Arun Singhal MD, PhD, assistant professor of surgery, department of cardiac and thoracic surgery. Cases are defined as high risk based on the anatomic location of the aortic dissection or aneurysm, patient co-morbidities such as heart disease, or the presence of Marfan's syndrome.

Traditional morbidity and mortality rates of aortic dissections and aneurysms as well as from the surgical repairs are relatively high. One-year survival rates for patients with acute type A aortic dissections are approximately 60 percent with surgical treatment versus 5 percent with medical management. The mortality and paraplegia incidence for surgical repair is approximately 10 percent and 5 percent respectively for descending thoracic aneurysms and 10-50 percent and 7-25 percent respectively for thoracoabdominal aneurysms.

The goal of the Aortic Surgery Center is to reduce these risks, emphasizes Robert Larson MD, section of vascular surgery and Mahender Macha, MD, Center of Cardiac and Thoracic Surgery.

"As part of this center, we have thoracic surgeons, vascular surgeons, interventional radiologists and interventional cardiologists, all experienced in the management of complicated high-risk aortic problems. Of equal importance are our high-risk anesthesia support and quality critical care services for diagnosis and surgical treatment, including emergency surgeries, and our outpatient follow-up by Temple University Hospital's specialized personnel."

The Temple University Aortic Surgery Center offers minimally invasive aneurysm surgery with abdominal stent graft repair. Stent graft repair, using a smaller operative incision, may offer advantages over open repair for high-risk patients.

"Our staff is geared to respond to physicians who diagnose a thoracic or abdominal aneurysm in a patient or who have a highly complicated case," says Dr. Singhal. The Center's staff includes thoracic surgeons Satoshi Furukawa, MD, Arun Singhal, MD, Ph.D., and Mahender Macha, MD; vascular surgeons Anthony Comerota, MD, Steven Kagan, MD, Robert Larson, MD, and Mohammad Eslami, MD; interventional radiologists Gary Cohen, MD, Jorge Arsuaga, MD, and James McGuckin, MD; and interventional cardiologists James Burke, MD, PhD, Brian O'Murchu, MD, and Timothy Jayasundera, MD. Drs. Furukawa and Comerota are the Center's co-directors.

Outcomes at Crozer's Burn Center Enhanced by Team Approach; One of First To Gain Accreditation

When the Nathan Speare Regional Burn Treatment Center opened its doors in November 1973, no one could have imagined the high demand for care and the enormous challenges that would be faced by the Burn Treatment Center staff and their colleagues throughout Crozer-Chester Medical Center.

"We anticipated that our beds might be full within a year, and we were full within six weeks," recalls Bette Bayley, MS, PhD, RN, who was the Burn Treatment Center's first clinical coordinator and is now Nursing Research Facilitator at Crozer and a professor of nursing at Widener University.

Today, the Burn Treatment Center at Crozer provides all the services needed to meet the complex needs of burn patients and their families within a single unit. Crozer's multidisciplinary team of physicians and surgeons, nurses, occupational and physical therapists, social workers, pharmacists, nutritionists and clinical educators are committed to providing the highest level of quality burn treatment.

"A dedicated team approach is essential for a successful outcome," explains Mary Lou Patton, MD, co-director of the Burn Treatment Center. "Each member of the team makes a unique contribution to that process, from the surgeons to the nurses to the physical and occupational therapists. At Crozer, people are proud to be a part of that team."

Linwood R. Haith, Jr., MD, co-director of the Burn Treatment Center, believes the team is among the best in its field. "When I joined the Burn Center in 1981, I was struck by the camaraderie, sense of purpose and altruism of the staff," he observes. "Here, you have a staff that you could put in any university hospital, and they would excel."

The team at the Burn Treatment Center develops each patient's care plan, and meets once a week to monitor progress. "The team approach is an awesome thing," says Cynthia Reigart, BSN, RN, nurse manager of the Burn Treatment Center.

Cynthia Hoffman, MS, RD, CNSD, nutritionist, has been with the center since 1984: "There is a lot of interplay between the staff and doctors. The patients' nutritional demands are almost double those of a healthy person, and we are doing a lot of IV and tube feedings, so it is very challenging - we're applying concepts we might otherwise only read about in textbooks."

Marla Stoering, PT, senior physical therapist, has been with the center three years after treating patients with spinal injuries: "I am interested in working with patients who have wounds - seeing them start to move and eventually return to their former way of life. And I like the closeness of this group. It's the best team approach I've ever experienced."

Throughout its history, the Burn Treatment Center has pioneered methods of burn treatment. Crozer was one of the first to use cultured cell transplantation, or cloning, of a patient's skin. The Burn Treatment Center continues to employ the current state-of-the-art surgical techniques, medications, therapies, wound care and skin replacement products in its individualized treatment plans. The center's staff also helped design the shower trolley used in the daily care and gentle cleansing of burn wounds.

Since 1997, the center has employed Jean Klein, MS, DNSc., RN, a full-time psychiatric liaison nurse, who provides psychological counseling and emotional support to burn patients, their families and the treatment team. Klein sees every patient in the Burn Treatment Center, from admission through follow-up outpatient care. The position is rare, if not unique to Crozer. "In other burn centers there is a psych presence, such as psychiatric consultations," explains Klein. "But to find a dedicated psych nurse in a burn unit is very rare."

In addition to the dedicated burn team, within the Medical Center itself there are consulting staff in emergency medicine, critical care medicine, intensive care medicine and surgery, who are prepared to report immediately to the Burn Treatment Center if needed. This is why the 13-bed Burn Treatment Center has earned an international reputation for excellence in holistic burn care, receiving more than 6,200 new burn admissions since 1973, an average of 300 patients annually. It is the first burn center accredited by the Commission on the Accreditation of Rehabilitation Facilities (CARF).

In June 2000, the Burn Treatment Center became one of approximately sixty-five burn units/centers in the United States -- and the first in the Philadelphia area -- to meet the stringent criteria of the American Burn Association's Burn Center Verification/Consultation Program. This recognizes that the Burn Treatment Center met the highest standard of care for burn patients as approved by the American College of Surgeons.

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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