PHILADELPHIA INTERNATIONAL MEDICINE® NEWS BUREAU
Contact: Leonard N. Karp
lkarp@philadelphiamedicine.com
215-735-3989
March 28, 2005

For immediate release:

In this month's issue:

1. MossRehab Opens New Center; 30-bed Stroke Unit and 20-bed Spinal Cord Injury Rehab Unit
2. Penn Researchers Identify Link between Critical Cancer Pathway and Epstein-Barr Virus Protein
3. Children’s Hospital Study Suggests Efforts to Prevent Obesity Should Focus on Children with Overweight Mothers
4. Temple University Hospital’s Innovative Rapid Response Team Improves Patient Outcomes; Reduces Patient Mortality and Morbidity

Editors note: Research by Philadelphia International Medicine physicians may lead to new ways to treat some of our most challenging diseases. Below are some examples from our hospitals.

MossRehab Opens New Center; 30-bed Stroke Unit and 20-bed Spinal Cord Injury Rehab Unit

Philadelphia – MossRehab, one of the leading providers of physical medicine and rehabilitation in the United States, recently completed renovations to more than 57,000 square feet at its newest facility. The renovations included a 30-bed stroke and a 20-bed spinal cord injury rehabilitation unit, as well as a newly constructed outpatient center and three diagnostic labs, including the renowned Sheerr Gait and Motion Analysis Lab.

In addition to the 50-bed musculoskeletal rehab unit for orthopaedic, joint replacement, trauma, and amputation, which has been fully operational in Elkins Park since late 2003, “this new space gives Moss the opportunity to treat more patients experiencing a wide range of conditions, from common problems such as back pain and arthritis, to those more debilitating as with stroke and spinal cord injury,” said Ruth Lefton, chief operating officer.

For individuals recovering from a stroke or spinal cord injury, the comfortable patient rooms and designated treatment areas on the new units offer patients the opportunity to rehabilitate with other individuals experiencing the same or similar situations. “Patients on these units are also treated by a multidisciplinary team of medical, nursing and therapy staff dedicated to and experienced in stroke or spinal cord injury rehabilitation,” said Alberto Esquenazi, MD, chairman of the Department of Physical Medicine and Rehabilitation and chief medical officer at MossRehab. “This environment fosters better communication, a greater integration of rehabilitation activities and a stronger sense of community.”

For individuals with outpatient therapy needs, the newly constructed outpatient facility at Elkins Park is equipped with the latest rehabilitative and exercise equipment, specially selected to meet the unique needs of rehab patients. “The facility was designed to comfortably accommodate a much larger patient volume and allows us to offer our comprehensive services and programs in a more convenient location,” added Lefton. Programs and services offered here include physical, occupational, hand and cardiac rehabilitation, as well as, lymphedema treatment, functional capacity evaluations and wellness programs.

Penn Researchers Identify Link between Critical Cancer Pathway and Epstein-Barr Virus Protein

Researchers at the University of Pennsylvania Medical Center have identified a link between a critical cancer pathway and an Epstein-Barr Virus (EBV) protein known to be expressed in a number of EBV-associated cancers. Their findings demonstrate a new mechanism by which EBV transforms human B cells from the immune system into cancerous cells, which can lead to development of B-cell lymphomas.

Erle S. Robertson, PhD, associate professor of Microbiology and Director of Tumor Virology, with Penn’s Abramson Cancer Center and MD/PhD student Jason Knight, published their results in the early March issue of Molecular and Cellular Biology.

Using human cell cultures infected with the Epstein-Barr virus, the investigators found that a specific viral protein targets a molecule that normally regulates the cell-cycle progression, or duplication process, of resting B cells. In the presence of this viral protein - called EBNA3C (for EBV nuclear antigen) - the cell cycle of the usually quiescent human B cells gets a jump start, which ultimately initiates uncontrolled growth.

EBV, a member of the herpesvirus family and one of the most common human viruses, plays a role in cancers such as lymphoproliferative diseases in transplant or AIDS patients, Burkitt’s lymphoma, Hodgkin’s lymphoma, and nasopharyngeal carcinoma, and also causes the well-known disease, infectious mononucleosis. As many as 95 percent of adults 20 years and older have been infected with EBV, but show no symptoms.

“Viruses that are associated with cancers typically target the cell cycle to gain control,” says Robertson. “However, this is the first time that laboratory research into how EBV drives the cancer process has directly identified a critical component of the cell cycle for control. Now we can develop targeted therapeutics to disrupt the function of this viral protein.” The researchers surmise that the first use of future therapies from these studies will be in lymphoproliferative disease in transplant and immunocompromised patients because this is a clear case of EBV-driven B-cell lymphoma.

The use of peptides to block the interaction between this essential EBV protein and the specific pathway in human B cells is currently underway. Initial studies show that the growth of EBV-associated cancer cells can be inhibited in tissue-culture assays. The investigators are actively pursuing this line of investigation for developing potential therapies.

Children’s Hospital Study Suggests Efforts to Prevent Obesity Should Focus on Children with Overweight Mothers

By age six, children of overweight mothers are 15 times more likely to be obese than children of lean mothers. The research, at The Children’s Hospital of Philadelphia and the University of Pennsylvania Medical Center, showed the strength of genetic influences, and suggests that efforts to prevent obesity should focus on such children at risk, preferably by four years of age. The study appears in the January issue of the American Journal of Clinical Nutrition.

Researchers followed 70 children over a six-year period at Children’s Hospital; of that number, 33 had overweight mothers and 37 had lean mothers. During the first two years of age, weight and body composition differed little between the two groups. But the high-risk group (children whose mothers were overweight) had greater overall weight by age four, and both greater weight and more body fat by age six.

“We found dramatic increases in body fat between ages three and six,” said lead researcher Robert I. Berkowitz, MD, chair of Child and Adolescent Psychiatry and executive director of the Behavioral Health Center at The Children’s Hospital of Philadelphia. “This suggests that some genes controlling body weight may become active during this period.”

Among the low-risk group, only one of the 37 children was overweight, suggesting that genetic influences can protect against obesity as well as predisposing to it.
The one environmental influence apparent in the study was family income; lower income was associated with higher body weight, similar to the pattern found in adults. The researchers found no genetic influence for the fathers’ weight, possibly because the number of children studied was not large enough.

“This research has important implications for preventing obesity,” said Virginia Stallings, MD, director of the Nutrition Center in the Division of Gastroenterology and Nutrition and deputy director of the Joseph Stokes Research Institute at Children’s Hospital and a co-author on this study. “It points to an important target group - children whose mothers are overweight. There could be greater benefits to focusing intense prevention efforts toward these children, rather than to the entire pediatric population.”

The fact that increased body weight at age four is followed by increased body fat at age six indicates that prevention efforts should begin by age four for overweight children of overweight mothers. “It is not necessary to wait to see increased body fat by age six if the child is already overweight,” Dr. Berkowitz said.

“There appears to be an interaction between the genes that control body weight and environmental factors such as increased intake of sweets and fats as well as inactivity, all of which are associated with the development of childhood obesity,” noted Albert Stunkard, MD, of the University of Pennsylvania Medical Center and a co-author on this study.

A future report will describe social and behavioral factors influencing the children in the study group.

The National Institutes of Health supported this study. Dr. Berkowitz’s co-authors were Dr. Stallings, Dr. Stunkard, and Greg Maslin of Biomedical Statistical Consulting, Wynnewood, Pa. Drs. Berkowitz and Stallings also are faculty members of the University of Pennsylvania School of Medicine, where Dr. Berkowitz is medical director of the Weight and Eating Disorders Program.

Temple University Hospital’s Innovative Rapid Response Team Improves Patient Outcomes; Reduces Patient Mortality and Morbidity

Safety and quality initiatives are a priority at Temple University Health System’s hospitals. Temple University Hospital recently implemented the multidisciplinary Rapid Response Team (RRT), designed to reduce patient mortality and morbidity through timely identification, intervention and treatment of at-risk patients before they require resuscitation.

To date, the team has been activated nearly 200 times, resulting in a measurable increase in positive patient outcomes while decreasing resuscitation events.

“The Rapid Response Team is the most successful patient safety initiative I have seen,” says David Shulkin, MD, Chief Medical Officer. “In fact, The Institute for Healthcare Improvement lists RRTs as its number one initiative to prevent avoidable deaths and Temple is one of the first in the country to implement a Rapid Response Team program.”

Nationally, survival rates for patients requiring CPR during their inpatient admission is about 40 percent. The percent of patients who are successfully resuscitated and survive to be discharged from the hospital falls approximately 10 percent.

“The national data is startling,” says Dr. Shulkin. “It suggests that only 10 percent of patients who have a cardiac arrest survive to discharge. [JAMA 2005, 293(3) 305-310, Abella, BS et al] So, the concept behind Rapid Response Teams is that early intervention can have a huge impact.”

It may seem surprising at first that hospitals need an RRT for potential emergencies that are relatively common. But safety experts assert that in many hospitals such potential crises are not handled as quickly as they could be. When a patient is in serious distress, the nurse’s first step is to contact the patient’s doctor —who may or may not be immediately available. And when it comes to avoiding a crisis, early intervention is critical.

The RRT is comprised of a board-certified general medicine or critical care attending physician, a critical care nurse, respiratory therapist, pharmacist and transporter. The team is on-call 24 hours a day, seven days a week. “The RRT demonstrates the power of a multidisciplinary team working together,” says Dr. Shulkin. “It is not just about getting the right physician there. The entire team is needed to respond most effectively to an emergency situation.”

For the Rapid Response Team, standard treatment procedures are followed but standard response time is not. The team moves instantly. Functioning much like a roving emergency room team, they stabilize patients who are at risk for an adverse event.

“Any time anybody who works in the hospital observes that a patient’s clinical condition is deteriorating, they can call an RRT,” explains Dr. Shulkin. The staff has been educated as to what early signs and symptoms of clinical deterioration should trigger a call to the RRT.

“The patient’s own physician remains the first line of response,” explains Dr. Shulkin, “But when that physician, for any reason, needs additional resources, the RRT comes to evaluate the patient. The RRT program gives the physicians and nursing staff great support.”

Temple’s program is nearly a year old and data indicates that 85 percent of the rapid responses are believed to have prevented further clinical deterioration. In the first three months of the program implementation there was one rapid response team call for every three code calls.

“Now, for every code call there is one RRT call,” says Dr. Shulkin. “This tells us that we are getting better at identifying patients who can benefit from the Rapid Response Team before they get into further trouble.”

The ultimate goal of the RRT program is to decrease the number of codes. “Last year we had approximately 300 codes. This year we expect to have an equal amount of RRTs and codes,” says Dr. Shulkin. “This one to one ratio tells us that without the RRT program in place, many more patients would have potentially coded. Our studies show that we are having a positive clinical impact.”

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 .