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Promising Results from DNA-Based HIV Vaccine

"Hope to the end."

--The First Epistle General of Peter 1:13

A research team led by University of Pennsylvania Medical Center scientists announced in late April that they had developed a DNA-based HIV-1 vaccine that has proven successful in protecting chimpanzees against the virus that causes AIDS.

In the study, three chimpanzees were immunized with a vaccine containing the attenuated HIV-1 genes. As a control, a fourth chimpanzee was given a vaccine preparation identical in every way except it did not include the HIV-1 genetic material. Two of the three immunized chimpanzees and the control chimpanzee were exposed to a large dose of HIV. The third immunized chimpanzee was kept as a negative control and not injected with the virus.

After 48 weeks, the virus was undetectable in the two immunized chimpanzees, but the control chimpanzee showed persistent HIV infection.

The finding gives hope that a human HIV-1 vaccine may prove possible. As David B. Weiner, PhD, associate professor of pathology and laboratory medicine and senior author of the study, explained in The Washington Post, "Chimps have very similar immune systems to people. It would be a very wonderful thing if this led to a usable vaccine."

But Weiner remained cautious. "A great deal of additional work remains to be done before we can say that [we can develop a vaccine for humans]. These results do give us confidence to go forward. And they strongly suggest that this new technology will find its place in the treatment of human disease."

The vaccine was manufactured by Apollon Inc. of Malvern. Penn and the National Institutes of Health are testing it in a small number of healthy, uninfected men. The study was published in the May issue of Nature Medicine.

Reports began April 29.

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Popular Cold/Allergy Relievers Linked to Stroke

In investigating the cases of eight relatively young individuals who had suffered strokes, researchers at the University of Pennsylvania Medical Center found a common link--the use of over-the-counter cold and allergy pills.

All of the patients were relatively young--ranging in age from 36 to 60--and were not considered at high risk for stroke. Each had used either pseudoephedrine, the active ingredient in Sudafed and Actifed, or phenylpropanolamine, the ingredient in Contac and Dimetapp, for an extended period prior to the onset of stroke symptoms.

The researchers theorize that individuals whose blood vessels constrict more easily than others may be more sensitive to decongestants. The conditions that suggest this tendency include migraine, livedo reticularis, and Raynaud's phenomenon. Five of the eight patients had histories of migraine headaches.

"The study suggests that it may be possible to identify patients who run a higher risk of stroke when using decongestants," said lead author Lidgia Vives, MD, stroke and neurointensive care fellow at the University of Pennsylvania Medical Center.

Eric Raps, MD, associate professor of neurology, presented the finding at the annual meeting of the American Academy of Neurology in April. "We have put up a yellow flag, not a red one," Raps said in USA Today. "This is only a question that we've raised, but not one we've answered."

Raps added that the decongestants are safe for most people when taken as directed. However, patients with diabetes, heart disease, glaucoma, a history of stroke, or high blood pressure should consult their physicians before taking the medications.

Reports began April 16.

The New York Times

Late-Paying HMOs

According to an article in The New York Times, many major HMOs do not make timely payments for claims submitted by hospitals and private physicians. And many hospital business administrators are complaining that the lateness is adding to overall costs and interfering with patient care.

The report said that the average HMO takes 54 days to pay providers for services. But many of the larger HMOs take much longer than that. Oxford Health Plans, the United Healthcare Corporation, and Humana Inc. took, respectively, 94, 77, and 71 days to pay claims.

Representatives from major HMOs say that their companies are growing so quickly that they are unable to keep up, and that the matter is complicated by their introduction of many "traditional" benefits that involve time-consuming paperwork. Representatives also deny allegations that HMOs purposefully delay payments in order to collect interest on money they are withholding, a practice called "floating."

"The HMOs are adding to our costs of doing business," said John Wynne Jr., senior vice president for finance, chief financial officer, and treasurer. "We still have to pay the salaries of the nurses and doctors." Waiting time for payments has increased by 40 percent, to between 90 and 100 days. Wynne said that unpaid managed-care charges owed to the hospital and its staff average between $7 million and $10 million.

The article appeared April 17.

The New York Times

The Boston Herald

Defining Death

Many organs that are donated for transplantation are taken from "brain-dead" patients dependent upon life support. When families choose to remove the patient from the life support, and death inevitably follows, organs are quickly removed. But the matter raises many ethical issues. How does one define the moment of death? And what about the practice of giving drugs to a person on life support--drugs that some say may hasten death--solely to preserve that person's organs for transplantation?

In the Cleveland Clinic Hospital, the matter is a subject of hot debate. There, Dr. Mary Ellen Waithe, Cleveland State University's director of advanced studies in bioethics, raised the concern that physicians at the hospital might be hastening patients' deaths in order to get their organs. Waithe likened it to this scenario: "Suppose your mother was dying of breast cancer and you knew she was going to die soon but you didn't know when... [and] you put a pillow over her face."

In The New York Times, Arthur L. Caplan, PhD, director of the Center for Bioethics, commented on the subject. "There's a real danger here," Caplan said. "If you scare people about fuzzing the line between life and death, if you frighten people into thinking that doctors kill patients to obtain organs, you will devastate the system. The whole system depends on altruism, and altruism depends on clear standards that everyone agrees to. You can't innovate in this area, institution by institution, doctor by doctor."

Experts fear that the debate will scare away many already-wary potential donors. To add a wrinkle, a report came out of Boston in mid-April that a man declared brain dead by his physicians was revived by an injection of a clot-busting drug. As one of the patient's physicians put it, prior to the revival, he was about to discuss organ donation with the patient's family. Instead, he found himself discussing rehabilitation.

"The team treating the patient can't have anything to do with transplantation," Caplan commented in The Boston Herald. "If we blur that line, we'll create so much doubt that no one will want to be an organ donor."

Reports began April 13.

World Class Docs

The physicians of the University of Pennsylvania Medical Center have always enjoyed high placement on the lengthy annual "Top Docs" lists published by Philadelphia Magazine. This year, the magazine opted to focus on "world-class" physicians; that is, physicians who have both a national and an international following. A subhead on the cover of the issue states, "People travel from around the globe to see elite Philly specialists. You can take a cab."

Of the 35 doctors named in the listing, seven of Penn's faculty were profiled, and 11 others were mentioned. The criteria that candidates had to meet to be considered this year were limiting. The doctors had to have an active clinical practice, and those who concentrate on research were excluded. Some specialities were not included because patients requiring care in those areas do not generally travel long distances to get it--for example, dermatology and obstetrics.

Philadelphia obviously has no shortage of world-renowned physicians, but will the trend continue? Philadelphia editor Carol Saline wrote, "American doctors have long held a pre- eminent position in international medicine, but there is concern that status may be threatened by managed care's emphasis on reining in specialists to control costs."

Said David Kennedy, MD, chair and professor of otorhinolaryngology-head and neck surgery and one of the profiled doctors, "My guess is that if you were to repeat this article on world-class docs in ten years, there will be fewer from the Philadelphia area, because a smaller percentage of the truly world-class physicians internationally will be from the United States."

Besides Kennedy, Philadelphia Magazine profiled the following Penn "international" physicians:

Beverly Lange, MD, professor of pediatrics (CHOP); Linton Whitaker, MD, professor of surgery; Alan J. Wein, MD, professor of urology; Elaine Zackai, MD, professor of pediatrics (CHOP); Stuart Fine, MD, the William F. Norris and George E. de Schweinitz Professor of Ophthalmology; Eugene Flamm, MD, the Charles Harrison Frazier Professor of Neurosurgery; Larry Kaiser, MD, professor of surgery; Scott Adzick, MD, the C. Everett Koop Professor of Surgery; John Glick, MD, the Leonard and Madlyn Abramson Professor of Clinical Oncology.

Also highlighted were Thomas Spray, MD, professor of pediatric surgery, cited for lung transplants, Paige Kaplan, MB,BCh, professor of pediatrics (CHOP), and Stanton Segal, MD, professor of pediatrics, who are "among the world's leading experts in two relatively rare diseases--Kaplan for Williams syndrome, a congenital condition often misdiagnosed as mental retardation, and Segal for galactosemia, the inability of the body to break down a kind of sugar." Alan Cohen, MD, professor of pediatrics (CHOP), was recognized for his expertise in treating thalassemia, and Anna Meadows, MD, professor of pediatrics (CHOP), for her "leadership in the study and treatment of long-term survivors of childhood cancers."

Barbara Weber, MD, associate professor of medicine, was called "the person you'd want to see for an evaluation if you have a strong family history of breast cancer."

Scheie's Alexander Brucker, MD, professor of ophthalmology, was called the "renowned authority on retinal detachment and strokes in the eye," and Luigi Mastroianni, MD, the William Goodell Professor of Obstetrics and Gynecology, was described as "a pioneer and still a major force in infertility."

The article was featured in the May issue.

Radnor's Grand Opening

Although Penn Medicine at Radnor saw its first patient in November, the facility celebrated its official grand opening in grand style in early April. According to Main Line Life writer Jim McCaffrey, William N. Kelley, MD, CEO of the University of Pennsylvania Health System and Dean of the School of Medicine, "played father of the debutante and introduced his progeny this way: 'This is Radnor's introduction to one of the best academic integrated health systems in the country. There are 36 specialty care practices here. We have everything from pediatrics to geriatrics.'"

Attendees were treated to valet parking, fine wine and food--including shrimp, crab cakes, and canapŽs--and the music of Penn's a capella singing group, the Quaker Notes.

Those who toured the facility were able to peek into Radnor's full-service gym, its "nutrition kitchen," and also the offices of Penn Health for Women, one of the country's six NIH-designated Centers for Excellence in Women's Health. Guests were offered screening for skin cancer, blood pressure, vision and hearing, sleep disorders, and a general health assessment. In addition, 25 Health System physicians spoke on health-care topics.

At the gathering, Kelley declared that Radnor would "set a new standard of service for patient care."

The article appeared April 3.

Men's Health at Overbrook

The University of Pennsylvania Health System opened its first Men's Health Center at the Overbrook Medical Center in early March.

Male African-American physicians at the center offer clinical services and screenings to men for two hours every Wednesday evening. Guests can also attend classes and informational sessions on the topics of parenting, male/female relationships, prostate cancer, and other subjects.

The center aims to reduce disturbing health trends in the African-American population. According to the Health System's Office of Community Affairs, studies show that the death rate is higher in African Americans than in white men, and life expectancy is lower. The HIV death rate is 3.4 times higher in the adult African-American male population between 35 and 44 than in that population of white Americans. In addition, African Americans under the age of 45 are 10 times more likely to die from complications of hypertension than whites in that age group.

Surveys also show that some African-American men avoid the health care system because they believe that they are more likely to die from a violence-related injury than from disease, so they assign a low priority to illnesses such as cardiovascular disease. They also may see illness as a sign of weakness, and admitting to having one threatens their sense of masculinity.

"Our program creates an environment that encourages men to participate in a regular pattern of health care for themselves," said Harold Mignott, MD, assistant professor of medicine and a physician at the Overbrook Medical Center. "Special emphasis is being placed on meeting the needs of African-American males because this group, historically, has been the least responsive to accessing the health-care system in America. As a black physician, I see this initiative as an important breakthrough in primary-care medicine."

The article appeared March 13.

An Asthma Program That Gets Results

Disease management programs can help physicians determine which treatments are most effective for treating chronic diseases. A particularly successful program, the asthma program at the University of Pennsylvania Health System, was recently highlighted in an article in The Philadelphia Inquirer. Penn's asthma education program has drastically reduced emergency room visits and hospitalizations.

"There's a single standard of care in our health system," explained David Shulkin, MD, chief medical officer for HUP and chief quality officer for the Health System. "It's just not going to work to let everyone come to their own conclusion about best practice."

The article told the story of a patient who had been receiving asthma care from various doctors for 17 years. But he was now under the care of the physicians at Yardley Medical Center, a Clinical Care Associates practice. A patient educator, Maureen George, MSN, RN, coordinator of the Health System's Comprehensive Asthma Care Program, explained to the patient that some drugs are "rescuers" that relieve immediate breathing problems, and some are "preventers" that help control irritation within airways. The patient learned that he had not been using his medications properly, and he left the office feeling inspired to properly manage his asthma.

J. T. Howell III, MD, a physician at Yardley Medical and CCA's medical director for region IV, said that he likes the way Penn trusts individual doctors to treat most asthma cases. "To have somebody come in who's clearly on the cutting edge say, 'Look, you guys can do this and here's the way it is; here's the straight poop'--that was very refreshing."

The article appeared April 20.

Treating Patients Like Customers

"Academic medical centers are not known for their hospitality," began an article by Eric Hollreiser in a recent issue of Philadelphia Business Journal. But Michele Volpe, chief operating officer for the Hospital of the University of Pennsylvania and Presbyterian Medical Center, is trying to change that image. The article highlighted some of her recent successes.

Volpe joined Presbyterian in May 1996 as chief operating officer with the mission of integrating Presbyterian's campus with HUP's. In December 1996, Volpe was named COO of HUP as well. Volpe's style, Hollreiser reported, is to open a dialogue with every person who works in the organization--"rank and file" as well as senior staff and medical leadership.

"I start every employee meeting by saying, 'Each person in this room makes a difference,'" Volpe said. She then reminds employees that every one of them has an impact on patient--or customer--satisfaction.

"I am not a physician. I'm not a nurse," Volpe said. "But if I see someone who needs attention, I know how to get them that care. I want everyone on both the Presbyterian and HUP campuses to be able to do that."

Volpe explained her empowerment plan, which includes assigning teams to individual patients to minimize the actual number of people a patient has to deal with during a hospital stay. In this way, the patient can form a relationship with the staff.

"We've got a lot work to do and we recognize it," Volpe concluded.

The article appeared in the May 2 issue.