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Banking on DNA

"Your descendants shall gather your fruits."

-- Virgil

Families have many choices to make when they meet with a funeral director to plan the funeral of a loved one. In the future, it appears, they will have an additional decision to ponder: whether to have a sample of their relative's DNA preserved and stored in a DNA bank.

Now, new companies, such as GeneLink of Margate, N.J., are offering such services to families who feel there might be a future need to find out what disease-linked genes have been handed down.

GeneLink has enlisted the sales expertise of funeral directors, who are experienced in dealing with the recently bereaved and in handling corpses. The company trains the directors on how to obtain samples and answer questions.

Barbara Weber, MD, associate professor of medicine in hematology-oncology, commented that DNA banks are capitalizing on "people's fear about their DNA." "I can't see that this is going to be of tremendous value," added Weber, who stores DNA for research purposes. For example, Weber said, a woman who wants to find out if she has the breast cancer gene can simply get her own blood tested.

The article appeared December 24.

Wall Street Journal

The Philadelphia Inquirer

Times Leader

Another Look at Lung Volume Reduction Surgery

Penn's Lung Center has been awarded a $1.2 million grant to participate in a seven-year, randomized clinical trial to study the effectiveness of lung volume reduction surgery in treating emphysema. The study will be funded jointly by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health and the Health Care Financing Administration (HCFA).

The two funding agencies seek to determine whether it is advantageous for Medicare to cover the surgery. Medicare suspended coverage of the procedure in January, 1996, questioning its safety and effectiveness. Experts interviewed by the Wall Street Journal estimated that between 10 and 20 percent of emphysema patients could be considered candidates, and that the cost is between $25,000 and $50,000 a procedure. Therefore, lung volume reduction surgery could add more than $3 billion a year to Medicare costs.

Penn was selected as one of 18 trial sites in the nation, and one of three sites awarded funding for studying a comprehensive "three-track" approach--a medical-management approach; an open-chest approach to lung volume reduction surgery; or lung volume reduction surgery using a thorascope.

Nationally, some physicians have expressed fear that Medicare is rationing life-saving technology that has already been proven effective. According to The Philadelphia Inquirer, over 20 medical centers have published good results on the surgery. To date, more than 140 patients have received lung volume reduction surgery at the Hospital of the University of Pennsylvania.

Lung volume reduction surgery works by reducing the overall volume of the lung by removing a portion of nonfunctional lung tissue. The decreased lung size restores elasticity to the remaining tissue, which improves breathing function.

"This is a warning call to medicine that if we're going to introduce something new, we need to prove that it is beneficial," Larry Kaiser, MD, chief of general thoracic surgery and professor of surgery, told the Wall Street Journal.

Reports began December 20.

Dallas Morning News

Los Angeles Times

Strokes After Bypass Surgery

A new study of over 2,000 patients at 24 major medical centers revealed that about 6.1 percent of patients who undergo bypass surgery for heart disease suffer strokes immediately after surgery.

The results of the study, published in the New England Journal of Medicine, came as a surprise to many doctors, who previously estimated the risk to be less than one-half of 1 percent. The study estimated that strokes linked to bypass surgery lead to extended hospital stays for 24,000 Americans, costing an additional $2 to $4 billion a year.

Rates may have increased, researchers say, because the population having bypass surgery is older than it was two decades ago and age increases risk.

Timothy J. Gardner, MD, professor of surgery, told the Los Angeles Times that the results were not that impressive to him. "I don't think there is anything in the study that most surgeons aren't already telling their patients," Gardner said "It's useful for the public to know that bypass surgery, like any other major surgery, involves a potential risk. But there's really nothing new about it."

Reports began December 18.

USA Today

Patriot-News

McKeesport News

Carlisle Sentinel

Bedford Gazette

Herald-Standard

CNN-TV

KYW-TV3

WPVI-TV6

KSAT-TV12 San Antonio

Eating Less Is the Key

Dieters who do aerobics or lift weights do not always shed more weight than dieters who are sedentary, according to a study by Thomas Wadden, MS, PhD, professor of psychology in psychiatry and director of Penn's Weight and Eating Disorders Program. Wadden's study, which is to be featured in the April issue of The Journal of Consulting and Clinical Psychology, included 128 obese women divided in two groups--those who exercised and those who did not. Both groups consumed the same diet of four glasses of a liquid diet drink during the day, and a low-calorie frozen dinner at night. Weight loss tended to be consistent between the two groups--about 33 pounds per woman over 48 weeks.

Wadden also found that exercisers do not always have leaner bodies, they don't necessarily have higher metabolisms, and they are not always happier about themselves. He concluded that, although exercise is important for a number of health reasons, eating less is the key to weight loss. And even though exercise doesn't appear to make a difference in terms of weight loss, exercisers in the study had more success keeping their weight down on a long-term basis. "It's surely not a study that says stop exercising," Wadden cautioned.

Reports began on January 15.

Houston Chronicle

Tri-County Sunday

Unnecessary Pregnancy Monitoring

Experts from the American College of Obstetricians and Gynecologists (ACOG) announced in early January their position that many high-tech devices used to monitor pregnancies should not be used routinely in healthy pregnancies.

One procedure being scrutinized is ultrasound, which is used on 70 percent of pregnant women to rule out fetal abnormalities. According to Fredric D. Frigolette, Jr., MD, president of ACOG, a 1993 study of more than 15,000 women found no advantages to performing routine ultrasound in low-risk pregnancies. Also under scrutiny are home uterine-activity monitoring devices designed to identify preterm labor in women at risk. No clinical trial has proven these devices effective, either.

Michael T. Mennuti, MD, professor and chair of obstetrics and gynecology, commented on the usage of uterine-activity monitoring devices. "After more than 10 years and dozens of studies, we still don't have proof that this technology is effective in preventing preterm birth," Mennuti told the Houston Chronicle.

Mennuti added that the widespread use of the monitors could lead to inappropriate treatment. ACOG does not recommend the devices.

Reports began on January 5.

Washington Post

Boston Globe

Buffalo News

Pittsburgh Post-Gazette

Tribune (Scranton, Pa.)

San Diego Union-Tribune

Sunscreen for Wrinkle Cream Users

In December, the Food and Drug Administration announced plans to evaluate the safety of over-the-counter alpha hydroxy skin creams. The popular creams, which constitute a half a billion dollar a year industry, speed up the natural process of shedding skin cells and promise to reduce fine surface wrinkles.

Over-the-counter creams contain up to 10 percent alpha hydroxy. Alpha hydroxy "chemical peels," offered in salons, can contain as much as 30 to 70 percent of the active ingredient.

There is speculation that the creams make skin more sensitive to sunlight, a claim that the FDA will be investigating. Because the FDA does not strictly regulate the cosmetics industries, no one has yet studied the long-term effects.

A seven-member scientific panel that advises the cosmetics industry declared that manufacturers of alpha hydroxy products should include sunscreen in their lotions, or advise users to apply sunscreen simultaneously.

James Leyden, MD, professor of dermatology, already tells his patients who use the creams to also use sunscreen. "You're not by day going to wreck yourself and then at night try to repair the damage," Leyden told the San Diego Union-Tribune. "[If you're] trying to make your skin better, you'd be foolish not to use some sun protection."

Reports began December 18.

Los Angeles Times

Plain Dealer

Tribune-Review

WPVI-TV6

Potty Training in the 1990s

The first large-scale study of American toilet training practices in over 30 years revealed that toddlers are completing training at much later ages than in the past, and that toilet training problems are still common.

The study of 482 healthy children, authored by Bruce Taubman, MD, associate professor of pediatrics, found that 4 percent of toddlers were trained by age two, 22 percent were trained by age 2-1/2, and 60 percent by age three. Two percent were still not trained at age four.

The statistics have changed considerably since 1962, when renowned pediatrician T. Berry Brazelton published a toilet training study in Pediatrics that showed that most children were fully trained by 27 months. In the paper, Brazelton recommended that parents not start training until children express an interest in toileting (usually about age two). His method was adopted by millions of parents over the years.

Taubman's study found that many children developed peculiar and unhealthy habits during training. One in five experienced a period of "stool toileting refusal," meaning they would use the potty to urinate, but would only have bowel movements into a diaper. Some children would even hold their bowel movements for long periods of time, causing adverse health effects.

"In our study population, it would appear that bowel training problems continue in a non-coercive environment, although in different forms," Taubman said. "I don't think we should throw out Brazelton and go back to training at age one year of age. But I think we may need some modification in order to train kids earlier and without so many problems."

Nathan J. Blum, MD, assistant professor of pediatrics and author of a related behavioral study, said that children who train late or have problems with stool toileting refusal do not have more behavioral problems than those who have an easy time of it. "There are some guidelines we know are helpful," Blum said. "But there may be other things we haven't come up with yet. And parents may need to adapt guidelines to their individual children."

Reports began January 14.

San Diego Union-Tribune

Times & Post-Intelligencer

Watching the "Wheels Turn" in the Brain

In recent years, scientists have discovered that the brain physically changes in response to a person's environment and experiences. Neurons in the brain grow or shrink, new connections between neurons are made, and old connections are strengthened.

"For the first time [through precision electronic-scanning devices], we can see the thinking, working, living human brain," said Steven Hyman, director of the National Institute of Mental Health, at a November neuroscience conference. "It's as if there were little gremlins running around rewiring the circuits all the time."

A normal adult has about 200 billion neurons, and a trillion supporting cells in his or her head. Each neuron may connect to more than 1,000 others. Scientists have learned that the conversion of short-term into long-term memories requires the growth of new connections between neurons.

According to Martha Farah, PhD, a professor of psychology who has appointments in the departments of neurology and psychiatry of the University of Pennsylvania School of Medicine, "Learning can create a new brain area as well as modify an old one. The size of a brain area grows or shrinks, depending on experience."

Neuroscientists at the conference discussed other findings in the areas of vision, smell and taste, consciousness, and mental disease. As knowledge of the brain's "wiring" increases, researchers hope that the new understanding will make it possible to develop better treatments for strokes, mental illness, and memory loss.

Reports began December 8.

Launching Radnor

In November, the University of Pennsylvania Health System opened a state-of-the-art, multispecialty health care center in the suburbs of Radnor. The new center, called Penn Medicine at Radnor, is located at the former site of the TV Guide offices. During a tour in January, William N. Kelley, MD, CEO of the University of Pennsylvania Health System and Dean of the School of Medicine, addressed the physicians and staff of the new facility. "For a whole area and maybe even the whole country, you will set an example for how patient service can meet patient care," Kelley said.

More than 100 physicians representing primary care and 36 specialties will staff the facility. The two-floor, 80,000 square-foot complex contains 70 exam rooms, 40 procedure rooms, and 40 office and consultation rooms. The center will celebrate an official grand opening in early April.

The new facility will provide "one-stop shopping" for suburban residents who find it inconvenient to travel into West Philadelphia, said Michael A. Grippi, MD, associate professor of medicine and medical director of Penn Medicine at Radnor.

In fact, the facility was designed to contain many of the positive aspects of a shopping mall. Hallways flow from one module to another. "We are looking at Nordstrom and the Four Seasons as our model," Kelley said. "We literally looked at them and learned as best we could about the kind of service they provide and how they do it."

The article appeared in the January 24-30 issue.

Young at Mind

What are the secrets to staying young? Philadelphia Magazine looked at various ways Philadelphians over age 50 try to stay youthful. Forget plastic surgery, vigorous exercise, and vitamin supplements. According to Risa Lavizzo-Mourey, MD, director of the Penn's Institute on Aging and chief of the division of geriatric medicine, the most important thing you can do is use your brain. "Disuse--allowing your mind and body to rot in front of a TV--is one of the biggest impediments to successful aging. An awful lot of negative qualities of aging are due to disuse." Lavizzo-Mourey added that there are a lot of pluses to getting older, including mental and emotional maturity. "Executive function--the ability to make decisions and juggle many things at once--does not diminish. In fact, because judgment is better, you'll make wiser decisions."

Many patients in this age group turn to cosmetic surgery to correct the effects of aging, said Linton Whitaker, MD, professor and chief of plastic surgery, but the desired results have changed over the years. "In the past, patients came into my office telling me they wanted to look younger. Now they'll say, 'I want to look like a better version of myself.'"

Also interviewed for the piece were James Leyden, MD, professor of dermatology, Louis Bucky, MD, assistant professor of surgery, Leonard Dzubow, MD, professor of dermatology, and David Low, MD, assistant professor of surgery.

The article was featured in the December issue.

Decisions About Death

A five-part series in The Philadelphia Inquirer (Nov. 17-21) addressed the different ways that people and their families approach the end of life. The first in the series focused on Gene Moore, a patient at the Hospital of the University of Pennsylvania, and his family as they prepared for his inevitable death.

Moore, a 63-year-old steel worker who suffered from pulmonary fibrosis, had a lung transplant in February at Penn and made a temporary recovery. In June, however, Moore was re-hospitalized because his body was rejecting the lungs. Despite medical efforts to help him, Moore rapidly deteriorated in Penn's MICU, until his physicians told the family that there was no chance for his recovery and that further treatments might actually be causing Moore discomfort. After much discussion and soul-searching, the family decided to take Moore off of life support.

David Gaieski, MD, a MICU resident in internal medicine, told the Inquirer that families very often have a hard time accepting the futility of prolonged treatment. "Almost invariably families want to push on when we want to stop." MICU nurse Cheryl Maguire, RN, CCRN, echoed Gaieski's sentiment: "It's only one in 20 that a family comes to us and says stop. It's much more the case that we see there's no hope, and we keep working until they get to that point, too."

The Inquirer series examined hospice care, assisted suicide, living wills, and other end-of-life concerns.

Fifty Years After Nuremberg

The 1947 Nuremberg trials of 23 doctors and Nazi officials who performed medical experiments on concentration camp inmates resulted in an international code of medical ethics and rules on informed consent. But how does the code affect the practice of medicine and research today?

Delaware County Daily Times staff writer Patti Mengers reported on Penn's Center for Bioethics September 30 conference on "The Nazi Medical Trials: A Legacy of Horrors." Mengers looked at various ways the Nuremberg Code has been used--and abused--since its inception.

The Nuremberg Code states: "The voluntary consent of the human subject is absolutely essential." But debate continues over how the code should be interpreted. And last fall, the Food and Drug Administration and the National Institutes of Health ruled that some medical research can be conducted under strict guidelines on uninformed patients.

Mildred Cho, PhD, research assistant and professor of molecular and cellular engineering and research assistant professor of bioethics at the Center for Bioethics, expressed her belief that researchers must be particularly mindful of informed consent as they perform experiments in the field of genetic research. "In the Nazi era, they believed there were genetic roots for shiftlessness, criminality, and alcoholism, and they wanted to solve social ills through medical research," Cho said. "We do need to be vigilant and not let ourselves off the hook about our own prejudices."

The article appeared in the December 9 issue.