INTERNATIONAL

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Penn Survey: ICU Nurses Admit They Hasten Death "I shall tell you a great secret, my friend. Do not wait for the last judgment, it takes place every day." - Albert Camus Nearly one in five nurses who care for critically ill adults have caused a patient's death either through euthanasia or assisted suicide, according to a national study led by David A. Asch, MD, assistant professor of medicine and a medical ethicist with Penn's Center for Bioethics. Patients or family members usually made the request, but a small number of nurses performed euthanasia on their own, the study reveals. Dr. Asch mailed 1,600 eight-page surveys to subscribers of Nursing magazine and got back anonymous replies from 852 critical-care nurses. It is, medical experts say, the first national survey to ask nurses about this subject. Findings - which drew fire from representatives of several nursing organizations - were published in the May 23 issue of the New England Journal of Medicine. The nurses reported feeling overwhelming responsibility for their patients' pain. "Physicians are sometimes inadequately responsive to a patient's suffering," Dr. Asch told USA Today. Most often, nurses gave high doses of morphine to induce respiratory failure. Dr. Asch was careful to point out the reality behind the numbers in an interview with Channel 3 News: "These nurses had careers that lasted about nine years, during which time they may have taken care of thousands of patients. And most nurses who reported doing this at all might have reported doing this once or twice." The "tragedy," he told The Washington Post, "is that some of the nurses act as if they feel euthanasia was the best option for patients because other options," - such as better pain control or moving to a hospice - "seem unavailable to them." Coverage began May 23 in response to pitches made by the Media Relations staff.

NATIONAL

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Penn Researchers Discover One Path HIV Uses To Enter Cells Penn researchers made front page headlines with their discovery of an important set of so-called "co-factors" used for cell entry by the HIV strains that are commonly transmitted between people. In a paper published in the June 28 issue of Cell, Robert W. Doms, MD, PhD, assistant professor of pathology and laboratory medicine, and his colleagues identified a series of cell-surface proteins called CKR2b, CKR3, and CKR5 used by the virus in conjunction with another protein, CD4, to enter the cells in the earliest stages of infection. The CD4 protein, known to scientists for almost a decade, is necessary but not sufficient for infection; a second protein is also needed. In May, scientists identified one such protein, fusin. Dr. Doms's study represents a significant expansion on this work, bringing to light a second set of proteins that, again with CD4, play a crucial role in initial infection. "Discovery of these proteins opens up whole new ways of trying to prevent HIV infection by blocking the virus from getting into the cell in the first place," says Dr. Doms. "We can isolate viruses from patients now and very quickly find out which co-factors their viruses use. We'll then be able to try to develop agents that will interfere with those interactions that lead to infection." Print and broadcast coverage began June 20 in response to pitches made by the Media Relations staff.

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Gene Link to Diabetes A multi-national team of 33 researchers including a genome-scanning team at Penn have found the first of what may be a cluster of genes that causes "adult onset" diabetes. The scientists have determined the general location of the gene they believe is at least partly responsible for Type II, noninsulin-dependent diabetes, the most common form of the disease. Published in the June issue of Nature Genetics, the gene - which they named NIDDM1- has been mapped to one end of chromosome 2. Type II diabetes affects an estimated 15 million people in the United States, and is the nation's seventh-leading cause of death. Abnormalities in the NIDDM1 gene are thought to account for at least 30 percent - and as much as 75 percent - of the familial clustering of noninsulin-dependent diabetes in Mexican-Americans, a population with a high incidence of this form of the disease. The team analyzed DNA from 330 pairs of affected Mexican-American adult siblings. "This gene was identified because the disease-predisposing version of it appears to be relatively common in Mexican Americans," said investigator Richard S. Spielman, PhD, professor of genetics. "But, of course, some version of this gene is present in all humans. Figuring out its normal function will be of considerable interest in its own right." The report was published May 31 in response to pitches made by the Media Relations staff.

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Genetic Testing: To Know Or Not To Know? Being tested for a gene such as BRCA1, which Breast Cancer Program director Barbara L. Weber, MD, says is responsible for 50 percent of inherited breast cancer cases - or up to five percent of all breast cancers - is so fraught with dilemmas that the American Society of Clinical Oncology drew up guidelines this year to steer doctors and patients through the process. "This isn't like going to your family doctor and getting your cholesterol checked," Lynn Godmilow, MSW, director of Penn's Genetics Diagnostic Referral Service, told Good Housekeeping. "If you want the test, you need genetic counseling first to help you decide what to do with the results, or even if you want them." Genetics counselor Jill Stopfer, MSN, told CBS correspondent Jacqueline Adams that "It can be very scary information to have." Medical options are limited: Short of increased mammograms and ovarian cancer screenings, researchers can only recommend prophylactic surgery for those who test positive - a radical intervention that lowers the risk of cancer, but doesn't guarantee the disease won't strike. Commentary was seen throughout April, May and June with facilitation by the Media Relations staff.

Wall Street Journal

Alert or Oblivious: Preoperative Choices In the past, if the surgeon was in, chances are, the patient was out - thanks to general anesthesia. Today, whether to be unconscious during surgery is often a matter of personal choice. Many operations once routinely performed under general anesthesia - from Caesarean deliveries to knee repairs - are now done under local or regional anesthesia. "If there's an option, I give it to the patient," Norig Ellison, MD, professor and vice chair of anesthesia and president of the American Society of Anesthesiologists, told The Wall Street Journal. "Patients have always had those rights, but I don't know if doctors have always been as attentive to them as we are today." Local or regional anesthesia, accompanied by sedation, numbs only the area being operated upon and is now commonly used in limb surgery, prostate surgery, breast biopsy, cataract surgery, hernia repair, and much plastic surgery. Medically, there isn't always a choice, but for many kinds of surgery, patients who opt for local or regional anesthesia are likely to recover more quickly and suffer less nausea. It also eliminates what may be their biggest fear: not waking up. The article was published June 24 with facilitation by the Media Relations staff.

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Too Few Z's: Personal & Public Health Hazard A recent Gallup poll compiled for the National Sleep Foundation found that 56 million Americans - one in three adults - lost an average of two-and-a-half hours of sleep eight nights a month to intermittent pain - mostly backache, headaches and arthritis. Calling it "a detrimental cycle for millions of Americans," foundation director Allan I. Pack, MD, PhD, director of Penn's Center for Sleep and Respiratory Neurobiology, said, "If you have sleep apnea or pain that causes frequent sleep disturbances, you may not realize that you're not getting enough deep sleep," he said. "But it can really impair your daytime performance." Indeed, a recent study found that just one night of frequently disturbed sleep can cause daytime sleepiness, shortened attention span and mental grogginess. Whether it's the result of a sleep disorder, pain, a crying infant or shift work - or simply because one goes to bed too late and gets up too early - sleep-deprivation is more than a personal detriment: It's a public health hazard. Sleep and traffic experts say at least 1,500 Americans die every year because sleepy drivers insist on staying at the wheel. Reports appeared in April, May and June with facilitation by the Media Relations staff.

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Acne, Wrinkles, Cancer: Help In One Tube At first, tretinoin - the active ingredient in Retin-A and Renova - causes the skin to shed its dry, older outermost layer and stimulates it to replace the exfoliated cells at an accelerated rate. Then the vitamin-A derivative does something more: It causes the skin to normalize cells. "In undamaged skin, cells differentiate and produce a variety of structures and proteins, such as collagen," James J. Leyden, MD, professor of dermatology, said in a Glamour interview. "After a person has spent years in the sun, perhaps smoked cigarettes and simply aged, the cells start to differentiate irregularly. Renova redirects skin cells to function more regularly." "It's a medical drug that should not be seen mainly as improving appearance, but improving the physiology of the skin," Retin-A developer Albert M. Kligman, MD, PhD, emeritus professor of dermatology, said in a Philadelphia magazine feature article. "It has an important medical impact in the prevention of cancer." At a dermatology conference at Rutgers University, Dr. Kligman revealed that six months of Retin-A use wiped out pre-cancerous lesions in every one of the 13 women studied. Interviews appeared in April, May and June with facilitation by the Media Relations staff.

LOCAL

Philadelphia Inquirer Philadelphia Business Journal

Practice Makes Perfect: Physicians Are Key for Penn Health The national debate over health-care reform ran out of steam, but market forces have continued to drive practitioners and hospitals to change the way they do business. Several articles have focused on Penn's strategy, which hinges on buying doctor practices, establishing satellite medical offices, and affiliating with - not buying - community hospitals. "It is our view that owning a large network of hospitals is not a particularly attractive way to go in the long run, but rather a large physician organization is the way to go," William N. Kelley, MD, CEO of the University of Pennsylvania Medical Center and Health System and Dean of the School of Medicine, told the Philadelphia Business Journal. The system has already acquired almost 200 top notch community-based primary-care physicians. "We were the first major player when we announced what we're doing and it's still evolving," said John C. S. Kepner, Esq., senior vice-president for Penn Health System's network programs. "We think we can develop a model health-care system," Dr. Kelley told the Inquirer, "where patients have easy access to physicians ... and the most sophisticated care." Commentary was seen in the Inquirer on April 1 and in PBJ 's "The State of Health Care" section on June 14, with facilitation by the Media Relations staff.

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Creative Medicine: Art As A Source of Healing "As the body has its needs, so, too, does the spirit," John H. Glick, MD, director of the University of Pennsylvania Cancer Center, told The Philadelphia Inquirer. "Art as a therapeutic expression of the cancer experience is beneficial not only for the individual who creates it, but for those who view it as well." It was fitting, then, that the Cancer Center sponsor a juried exhibit of works by artists whose lives have been touched by cancer - either directly or through a loved one's experience. "Confronting Cancer Through Art," on display at the university's Arthur Ross and Meyerson Galleries from June 22 through August 25, contained more than 80 works in media as diverse as the disease itself - paintings, sculpture, photography and mixed media - and vividly illustrated the myriad emotions of the cancer experience. City Paper's Anne Kleisman called it "a poignant look at the affirmation of life in the face of death, as seen in the expression of art." Judith Burkhauser, a cancer survivor whose Brushing My Hair Until It Falls Away was part of the exhibit, told Channel 3 viewers that she and her fellow artists hope to convey an important message. "It's a way of communicating to other people who are facing cancer that they're not alone," she said. Print and broadcast coverage began in April in response to pitches made by the Media Relations staff.

Philadelphia Inquirer WTXF-TV29

fMRI: Tracking Down Thoughts A new technique is allowing researchers to peek at the brain while it works: functional magnetic resonance imaging, or fMRI, captures images of oxygen-carrying hemoglobin in the blood as it races from place to place with each shifting thought. "When you think, you burn more oxygen and get more blood flowing to the parts that are working hardest," graduate student Geoffrey Aguirre explained in an Inquirer feature. "What we are looking at is the amount of distortion in the field as a result of having more hemoglobin." Assistant professor of neurology Mark D'Esposito, MD, and his colleagues are searching for the brain's center of navigation. Brain scans record the mental activity of volunteers using a "virtual reality" video game that lets them travel mentally through a maze. While the team is currently mapping healthy brain activity, Dr. D'Esposito hopes to study stroke victims as well. "We know that ... over time those patients can recover some function," he told Channel 29 viewers. "We're not sure if it's that part of the stroke that gets better or if some other part of the brain actually takes over." The article was published May 20; the segment aired May 27 in response to pitches made by the Media Relations staff.

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Breathless: High Ozone Levels & ER Visits Smog doesn't just ruin a clear view of the city's skyline. Its main ingredient - ozone - exacerbates respiratory diseases, like asthma and bronchitis. "Smog is not simply an inconvenience," Reynold A. Panettieri, Jr., MD, director of the Asthma Program, told the Philadelphia Daily News. "Being unable to catch your breath is not an inconvenience." "It makes the airways narrow and it makes it very difficult for asthmatics to breathe," William H. Shoff, MD, assistant professor of emergency medicine, told Channel 6 viewers. "It sets up a vicious cycle and they can get into trouble very fast." According to a Harvard study, smog sent more than 3,250 people to Philadelphia-area hospitals in a single year. "When the ozone levels go up, in the spring and summer, we see more patients with problems," Dr. Panettieri told The Philadelphia Inquirer. He estimates that on a day of high-ozone levels, the number of calls from people with breathing problems will jump from an average of 30 to as many as 140. Up to 10 percent of emergency room visits and hospital admissions in 13 U.S. cities may be caused by smog, according to the study. "There is no question air pollution has a big impact on health," Dr. Panettieri said, "and that also adds up to big health-care dollars." (Last year, he estimated, nearly $60 million was spent on asthma hospitalizations alone in the region.) Print and broadcast coverage began June 20 in response to pitches made by the Media Relations staff.

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Praying Off The Pounds: Faith-based Weight Loss Can God, prayer and Bible study be the best weapons in the battle against fat? Emanating primarily from the South, Christian weight loss programs like the Weigh Down Workshop and Overeaters Victorious are making their way around the country, church by church. According to the Inquirer's Kristin Holmes, faith-based programs "urge followers to turn to God when temptation takes the shape of a Big Mac." Thomas A. Wadden, PhD, director of the Weight and Eating Disorders Program, says weight-management programs that incorporate faith have the potential to be very important. "Social support is a major factor in long-term weight control. When people find a community of support at the workplace or at the church, they will do better in the long term." Indeed, patients in Penn's program are encouraged to involve spouses or other key family members as a part of their weight loss efforts. In an interview in the Delaware County Daily Times, Gary D. Foster, PhD, clinical director of the program, said, "The first step for a patient is to define just what they need in terms of support." Reports were seen May 6, May 13 and June 2 with facilitation by the Media Relations staff.

Issues & Answers

Here are some of the comments Arthur L. Caplan, PhD, director of the Center for Bioethics, recently made to the media:

"I love my freedom as much as the next person, but a nation that has created a health-care system in which doctors, nurses and administrators are not sure whether it is the right thing to do to sew a mentally ill man's severed hand back onto his arm is a society gone over the edge regarding autonomy."

Snips & Snips

KUDOS. . . to Marla Rae Davis, director of the Office of Community Affairs, who was one of four Black women designated "Community Leader of the Year" for 1996 by the Philadelphia Council of the National Council of Negro Women, Inc. Davis was honored at an awards ceremony on May 18 for her leadership, generosity, and diligence in working to create a better environment for her community and improving the life of its residents. The award was announced on WPVI-TV6's Action News on May 18 and in regional papers throughout June.

THE GOOD EARTH. . . When Burlington County residents learned that the soil around their homes might be contaminated with pesticides, they feared for their health. Although township officials assured them the levels of pesticides were not high enough to be dangerous, KYW-TV3 reporter Ren Scott asked Marilyn Howarth, MD, assistant professor of emergency medicine, about how children might be affected. "It is a real concern if ingested," Dr. Howarth said. "In this particular situation, the way it might be ingested would be with children who are playing in the dirt, in particular, and anyone else who has direct contact with the soil." Aired 6/6.

AN OLD STORY. . . They're called the 'Golden Years,' but too often, the elderly find themselves feeling alone, depressed - even suicidal. About 15 percent of older Americans suffer from late-life depression, and senior citizens commit 20 percent of suicides while accounting for only 12.5 percent of the population. "The demographic trend is really frightening," Ira R. Katz, MD, PhD, professor of psychiatry, told Knight-Ridder newspapers. But in a related article in the Medical Tribune for the Obstetrician/Gynecologist, Dr. Katz said that depression is not a natural part of the aging process: "Depression in the elderly is treatable and reversible," he said. Printed in May and June.

UNDER YOUR SKIN. . . Solace; attention; compassionate advice - everybody knows their value for mending wounded spirits. But can learning to better cope with life's pressures also help skin problems? For may patients, the answer may to be yes. George F. Murphy, MD, professor of dermatology and pathology and laboratory medicine, told Good Housekeeping that he was able to track the actual cellular process that may link today's emotional turbulence with tomorrow's skin inflammation. "We hadn't known before how nerve fibers communicated with the immune system," he said. Printed in the May issue.

MAGIC MOLECULES. . . When researchers recently discovered a versatile bacterial weapon that fires harmful proteins directly into cells, they opened the door to deeper understanding of diseases ranging from bubonic plague to tree blight. Daniel Portnoy, PhD, associate professor of microbiology, told Science that the so-called type III system is not made up of ordinary proteins. "These are the magic molecules of pathogenesis," he said, noting that they are the focus of intense scrutiny because of their ability to manipulate their host in subtle - but potentially deadly - ways. "Finding out the precise targets [of the virulence molecules] will tell us interesting things" about how plants and animals normally fight infection, he explained. Printed 5/31.

BAN THE TAN. . . Looking for that deep, dark summer tan? Look into the future before you sprawl out under the sun. Even sun worshipers in their late 20s can show premature signs of aging, a result of too much exposure. "The sun greatly accelerates the aging process," warns Leonard M. Dzubow, MD, professor of dermatology. "The sun takes all the elasticity out of the skin. People chronically exposed to the sun get very deep wrinkles, very leathery skin and are very blotchy," Dr. Dzubow told the Houston Chronicle. Printed 5/30.

DANGEROUS LIASONS. . . In the fight against cancer, finding the right doctor may be half the battle. Researchers at the National Cancer Institute have found that as many as 90 percent of women with early ovarian cancer are not properly diagnosed or treated, a staggering statistic that points to a crucial need for educating both physicians and patients. "The problem we see is that many women never knew or were never told that there were people who specialize in this sort of thing," gynecologic oncologist Mark A. Morgan, MD, director of maternal-fetal medicine, told ABC's World News Tonight. Aired 5/22.

HARD TIMES. . . We hear the stories all the time: people mustering every bit of spirit, strength and conviction they have to fight cancer. It is a long and painful road, but many manage to survive. But what happens when the disease - and the treatment - begin to ravage the body? "It's not unusual for very sick patients to get depressed when they finally start to see evidence of the disease in their lives," Paul N. Lankin, MD, medical director of the medical intensive care unit, told the Los Angeles Times. "It's hard for people to accept a bad prognosis when they're feeling fine," he added. "But then the disease catches up to them, and it becomes real." Printed 6/10.

SPREAD THE WORD. . . In the continuing debate over whether the FDA should approve the use of birth control pills as emergency conraception, Steven J. Sondheimer, MD, professor of obstetrics and gynecology, told National Public Radio listeners that there is little risk to a woman's health by taking the pill as a morning-after treatment. Instead, the problem is that few patients know the option is available, he said, and therefore don't ask for it. "The problem has been that is needs to be used within 72 hours, so the patients need to know about it," he explained. "The men and women who are involved need to know they have to contact somebody soon." Aired 6/28.

WORK IT OUT. . . Your job can be a pain in the neck Ñ literally. Injury to joints, muscles, nerves, bones, tendons, and ligaments related to work are common, David Allan, MD, PhD, director of the Repetitive Strain Injury Center at Presbyterian Medical Center, said in an article that was published in neighborhood newspapers throughout the Delaware Valley. Dr. Allan recommended that workers take note of tasks requiring repetitive movements - such as typing - and try to spread those activities over the course of the day. Adjusting your chair may help,too. Printed in May.

HELP WANTED. . . Now that most insurance companies pay for bone marrow transplants, many people have the impression that transplantation works better than conventional therapies. According to The Philadelphia Inquirer, the National Cancer Institute (NCI) is concerned that patient enrollment in trials that compare the procedure to standard dose chemotherapy and radiation has been slower than expected. "People think: If insurers are paying for it and there is evidence that it works, why are we having all these studies?" said Edward A. Stadtmauer, MD, director of the Bone Marrow Transplant Program and leader of one of the NCI studies. "But it's a more subtle issue." Printed 6/17.

A PERFECT EXCUSE. . . to pick up an issue of Penthouse: The commentary of Daniel J. Rader, MD, of course! The assistant professor of medicine talked about the Ultrafast CT, the state-of-the-art predictive test that "can be used to determine who already has evidence of coronary plaque, how much, and how likely they may be to develop symptoms of heart disease in the future." The non-invasive, 15-minute test, says Dr. Rader, is a good idea for people with a family history of heart disease, even if they have no symptoms. Printed in the May issue.