Cause of Diabetes-Related Erectile Disfunction is Clarified by Johns Hopkins Researchers

Researchers at Johns Hopkins have found that one particular simple sugar, present in increased levels in diabetics, interferes with the chain of events needed to achieve and maintain erection and can lead to permanent penile impairment over time. The results have implications for new types of erectile dysfunction treatments targeting this mechanism of erection.

Previous research had shown that diabetic erectile dysfunction was partially due to an interruption in an enzyme that starts the chain of vascular events leading to an erection. The Johns Hopkins team suspected O-GlcNAc, a blood sugar present in hyperglycemic (high blood sugar) circumstances, to be that interrupting factor.

An estimated 50 to 75 percent of diabetic men have erectile dysfunction to some degree, about threefold higher than in non-diabetic men. This is not the same type of erectile dysfunction seen in non-diabetics, and it is less effectively treated with conventional drugs like Viagra.

The study emphasizes the reduced blood vessel function present in patients with diabetes. Additionally, speaking to more than just the sexual issues related to erectile dysfunction, the research addresses implications related to the overall understanding of penile health.

According to Arthur Burnett, M.D., a professor of urology and head of the research team, "eNOS plays roles in both immediate erectile response and the overall health and function of the penile tissue."

Burnett, whose lab has studied penile erection since the early 1990s, continues, "The insight here is tremendous because it speaks to fundamental biological and vascular mechanisms of diabetes. This paper gets back to the physiological relevance of hyperglycemia and how it affects erection."

This research was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Kidney Foundation of Maryland Professional Development Award.

To see an interview with Dr. Arthur Burnett, click here.

Risk Factors for Prediction of Lethal Prostate Cancer Identified

Researchers at Johns Hopkins have identified three risk factors and developed a simple reference tool that doctors can use to determine who is at high risk of death after prostate cancer recurrence following surgery.

The new tool, a set of tables that assess a combination of blood tests, the surgical pathology results and time following surgery, can be used to tell which men with recurring cancer after surgery are most likely to die from their renewed disease and would benefit from further treatment.

"We identified three risk factors associated with death from prostate cancer after recurrence that may allow doctors to distinguish early on between those who need further treatment versus those who are relatively safe and can be carefully watched," says Stephen J. Freedland, M.D.,
instructor of urology at Johns Hopkins.

The risk factors are based on:
* The amount of time, in months, it takes the level of prostate specific antigen (PSA) in the blood to double after surgery. The shorter the time, the higher the risk.
* The elapsed time, in years, from surgery to recurrence as measured by the PSA test. Again, the shorter the time the higher the risk.
* The Gleason score (2 10), a microscopic measurement of prostate cancer aggressiveness when viewed under a microscope. Higher scores reflect more aggressive tumors.

To identify the risk factors, the researchers studied 379 patients treated with radical prostatectomy at Johns Hopkins who had a biochemical (PSA) recurrence, and had at least two PSA tests after recurrence that were separated by at least three months.

The researchers found that the time for the PSA to double, the time from surgery to recurrence, and the Gleason score were significant risk factors for predicting time to death from prostate cancer recurrence and that patients could be divided into either a high risk or a low risk group.

For example, patients with a PSA doubling time of less then three months (23 patients) had a median survival of six years. Patients with a PSA doubling time of less than three months, biochemical recurrence three or fewer years after surgery, and a Gleason score of eight to 10 (15 patients) had a median survival of three years. However, patients with a PSA
doubling time of 15 months or more and a biochemical recurrence more than three years after surgery (82 patients) had a 100 percent survival.

The research was supported by the National Cancer Institute, the Prostate Cancer Foundation, the U.S. Department of Defense, the American Foundation for Urologic Disease and the American Urological Association.

To visit the Brady Urological Institute, click here.

Dialysis Treatment Choice Affects Risk of Death in Patients with End-Stage Kidney Disease

Researchers at Johns Hopkins have found that in people with end-stage kidney disease (ESRD), choosing peritoneal dialysis over hemodialysis increases their risk of dying by 50 percent.

Currently, more than 400,000 Americans require one of the two kinds of dialysis to remove waste products and excess water from the blood because their failing kidneys have less than 15 percent of their normal function remaining. By 2030, the number of Americans needing dialysis is expected to jump to 2 million, due in part to rising rates of diabetes, the leading cause of kidney failure.

"Until now, people with kidney disease have picked the kind of dialysis that best suits their lifestyle, sometimes switching from one method to the other, but we have always wondered if one of the two methods helped people live longer," says Bernard G. Jaar, M.D., M.P.H., the study's primary author.

To find out, the study, called the Choices for Healthy Outcomes in Caring for ESRD, or CHOICE for short, followed 1,041 newly diagnosed patients from 81 dialysis clinics across the United States.

In peritoneal dialysis, the membrane lining of the body cavity is used as a substitute filter to do the work of the kidneys. A tubelike catheter, permanently implanted into the abdominal cavity, is used to inject waste-absorbing fluid into the cavity, where it remains for anywhere from two to six hours before it needs to be drained. The process must be performed four to six times per day.

In hemodialysis, a patient's vein or catheter tubing is used to pump blood outside of the body and through a machine, called a dialyzer, which filters out waste. The cleansed blood is then pumped back into the body. The treatment lasts approximately three to four hours, and needs to be performed approximately three times per week.

Initial results showed that during the first year of treatment, patients choosing peritoneal dialysis were doing as well as patients on hemodialysis. However, the Johns Hopkins team noted that patients starting treatment with peritoneal dialysis were healthier overall.

When differences were taken into account, the researchers discovered that while healthy patients did well on either form of dialysis, hemodialysis was of greater benefit for those patients with coexisting illnesses, such as cardiovascular disease. After one year of dialysis treatment, the risk of death for patients who started on peritoneal dialysis was greater than the risk of death for patients who started on hemodialysis.

"Our results show that there is clearly a benefit in choosing hemodialysis over peritoneal dialysis, particularly for patients suffering from cardiovascular disease," says the study's principal and senior investigator, Neil R. Powe, M.D., M.P.H., M.B.A., a professor and director of the Welch Center for Prevention, Epidemiology and Clinical Research at Johns Hopkins.

Funding for this study was provided by the Agency for Healthcare Research and Quality, and the National Institutes of Health, including the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Heart, Lung and Blood Institute.


Treating Adults as Adults

The food regimen Michael Boyle puts many of his patients on seems, at first glance, to violate every sound dietary recommendation known to the medical profession. Yet, the Johns Hopkins pulmonologist doesn't blink when telling them to "go to McDonald's for lunch, and stop at Burger King on the way home."

Boyle specializes in cystic fibrosis (CF), a disease that impairs the body's ability to absorb salt and water. Eating high-fat, high-sodium foods - like those served at fast-food restaurants - therefore becomes a must for CF patients.

Starting as a pulmonary fellow at Hopkins, Boyle was used to see adults scattered among the clinic's pediatric patients. Knowing that medical advances were keeping CF patients living longer, he found it incongruous that adults didn't have their own treatment facility and began a change in direction for his medical career.

He focused his fellowship training on cystic fibrosis, and in 1999 started the Johns Hopkins Adult CF Program. Today, the multidisciplinary group he leads includes two pulmonologists, two nurses, a dietitian, a physical therapist and a social worker. It is recognized by clinical care experts as one of the finest adult CF centers in the United States.

"The image of CF used to be a child wearing oxygen, appearing at a telethon," Boyle notes. (In the 1960s, the life expectancy for those with the condition was at best the early teens). Today, the median life expectancy for a CF patient is up to 35, and by 2015, it is expected that there will be more adult patients than pediatric ones.

To read more about cystic fibrosis, click here.

MORE NEWS FROM JOHNS HOPKINS MEDICINE INTERNATIONAL

Johns Hopkins Medicine International is always trying not only to provide the best services to its patients and clients, but also to be a great company to work for.

The whole company is going through major changes in the design of offices, and some groups are being relocated to a campus located in the district of Mount Washington to make the offices located in downtown Baltimore focused exclusively in patient care.

Photos from the offices' "make over" will be posted in the next issue of Hopkins News For You.

Into the Heart of It

The sobering reality for health care is that cardiovascular disease is the elephant in the room that's only going to get bigger. Already a number-one killer, it could find a feast in the alarming numbers of obese people in the United States (60 million and rising) and the looming horde of baby boomers heading into their senior years. While curbing the disease's appetite through better prevention and therapy is an immediate need, it will require a far different approach from medicine.

Rick Lange knows this better than most. The Hopkins chief of clinical cardiology, along with others, including chief of cardiology Eduardo Marbán and cardiac surgery chief Bill Baumgartner, is shaping the Johns Hopkins Heart Institute and planning the cardiovascular portion of a new critical care tower with a new direction in mind. The two combined will be twice as big as the current cardiac care space and bring together physicians and researchers from different specialties in a state-of-the-art clinical building to battle this all too common and deadly disease.

The institute's new home, scheduled to open in 2009, will integrate advanced diagnostic and therapeutic services from every cardiac care specialty, including cardiology, cardiac surgery, vascular medicine, radiology and critical care medicine. "We're going to be establishing a new paradigm for cardiac care," says Lange. The new space, he explains, will house both clinical researchers and practicing physicians in an allout effort to advance discoveries "from bench to bedside more efficiently than ever before." In addition, Lange says, the Heart Institute's cardiac wing will enable cardiologists to work shoulder-to-shoulder, for the first time, with an entire team of cardiac care specialists, including interventional radiologists and vascular surgeons, which will lead to better care management. "And that's something managed care companies should know about," he adds.

This integrated cardiology wing, ticketed for completion in 2009, will offer various new services and capabilities, including operating rooms large enough to accommodate CT and MRI scanners and flexible enough to become catheterization labs, if necessary, Lange says. "We're designing the cardiology floor not only for today, but also for the nest 20 to 30 years," he explains.

Foreshadowing things to come, Hopkins today is poised to make its most startling advances ever. Johns Hopkins cardiologists, led by Joshua Hare, have begun the first clinical trial in the United States using adult mesenchymal stem cells to repair muscle damage from a heart attack. Hopkins is developing cutting-edge imaging techniques, such as tissue Doppler, pioneered by Ted Abraham, which takes clearer, more precise views of the heart. Hopkins is also implementing new interventional cardiac catheterization procedures that infuse alcohol into arteries supplying heart muscles to eliminate surgery.

Marbán recruited Lange, a former Hopkin intern and resident who spent more than 20 years at Texas Southwestern Medical Center, to spearhead clinical efforts here. He says that with Lange's experience as director of the Texas Southwestern's catheterization lab and congenital heart disease clinic, "Rick was the logical choice to lead us as we develop new approaches to cardiac care."

Lange is aware of the stakes ahead. "As baby boomers age and we increasingly deal with the cardiac fallout from obesity,", he says, "what we do at the Heart Institute and in the new cardiology wing takes on even a greater meaning."

To visit the Cardiology department website, click here.

NEWS FROM JOHNS HOPKINS MEDICINE INTERNATIONAL

Mary Ann Wood was recently recognized for her excellent service and patient care at Johns Hopkins Medicine International. During the annual Staff Recognition party, Steve Thompson, Senior Vice-President of Johns Hopkins Medicine and CEO of Johns Hopkins Medicine International, and Harris Benny, Vice President and COO of Johns Hopkins Medicine International, presented Mary Ann with a plaque and a painting.

"I have a passion to make a difference in the lives of our patients. On hearing Harris, it thrilled me that there was a 'someone' among us who shares this passion... I thought of other colleagues of mine, but when he called my name, it came as a total surprise," says Mary Ann.

"We usually have Employee of the Quarter awards and an Employee of the Year award at Johns Hopkins Medicine International. However, we felt that we need to recognize individuals who embody the values and the spirit of this organization - values such as compassion, integrity and passion. Mary Ann is exactly that individual. She has been with us for many years, during which she has provided nothing but excellent care and true compassion to our patients," says Harris Benny.

All Johns Hopkins Medicine Employees stood up to cheer Mary Ann on the receipt of the award, showing she is not only dear to her patients, but certainly to all her colleagues.