The latest medical advances from Johns Hopkins Medicine


A Message to Older Adults: Don't Fear the Effects of Sensible Exercise
 
A Johns Hopkins study should ease the concerns held by many older adults with mild high blood pressure about the strain or harm exercise could cause their hearts. Results of the research on 104 men and women age 55 to 75 showed that a moderate program of physical exertion had no ill effects on the heart's ability to pump blood nor does it produce a harmful increase in heart size.

In this study, "moderate" translated to sustained exercise for about an hour, three times a week. The Johns Hopkins study is believed to be the first to evaluate the effects of exercise on the heart's ability to function, to pump and to fill up with blood.

"While having high blood pressure at rest is a well-established risk factor for heart problems, older people should not fear the effects of moderate exercise on the heart, despite short-term bump-ups in blood pressure during their workout," says lead study investigator and exercise physiologist Kerry Stewart, Ed.D., a professor of medicine and director of clinical and research exercise physiology at The Johns Hopkins University School of Medicine and its Heart Institute. "Exercise is a highly effective means of increasing the heart's efficiency and reducing body fat, factors that may ward off future health problems, such as heart disease and diabetes."

A report on the Johns Hopkins study, published in the July issue of the journal Heart, showed that after six months of aerobic exercise on a treadmill, bicycle or stepper, plus weightlifting, participants showed no overall ill effects in 11 measures of diastolic heart function, when the organ's main chamber fills with blood between beats. They also found that exercise produced no increase in eight measures of heart size, including left ventricular mass and wall thickness. In contrast, a long-term effect of hypertension, even when the body is relaxed, is hypertrophy, an enlargement of the heart that eventually stiffens and weakens the muscle.

Not only were there no ill effects sustained, despite periodic increases in blood pressure during the workout, Stewart and his team reported, but results also suggest that the exercise producing these effects benefited the hearts of those who made the most gains in physical fitness and for those who lost the most abdominal fat.

"Making gains in body fitness and losing abdominal fat are truly important to the long-term health of the heart," says study co-author and cardiologist Edward Shapiro, M.D., a professor at Johns Hopkins. "Our results confirm that moderate-intensity exercise can have many health benefits - including gains in heart function that are linked to increased fitness and reduced fatness.

A study published last year by the Johns Hopkins scientists showed that exercise reduced by more than 20 percent the number of people who develop metabolic syndrome, a clustering of three or more risk factors for developing heart disease, diabetes and stroke. Risk factors include high blood pressure, elevated blood glucose levels, excess abdominal fat and abnormal cholesterol.

Funding for the study was provided by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH), with additional assistance from the Johns Hopkins Bayview General Clinical Research Center, also funded by the NIH. Besides Stewart
and Shapiro, other Hopkins researchers who took part in this study were Pamela Ouyang, M.D.; Anita Bacher, M.S.N., M.P.H.; and Sandra Lima.
 
Antihistamine Identified as Potential Antimalarial Drug
 
The allergy medication astemizole could have another life as a potential treatment for malaria, according to a study conducted by researchers from the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins University School of Medicine.

The study, largely funded by the Johns Hopkins Malaria Research Institute (MRI), determined that in a test tube the antihistamine killed the parasite, Plasmodium falciparum, that causes malaria in humans, including parasite strains that were resistant to traditional malaria therapies. The drug was also shown to be effective in mouse models. The findings are published in the online edition of Nature Chemical Biology.

"Astemizole is promising as an antimalarial, but still needs to be evaluated for effectiveness as an antimalarial in humans." said senior study author David Sullivan, MD, an associate professor with MRI and the Bloomberg School's W. Harry Feinstone Department of Molecular Microbiology and Immunology.

For the study, Sullivan and colleagues Curtis Chong and Jun Liu of the Johns Hopkins School of Medicine's Department of Pharmacology first assembled the Johns Hopkins Clinical Compound Library, which is a collection of 2,687 drugs. Seventy percent of the compounds are approved by the U.S. Food and Drug Administration, while the remaining 30 percent are approved by regulatory agencies in other countries. The researchers screened the drugs for their effectiveness in killing the malaria-causing parasite and found that astemizole was one of the more promising.

Astemizole was voluntarily withdrawn from the U.S. and European markets in 1999 after 15 years of use when sales became sluggish after warnings about the drug's safety and the introduction of newer antihistamines. The drug was reported to cause rare, but life-threatening heart arrhythmias when patients took an overdose or with drugs that affected its metabolism. However, arrhythmias are also reported with existing malaria drugs and other antihistamines now sold over the counter. Astemizole is currently still used in 30 countries, including Cambodia, Thailand and Vietnam where malaria is endemic.

The research was supported by the Johns Hopkins Malaria Research Institute, the Johns Hopkins University Fund for Medical Discovery and Department of Pharmacology, and the Keck Foundation.
 
"Domino" Transplant Program Makes Best Use of Altruistic Donated Kidneys
 
A team of Johns Hopkins researchers reporting their early experiences with "domino" kidney donation suggest that wider use of this strategy could effectively double the benefit of the organs from these non-directed, altruistic living donors.

In a paper published in the August issue of the British journal Lancet, the team led by Robert A. Montgomery, M.D., chief of transplantation at the Johns Hopkins University School of Medicine, show that by serving the needs of multiple recipients, such domino transplants can maximize the benefits of these donors' altruistic acts.

Under the terms of the domino-paired donation program, a kidney transplant patient who has a willing but incompatible living organ donor is matched with an altruistic, compatible donor. The incompatible kidney from the recipient's intended donor is then domino-matched with the next compatible patient on the United Network of Organ Sharing (UNOS) waiting list. This strategy can be further used to enable a triple transplant by simply adding an additional incompatible donor-recipient pair to the chain.

To date, Johns Hopkins surgeons have performed two triple and one double domino-paired kidney transplant initiated by three altruistic donors who were able to provide eight recipients with compatible kidneys. According to Montgomery, if conventional allocation strategies had been used, only three of these recipients would have benefited from these altruistic donations.

UNOS reports that since the first altruistic donor came forward in 1998, 302 altruistic kidney transplants have been performed in the United States. Using a computer simulation program, Montgomery and his team calculated that 583 transplants could have been achieved if the domino-donation model had been in place.

"In light of the crisis the transplant community continues to experience in terms of the number of available organs," Montgomery says, "the fact that people are coming forward voluntarily to help ease this shortage should not be treated with suspicion but rather should be considered morally praiseworthy. These are good people doing good things."

Other members of the research team who contributed to this paper include Dorry L. Segev, M.D.; J. Keith Melancon, M.D.; Warren R. Maley, M.D.; Christopher Simpkins, M.D.; Sommer E. Gentry, Ph.D.; Janet Hiller and Daniel S. Warren of the Department of Surgery; Andrea A. Zachary, Ph.D., and Julie Houp of the Department of Medicine; and Hamid Rabb, M.D., of the Department of Nephrology. In addition, William H. Marks, M.D., of the Department of Organ Transplant at Swedish Medical Center in Seattle, Wash., contributed to the paper.
 
Antioxidants May Slow Vision Loss
 
Scientists at Johns Hopkins have successfully blocked the advance of retinal degeneration in mice with a form of retinitis pigmentosa (RP) by treating them with vitamin E, alpha-lipoic acid and other antioxidant chemicals.

"Much more work needs to be done to determine if what we did in mice will work in humans," said Peter Campochiaro, the Eccles Professor of Ophthalmology and Neuroscience at The Johns Hopkins University School of Medicine. "But these findings have helped to solve a mystery."

In patients with RP, rod photoreceptors die from a mutation, but it has not been known why cone photoreceptors die. After rods die, the level of oxygen in the retina goes up, and this work shows that it is the high oxygen that gradually kills the cones. Oxygen damage is also called "oxidative damage" and can be reduced by antioxidants. Campochiaro's findings appeared in the July online edition of the Proceedings of the National Academy of Sciences.

Retinas in all mammals, from mouse to man, are made up of light-sensitive cells known as cones and rods, named for their shapes, which convert light into nerve signals that are then transmitted to the brain via the optic nerve. Cones are needed to see colors and make vision possible in bright light, whereas the far more numerous rods permit sight in low light. The human retina contains approximately 125 million rod cells and 6 million cone cells. In diseases like RP and age-related macular degeneration (AMD), these cells die off and eventually lead to blindness (in the case of RP) or legal blindness (in the case of AMD).

In this mouse model of retinal degeneration, the rods have completely degenerated by the 18th day of age, and then the cones start to degenerate, with 85 percent of them dying off by the time the mice are 35 days old. Campochiaro and his team injected vitamin E, vitamin C, alpha-lipoic acid or an antioxidant similar to superoxide dismutase between the 18th and 35th day. In mice that received vitamin E or alpha-lipoic acid, 40 percent of the cones survived, about twice as many as in the control group or the groups treated with the other antioxidants, which had no identifiable effect.

"What's clear is the link between oxygen and photoreceptor damage, as well as the potential of antioxidant treatment," Campochiaro said. "These experiments suggest that an optimized regimen of antioxidants may help to protect patients with retinitis pigmentosa."

RP affects only about 100,000 people in the United States. But oxygen damage has also been implicated in other more pervasive eye diseases, like AMD and cataracts.

Antioxidants naturally occur in some fruits and vegetables, and are available as supplements, but Campochiaro said it remains unclear whether the amounts of antioxidants consumed in foods provides any benefit to people with these types of vision impairments.

The funding for this study was provided by the Macula Vision Research Foundation, as well as gifts from Dr. and Mrs. William Lake, and Mrs. Susan Meyers. Co-authors of the study included Keiichi Komeima, Brian Rogers and Lili Lu, all of the Johns Hopkins School of Medicine.
 
Tracking Computer-Based Error Reports Improves Patient Safety
 
To err is human, but asking nurses, physicians and other hospital staff to report medication errors and log them into a computer database can help improve patient safety systems as well as human error rates, according to a study from the Johns Hopkins Children's Center. Voluntary error-reporting systems are not new, but few studies have looked at the accuracy of the reporting and its impact, the Johns Hopkins investigators say.

"Our goal was to explore the validity of this voluntary error-reporting system and whether front-line error-reporters were capturing the essence of the actual errors that occurred," says author Marlene Miller, M.D., M.Sc., director of quality and safety initiatives for the Children's Center.

Miller emphasizes that error data are valuable only if consistently monitored for patterns and used to create safety checks that prevent common errors from happening again.

"Error reporting is only as good as the actual changes that are made as a result of it," says co-author Christoph Lehmann, M.D., director of clinical information technology at the Children's Center. "Identifying and fixing potential medical errors is at the core of the Children's Center patient safety program. Monitoring voluntary error reports has led to the creation of several programs that reduce and prevent medication errors."

Among these:
- A computerized ordering tool for pediatric chemotherapy that reduces medication errors in children undergoing cancer treatment
- An online infusion calculator that reduces medication errors in children undergoing IV infusions
- An online total parenteral nutrition (TPN) calculator, designed to prevent nutrition errors among premature babies in the neonatal intensive care unit, and currently used system-wide for all pediatric patients

Since 2004, Johns Hopkins has implemented a hospital-wide computer reporting system that captures a variety of medication errors, the vast majority of which do not harm a patient but may have the potential to do so if systems are not corrected.

"One of the more interesting findings was that drug-administering errors, such as giving the patient the wrong drug or the wrong dose or at the wrong time, were quite common," Lehmann says. "We had focused in the past on ordering errors. This finding made us look for possible interventions on the administration side."

Of the 1,010 originally reported errors during the 19-month program, 173 (17 percent) were near-miss errors, which researchers describe as an error that didn't harm the patient but would likely cause serious harm if it occurred again. A typical near-miss scenario would involve a physician prescribing the wrong dose, followed by a pharmacist dispensing the wrong dose, but a nurse catching the error before giving the wrong dose to the patient.

Of the 1,010, 38 percent (379 errors) did not reach the patient, half (511) reached the patient but no treatment or increased monitoring was required, 10 percent (103) reached the patient and required increased monitoring, 2 percent (17) reached the patient and required additional treatment or prolonged hospital stay. None was fatal or caused serious harm.

Nearly one-third were prescribing errors, one-quarter were dispensing errors, 38 percent were administering errors, and 8 percent were documentation errors. Half of all errors occurred in children under 6.

Most errors occurred with anti-infective medications, such as antibiotics or antivirals (17 percent), followed by pain relievers and sedatives (15 percent), antihistamines for allergies (15 percent), nutritional supplements and vitamins (11 percent), gastrointestinal medications (8 percent), cardiovascular medications (7 percent) and hormonal medications (6 percent).

Authors on the paper are Miller, Lehmann and John Clark, Pharm. D., of the Department of Pediatric Pharmacy.
 

 
Johns Hopkins Hospital Ranked as #1 for 16 Consecutive Years
 
For the 16th year in a row, The Johns Hopkins Hospital has topped U.S. News & World Report's annual Rankings of American Hospitals. For a complete list and methodology of rankings, please visit www.usnews.com

Johns Hopkins Hospital ranked in the top 10 in 15 of the 16 speciality categories listed. In addition to landing at the top of the honor roll, The Johns Hopkins Hospital had the following rankings:

#1
Ear, Nose & Throat (Otolaryngology)
Gynecology
Kidney Disease
Rheumatology
Urology


#2
Neurology/Neurosurgery
Ophthalmology (Wilmer Eye Institute)
Psychiatry

#3
Cancer
Digestive Disorders
Heart/Heart Surgery
Hormonal Disorders (Endocrinology)
Pediatrics
Respiratory Disorders

#4
Orthopedics

#17
Rehabilitation
 
Maryland Supports Stem Cell Reseach
 
The members of a new state stem cell research commission were announced by Maryland's Governor, Robert Ehrlich, who promised science will dictate which research in the politically sensitive area will get funded.

Federal funding of embryonic stem cell research, which supporters say holds the promise of treating or curing a number of diseases, has been sharply restricted by President Bush. In response, Maryland and other states have approved funding for stem cell research, including embryonic stem cells.

Embryonic stem cells are master cells that can form every other cell in the body and because of that ability researchers say they may lead to cures and treatments for a number of diseases, conditions and injuries. While adult stem cells also exist, researchers say they are more limited.

Obtaining embryonic stem cells for research kills the embryo they are taken from, which is opposed by many conservative religious groups. Supporters say the stem cells can be obtained from unused embryos created for in vitro fertilization that would otherwise be destroyed.

Maryland is among a number of states that have voted to fund stem cell research on their own follow Bush's decision.

California has dedicated the most, with a $3 billion stem cell research institute, which is being challenged in court by opponents of embryonic stem cell research.
 
The Next Era for Johns Hopkins Medicine
 

Confetti rained down on the nearly 250 people gathered in The Johns Hopkins Hospital's Houck Courtyard as the centerpiece of the largest and most expensive hospital project in Maryland's history was officially unveiled. Two new clinical buildings will move Johns Hopkins Medicine, and American medicine, far into the future.

University President William R. Brody, Johns Hopkins Medicine CEO Edward D. Miller, JHH President Ronald Peterson and other top administrators were present to celebrate the groundbreaking of the Cardiovascular and Critical Care Tower and the Children's Tower, two buildings that will form the new face of the hospital.

The masters of ceremonies for the event were George Dover, the Given Foundation Professor of Pediatrics and director of the Department of Pediatrics at the School of Medicine, and William A. Baumgartner, the Vincent L. Gott Professor of Cardiac Surgery, cardiac surgeon in charge at the hospital and vice dean for clinical affairs at Johns Hopkins Medicine.

The new clinical towers are part of the comprehensive 10-year master plan that will transform the medical campus. Construction on that project is expected to get under way in early 2007, with a completion date scheduled for 2008-2009.
 
Johns Hopkins Medicine International Annual Symposium: Strategies for Global Health Care Leaders
 

Baltimore, Maryland
November 6-8, 2006

Leading a trend of rapid global changes in health, Johns Hopkins Medicine International works with international patients, physicians and institutions to bring the best Johns Hopkins Medicine - excellence in research, education, training and clinicl services - to the world community.

This November, join our leaders and international partners as we discuss:

- Quality Improvement and Safety
- Marketing and Branding
- Integrating Research into Clinical Practice
- Facility Management and Efficiencies
- Human Capital Recruitment and Retention
- Nursing Leadership

For a formal curriculum and registration brochure, please contact Carol Velandia at 1-410-735-6583 or cvleand2@jhmi.edu
 

If you have any questions, comments or suggestions, please email us at ccostab1@jhmi.edu.