Digital Mammography Better at Finding Cancer in Younger Women

A study of 42,760 women at 33 sites across the United States and Canada, including Johns Hopkins, found that digital mammography is better than standard X-ray mammography at locating cancer in young women and those with dense breast.

The study, one of the largest breast cancer screening studies ever performed, was conducted by the American College of Radiology, funded by the National Cancer Institute, and reported September 16, 2005 in a special online publication of the New England Journal of Medicine.

Digital mammography detected up to 28% more cancers than X-ray mammography in women 50 and younger, premenopausal and perimenopausal women, and women with dense breasts, according to the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST). However, the ACRIN results showed no difference between digital and film (X-ray) mammography in detecting breast cancer for the general population of women.

Nagi Khouri, M.D., director of breast imaging at Johns Hopkins Medicine and the principal investigator for the Hopkins site of the study, says its conclusions have important implications for women. "There is a large percentage of women for whom we can now demonstrate that digital mammography is the preferred modality," he said.


Emphasis on Improved Care, Faster Access Shortens Hospital Stays

Physicians at The Johns Hopkins Hospital have disproved the notion that longer hospital stays mean better care. On a recently established program the goal is to improve patient care and cut down on wait times. According to statistics released by the hospital, the program has led to a 4 percent decrease in the overall amount of time patients have to spend in any one of the hospital's 850 acute-care beds.

"Our results show that there is room for improvement in the way large teaching hospitals deliver high-quality care and that they can provide more of it without long wait times and to the better satisfaction of the patients we serve," says JHH physician in chief Myron Weisfeldt, M.D. "Our next step is to strengthen this program as part of the management culture within Hopkins and to see if other hospitals can adopt our efforts to form the basis of a national program."

"The amount of time a patient stays at the hospital is a tough judgment call that requires more than medical training; it requires constant questioning and review of how we manage a large hospital, practice medicine and treat our patients," says kidney specialist Paul Scheel Jr., M.D., vice chairman of medicine at Johns Hopkins.

Taking cues from best practices and management review systems already in place in the airline industry and at NASA, the Johns Hopkins team set out to do a step-by-step analysis of how hospital services, such as tests and
treatments, are managed as patients move among them.

The Johns Hopkins data was compared to those of other hospitals by using scores available from a well-known U.S. actuarial firm that has for decades calculated average lengths of stay for hundreds of hospital procedures and diagnoses. The team not only interviewed physicians whose patients stayed longer than anticipated but also reviewed the patients' files in search of common sources of delay in delivery of care.

Interviews with cardiologists revealed a nagging problem of one-day or two-day waits for ultrasound results, which are needed to update a patient's condition before discharge. In response, the Department of Radiology agreed to a policy of "same-day" discharge service for ultrasound procedures and revised its lab hours when necessary to accommodate the workload. The radiology department went even further, altering its consultation schedule to fit demand and alleviate backlogs and moving to a seven-day-per-week schedule for elective, or non-emergency, cases.

The most dramatic example was applied to patients needing intravenous infusions because they were experiencing organ rejection after transplantation, or as part of their treatment for lupus. The Johns Hopkins team established an outpatient intravenous center, allowing patients to go home after one or two days before having to return to the hospital as outpatients for their remaining infusions.

According to Johns Hopkins' chief of surgery, Julie Freischlag, M.D., "Heading home from the hospital after a traumatic illness is a very emotional time for patients and their families. It is a major step in recovery for any patient to leave the hospital, a place where they have grown to feel safe and secure.

"Linking quality of patient care to efficient lengths of stay was a learning process for everyone involved," says neurosurgeon Henry Brem, M.D., professor and director of neurosurgery at Johns Hopkins. "But it was not until we looked at the numbers that we realized we really could do more with less, especially delays."

Studies of Antibiotic as New Treatment for Tuberculosis

A Johns Hopkins infectious disease expert will lead two international studies of the effectiveness of the antibiotic moxifloxacin as a new treatment for tuberculosis, the highly contagious bacterial disease that kills more than 2 million people worldwide each year and is the leading cause of death of people living with HIV and AIDS. Moxifloxacin is currently approved in more than 100 countries, including the United States, as a treatment for bacterial respiratory infections, such as bronchitis, sinusitis and pneumonia.

"Defeating the spread of tuberculosis in the United States and the developing world will require scientists to take bold and creative new approaches because there has not been a new therapy for tuberculosis in more than 40 years," says tuberculosis expert Richard Chaisson, M.D., a professor of medicine, epidemiology and international health at The Johns Hopkins University School of Medicine.

Chaisson will conduct the research as part of a series of studies on moxifloxacin that are being coordinated by the nonprofit Global Alliance for TB Drug Development (GATB) in collaboration with Bayer Healthcare AG, the drug's maker. His research will assess the ability of moxifloxacin to shorten the treatment period required to cure the disease.

One of Chaisson's studies will take place in Brazil, with support from the U.S. Food and Drug Administration's Office of Orphan Product Development. He will co-direct the second study with Susan Dorman, M.D., an assistant professor at Hopkins, and John Johnson, M.D., of Case Western Reserve University. The study will take place in five countries - the United States, Canada, Brazil, Spain, South Africa and Uganda - with funding support from the U.S. Centers for Disease Control and Prevention's TB Trials Consortium. (Maryland is one of the 10 U.S. states where the second study will take place.)

The overall research program, expected to last two to three years and enroll close to 2,500 patients worldwide, was to be announced today at a news conference during the 36th annual World Conference on Lung Health in Paris, France. Other related studies of moxifloxacin will be led by Stephen Gillespie, M.D., of the University College-London, and Andrew Nunn, M.D., of the British Medical Research Council.

The GATB estimates that 1 billion people worldwide will be infected with tuberculosis by the year 2020, of whom 200 million will fall ill and 35 million will die. The group is developing moxifloxacin and other drugs in an effort to cure more patients by shortening the length of time it takes to treat the disease.

"Shortening the time required to cure the disease could save millions of lives in the coming years," Chaisson says.

Chaisson has more than two decades of experience researching the tuberculosis epidemic, especially its impact on the health of people in developing countries, where most of the 9 million new cases of the disease occur each year. Current treatments for tuberculosis, Chaisson says, consist of a regimen of four antibiotic drugs usually, but not always, given in view of a caregiver. Called Directly Observed Therapy Short-Course, or DOTS, the drugs must be taken several times daily for six to eight months. Although DOTS cures 95 percent of those treated, the lengthy treatment period has proven a problem for patients, who sometimes miss taking their drugs on time, minimizing the therapy's effectiveness.

Chaisson notes that multidrug-resistant strains of the tubercle bacillus, formally known as Mycobacterium tuberculosis, are spreading at a rate of 300,000 newly diagnosed cases each year that cannot be treated by current drugs. "New options are needed, and they need to be both effective and easier for patients to tolerate," he adds.

Chaisson says that substituting moxifloxacin for one of the key ingredients in DOTS could shorten the treatment period by nearly two months, to three to four months, making the form far less costly overall.

As part of the research program, Bayer has agreed to donate supplies of moxifloxacin for all of the trial sites, including those in Tanzania and Zambia that are part of a third study not involving Hopkins. The TB Alliance will coordinate the trial and cover study costs, with additional support from the European and Developing Countries Clinical Trials Partnership.

In addition to the moxifloxacin study, Chaisson directs the Hopkins-based Consortium to Respond Effectively to the AIDS/TB Epidemic, called CREATE, an international effort to control the spread of tuberculosis and treat the disease in countries hit most hard by the duel epidemics. CREATE, which is sponsored by the Bill and Melinda Gates Foundation, has three community-based studies under way in Africa and Brazil.


Discovery of Ovarian Cancer Gene Gives Hope

A specific gene, located on the 11th chromosome, has been found to be associated with aggressive ovarian cancer.

According to the American Cancer Society, ovarian cancer will be diagnosed in an estimated 22,220 women in 2005. More than 16,000 women will die from the condition annually. The disease is nebulous at onset presenting minimal or no symptoms. Unfortunately, roughly 80 percent of ovarian cancer cases are diagnosed in later stages when the five-year survival rate is only about 30 percent.

In the study, headed by Tian-Li Wang of Johns Hopkins University School of Medicine, seven unique ovarian cancer tissue samples were examined using a technique called digital karotyping. The researchers discovered a gene, called Rsf-1, that was overproduced or amplified on chromosome 11 in 13.2 percent of all types of aggressive ovarian cancers, but not in any of the lower-grade forms of the cancer.

"The gene is a 'candidate' oncogene," said Wang. "An oncogene is a gene that will trigger cell growth abnormally, so if you block this you can inhibit cancer cell growth."

Researchers have discovered oncogenes for other forms of cancer and have used the knowledge to develop targeted or specialized chemotherapy interventions to specifically address the overexpressed gene and inhibit growth of the cancer. A classic example is the development of the breast cancer antibody Herceptin, targeted for the HER2/neu gene.

Clinicians view the discovery as good news and an outgrowth of the rapidly expanding field of biotechnology. "This is very hopeful news and raises the possibility of vastly improved treatment of this disease. There is still a long way to go from finding a gene to raising a drug that proves useful against it, but new technologies have made it a much speedier process."


NEW ON THE WEB

The new Annual Report for Fiscal Year 2005 is now available at the Johns Hopkins Medicine International website. There you will find everything you always wanted to know about Johns Hopkins Medicine International, with emphasis on the activities of our last fiscal year.

To view the 2005 Annual Report or to download a copy of the PDF file, visit our website: www.jhintl.net.

Reconstructive Surgery for Hopkins Medical Campus

Johns Hopkins Medicine plans to break ground on two new hospital towers on Orleans Street, beginning a $1.2 billion overhaul that could eventually raze nine buildings and a parking garage on its East Baltimore Medical Campus.

Demolition will likely begin this month on the Broadway garage on Jefferson Street to make way for the towers, which will share a lobby and consolidate many services now provided in the buildings slated for demolition, said Gary M. Stephenson, a spokesman for Hopkins.

One tower will house a 530,000-square-foot Children's and Maternal Health Hospital, providing the state's only dedicated pediatric trauma center. The building will include 205 inpatient beds; 10 children's operating rooms; and outpatient care for oncology, psychiatry and the Pediatric Clinical Research Unit, among other services.

The second will bring an 830,000-square-foot Cardiovascular and Critical Care Tower, two floors of which will be occupied by the Johns Hopkins Heart Institute, a new entity that will integrate Hopkins' various cardiac services. The tower will provide 320 beds, 14 endoscopy and bronchoscopy rooms and a full complement of radiology equipment.

Half of all the campus' hospital beds are in buildings erected before 1963 and ill-equipped to handle the electrical power needed for modern health technologies. Outdated power plants operate at full capacity and the buildings need costly ventilation, heating and air-conditioning upgrades.

The Joint Commission on Accreditation of Healthcare Organizations has also stressed a need for single-patient rooms, which decrease the chance of patients spreading disease.

Hopkins' two new towers will have only single-patient rooms, Stephenson said. "In many cases, it's easier to replace the facilities than to try to renovate. It's much more cost effective."

Once built, likely by late 2008, the Critical Care and Children's and Maternal towers "will form a new main entrance to the hospital accessible from Orleans Street."

Other additions could also bring new research buildings and renovated housing for medical students.

"It's not only going to be a new hospital for now, but a hospital for the future," Stephenson said.


INTERNATIONAL NEWS

For Two Girls, a Chance to Lead Separate Lives

They have never been able to sleep apart, sit upright or see each other face to face. Yet if an operation by a team of doctors from India and the US is successful, two 10-year-old Indian girls joined at the head will finally be able to lead separate lives.

Benjamin Carson, director of pediatric neurosurgery at Johns Hopkins Children's Centre, in Baltimore, Maryland, who is leading the medical team, said the procedure was possible after studying an angiogram of the brains of the twins and consulting doctors at the Indraprastha Apollo hospital in New Delhi. The pioneering US neurosurgeon was flown in after Abu Dhabi's crown prince, Mohammed bin Zayed Al-Nahyan, said he would pay for any operation. He had read about the twins in a newspaper.

Dr. Carson said the operation would be complex but "if everything goes the way we plan, I expect they will both be alive".

The Indian twins share a blood drainage vessel in the brain - a concern for doctors. Dr. Carson said that at each stage of the operation there was a 20% chance of failure, but that without the operation the twins would face a lifetime of procedures.

The problem with the girls, Farah and Saba, is that Farah has two kidneys and Saba has none, so Farah's body has to carry her sister's functions. "What we are seeing is evidence of cardiac malfunction in Farah because she is carrying her sister. That will get worse with time," said Carson.

Conjoined twins originate from a single fertilized egg, so they are always identical and of the same sex. The number of twins joined at the skull worldwide is believed to be between 10 and 20. "Eventually I want to reach a point where all separations like this will become routine," Carson points out.

The operation will be a first for India, where there has been a rapid expansion of western-style private hospitals in city centres. "We can both learn something from each other. Our team of 20 doctors will be there working with Dr Carson's group. It will be a joint effort," said Anupam Sibal, director of medical services at Indraprastha Apollo hospital.


CME COURSES

November 5, 2005
14th Annual Lipid Disorders Training Center Program Advanced Update
Johns Hopkins University School of Medicine, Turner Bldg.
Baltimore, MD

November 6-7, 2005
Fifth Annual Current Topics in Gastrointestinal Pathology
Hyatt Regency Baltimore
Baltimore, MD

November 10, 2005
Looking Forward: Tomorrow's Neurology
Johns Hopkins School of Medicine, Turner Auditorium
Baltimore, MD

November 11, 2005
Fluoroscopy Credentialing Conference
Johns Hopkins Hospital
Baltimore, MD

November 18, 2005
Sixth Annual Topics in Psychiatry
Johns Hopkins School of Medicine, Turner Auditorium Baltimore, MD