Johns Hopkins Health - Spring 2013

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Insight and news from Johns Hopkins Medicine

Healthier at Home Better care outside the hospital promotes and protects independent living

Are you making your kids anxious?

It’s never too late for breast reconstruction Baby boomers at risk for hepatitis C

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Contents

24/7 HEALTH INFORMATION FROM JOHNS HOPKINS To learn more about menopause and other medical conditions, visit

hopkinsmedicine.org/healthlibrary.

S P R I N G 2 013

For more information, appointments or consultations, call 877-546-1872.

Calm and 4 Keep Pass It On QU IC K CON S U LT

Don’t hand down your anxiety disorder to your kids.

5 Sharing Is Caring

Johns Hopkins and Facebook have teamed up to increase organ donations.

Early Menopause’s New Health Risk

10 New Beginning F IRST PE RSON

A Pennsylvania woman shares her story of cancer treatment and breast reconstruction.

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for a 11 Testing Hidden Threat S ECON D O PI N ION

Attention baby boomers: The CDC wants you to be screened for hepatitis C.

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ON THE COVER

Healthier at Home Medicine’s thought leaders are strengthening a transition from hospital to home that builds independence as much as wellness.

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uch attention is given to the symptoms of menopause—hot flashes and hormone fluctuations among them. For women who experience menopause before age 46, which is considered early, there is a newly recognized threat. Early menopause is associated with double the risk of coronary heart disease and stroke compared with women who go through the transition later, according to a new study at Johns Hopkins.

“Women who experience early menopause should work with their primary care physician or cardiologist to reduce or eliminate other cardiac risk factors,” says Lili Barouch, M.D., a cardiologist at Johns

Hopkins. “The best ways to minimize risk are to maintain a healthy weight, be active and avoid or quit smoking.”

Additionally, the researchers suggest these tips. ◗ Keep cholesterol levels and blood pressure low. ◗ Take medications as directed by your doctor. ◗ Manage your diabetes, if you have the disease.

If you’ve experienced early menopause, ask your doctor how it could affect your health and to help you evaluate your lifestyle and hereditary factors for ways to reduce your overall risk of stroke and heart disease.

SHOULD I SEE A DOCTOR FOR THIS RASH? It’s the season for getting back into gardening or simply spending more time outdoors. It’s the season, too, for poison ivy and other causes of contact dermatitis.

Though over-the-counter products are within reach at the local drugstore, be cautious when self-medicating.

“Using topical anesthetics [these usually end in -caine] and antihistamines can cause an allergic reaction,” says William H. Convey, M.D., ABFM, a family medicine physician at Johns Hopkins. “Witch hazel and calamine are OK [for most skin reactions], but for severe, uncomfortable rashes or those that persist for more than a week, see your doctor. We can prescribe a medicine that takes care of it much more effectively.”

Find more questions answered by Johns Hopkins experts and others at sharecare.com, a website designed to simplify your search for quality information on topics of health and wellness.

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healthinsights Bad Buzz About Energy Drinks Excessive caffeine consumption, especially from energy drinks, is making everyone take a closer look at what we—and our kids— are drinking.

“Caffeine is a mildly addictive, psychoactive drug associated with negative health consequences, including increased heart rate, palpitations, insomnia, anxiety, hypertension, bladder instability and pregnancy complications,” says Johns Hopkins researcher Steven Meredith, Ph.D. “Vulnerable individuals, such as children, pregnant women and those with certain heart conditions, should avoid excessive consumption.”

Though adults should consume no more than 500 milligrams of caffeine per day, experts set a much lower limit—100 milligrams—for teens (ages 13 to 19) and advise no caffeine for children younger than 13 because of the amplified effects on their smaller bodies and their lower caffeine tolerance. A recent study showed that up to 75 percent of kids ages 5 to 12 consume caffeine daily.

LOSE WEIGHT, SLEEP BETTER, HAVE A HEALTHIER HEART

A 12-ounce cup of coffee contains about 100 to 400 milligrams; energy drinks contain 50 to 500 milligrams, plus high amounts of sugar, which can elevate blood glucose levels and lead to weight gain.

If you’re a parent, share the risks of too much caffeine with your kids, then look at labels together to help limit or eliminate caffeine in their diet.

The benefits of whittling inches from your waistline are well known, from fitting into your “skinny” jeans to reducing your risk of a heart attack. A recent study at Johns Hopkins suggests that losing weight can help you get a better night’s sleep, too.

“The study found that weight loss, whether from diet alone or diet combined with exercise, improved sleep quality among people who are overweight or obese,” says Kerry J. Stewart, Ed.D., director of clinical and research

Self-Treating Sprains and Strains IF AN E XU B ER ANT RE TURN to warmer weather leaves you wincing in pain from a sprain or a strain, don’t despair.

“Most minor sprains [twisted or wrenched ligaments] and strains [overstretched or torn muscles or tendons] are easy to treat at home,” says Sameer Dixit, M.D., a sports medicine physician at Johns Hopkins.

For self-care, he suggests the PRICE technique. ◗ Protect the injured area. ◗ Rest the affected limb. ◗ Ice or apply a cold pack to the swelling. ◗ Compress the area using a bandage. ◗ Elevate the injured limb.

“If you don’t see noticeable improvement within a week, see your doctor,” Dixit says. “If you want a quicker return to activity, rehabilitation and physical therapy can help get you there.”

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exercise physiology at Johns Hopkins. “That translates to a reduced cardiac risk—not only because of weight loss, but because of a reduction in symptoms of sleep apnea, a powerful risk factor for cardiovascular disease.”

According to the study, Stewart says, people who lost fat from around the midsection experienced more striking benefits.

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quickconsult

Keep Calm and Pass It On If you have an anxiety disorder, you might be handing it down to your kids without realizing it. Golda Ginsburg, Ph.D., a child psychologist at Johns Hopkins, explains why—and what you can do to prevent it

How are parents creating anxiety in their children?

Research has shown that there is a trickle-down effect: Children of parents who have anxiety disorders are up to seven times more likely to develop anxiety themselves. There is good evidence to show that this is due to a combination of nature and nurture. In some families, there is a biological component. Other parents may be inadvertently causing anxiety in their kids through their own behaviors.

What kinds of parental behaviors are responsible?

Parents who frequently highlight all the dangers and threats in the world can make their children fearful. They can model anxiety by saying things like, “Don’t touch that doorknob because it’s full of germs and you’ll get sick.”

Parents who are overprotective can subtly communicate to their children that they don’t have good coping skills, which can cause anxiety.

Can parents do anything to change this pattern?

We’re learning that they can. In a pilot study at Johns Hopkins of parents who have anxiety and their children, we provided interventions to some children, and none of those children developed anxiety. Among the children who didn’t receive intervention, 30 percent developed an anxiety disorder. Johns Hopkins is conducting a larger trial that will conclude in mid2013, and we think we’ll see very similar findings.

Are there resources that can help?

Interventions focus on both parents and children. First, they help to identify the signs of anxiety, such as stomachaches and avoidance of certain situations. Then they open the door to developing coping skills. Parents might work on not modeling anxiety and not being overprotective. Kids can learn to change their thoughts, such as realizing nothing terrible will happen if they give a wrong answer when they’re called on in class.

Early intervention is key to preventing a full-blown disorder.

Professional guidance is a good idea if anxiety interferes with daily activities. n

For more information, appointments or consultations, call 877-546-1872.

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Sharing Is Caring Johns Hopkins and Facebook harness the power of social media to increase organ donations

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lmost every hour of every day, someone in the United States dies waiting for an organ transplant. But it doesn’t have to be that way—and Johns Hopkins is working with Facebook to change it.

Anyone can register to be an organ donor through his or her state’s motor vehicle department. But even though a 2005 Gallup poll showed that 95 percent of Americans support organ donation, a little more than half have granted permission to donate their organs or tissue on a driver’s license or an organ donor card.

“People aren’t always comfortable talking about organ donation or just don’t understand it,” says Andrew Cameron, M.D., a transplant surgeon at Johns Hopkins. “We wanted to make it easier to have that conversation and register as a donor.”

That idea became a reality in May 2012, after Cameron and his former Harvard classmate, Sheryl Sandberg, chief operating officer at Facebook, started brainstorming at a reunion the year before.

Facebook users now can add “Registered as an Organ Donor” to their Facebook timeline as a “Life Event.” They can also click a link and register as a donor in a matter of minutes (see “State Your Intentions” at right) and share this information with their friends.

“It’s a comfortable environment to gather data and make an informed decision about organ donation,” Cameron says.

“It also gives people a place to share their wishes about what happens to them after they’re gone.”

Just two weeks after the Facebook initiative launched, Cameron says, the number of registered organ donors nationwide increased by 2,000 percent.

Although Facebook facilitates registration only for deceased donations, the social

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phenomenon improves the search for live donations, too. For example, Cameron says, Johns Hopkins developed a program that teaches an advocate, usually a friend or a relative, how to spread the word about a loved one’s need for a live kidney donor; researchers discovered these advocates improve the odds of finding a donor by nearly 50 percent.

“We’ve seen the difference that kind of advocacy makes,” Cameron says, “and we think it’s something that can be enhanced by social media and Facebook.” n

State Your Intentions To register as an organ donor through Facebook:

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o to your profile page G (you’ll see your profile and cover photos).

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here you would type W your status update, click “Life Event.”

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lick “Health & Wellness” C and then “Organ Donor.”

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Click “Save.”

E nter all the details you want to share with your friends.

To register officially through Donate Life America, a nonprofit alliance of state and national registries, click “sign up with the appropriate registry” before you save your Life Event or go directly to bit.ly/stateintentions. There, click your state to open up the registration form for your area.

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Better care outside the hospital promotes and protects independent living

H e a lt h i e r at

Home I

magine you are at home when

the telephone rings. The voice on the other end asks with interest how you are doing.

You mention your car needs repairs this week; can someone give you a ride to the pharmacy? Then you bring up the family barbecue at the end of the month. The other person on the phone suggests you avoid Aunt Sheila’s famous potato salad in favor of some fresh fruit …

Such an exchange might be expected with friends and family, but typically not with your doctor or nurse. But why not? Clearly, health care needs aren’t confined to hospitals, which is why Johns Hopkins health care providers are extending their reach into homes and even beyond—and serving as a model for the rest of the medical community and perhaps for the future of health care.

From Hospital to Home

The period after hospitalization is a time when medical assistance is often still needed, yet, traditionally, that’s when hands-on health care usually ends.

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A woman on IV therapy may be well enough to get back to work but needs treatment in the middle of the day. Or a man with sleep apnea requires a breathing mask but isn’t quite sure how to operate it. Helping people acclimate to their lives after a hospital stay, and seeing to it that they’re able to maintain their independence, daily functioning and quality of life, is being viewed more as part of the natural recovery process. Johns Hopkins Home Care Group has been providing this kind of assistance for 30 years.

“Our job is to help people be more independent in their own care and know how and when to get help,” says Kimberly Carl, director of Johns Hopkins Home Health Services, a division of Johns Hopkins Home Care Group, which offers adult and pediatric home health care; wound treatment; help with managing chronic diseases, such as diabetes and congestive heart failure; infusion therapy, such as chemotherapy and IV medications; enteral care, such as feeding tubes; pharmacy services and home medical equipment; respiratory care; and much more. >

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But in the last few years the approach has become even more holistic, creating closer bonds with physicians and their patients.

Science Meets Service

In 2007, Johns Hopkins launched a study that set the stage for an innovative approach to health care delivery outside the hospital. Named for Greek philanthropist Aliki Perroti, the Aliki Initiative was designed for medical residents to get to know their patients better.

“W e wa n t e d ou r d octo r s

to know their patients as p e o p l e — th e i r as p i r atio n s , th e i r goa l s , th e p e o p l e who a r e

im p o rta n t i n th e i r l i v e s.”

“And what we meant by that was, we wanted them to know all of the conventional medical information, but we also wanted our doctors to know their patients as people—their aspirations, their goals, the people who are important in their lives,” says David Hellmann, M.D., director of the Johns Hopkins Center for Innovative Medicine and director of the Department of Medicine at Johns Hopkins Bayview Medical Center. “Sir William Osler, who founded the Department of Medicine at Johns Hopkins 120 years ago, said, ‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.’ ” As part of the Aliki Initiative, residents, interns and medical students were asked to engage in activities to enhance their relationships with their patients, such as spending more time sitting and speaking with them; calling them after discharge to discuss transition and troubleshoot problems; and, for a minority of patients, making in-person visits as needed. The result? Patient satisfaction skyrocketed and, for patients who had heart failure, hospital readmissions within 30 days of discharge were reduced.

It has been six years since the Aliki Initiative was introduced. Since then, the scientific study with the curious name has become the standard of care throughout the Department of Medicine at Johns Hopkins Bayview.

“It’s very interesting to watch how our entire program has changed because of this project,” says Colleen Christmas, M.D., director of Johns Hopkins Bayview’s internal medicine residency program. “We

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Is Home Health C are There are tens of thousands of home health agencies in the United States, and that number continues to rise. But it can be hard to decide when you need help—and for some people it can be even harder to ask for or accept it.

A person taking care of an elderly parent is a common dilemma, as is an older person doing his or her best to remain independent while in failing health. But even a short recovery period after surgery can necessitate in-home assistance.

Johns Hopkins Home Support, a division of Johns Hopkins Home Care Group, helps families who could use a range of personal care services, whether it’s cooking, companionship or medication compliance.

One woman was unable to bathe independently or remain steady on her feet. Her grown daughter worked during the day and was not comfortable leaving her mother alone at home.

Concerned about falls and particularly safety in the kitchen during meal preparation, the

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found that once residents have rotated through this service, they start calling patients after discharge, they’re more likely to make home visits, and they contact the patient’s primary care providers.”

Proving That Relationships Matter

Right for You? daughter called Johns Hopkins Home Support and asked for help. Johns Hopkins sent a registered nurse to the mother’s home to assess her environment and gain an understanding of her needs and desires and then developed a collaborative plan of care.

“What’s so important about what we do is that not only do we provide equipment and infusion services, we provide experts,” says Mary Myers, vice president and chief operating officer for Johns Hopkins Home Care Group.

Johns Hopkins Home Care Group’s nurses; physical, occupational, speech and respiratory therapists; social workers; home health aides; clinical pharmacists; disease managers and other specialists are encouraged to look beyond the medical chart and learn who their patients and their families really are. They can also have a conversation to determine how much help is actually needed. Sometimes it’s just a part-time caretaker so a family member can return to work or just take a break.

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Trends have emerged that suggest we all should consider how well our doctors know us and not just our symptoms. A better relationship with their providers gives individuals a better understanding of their treatment regimens, and thus they’ll adhere to them more closely. People take their medication as prescribed and therefore tend not to make repeat visits to the hospital.

They are more apt to follow up for X-rays or appointments with specialists. When people are more educated about their care, they lead healthier lives. The cumulative effect of a close doctor-patient connection seems to be better health in general.

There is a lot of research to show that the transition from one care setting to another is a troublesome time, a time when mistakes can happen, particularly for older patients and for people who have complex diseases.

“Very commonly,” Christmas says, “medications are changed at discharge, and people go home and realize they have some of the same medications, or even different medications, and they’re not sure which ones to take.”

With relationship-focused care, Christmas says, problems are caught early. “There are many things that we ask patients about,” she says. “Do they understand what they need to do to keep themselves well? Do they understand the next steps in their plan of care? For example, if they have an abnormal chest X-ray and need a CT scan, are they aware of that? Do they make that appointment?”

Adds Hellmann, “You find out a number of important things when you know your patients better.” He recalls one man who struggled with taking medications as prescribed. When the man’s physicians learned that he was particularly concerned about the welfare of his dog, this became an opening to motivating better adherence: If he were to fall ill, who would help care for his pet?

“Sometimes a person will take medication to better care for their dog than they would to better care for themselves,” Hellmann says. “It was the perfect illustration of why it is important to know people.” n

Watch this video

See how the Aliki Initiative is transforming patient care through personalized, individualized medicine at Johns Hopkins. Visit bit.ly/jhhealthvideos or use your smartphone to scan the code to the left. For more information, appointments or consultations, call 877-546-1872.

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firstperson

New Beginning Pam Vierra is healthier and happier than ever after cancer treatment and breast reconstruction

When I was diagnosed

with breast cancer in April 2011 at age 45, it was a nightmare. But after doing a lot of research, I discovered that knowledge is a powerful tool. And that’s when I took charge of my health.

I encourage every woman to explore all of her options, and the physicians who will be treating her, very carefully. After speaking to a surgeon near my home in southern Pennsylvania, I went to Johns Hopkins for a second opinion. That was the best decision I could have made.

Even though I took a lot of trips back and forth to Johns Hopkins, which is 90 minutes away, I don’t regret a single one. Because of their multidisciplinary approach, I worked with a team of experts who helped me decide what was best for me.

The cancer was only in one breast, but I chose a bilateral mastectomy because I didn’t want to spend my life worrying about the cancer coming back.

I also decided before my mastectomy that I’d have reconstructive surgery, using tissue from my stomach instead of implants.

During my mastectomy, breast tissue expanders were inserted to prepare me for the reconstruction, which was done in three stages. I waited three months between each procedure to give my body time to heal.

The results are beautiful. Best of all, I’m cancer-free and I feel wonderful.

Breast cancer started out as an awful nightmare, but it turned into one of the best things that ever happened to me. It motivated me to take better care of my health, and being given the power to make health decisions has made me a stronger person. n

Treatment Can’t Wait, but Reconstruction Can

Breast reconstruction can be performed at the same time as a mastectomy, or anytime after surgery when a woman decides it’s right for her.

Johns Hopkins surgeons educate women about the options, including the type of reconstruction and whether chemotherapy or radiation is part of treatment.

It’s a complex decision to be made in light of so much information, says Michele Manahan, M.D., FACS, a plastic and reconstructive surgeon at Johns Hopkins.

“There are many reasons women delay reconstruction. There’s no one right answer,” Manahan adds. “Some choose to wait so that they can make the decision when they have more of their mind free to think about it. Some wait to see how they do with the initial surgery and then plan from there. Others just want to do it at another time that’s more convenient.”

Women also have the option to revisit their decision, even 10 to 15 years after their mastectomies, whether they originally opted for no reconstruction or they want a previous reconstruction revised.

“It’s never too late to have a reconstruction performed,” she says. “There is no deadline.”

To watch a video of Pam Vierra telling her story, visit hopkinsmedicine.org/mystory.

For more information, appointments or consultations, call 877-546-1872.

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secondopinion

WHAT YOU CAN EXPECT An estimated 800,000 people ages 48 to 68 will discover they have hepatitis C after taking a one-time test recommended by the Centers for Disease Control and Prevention. The testing process is simple.

Testing for a Hidden Threat All baby boomers should get screened for hepatitis C—and take comfort in new treatments

I

f you’re a baby boomer, you might be relishing a new set of responsibilities that comes with age. You are approaching (or enjoying!) retirement, your children are grown, you have a few grandkids to spoil, and you’re still healthy enough to enjoy it all.

Now, the Centers for Disease Control and Prevention (CDC) has added one more responsibility to ensure you stay healthy: Get screened for hepatitis C. In August 2012, the CDC issued a recommendation that all Americans born from 1945 to 1965 get a one-time blood test for the disease. Although no one wants a positive result, knowing you have hepatitis C offers the opportunity for treatment that may ward off serious health concerns.

Baby boomers account for one in every four people in the United States but three of every four who have hepatitis C, says Mark Sulkowski, M.D., professor of medicine and medical director of the Johns Hopkins Infectious Disease Center for Viral Hepatitis.

“Peak spread occurred in the 1960s, ’70s and

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’80s, before the virus was identified and testing was available,” he says, “so many people were exposed during that time.”

The hepatitis C virus is mainly transmitted through blood, such as from a transfusion (prior to widespread blood supply screening in 1992) or contact with contaminated needles.

Though the disease can take years to manifest, “most people carry it, even for decades, without experiencing symptoms,” Sulkowski says. “As a result, many won’t find their illness until later on, after liver damage has occurred.”

Symptoms of liver disease include pain in the right upper abdomen, fatigue, dark urine, muscle and joint pain, jaundice, fever and nausea, and poor appetite.

“Hepatitis C infects the liver and can lead to a chronic infection, causing scarring over time and leading to cirrhosis, liver failure and even liver cancer,” Sulkowski says.

“Treatment includes three medications— interferon, ribavirin and new direct-acting antivirals—and has a 75 percent cure rate,” he adds. “And Johns Hopkins is in the last stages of testing oral therapies that have fewer side effects and better outcomes.” ■

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Your doctor will draw your blood and test it for the presence of hepatitis C antibodies. A positive test signals that you have been exposed to the virus at some point in your life.

With a positive antibody test, your doctor will order another blood test or two to confirm whether the virus is still present in your blood and help him or her determine the best course of treatment.

More than 90 percent of people taking new oral therapies currently being tested at Johns Hopkins are cured of hepatitis C. Insurance may or may not cover the one-time blood test. Be sure to check with your plan provider.

For more information, appointments or consultations, call 877-546-1872.

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