Hopkins Medical News Spring/Summer 1998
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Circling the Dome

 

Suddenly, the Hospital’s Full

Just a year ago, patient volumes at The Johns Hopkins Hospital looked as erratic as a seismometer during an earthquake, so departments were told to cut their budgets by 15 percent. Many did so by trimming staff. This spring, administrators find themselves singing a cheerier tune. The Hospital’s patient census report for this fiscal year is running about 4 percent above projections—an extra 500 patients during the four months from July to October—with occupancy rates now topping 90 percent on many days.

What’s happening here?

Hospital and Health System President Ronald R. Peterson claims that a number of recent business moves are paying off. First, patient volumes at Hopkins’ well-located Green Spring Station suburban satellite have increased 250 percent during the last two years, translating into a rise in the number of patients at the Hospital. Similarly, patients belonging to a local network known as Johns Hopkins Medical Services Corp., who used to land regularly in other hospitals, now are being steered instead to Hopkins’ two hospitals through a capitation agreement in which faculty physicians deliver specialty services for a flat fee.

Recently, recruited clinicians also are contributing to the rising census. The Department of Medicine, whose discharge volumes are at an all-time high, has added seven internists whose new patients are being admitted here; likewise, a crew of just-hired gynecologists and obstetricians is helping fill beds in that department, where occupancy is up 10 percent over last year. And finally, the number of international patients is growing steadily.

Peterson is quick to point out, however, that in the health care industry, more business doesn’t necessarily mean it’s like Christmas at Toys R Us. “We’ve had to incur greater expenses at a premium cost,” he says, “so even though volumes are up, financially we’re close to being on plan.” But noting that the boomlet comes at a time when other local hospitals are reporting dips in business, he adds. “It’s nice to know we’re so in demand. We’re bucking the trend.”

— MEM


Beeper Bonanza

For busy medical students whose campus roamings can put them out of touch when impromptu teaching sessions are called or they’re needed for other spontaneous meetings, the Medical and Surgical Association has provided a solution. Students in .Second-year student David Rosenberg and student affairs associate dean Frank Herlong show off the new trinkets. the clinical clerkships will be toting all-expense-paid beepers, thanks to the largesse of the Association that’s led this year by Surgery Professor Emeritus R. Robinson Baker.

The Medical and Surgical Association—anyone who’s been on the faculty or trained on the medical campus is automatically a member—is better known for funding several annual med student scholarships. But this year, it sought to improve life for medical students across the board and asked for suggestions. Students requested beepers, which until now have been used more commonly by fellows and residents. Med students who ordered them in the past went through a cumbersome billing process in which class representatives circulated monthly to collect payment from each. Now, the Med/Surg will pick up the total bill, taking over the payment hassles.

The devices should make students’ comings and goings easier. “With beepers, they can spend time in the library or go get sleep, and be called if the group is gathering to see a patient,” says Frank Herlong, associate dean for student affairs, who helped orchestrate the gift. “They also can be more directly involved in patient care and not feel they missed out on something,”

In another good-will gesture, the Med/Surg installed a fax machine for med students to use for loan applications and other crucial correspondence.

— Kate Ledger


Kelly Ripken Says, ‘You Can’t Have It All’

Kelly Ripken, like Barbara Bush, has Graves' disease, which affects about two in every 1,000 people. Kelly Ripken doesn’t blame people for thinking her life is a Cinderella story. She is stunning in person, lovelier than photographs make her out to be. Statuesque at 6 feet tall, she dresses with unexpected but smart touches (today, it’s a lilac sweater casually draped over a dark plaid suit), is coifed by Cristophe (like the Clintons), and has striking, limpid green eyes. And that’s to say nothing of her marriage to The Man Who Saved Baseball, their two winsome, blond children, and a spectacular home.

Kelly admits she might even have to pinch herself—if her body didn’t already do that for her. “My reminder is my health,” says the wife of Oriole “Iron Man” Cal Ripken. “Because of having an illness, and going through what I went through, I’m always aware you can’t have it all.”

Diagnosed 12 years ago with a thyroid condition, Kelly, 38, has set up a patient education program at Johns Hopkins to alleviate the frustrations she experienced learning how to live with her illness. “I swore to myself that when I found out what was wrong, I was never going to feel that way again if I could help it,” she says. “The more you know abut this disease, the better you’re going to be.”

For Kelly, getting to the root of what was wrong was no easy task. Her problems began in 1984, just at the time she and Cal started talking about marriage. She had a tormenting, around-the-clock headache, she couldn’t sleep and felt irritable. Her appetite increased—every morning she ate an entire box of chocolate donuts, yet lost 25 pounds. She was tested for brain tumors, Hodgkin’s disease, lupus; received cortisone shots in her neck for a supposed cervical injury; even had all four of her wisdom teeth extracted.

“I felt terrible,” she recalls. “Your body is running so fast, and it won’t rest. There were days when I thought, ‘Today’s the day I’m gonna go out of my mind.’

'Finally, some two years, 12 physicians and two dozen medications later, Kelly was correctly diagnosed with Graves’ disease, a common type of hyperthyroidism caused by the effects on the body of too much thyroid hormone.

According to Paul Ladenson, M.D., Hopkins’ director of endocrinology and Kelly’s specialist for the last five years, stories like hers are not unusual, because the symptoms of thyroid disease—fatigue, anxiety, palpitations—are so common.

“In the shoes of a primary care physician, who may only see a few cases of thyrotoxicosis in a lifetime, it’s easy to see how this wouldn’t be the first thing on your list when someone comes in with complaints that are often written off to life stress,” says Ladenson. But once a doctor thinks of the possibility, there are simple and accurate blood tests to rule thyroid conditions in or out, and very effective medications to control both hyper- and hypothyroidism (when too little thyroid hormone is produced). In addition, radioactive iodine treatment can permanently prevent the thyroid from producing too much hormone in cases of hyperthyroidism.

Still, Ladenson admits, “there are other dimensions of thyroid disease beyond how the drugs are working—concerning the anxiety you feel while getting over this.”

Kelly recalls how she felt. “In the beginning, I had no one to talk to and all these questions in my head—Is this something I have to deal with every day? How do I do it? What about having children? Every time I didn’t feel well, I’d get over-anxious about my health. It was all I talked about.” Eventually, time, and talking to other people with her condition, helped Kelly regain control of her life. “This is the best I’ve felt in 10 years,” she says.

Now, she intends for the Kelly G. Ripken Program at Hopkins, which the Ripkens will support with a $250,000 gift, to become a clearinghouse of information—in print, on video and the Internet—and assistance for patients with thyroid disease. Nurse educator Marge Ewertz will coordinate services, which include making multiple medical appointments at Hopkins, or helping those who live outside the area find a doctor close to home. Ewertz is even compiling a database of patients with thyroid disease who are willing to share their experiences.

As for Ripken, she couldn’t be more pleased with her new program. "I plan to be very hands-on with it, because it’s true to my heart," she says. To contact the Kelly Ripken Program, call (410) 955-4476 or 1-888-595-2131, or log onto the website at http:\\thyroid-ripken.med.jhu.edu.

— Mary Ellen Miller



Bloomberg with patient

Bloomberg Donates Bloomberg

Patients spending time in the Hospital here no longer need miss a moment of what’s happening on Wall Street. Working with Hopkins’ medical video office, University Trustee Chairman Michael Bloomberg has donated the signal and equipment to bring his financial-information television network, Bloomberg News, to all bedsides at Hopkins. Now, patients can tune in to channel 43 at any hour of the day for the latest financial updates, weather forecasts, sports scores and news headlines. Hopkins receives the broadcast, which also appears in TV-equipped conference rooms around the Hospital, at no charge.



Is Doctoring Looking Tarnished?

At the medical school application deadline last December, admissions offices across the country discovered the pool of students vying for slots in the class of 1998 was smaller—by nearly 9 percent—than last year. The 43,020 hopefuls presented the first downward turn in applications in over 10 years.

Even the nation’s most elite schools sensed tremors of a trend. At Hopkins, the number of applications fell by 6.2 percent. Administrators here are taking note, says Catherine De Angelis, vice dean of faculty and academic affairs. But, she adds, they’re not worried about the caliber of the incoming class. Hopkins’ 3,282 prospectives still offered a large pool from which to select 120 students. “And we do very well in the competition for what we feel are the very best applicants in the country. We’re not in a situation where we’re desperate about the quality of our students.”

Whether this year’s drop represents a one-time dip in applications or simply a trough in a continually fluctuating pattern is anyone’s guess. What administrators and educators agree about is that an ongoing downward trend could have serious implications. And they’re beginning to speculate about why a medical career might suddenly be less attractive to college graduates.

Robert Beran, vice president for student affairs and education services at the Association of American Medical Colleges, maintains that it still isn’t clear whether there are definite reasons for the smaller applicant pool: “Nobody’s done that study yet.”

One serious issue that administrators acknowledge needs to be factored in, however, is the ever-burgeoning cost of medical training. With grants and scholarships harder to come by and the average debt from a private medical school education hovering at $92,000—and public at $65,000—becoming a doctor now is expensive, no matter how you look at it. And recent legislation stipulates that graduates must begin loan payback immediately, with no grace period for residency training.

Couple that with the changing face of medical practice itself. With the rise of managed care, those entering medicine today will have less autonomy as physicians than their predecessors, a concern that’s much on their minds, according to a recent survey by the medical student publication New Physician. New payment structures also make it harder to earn enough to pay off their huge debts easily. Finally, rumors about “gluts” in certain specialties raise doubts about whether today’s students might find themselves closed out of the medical field of their choice.

But even with all these issues, says Leon Gordis, associate dean of admissions, there’s no evidence that undergraduates are basing their choices on their perceptions of the job market.

Beran describes the ebb and flow of interest in medicine as cyclical, and points out that in the mid-’80s, business schools were flooded with applicants while medicine and law took a hit. Since then, medicine’s applicant pool has been swelling annually, inundating schools with top-notch undergraduates. A brief dip in numbers, he notes, is hardly an alarming phenomenon.

Since Hopkins has seen no drop in the quality of its applicants, says David Trabilsy, assistant dean of admissions, the sticking point is “we don’t know who’s not applying.”

If the pool continues to decline here and nationally, there are going to be a lot of issues to contend with, he adds. One thing most admissions experts already agree on is that it’s time to address skyrocketing student debt and ways of stabilizing tuition and making scholarships more readily available. Still, it’s by no means certain that a downward trend in medical school applications is in motion.

“This was the first big drop,” points out Edward Miller, CEO/dean of the School of Medicine. “Let’s see what happens next year.”

—KL


Next Time You’re in Singapore, Drop in

In this epoch of mega health care mergers and acquisitions, Hopkins quietly headed east—far east—this winter for an interesting, new partnership. University President Bill Brody and Hopkins Medicine CEO Ed Miller were in Singapore in January to sign a preliminary agreement through which this medical center will create a small replication of itself in the tiny—“You can drive across it in an hour,” Miller reports—ultramodern, Southeast Asia nation.

To be known as Johns Hopkins Singapore, the base will combine research, teaching and patient care. Hopkins physicians will gain a facility in Asia from which to fast-track clinical trials of new treatments for such prevalent Southeast Asian diseases as cancers of the nasopharynx and liver, and rheumatic heart disease, which are less common here. Hopkins faculty also would study the genetic foundation of disorders among Asians and help tailor therapies to treat these diseases worldwide. Initial research funding would come from the Singapore government.

With the partnership, Singapore, meanwhile, gains a respected medical associate that will help train its physicians, build its biomedical industry and enhance its reputation as an education and health care hub. The undertaking will start with a 36-bed wing at the National University Hospital and is expected to grow to 200 beds over several years. Hopkins will be an owner and retain managerial and quality control of the organization and its medical functions. Its own faculty physicians, scientists and administrators would oversee all Singapore operations.

The deal is good news for investigators here, who have been feeling the pinch of managed care on Hospital revenue, especially the part that supports applied clinical research. Although the Hopkins review board must approve all clinical research, a major advantage, according to Miller, is that things can be done faster in Singapore and with fewer regulatory burdens than in this country. “I also thought it would be a nice place for a mini-sabbatical,” he quips.

Hopkins' new outpost-ultramodern Singapore.

— ERN


Women in Medicine Stand Tall

Five years ago, when the Department of Medicine issued a report showing an improvement in salary equity between male and female faculty and other signs of gender equality, 44 medical schools in the United States and several in Europe asked how such strides had been achieved. The answer lay with eight trail-blazing women called the Task Force on Women’s Academic Careers in Medicine.

Formed in 1990 by then-department director John Stobo, the task force had been the department’s response to reports from the University that female faculty here weren’t being promoted in a timely fashion, and several national surveys showing that women overall were less likely to become department leaders. Stobo asked the group to assess the situation within Medicine.

What it discovered after questioning the faculty about everything from feelings of sexual inequality to access to professional networks—and analyzing salary and promotions data, says member Susan MacDonald, were “major problems.”

The task force pinpointed, for instance, a difference in the way female faculty were mentored by senior colleagues. “The work women were doing was more likely to be used for their mentors’ benefit,” MacDonald says. “And there was decreased access to the mentoring network.” What’s more, women faculty didn’t seem to know what was expected of them at various ranks, how decision-making took place or how resources were allocated.

The department immediately set about changing its profile. It established both annual evaluations for faculty and a review of women’s curricula vitae by the promotions committee to see if they were on track; it developed a women’s mentoring network, instituted a monthly colloquium on faculty development and began holding open discussions about gender bias.

The results were spectacular. During the next few years, the number of female associate professors in Medicine shot up from four to 26. Women faculty reported their promotions were no longer being overlooked, and one quarter said their mentoring had improved.

Today, the task force has become a model for medical schools around the country, who are assessing their own status with the Hopkins group’s survey. Meanwhile, the women here push on. Their new five-year goals include better retention of high-quality female faculty and recruiting more women into leadership roles.

But, assures MacDonald, “consciousness has been raised and salary equity has been achieved.”

— Gary Logan


Surgical Technique Puts the Freeze on Kidney Tumors

Fray Marchall has begun using cryosurgery for partial nephrectomies for kidney cancer. Cancer of the kidney is relatively common: about 20,000 people are diagnosed with renal cell carcinomas every year. And thanks to better techniques for spotting the malignancies, says Fray F. Marshall, M.D., who directs the division of adult urology, many of those cancers are caught as small tumors. That’s the perfect scenario, he adds, for cryosurgery.

“Cryosurgery”—killing the cancer by freezing it with the touch of a liquid nitrogen-filled probe—“is one of those techniques that’s been around a long time but which comes into its own only under specific conditions,” Marshall says. “It’s been used for treating prostate cancer, but these days other surgical and radiation therapies are used more often for that. Now we’ve begun using cryosurgery for partial nephrectomies for kidney cancer.”

For kidney cancer, cryosurgery begins with a short incision off the end of the 11th or 12th rib. Separating the muscle layers, Marshall places an ultrasound probe on the kidney to determine the exact size and location of the tumor. With a tiny needle, he biopsies the mass, and then, using the same tiny needle track, injects the 3 mm cryosurgical probe. The probe freezes the tumor, leaving at least 5 mm of an iceball around it, cutting off blood vessels that nourish the malignancy. Typically, the procedure involves two 10-minute freezes, one right after the other. “But our experimental data suggest that one freeze will suffice,” Marshall says.

Because of possible complications with urine leakage, Marshall restricts cryosurgery to smaller, non-central tumors of the kidney. “Right now,” he adds, “we tend to reserve the procedure for older patients who might do better with a less rigorous therapy.” The technique reduces the size of the surgical scar from about 10 to four or fewer inches, “and we feel it also lessens complications. The patients we’ve done so far are doing beautifully.” Soon he plans to offer a laparoscopic approach to the cryosurgery that will whittle the recovery time even further.




For Testicular Cancer Victims, a Godsend

Urological surgeon Louis R. Kavoussi, M.D., has built a reputation for spotting major operations that can be performed successfully with a laparoscope. He and his surgical team were among the first in this country to excise a kidney through a hole no larger than a dime. Lately, this innovator has turned his attention to removing other tissues using the minimally invasive procedure. And he’s looking hard at how the technique can be applied to malignancies.

His focus is a godsend for people with testicular cancer that’s spread to the lymph nodes. “Traditionally,” Kavoussi explains, “patients who have cancer of the testicle, who’ve needed to be staged, had to have—and this is the only adjective that applies—a huge operation to remove their lymph nodes.” In that surgery, physicians make a full-length thoracico-abdominal incision that extends from the left side at about the 10th rib, all the way around and down the patient’s front to the pelvis. Because the lymph nodes are tucked away in the back, the physician has to dissect through the tissue around the colon and the bowel. Patients take up to six weeks to recover, but even a year later “don’t feel normal,” says Kavoussi. Some continue to experience asymmetrical swelling and are numb along the healing incision.

Now, Kavoussi has adopted the endoscope to remove the hard-to-reach nodes. Making only three holes, each a centimeter wide or smaller, in the patient’s midline, he’s able to insert the miniature tools—both a camera and a scalpel—to move smoothly through the abdomen. He watches his progress on a computer monitor and removes the nodes through the same midline holes. Patients recover with less pain and are left with considerably less scarring. Further, because there’s no large incision, they have fewer complications and often are back on their feet in two weeks.

Kavoussi’s team has the most extensive experience with this surgery in the United States. “Other places that offer it have done two or three,” he says. “We’ve already done 28—with great success.”




Problem Patellas Get in Line

As a scholarship athlete in college, Andrew Cosgarea, M.D., was no stranger to knee injury. Those early experiences with knee pain piqued his interest in the all-important joint. Today, as a sports medicine specialist, the somewhat unusual focus of his work is reconstructing knee ligaments and realigning the patella. The orthopedic surgeon performs some 250 knee operations each year.

Surprisingly, Cosgarea says, knee injuries can afflict those who’d never consider themselves athletes. Many patients, for example, are average teen-aged girls or young women with wide hips or slight knock-knees that make them susceptible to kneecap dislocation. “Typically,” he says, “these patients also suffer from a congenital malalignment, where the patellar ligament joining the kneecap and tibia attaches too far out to one side of the tibia.” Then the patella edges to that side and is easily dislocated.

Andrew Cosagarea inspects the results of his surgery on the knee.For patients whose knees are perpetually dislocating, Cosgarea usually corrects the problem surgically with an osteotomy: Making a two-inch wedge in the tibia, he shifts the whole affair laterally—ligament and all—and screws the bone down. Pinned in a more central position, the patella is less likely to dislocate. But the trouble, Cosgarea explains, is that two versions of the osteotomy exist: the Elmslie-Trillat, an operation that moves the patella straight to the side, and the Fulkerson, which first pulls the bone up at an angle before moving it laterally. And that, plus natural differences in patients’ ligament positions, can make matching patients with the right operation less than a snap.

To compare the procedures, Cosgarea recently performed each type of osteotomy on cadavers’ knees. Then, he subjected the knees to bone-breaking stress with a materials testing machine. In a report delivered to the American Academy of Orthopedic Surgeons, Cosgarea proclaimed the Elmslie-Trillat the winner of the stress-test. “Immediately following surgery, it could survive nearly twice the stress of the Fulkerson,” he says. “That doesn’t mean, however, that the Fulkerson isn’t a good operation.” It has its place, Cosgarea adds, in patients who have been prone to multiple dislocations and who have significant scarring under the kneecap. By first doing arthroscopy on prospective patients and evaluating the wear and tear on knee cartilage, Cosgarea determines the best surgical approach.



Refined Test for Prostate Cancer

It’s clear that the PSA (prostate specific antigen) exam is crucial for catching the early signs of prostate cancer before it becomes deadly. “The conventional recommendation has been that men have the blood test annually,” says urologist H. Ballentine Carter, M.D. “But until now, nobody had investigated carefully if this frequency was a good idea.”

H. Ballentine Carter's research could give men the piece of mind about scheduling their prostate exams Carter took on that task. In a recent issue of the Journal of the American Medical Association, he and his team published the results of a study that could give men peace of mind about scheduling their exams and also, he adds, save several hundred million dollars a year in health care costs. Using frozen blood serum samples from a cohort of men, both with and without prostate cancer, in the Baltimore Longitudinal Study of Aging, the researchers followed a two-decade development of the disease. In particular, they investigated how likely a normal, healthy man with a low PSA (less than 2) would be to develop a potentially dangerous PSA level of 4 or higher over the course of two years.

“What we found,” Carter explains, “was that it would be very rare for a man with such a low PSA to reach the comparatively higher one in the course of a mere two years. So what we recommend, formally, is this: If a man younger than 70 has a PSA lower than 2, and nothing can be felt upon rectal exam, then he can feel safe to schedule testing for every other year.

“That doesn’t apply to everyone,” Carter cautions. “Someone, for example, with a strong family history of prostate cancer might be better off with yearly tests. Also, African Americans, who have a higher risk of developing the cancer, may want more frequent testing.”




New Laser Procedure Staves off Blindness

Sharon Fekrat demonstrates the blue-green laser used for the procedure. The blurring in Jerry Jones’ right eye came on suddenly and painlessly. Jones runs a machine shop in Dublin, Va., and three years ago, when a labor dispute erupted among some of his employees, he found himself mired in an unusual amount of reading. Jones chalked up his problem to eyestrain. But three days later, when the blurring increased, he went to a local ophthalmologist who couldn’t offer any treatment.

By the time Jones came to Wilmer Eye Institute a year later, his right eye vision had dwindled so much he could barely read the eyechart. Wilmer set him up with ophthalmologist Daniel Finkelstein, M.D., and Jones underwent a new laser procedure that may well have saved his vision.

Through an ophthalmoscope, Finkelstein observed signs of retinal hemorrhage, a congested optic disc and the engorged veins characteristic of central retinal vein occlusion. The condition frequently causes permanent blindness. A fluorescein angiogram confirmed blockage in the vein, but with some small existing circulation.

Jones was a prime candidate for a laser technique first adapted in this country by Finkelstein, department head Morton F. Goldberg, M.D., and assistant chief of service Sharon Fekrat, M.D.

“The laser, we believe, causes the retinal vein to merge with an undamaged, free-flowing vessel, the choroidal vein, and bypass the site of the blockage,” Fekrat explains. “If you restore the venous outflow, vision may improve.”

Not everyone is helped by the laser treatment, cautions Fekrat, and there’s a small risk of fibrovascular scarring should the process spark unwanted vessel growth. “But we had none of that in the 30 patients we studied, and those who didn’t improve found their vision was not damaged by the procedure.”

As for Jones, his eyesight now is nearly normal. After one year of steady improvement, he can read, drive and, he says, “do just about anything I want.”



When an Eye Goes Out of Orbit

When Maureen McGarry, 37, looked in the mirror one morning last April, she couldn’t believe her eyes—literally. Her right one appeared sunken in comparison with her left. McGarry’s ophthalmologist ordered a CT scan and diagnosed silent sinus syndrome, a condition in which the wall of the orbit spontaneously reshapes itself and enlarges. It’s called “silent” because of the painless changes that appear without warning in the orbit and maxillary sinus.

In the eye, the “seeing” wand reads the shape of the orbit while the grid on a monitor reveals the exact location of the wand’s tip. "The Condition is extremely rare,” explains ophthalmic plastic surgeon Elba Pacheco, M.D. “Patients are otherwise healthy and have no history of trauma or disease that would lead to this condition.”

Because Pacheco is trained in oculoplastic surgery, she was an obvious specialist to take on the reconstruction of McGarry’s eye at Wilmer in the fall of 1997.

In the eye, the But the surgery’s tricky, because it has required guesswork to rebuild the abnormal orbit so that it’s perfectly symmetrical with the normal one. What’s more, this type of reconstruction carries a risk of damaging the optic nerve or injuring the eye muscles and causing double vision.

Fortunately for McGarry, Pacheco has at her disposal a CT-linked wand, recently developed by radiologist James S. Zinreich, M.D. “The technique is unique to Hopkins,” says Pacheco. Throughout the surgery, a computer monitor shows a CT image of the patient’s head with an overlaying grid pattern. When Pacheco touches the “seeing” tip of the wand to the patient’s orbit, the image on the screen reveals the exact corresponding location on the CT scan. The grid makes it easy to compare the sunken side with the normal side, so Pacheco knows at once how much the orbital wall needs to be changed and where to place the implant. “The CT wand takes the guesswork out of rebuilding the orbital walls,” she reports. “It adds time to the surgery, but we know instantly during the operation if we have the implant in the correct place with better precision than ever before. We’re very happy with it.”

Just ask McGarry, who went home from the hospital after an overnight stay. “Within three days,” she says, “my face was back to normal.”



Gene Therapies Fight Cancerous Tumors

Hopkins physicians were thrilled last year when three patients with end-stage kidney cancer inoculated with genetically modified cancer cells all developed the classic skin welt—the tell-tale sign their immune systems were mounting a response to the disease. While the vaccine didn’t cure the cancer, it provided dramatic results: In one man, all but two of 30 secondary lung tumors shrank for six months to the point of being invisible on a CT scan.

Gene therapy offers a new tack on fighting a cancer whose metastatic masses defy chemotherapy, says Jonathan Simons. The results were so encouraging, says oncologist Elizabeth Jaffee, M.D., who with Drew Pardoll, M.D., Ph.D., and Hyam Levitsky, M.D., pioneered a leg of the study, “we’ve applied the technique to earlier-stage pancreatic cancer patients and also to men with prostate cancer.”

For the latter group, gene therapy offers a new tack on fighting a cancer whose metastatic masses defy chemotherapy. Jonathan Simons, M.D., of the departments of oncology and urology, and his team took tumor cells from patients who’d had their prostates removed by urological surgeon Fray F. Marshall, M.D., but had subsequently shown signs of metastatic cancer. The researchers altered the DNA of the cancer cells so that they would produce the immune-flagging surface protein GM-CSF. Then, they reinjected the patients with the cells in three shots spaced several months apart. Now, in a phase II study for efficacy, the physician-scientists are keeping tabs on up to 30 men who will receive the vaccine once a week for eight weeks. By fall, they may know how well this new treatment knocks tumors into remission.

Simons also has another therapy in the works. Late this spring, he’ll begin a test of an injection of a genetically altered version of the common cold virus programmed with selective vision to target and kill only cells in the body that produce PSA (prostate specific antigen), those of the prostate and prostate cancer.

“No treatment for prostate cancer like this has ever been brought from the laboratory to the clinic in the history of man,” Simons states. “In the lab, the CN706 virus kills cells better than most chemotherapy. We don’t know yet how well this will work in men.” The experimental treatment must first pass scrutiny by the National Institutes of Health Recombinant DNA Advisory Committee and the U.S. Food and Drug Administration. Then, trials will begin for men who have undergone radiation treatment, but whose prostate cancer has recurred.



A Cooler Tool for Racing Hearts

For one middle-aged lawyer who was resuscitated after his heart raced out of control, an implanted defibrillator was no hardship. The man, who’d already suffered one heart attack years before, didn’t mind the powerful infrequent jolts in his chest set off by the defibrillator. They assured him the machine was keeping recurrent spells of rapid heartbeats from threatening his life.

Then, he became plagued by another type of arrhythmia: ventricular tachycardia, pattering at about 140 beats per minute. Brought on by an electrical short circuit in the region of his earlier heart attack, the palpitations occurred almost daily. Suddenly, the implanted defibrillator was firing all too often, causing a sensation that was both disconcerting and painful. Clearly, the ventricular tachycardia needed to be controlled.

“Until recently, when medications failed, there was nothing you could do short of open heart surgery to eliminate the problem in patients who’ve had heart attacks,” says electrophysiologist Hugh Calkins, M.D. Large areas of scarred heart tissue tend to make these patients poor candidates for the usual treatment for arrhythmias, a technique that Calkins helped pioneer and refine called catheter ablation. Usually in this procedure, he threads a catheter into the heart and, with radio frequency, cauterizes the site of the short circuit where the arrhythmia is occurring. “But in heart attack patients who have scarring and deep circuits, the crucial areas are hard to reach with standard catheters,” says Calkins.

Now, Calkins, who heads Hopkins’ Arrhythmia Service, is participating in a multicenter trial using a new ablation device designed specifically for this type of patient. The new tool has a cooling system on the inside, with saline circulating into the center of the catheter. “The internal cooling device allows us to give more power with the radio frequency, so we can reach deeper circuits than with the standard device,” Calkins explains. So far, he reports, the success rate for ablating ventricular tachycardia in heart attack survivors has jumped from 50 percent to about 80 percent.


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