Kidney Swap Central
First launched here, a domino-swap approach to kidney donations is extending ever more lives.
Photo by Dorry Segev
|> Gentry and Segev, match math whizzes
IN ITS OWN WAY, it was the ultimate test of paying it forward: If someone wanted to save a loved one’s life by donating their kidney but was blocked by clashing immune systems, how would they feel about giving their organ to a needy patient they’d never met? And what if that new patient had their own intended donor whose organ was also incompatible but perfect for yet another patient? And then, what if these new pairings could be extended among more and more new compatible pairs?
Of course, setting up a series of such trades had to work out in such a way that the intended patient #1 also got a life-saving kidney.
The challenge portended some ambitious mixing and matching, but Hopkins transplant surgeon Dorry Segev and his mathematician wife, Sommer Gentry, untangled the knot in 2004, unleashing a growing series of kidney swaps that have so far extended the lives of over a thousand patients here and around the world. Now, it seems, the program’s success is propelling it forward by leaps and bounds. “The volume is doubling every year,” says Segev.
The procedure is called kidney paired donation, or KPD. Hopkins’ transplant team launched its first KPD in 2001, performed its first triple-swap in 2003, and eventually graduated to its first six-way series of so-called “domino” transplants in 2007.
In February, surgeons here pushed the envelope, teaming up with transplant centers in Oklahoma and Missouri to further expand the domino swap process in an exquisitely choreographed series of exchanges—involving 12 patients and over 100 medical professionals—that Hopkins transplant chief Robert Montgomery hailed as a “blueprint for national matching.”
And it doesn’t stop there. Until recently, the domino-swap efforts had been aimed at making all the complex exchanges happen within the same calendar day, ensuring that all donors were committed together.
But in March, Montgomery led a paper in the New England Journal of Medicine that unveiled an even newer strategy, called a “daisy chain” kidney swap. The article shows how optimal pairings can be identified amid an even longer chain of matches, with surgeries then executed one pair at a time. In this way, an altruistic donor unconnected to any patients on the American waiting list can set in motion a chain of transplants that rolls across time zones and could, ostensibly, reach around the world.
Montgomery’s team identified just such an extended swap that began with an altruistic donor in Arizona in 2007. That initial pairing began a series that culminated in 10 successive swaps over the coming months, with the majority of them, including the final one, performed at Hopkins.
All told, the expanding kidney-swap idea is clearly poised to save more lives than ever—some 3,000 of the 60,000 U.S. patients currently on the waiting list die before getting a matching kidney. Segev expects that a fully functioning national KPD system can add up to 2,000 more successful transplants annually. Ramsey Flynn
Port in A Storm
Dean/CEO's main message in open forum series: It's not as gloomy as we think
About 45 minutes into his “State of the School of Medicine” talk in late-February, Ed Miller began to suspect some in the audience might be holding out on him. He broke away from the microphone and began pacing across the Turner Auditorium stage, seeking out the wallflowers. ”Other questions?” he asked. “Concerns? Complaints? Speak!”
The momentary silence testified to Miller’s forthrightness, as many of the 350 mostly senior faculty types in the assembly seemed broadly reassured by the dean/CEO’s disclosures. Hopkins Medicine, it appears, is better prepared to survive the economic storm than the nation in which it resides. “Compared to the rest of the economy,” Miller said in his opening words from the podium, “we’re doing, really, very well.”
Though the institution’s investment portfolio has taken a knock, Miller was happy to report that Hopkins’ traditional lack of reliance on endowment funding makes it less vulnerable in a market downturn. Most of Hopkins Medicine’s entities—all three hospitals, along with Johns Hopkins Health Care and the Community Physicians Association—are in the black.
The notable exception, he allowed, was the School of Medicine—yet even the school’s deficit is shrinking in the face of a top-to-bottom campaign for greater efficiency. Reports in the fall pegged the school’s gap at $18 million. Now, said Miller, the shortfall had been pared to $10 million. “So we’re making some progress,” he said.
On the whole, Hopkins Medicine is “going to keep moving forward,” Miller said. “That’s what we do. We’re not going to stop.”
Even the hiring freeze announced in the winter has a soft spot. While most of the 525 positions requested by departments were initially denied, Miller described a gradual series of reconsiderations based on need. He also said that new hires would be approved wherever 75 percent of the needed funds could be identified.
Amid the other cutbacks, capital spending has stopped. “What we’re really trying to do is keep everybody employed,” said Miller. “We have been able to preserve most jobs and we’ll continue to do that.”
On the prospect for new revenues, Miller held out hope for new business from Hopkins International. A larger infusion will come from President Barack Obama’s stimulus package that should be available this fall. Hopkins will see up to $250 million in stimulus funding over the next two to three years, including an uptick in grant funding from the National Institutes of Health.
While Miller hopes to steer some stimulus money to key areas like structural needs for the Ross Building, animal facilities, shared equipment and to information technology—a key priority in the Obama package—he urged the faculty not to get too comfortable with the boost, which is temporary. “The stimulus package is not our lifeline,” he said.
He cited CFO Rich Grossi’s report that Hopkins must spend all of the money within two years of receiving it, and must make quarterly reports demonstrating the funds are aimed at stimulating the economy.
Other key points made by the Dean:
- Equity and promotion will be “addressed appropriately.”
- “Productive faculty” will still be eligible for salary hikes.
- All of the new building projects—the new Armstrong building, the new Wilmer building, and the two clinical towers—are “on budget and on schedule.”
- The biotech park’s first phase north of the campus is 52 percent leased, but the retail space is not yet spoken for.
- Some 242 new houses in the park’s adjoining neighborhood should be completed by the end of summer.
- With the official end of Hopkins’ eight-year fundraising campaign, and the downturn in the economy, philanthropy is “down somewhat,” but, says the Dean, “we’ll keep pushing.”
Toward the presentation’s close, CFO Grossi spoke of savings under way “behind the scenes,” including nighttime reductions in energy consumption that would save $1.2 million annually. On that note, Miller rejoindered from stage right: “I’ve noticed it’s getting really cold in my office!” Ramsey Flynn
What Else Is There?
After NIH, Zerhouni returns
What else could a shooting star do after finishing a six-year turn atop the National Institutes of Health? At 57, former Executive Vice Dean Elias Zerhouni has turned his sights back to the medical school where he had raced through the ranks after earning his medical degree in Algiers in 1975. He’d completed his residency in diagnostic radiology here by 1978, became full professor by 1992, attained the same rank in biomedical engineering by 1995, and then became chair of Radiology. Then vice dean for clinical affairs, president of the Clinical Practice Association, vice dean for research, and executive vice dean before his nomination to direct the NIH.
Zerhouni, who began his new turn here starting May 1, said he hopes to advise leaders from the School of Medicine on how to navigate the more complicated national landscape of grant funding and health reform. Under his leadership, the NIH embarked on the Roadmap for Medical Research.
Patient safety researcher raises awareness of the toll of stress and sleep deprivation.
While looking into the effects of fatigue, patient safety researcher Bryan Sexton discovered an unsettling truth: The more tired you become, the less convinced you are that you’re tired. Now the psychologist is on a quest to educate health care providers about what else happens to the human body when it’s stressed, sleep-deprived, or both.
His mission is particularly appropriate for Hopkins Hospital: Less than half of the workers in 174 clinical units recognize how stress affects their performance, according to a 2008 survey of safety attitudes. “The research is pretty damn conclusive,” says Sexton, who works in the Johns Hopkins University Quality and Safety Research Group. “Sleep-deprived people have slower reactions, make more mistakes, are crankier, and more prone to burnout and depression.”
He points out that after going 24 hours without sleep, people perform on cognitive tests as they would with a blood alcohol level of .10—legally drunk. In one study of sleep loss and performance, fatigued medical residents were 90 percent less efficient on simulated procedures than those who were well rested.
The Safety Attitudes Questionnaire (SAQ), which Sexton developed over a 14-year period, is now used in more than 2,000 hospitals worldwide. It measures the safety culture of each clinical area within a hospital by assessing caregivers’ attitudes toward teamwork and safety, their perceptions of management and working conditions, their job satisfaction, and their stress recognition. At Hopkins, scores for all these areas have improved except for stress, which has remained the same for the past five years. Only 44 percent of all respondents agree that such factors as an excessive workload and fatigue increase the likelihood of errors.
“Overall, Hopkins has done a remarkable job of improving safety norms,” says Sexton. “However, while such categories as working conditions and trusting your boss have gotten better, stress recognition hasn’t budged. It’s also the only domain of the culture where we haven’t done an intervention. We haven’t done anything to make people more stress-savvy.”
The Joint Commission has flagged communication failure as one of the leading causes of medical errors and adverse events. Sexton attributes some of the breakdowns to intimidating and disruptive behavior fueled by chronic fatigue or sleep deprivation. He says that functional MRIs—brain scans that measure blood flow—reveal disturbing facts about fatigue. After 35 hours without sleep, a normal brain resembles that of someone with paranoid schizophrenia or an antisocial personality disorder.
“There’s a disconnect between the prefrontal cortex, which controls logic, and the amygdala, the emotional center,” he says. “You overuse the amygdala, which means you can interpret a hand gesture or comment in an emotional, even violent way. You tend to fly off the handle, and say or do foolish things. Essentially you become a jerk.”
Anesthesiologist Sean Berenholtz, co-director of the Quality and Safety Research Group here, says providers often misjudge the potential impact of sleep deprivation on communication. In his role as director of performance improvement for Hopkins Hospital’s adult surgical ICUs, he often admonishes providers who lash out at other team members, warning that such behavior may keep their coworkers from voicing important safety concerns. “Although I’ve seen providers raise red flags by saying they need advice on certain cases, I’ve never seen one ask for help because he or she was too tired,” he says.
Joy Rothwell, nurse manager of the Cardiology Care Unit at Hopkins, believes that many nurses misunderstand the section of the survey pertaining to stress measurement. “They think if they answer positively, they’re not being the heroic people they’re supposed to be. On the other hand, they also tend to think that they’re super people, and that if they come to work tired it won’t hamper them because their adrenaline will kick in.”
That’s exactly the attitude that Sexton hopes to help change by speaking to more groups at Hopkins. “A high stress recognition score doesn’t mean you’re more stressed,” he points out. “It means you’re more realistic.” Linell Smith
Passionate About Patient Care
Kravet named president of Johns Hopkins Community Physicians.
Photo by Keith Weller
|> Kravet: “Medicine is a public trust.”
A third-generation pharmacist as well as a primary care physician, Steven Kravet remembers hearing customers at his family’s Spotswood, N.J., pharmacy addressing his father and uncle as “Doc”—a common honorific for the operators of small town drug stores. “I recall thinking how special that was and always wanted to have that relationship with a community. My aspirations for becoming a doctor were based on that desire to serve a community,” says Kravet, a faculty member here since 1995.
An assistant professor of medicine and a primary care physician at the Johns Hopkins Bayview Medical Center, Kravet had his care community expanded exponentially in January with his appointment as the new president of Johns Hopkins Community Physicians (JHCP). The largest primary care group in Maryland, JHCP handles more than 450,000 patient appointments annually at its 17 locations statewide.
In announcing Kravet’s appointment to succeed Barbara Cook, the first head physician of JHCP, Johns Hopkins Hospital and Health System President Ron Peterson noted that Kravet has a thorough understanding of “the challenges facing primary care.” At Hopkins Bayview, Kravet has served as medical director of ambulatory services, chief medical officer for quality and patient safety, and as deputy director for clinical activity in the Department of Medicine. He is “passionate about patient-centered care,” Peterson says.
“To quote the mantra of my mentor, David Hellman [head of the Department of Medicine at Bayview], ‘Medicine is a public trust,’” says Kravet, who will maintain his own primary care practice. “Physicians are respected and rewarded well in our country. In exchange, the public expects us to do everything possible to enhance the health and lives of our patients.”
“Hopkins is in a unique position to be a driving force behind health care reform,” with JHCP playing an important role, says Kravet. “The existing and potential collaborations between Johns Hopkins Healthcare; the schools of Medicine, Public Health, and Nursing; and Johns Hopkins Community Physicians, all in the shadow of our national policy makers in D.C., are enormous.” Neil
Change of Heart
Hopkins veteran tapped for a top cardiac post.
Photo by Keith Weller
|> Tomaselli now heads the Division of Cardiology.
Gordon Tomaselli once considered becoming a neurologist, given his long-standing interest in biomedical research and the mysteries of biological electricity. His focus shifted to cardiology when his mother had a heart transplant.
“She was 49 and had her life miraculously turned around after that transplant and lived for 22 years afterward,” recalls Tomaselli, professor of cardiology, cellular and molecular medicine. His mother’s medical miracle—and the solidification of his interest in the heart—occurred while Tomaselli was obtaining his MD at Yeshiva University’s Albert Einstein College of Medicine and serving his residency at the University of California, San Francisco.
He came to Hopkins as a cardiology fellow in 1986, joined the faculty three years later, and last January was named the new director of the Division of Cardiology and co-director of the Johns Hopkins Heart and Vascular Institute.
After nearly a quarter century at Hopkins and landmark research on cellular electrophysiology and heart arrhythmias, Tomaselli, 53, “has made his mark by establishing himself and the School of Medicine as a world leader in the study of causes and potential therapies to prevent sudden cardiac death,” says Mike Weisfeldt, physician in chief of the Hopkins Hospital and head of the Department of Medicine. “This is a tremendous appointment for Hopkins.”
Tomaselli says he will pursue priorities in “all parts of Hopkins’ tripartite mission” of research, education, and patient care. “We need to enhance training of the next generation of leaders in cardiovascular medicine, which requires further improvement in what already is a world-class research program and maintenance of outstanding clinical services.” NAG
More Alpha Docs
Robert Cotter, professor of pharmacology and molecular sciences and director of the Middle Atlantic Mass Spectrometry Laboratory at Hopkins, has received the American Chemical Society’s Analytical Division Award in Chemical Instrumentation for landmark advances in the field. Decades ago, Cotter was among the first to use mass spectrometers to analyze proteins and since has made significant improvements in the technology.
Ted Dawson, professor of neurodegenerative diseases; Jun O. Liu, professor of pharmacology and molecular sciences and oncology; and
Jeremy Nathans, professor of molecular biology and genetics and ophthalmology, have been elected fellows of the American Association for the Advancement of Science (AAAS). Nathans also has received the 2009 Edward M. Scolnick Prize in Neuroscience, a $50,000 award recognizing his exceptional achievements in the field.
Catherine DeAngelis, professor of pediatrics, former vice dean for academic affairs and faculty in the School of Medicine, and now editor in chief of the Journal of the American Medical Association, won a $100,000 Medical Award of Excellence from the Ronald McDonald House Charities for her contributions to pediatrics. With the prize, she established the Dr. Cathy DeAngelis Endowment Fund for the Johns Hopkins Children’s Center’s Child Life Program.
Barbara de Lateur, distinguished service professor of physical medicine and rehabilitation, has received the Distinguished Member Award from the Association of Academic Physiatrists.
Eric Howell, assistant professor of medicine and director of the Collaborative Inpatient Medicine Service (CIMS) at Hopkins Bayview, will receive the Society of Hospital Medicine (SHM) Award for Excellence in Teaching at the SHM’s annual meeting in May.
Susan Lehmann, assistant professor and director of the geriatric psychiatry day program, the geriatric psychiatry clinic, and the psychiatric clerkship program, has been awarded the American Psychiatric Association’s 2009 Nancy C.A. Roeske, MD, Certificate of Recognition for Excellence in Medical Student Education.
João A.C. Lima, professor and director of cardiovascular imaging, and Wendy Post, associate professor of medicine and epidemiology, have received an additional $9 million grant from the National Heart Lung and Blood Institute to extend their Multi-Ethnic Study of Atherosclerosis (MESA) through 2015.
Justin McArthur, professor of neurology, pathology and epidemiology, has been named director of the Department of Neurology. A 24-year veteran of Hopkins, he has won international recognition for an impressive body of work in the biology and development of HIV infection, its management and treatment.
Jeffrey Palmer, professor and director of the Department of Physical Medicine and Rehabilitation, has been named the 2008 recipient of the American Congress of Rehabilitation (ACRM) Award of Distinction, the highest scholarly accolade in the field.
Aleksander Popel, professor of biomedical engineering and director of the systems biology laboratory, has received the 2009 Eugene M. Landis Research Award from the Microcirculatory Society, recognizing outstanding investigatory work in microcirculation.
Jonathan Schneck, professor of pathology, medicine and oncology, will lead a team of five researchers on projects funded with a $10.3 million NIH grant—the largest basic immunology grant ever received by Hopkins—to determine precisely how the human immune system works. In addition to Schneck, the researchers are Stephen Desiderio, professor and director of Hopkins’ Institute of Basic Biomedical Sciences; Michael Edidin, professor of biology; Joel Pomerantz, assistant professor of biological chemistry; Abraham Kupfer, professor of cell biology; and Jonathan Powell, associate professor of oncology.
Hongjun Song, associate professor of neurology, has received a 2008 Young Investigator Award from the Society for Neuroscience. Song’s research has focused on understanding cellular and molecular mechanisms that regulate adult neural stem cells and their development in the mature central nervous system.
Jeremy Sugarman, professor of medicine and bioethics and deputy director of the Berman Institute of Bioethics, and also professor of health, has received the 2008 Distinguished Service Award from Public Responsibility in Medicine and Research (PRIM&R), a Boston-based organization of medical research ethics professionals.