Research is crucial to excellence in clinical care. While that seems self-evident, the reason research and patient care need to exist side by side and be pursued with equal vigor has several levels.
First and foremost, advances in research, both clinical, basic and in-between (which goes by the name of translational research) offers the benefit of immediate therapies for our patients. Second, the ability to offer clinical trials to patients who have diseases for which effective therapies are not available gives both patients and their doctors a sense of hope and optimism for the future. Finally, and most importantly, a research environment that is truly excellent attracts the best doctors, because they feel their talents will be appreciated and they want to contribute.
An environment which demands excellence in research ensures excellence in patient care. The two are not separable. The Johns Hopkins Bayview Scientific Advisory Board was established to ensure excellence in research at all the levels outlined above by providing the resources our scientists need to thrive. Included in this are the development of core facilities, fundraising, space allocation and the opportunity to develop collaborations across disciplines.
Aging and Dementia
With the population of the United States and the world rapidly aging, such that 20 percent of the population will soon be 65 or older, discoveries that will improve the health and well-being of those who are living longer are critical to improving the quality of life and to decreasing health care needs and costs.
The Division of Geriatric Medicine and Gerontology offers exciting programs dedicated to improving the health of our aging society and provides a full continuum of clinical care programs for older adults who would benefit from care by geriatricians and a geriatric team, ranging from primary care in the Beacham and Keswick ambulatory care centers to outstanding home-based care for older patients and our PACE program of daily outpatient care and programs for nursing-home eligible adults. We offer outstanding post-doctoral and continuing education in geriatric medicine, education scholarship, and training of the next generation of researchers on aging.
This Division includes a substantive body of highest quality research programs: basic science research, particularly focused on the biology of frailty in older adults, and clinical, population-based and health services research focused on improving health in aging. Much of this research is conducted within the Center on Aging and Health, a multidisciplinary center of excellence for aging research for the Johns Hopkins Medical Institutions; this also includes the Older Americans' Independence Center, dedicated to determing approaches to prevent or treat frailty in older adults.
Dementia is a major public health emergency associated with the aging of the population. One in ten (10%) of people 65 and older and at least 1 in 3 of people 85 and older are expected to develop dementia. This is a chronic illness due to one or more brain diseases, with Alzheimer’s disease being the most common cause. Dementia typically is progressive and leads to death in most patients over an average of about a decade. In addition to the person with dementia, the disease affects families and caregivers, usually women who are either spouses or daughters in the “sandwich generation.” Since over 2/3 of dementia victims are women, dementia is very much a women’s disease.
Impressive advances and diagnosis and treatment of dementia have taken place. While it cannot be cured there is good evidence that it can be treated in ways that help improve symptoms, reduce disability, improve life quality, and meaningfully help caregivers. Good “Dementia Care” can make a great difference in the lives of dementia patients and their caregivers, and can typically help them stay in their homes longer.
An international effort is underway to develop better treatments for dementia. Over 60 medications are in development and show some promise. Key to this effort are better ways to detect the biological signatures of dementia on the brain or blood at very early stages so that it can be treated as early as possible.
Johns Hopkins has been at the forefront of dementia research and care for over thirty years. Clinical experts at Johns Hopkins literally “wrote the book” on dementia care in books that are of help to caregivers or clinicians caring for dementia patients Johns Hopkins Bayview is now home to the Johns Hopkins Memory and Alzheimer's Treatment Center a comprehensive, soup to nuts clinical care program that provides for all the clinical care needs of dementia patients and their caregivers. Additionally pioneering research is being carried out at Johns Hopkins Bayview to develop new treatments for dementia, especially Alzheimer’s disease. A major focus is the development of brain imaging, blood, and other biomarkers that will accelerate treatment development. The wide dissemination of current cutting edge dementia care to people with dementia where ever they may live, especially in their community homes and in assisted living homes is also ongoing.
The Department of Psychiatry at Johns Hopkins Bayview has a rich history of premier clinical research programs related to addictions. Historically, the clinical research programs began with the Behavioral Pharmacology Research Unit (BPRU), which has operated for over 30 years. Other addictions research programs in the Bayview Department of Psychiatry that currently operate include Addiction Treatment Services (ATS), the Center for Addiction and Pregnancy (CAP), the Mid-Atlantic Clinical Trials Network (CTN) node, and the Center for Learning and Health (CLH). In addition, the Department’s Division of Behavioral Biology (DBB) is a major site for preclinical studies of drugs of abuse. There are over 20 full-time faculty members distributed across these clinical and preclinical research programs, and work conducted is primarily supported by grants from the National Institute of Health and contracts from pharmaceutical companies.
The primary mission of these programs is research related to addictive disorders. In addition, the BPRU operates a National Institute on Drug Abuse (NIDA) post-doctoral training program for doctoral level professionals interested in gaining experience conducting research in this area. Post-doctoral fellows supported by the BPRU’s training grant can have their primary research site be one of the affiliated addictions research programs in the Department (as well as the BPRU itself). Several of the clinical research programs also provide treatment services, either as a part of their direct research or as routine care for non-research patients.
The work conducted in the Department’s programs has included essentially all drugs of abuse (alcohol; nicotine, caffeine, cocaine and other stimulants; opioids including both heroin and prescription analgesics; hallucinogens; sedative hypnotics). In addition, studies have examined, for example, the rates and optimal treatment of comorbid disorders in this patient population, the standardized care of treatment services, novel behavioral interventions, job training skills, the generalization of research findings to community providers, the development of new medications for the treatment of addictions and abuse liability testing of novel medications.
The Department of Psychiatry’s addictions research work has made substantial contributions to our understanding of the nature of substance abuse, and the optimal treatment of patients who suffer from these disorders. While the programs have been highly productive research sites, they also have served as important teaching and clinical service centers, and continue their history of valuable contributions to the overall academic mission of Johns Hopkins.
Allergy and Inflammation
Inflammation is a term originally coined centuries ago to describe the concept of pain, swelling, loss of function and color change, typically redness, that accompanies a tissue infection or injury. With the invention of the microscope, inflammation took on a new meaning, namely that of the microscopic appearance of a tissue in which an injury, infection or other perturbation has resulted in a change in the tissue with characteristics such as edema, fibrosis and accumulation of white blood cells. Such inflammation may be useful to the host as is the case during a response to an infection or injury, but also may be detrimental to the host as is the case in a number of chronic illnesses such as asthma. Understanding how inflammation occurs in the right and wrong settings, or does or does not resolve once healing has occurred, therefore, may be critical to comprehending not only the causes of illnesses, but also may suggest ways to enhance or inhibit these processes depending on the potential outcomes of this type of inflammatory response.
At Johns Hopkins Bayview, a wide range of physicians and scientists are exploring mechanisms involved in inflammation. This includes how blood vessels supply inflamed tissues with proper substances to help with infection and wound healing; how subsets of white blood cells are selectively attracted to different tissues and organs, depending on the type of inflammation involved; and how medications such as corticosteroids inhibit inflammatory responses when inflammation become excessive or unwanted. Therefore, the study of inflammation spans virtually all specialties and is an active area of research throughout the medical community as well as the pharmaceutical industry. A better understanding of processes involved in inflammation might some day lead to better ways to diagnose and treat a wide variety of illnesses.
It is estimated that 50-70 million Americans suffer from sleep disturbances, with serious health consequences, including cardiovascular and respiratory disease, metabolic abnormalities, and neurologic and psychiatric disorders. For more than 20 years, clinicians and investigators at Johns Hopkins Bayview have been focused on fundamental questions related to the evaluation and management of patients with sleep disorders. A number of seminal findings related to sleep and sleep disturbances have been made by Johns Hopkins investigators.
Sleep medicine continues to grow at Johns Hopkins. The Center for Interdisciplinary Sleep Research and Education, housed on the Johns Hopkins Bayview campus, includes faculty and trainees from Medicine, Neurology, Psychiatry, Pediatrics, Otolaryngology and Anesthesiology. Working closely with the Clinical Research Unit of the Institute for Clinical and Translational Research, this group of investigators is engaged in cutting edge research to elucidate the causes of sleep disturbances, as well as to identify new strategies for diagnosis and therapy. Leveraging new investment in the sleep program by the institution, Johns Hopkins faculty are committed to generating new insights that will translate into better care for patients with sleep disturbances.
Wound and Burn Care
The surgical wound service is an extension of the Johns Hopkins Burn Center and functions in collaboration with the wound center run by Gerald Lazarus, M.D. Patients requiring often complex surgery benefit from a multidisciplinary team that includes specialist nurses, therapists, nutritionists, psychologists and intensivists.
Importance of Wounds in US Population
- Every year, more that $15 billion are spent treating chronic wounds in the USA. The figure grows steadily, rising by 15 percent annually as an aging population develops more chronic disease resulting in an increase in non-healing wounds.
- Non-healing wounds cause patients to lose mobility, which leads to a decline in general health and emotional well being. Patients often become disabled, unable to work, and dependant on care from their families.
- Chronic wounds almost always are associated with underlying diseases. Atherosclerosis, venous disease, orthopedic disabilities, neurological disease and diabetes are very common. More than 86,000 amputations each year are the result of foot ulcers that plague one out every seven people with diabetes.
- A recent article in the New England Journal of Medicine on venous ulcers (J.J. Bergan et al NEJM 2006; 355:488-498) indicated that the cost of venous ulcers in the US was over three billion dollars per year; the quality of life in patients with active lesions was felt to be comparable to individuals with congestive heart failure.
- There are exciting new insights in the patho-physiology of chronic ulcerations of all types. There are many new therapeutic interventions which offer the promise of important breakthroughs in care. Never has this field needed a comprehensive approach to basic and clinical data than now.
Wound Care Program at Johns Hopkins Bayview
- As a major component of one of the nation’s premier academic medical centers, The Johns Hopkins Wound Care Program at the Johns Hopkins Bayview Medical Center is at the cutting edge of modern wound care diagnosis, therapy and research. There are continuous attempts to quantify wound healing using digital photography techniques. For example, in The Wound Center we are conducting several exciting clinical studies including the use of ultrasound to diminish pain in patients with ulcers, thus use of the growth factor Veg F in diabetic ulcers and the use of human Fetal Keratinocytes and Fibroblasts in a Fibrin Gel to increase wound healing rates.
- Coordinated approach. The distinguishing characteristic of the Johns Hopkins Wound Care Program at Johns Hopkins Bayview is the integration of unique components into a functioning dynamic whole.
1. The Wound Center led by Dr. Lazarus is responsible for outpatient care. It is the major intake mechanism for the program and offers a comprehensive holistic approach. All patients are evaluated for underlying diseases employing the extensive diagnostic and therapeutic resources of Johns Hopkins Medicine. The Wound Center not only designs a specific therapeutic regimen but it also focuses on a feasible and effective home care program to insure healing. There is a dedicated staff of 5-full time registered nurse wound care specialists who facilitate a “total approach to healing”. The clinic is truly collegial and there is participation by leaders of the Bayview medical community including The Chief of the Burn Surgery and Director for Surgery in the Wound Center (Dr. Milner), the Chief of Infectious Disease (Dr. Zenilman), and the Chief of Reconstructive Burn Surgery (Dr. Spence), The Wound Reconstruction Inpatient Ward led by Dr. Milner is a dedicated unit for acute surgical interventions for wound patients. The unit abuts the burn unit, guaranteeing the most effective skin care, and draws on the expertise of the internationally recognized Hopkins Burn Program.
2. The Johns Hopkins Bayview Care Center (JHBCC) Program led by Dr. Greenaugh has 220 beds for patients with rehabilitation and long-term care requirements. Pressure sores, vascular ulcers and post-surgical complications characterize the most complicated of these patients. This unique service cares for longer term care of patients with large wounds unsuitable for outpatient management.
- There is free flow of patients between the Wound Center, the Wound Reconstruction Ward in the acute hospital, and the JHBCC. All units are within a 5 minute walk of each other. A patient might be seen in the outpatient Wound Center, admitted for an acute surgical intervention in the Wound Reconstruction Ward and then transferred to JHBCC for long-term care. Patients who require surgical interventions in the long-term care center can be transferred to the acute reconstruction ward in the hospital and any discharged patient may be followed by the Outpatient Wound Center. Minor surgical procedures can be carried out in JHBCC where all complications are followed by an expert wound team headed by a wound care specialist/certified nurse. The uniqueness is that one patient is continually followed by the same group of individuals. For example Dr. Zenilman and infectious disease is involved with the same patient whether he/she has a soft tissue infection, develops osteomyelitis or is stricken with septicemia. We are unaware of any program in the US with this unique system. Geriatrics Program.
- The Johns Hopkins Department of Geriatrics, housed at Johns Hopkins Bayview is consistently rated the #1 Geriatrics Program in the United States. Its signature is the total care of the aging patient. There are robust outpatient programs and model home care systems oriented to maximizing the quality of life for the elderly. The 220 bed John Burton Care Center provides geriatric patients, all levels of patient therapy from domiciliary accommodations to high intensity facilities dealing with ventilator patients and large wounds. There are superb programs for nutrition and psychological support. To reiterate, the focus of the Department of Geriatrics is the “whole patient”.
- There are a number of teaching programs at Johns Hopkins Bayview within the purview of the Wound Care Program.
- There are joint conferences focusing on complex problem patients involving Drs. Lazarus, Milner, Zenilman, residents and fellows.
- Rounds on the Burn Service, Acute Wound Surgery Wards, and JHBCC are conducted weekly and are well attended.
- Drs. Lazarus and Milner have presented joint conferences at a series of dermatological and primary care meetings. The Wound Care Program has been presented at Grand Rounds in Internal Medicine both at Johns Hopkins Bayview and Johns Hopkins Hospital and there will be similar presentations at Grand Rounds in surgery at Bayview and Johns Hopkins Hospital.
- Dr. Greenaugh and the nursing team have presented at the National Meeting of AGS and annually at the National Post-Graduate Conference held by the Division of Geriatric Medicine.
- The wound care team is now developing additional joint didactic conferences that focus on new developments in diagnosis, treatment, pathophysiology and other research topics.
- There is a very robust resident, fellow, medical student and nursing teaching program. Residents in Dermatology, Surgery and Internal Medicine regularly attend the clinic. Fellows in Infectious Disease, Rheumatology and Burns also rotate through the program. Hopkins medical students are electing to spend up to 3 months full-time in the Wound Center because of its educational and research opportunities. The program is universally acclaimed for its teaching excellence and relevance.
Quality of Care, and Translational and Basic Research
Quality of Care
There is increasing research within the Wound Care Program. We are developing a world class clinical research program which utilizes outcomes and cost effectiveness as measures of therapeutic efficacy:
- Prospective studies on wound imaging and testing interventions designed to hasten healing of pressure sores have been done in the JHBCC by Dr. Greenaugh and the Wound Team in collaboration with Dr. Harmon and Dr. Ross Andersen.
- Within the past two years we have installed a quantitative digital photographic system (Wound Matrix) which is state of the art. This system will be further modified to produce wound healing coefficients which can be of great assistance in guiding therapy. There are now multiple clinical studies in process; one measures the use of ultrasound as an agent to decrease pain, a second to evaluate Veg F in Diabetic ulcers and another to use gene therapy with platylettte derived growth factor in diabetes. We are one of only a few centers to be involved in this first of a kind study. Drs. Zenilman and Milner have 2 funded research studies evaluating distinctive antibiotics in the treatment of diabetic foot ulcers and soft tissue infections. Drs Lazarus Zenilman and Milner are finalizing arrangements with the Department of Defense including Walter Reed and the National Naval Medical Center to be one of 2 collaborative centers in the Wounded Warriors Initiative. The first step will be a series of bioload investigations which measure wound contamination using quantitative microbiology and cutting edge molecular methods including Phyla chips which can measure up to 9000 different microorganisms in the same sample
- A high priority is the establishment of an evidence-based health approach to diagnosis and treatment. This demands careful collection of objective high quality data such as standardized history, digital photographic images that are quantifiable, and precise evaluation of the data. Bayview is blessed by having Dr. Linda Fried, Chief of Geriatrics at Hopkins, who is a world class outcomes authority, on campus. This provides an opportunity to mount a unique clinical research enterprise. We recently recruited a Wound Care research Fellow, Dr Yelena Frankel who will focus on some of the clinical research protocols and the development of the Outcomes Initiative. Dr. Frankel has an MD and an MPH from Hopkins and is enthusiastic about outcomes. During Dr. Lazarus’ tenure as Chair of Dermatology at Penn he served as a member of the Skin Care Counsel at Johnson and Johnson for over 10 years. He is very aware of the importance of having a preeminent site to quantitatively evaluate outcomes- from healing rates to quality of life measurements-for the pharmaceutical industry. In today’s cost conscious environment it is critical to have objective pharmaco-economic data to justify the use and reimbursement of new forms of therapy.
- Evaluation of wounds is often subjective. We now have the ability to utilize existing expertise to develop a quantitative approach to defining wounds and their healing.
- Definition of terms
- Uniform parameters and databases to measure clinical healing
- Methods to quantify results
- Methods for power calculations
- Develop governance of studies so participating groups have reproductively between sets
- Assessment of Outcomes in collaboration with Dr. Linda Fried and development of an outcomes group
- Time to healing
- Cost effectiveness
- Quality of life
- Reduction in indirect costs-voluntary care givers
- Utility of various interventions including general care and specific pharmaceutical interventions
- The latter can lead to a program which can successfully compete for research dollars
- Development of unique competence in analyzing wound healing data
- Common publications
- Common educational programs
- Possibility of a funded “institute” which provides international leadership
Translational and Basic Research
- Johns Hopkins is amongst the leading Research Universities in the world. Hopkins is number 1 in research grants from the NIH and leads all Medical Schools in the US in NIH total research support.
- There is an excellent infrastructure in research funding. Indeed Hopkins is a leader in bioethics and the development of contractual arrangements in research funded by corporate sponsors.
- There are flourishing laboratory programs in wound healing at Johns Hopkins Bayview in Dr. Milner’s and Dr. Harmon’s laboratories. Dr. John Harmon is a well known surgical researcher who has focused on growth factors in wound healing and is now interested in the development of stem cell therapy for burn and chronic wounds. His most recent focus has been on endothelial cell precursors as therapeutic agents. He also has an NIH-funded research program to add growth factors using bacterial vectors directly to the wound base.
- Dr. Jonathan Zenilman recently submitted a very exciting NIH proposal dealing with early diagnosis of infectious agents in patients with burns, using cutting edge molecular biological techniques. Drs. Lazarus and Zenilman anticipate extending this research to the study of wound infections and employing these methods to determine the boil-burden of microorganisms in the healing process.
- Dr. Dana Andersen was recently recruited as the Chairman of the Department of Surgery at Johns Hopkins Bayview. He is an internationally-known clinician and peer review-funded investigator. His laboratory has focused on glucose and energy metabolism in surgical patients and especially on wound repair and remodeling. He has established a “metabolic balance” laboratory located adjacent to Dr. Milner’s acute Wound Intervention Ward. In preliminary conversations he has indicated great interest in collaborating with our Wound Healing Network.
- The Division of Endocrinology at Johns Hopkins Bayview is very involved with diabetes care and research. Over the past 2 years this group has been very helpful in the management of our patients and is very receptive to research collaborations.
- Dr. Pierre Coulombe is a world class leader in epithelial biology whose recent studies of specific keratin proteins (K6, K16, K17) have provided novel insights into the activation of keratinocytes towards wound re-epithelialization. His work points to three distinct contributions of these keratins to wound repair: modulation of cellular viscoelastic properties (J Cell Biol 2003), cell survival (Gens & Dev 2006), and regulation of protein synthesis and cell growth (Nature 2006). He suggests that careful study of the regulation and function of these and related proteins may offer unique opportunities to predict outcomes, and manipulate the regenerative response. Dr. Coulombe has agreed to spearhead the basic science initiatives. There are other world class researchers at the School of Medicine who have collaborative strengths who can be attracted to joint programs involved with fundamental wound healing research. These will be detailed in another document.
Education and Communication
The treatment of patients with chronic skin ulcers requires a team approach. To be successful there must be knowledgeable collaboration between wound care specialists (both physicians and nurses), geriatricians, surgeons, and primary care physicians. As important, there must be a partnership between the patient and their families with the medical team and outpatient support agencies. Clear communication and an understanding of fundamentals of care is essential between all individuals. The most expert wound care team will fail if communication is faulty with the patient and their families. There is a program anticipated including nursing and physicians to quantify the effectiveness of communication in the care of our patients.