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Andersen D.K.,Johns Hopkins Bayview Medical Center | Frey C.F.,University of California at Davis
Annals of Surgery | Year: 2010

OBJECTIVE: To establish the current status of surgical therapy for chronic pancreatitis, recent published reports are examined in the context of the historical advances in the field. BACKGROUND: The basis for decompression (drainage), denervation, and resection strategies for the treatment of pain caused by chronic pancreatitis is reviewed. These divergent approaches have finally coalesced as the head of the pancreas has become apparent as the nidus of chronic inflammation. METHODS: The recent developments in surgical methods to treat the complications of chronic pancreatitis and the results of recent prospective randomized trials of operative approaches were reviewed to establish the current best practices. RESULTS: Local resection of the pancreatic head, with or without duct drainage, and duodenum-preserving pancreatic head resection offer outcomes as effective as pancreaticoduodenectomy, with lowered morbidity and mortality. Local resection or excavation of the pancreatic head offers the advantage of lowest cost and morbidity and early prevention of postoperative diabetes. The late incidences of recurrent pain, diabetes, and exocrine insufficiency are equivalent for all 3 surgical approaches. CONCLUSIONS: Local resection of the pancreatic head appears to offer best outcomes and lowest risk for the management of the pain of chronic pancreatitis. Copyright © 2009 by Lippincott Williams & Wilkins.

Scheel Jr. P.J.,Johns Hopkins University | Feeley N.,Johns Hopkins University | Sozio S.M.,Johns Hopkins Bayview Medical Center
Annals of Internal Medicine | Year: 2011

Background: Small case series suggest that a combination of my-cophenolate mofetil and prednisone may be an effective treatment for patients with retroperitoneal fibrosis. Objective: To describe the outcomes of adults with retroperitoneal fibrosis who received a combination of prednisone and mycophe-nolate mofetil. Design: Prospective case series of patients followed between 1 April 2005 and 1 July 2009. Setting: Single tertiary care facility. Patients: 28 patients with retroperitoneal fibrosis. Intervention: Prednisone, 40 mg/d, tapered over 6 months, and mycophenolate mofetil, 1000 mg twice daily, for a mean of 24.3 months. Measurements: Clinical course, laboratory assessment, and measurement of periaortic mass. Mean follow-up was 1012 days, and no patients were lost to follow-up. Results: Systemic symptoms resolved in all patients; 89% had a 25% or greater reduction in periaortic mass. Elevated erythrocyte sedimentation rate and serum creatinine level and decreased hemoglobin level normalized in all patients. Disease recurred in 2 of 28 patients. Limitation: This was a small case series. Conclusion: Combined prednisone and mycophenolate mofetil therapy is a potentially effective treatment for retroperitoneal fibro-sis that warrants evaluation in randomized trials. Primary Funding Source: None. © 2011 American College of Physicians.

Gitlin L.N.,Johns Hopkins University | Kales H.C.,University of Michigan | Kales H.C.,Center for Clinical Management Research | Lyketsos C.G.,Johns Hopkins Bayview Medical Center
JAMA - Journal of the American Medical Association | Year: 2012

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behavior scan accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, andresult in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case,we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction. ©2012 American Medical Association. All rights reserved.

Earley C.J.,Johns Hopkins Bayview Medical Center
The Journal of clinical psychiatry | Year: 2014

Restless legs syndrome (RLS) is a common disorder that can have a considerable impact on a patient's functioning and quality of life. The pharmacologic armamentarium for RLS contains dopamine agonists, a-2d ligands, and opioids, among other agents. Each of these types of drugs has strengths and limitations, and treatment selection should be based on the frequency of RLS symptoms and any accompanying pain. Dopaminergic augmentation, which exacerbates RLS symptoms, is the most common and challenging side effect of long-term RLS treatment with dopamine agonists and requires special clinical consideration. Iron status is also important to the effective management of RLS.

Szymanski L.M.,Johns Hopkins Bayview Medical Center | Satin A.J.,Johns Hopkins Bayview Medical Center
Obstetrics and Gynecology | Year: 2012

OBJECTIVE: To evaluate acute fetal responses to individually prescribed exercise according to existing guidelines (U.S. Department of Health and Human Services) in active and inactive pregnant women. METHODS: Forty-five healthy pregnant women (15 nonexercisers, 15 regularly active, 15 highly active) were tested between 28 0/7 and 32 6/7 weeks of gestation. After a treadmill test to volitional fatigue, target heart rates were calculated for two subsequent 30-minute treadmill sessions: 1) moderate intensity (40-59% heart rate reserve); and 2) vigorous intensity (60-84%). All women performed the moderate test; only active women performed the vigorous test. Fetal well-being measures included umbilical artery Dopplers, fetal heart tracing and rate, and biophysical profile. Measures were obtained at rest and immediately postexercise. RESULTS: Groups were similar in age, body mass index, and gestational age. Maternal resting heart rate in the highly active group (61.6±7.2 beats per minute [bpm]) was significantly lower than the nonexercise (79.0±11.6 bpm) and regularly active (71.9±7.4 bpm) groups (P<.001). Treadmill time was longer in highly active (22.3±2.9 minutes) than regularly active (16.6±3.4) and nonexercise (12.1±3.6) groups (P<.001), reflecting higher fitness. With moderate exercise, all umbilical artery Doppler indices were similar pre-exercise and postexercise among groups. With vigorous exercise, Dopplers were similar in regularly and highly active women with statistically significant decreases postexercise (P<.05). The groupxtime interaction was not significant. Postexercise fetal heart tracings met criteria for reactivity within 20 minutes after all tests. Biophysical profile scores were reassuring. CONCLUSION: This study supports existing guidelines indicating pregnant women may begin or maintain an exercise program at moderate (inactive) or vigorous (active) intensities. © 2012 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.

Neubauer D.N.,Johns Hopkins Bayview Medical Center
International Review of Psychiatry | Year: 2014

Advances in understanding the neurochemistry of sleep and waking have stimulated new pharmacological directions in the treatment of insomnia. While the sedation of historic insomnia medications was discovered serendipitously, now compounds can be developed for specific molecular targets with known sleep-related actions. Numerous investigational compounds, including some entirely novel approaches, are being evaluated currently as possible insomnia treatments. In recent years the US Federal Drug Administration (FDA) has approved medications with new pharmacodynamic and pharmacokinetic properties thereby extending the options for personalized pharmacotherapy. The FDA is reviewing new applications for innovative sleep-promoting medications currently, including suvorexant and tasimelteon. Presently the FDA-approved insomnia treatment medications include benzodiazepine receptor agonists available in immediate-release, extended-release, and alternative delivery oral absorption formulations; a melatonin receptor agonist; and a histamine receptor antagonist. Clinical indications include insomnia associated with difficulty with sleep onset, sleep maintenance, and middle-of-the-night awakenings. Alternative approaches to treating insomnia have included prescription medications employed on an off-label basis for insomnia, over-the-counter sleep aids, and assorted unregulated substances marketed to enhance sleep. © 2014 Institute of Psychiatry.

Mammen A.L.,Johns Hopkins Bayview Medical Center
Nature Reviews Neurology | Year: 2011

The different autoimmune myopathiesg-for example, dermatomyositis, polymyositis, and immune-mediated necrotizing myopathies (IMNM)g-have unique muscle biopsy findings, but they also share specific clinical features, such as proximal muscle weakness and elevated serum levels of muscle enzymes. Furthermore, around 60% of patients with autoimmune myopathy have been shown to have a myositis-specific autoantibody, each of which is associated with a distinct clinical phenotype. The typical clinical presentations of the autoimmune myopathies are reviewed here, and the different myositis-specific autoantibodies, including the anti-synthetase antibodies, dermatomyositis- associated antibodies, and IMNM-associated antibodies, are discussed in detail. This Review also focuses on a newly recognized form of IMNM that is associated with statin use and the production of autoantibodies that recognize 3-hydroxy-3-methylglutaryl-coenzyme A reductase, the pharmacological target of statins. The contribution of interferon signaling to the development of dermatomyositis and the potential link between malignancies and the initiation of autoimmune myopathies are also assessed. © 2011 Macmillan Publishers Limited. All rights reserved.

Christopher-Stine L.,Johns Hopkins Bayview Medical Center
Current Opinion in Rheumatology | Year: 2010

Purpose of Review: Inflammatory myopathy (IIM) classification criteria have been the source of considerable debate. In the three decades since Bohan and Peter published their criteria which have long stood as the gold standard for diagnosis in clinical practice as well as inclusion into clinical trials, more sophisticated understanding of immunopathogenesis, histology, and specific autoantibody associations has broadened our understanding of these diseases. This editorial review examines the diverse approaches between different subspecialists in deriving appropriate IIM classification utilizing this updated knowledge. Recent Findings: Several investigators have proposed improved IIM classification criteria. More recently, larger scale consensus efforts have been undertaken by various expert groups including the European Neuromuscular Centre (ENMC) and The International Myositis Assessment and Clinical Studies Group (IMACS). The intent is to refine the classification criteria utilizing our enhanced understanding which has matured since the original publication of Bohan and Peter's proposal in 1975. Summary: Many diagnostic/classification criteria have been proposed for different forms of IIM over the last three decades. The majority of these have been based on clinical impressions rather than rigorous data analyses or expert consensus and none has been fully tested for sensitivity or specificity using appropriately powered studies that take into account relevant disease confounders. Different sets of criteria proposed and adopted by different specialties hamper the ability to compare clinical studies and assess clinical trials' outcomes. Large, multicentered, multispecialty studies are required to develop improved IIM criteria. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Moseley K.F.,Johns Hopkins Bayview Medical Center
Current Opinion in Endocrinology, Diabetes and Obesity | Year: 2012

PURPOSE OF REVIEW: To discuss current literature and hypotheses pertaining to the pathophysiology of increased bone fragility and fracture in men and women with type 2 diabetes mellitus. RECENT FINDINGS: Despite high bone mineral density, studies have shown that men and women with type 2 diabetes mellitus (T2DM) are at increased risk for fracture. Complications of T2DM including retinopathy and autonomic dysfunction may contribute to bone fracture by increasing fall risk. Nephropathy may lead to renal osteodystrophy. Lean mass and potentially fat mass, may additionally contribute to skeletal health in diabetes. There is increasing acknowledgement that the marrow microenvironment is critical to efficient bone remodeling. Medications including thiazolidinediones and selective serotonin reuptake inhibitors may also impair bone remodeling by acting on mesenchymal stem cell differentiation and osteoblastogenesis. T2DM is associated with significant alterations in systemic inflammation, advanced glycation end-product accumulation and reactive oxygen species generation. These systemic changes may also directly and adversely impact the remodeling cycle and lead to bone fragility in T2DM, though more research is needed. SUMMARY: Fracture is a devastating event with dismal health consequences. Identifying the extrinsic and intrinsic biochemical causes of bone fracture in T2DM will speed the discovery of effective strategies for fracture prevention and treatment in this at-risk population. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Sacktor N.,Johns Hopkins Bayview Medical Center | Robertson K.,University of North Carolina at Chapel Hill
Current Opinion in HIV and AIDS | Year: 2014

Purpose of review To describe the changes in the presentation of HIV-associated neurocognitive disorders (HAND) comparing the current combination antiretroviral therapy (cART) treatment era to the pre-cART era. Recent findings The frequency of the most severe stage of HAND, HIV-associated dementia (HAD), has decreased, but the frequencies of milder stages of HAND, asymptomatic neurocognitive impairment (ANI) and mild neurocognitive disorder, have increased. In the pre-cART era, HAD was a progressive disorder leading to death within months. With cART, HIV+ individuals with HAND frequently remain stable over many years, though they may still show signs of the ongoing central nervous system (CNS) injury. On neuropsychological testing, there may be a shift from the prominent slowed motor and speed of processing deficits in the pre-cART era to a greater impact on learning, memory, and executive functioning deficits in the cART era. Importantly, ANI has recently been shown to lead to a two-fold to five-fold increased progression to symptomatic HAND. Thus, early recognition and treatment of those with ANI is important to protect the CNS over the long term. Summary HAND continues to be an important neurological manifestation in both HIV+ individuals naïve to cART and on cART. Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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