News Article | May 8, 2017
In an analysis of medical records gathered from more than 300 hospitalized patients, a team of researchers reports that routine imaging scans used to help diagnose heart attacks generated "incidental findings" (IFs) in more than half of these patients. The investigators say only about 7 percent of these IFs were medically significant and urged imaging experts and hospitals to explore ways to safely reduce the added costly -- and potentially risky -- days in the hospital the IFs generate. "Incidental findings present clinical and financial challenges," says Venkat Gundareddy, M.D., M.P.H., a director of the Collaborative Inpatient Medicine Service at Johns Hopkins Bayview Medical Center in Baltimore. "In our new study, we saw an association between the presence of incidental findings and longer length of stay in the hospital, in some cases because of further tests to explore those findings." "Because this was an observational study, we can't conclusively attribute the added hospital days to one case, but we believe we have added to evidence that IFs are a factor," he adds. It's long been the case, Gundareddy notes, that people experiencing chest pain are usually admitted to a hospital and undergo CT or other forms of imaging. In their review, they discovered that findings unrelated to chest pain kept patients in the hospital an average of 26 percent longer than people without IFs. Results of the retrospective study appear in the May issue of the Journal of Hospital Medicine. The higher sensitivity and accuracy of X-rays, MRIs, ultrasound examinations, and especially CT scans, has led to more incidental findings such as kidney cysts, renal stones, thyroid nodules, enlarged lymph nodes, bone lesions, lung nodules and masses. Unexpected incidental findings are very common in patients hospitalized with chest paint thought to be cardiac related, the investigators say. Chest CT scans done to image the heart can end up showing lung or thyroid nodules or enlarged lymph nodes. Chest X-rays often show more than heart size, when bone lesions and arthritic changes are noted. The new study analyzed the medical records of 376 patients admitted to Johns Hopkins Bayview Medical Center, an urban academic medical center, over a two-year timeframe. Some 197 of them had unexpected incidental findings in diagnostic images, findings that were not related to their chest pain complaints. Fifty percent of the unexpected findings were deemed medically minor, 42 percent moderate and seven percent of major clinical significance. The unexpected findings are associated with a 26 percent increase in length of hospital stay. When unexpected findings such as nodules or bone lesions are discovered after diagnostic imaging, further tests are generally ordered. If the finding was of major clinical significance, often that workup takes place during the same hospitalization, increasing the length of stay, adding to provider workload, and increasing expenses for testing, imaging, surveillance, consults and labor. Clearly, the researchers say, such additional time and costs are needed for some patients, but nationwide efforts to reduce unnecessary costs could benefit from closer study of and attention to the best setting for dealing with incidental findings. "Choosing wisely what tests are needed for each patient, based on presenting complaints and pertinent history, would prevent unnecessary use of imaging and detection of incidental findings," notes Gundareddy. "Establishing a robust outpatient care pathway to further workup incidental findings, as needed, would also decrease inpatient length of stay," he adds. Gundareddy says radiologists' groups and associations already have some guidance related to follow up for certain incidental findings, such as the American College of Radiology's guidance on managing incidental findings from abdominal CT scans. However, no clear follow up guidelines exist for most incidental findings appearing in hospitalized patients. "It's important for patients and providers to understand that as imaging gets more sensitive, it will pick up more things that are unrelated to the main problem for which imaging is done," Gundareddy says. "These findings might or might not be clinically significant, and although they may need attention, they don't necessarily need inpatient hospital attention." Other authors on this paper include Nisa M. Maruthur, M.D., M.H.S. (co-first author), Abednego Chibungu, M.D., Regina Landis, M.S., and Shaker M. Eid, M.D., M.B.A., of The Johns Hopkins University; and Preetam Bollampally, M.D., of Saint Vincent Hospital.
News Article | April 22, 2017
Peter Uribe left Chile at 21 with his wife and 2-year-old daughter, landing in Baltimore and finding steady work in construction. His social life revolved around futbol, playing "six or seven nights a week in soccer tournaments," he says. A couple of years after his arrival, he broke his foot during a game and afraid of the cost, didn't seek medical care. "Some of my family warned me that if I went to the hospital and couldn't pay the bill, I'd get a bad credit record," says Uribe, 41, who made about $300 a week and had no health insurance. "I wanted to buy a car or a house someday." Instead, he hobbled through workdays and stayed off the field for three years; the residual pain is sometimes disabling, even two decades later. For reasons both economic and cultural, Hispanic men are loath to interact with the health system. Women across all races are more likely to seek care than men. But the gender gap in the Hispanic community is especially troubling to health care providers. Studies show that Latino men are much less likely than Latinas to get treatment. That is true even though Hispanic men are more likely than non-Hispanic whites to be obese, have diabetes or have high blood pressure. Those who drink tend to do so heavily, contributing to the group's higher rates of alcoholic cirrhosis and deaths from chronic liver disease. Many take risky jobs such as construction workers and laborers, and are more likely to die from on-the-job injuries than other workers, government data show. Hispanics' share of the population is expected to widen from nearly a fifth now to a quarter by 2045. As that number grows, researchers worry that the nation could face costly consequences as long-ignored conditions lead to serious illness and disability. "It could literally break the health care system," says José Arévalo, board chairman of Latino Physicians of California, which represents Hispanic doctors and others who treat Latinos. And now, some medical professionals fear the effects of President Donald Trump's crackdown on illegal immigrants. "When the community faces this kind of stress, I worry that people will do unhealthy things, like abuse alcohol, to deal with it," says Kathleen Page, co-director of Centro SOL, a health center at Johns Hopkins Bayview Medical Center, and founder of the city's Latino HIV Outreach Program. "That means they may not work as much," she adds. "They'll have less money, which means they're less likely to seek care." Welcomed by Baltimore officials, immigrants have driven the city's Hispanic population, tripling it to 30,000 since 2000. Here, as elsewhere, evidence suggests that for many Hispanic men, seeking health care is an extraordinary event. Hospital data show they are more likely than Hispanic women, white women and white men to go to the emergency room as their primary source of treatment – a sign that they wait until they've no choice but to get help. Some care providers say medical institutions haven't done enough to keep Hispanic men healthy, or to persuade them to get regular exams. "There's been an ongoing need for institutions to become more culturally attuned and aware of bias," says Elena Rios, president of the National Hispanic Medical Association, which represents the nation's 50,000 Latino physicians. There are some significant differences in health risk and illness rates among Hispanic subgroups – Puerto Ricans are more likely to be smokers, for example. Compared with Hispanics born in the U.S., those born elsewhere have much lower rates of cancer, heart disease and high blood pressure. Overall, Hispanics live longer than whites. But these advantages may be dissipating as Latinos become Americanized and adopt unhealthy habits such as smoking and diets high in fatty, processed foods. "I tell people we live longer and suffer," says Jane Delgado, a clinical psychologist and Cuban-American who serves as president of the National Alliance for Hispanic Health. Researchers who investigate gaps in cancer testing have found that all ethnic groups and genders have seen a decrease in late-stage colon cancer diagnoses and deaths in recent years — except Hispanic men, who get screened at the lowest rates of any race or ethnic group. Often, health problems arise after immigrants come up against an insurance barrier. A few years after Jose Cedillo came to Baltimore from Honduras, the 41-year-old cook noticed his legs were often numb or painful. Worried about finances, he eschewed treatment and continued to work, before finally going to a clinic where he was diagnosed with diabetes. In the seven years since, his health has so deteriorated he can't work, is frequently homeless and spends long stints in the hospital. As an immigrant who came to the U.S. illegally, he is not eligible for government-paid insurance or disability payments. And he can't afford medicine. Instead, he says, "I'll drink alcohol to numb the pain." Part of the problem is that Spanish speakers are underrepresented among medical professionals. After arriving here, Uribe's family members frequently brought along an English-speaking nephew or niece when they could afford to see doctors. Otherwise, "we'd travel a long ways to find a doctor who spoke Spanish," he says. Hospitals frequently lack cultural understanding and bilingual staffing, administrators admit. Though Latinos make up nearly 20 percent of the population, only 5 percent of physicians and 7 percent of registered nurses are Hispanic. That gap has widened as more Hispanics have come to this country during the past three decades, according to a UCLA study released in 2015. "Too often, people don't understand what you're saying, they don't know what you're going to charge them, what dietary restrictions you might place upon them," says James Page, vice president for diversity at Johns Hopkins Medicine. "It creates a trust issue for Hispanics. We've got to get better at serving them." That is particularly true in mental health. Only 1 percent of psychologists in the U.S. are Hispanic, meaning that Spanish-speaking men who do seek therapy will probably struggle to find it. In Baltimore, there is only one Spanish-language support group for men who suffer from anxiety and depression, local psychologists and Latino advocates say. The city employs one Spanish-speaking substance abuse counselor. A small handful of bilingual social workers citywide offer reduced-rate counseling sessions, and only three psychiatrists offer therapy sessions conducted in Spanish. For Peter Uribe, the key to maintaining his family's health is getting help paying for care. His wife and brother both suffer from epileptic seizures, and his brother's despondency caused Uribe to become depressed, he says. In 2015, he obtained insurance for his family through a charity program. With the help of now-affordable medicines, his wife's seizures waned, and he sought help for chronic depression. Since he now speaks English, finding counseling help is easier. In January, after intervention from a Latino advocacy group, the charity renewed the Uribes' policy for two years. Peter Uribe calls it a godsend: "I honestly have no idea what we'd do without it." Michael Anft is a Baltimore-based journalist and writer whose work regularly appears in AARP: The Magazine, The Chronicle of Higher Education and other publications. Daniel Trielli, a data journalist at Capital News Service at the Philip Merrill College of Journalism, contributed to this report. Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. The Annie E. Casey Foundation supports KHN's coverage of health disparities in East Baltimore.
News Article | May 2, 2017
The International Nurses Association is pleased to welcome Laila Shrestha, RN to their prestigious organization with her upcoming publication in the Worldwide Leaders in Healthcare. Laila is a Registered Nurse with over a year of experience in her field and an extensive expertise in all facets of nursing. She is currently serving patients within Johns Hopkins Bayview Medical Center in Baltimore, Maryland. Laila’s career in nursing began in 2015 when she graduated with her Nursing Degree from Baltimore City Community College. Additionally, she holds a previous Bachelor’s Degree from Saginaw Valley State University, a degree she gained in 2008. She attributes her success to being able to take part in helping patients overcome their problems. Seeing her patients health improve is a source of inspiration for her every day. When she is not assisting her patients, Laila enjoys cooking, dancing, and traveling. Learn more about Laila here: http://inanurse.org/network/index.php?do=/4136464/info/ and be sure to read her upcoming publication in the Worldwide Leaders in Healthcare.
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.
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.