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Still Fabulous at Fifty

In its 15th edition, “The Lane” is a medical must.

The Harriet Lane Handbook turns 50 this year. It’s come a long way, baby. The stack of mimeographed basic clinical information that senior pediatrics residents first put to-gether for fellow house officers back in 1950 has turned into one of the most well-respected and oft-read texts in medicine. Recently released in its 15th edition, the handbook, published by Mosby and Harcourt Health Sciences, now sells more than 100,000 copies per edition and is used by virtually every pediatrician in the nation for fast, accurate bedside consultation.

Some things, however, have remained constant. The volume continues to be put together by Hopkins senior residents. It’s still chockablock with up-to-date diagnostic guidelines, recommended tests and therapeutic information. And although at 1,000-plus pages it’s fatter than ever, it still fits ( just barely) into a lab coat pocket.

What’s new? Chapters on surgery, psychiatry, oncology and biostatistics. And the ever-important listing of drugs, called the formulary—now with red edged pages for quick reference and easy-to-understand icons—for the first time was created from a continually updated computer database. There’s also more information on the management of clinical scenarios.

“We’ve built in a lot more specifics for individual cases,” says co-editor George K. Siberry, who along with Robert Iannone, last year’s other chief pediatrics resident, edited the most recent edition. Even though each chapter has a faculty advisor, the residents enjoy a measure of freedom in shaping the volume. “The faculty feels they can give us some latitude,” says Iannone, “but they’re careful about controversies, and they make sure everything’s accurate—particularly with the formulary.”

Siberry and Iannone worked flat out for two years supervising contributors. And even though The Lane, as it’s known at Hopkins, comes out every three years and has just been released, house staff are already at work on the 16th edition.

As ever, the current editors-in-chief have put their personal stamp on their oeuvre. They’ve kept alive a few running jokes. “Porcelain,” for example, continues as a heading under body fluids, and blended into the index are the names of Siberry’s and Iannone’s wives and children with their birth dates.

To honor the publication’s 50th anniversary, the editors enlisted two venerable emeritus professors, Barton Childs and Henry Seidel, to write, respectively, a brief biography of Harriet Lane and a history of the handbook. “I’m tickled pink that it’s going the way it is,” says founding editor Seidel from the distance of a half-century. “None of us ever dreamed this would happen.”

-- ABS

Vive La Difference

When a group of leading Baltimore architects got together recently to discuss the designs of Hopkins’ two new medical campus buildings, they wondered why the structures were so dissimilar stylistically. Judging from remarks by the buildings’ architects, the different looks represent the old “form follows function” adage. The light-filled Weinberg building, where most people being treated for cancer now will receive treatment, is designed to blend with the original Victorian-era buildings on Broadway and to convey a sense of comfort to patients, said Odell Associates’ Paul Watson. The Bunting-Blaustein Building, dedicated Dec. 6, meanwhile, will act as home to much of the cancer research now taking place on campus. With its straightforward, minimalist exterior and five levels of labs layered with state-of-the-art “interstitial” mechanical spaces, said James Draheim of HDR Architecture Inc., it suggests the “leading-edge look” University researchers expect.

Weinberg building


Friendly Weinberg (top) and high-tech Bunting-Blaustein (above).

-- ABS

Cathy D. Heads for JAMA

When longtime editor George Lundberg left JAMA, the Journal of the American Medical Association, after a dustup over an article he’d published during the Clinton/Lewinsky scandal, readers demanded a replacement hardy enough to wrest editorial freedom and resolute enough to maintain it. That person turned out to be the School of Medicine’s Vice Dean for Faculty and Academic Affairs, Catherine DeAngelis. The choice, many say, was inspired. “She is brutally honest,” pediatrics chief George Dover told The Baltimore Sun. “She will not bend just to please people.”

Cathy DeAngelis, M.D.

Outspoken, determined and staunchly principled, DeAngelis never has been one to shy away from controversy. Recently, for instance, as editor of the AMA’s Archives of Pediatrics & Adolescent Medicine, she published an article that provided evidence against parents sleeping in the same bed with their babies. At JAMA, she’ll be on the lookout for articles on women’s and children’s health, on the impact of violence and on the molecular aspects of medicine. But she will not, she has said, publish an article just because it might be sensational. For all editorial matters, she now is responsible to a seven-member oversight committee—a newly constructed buffer between the editorial process and AMA officials.

Though DeAngelis is gone, she will not soon be forgotten. She leaves a revamped curriculum that helps medical students learn skills for modern-day practice; a 1999 book, Johns Hopkins Curriculum for Medical Education in the 21st Century, that is serving as a model for medical schools nationwide; and a vastly expanded continuing medical education program, including an award-winning master’s degree program in the business of medicine.

But it is as a champion of women in academic medicine that DeAngelis is perhaps best known. Starting in 1991, she issued the School of Medicine’s annual Report on the Status of Women, in which she kept a watchful eye on gender inequities in salary and promotions. It has led to reforms here and elsewhere. Not much escaped her attention. In 1994, for example, she happened to notice that only one of the 76 professors who’d given Dean’s Lectures since 1973 was a woman. A talk with the dean changed that.

DeAngelis, who comes from blue-collar beginnings in rural Pennsylvania, began as a nurse, then earned de-grees in public health and medicine. At Johns Hopkins, she started on the pediatrics faculty and rose through the ranks to a position from which she oversaw an empire. She was the longest serving senior member of the dean’s office, with a job so big it’s likely to be filled by two people. She took over at Chicago-based JAMA on Jan.1, the first woman to edit the journal in its 116-year history.

Have a Kidney

Surgeons have gotten so good over the last quarter century at stitching a healthy kidney from one person into someone else’s body that some 4,000 Americans each year now donate one of their pair of organs to save the life of a relative or friend. Still, until last September, when Joyce Roush arrived at Hopkins no one had ever given a kidney to a person they’d never met.

Roush, however, had toyed with the idea for months. As an inveterate “do-gooder,” the former hospice nurse and current Indiana organ donation coordinator was drawn to the notion of contributing a kidney to someone—anyone—who needed it. All that was holding her back was the thought of the painful invasive surgery.

Ratner with patient Roush

Surgeon Ratner and patient Roush after her history-making donation.

Then Roush attended a conference in connection with her job and heard Hopkins transplant surgeon Lloyd Ratner describe a new procedure for taking out a kidney that he had pioneered with Hopkins’ Louis Kavoussi. The surgery requires just four small incisions in the abdomen. Patients recover in a matter of days.

That settled it for Roush, a 45-year-old mother of two and stepmother of three. On Sept. 7, Ratner removed her healthy kidney and transplanted it into a desperately ill 13-year-old boy from Aberdeen, Md., whose own kidneys had suddenly shut down.

Roush’s selfless act drew the attention of newspapers and TV stations from coast to coast. After her operation her upbeat surgeon, Ratner, emerged from the OR and announced to waiting report-ers, “It was a beautiful kidney. When you get a transplanted organ, it’s like getting a used car. This one had low mileage. It was well-maintained.”

-- ABS

Out of the Closet

Like a new age composition in the middle of a Mozart concert, complementary (alternative) medicine has been something that most Hopkins types didn’t feel belonged in the program. At a special meeting last fall, though, complementary medicine—the use of herbal compounds, dietary supplements and psychological interventions to ward off disease—became the program.

Catherine DeAngelis, then vice dean for faculty and academic affairs, arranged the gathering so faculty and staff with interests in the burgeoning but still-controversial field could meet. DeAngelis had heard rumblings that some faculty members were changing their tune about alternative medicine. To her amazement, some 130 faculty from the Schools of Medicine, Nursing and Public Health reported they were embarked on studies of alternative therapies.

A dermatologist was looking into why some of his patients responded well to hypnosis; a nutritionist was evaluating soy in preventing hot flashes; an ophthalmologist was studying antioxidants’ effect on macular degeneration. And on, and on.

Complementary medicine, it seems, has been simmering beneath the surface here for awhile, but spottily. The Physicians and Society course offers an introductory lecture on the subject for first-years, there’s an elective for medical and graduate students, and a popular annual CME seminar. But the number of research projects under way suggests more faculty involvement than anyone had imagined.

illustration“I think it’s time we do something serious,” DeAngelis said, like creating a center to assist in scientifically sound studies of alternative medicine. With DeAngelis headed for the editorship of JAMA, however, the fate of such a center remains uncertain. But faculty members like alternative medicine champion Gail Geller, a bioethicist and social scientist, are optimistic. She foresees a mounting interest in the field, especially as it relates to palliative care and women’s health. “The first step was coming out of the closet,” Geller says.

-- ABS

Studying Gravity on the Vomit Comet

The idea of doing research while floating in midair or spinning upside down might throw some scientists for a loop. But for biomedical engineer Mark Shelhamer, those are perfect conditions for the work he’s doing in NASA’s reduced-gravity test aircraft, a.k.a. the “vomit comet.”

Shelhamer is trying to figure out how changes in gravity during space travel affect balance and spatial orientation. A faculty member in the departments of otolaryngology and biomedical engineering, he studies neurovestibular adaptation, or the ways in which the brain interprets information it receives from the sensory systems in the inner ear and eyes. Because the vestibular system has been programmed to process information in the context of Earth’s gravity, astronauts typically have problems on space missions. Take away gravity’s downward pull, and they can become disoriented and nauseous for several days. Reintroduce it, and simple tasks like standing upright, walking and turning corners become a supreme challenge and a significant safety concern.

Shellhammer upside down
Mark Shelhamer (upside down) with fellow researchers

Shelhamer and staff engineer Dale Roberts sought to address these problems by weathering the ups and downs of parabolic—roller-coasterlike—flight on a military version of a Boeing 707 jet. This plane and its successors have been in service since the 1950s when they were used to train the Mercury Seven astronauts. One like it served as the setting for scenes in Apollo 13. Based at Ellington Field near the Johnson Space Center in Houston, the plane flies up and down from about 24,000 to 35,000 feet, making 40 one-minute parabolic arcs per flight. It’s a stomach-in-the-throat ride that provides a half-minute of weightlessness at the top of the arc and a dose of double-strength gravity at the bottom.

“Everything that flies in space—from astronauts to showers and toilets—has been tested on the plane to make sure it will work in weightlessness,” Shelhamer explains. He, for instance, recently made eight flights over a two-week period to study eye movements as a model of sensory-motor adaptation. “We want to determine if it’s possible to adapt so that we have appropriate reflexes and responses when there is gravity, and when there is no gravity, and if we can make immediate switches between the two.”

This was the third time Shelhamer conducted neurovestibular research aboard NASA’s weightless wonder. As ever, he was nauseous on the first and second days. “About half of all first-time fliers get sick at least once,” he says. “You get two plastic bags to put in your breast pocket. If you use them, you tie them up and take them with you.” Of course, missing the barf bag at zero-G poses its own particular set of problems. But, says Shelhamer, you’re pretty much on your own. “The flight crew is not there to wait on you. They don’t want to clean up after you.”

Shelhamer’s work is being funded by the National Space Biomedical Research Institute (NSBRI), a consortium of academic institutions, including Hopkins, that is working with NASA to study health and safety for astronauts with the hope of making a mission to Mars. Researchers from here are participating in nearly all of NSBRI’s eight research areas, which range from radiation effects to bone loss and cardiovascular alterations brought on by zero gravity. If Shelhamer and his team succeed in developing ways to adjust to gravity changes, their work will have implications not just for astronauts but also for the millions of people who have common neurovestibular disorders—including that enduring bête noire: motion sickness.

-- ABS

Up Close and Personal at the Medical Center

Six weekly ABC installments will give viewers the whole picture.

y December, just about everyone had gotten used to seeing the two-person crews traveling the medical campus, toting unobtrusive digital cameras in patients’ rooms, doctors’ offices, the ED, the OR, in lecture halls and labs, even in the tunnels under the Hospital filming the linen workers. When they returned to New York at the end of their three full months, they’d shot a total of 1,300 40-minute tapes.

The cameramen were part of a team of producers, reporters and videographers covering life inside an academic medical center for a forthcoming six-part ABC News documentary based solely at Hopkins. The series will focus on real-life stories, illuminating not just clinical care but also the less-understood missions of research and teaching.

ABC crew filming
On location in the OR with ABC.

ABC said it chose Johns Hopkins from a field of eight institutions not just because of its top ranking among America’s hospitals, but also because of its involvement in urban health and the surrounding community. Key, too, was the fact that Hopkins was willing to give the network unprecedented access.

As part of an arrangement hammered out by legal advisers from both parties, production crews had to obtain written consent from patients and visitors who appear in discernible focus, but not from faculty, staff or students during normal work and class hours.

It’s a warts-and-all approach, but one that should help viewers understand the vital role of academic health care centers in American medicine. The one-hour weekly installments, to be hosted by a top ABC News correspondent, are due to air sometime between April and June.

-- ABS

A Lift of Hope

Sitting with his wife, Anita, in a tiny adult medicine waiting room on the seventh floor of the Outpatient Center, Clint Crockett looked the picture of health. Tall, barrel-chested, outwardly calm, he seemed out of place among rail-thin patients towing oxygen. But just over two years ago, the strapping 30-year-old waterman from Tangier Island, Va., learned that the shortness of breath he’d suddenly begun to experience was due to primary pulmonary hypertension, an illness that’s robbed him of his livelihood and turned each day since into a test of mental stamina.

“Both my grandfathers and my father were crabbers,” said Crockett in the lilting English accent that harks back to his Cornish ancestors, who three centuries ago settled the remote Chesapeake Bay island he calls home. “Until this, I was a crabber. Now, I can’t do much of anything.”

Jon Wurtzburger helping Clint Crockett
AirLifeLine President Jon Wurtzburger helps Clint Crockett of Tangier Island, Va., off the plane at BWI.

“In terms of life expectancy,” Crockett’s physician, pulmonologist Sean Gaine, says “primary pulmonary hypertension is a diagnosis worse than cancer. Most patients die within two years, often because their condition is critical by the time they get to a specialist.” Unlike ordinary hypertension, soaring blood pressure in the lungs is not only rare (affecting about two people per million) and tricky to diagnose, its treatment requires highly trained specialists found at only a few medical centers in the country.

For Crockett, that meant Johns Hopkins, hundreds of miles away. And until he discovered AirLifeLine—an organization of pilots who transport patients who can’t afford the medical travel they need—getting to his doctor every three months to keep his appointments was becoming nearly as nerve-wracking as his illness itself. From tiny Tangier Island the nearest Maryland town is an hour away by ferry, and a round-trip drive to Baltimore totals seven hours.

The private pilot who’s transformed the Crocketts’ ordeal into a 40-minute jaunt each way is AirLifeLine President Jon Wurtzburger. Headquartered in Sacramento, Calif., his non-profit organization consists of more than 1,000 pilots who donate their time, skills, aircraft and fuel to help financially strapped people with serious or life-threatening illnesses reach the medical care they need.

“We fly close to 3,000 missions a year,” Wurtzburger says, “any time of the day or night.” Patients must be ambulatory, able to travel in an unpressurized plane and not require medical personnel or equipment during the flight. Most trips involve one pilot flying up to a few hundred miles, but AirLifeLine’s regional coordinators can arrange multileg flights of up to 1,000 miles.

“I always wanted to be a doctor,” says Wurtzburger, who opted instead for a 25-year career on the floor of the New York Stock Exchange. “AirLifeLine is a way for me to help patients.” For more information, call 800-446-1231, fax 916-641-0600, e-mail staff@airlifeline.org or click on www.airlifeline.org.

-- Mary Ann Ayd

Med School Applicants Do Lunch

They sit anxiously outside the dean’s office, a group of well-groomed 20 somethings on a cluster of sofas in the starkly modern administration lobby awaiting what could be the appointment of a lifetime. From San Diego, Gainesville, Charlottesville, Chicago and Providence, this tense group of applicants to the School of Medicine’s Class of 2004 have flocked onto campus on a perfect Indian summer day to stand at a crossroads in their academic pursuits. Some make small talk, some nervously clear their throat and others sit politely contemplating their fate. Their admissions interviews will begin shortly.

But first it’s time for lunch. “Tell me, is Baltimore safe?” one visitor asks the student seated next to him. An earnest young woman wonders about day-to-day life in med school. Others marvel at the rich history under the dome. Such chitchat is exactly what administrators are after as they use chicken Caesar salads, deli sandwiches, fruit juice and cookies to break the ice with prospective students.

The off-the-record lunches began a few years ago in the School’s wood-paneled board room under a lineup of watchful portraits of Hopkins legends. Seated at each table is a member of the medical school faculty who, as host, is charged with peppering the conversation with bits of wisdom, day-to-day battle stories and general testimony about life on campus and his or her own educational background. “There’s no substitute for a little friendliness,” explains James L. Weiss, M.D., associate dean for admissions, who oversees the selection process. “The lunches are nonconfrontational and help the students get a feel for the institution.”

Administrators use the interview to gain insight into an applicant’s personal viewpoints. In a single day, pre-med students are escorted around the campus by third-and fourth-year students who show them classrooms, auditoriums, labs, hospital corridors and classic architecture. The twice-weekly lunches were added as a “personal touch” at an institution, which Assistant Admissions Dean Dave Trabilsy admits can seem “larger than life.”

LunchWeiss said about 700 students were ushered through interviews here late last year as a record 5,700 applications flooded the admissions office—topping a standing record of 3,900. That increase, most agree, is a direct result of Hopkins’ having listed itself as a checkpoint for the first time this year on the standard AMCAS application. Two hundred acceptance letters will be mailed on a rolling basis for the 120 slots in the fall class.

Trabilsy admits the downside of any medical school interview for applicants is the expense of getting there and then the pressure of the ordeal. “We expect a lot from pre-meds in regards to the hurdles they have to overcome,” he says. “So, we want to make this as positive and informative an experience as we can in a short period of time.” The lunches, he says, add a touch of hospitality.

The new tradition has yielded a stock of thank you notes. “Applicants seem to appreciate the pleasure-before-business approach,” Trabilsy adds. “I believe the faculty are the highlight of the institution. The students’ interaction with them is key.”

-- Melody Simmons

Millennium Musings

What you can expect medically.

As we say goodbye to the 20th century, we couldn’t let the momentous calendar change go unnoticed. So we checked in with a handful of department and division chiefs and asked them to say something about where their fields are headed.

John Bartlett, Infectious Diseases: I expect that microbes will be found as a cause for more chronic diseases: cancer, diabetes, Crohn’s disease and multiple sclerosis are good bets. Microbial resistance will be a problem with all kinds of organisms, including bacteria, viruses, fungi and parasites. We’ll discover new microbes that cause disease and develop antimicrobial agents to treat infections and vaccines to prevent them. Globally, malaria, tuberculosis and AIDS will continue to be problems.

Edward BenzEdward Benz, Medicine: Knowledge of all the genes that control the human body will permit us to be far more effective in screening for both genetic disorders and complex acquired diseases like cancer and atherosclerosis. The DNA sequence also will tell us the structures of key proteins involved in disease and permit the development of designer drugs that are far more specific and effective than current ones. We’ll feel this impact especially in treating conditions that cause abnormal blood clotting, like coronary artery disease and hemophilia. Knowledge of the genes will also accelerate the development of gene therapy for inherited conditions like sickle cell anemia and cystic fibrosis.

Charles CummingsCharles Cummings: Otolaryngology, Head and Neck Surgery: There will be improvement in early detection of head and neck cancer through molecular biology. Also, treatment of head and neck malignant diseases will be much finer tuned—probably more successful with fewer side effects. Our understanding of cranial nerve deficits (affecting the ability to speak, swallow, hear and smell) will be much enhanced. There will be nerve regeneration through nerve growth factors, and if that is not successful, we will be able to electrically simulate the motor or sensory neurons involved.

Morton GoldbergMorton Goldberg, Ophthalmology: We’ll see the transplantation of the human retina to treat blindness, and the development of gene therapy for eye diseases such as retinal degeneration, macular degeneration and glaucoma. We hope to develop an implantable photo microchip to gain some eyesight for patients who are blind. Finally, through new drugs, we’ll soon be able to control the over and undergrowth of blood vessels in the eye, a condition that can lead to vision loss.

Donlin LongDonlin Long, Neurosurgery: The major focus will be on correcting the basic pathophysiology of particular diseases in the brain. Because we’ll be able to treat people with gene therapy, growth factors and selective toxins that destroy abnormally functioning nervous tissue, fewer surgical skills will be required. Robotic-controlled instruments will augment what the surgeon can do, and operating rooms will feature imaging, modular design and robotics.

Paul McHughPaul McHugh, Psychiatry: The major question in psychiatry will be how human genetic constitution and life experience explain the development of major mental illnesses.

Solomon SnyderSolomon Snyder, Neuroscience: As a psychiatrist, I think the biggest questions are the identity of the predisposing genes to major mental illness, such as schizophrenia and affective disorder. Numerous teams seem to be making inroads. Knowing the identity of the major abnormal genes should teach us a great deal about how the brain regulates emotional behavior. Such insights should lead to new drug treatments.

Patrick WalshPatrick Walsh, Urology: The miniaturization of instrumentation and the development of less- invasive techniques will revolutionize the surgical approach to all urological diseases. Research will provide insight into the causes and prevention of prostate cancer, the most common cancer in men. Finally, management of both localized and advanced prostate cancer will be much improved.

Elias ZerhouniElias Zerhouni, Radiology: I think that imaging is going to help revolutionize the way we treat diseases through the wider use of therapies such as robotic-guided surgery and in situ imaging of the human body.