Johns Hopkins Magazine -- February 1999
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H E A L T H    &    M E D I C I N E

Treating hypertension holistically... boyhood aggression rechanneled... new promise for liver transplants... surgery from the lectern... stem cells and the Senate... a birthing tradition renewed... Sex? Me?!

Reaching out: Nursing's Mary Roary and team.
Photo by Mike McGovern
Compassionate help for hypertension

Can helping patients find a job or seek drug abuse treatment reduce their high blood pressure?

A two-year study of 309 African-American men suggests that the answer is yes. Johns Hopkins School of Nursing professor Martha Hill directed the study.

African-American men have one of the highest rates of high blood pressure and have the highest rate of untreated hypertension. But through questionnaires and surveys of African-American men in Baltimore, says project director Mary Roary, "We found they didn't give a hoot about blood pressure."

Alcoholism, unemployment, incarceration, and other problems superseded their concern about hypertension. Of the 309 men who participated in the recent study, 72 percent were unemployed, 64 percent had been incarcerated, 62 percent had a history of alcohol abuse, half had a history of regular drug use, and 51 percent lacked health insurance.

So the researchers introduced a community-based intervention aimed at reducing blood pressure that involved helping men find jobs and assistance from social service agencies as well as offering medical care.

About half the group (157 men) received assistance from an intervention team consisting of a community health worker, nurse practitioner, and physician. The remaining 152 men did not receive this intervention and served as a control group. Those in the first group received free medication and blood pressure screening. A nurse practitioner counseled them about how to control hypertension. A community health worker visited each man in his home every six months.

In addition, the researchers tailored their services to each man's particular needs. If a study participant was an alcoholic or drug abuser, Roary and research assistants helped arrange referrals to a detox center. If a volunteer was unemployed, they helped him write a resume and ran him through mock interviews, then accompanied him to job interviews.

The researchers also used "smart caps," pill bottles containing a computer chip that records each time a pill is dispensed, to check on whether a patient was regularly taking his medication. If he neglected to take his pills, the community health worker would then help devise strategies for remembering or would telephone to remind him.

Over 12 months, the mean diastolic blood pressure of the men in the study group dropped from 121.9 to 113.3. For men in the control group, diastolic blood pressure dropped only slightly, from 122.7 to 119.3. In November, Roary presented the team's findings in Dallas at the annual scientific meeting of the American Heart Association.

The intervention program also apparently sharply reduced emergency room visits. Unchecked hypertension can cause chest pain, dizziness, headaches, and nosebleeds, notes Roary. The men who participated in the study, she says, had been using the Johns Hopkins Emergency Department as their primary means of healthcare. The intervention, she says, could represent a significant cost savings, since emergency departments are an expensive means of delivering primary care.
--Melissa Hendricks

Helping Johnny behave

Boys who are aggressive and disruptive in first grade apparently are at an increased risk of continuing to behave badly in middle school, researchers at the School of Public Health reported recently. The good news is that teachers and peers can help aggressive boys learn to tame their rambunctious inclinations.

Professor of mental hygiene Sheppard Kellam led a team of researchers who began studying children at 19 Baltimore public schools starting when the children were in first grade. They are now ages 19 and 20.

Highly aggressive first-grade boys who are in classrooms where the teacher is not able to maintain order were 59 times more likely to be unruly in middle school than were their classmates who showed average levels of aggression. Being part of an environment of unchecked aggression reinforces bad behavior, concludes Kellam. (The classes were matched so that each contained roughly the same number of highly aggressive children.)

Kellam stresses that he is not blaming the teachers for being unable to maintain control of the classroom. "They were really struggling," he says. "They just didn't have the tools."

However, the researchers also found that teachers can acquire these tools. Some who participated in the study received training in a technique that involves rewarding teams of students when team members behave well--a peer-pressure approach, explains Kellam. "It's like football; every team member is rewarded for the good plays of his teammates."

Highly aggressive boys whose first-grade teachers used this "good behavior game" were markedly less aggressive in middle school.

"There are very precise, inexpensive things you can do to prevent aggression in older children and adults," says Kellam, who was the founding director of Public Health's Prevention Research Center. And first grade "is a critical time to do it," he says. "If it doesn't happen in first grade, then you're behind. And if you're behind in elementary school, the data show you don't catch up."

The study appeared in a recent issue of Development and Psychopathology.

New promise for liver transplants

In November, 22-year-old Daniel Reilly made a sacrifice that saved the life of his dying mother, 51-year-old Kathleen Reilly, when he agreed to donate 60 percent of his liver.

Hopkins surgeons Andrew Klein and Warren Maley successfully performed the split-liver transplant, marking the first time Hopkins doctors transplanted a portion of liver from a living donor into an adult.

In the past, surgeons at Hopkins and other hospitals have performed split-liver transplants on child recipients--but that procedure requires a much smaller portion of the donor's liver. The new procedure, which has been successfully performed 30 times in the United States, holds great promise for the thousands of adults on waiting lists for new livers.

Klein and Maley said they expected Daniel Reilly's liver to regenerate within six weeks.

Surgery from the lectern

Urologist Louis Kavoussi recently directed a fairly simple surgical procedure in a rather extraordinary way. Kavoussi helped operate on a patient's scrotum as his patient lay on an operating table at the Johns Hopkins Bayview Medical Center in Baltimore. But the surgeon did it from 200 miles away--standing on a stage in a hotel ballroom in New York's Times Square.

Kavoussi used endoscopic tools linked to a computer on the stage through four high-capacity telephone lines to perform a varicocelectomy, or removal of enlarged veins in the scrotum. He directed an attending physician and resident stationed in the operating room on where and how to cut, while he manipulated an endoscopic camera and electric cautery.

One thousand physicians attending a meeting of the Endourology World Congress watched the procedure on a large screen over the stage.

Kavoussi has performed more than 50 procedures through telesurgery. The purpose of showing the procedure at a conference, he says, "was to demonstrate the feasibility of the technology." Telesurgery enables specialists to train colleagues in far-flung locations, says Kavoussi, who was planning in November to "telementor" physicians in Singapore in laparoscopic kidney surgery.

"This is just the infancy of telemedicine," notes Kavoussi. "One day I'll wake up and be able to operate from my library at home."

Embryonic stem cell research holds "enormous promise," says Gearhart.
Photo by JHMI Office of Public Affairs
Gearhart goes to Capitol Hill

In December, Hopkins researcher John Gearhart went before a U.S. Senate subcommittee with hopes of gaining federal support for research on human embryonic stem cells. The primordial cells can give rise to virtually any of the 200 different human cell types, and thus such research holds "enormous promise" for treating debilitating diseases and injuries that affect millions of Americans, Gearhart testified.

But for the potential to be realized, the lawmakers must rescind a 1995 funding ban on human embryo research.

Since stem cells are not yet specialized, scientists could theoretically coax them to grow tissues of any variety for transplantation into patients who have lost that tissue from injury or illness. For instance, neurons grown from stem cells could be transplanted into a patient with Parkinson's disease to compensate for the loss of neuronal functioning.

Gearhart, a professor of gynecology and obstetrics, first isolated what appeared to be embryonic stem cells (Johns Hopkins Magazine, November 1997) in 1997. In the November 10 Proceedings of the National Academy of Sciences, his team reported tests confirming that the cells are, in fact, embryonic stem cells. The same month, a University of Wisconsin team reported in Science that they, too, had grown embryonic stem cells, though using a different technique.

During his testimony, Gearhart showed Senate subcommittee members a photograph of a neuron that his lab had grown from embryonic stem cells. Gearhart tempered the excitement of the breakthrough by pointing out the limitations of current research: namely that scientists cannot "direct" the growth of stem cell cultures--into a particular type of neuron, for instance. "Only a supportive research environment, both in terms of policy and resources, will move this work forward rapidly," Gearhart reported. Without federal funding, particularly from the National Institutes of Health, biomedical scientists are severely limited in the amount of research they can do, he adds.

Gearhart receives no federal funding for his research on embryonic stem cells and is supported by the Geron Corporation, of Menlo Park, California. Technically, however, he is eligible for federal funds. The 1995 ban prohibits federal money for research that makes use of embryos that are discarded by in vitro fertilization clinics. The University of Wisconsin team used embryos from fertility clinics as a source of its stem cells. Gearhart's team, however, uses tissue obtained from aborted fetuses, with the donor's consent.

Both techniques have their critics. Some critics oppose the first method because it makes use of an entity that has the potential to become a human life. Abortion foes oppose the technique employed by Gearhart's team because it makes use of tissue collected from abortions.

Gearhart says that with further advances in stem cell research, labs eventually might be able to grow renewable cell cultures of particular lineages, and thus reduce the number of embryos required as starting material.

He noted another plus for federal funding: oversight. If the NIH were overseeing this research, it could provide a "very rational" method of supervision, he says. For instance, the NIH could determine the maximum number of embryos that could be used as source material, and select which labs would be able to procure them. Those labs would develop bankable cell cultures that would be made widely available for research or therapy.

A birthing tradition renewed

Stephanie Rhodes (BSN '98) will always remember one particular woman she assisted through labor at the Johns Hopkins Bayview Medical Center. From early evening until morning, Rhodes listened while the woman told her tragic life's story--of miscarrying twice and giving birth to a child with severe heart problems who died in infancy. She was now using heroin and cocaine, and three days earlier had learned that she was HIV-positive. The woman did not even have a friend or relative who could accompany her to the hospital.

"It was a pretty intense experience," says Rhodes. "I mostly listened and cried. She had a very, very sad story."

Rhodes was learning to be a doula, or birth companion, and was among the first students to take a birth companion training course at Hopkins's School of Nursing. She is now training to be a nurse-midwife at Georgetown University.

A role performed in many cultures by a mother, aunt, or other relative, the doula accompanies a woman throughout labor and delivery and even helps her in the weeks before or after her child's birth. While the use of doulas has been increasing nationwide, Hopkins is the first school to offer an undergraduate birth companion course. Roughly 20 nursing students take the course each semester.

"There was a time a century ago when birth took place at home," says Michele Oseroff, a certified doula and registered nurse who teaches the Hopkins class and directs doula services for Helix Health Systems in Baltimore. Today, expectant mothers can live a continent away from their families. While a midwife may perform some of the same duties as a doula, her primary goal is to deliver the baby. In contrast, says Oseroff, "the doula recognizes that Mom needs to be taken care of."

Hopkins student doulas recruit clients from populations that are likely to need companionship most. They distribute brochures advertising the free services in neighborhood health clinics, schools for unwed mothers, and drug and alcohol treatment centers in and around East Baltimore. Many of their patients are in dire need of accurate information about childbirth and infant care. Rhodes has attended to pregnant teens who did not understand that sex leads to pregnancy.

Hopkins also offers a birth companion to any woman who requests one, and women from a wide variety of backgrounds have been calling. The program has a large following among orthodox Jewish women. Orthodox Jewish practices prohibit a man from touching his wife during advanced labor and childbirth.

Student doulas make at least one prenatal home visit, during which they talk to their client about birthing options and parenting. Many students also accompany their clients to prenatal classes. They then are with the client during labor and delivery, coaching her in proper breathing techniques, massaging her back, or simply listening.

After the birth, the students visit the mother in her home to be sure she has made arrangements for pediatric care for her child and to talk to her about her birth experience.

Illustration by Kevin O'Malley
Forgettable sex

You've heard about being blinded by love--but what about being rendered amnesic? In the November 7 The Lancet, two Hopkins hematologists report that bearing down hard, the way some people do when they deliver a baby, move their bowels, or have intercourse, can produce six to 12 hours of "transient global amnesia"--the inability to form new memories.

Chi Van Dang and Lawrence Gardner reported the cases of two elderly men, ages 72 and 75, whose wives took them to the emergency room about 30 minutes after having sex. Both men were seriously confused, though fully conscious. The physicians concluded that the act of bearing down, combined with typical activation of the sympathetic nervous system during sex, created intense pressure in the brain's blood vessels; the pressure temporarily cut off blood flow to the central part of the brain, causing amnesia.