Johns Hopkins Magazine -- April 1998
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APRIL 1998

H E A L T H    &    M E D I C I N E

A virtual rehearsal for surgery... who's prone to headaches?... avoiding the "quick fix" of antibiotics... a record- breaking case of malaria... when kids dream

"Sneak preview" aids in courageous surgery

Neither Gray"s Anatomy nor any other medical book could help Benjamin Carson prepare for the surgery he performed December 31. Nothing about this case was textbook. Carson"s patients, 11-month-old Zambian twins Luka and Joseph Banda, were born joined at the backs of their heads. They shared a tangled array of blood vessels.

But when Carson began delving into the vasculature of the infants" brains on New Year"s Eve morning, he says, "It was like I"d been there before. I knew everything I would encounter."

Carson, a world-renowned pediatric neurosurgeon at Hopkins, had already experienced a sort of sneak preview of the surgery. Before the operation, he had rehearsed the surgical procedure using a computerized, virtual reality toolbox, which combines many two-dimensional images of a patient"s brain taken through CT or MRI to create a 3D image. Sixth-year surgical resident Tushar Goradia helped develop the toolbox"s software.

To view the image, a surgeon dons special glasses similar to ones used to watch 3-D movies. The viewer can then inspect different regions of the brain, and manipulate structures using a joystick. "It looks like you"re looking directly at the brain," says Carson. "You can take it, and turn it, and follow planes, and follow vessels."

To plan the surgical procedure without this tool, Carson would have had to imagine the three-dimensional structure of the twins" brains based on two-dimensional images, he says. "That is extraordinarily complex, especially if we have not seen the anatomy before. It"s akin to placing a cab driver in a new city and giving him a map," as opposed to having the driver find his way around from firsthand experience.

Twins who are joined at the head occur only once in every 2 million live births. Only 12 times before had surgeons attempted to separate conjoined twins who were joined at the head. Of those, only 10 individuals survived, and seven are impaired. Carson had separated conjoined twins twice before this recent case.

He operated on the twins at Ga-Rankuwa Hospital, 30 miles outside Pretoria, South Africa. The Banda family is from Zambia.

Says Carson, "I was able to determine through the virtual workbench which vessels were draining primarily to which twin, which made me more courageous in doing what was unique." The most challenging part of the surgery was separating the blood sinus, or major draining vessel, shared by the two brains. "After much meditation and prayer," Carson decided to divide the sinus, giving one half to one twin, and one half to the other.

Carson"s team completed the laborious operation in 28 hours, sustained by adrenalin and a break for tea. "It"s like you"re in the jungle with a hungry tiger after you," he declares.

The Banda twins will have reconstructive surgery sometime in the months ahead to create a bony covering over regions of their brains that are now exposed.

It is too early to tell what the twins" long-term prognosis will be, or to know if they will have any cognitive deficits. But Carson exults in their progress so far. Two days after surgery, the babies started eating porridge. "Within two weeks, they were already crawling, having never crawled before," says Carson.

Surgeons at Hopkins expect to use the virtual toolbox for plotting many future procedures. --MH

Illustration by Kevin O'Malley
Pass the aspirin

If you thought earning your advanced degree was a headache, don"t expect relief once the sheepskin"s in hand, say researchers at Hopkins"s School of Public Health, who report in February"s Journal of the American Medical Association that tension headaches afflict 50 percent of people with graduate school degrees, compared to just 20 percent who only attended grade school. Also of note: Women were 15 percent more likely to get tension headaches than men, and people in their 30s suffered more than any other age group.

Antibiotics: Learning to just say no

In Baltimore in the late 1980s, penicillin could easily vanquish almost every case of pneumonia, meningitis, or middle-ear infection caused by the bacterium Streptococcus pneumoniae. But by the early "90s, 15 percent of Strep pneumoniae isolates were penicillin resistant.

Baltimore is not alone. Antibiotic resistance is increasing throughout the nation, as a result of overuse and inappropriate use, says Lee Harrison, adjunct professor of international health at the School of Public Health.

To slow this trend, Harrison is helping to spearhead the Judicious Use of Antibiotics program, aimed at educating physicians and patients. The two-year, $250,000 pilot program is funded by the federal Centers for Disease Control and Prevention, and conducted in conjunction with the Maryland Department of Health.

Program staff recently trained 20 "peer educators"--pediatricians and family physicians from Baltimore--in the rudiments of antibiotic resistance. The doctors will now teach peers throughout Maryland. Among the points they will make:

  • Antibiotics are only effective against bacterial infections; colds, coughs, and sore throats are generally caused by viruses.

  • An antibiotic kills sensitive bacteria, sparing resistant bugs; misuse of antibiotics increases the chances that resistant bacteria will proliferate.

  • About one-third of antibiotic use is inappropriate--including 17 million antibiotic prescriptions given out annually for the common cold.

    Many physicians and nurses are already aware of the dangers of antibiotic abuse, says Bernadette Albanese, project director of the Judicious Use Program, and a research associate at Public Health. But in today"s hectic doctor"s offices, physicians don"t always have the time to educate patients.

    "A doctor has eight or 10 minutes to see a patient," says Albanese. "By the time you talk about their illness, and examine the patient, you have less than a minute left. Often, the physician ends up picking up the prescription pad and prescribing an antibiotic. The physicians feel like they"ve done something, and the patients feel they"re getting something."

    Managed care companies reinforce these habits, says Albanese, because many companies favor physicians who earn high patient satisfaction ratings.

    But patients may be even more satisfied with doctors who take the time to explain health issues, rather than simply handing out prescriptions, says Albanese. Peer educators will provide doctors with "nonprescription pads," which list treatment alternatives to medication (drink a lot of fluids, get bedrest, etc.). The "non-prescription" gives patients the material evidence of a doctor"s visit but not the potential risk of a hastily prescribed antibiotic. --MH

    A record-breaking case of malaria

    An infectious disease specialist at Hopkins recently cured a 74-year-old patient of a case of malaria that she apparently contracted 70 years ago. "This appears to be the longest documented case of malaria on record," says Joseph Vinetz, the specialist, who is now at the National Institutes of Health. The patient, who is from Greece, apparently became infected when she was about three years old, but appeared to recover. Following three days of anti-malaria medication, the woman is now cured, Vinetz reports in the February 5 New England Journal of Medicine. She gained 22 pounds and is much more energetic. Vinetz plans to visit Greece to search for other undiagnosed cases of malaria, a disease that was thought to be eradicated there by about 1950. --MH

  • The stuff kids" dreams are made of

    Ten-year-old Brian has a nightmare that he is alone in a decrepit house searching desperately for his family. Sophia, 2, dreams that an evil tortilla is trying to smother her. Five-year-old Ariel dreams she is chased by a unicorn.

    While many parents might dismiss these episodes as products of overactive imaginations, Alan Siegel "73 believes that children"s dreams are as important as those of adults. In his new book, Dreamcatching (Three Rivers Press, 1998), Siegel evaluates a topic often ignored in dream analysis: childhood dreams. Co-written with Kelly Bulkeley, president of the Association for the Study of Dreams, Dreamcatching offers some explanations for common childhood dreams, while avoiding an over-reliance on symbolism.

    "I am very cautious about the cookbook approach to dreams that says, `This image means this and another image means something else,"" says Siegel, a clinical psychologist. "Every dream, like every person, is unique. You have to use your own creativity to figure out what it means."

    In Dreamcatching, Siegel and Bulkeley offer logical explanations for dreams based on the child"s experiences. For example, Brian"s parents had just divorced when he began complaining of nightmares. Sophia burned herself on a hot tortilla the night before her bad dream. Ariel was nervous about her second day in kindergarten when she dreamed of the evil unicorn.

    More important than analyzing dreams, says Siegel, is supporting children who suffer from nightmares. "You don"t have to interpret or `solve" the dream," he says. "Nightmares are traumatic events. The most important thing is reassurance." In his book, he suggests re-enacting the dream and working with alternative, happier endings. "`Magical tools," `monster sprays," and nets are all assertiveness tools of the imagination," explains Siegel. "Once kids cope with the nightmare, they can begin to play with the images and reduce or stop recurrent nightmares."

    Siegel plans to continue his study of children to determine the impact of gender, ethnicity, the media, and societal violence on children"s dreams. --KR

    Written by Melissa Hendricks and student intern Kari Rosenthal "00.