Weighty MotivationWhy a woman’s

weight may correlate to her risk of cancer

When does ordinary anxiety become a disorder?

a doctor’s prescription for chronic cough

Surgery might bring lymphedema relief

Insight and news from Johns Hopkins MedicineFALL 2014

Compliments of

Johns HopkinsUSA

New Moms, Take Care

of Yourselves

Fall 2014

Quick consult

4 calming that cough at what point is there cause for concern? Find out when it’s time to see a doctor.

5 Find Your Balance learn the subtle differences between normal anxiety and a disorder that needs treatment.

First Person 10 skillful solution a Kansas man couldn’t be more pleased with his robotic heart surgery at Johns Hopkins.

second oPinion

11 take comfort People with lymphedema now have a surgical option beyond traditional therapy.

on tHe coVer

Weighty MotivationSurprising new research shows that for women, losing weight is key to lowering cancer risk.

Contents

6

Get the latest news on health and wellness topics impor-

tant to you and your family, all from the

experts at Johns Hopkins Medicine. the Your Health e-newsletter is delivered straight to your inbox. Visit hopkinsmedicine.org/news/ e-newsletters for your free email subscription.

Sign Up for Health Information from Johns Hopkins

Save the DateWomen’s Health conferenceSeize this rare opportunity to learn about a wide variety of women’s health issues from renowned Johns Hopkins physicians and faculty in one day. Treat yourself to this educational and exciting event devoted to women’s health. attend A Woman’s Journey, Johns Hopkins Medicine’s annual women’s health conference, on Nov. 1 in Baltimore, featuring 34 Johns Hopkins experts. For more information about a conference near you, call 410-955-8660 or visit hopkinsmedicine.org/awomansjourney.

More PostPartuM adVice FroM JoHns HoPkinsGo to the Johns Hopkins Health library for more information on postpartum care—and thousands of other health topics. Visit hopkinsmedicine.org/healthlibrary.

W hen you have a baby, you have your hands full. And in this hectic time, if you’re think- ing twice about whether to see your doctor

for a follow-up, you’re not alone. A study of more than 30,000 women at Maryland hospitals found that nearly half failed to go to their doctors for postpartum visits.

“Women are much more likely to attend to their baby’s needs than their own,” says Johns Hopkins internist Wendy Bennett, M.D., who led the study.

But Bennett says postpartum visits are important for all women after pregnancy, particularly for those who suffered complications like diabetes or high blood pres-sure. Though the conditions may have eased when the pregnancies ended, those women remain at higher risk of developing chronic illnesses later in life, Bennett says.

At postpartum visits, doctors can plan preventive care, discuss birth control, screen for postpartum depression and answer new-mom questions.

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healthinsights

Your Guide to Healthy aging and caregivingThe new Johns Hopkins Healthy aging website is designed to help you and your loved ones maintain your health, manage conditions you may have and support aging family mem-bers who face serious diagnoses—all based on Johns Hopkins research and expert insight.

Visit hopkins medicine.org/ healthyaging for more information and to sign up for a free, 13-page guide for fam-ily caregivers.

the Gene that Might Help People Go to sleepa study of the sleeping patterns of fruit flies might someday help people who have trouble getting their ZZZs.

Flies, like people, tend to doze off at the same time each night, guided by a circadian (biological) clock. But flies with a mutation of a cer-tain gene stay awake, says Mark Wu, M.D., ph.D.,

a Johns Hopkins neurolo- gist and neuroscientist who conducted the study.

Wu says this mutant gene, called Wide awake (or Wake for short), appears to interfere with how the internal clock normally tells the fly it’s time to sleep. If research-ers figure out a way to change the Wake gene’s message, falling asleep could become much easier for the flies and—because the gene is found in flies and humans—eventually for people, par-ticularly those who work night shifts or otherwise fall out of sync with their circadian clocks.

Does Brain Training Work?Private companies have been promoting brain exercises they say help older adults retain their mental prowess. But is there science behind the claims? A study by George Rebok, Ph.D., a professor in the Johns Hopkins Bloomberg School of Public Health, finds benefits for people who receive certain types of brain training—though Rebok isn’t aware of strong evidence to support “as seen on TV” exercises.

In his study, people 65 and older, without dementia, took part in 10 hourlong classroom sessions led by certified trainers. Some of these older participants were taught memory strategies, some received problem-solving lessons, and some honed their visual-attention skills. A fourth group received no training.

Years later, the training was still paying off. Study participants who received any of the specialized training had stronger abilities to navigate everyday tasks, like taking medications, looking up phone numbers and reacting quickly while driving, than those who were not trained.

Rebok and his team have received a grant from the National Institute on Aging that will enable them to continue research and develop an online version of their memory training, which would open up these exercises to more people.

Eggs cost 18 cents a dozen ($2.68 in 2013)

The Johns Hopkins Hospital opened 125 years ago, in a time that ...

Thomas Edison

Thomas Edison revealed the first motion picture

William Gray patented the coin-operated telephone

The average home price was $3,250 (1890)

The Wall Street Journal began publishing

The Eiffel Tower officially opened

For videos, an interactive timeline and more, visit hopkinsmedicine.org/125th.

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quickconsult

What if it’s something more serious?

A lot of people ask whether their cough might be cancer, but that’s unlikely. Most causes of cough aren’t life-threatening. If treating for the most common causes of a cough doesn’t resolve the issue, then we’ll do more tests to check for asthma or GERD. I don’t do more specialized tests unless a cough doesn’t go away after six months, so be patient with the process. I try to rule out causes one by one, so we can identify what’s going on. The best thing you can do is to follow your doctor’s orders and stick with the prescribed treatment to give it time to work.  n

Calming That Cough

I have a cough I just can’t shake. At what point is it “chronic”?

A cough can last a couple of days, a couple of weeks or a couple of months. Most of the people I see for a lingering or chronic cough have had it for more than eight weeks. The majority of coughs that last that long are related to sinus problems and allergies. Sometimes they are linked to asthma, gastroesopha-geal reflux disease (GERD) or certain medications.

Lingering tickles and hacks can be a nuisance, but are they cause for concern? Johns Hopkins pulmonologist Christian Merlo, M.D., explains

How will a doctor determine what’s causing my cough?

I start with a detailed history, including a list of current medications. One of the questions I ask is, “Do you smoke?” Smoking causes lung disease and is the biggest symptom of chronic bronchitis. Coughs can also be caused by an infection, which may need to be treated with antibiotics that can clear it up in about a week. But if it’s a viral infection, remember that antibiotics won’t help. In that case, I may prescribe nasal sprays to help reduce inflammation and ease symptoms.

For more information, appointments or consultations, call 877-546-1872.

What solutions can I try at home?

I don’t know of too many over-the-counter fixes for a chronic cough. So take good care of your health with diet, exercise and plenty of rest, and if you’ve had a cough for about eight weeks, it’s time to see a doctor. The evaluation should be a stepwise process, and, if nothing else, the doctor can offer reassurance that it’s nothing serious.

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Find Your BalanceDo you have anxiety or an anxiety disorder?

Here are some clues

Working on a tight deadline. Caring for a terminally ill loved one. Everyone can feel anxious

now and then. But if the anxiety starts get-ting in the way, it might be a condition called generalized anxiety disorder (GAD).

How can you tell the difference? Although there is no sharp dividing line between normal anxiety and GAD, it may come down to just how much time you spend being anxious, says Joseph Bienvenu, M.D., Ph.D., a psychiatrist at Johns Hopkins.

“If you’re worrying about things that are weeks or months into the future, that could be a sign of GAD,” he explains. “Worrying about a number of things can also be a symptom, but some people with GAD focus on a sin-gle area of concern.”

GAD is often accompanied by physical symptoms, too, including rest-lessness, edginess, fatigue, difficulty concentrating, irri-tability and muscle tension. Depression and anxiety often go hand in hand, so feeling deeply sad for more than a couple of weeks could be a warning sign and should be addressed regardless.

Obsessive-compulsive disor-der (OCD) and

hoarding disorder are other forms of anxiety. OCD behaviors, like frequent hand-washing or excessively checking that you turned off the stove, are often driven by the need to relieve anxiety. Spending more than an hour a day on such activities is a sign of a disorder. In people who have hoarding disorders, the idea of throwing things away is disquieting.

Nevertheless, “there’s a big difference between making sure you didn’t leave the iron on and having OCD,” Bienvenu says. “As with any anxiety-related disorder, if the behavior is disrupting your life, then it’s time to see an expert for treatment.”  n

Recognizing and Treating Anxiety DisordersWould you know if you had generalized anxiety disorder? Probably not. Most often, it’s spotted by a loved one who might say something like, “You’re always stressed out” or “Your muscles are so tense!”

Even hoarding behaviors might seem perfectly OK to people who save every newspaper in case they need to look up something, but their relatives might have a very different view.

Getting the right diagnosis is crucial, because treatment is individualized across conditions, and even across patients with the same disorder. In addition to cognitive therapy, which helps patients reshape their thinking to address their anxieties or behaviors, medications including antidepressants and antianxiety drugs can be beneficial.

For more information,

appointments or consultations, call

877-546-1872.

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Weighty Motivation

Studies show the correlation between extra pounds and a woman’s risk of certain cancers. Johns Hopkins researchers have

a clear message to women: Be at a healthy weight

For women, healthy weight is no longer just about vanity, body image or whether you can fit into those jeans from 10 years ago. As recent research—much of it done at Johns Hopkins—has proved, the stakes are much higher than that.

“It is absolutely a matter of life and death,” says Amanda Nickles Fader, M.D., director of the Johns Hopkins Kelly Gynecologic Oncology Service. “It’s not just a question of you feeling good about yourself.”

Not that feeling good about yourself isn’t important. What Fader is talking about is the recognition among oncologists—particularly those who deal with ovarian, cervical, uterine and breast cancers—that excess weight is closely associated with the incidence of certain cancers. ➻

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One-third Of cancer deaths in wOmen are nOw attributable tO excess bOdy weight.

Free online seminar

Losing Weight and LoWering risk: What you need to

knoW about WoMen’s CanCer and nutrition

tuesday, december 2, 7–8 p.m. estdid you know that up to one-third of cancer deaths in women are attributed to excess body weight? during

this interactive webinar, director of gynecologic oncology Amanda Nickles Fader, M.D., and oncology dieti- tian Mary-Eve Brown, R.D., LDN, CSO, discuss

the correlation between excess weight and the risk of certain women’s cancers. to register,

visit hopkinsmedicine.org/ healthseminars.

The one most linked to weight is endometrial, also known as uterine, cancer. Indeed, studies have shown that the risk increases linearly with increasing BMI (body mass index), a ratio of height to weight that measures body fat. But weight has also been found to be a key risk factor for breast, colorectal and, to a lesser extent, ovarian cancers.

Added up, they make for an alarm-ing statistic: One-third of cancer deaths in women are now attributable to excess body weight, a fact that draws gasps when Fader presents to audiences. “Women are shocked to hear this,” Fader says. “They have no idea. But they often don’t know much about the cancers themselves, let alone the risks for those cancers.”

Dropping the pounds is a smart idea whether you are interested in preventing cancer in the first place or a recurrence. “Generally, it’s good for women to lose the weight,” says medical oncologist Kala Visvanathan, M.D., of the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. “For some cancers there is more data to show the relationship between weight and recurrence, but there’s clear-cut data that a woman’s overall survival is defi-nitely improved by optimizing her weight.”

contributing FactorsHow is excess weight impli-cated in the production of cancerous cells?

The first factor is fatty tis-sue, which used to be thought of as inert in regard to cancer—not something desirable or cosmetically pleasing, perhaps, but certainly noth-ing that would play a role in a potentially life-threatening disease. “Now we know

that’s not true,” says Mary-Eve Brown, an outpatient oncology dietitian at the Kimmel Cancer Center. “Fat tissue actually produces estrogen, and the overproduction of estrogen can be implicated in some types of breast and endometrial cancers.”

The second factor is insulin, which is now recognized as a growth factor for cancerous cells. “People who are over-weight have more cells and more insulin,” Brown says. “If you have a malignancy, it can grab on to all that insulin and use it to grow.” In other words, the insulin becomes a nutrition source for tumors.

Scary? Yes, but the good thing is that you can do something about your weight, unlike other contributors to cancer, such as genetic predisposition. Though slimming down is not easy, Brown has found that a cancer diagnosis has a way of sharpening the focus and mobilizing resolve in her patients.

“The women I see in the cancer center are highly motivated to lose weight,” she says. “They’re looking at how they can reduce their risk of recurrence. They’re asking, ‘What risk factors can I control?’ And they know that if they go on eat-ing the way they have been, and stay overweight, it’s not going to help them.” Brown adds that for those undergoing cancer treatment, weight loss may not be medically advised. Once treatment is fin-ished, however, the recommendation is, as she says, to try to be “as lean as possible.”

Proper GuidanceWhat will help, of course, is a sensible eating plan and increased physical activity. In some cases, weight-loss surgery, known as bariatric surgery, could be beneficial. But the most effective weight plans are tailored to the individual. For cancer patients, who does the tailoring? And who is responsible for the obesity counseling?

A recent study at Johns Hopkins, co-authored by Fader and published in the American Journal of Obstetrics & Gynecology, queried oncologists on this issue. Eighty-five percent said it was important to talk to patients and explain how weight is related to cancer. But, she adds, “the majority of oncologists were referring to other providers—to nutrition-ists, to bariatric specialists, to internal medicine practitioners. But we still stay involved in the counseling.”

In another, currently unpublished, study, Fader and her colleagues posed

the same question to survivors of uter-ine cancer. “We asked, ‘Are your doc-tors talking to you about this?’ And the response was similar. They said their doctors were but that they needed more concrete information and a specific weight-loss plan.”

Like Brown’s patients, the respondents in this study were eager

to get to work on losing weight. “They were motivated,” Fader says.

“They felt this was a teachable, or learn-able, moment for them.”

People who come to Johns Hopkins have an advantage, Fader adds. “We have

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a multidisciplinary survivorship care approach here,” she says. “Our oncology division is the quarterback of the care. We meet with patients during treatment and after, identifying how we can help them live longer, higher-quality lives. And we frequently refer to other specialists, like physicians and nutritionists at the Johns Hopkins Weight Management Center, who help our patients achieve this.”

‘be a bit selfish’Of course, it shouldn’t take a cancer diag-nosis to make you decide once and for all to get to a healthy weight. And yet the rising incidence of obesity among women suggests that as much as they may know about the dangers of excess weight, losing it is often set on the back burner behind family needs.

“Women are often the caregivers in their families and don’t put them-selves and their health care first,” Fader says. “We see this time and time again, whether young or older. They’re always thinking of their other family members. I’d say be a bit selfish. Take care of your-self. It’s never too late to see your physi-cian about your weight and your lifestyle. Even changes made in your 40s, 50s and 60s can make dramatic, positive changes on your health.”

Including a lower risk of cancer or the likelihood of a recurrence.  n

Make sure you know your body mass index (bMi), a ratio of height to weight that measures body fat. use this calculator to determine whether your weight is in the healthy range: hopkinsmedicine.org/healthnews/bmi.

Find out if you are Overweight

Want to make Healthy changes?

➻start HereWith excess weight implicated as a risk factor in

many female cancers, isn’t it time to make the nec-

essary changes in your life to get lean and healthy?

here are some tips.

➻ Don’t be afraid to ask for help. “it’s unfair to tell women to just ‘lose weight,’ ”

says Kala Visvanathan, M.D., a Johns hopkins

medical oncologist. “it’s ok to ask for advice, to

seek the help of nutritionists or other specialists.”

➻ Make gradual dietary changes. the eating habits you’ve developed over a lifetime

are not going to change overnight. start gradually,

and make changes slowly. “if you’re drinking whole

milk, can you get to 2 percent?” says Mary-Eve Brown, an outpatient oncology dietitian at Johns

hopkins. “once you’ve done that, can you get to

1 percent and eventually to skim? if you eat meat

five times a week, how about one vegetarian meal

a week? after a few weeks, can you make it two?”

➻ Follow a largely plant-based diet. that means a diet rich in colorful fruits and

vegetables (the colors indicate the presence of

cancer-fighting phytochemicals). your diet should

include whole grains intact with fiber. it should

be low in saturated fats. eat less red meat:

Preferable protein sources include white-meat

poultry, fish, nuts and legumes.

➻ Get moving. don’t forget that physical activity is part of the

weight-loss formula. Most national public health

agencies recommend 150 minutes a week of

moderate-intensity exercise, such as brisk walk-

ing. “there’s good evidence that reducing weight

and increasing the amount of physical activity can

reduce the risk of many cancers,” visvanathan says.

“it doesn’t have to be that much. even walking a

half-hour is fine. as long as you do it regularly.”

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firstperson

I had known my mitral valve wasn’t working the way it should since 2000, but doctors said it wasn’t bad enough to do anything about except keep an eye on it.

That all changed in late 2013, when my routine checkup and tests showed a rupture in my mitral valve that would require surgery to repair.

I didn’t want to have the kind of surgery where they crack your chest open, so I started looking into robotic surgery that uses a much smaller inci-sion so you recover faster. In January, a hospital with a great reputation told me I was a good candidate for the robotic procedure. But they couldn’t get me on the schedule until after a planned vacation in May.

At age 68, I didn’t want to wait that long. So I called Johns Hopkins. A few minutes later I was on the phone with Kaushik Mandal, M.D., who could do the surgery on Valentine’s Day.

He reviewed my test results and had me come to Baltimore a couple of days before the surgery for a heart catheteriza-tion. The other hospital didn’t do that test, but Dr. Mandal said he needed it to confirm I was a good candidate for the robotic surgery. Fortunately, I was.

Just seven days after surgery, my wife, Lisa, and I had dinner with friends in Washington, D.C., before we returned home to Kansas.

People ask why I went all the way to Johns Hopkins, and I tell them I wanted the best. I’ve never needed any pain medication since the surgery, and I’m back to my active life—including taking a trip to Europe with Lisa. I couldn’t be more pleased with the way everything turned out.  n

Skillful SolutionWhen he needed heart surgery, Jim Watkins chose Johns Hopkins for its expertise and reputation

The RighT PRoceduRe foR eveRy PaTienT

a robotic-assisted mitral valve repair is an option for about 80 percent of people, but thorough presurgery tests are essential, says Kaushik Mandal, M.D., a cardiothoracic sur-geon at Johns hopkins.

People need to be checked for narrowing of their arteries due to a buildup of plaque called athero-sclerosis. Those people aren’t good candidates for robotic surgery, but most of them can still have tradi-tional open-heart surgery. There are other minimally invasive options for patients too sick to undergo major surgery, such as a percutane-ous mitral clip.

“My colleagues and i offer the full spectrum of these options,” Mandal says. “The first priority is having a safe and durable repair, which is why we carefully screen every patient to determine the best approach.”

To watch a video of Jim Watkins telling his story, visit hopkinsmedicine.org/mystory. For more information, appointments or consultations, call 877-546-1872.

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secondopinion

People who have lymphedema are all too familiar with the swelling, fullness and heaviness associated with their

condition—and the limitations of tradi-tional treatment. Although decongestive therapy remains the primary prescription for lymphedema, a new surgical procedure at Johns Hopkins alleviates the discomfort for some people.

There is no known cure for lymphedema. It can be inherited, caused by injury or, most commonly, developed after removal of lymph nodes during cancer treatment. In fact, about 25 percent of people who have lymph nodes removed from their armpits or groins develop the condition, sometimes years later.

Lymph nodes work as filters that elimi-nate impurities from fluids in the body. When those filters are removed or damaged, the fluid can back up. Extremities can swell, and infections become more serious.

The first step for people with lymph-edema is decongestive therapy, which

includes massage, compression therapy and exercise to ease swelling, explains Elizabeth Erhardt, a certified lymphedema therapist at Johns Hopkins. Those with mild to moderate conditions who do not respond to therapy, however, may be can-didates for lymphovenous bypass surgery, which is performed at just a few facilities nationwide. The treatment is not a cure, but it eases symptoms by giving fluid a place to go.

During the surgery, lymphatic channels are connected to veins in the arms or legs, “bypassing the blockage that exists in the armpit or groin,” says Justin Sacks, M.D., a plastic and reconstructive surgeon at Johns Hopkins. The procedure takes four to five hours and is performed under general anes-thesia. Patients typically go home the same day and recover quickly.

“It’s not a cure-all,” Sacks says. “But it is the first surgical treatment and has a low risk of complications.”  n

A surgical option beyond traditional therapy might relieve the swelling and discomfort of lymphedema What to

expect During Decongestive TherapyTwo or more times a week, depending on the severity of the per-son’s swelling, a physical therapist, an occupa-tional therapist or other specially trained profes-sional massages the affected areas, helping move excess fluid to healthy tissue. The per-son receiving therapy is given exercises to do to ease swelling and is urged to avoid cuts or scratches, which can get infected and exac-erbate the condition.

in between visits, the person wears com-pression garments to increase tissue pressure and keep fluid mov-ing, and continues with the exercises.

Take comfort

Free Online SeminarManaging

LyMPhedeMa: diScoveR youR oPTionS

Thursday, november 6, 7–8 p.m. eSTJoin Johns hopkins experts and learn about upper and lower extremity lymphedema treatment and

management options, such as decongestive therapy and surgery. Plastic and reconstructive surgeon

Justin Sacks, M.D., and certified lymphedema therapist Elizabeth Erhardt will discuss ways to manage your symptoms and provide answers

to your questions. To register, visit hopkinsmedicine.org/

healthseminars.

hopkinsmedicine.org/usa | 877-546-1872 fall 2014 johns hopkins health | 11 |

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Protects his hearingHearing loss is a natural consequence of aging, but it can also be caused by exposure to noise—and the damage is cumulative. so i take simple steps to protect my hearing.

Anytime i’m exposed to a loud noise, even a brief one—like a siren, a power tool or a kitchen blender—i cover my ears or move away from the sound. if you have to raise your voice to talk over the noise, it’s too loud, even if it’s a short burst.

i don’t go to rock concerts anymore, but if i did i’d wear foam earplugs from the drugstore. my children are just beginning to use mP3 players, so i’ll be looking into noise-limiting headphones and the settings on their devices that limit volume.

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Johns Hopkins Health is published quarterly by the Marketing and Communications office of Johns Hopkins Medicine. Information is intended to educate our readers and is not a substitute for consulting with a physician.

Kathy Smith, Vice President, Marketing & Communications, The Johns Hopkins Hospital • Steven J. Kravet, M.D., Physician Adviser Designed by McMurry/TMG

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Frank lin, m.D., Ph.D., is an otolaryngologist and epidemiologist with the Johns Hopkins Listening Center and an associate profes-sor of otolaryngology–head and neck surgery, geriatric medicine, mental health and epidemiology at Johns Hopkins. His research includes hearing loss and its effects on aging and public health.H

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