From the category archives:

Ask the Expert

November is National Diabetes Awareness Month. With approximately one in three Americans at high risk for diabetes, and 29.1 million Americans diagnosed with the disease, it's important that people become educated on the disease and the risks associated with it. Rita Kalyani, Assistant Professor of Medicine at Johns Hopkins School of Medicine and editor-in-chief, Johns Hopkins Diabetes Guide clarifies some common misconceptions about diabetes.

kalyaniGet more information about Diabetes awareness, including the latest reasearch findings, at the Johns Hopkins Medicine health awareness page. Or visit the diabetes page at the online Johns Hopkins Medicine health library.

What is diabetes?

Diabetes is a serious disease that occurs when the body cannot maintain normal levels of glucose, an important energy source. There are two major types of diabetes: type 1 and type 2. People with type 1 diabetes are unable to produce insulin, a hormone that helps the body metabolize glucose. People with type 2 diabetes can still produce insulin early in the disease, but the body doesn’t appropriately respond to its effects.
Gestational diabetes is a type of diabetes that is diagnosed for the first time during pregnancy in women.

What is prediabetes?

People with prediabetes have elevated blood glucose levels that are higher than normal but fall just below the criterion for diagnosing type 2 diabetes. Prediabetes is often a precursor to type 2 diabetes, but those with prediabetes can delay or prevent the development of type 2 diabetes by making healthy lifestyle adjustments.

Is diabetes preventable?

Based on current knowledge, it is not clear whether type 1 diabetes is preventable, but a healthy diet and regular exercise can dramatically decrease your risk of type 2 diabetes. Losing just 5 percent of your body weight can make a big difference. If you have type 2 diabetes, these same measures may help you manage your blood glucose without insulin.

How is diabetes managed?

If you have type 1 diabetes, you’ll need to start taking insulin upon diagnosis. If you have type 2 diabetes, you may initially be able to manage your disease with weight loss alone, but most patients take pills for diabetes and some take insulin. You should work with your doctor to make sure you’re on track with your treatment goals.

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Charles Reuland, executive vice president and chief operating officer for Johns Hopkins Bayview Medical Center and 2014 United Way campaign chair, talks about the 2014 Johns Hopkins United Way campaign and how we can all help "Change the Odds" for people in need.


reulandWho are our partners in the United Way campaign?

We partner with two affiliates of United Way: United Way of Central Maryland and United Way of the National Capital Area. Both have shown great strength at identifying regional and local needs, establishing priorities for supporting those needs, and serving as a convening force to bring together the resources needed to help address these issues. Examples include providing access to healthy food and promoting stable families, where United Way not only identified these issues but worked to bring together a coalition of like-minded charities and government programs to improve these situations.

The 2014 United Way campaign theme is “Changing the Odds for Families and Communities.” Can you elaborate on what that means?  

Those who live in poverty have—to no one’s surprise—worse experiences and outcomes compared to those who do not live in poverty. By providing targeted and intentional support to people living in poverty, we may not eliminate all bad outcomes, but we will certainly improve the odds of a better outcome for those recipients. For example, by providing an afterschool program for a child whose family lives in poverty, we increase the likelihood that that child completes his or her education successfully.

Why does Johns Hopkins participate in the United Way campaign? 

Our very mission includes caring for the people of our community, and we proudly do that every day in an ever-expanding population. Beyond that, the people who work for Johns Hopkins Medicine share the core value of providing service to those in need. Our individual contributions to United Way make Johns Hopkins Medicine an even stronger contributor to the good in our communities. And I think our organizational credibility is much higher when we can say that our staff and faculty members are the largest contributors to United Way in the region.

What is the goal of the campaign?

Our goal is $1.69 million. We want Johns Hopkins to be the highest contributing organization in the region.

How is my donation used by United Way to help families and communities in need?

When you donate to United Way, your donation goes to help all members of our community have a better life. United Way’s programs and initiatives focus on the building blocks of a good life—a quality education, financial stability for individuals and families, and good health.

Here are a few ways your donation may be used:

  • Your donation may help connect people individuals and families in need to basic services, such as food, shelter and affordable medical care.
  • It may help feed those who are hungry. Nothing else matters if people in need don’t have access to healthy food. United Way supports afterschool meal programs, virtual supermarkets and access to public benefits.
  • It may help empower youth so they can learn to read, read to learn, and succeed in school and beyond. United Way invests in programs with proven success in conducting early interventions and providing academic and social support to students to help them reach their full potential.
  • Your donation may help provide financial education, including asset-building, budgeting and employment coaching, to families in need. United Way invests in workforce development and job training programs that prepare adults for careers that pay a family-sustaining wage and in financial literacy programs that help people better manage their finances.

 Are there any special activities being held to help generate enthusiasm and contributions?

There are host of activities both big and small that have been planned to bring attention to the United Way campaign and to encourage all Johns Hopkins Medicine employees to donate. We recently held a weeklong Food Truck Frenzy on many of our campuses. In addition, all of our entities are participating and have been very creative in coming up with fun events to generate excitement and donations. Examples include a chili cook-off, bake sales, silent auctions, raffles, dress-down and professional sports team outfit days, snack sales, special breakfasts, luncheons and more.

How can the Johns Hopkins Medicine community make a contribution to the campaign?

There are many ways to contribute, including by volunteering and by making a monetary donation. We do not require anyone to volunteer or give to United Way, but we certainly encourage everyone to consider making a contribution in support of this campaign.  We further ask all who are in leadership positions to help us inspire everyone to consider a contribution.

Use this link to make your online donation or pledge if you are employed by the following institutions:

  • The Johns Hopkins Hospital
  • Johns Hopkins University School of Medicine
  • Johns Hopkins Health System
  • Johns Hopkins Bayview Medical Center
  • Johns Hopkins Medicine International
  • Johns Hopkins Community Physicians
  • Johns Hopkins HealthCare
  • Johns Hopkins Home Care Group

If you are employed by Howard County General Hospital, use this link to make your online donation or pledge.

If you are employed by Sibley Memorial Hospital or Suburban Hospital, use this link to make your online donation or pledge.

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As a designated site to care for potential patients with Ebola virus disease, The Johns Hopkins Hospital has and continues to set plans in place to implement the safest procedures possible to keep its patients, employees and visitors safe. Although there are currently no patients with Ebola at any Johns Hopkins Medicine hospital, Johns Hopkins will continue to be proactive in identifying the best measures for preparedness. Dianne Whyne, director of operations for the Office of Critical Event Preparedness and Response (CEPAR), talks about the current state of Ebola preparedness at Johns Hopkins Medicine.

If you have any questions for Dianne on Ebola prepareness at Johns Hopkins, ask your questions in the comments section below and she will answer some of them throughout the day.


How prepared is Johns Hopkins for a patient with Ebola?

Johns Hopkins is well prepared to identify and isolate any potential patients with possible exposure to Ebola, and to work closely with local and state health authorities to make an Ebola case confirmation or rule-out. In addition, The Johns Hopkins Hospital has been designated as one of three hospitals in the Baltimore–Washington region that would care for a patient with Ebola. As a result of many high-level discussions and detailed planning, patient screening procedures, clinical protocols, personal protective equipment training, patient care guidelines and other guidance has been developed in accordance with Centers for Disease Control and Prevention guidelines. To learn more, visit the CEPAR web site:


As an employee, should I be worried about exposure to the virus?

Employees should not be overly worried about exposure to the virus unless they have traveled or are planning approved travel to the areas of West Africa affected by the Ebola outbreak. All faculty, staff and students should become familiar with CEPAR’s interim guidance regarding Ebola and international travel. Read the document:


Are we using what we learned from past emerging disease events, like swine flu, severe acute respiratory syndrome and others?

CEPAR and its experts use lessons learned from disease outbreaks and other threats to help improve future preparedness.


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Some people feel burning in their chest after eating. Others complain of a cough, hoarse voice or trouble swallowing. And then there are those who experience frequent belching or taste acid in their mouth. All of these are symptoms of gastroesophageal reflux, a digestive disorder commonly known as heartburn, which is often humorously depicted in TV commercials touting over-the-counter remedies. But for the estimated 60-million-plus Americans who suffer regularly from gastroesophageal reflux, the condition is no laughing matter. And for a small percentage of people, it can lead to a serious precancerous condition. To learn more about heartburn and gastroesophageal reflux, we turned to Jim Williams, M.D., a family practitioner with JHCP at Sibley Memorial Hospital.

What causes reflux?

Gastroesophageal reflux occurs when acid comes up out of the stomach and travels up the esophagus. This happens because the esophageal sphincter, which opens to allow food into the stomach and closes to keep it in, becomes relaxed for too often or too long. “Certain foods that you eat will make this relaxation of the esophageal sphincter more likely to happen—anything with caffeine, nicotine, alcohol and peppermint,” says Williams. Medications, including those used to treat osteoporosis, can also cause heartburn. So can lying on the couch after dinner.

Who is most at risk?

People with large abdominal girth, smokers and pregnant women. Those who have a hiatal hernia—when the upper part of your stomach pushes up through your diaphragm and into your chest—are also more at risk. “With a hiatal hernia, stomach acid can slide up the esophagus more easily,” Williams says. Hiatal hernias occur in about 3 to 10 percent of people, are more prevalent with age and can be treated with surgery if necessary.

What can I do to prevent reflux?

“The most important thing you can do is to identify the habit that’s the problem and change it,” says Williams. “For example, people who find heartburn and reflux intolerable at bedtime need to avoid eating two hours before they go to bed.” In addition, losing weight, quitting smoking, cutting down on alcohol and avoiding overeating can all help prevent reflux.

What are the most effective treatments?

Over-the-counter antacids like Tums can be helpful in treating reflux, Williams says. For more persistent reflux, Williams recommends taking H2 blockers (acid reducers), like Zantac and Pepcid, which often have to be taken with every meal. “Far and away the best over-the-counter type of medication is a proton pump inhibitor known as Prilosec OTC,” he says.

When should I see my doctor?

Any regular need for H2 blockers or Prilosec OTC should be reviewed with a physician. “You don’t just want to put a bandage on a problem that needs something more,” Williams explains. Here’s why: Neglect your reflux for too long and the condition can become chronic. “If the esophagus is exposed to hydrochloric acid of the stomach repeatedly over time, it gets burned and injured,” he says. One can even develop adhesions in the esophagus that make swallowing difficult. Over years, the affected cells in the esophagus can become precancerous, a condition known as Barrett’s esophagus. “Heartburn ignored for long enough, especially in combination with smoking and too much drinking, puts you at increased risk for cancer of the esophagus,” says Williams.

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Almost everyone expects that the new Maryland Medicare waiver will change the way the Johns Hopkins Health System operates. But what does that mean? Ed Beranek, senior director of regulatory compliance, is responsible for the health system's revenue budget—a forecast of hospital revenue—and regulatory matters involving the Health Services Cost Review Commission (HSCRC), which establishes hospital rates in Maryland. In today's Ask The Expert, Beranek answers some important questions about the waiver.

ed-beranekBeranek will also answer any questions about the Maryland Medicare waiver in the comments section below.

How does the new  waiver affect the Johns Hopkins Health System?

In the past, we generated revenue by increasing our patient  volume; that no longer is the case for our Maryland patients. Now we have a  revenue cap. That means there's a top limit over which we may not go. The  revenue cap is all-inclusive, including volume growth, inflation and growth in  expenses. If our patient volume increases, we need to lower our rates within  the limits set by the HSCRC. Likewise, if our volumes decrease, we need to  raise our rates.

It's a very different mindset. It's going to take us time to  adjust to that; not just us here at Johns Hopkins, but throughout the state.

Why do you draw a  distinction between Maryland and non-Maryland patients?

Twenty-five percent of the revenue at The Johns Hopkins  Hospital comes from outside Maryland. Although those patients are still charged  HSCRC rates, the revenue associated with those out-of-state cases is not  counted in the revenue cap. If we increase the number of patients we treat from  outside Maryland, that additional revenue is ours to keep.

What are we doing to  adjust to this new environment?

It's now more important than ever that we control costs. As an institution, we have certain fixed costs, such as our buildings and the costs of maintaining them, that are not easily reduced.   However, we can drive down our fixed cost per unit by optimizing the volume that we see in those areas. In addition, we can reduce our variable costs, such as supplies. With our large supply chain initiative, we're centralizing purchasing so we can leverage our buying power and get better pricing on medical supplies. We'll also be looking at pharmaceuticals.

The goal is to drive the cost per patient to the lowest level we can while also providing the highest quality care we can. That's how we're thinking about it. We need to focus on the value equation, which is essentially providing the highest quality care at the lowest cost. That is the value that patients and insurers are looking for in the new environment.

What does the waiver  mean for people who work here?

There should be little change, if any, in direct patient  care. We'll stay true to our mission and care for the patient the best way we  can in the most appropriate setting.

What the Maryland Medicare waiver has changed is how we  think about planning. What types of services should we be providing, and where  should we be providing them? Where should we concentrate our marketing efforts?  If a physician wants to start a new clinic, do we do it at The Johns Hopkins  Hospital or at one of our ambulatory sites, such as White Marsh or Green Spring  Station? What location will benefit the patient and Johns Hopkins Medicine the  most?

Our strategic  priority of integration must be key, to have all these individual units moving  more fluidly as a system.

Yes, integration is key to success under the waiver. We have  all the components to be successful in an integrated model. We have medical  assets like the clinics at Green Spring Station, Odenton and White Marsh. We  have community physicians. We have our hospitals.

Now we need to think as a system. For instance, stop  thinking in terms of hospital silos—The Johns Hopkins Hospital, Johns Hopkins  Bayview Medical Center, Howard County General, Suburban Hospital, Sibley  Memorial Hospital. We need to weigh whether it makes sense to take a particular  service and have it at a single site, rather than offer it at both Johns  Hopkins Bayview and The Johns Hopkins Hospital, which are only 3 miles apart.

One very important thing to keep in mind is that we can't  sit back and look at the changes under the waiver and think, "Oh, I wonder  what's going to happen?" We have to take an active role to make sure we succeed  under this system. And the only way we can do that is through integration.

From the patient's  perspective, will we look different?

Over time, we will probably look different. For instance,  wait times are a problem for us. Hopefully, as we become more integrated, long  wait times will decrease, and we can get our patients in faster and more  efficiently. This will improve our efficiency of care, which will improve our  throughput. That, in turn, helps us maximize our patient volume and lower our  costs per patient.

Where else are we  looking for efficiencies?

One initiative we're working on is Clinical Communities.  With physician leadership, we are partnering with the Armstrong Institute for  Patient Safety and Quality to bring together clinicians around a common service  and solicit their input on improving what they're doing. We ask each group,  "What types of data do you need to better manage patients?" Physicians are very  data-driven.

The Clinical Communities develop clinical pathways and best  practices. They're standardizing care, eliminating variations, making it more  efficient. Say our orthopods are using many different artificial joints. Maybe  we can narrow that down and then get better pricing.

Clinical Communities represent a step toward integration,  involving not just The Johns Hopkins Hospital, but also Hopkins Bayview, Howard  County General, Suburban and Sibley. As one of our financial directors says, "We all work for Mr. Hopkins."

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The Johns Hopkins Center for Fetal Therapy, which specializes in diagnosing and correcting rare and complex diseases in the womb, opened its doors in July. With specialists in fetal, maternal, neonatal and pediatric care, the team is changing lives by identifying and treating a growing number of conditions before birth. The Center for Fetal Therapy takes a comprehensive approach to achieve this goal in caring for patients by integrating the full spectrum of clinical and support services.

ahmetbaschat2The director of the center, Ahmet Baschat, is a veteran in maternal-fetal medicine. He was one of the first published authors in the field regarding the potential benefits of a newly modified laser technique for twin-to-twin transfusion syndrome, which has been widely adapted as the standard of care. Baschat will be one of 32 presenters at the 20th annual A Woman's Journey conference on Sat., November 1, where he will speak about how diseases can be treated in utero to preserve life. Visit for more information and to register for this event.

What is fetal therapy?

Fetal therapy is the management of conditions that affect the unborn child. Fetal therapy ranges from direct surgical interventions on the baby, minimally invasive treatments such as fetoscopy, to medical treatments that are either given to the baby directly or to the mother as administered medication that cross the placenta. Part of the treatment is the surveillance for known complications and making absolutely sure that the baby is delivered in the best condition to a pediatric team that is aware of the full spectrum of problems they have to deal with. So it really is a multidisciplinary approach that initiates the treatment for a range of conditions before the baby is born.

What does the Center for Fetal Therapy do? What distinguishes it from other centers in the fetal medicine field?

The Center for Fetal Therapy offers prenatal diagnosis, prenatal assessment of specific conditions, and the counseling and support of all family-related issues that are part of preparing the family to deal with a complicated fetal problem. We offer fetal treatments, both invasive and noninvasive, such as operative fetoscopy and medications. We offer specific delivery timing in coordination with our pediatric colleagues. In addition, we provide maternal management, which is sometimes required, as fetal conditions can also affect the mother.

The important difference between the Center for Fetal Therapy at Johns Hopkins and many fetal therapy centers that exist is that here, all fetal, medicine, maternal medicine, obstetric, pediatric and long-term services are all available under one roof. That is a very unique combination that isn’t offered in many fetal therapy centers.

Why was it important to create this center at Johns Hopkins?

Prior to the opening of the Center for Fetal Therapy at Johns Hopkins, fetal treatments were offered through the Prenatal Diagnosis and Treatment Center. What is different about the Center for Fetal Therapy is it offers more prenatal treatments. We have created a dedicated service that is expanding to offer all the invasive and noninvasive treatment options that are available in the field of fetal therapy.

We also are building a research infrastructure that is absolutely essential to improve these treatments.

In addition, we are instituting a fetal intervention training program, where future physicians, who will be leading this specialty forward, can be trained in the disease-specific applications of all the other techniques that obstetricians and maternal-fetal medicine physicians may use.

How does the decision-making process work as far as how the fetus is treated?

We are trying to establish the most accurate assessment of the condition. Based on the diagnosis, we counsel patients about what the likely outcomes will be. That includes the counseling of outcomes with and without treatments. Then, we present the possible treatment options—there is always more than one option. Next, the risk-benefit ratio is discussed—this is a very individual decision that parents make. At the end of the counseling process, it is imperative for patients to understand what it is that we are dealing with, what will happen if we don’t do something, what we can achieve by doing something, and what the risks to the mother and the fetus are. Based on that, parents have to make a decision.

In conditions that are more complicated, we will sometimes include counseling from colleagues in pediatric surgery, neonatology or pediatrics. This specifically applies to conditions such as spina bifida or congenital diaphragmatic hernia, where it is expected that specific care after delivery will still be required. The prenatal treatment alleviates the amount of damage that is caused by the conditions before delivery.

Why is the management of maternal health so imperative to fetal therapy?

The ability to manage maternal health is imperative, because fetal conditions can affect maternal health, maternal health can affect the fetal conditions and sometimes the treatments we administer have side effects that are pregnancy-specific. So it really is not possible to offer comprehensive care for fetal conditions without also being able to manage complications that can arise in the mother, including preterm labor and cervical shortening. Sometimes even cardiovascular conditions arise when babies are very, very sick, and the recognition of these problems and their management fall into the area of maternal-fetal medicine.

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With flu season approaching, the third year of the Johns Hopkins Medicine mandatory flu vaccine program is in full swing. We sat down with Debbie Dooley, an occupational health clinical nurse manager, to talk about why the vaccination is so imperative this year and about other ways to keep the virus away from you and the people around you this season.

Every staff member, trainee, faculty member, student and volunteer who works with patients or works in a patient care area must receive an influenza vaccination by Tuesday, December 2, 2014

This year,vaccination stations will offer a trivalent vaccine or the recently created quadrivalent vaccine, designed to protect against four different flu viruses instead of the usual three. Dooley says the quadrivalent vaccine is available in small amounts and thus will not be available to everyone, but the trivalent vaccine is still a more than sufficient combatant of the virus.

Why is it so imperative to get vaccinated?

I think first, it’s a patient safety issue. It’s important for us, that we can protect our patients from the communicable diseases. Our patients are already sick, and if we are immune to the flu bug, then we are going to protect them.

The second reason is because it’s a health and wellness precaution for our employees to stay healthy during the flu season. It’s shown that if you get a flu shot, you are less likely to get the flu. It’s not 100 percent, but it would certainly be less likely than if you didn’t get the shot.

The third reason is to protect our families. We don’t want to expose our families to the flu. It’s actually something the whole family should do together to promote their health during this time.

When should people get vaccinated?

We encourage people to get their flu shots now so that their immunity is established before the holidays. I always say it’s important to get your vaccination by mid-November, because when the holidays come, we’re all around each other, and it’s easier to share germs. It takes two weeks for the regular shot to reach full immunity for most people, so it’s important that you get the vaccination two weeks before the holiday’s start.

Are there increased concerns this year with some of the other stories on viruses making news this year?

Definitely. I’m hearing a lot more people interested in also getting pneumonia and shingles vaccinations, which are also related to the spread of bacteria. So I think that has spurred people into looking at protecting themselves with all vaccines to keep themselves as healthy as possible, especially with these other virulent viruses out there. So if you can keep yourself healthy and keep your immune status up, then you’ll be able to fight those as well.

What other precautionary measures can people take to protect themselves this year from the flu?

The number one thing is to always wash your hands. Just touching your face after you’ve touched something unclean can cause you to be exposed to germs, so use the sanitizers and the sanitizing devices you see around. You see people carrying that around with them when there are not adequate facilities to wash their hands, that’s a great thing you can do.

Another thing is to keep yourself hydrated and to eat well. You should also get a good night’s sleep so that you aren’t run down and so your immunity status stays strong. Exercising is important, too. All those things, especially this time of the year, are so important to do, because you keep your body in shape to fight these viruses.


For more information, including schedule and locations for flu vaccination, please visit

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The Johns Hopkins Medicine Healthy Beverage Initiative aims to help faculty, staff, patients and visitors make healthier drink choices in their everyday lives. Part of the initiative is to increase the availability of healthy beverages to help offset that of sugar-sweetened beverages, which have shown to elevate problems such as obesity and diabetes, among others.

LawrenceAppelLawrence Appel, director of the Welch Center for Prevention, Epidemiology and Clinical Research, is one of five subject matter experts from the school of medicine and Bloomberg School of Public Health who contributed to the healthy beverage strategy. In today’s Ask the Expert, Appel explains the risks in drinking sugar-sweetened beverages and ways to reduce consumption.

Be sure to visit the Johns Hopkins Healthy Beverages page for more information on this initiative.

What is a sugar-sweetened beverage?

Sugar-sweetened beverages are drinks sweetened with sugar, high-fructose corn syrup or other caloric sweeteners. In addition to nondiet soft drinks, sugar-sweetened beverages include flavored juice drinks (like apple juice), sports drinks, sweetened tea, coffee drinks, energy drinks and electrolyte replacement drinks.


What different types of sugar are added to beverages? Are some better for you than others?

The most common form of sugar in sugar-sweetened beverages is high-fructose corn syrup. The term is a bit misleading, because high-fructose corn syrup is only about half fructose. It is similar in composition to routine table sugar. There is some debate about whether high-fructose corn syrup is worse than other forms of sugar. I tend to focus on total calories, which is probably the major culprit, rather than the form of the sugar.


Why is it important for us to limit the number of sugar-sweetened drinks we consume?

Sugar-sweetened beverages contain large numbers of calories, especially given the current size of beverage containers—often 18 ounces or more. Humans also have a problem regulating calorie intake from beverages. Our bodies don’t sense the excess calories, and we continue to consume these beverages even though we don’t need more calories.


Does drinking sugar-sweetened beverages really have an impact on our health?

Evidence on the harmful effects of sugar-sweetened beverages continues to get stronger. The primary concern is excess weight gain, particularly in children and young adults. It has been estimated that in young adults, approximately 20 percent of calories come from sugars. Obesity is a major risk factor for type 2 diabetes. In addition, there is emerging evidence that sugar-sweetened beverages increase the risk of heart disease.


Why are diet beverages classified in the green, or “healthy,” category as part of the Healthy Beverage Initiative?

The focus of the Healthy Beverage Initiative is to reduce excess calorie intake. Hence, diet beverages, which have few calories, are placed in the “green” category.


If someone doesn’t want to totally give up sugar-sweetened beverages, are there tips you can offer to cut the calories in sugary drinks?

There are several strategies. First, buy the smallest size of the sugar-sweetened beverage that is available. Don’t be lured by value—“Only 10 cents more to supersize it!” Value now comes at the expense of excess weight later in life. Second, never finish the sugar-sweetened beverage all at once. Stretch out consumption over more than one drinking occasion. Third, avoid purchasing sugar-sweetened beverages when you’re thirsty—you need the water, not the calories, that come with the beverage. Fourth, add ice cubes to the drink so it looks like you’re getting more. Pay attention to what triggers you to want a sugar-sweetened beverage. Before drinking one, make sure you really want it. And if you must have a sugar-sweetened beverage, be sure to savor it as special and not routine.


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October is Breast Cancer Awareness Month, which has gained widespread attention and support over the last decade. Through all of the fundraising efforts and creative initiatives that have coincided with the campaign, it may be easy to forget a key component to helping fight the disease – getting screened.

Dr. Susan HarveySusan Harvey, director of the Johns Hopkins Breast Imaging section, leads the breast imaging enterprise at Johns Hopkins including the Johns Hopkins imaging sites located at Green Spring Station and White Marsh, the Johns Hopkins Outpatient Center, and the Bayview Medical Center Breast Center. In today’s Ask the Expert, Harvey answers some commonly asked questions about the screening process and explains why getting screened is so vital.

If you have any questions about breast cancer screening, Bonmyong Lee, Assistant Professor of Radiology and Radiological Science will be available throughout the day to answer your questions in the comment section.

What are the current guidelines for getting a screening mammogram?

The guidelines for screening mammography have not changed, but they are inconsistent here in the United States. They vary from beginning annual screening at age 40 without a defined age end point to beginning at age 50 and continuing every other year until age 65. The unfortunate result of the lack of clarity is confusion for both patients and primary care providers. In breast imaging at the Johns Hopkins Department of Radiology and Radiological Science, we follow the American College of Radiology guidelines suggesting annual screening from age 40 onward, which matches several other society recommendations.

What are some of the high-risk factors of breast cancer?

Risk factors for breast cancer can be divided into factors women can change and factors women cannot change.

Factors that cannot be changed include:

Being a woman: Women are 99 times more likely than men to have breast cancer

Aging: The risk of breast cancer increases with age in a linear fashion.

Family and genetics: Only about 10 percent of breast cancers are related to inherited genetic mutations. The most common are BRCA 1 and BRCA2. However, it is important to recall that most cancers arise from spontaneous not inherited mutations.

Breast tissue density

Age of menarche: The age at which women begin their periods is a risk factor. Women are at higher risk when they get their period at a younger age.

Radiation to the chest for malignancy: This is unusual, but treatment of other malignancies with chest radiation elevates the risk of breast cancer.

Previous personal history of breast cancer: This makes breast cancer more likely.

Factors that women can change include:

Weight: Obesity is a breast cancer risk factor

Smoking: This increases lung and breast cancer risk.

Exercise: Women who exercise regularly have a lower cancer risk.

Alcohol intake: Heavy drinking is related to an increase in cancer risk.

Hormone replacement: Long-term hormone use is considered a risk factor.

Child birth: Having no children or being an older age at child bearing is a risk factor.

What can mammogram results tell a woman?

Mammography results can inform women of their breast tissue density and also about vascular calcifications, which in some instances can be reflective of other vascular disease. There is compelling evidence that breast density is a risk factor for breast cancer, either on its own or in combination with other risk factors. A higher breast density may signal the need for supplemental screening examinations, such as a breast ultrasound or breast magnetic resonance imaging.

Can those results indicate other issues?

There are other findings on mammography that can be clues to or are signs of disease. For example, enlarged lymph nodes can be a sign of lymphoma, autoimmune diseases, inflammation or infection. There are times when edema, or swelling, in the skin, can be seen with cardiac dysfunction or infection. Calcifications in lymph nodes can be seen with previous fungal infections and sometimes with previous radiation treatment.

Are there any new technologies being applied to the breast screening process?

Three-dimensional mammography is a new technology that is an advanced digital mammogram. This technique allows several low-dose images to be reconstructed into 1 millimeter slices through the breast. This is similar to computed tomography, or CT, used in other parts of the body. Three-dimensional mammography mitigates the impact of overlap and summation of tissues, which can both obscure and mimic cancers. This allows an increase in invasive cancer detection and a decrease in the number of women recalled for further evaluation. Three-dimensional mammography is a more accurate screening test, as shown by several large trials in the U.S. and Europe.

What does it mean when someone is called back for additional imaging?

Being called back means that a possible abnormality has been seen on screening mammography and requires further evaluation to assess if there is a significant finding that could be suggestive of breast cancer. The majority of women asked to return are found to have normal breast imaging or a benign, non-cancerous, finding at the time of further evaluation. Only about 2 percent of women require biopsy after this further imaging is performed.

What is the difference between a screening mammogram and a diagnostic mammogram?

Screening mammography is a four-view imaging exam performed in women who have no clinical symptoms or signs of cancer. This exam has been proven to decrease mortality from breast cancer from 30 to 40 percent.

Diagnostic mammography is performed for women who have symptoms such as a palpable lump or nipple discharge. In addition, diagnostic mammography is performed for women who have had breast cancer treated in the past or who have been identified to have an abnormality on their screening mammogram that requires further evaluation. Breast pain can be an indication for diagnostic mammography but only when previously assessed by a woman’s primary care provider.

What can women do to help avoid breast cancer or detect breast cancer early?

Annual screening mammography was proven to decrease mortality by 20 to 40 percent in large European and American trials. Annual screening mammography is one of the most significant actions women can take to allow earlier detection of breast cancer.

As mentioned above, there are also some behaviors and life style choices that can impact breast cancer risk.


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As people age, memory loss can suddenly become a concerning issue. While some people expect that distant memories will natually become foggy, it doesn't have to be a foregone conclusion. In fact, there are a number of ways to help keep your memory sharp as you get older.  Dr. Constantine G. Lyketsos, MD, Director of the Memory and Alzheimer's Treatment Center, provides some tips for healthy mental aging.

For more on memory preservation and the difference between normal memory changes and signs of dementias, register for the 2014  A Woman's Journey conference where Dr. Lyketsos will host one of 32 featured seminars, "A Trip Down Memory Lane." A Woman's Journey conference takes place Saturday, Nov. 1. For more information visit,

  • Track your activity, sleep, steps and weight
  • Avoid unnecessary medication use. Don’t take pills you absolutely don’t need.
  • Be wary of what is being sold in alternative health care. Make sure that you are getting what you pay for and understand any potential risks.
  • Don’t fully retire unless you must. If you do retire, keep as active as possible
  • Stay healthy: manage your weight, blood pressure, blood sugar and other health conditions. Stay engaged with a good primary care doctor.
  • Sleep well – at least seven hours a night. Make sure that you are getting enough rest!
  • Limit the effects of stress on your body (try meditation!)
  • Keep physically active. Emphasize variety, combine different forms of physical activity over time. Formal exercise is only one form of physical activity. Change your regimen once a year.
  • Keep mentally active. Learn new things: a language or musical instrument, for example. Take a course in a field that is outside of your past experience and comfort zone.
  • Keep socially active. Stay engaged with family, social organizations, religious activities, etc.
  • Follow a Mediterranean diet. Eat lots of fruits vegetables, fish and olive oil.
  • Consume antioxidants. Examples of these include blueberries, red wine or dark chocolate.

For more information on memory loss and related conditions, visit the Memory and Alzheimer's Treatment Center

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