MedStar Health Blog

MedStar Health has been conducting a large scale, multi-site Centers for Disease Control and Prevention (CDC) funded Community Research Partnership (CRP) study, “A Prospective Study of COVID-19 Using Real-Time Syndromic Surveillance, Scheduled At-home Serologic Testing, and Electronic Health Records”. The goal of the study is to determine how much of the population has been exposed to the COVID-19 virus by utilizing daily syndromic surveillance, monthly serologic testing, and electronic health record data. The CDC COVID-19 CRP is an at-home research study to help us better understand the best ways to treat and prevent COVID-19.

The study began in November of 2020 and has gained more than 60,000 participants, over 4.5 million daily symptom updates, received over 150,000 serology results, and collected more than 17 million electronic health record data elements. At MedStar Health, there are 11,095 participants who remain engaged in daily syndromic surveillance. There are 8,538 participants enrolled in monthly serology testing with over 44,000 serology kits distributed. More than 50% of these participants have been participating in monthly serology for at least six months – representing incredible engagement from our community that allows the research team to evaluate antibody development and decay over time.

Preliminary study results show that antibodies are identified at a detectable level around two weeks after natural infection or vaccination and these antibodies take longer to develop in older participants. The results also show that in participants with natural infection, antibodies drop to undetectable levels within two to three months as compared to vaccinated individuals with detectable antibodies lasting at least eight months. For patients who were infected with the SARS-CoV-2 virus, antibody decay is more rapid in participants with no or few symptoms as compared to more significant infection.

For participants who seroconverted (serology results were first negative then positive), 35% reported symptoms in the month prior to seroconversion. Participants with positive serology results reported symptom combinations like congestion and anosmia or ageusia (loss of smell or taste). However, symptom combinations like diarrhea and nausea were strongly associated with negative serology. Cumulative reports of symptoms logged by participants in their daily symptom surveillance showed that self-reported symptoms persist weeks after seroconversion with runny nose, muscle pain, headache, fever, and fatigue being commonly reported.

Significant work of the study team is focusing on vaccine effectiveness (with a research letter to be published in the New England Journal of Medicine on October 6, 2021). Looking at both the Pfizer-BioNTech and Moderna RNA vaccines in a case control evaluation, infections were significantly higher in unvaccinated than vaccinated participants, with effectiveness in preventing over 90% of self-reported positive tests for COVID-19. The study team is currently analyzing breakthrough infections and sharing findings to the CDC highlighting the need for ongoing surveillance, screening for novel variants, and possible booster vaccination programs.

As part of daily symptom surveillance, participants self-report symptoms, healthcare utilization, COVID-19 exposures, and public health behaviors including mask use and social distancing. The research team found that mask use is higher in vaccinated participants than unvaccinated, regardless of the month of their first vaccination dose. Mask use remained relatively stable from December 2020 through April 2021 and declined in all groups beginning in mid-May 2021. In all groups, mask use increased again in July 2021, which aligns with public health concerns around the Delta variant. Independent predictors of higher mask use include vaccination, aged 65 and older, female sex, racial or ethnic minority group, and healthcare worker occupation, whereas a history of self-reported prior COVID-19 illness was associated with lower use.

Supplemental surveys were distributed to participants in the winter of 2020 to collect self-reported information on protective behaviors while gathering with friends and family outside their immediate household and if they engaged in protective behaviors including hand washing, social distancing, mask wearing, gathering outdoors, and COVID-19 testing. Significant findings include self-report of gathering with non-household members at Thanksgiving (47%) and during the winter holidays (69%). Only 30-40% of participants wore masks and less than 1/5th were tested prior to gathering.

The study team also distributed a supplemental survey to identify vaccine hesitancy. Results showed that 76% of those who responded intended to get the vaccine, but the data also identified hesitancy in African Americans, suburbanites, women, and those with prior infection. Participants most frequently cited concern over safety and lack of testing. Vaccine updates from participants were monitored through May of 2021. Subsequent vaccine uptake was 99% in non-hesitant participants and more than 50% in those who were initially resistant.

The MedStar Health study site is led by William S. Weintraub, MD, Director of Population Health Research, MedStar Health Research Institute; and Kristen E. Miller, DrPH, Scientific Director, National Center for Human Factors in Healthcare, MedStar Health Research Institute.

When it comes to the aorta—the main artery that takes blood away from the heart to the rest of the body—any condition is challenging. But when the weakened area, tear, or degeneration of the aorta occurs in the chest and abdomen or pelvic area, we classify it as a complex aortic disease. 

Problems such as aortic aneurysms, tears, ruptures, dissections, ulcers, and connective tissue disorders often occur in patients who may be poor candidates for open surgery. So, they need a specialized, minimally invasive procedure. Using fenestrated and branched endovascular aortic repair (FEVAR/BEVAR), I can implant a device that repairs the aortic pathology using stent grafts, without the need for big incisions or the physiologic stress of open surgery. 

In most cases, anatomic location is the deciding factor between traditional surgery or an endovascular procedure, which uses tiny incisions and the body’s blood vessels as the route to repair the aorta. If we can say “yes” to any of these questions, complex FEVAR/BEVAR endovascular repair may be the best route:

• Is the patient too weak or ill to survive open aortic surgery?
• Is the problem area close to important blood vessels, such as the visceral or cerebrovascular vessels? 
• Is there very little healthy tissue remaining on which to attach a stent graft?

Devices used in fenestrated and/or branch technology are tailored to the patient’s anatomy. Two of the more common procedures we perform in the MedStar Heart & Vascular Institute include:

• Fenestrated aortic aneurysm repair surgery (FEVAR): A mesh-supported fabric tube (stent graft) supports weakened areas in the artery. Blood supply is preserved through strategically placed “windows” (fenestrations) in the tube that are bridged into the respective blood (target) vessels using additional stent grafts.
• Branched endovascular aortic aneurysm repair (BEVAR): A stent graft bridges the gap between the aorta and target vessels when the aorta is too wide.

I am one of a handful of  vascular surgeons in the U.S. with an investigational device exemption (IDE) for aortic devices, and the only female surgeon to date. I have the expertise to not only implant these devices, but also design and assemble them to fit a patient’s aorta in a minimally invasive manner.

What to expect at your visit.

We receive many referrals from community vascular surgeons. Patients who come to me are often past the shock of their diagnosis but concerned about going to a specialty center instead of their normal hospital. 

We counter this apprehension with knowledge. I like to draw out the patient’s aortic anatomy, and how a custom device and procedure might correct it. Then, I send the drawing home with the patient to show loved ones and help them get comfortable with their surgical plan. 

We encourage patients to write down any questions they or their family have so we can give them answers by phone or at their next visit. Patients have said they appreciate the drawings as it helps simplify the understanding of this complex disease process.

No matter how many greens you eat or hours of sleep and exercise you get, you can’t stop the aging process—and aging is the No. 1 driver of atrial fibrillation (AFib), which increases the risk of stroke and is the most common type of arrhythmia. 

However, forming healthy habits can reduce your risk of developing AFib. And a newly FDA-approved treatment—which uses technology that MedStar Health experts have mastered for 10 years—is 70% effective at stopping AFib symptoms if you do develop it. 

AFib is a change in the way your heart beats. Your heart has two upper chambers and two lower chambers. To keep your blood circulating, these chambers contract in a specific rhythm: the upper chambers first, followed by the lower ones.

When AFib develops, instead of contracting normally—slowly while you rest and more quickly during activity—the upper chambers get hijacked by chaotic electricity that makes them quiver rapidly. This causes the bottom chambers to contract abnormally.

AFib affects one in four adults over 40, but many people don’t even know they have it. To help you avoid a surprise diagnosis, we’ll discuss how AFib develops, symptoms to look out for, life-changing treatments we offer—and why it’s important to be treated as soon as possible.

How does AFib affect your heart?

AFib is progressive over time, which is why age is the biggest contributor. The progression is similar to the growth of dandelions in your yard: These weeds often appear in just a couple of places and are fairly easy to manage. If you neglect your yard, they multiply until you eventually have no healthy lawn left.

As episodes come and go, they stretch and alter your heart muscle tissue. We classify AFib into four types:

• Paroxysmal: Irregular contractions, or “episodes,” come and go, never lasting longer than a week.
• Persistent: Episodes last longer than a week at a time—even up to a year.
• Long-standing persistent: Irregularities continue for over a year.
• Permanent: Treatment can reduce episodes, but they’ll never go away.

Restoring rhythm earlier can prevent downstream changes—and extend life expectancy. Patients with AFib who are over 65 have a worse five-year survival trajectory than patients with colon cancer or Hodgkin's lymphoma. 

What causes AFib?

Along with aging, internal and external factors can drive AFib. The condition is exacerbated by medical conditions such as:

• High blood pressure
• Obesity
• Obstructive sleep apnea
• Valvular heart disease
  

• Alcohol
• Caffeine
• Dehydration
• Poor sleep patterns
• Stress
  

How is AFib diagnosed?

Diagnosis often begins with a patient’s awareness of an irregularity in their heart rhythm. Nobody shares identical symptoms, but we see common themes such as lightheadedness, neck or chest discomfort, shortness of breath, or what is often described as the feeling of a fish flipping in the chest.

As we treat patients for other cardiovascular risk factors, we also consider their risk for AFib. If you might be at risk, we’ll use an electrocardiogram (EKG) to record your heart’s electrical signal and detect irregular rhythm. 

We don’t currently have recommendations for asymptomatic screening. Fortunately, heart rhythm monitoring is becoming much easier and more common because of the ability to do it through phone- or watch-based apps. As more people use these tools to track their heart’s electric activity, we are seeing many more episodes of arrhythmia occurring in patients without symptoms.

Can AFib be cured? 

With AFib, it’s important to not get stuck on the term “cure.” Literally a lifetime of changes within your heart led to this condition, so our goal isn’t to eliminate every episode but to keep the burden of AFib lower than 1%. 

Regardless of the type of AFib you have, we need to restore your heart’s rhythm. When determining the best treatment for your condition, we focus on:

• Risk of stroke
• Current symptoms 
• Future symptoms
  

Our first and foremost goal is to treat what’s most dangerous. With AFib, that’s stroke risk. Not every patient with AFib has the same risk, but AFib elevates the risk of stroke in everyone, regardless of any other health conditions they have. 

Stroke prevention is primarily done in two ways: medicine (daily aspirin or a blood thinner) or an implantable device that detects rhythm irregularities. Once we address stroke prevention, we focus on symptom management.

Patients may be minimally symptomatic early on, but we must think of the long-term effects of your heart persistently being out of rhythm. Previously, treatment options were primarily drugs that either controlled blood clotting or heart rate. But we’ve learned many other treatment options can effectively get rid of AFib or reduce its burden significantly, which has huge implications for length and quality of life.

Based on how advanced your AFib progression is, we start with simpler approaches and work our way up to more complex, invasive strategies.

We typically start with medication to slow your heart rate and calm the chaos by suppressing the rapid quivering of your upper chambers—a chill pill, if you will. It can work reasonably well but usually not long term.

Our next best step is pulmonary vein isolation, also known as a catheter ablation. We perform this same-day procedure by inserting a thin tube into your heart through the large vein in your thigh.

Delivering radiofrequency energy through this tube, we create scar tissue within your heart to block the chaotic electric signals. This method can be effective for persistent AFib, but it usually needs to be performed more than once. Long-standing persistent AFib often requires a more advanced procedure.

If catheter ablation isn’t effective, we will consider Hybrid AF™ Convergent Therapy, which was recently FDA approved. This type of ablation is hybrid because it combines two specialties—electrophysiology and cardiac surgery—to treat both the inside and outside of the heart.

During this minimally invasive surgery, a cardiac surgeon makes a small incision below the breastbone and three small incisions in the ribs to access the outside of the heart and create scar tissue on its back walls. Then, an electrophysiologist accesses the inside of the heart through the groin and delivers radiofrequency energy that eliminates the abnormal electrical activity. This procedure is available at MedStar Washington Hospital Center and MedStar Union Memorial Hospital.

Convergent therapy is best suited for patients with long-standing persistent AFib, which can be incredibly frustrating. Returning to the dandelion example, at this point the heart is so overrun by “weeds” that drugs and catheter ablation are not enough.

The convergence of technology, specialties, and expertise in a physical location on the heart tissue blunts the progression of AFib and restores normal rhythm, which improves symptoms, helps patients feel better, and improves quality of life. 

This hybrid procedure is the perfect example of our collaborative approach at MedStar Health. We keep your best interest as our focus as we bring different experts into the same room to solve complex problems. We have seen tremendous progress in patients who were told they had no treatment options in the past.

A former patient of mine had psoriasis symptoms that were so severe they couldn’t work or drive due to thick, painful plaques on their hands. I prescribed a biologic therapy—a medication that targets a specific part of the immune system. Six weeks later, the patient was 100% clear and a completely different person.

Today, experiences like this aren’t unique. Because of the advancements in psoriasis research, the ability to be 90-100% clear when using newer medications is very achievable. In the past, our expectations for clearance were much lower. Today, we have so many wonderful options that are much more effective and can truly change a person’s quality of life.

For years, the main goal of prostate cancer surgery was to get rid of the cancer, potentially adding years of life. But advances in prostate cancer screening and treatment have led to radical shifts in treatment recommendations, centered on a key question: How can we not only extend life but also improve a man’s quality of life after prostate cancer surgery?

Prostatectomy—surgery to remove the prostate due to cancer—has evolved over my 15 years of performing these procedures at MedStar Health. 

As the Mid-Atlantic’s most experienced nerve-sparing robotic prostatectomy provider, I’ve seen techniques shift from open surgery with long-term urinary, sexual, and mental health side effects to a modern, precise, minimally invasive procedure that greatly reduces negative side effects with dramatic improvements to patients’ long-term quality of life.   

For men in the U.S., prostate cancer is the second most common cancer and second leading cause of cancer death. By the end of the year, nearly 250,000 men are expected to receive a new diagnosis and just over 34,000 men will die from prostate cancer. 

The good news is that diagnosis of new prostate cancer cases continues to decline while survival rates increase. Reduction of stigma around men’s mental health—paired with advanced screening and imaging technology and refinements in robotic surgery—are making all the difference in not only successful cancer treatment outcomes but also men’s happiness and satisfaction with their care.

Focusing on men’s mental (and physical) health.

Having prostate cancer and undergoing treatment historically has been associated with negative side effects men might be hesitant to discuss, including:

• Depression
• Erectile dysfunction
• Urinary incontinence (leakage, frequency)
  

Because better screening technology helps us detect cancer sooner, patients are living longer—and our modern treatment options support both longevity and quality of life.  

At MedStar Health, we look at the whole picture to determine the most effective treatment options that give patients the best chance to maintain or regain their sense of well-being. Our multidisciplinary team includes not only cancer experts and surgeons but also licensed therapists to help manage mental health symptoms. We make every effort to provide a safe, honest environment where patients feel comfortable discussing their concerns. 

Quality of life will be a leading area of focus in our fall 2021 study with our research partner, Georgetown Lombardi Comprehensive Cancer Center, in collaboration with Hackensack Medical Center in New Jersey. The study will research treatment options that lessen the long-term effects of prostate cancer, as well as bladder and kidney cancer, to help patients live longer, healthier lives.

MRI technology revolutionizes screening results.

Advances in magnetic resonance imaging (MRI) technology over the past five years have revolutionized the way we screen men for elevated levels of prostate-specific antigen (PSA)—a protein made in the prostate and released into the bloodstream. 

Men with prostate cancer typically have elevated levels of PSA. Previously, when high levels were detected through a PSA blood test, we would conduct a biopsy to collect and test prostate gland tissue for cancerous cells. This process had several drawbacks:

• PSA tests can show elevated levels when no cancer is present. 
• Elevated PSA can be a sign of other conditions, such as benign prostate enlargement, a urinary tract infection, or an inflamed prostate gland. 
• Not all prostate cancers are life-threatening, since the cancer is slow growing in many men. Thus, the current goal is to identify patients at high risk of having clinically significant prostate cancer while avoiding unnecessary biopsies in men at low risk.

Using advanced MRI technology, we’ve reduced the number of biopsies we perform by almost half while detecting the same number of cancer cases. Getting sharper, clearer MRIs also helps clinicians and patients make better decisions about who should undergo biopsy for prostate cancer—and who might benefit from certain treatments, including nerve-sparing robotic prostatectomy.

The benefits of robotic surgery.

MRI technology helps us precisely visualize where the cancer is located and whether it is spreading. Based on this information, as well as a patient’s age, overall health, and personal preferences, prostate cancer treatment can include:

• Surgery
• Radiation
• Medication

Surgery is typically the best way to remove the cancer, and MedStar Health continues to lead the Mid-Atlantic region in robotic surgery expertise. Using the da Vinci® surgical robot system, I have performed over 3,000 robotic nerve-sparing radical prostatectomies to treat prostate cancer by removing the entire prostate.

Robotic surgery uses small incisions in the abdomen, through which the surgeon inserts tiny instruments. The robot’s movements mimic the human wrist but with greater dexterity, and its small camera provides a 3-D, magnified view of the prostate and surrounding tissue. Using a console to guide these instruments with extreme precision, we remove the prostate with minimal disruption to the surrounding healthy nerves and tissue that support normal urination and erection. 

Benefits of this approach compared to open surgery include:

• Shorter recovery time
• A faster return to your normal urinary and sexual function 
• Lower risk of surgical site infection
• Less blood loss
• Less pain overall

Robotic surgical removal of the prostate is most beneficial for younger men because radiation can still be used if they have a cancer recurrence after surgery. Regardless of the patient’s age, I approach every patient’s treatment as if it were my own or a family member’s. I am frank and transparent about the risks and complications, such as urinary or erection problems, and remind them that healing is not the same in all men.

MedStar Health has 15 years of follow-up data on men who have had the procedure. Many of my former patients are willing to share their experience with men who are considering the surgery. Every patient who is strongly considering surgery will have the option to speak with a former patient of a similar age and circumstance, which gives them more relatable expectations for life before and after surgery.

As my practice is solely dedicated to performing robotic nerve-sparing prostatectomies, I  have assembled a robotic surgery team around me  which allows me to be directly available to all of my patients and their families through my email and our myMedStar Patient Portal; this communication approach has been especially helpful for men who travel more than one hour away from DC for their surgeries. I am here to support my patients and their families all the way from consultation through surgery and recovery.

What to expect during recovery.

After surgery, patients stay in the hospital for 23 hours or less—a major reduction from the three- to five-day stay typically required for open surgery. Most patients can walk independently the day of surgery, and most feel well enough to go back to work after three weeks.

You will need to keep a catheter in for seven days (instead of three weeks with open surgery), and patients can safely remove the catheter at home. After it’s out, you can start driving right away—but you don’t have to drive to follow-up appointments! If you have no post-operative issues, we can conduct our follow-up visits virtually to save you time and stress.

New technologies and research.

Beyond the da Vinci robotic surgery system, many more technologies in the pipeline will continue to allow surgeons to deliver increasingly precise prostate cancer care.

Experimental studies and trials are using energy-based technology, such as cryotherapy, laser therapy, and high intensity focused ultrasound (HIFU), to develop effective treatments that focus only on the affected tissue. Whether robotically or manually driven, energy-based therapies are the new frontier in prostate cancer treatment.

To determine if prostate cancer screening is right for you, first consider the risk factors: age over 50; being of African descent; having a family history of prostate cancer or an inherited gene mutation linked to colon, breast, or ovarian cancer. 

Falling into one or more of these categories doesn’t mean you should be screened immediately, however. Current prostate cancer screening guidelines from the U.S. Preventive Services Task Force recommend that:

• Men age 70 or older should not be routinely screened for prostate cancer.
• Men age 55 - 69 should discuss the risks and benefits of screening with their doctor and decide together when to begin screening.

When you and your doctor decide to proceed with screening, your well-being will continue to be our highest priority.