Successful Delivery of Baby to COVID-19 Positive Mother: A Case Report from MedStar Health

Researchers from MedStar Washington Hospital Center and MedStar Georgetown University Hospital successfully delivered a healthy baby to a mom and dad who both tested positive for COVID-19. The case report, “An Uncomplicated Delivery in a Patient with COVID-19 in the United States” was published in the April 1 edition of The New England Journal of Medicine.

This case describes uncomplicated labor and delivery in a 34-year old woman, at 39 weeks of gestation who was tested positive for COVID-19.  When presenting to the hospital, the mother had experienced a 3-day history of fever, chills, dry cough, and myalgia. She also reported decreased fetal movements over the previous day. The patient had not recently traveled, and her husband shared similar symptoms.

The appropriate measures for care were initiated and she was transferred to the emergency department after no obstetrical intervention was determined to be needed.  The patient’s history and findings on the chest radiography were consistent with COVID-19.  On day two of her hospitalization, the patient began to experience irregular contractions and oxytocin was provided to initiate labor. Prior to delivery, neonatal intensive care physicians consulted with the patient to review hospital protocol for mother and baby separation in setting of COVID-19.  During her labor, the patient’s test results confirmed a positive result for COVID-19.

Personal Protective Equipment (PPE) of hospital staff included gown, gloves, bouffant disposable surgical cap, knee high shoe covers, eye protection, and N95 mask. The patient always wore a facemask and was able to have a vaginal delivery without complications.

The infant’s first COVID-19 test was performed at 24 hours of age, with a negative result and the second test at 48 hours is currently pending. The mother showed no subsequent fevers or increased symptoms and the infant was allowed home with parents after clearance given by the infectious disease service. The husband relocated to a hotel nearby to complete his quarantine period.

The pediatric team followed up with the family and confirmed the baby is doing well and remains asymptomatic. The patient has a mild dry cough without fever or shortness of breath. The father of the infant is also doing well.  7 days after delivery, no caregivers appeared to be infected.

The team included Sara N. Iqbal, M.D.; Rachael Overcash, M.D.; Neggin Mokhtari, M.D.; Haleema Saeed, M.D.; Stacey Gold, M.D.; Tamika Auguste, M.D.; Muhammad-Usman Mirza, M.D.; Maria-Elena Ruiz, M.D.; Masashi Waga, M.S.; Glenn Wortmann, M.D.; and Joeffrey J. Chahine, M.S.

Congratulations to the team on the successful patient outcome, successful provider precautions, and on publication of this case report.

The New England Journal of Medicine, DOI: 10.1056/NEJMc2007605

MedStar Health Top Enroller for COVID-19 Treatment Clinical Trial

MedStar Health is participating in a multi-center, randomized, placebo-controlled clinical trial to help evaluate treatment options for patients with COVID-19. We are proud to be contributing to the overall research happening during this pandemic.

In order to identify safe and efficacious therapeutics for emerging infections, conducting well-controlled, randomized trials is a necessary step. With limitations in resources and shortages during a pandemic, obtaining data on multiple therapeutic options is a critical element of operations.

The research is evaluating the clinical efficacy of sarilumab, a fully-human monoclonal antibody that inhibits the interleukin-6 (IL-6) pathway. This work is supported by preliminary data from a single-arm study conducted in China using another IL-6 receptor antibody. While the primary end-point of the study is to evaluate efficacy in all patients, the study will also seek to identify outcomes based on severity level of the COVID-19 infection, along with other clinical treatments used to support positive patient outcomes.

The press release from Regeneron on this research can be found here: https://investor.regeneron.com/news-releases/news-release-details/regeneron-and-sanofi-begin-global-kevzarar-sarilumab-clinical

Comparing Treatment and Outcomes for Patients with ACE-Inhibitor Induced Angioedema across MedStar Health

Recently published research from a collaborative team from across MedStar Health hospitals sought to compare patient demographics, treatment, and outcomes for Angiotensin-converting enzyme (ACE) inhibitor-induced angioedema to outcomes for patients with angioedema from other causes in our regional health-care system. ACE angioedema has not been characterized in comparison with angioedema from other causes in acute hospitalized patients.

Angioedema is the rapid or swelling of the area beneath the skin. It is normally an allergic reaction, but it can also be hereditary It tends to affect areas with loose areas of tissue, especially the face and throat, as well as the limbs and genitals.

The study “ACE inhibitor angioedema: characterization and treatment versus non-ACE angioedema in acute hospitalized patients” retrospectively compared patients admitted from the emergency department with angioedema or developed angioedema during the hospital course.   The electronic medical record data abstraction tool included demographics, etiology of angioedema, treatments, clinical outcomes, and intensive care unit (ICU) admission and intubation.

A total of 855 patient records were screened and 575 cases met the inclusion criteria of angioedema diagnosis. Of these, 297 had ACE angioedema and 278 had angioedema from other causes. Epinephrine was prescribed in 21% of ACE angioedema cases. One-third of patients in all groups were admitted to the ICU, and about 25% required intubation. Previous history of ACE inhibitor-induced angioedema was found in 63 of 278 non-ACE cause angioedema patients (23%) and in 23 (8%) in the ACE cause group. Age was significantly higher in the ACE cause group. At least 80% of cases in all groups were African American.  The current data suggest that angioedema poses a significant risk to patients regardless of the etiology, as 25% of patients required airway protection in the form of intubation.

The research concluded that ACE inhibitor-induced angioedema represented half of angioedema admissions over the study period.  The study found that physicians often prescribed medications that are known not to be effective for treating ACE-induced angioedema. This finding may be to the difficulty of making a definitive diagnosis. The study also identified that over 95% of the documented indications for ACE inhibitors were for hypertension. This finding supports consideration of alternate medications such as angiotensin receptor blockers to avoid the potential for angioedema from ACE inhibitors, especially in high-risk patients.

The study team included David S. Weisman, MD, DO; Nelly Arnouk, MD; M. Bilal Ashar, MD; Raheel Qureshi, MD; Anagha Kumar, Sameer Desale , Lyn Camire and Stephen Pineda  from MedStar Good Samaritan Hosptial, MedStar Union Memorial Hospital and MHRI.

Journal of Community Hospital Internal Medicine Perspectives, DOI:10.1080/20009666.2020.1711641

MedStar Investigator Evaluates Medicaid-funded Tenancy Support Services for Homeless Adults

Under the Affordable Care Act, large numbers of homeless adults gained Medicaid coverage and policymakers began to identify strategies to improve care and reduce avoidable hospital costs for homeless populations. “Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid‐Funded Tenancy Support Services” was published in The Milbank Quarterly by MedStar investigator Dr. Derek Delia, c Director of Health Economics Research at MHRI. The study sought to examine data that would suggest tenancy support services (TSS) can reduce avoidable health care spending.

 

The study utilized linked data from the Homeless Management Information System and Medicaid claims to identify homeless adults who could be eligible for Medicaid TSS in New Jersey.  The data compares their Medicaid utilization and spending patterns to matched non-homeless beneficiaries. Homeless adult beneficiaries have higher levels of health care needs compared to non-homeless adult Medicaid beneficiaries. 

In 2016, more than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS. Approximately 4,000 adults were living in permanent supportive housing, 800 formally designated as chronically homeless and 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. In this study, the homeless adults tended to have substantial difficulties with mental health and substance abuse disorders and are more inclined to visit the emergency department or require inpatient admission. The results showed that Medicaid spending for a homeless beneficiary eligible for TSS ranged from 10% to 27% ($1,362 - $5,727) over what was spent on a non-homeless Medicaid beneficiary.

The study found emergency care and inpatient admissions can possibly be avoided when individuals have access to high-quality, community-based care.  Providing tenancy support services to homeless adults may help the population achieve stable housing and other healthy living conditions.  In conclusion, Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

The research team included Derek DeLia, PhD, from MedStar Health Research Institute in collaboration with researchers from the Rutgers Center for State Health Policy, Monarch Housing Associates, and Rutgers School of Social Work.

The Milibank Quarterly, DOI: 10.1111/1468-0009.12446

RFA Now Available for Pilot Awards for Clinical Translational Studies through GHUCCTS

Applications are now being accepted for the Pilot Awards for Clinical Translational Studies (PTCS) through GHUCCTS.  Applications Submissions are online at PTCS Applications. The completed application and signed forms (institutional support forms) are due by Monday, May 4th, 2020 at 11:59 pm.

Funding Priorities

  • Research that addresses the transmission, course, and consequences of COVID virus infection
  • Investigations of environmental determinants of health, particularly those involving clinical and/or public health databases and geospatial mapping, and have potential to point toward solutions through surveillance or policy. 
  • Innovative community engagement methods and technologies including research aimed at engaging minority, vulnerable, or other understudied populations;
  • Research that brings together a new type of team;
  • Research that expands a translational research focus across the lifespan including to pediatric and/or geriatric populations;
  • Innovative approaches to the implementation of precision medicine;
  • Engaging individuals with Opioid Use Disorders in research and clinical care while developing effective models of care delivered within medical settings of interest;
  • Research to address health disparities and the significant burden of conditions that disproportionately affect rural, minority, and other underserved populations.

Eligibility

Applicants must have a full-time faculty appointment at one of the GHUCCTS institutions (Howard, Georgetown, DCVA, MedStar, ORNL). Each application should identify a Contact PI that will be responsible for coordinating and submitting the application. Research teams can include collaborators who are not GHUCCTS affiliated.

Funding Opportunity Details

  • Award Amount: up to $40,000 (includes Institutional cost share)
  • Duration: Funds must be spent by March 31st, 2021.
  • A 50% cost-share with the applicant institution is required. (In most cases this has previously been negotiated with the participating institutions.)

Applications Submissions are online at PTCS Applications. The completed application and signed forms (institutional support forms) are due by Monday, May 4th, 2020 at 11:59 pm

About GHUCCTS

The missions of Georgetown-Howard University Center for Clinical and Translational Science (GHUCCTS) and the national Clinical Translational Science Award (CTSA) programs highlight promotion of interdisciplinary research that translates basic research findings into clinical applications and clinical research into community practice, and improving the process of research. It is also our goal to implement research that will benefit underserved populations, including minorities, people with disabilities, and older adults. Additional priorities recently indicated by the agency that administers CTSAs, the National Center for Advancing Translational Science (NCATS) (see https://ncats.nih.gov/ctsa), further emphasize interaction and collaboration of the 62 CTSA hubs spread throughout the United States (see https://ctsacentral.org).  

March Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in March 2020. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation. Congratulations to this month’s authors. We look forward to seeing your future research.

View the full list of publications on PubMed.gov here.

Selected research:

  1. Combined Vascular Brachytherapy and Stenting for the Treatment of In-Stent Restenosis
    The American Journal of Cardiology, 2020. DOI: 10.1016/j.amjcard.2019.11.035
    Chen Y, Buchanan KD, Chan RC, Zhang C, Torguson R, Satler LF, Waksman R.
  1. Ten Best Practices for Improving Emergency Medicine Provider-Nurse Communication.
    Journal of Emergency Medicine, 2020. DOI: 10.1016/j.jemermed.2019.10.035
    Hettinger AZ, Benda N, Roth E, Hoffman D, Iyer A, Franklin E, Perry S, Fairbanks RJ, Bisantz AM.
  1. The Effects of Global Budgeting on Emergency Department Admission Rates in Maryland.
    Annals of Emergency Medicine, 2020. DOI: 10.1016/j.annemergmed.2019.06.009
    Galarraga JE, Black B, Pimentel L, Venkat A, Sverha JP, Frohna WJ, Lemkin DL, Pines JM.
  1. Nationwide Survey on Implementation of 2011 Nuclear Regulatory Commission Policy on Release of Patients After 131I Therapy for Thyroid Cancer.
    The Journal of Nuclear Medicine,  2020. DOI: 10.2967/jnumed.119.230730
    Wu D, Gomes Lima CJ, Bloom G, Burman KD, Wartofsky L, Van Nostrand D.
  1. Racial differences in takotsubo cardiomyopathy outcomes in a large nationwide sample.
    ESC Heart Failure, 2020. DOI: 10.1002/ehf2.12664
    Zaghlol R, Dey AK, Desale S, Barac A.

Spring Regulatory Update & Hot Topics in Clinical Research – Apri 20-22, 2020

The Spring Regulatory Update & Hot Topics in Clinical Research conference will be held on Tuesday, April 21 from 9:00am to 2:45pm.

This annual meeting brings researchers, administrators, and clinical professionals from throughout the Clinical and Translational Sciences Awards (CTSA) region together for collaborative discussion and response to regulatory revisions and identified clinical research priorities within the current landscape of clinical trials.

The focus for this meeting will be on “COVID-19: the Virus, Preparedness in the time of Crisis, and Clinical Research." The event is free and open to any individual in the capital region that leads or supports clinical research programs.

Please  register online by Wednesday, April 15, 2020.

The event organizers are committed to the safety and health of our community and are closely monitoring the COVID-19 situation and CDC guidelines. We encourage individuals that are interested in attending this program to RSVP. 

The Conference will be via web, the organizers will communicate any updates or changes to the registered attendees.  

Registration Now Open for the 2020 MedStar Health-Georgetown University Research Symposium

Registration is open for the 2020 MedStar Health-Georgetown University Research Symposium on Monday, April 6, 2020 at the Bethesda North Marriott Hotel and Conference Center.

The MedStar Health - Georgetown University Research Symposium and Colloquium for Educators in the Health Professions are open to all members of the research and education community interested in learning more about scholarship at MedStar and Georgetown.

Beginning in 2019, the Research Symposium partners with the Center for Innovation and Leadership in Education (CENTILE) at the Georgetown University Medical Center to host the Colloquium for Educators in the Health Professions as part of the event. The Colloquium is an opportunity for those across the system focused on education to gather, share ideas and learn together.

This full day event brings together the MedStar Health and Georgetown University communities to celebrate the great work of our colleagues. It offers the unique opportunity to connect with researchers, educators, residents, executive leaders, and collaborative partners from across the region and our system to build meaningful relationships to further advance the health of our community.

The Research Symposium features scientific poster presentations from investigators across the system and the spectrum of care, information on research support services offered by MedStar Health Research Institute and the opportunity to connect with residents and researchers dedicated to advancing health. 

Learn more and register at MedStarHealth.org/Symposium.

Agenda

8:30 am – noon

Seventh Annual Colloquium for Educators in the Health Professions

Hosted by GUMC’s Center for Innovation and Leadership in Education (CENTILE), the Seventh Annual Colloquium for Educators in the Health Professions Colloquium is an opportunity for those across the system focused on education to gather, share ideas, and learn together.

8:45 am: Opening Remarks

9 am: Oral Session 1

9:50 - 10 am: Break

10 - 10:50 am: Concurrent Symposia

  • - Leadership and Management Curriculum in Graduate Medical Education: Resident Initiatives and Program Director Intuitions
  • - Medical-legal partnership as a boundary spanning educational model for health professionals

10:50 - 11 am: Break

11:10 am: Oral Session 2 - Curriculum Innovations

Noon – 1:15 pm

Plenary Speaker and Lunch

David J. Skorton, MD, AAMC President & Chief Executive Officer

1:30 pm2:15 pm

2:30 pm – 3:15 pm

Pre-Symposium Professional Development and Advancement Sessions 
These 45-minute optional workshops are offered before the Symposium and are intended to provide small group educational sessions hosted by experts from the MedStar Health & Georgetown University community. Each session focuses on a specific academic topic and is open to all Symposium attendees. Seats will be reserved for those who pre-register for the event. Attendees who do not pre-register for a session or who register on-site may attend these sessions on a first-come, first-seated basis.

  • Abstracts, Manuscripts, Journals - Oh my!
    Kristen Miller, DrPH, CPPS
  • Demystifying the IRB
    Jim Boscoe; Kristen Katopol, MS, CIM
  • GUMC Academic Appointments & Promotions Updates
    Elliott Crooke, PhD
  • How to “Thrive” in Wellbeing Research
    Mihriye Mete, PhD; Daniel Marchalik, MD, MA
  • Stats Fundamentals
    Stephen Fernandez, MS
  • Tips for Funding Success
    Angela Thomas, DrPh; Federico Asch, MD
  • Can You Entrust Your Student/Resident/Fellow With This Patient Care Activity? Using Entrustment-based Discussions to Support Your Decision (90-min session)
    H. Carrie Chen, MD, PhD
  • Giving Feedback in Clinical Learning Environments (90-min session)
    Robin Gross, MD, FCCP
  • Principles of Design Thinking (90-min session)
    Brian Boston, MA; Mindy McWilliams, MA

2:30 pm – 3:15 pm

GME Town Hall
Residents, fellows, and faculty members from clinical sites throughout the MedStar Health GME consortium are invited to join for an interactive, system-wide town hall session.  Executive and administrative leaders representing MedStar Health corporate, hospitals, system GME, and local/institutional GME will present pertinent updates regarding our clinical learning and working environments, and be available to answer any questions that you may have.

3:30 pm - 4:30 pm

Resident & Fellow Oral Presentations
As part of the MedStar Health system-wide resident research day, residents and fellows with the top scoring abstracts are invited to give a short oral presentation on their research to attendees. These presentations allow residents and fellows to gain the experience of presenting their research and allow them to share their work with the larger MedStar Health & Georgetown University communities.

4:30 pm

Abstract Presentations & Moderated Poster Sessions
The main feature of the Research Symposium, the Grand Ballroom opens to showcase the peer-reviewed abstract presentations from across MedStar Health & Georgetown University. Ranging from health services research to critical care to orthopedics, all departments and entities are represented by established investigators, residents, and fellows. Also featured during this time is a moderated poster session for resident and fellow submissions.

5:45 pm

Main Stage Presentations & Keynote Address
Join leadership from MedStar Health and Georgetown University in the main ballroom to recognize the importance of research and collaboration in our community and present awards to investigators with top scoring poster submissions. The keynote speaker for this year is David J. Skorton, MD, AAMC President & Chief Executive Officer.

6:30 pm

Post-Symposium Gratitude Reception 
Hosted by MedStar Philanthropy, all are invited to attend an on-site reception directly following the Moderated Poster Presentations & Awards in the main ballroom. This will provide further networking with MedStar leaders, researchers, associates, grateful patients and donors to research.

 






Patient Outcomes After Liver Directed Therapies: MedStar Health Teaching and Research Scholars Capstone

MedStar Health Research Scholar Alexander Kim, MD recently presented his preliminary work on improving patient outcomes after liver directed therapies at the Research Scholars Capstone event. His two research studies were focused on the use of radioembolization and patient outcomes. Radioembolization is a type of intra-arterial therapy wherein radiation particles are infused from the hepatic artery to treat liver cancers.  Previous research has demonstrated that radioembolization leads to high rates of local tumor response rates. However, randomized trials of radioembolization in various tumor types have not led to improve patient overall survival.

The objective for the first study was to identify a liver function test which could improve both patient selection criteria and define liver toxicity better than the current standard. A secondary goal was to identify methods to improve particle delivery to tumor and reduce particle delivery to normal liver which would improve disease response and reduce liver toxicity. The most commonly used parameter when assessing patients for radioembolization in clinical practice is the total bilirubin level. It is common for radiologists to use a total bilirubin level of 2 as the cutoff to determine treatment eligibility.

 The study recruited 15 patients who were being considered for radioembolization. The patients underwent Quantitative Liver Spleen Scan (QLSS) and Perfused Hepatic Mass (PHM) values were correlated with the total bilirubin level and other indicators of liver function used in various clinical situations including Albumin, MELD, the ALBI score/grade, and Child Pugh Score (CPS). The study results found there was a poor correlation between PHM and all parameters except for the ALBI score, which was a moderate correlation. To conclude, even though total bilirubin level is often used to determine patient eligibility for radioembolization, it appears to be a poor measure of liver function in patients being considered for liver-directed therapy.

The objective of the second study was to identify a method which would allow for improved radiation targeting to tumor and sparing of the background liver. The goal was to improve treatment response rates but also reduce liver functional impairment.

The rationale for radioembolization and other intra-arterial therapies is dependent on the unique blood flow of the liver. However, for patient who develop liver cancers, studies have shown that over 90% of the tumor blood flow is arterial in origin. The standard method of performing radioembolization is to deliver radiation particles through a standard microcatheter. However, a newer type of catheter has recently been introduced in the market. These catheters have been demonstrated to alter the blood pressure in the hepatic artery.

To test Dr. Kim’s hypothesis, the research team used an animal model (woodchuck HCC) to perform a pathologic assessment of particle distribution. The woodchuck is large enough to allow for the performance of arterial catheterization. For this study, three woodchucks underwent embolization (two using the pressure altering catheter (PAC) and one with a standard microcatheter). After embolization, the woodchucks were sacrificed and pathologic assessment of the liver was performed where particles in tumor and background liver were manually counted.

The study results found that more particles appear to be delivered with the use of the pressure altering catheter compared to the standard catheters. The tumor to normal particle distribution ratio appears to overlap between the two catheter types. However, there appears to be a much greater particle density in tumors in the animals embolized with the pressure altering catheters. To conclude, when comparing particle distribution in the central half to the peripheral half of the tumor, there is a much greater ratio of particle deposition in the central half of the tumor, suggesting that the pressure altering catheter allows for deeper penetration of the infused particles.

For future research, the research team has a prospective study designed with partial funding secured in hopes to follow liver function prospectively, before and after treatment with radioembolization. The long-term goal is to identify a better measure of liver function and improved tumor delivery to perform a clinical study to test their overarching hypothesis.

This research was presented as part of the MedStar Health Teaching and Research Scholars Capstone event, which culminates both the two-year programs.






Researching Educational Approaches: Directed Resident Reading Intervention in Anesthesiology Program

Research undertaken by a MedStar Health Teaching Scholar sought to increase resident engagement with lectures on anesthesiology through understanding educational needs for a diverse group of learners. Anesthesiology residency programs have implemented uniform lecture series for all trainees. All residents, regardless of level or rotation, attend the same early morning lecture.  Given this structure, it is likely that the topic of the lecture will not apply to the learning rotation or focus of the attendees. The goal of this intervention was to use technology to target learners in a more personalized way, based on the patients they are seeing that day.

“Enabling “Push Notifications” in Anesthesiology Training”, led by Sumeet Gopwani, MD sought to use a targeting approach with technology to increase resident reading and create a facilitative teaching tool. In order to encourage learning, it was important to understand residents to be adult learners and the importance of teaching that would be relevant to their experiences. For this group of learners, Just In Time methodologies such as personalized web-based resources were ideal. Residents read 4 hours/week on average and are most motivated to read for their clinical cases.

The study included 10 residents that were randomized to be enrolled in a directed reading intervention for 2 months. The resident reading time was compared from their baseline when they were enrolled in the program and how the residents’ reading changed during the study period.  The effect on teaching evaluations was also measured. Baseline resident reading levels were 6.5 hours/week. During the first phase of the study, residents in the directed reading group increased their reading by 2 hours/week, while the control group decreased reading by 0.5 hours/week.

Direct reading articles were sent to faculty to use a facilitative teaching tool but the analysis concluded that only 15% of the time did faculty discuss the articles with the residents. During the second phase of the study, residents in the control group had essentially stopped reading altogether. However, residents in the directed reading program continued to read at their baseline levels. The research showed that technological feasibility for personalized, automated, case-based, directed reading can be established.  Also, using the adult learning theory and an understanding of residents’ motivation for reading, the direct reading program showed significant increase in resident reading. While faculty did not regularly use the program as a facilitative teaching tool, the results show a large effect on teaching evaluations. 

The research team believes next steps will be to evaluate why the directed reading program did not fully succeed as a facilitative teaching tool. They would like to consider the faculty user experience and layering their teaching preferences into the targeting. Also, there is a plan to expand the project to additional anesthesiology programs.

This research was presented as part of the MedStar Health Teaching and Research Scholars Capstone event, which culminates both the two-year programs.