MedStar Investigators Report on Myocardial Injury from COVID-19

MedStar Health researchers published a report highlighting two cases of COVID-19 infection with myocardial involvement with distinct mechanistic pathways and outcomes. The cases discussed the important decision strategies for these critically ill patients, such as the timing of cardiac catheterization (when indicated) and requirement of early hemodynamic support. “COVID-19 (SARS-Cov-2) and the heart – An ominous association” was published in Cardiovascular Revascularization Medicine.

Cardiovascular manifestations of COVID-19 can be diverse and complex, including myocardial injury, infarction, myocarditis simulating ST-segment elevation myocardial infarction, non-ischemic cardiomyopathy, coronary vasospasm, pericarditis, or stress(takotsubo) cardiomyopathy.  The publication discussed that based on the initial experience from Wuhan, China, that approximately 27.8% (52/187) of patients with COVID-19 exhibited myocardial injury. Myocardial injury was associated with worse out-comes of COVID-19, whereas the prognosis of patients with underlying cardiovascular disease but without myocardial injury was comparatively favorable.

The cases described in this report are patients with COVID-19 infection and myocardial involvement. The authors indicated that during the COVID-19 pandemic, management of patients with acute coronary syndrome and COVID-19 remains critically important.  Underlying cardiovascular disease and associated risk factors such as hypertension, coronary heart disease, and cardiomyopathy put patients at higher risk of developing myocardial injury during the course of their COVID-19 infection.

The team included Nauman Khalid, MD; Yuefeng Chen MD, PhD; Brian C. Case, MD; Evan Shlofmitz, DO; Jason P. Wermers, Toby Rogers, MD, PhD; Itsik Ben-Dor, MD; and Ron Waksman, MD.

Cardiovascular Revascularization Medicine, 2020, DOI: 10.1016/j.carrev.2020.05.009






Collaborative Research from MedStar Investigators Evaluates Racial Variations in Takotsubo Cardiomyopathy Outcomes

A collaborative team of researchers from across MedStar Health and partners published their work to assess the effect of race on in-hospital outcomes of takotsubo cardiomyopathy (TC) in a large nationwide sample. The team included investigators from MedStar Washington Hospital Center, MedStar Health Research Institute, MedStar Heart and Vascular Institute, Georgetown University, and National Heart, Lung and Blood Institute.

“Racial Differences in Takotsubo Cardiomyopathy Outcomes in a Large Nationwide Sample” was published in ESC Heart Failure. Takotsubo Cardiomyopathy or stress-induced cardiomyopathy is characterized by transient ventricular impairment, often preceded by emotional or physical stressors. Gender, racial, and ethnic differences have been reported with respect to incidence and prognosis of cardiovascular diseases including heart failure and acute myocardial infarction, in part due to variability in genetic, biological and socio-economic factors. Studies have reported increased in-hospital complications in African American patients presenting with TC; however, the effect of race on TC remains unknown

The research included data obtained from the National Inpatient Sample (NIS) database. Of 97, 650 patients included: 83,807 were women; 89, 624 identified as Caucasian; 8,026 identified as African American. Between the two races, demographic characteristics and insurance variables were significantly different.  African American patients were younger, having a higher percentage of men and lower median household income. The rate of TC hospitalizations increased in both races. Mortality rates initially increased from 50 cases (1–2%) to 340 cases (5–6%) and subsequently remained stable around 5–7% with fluctuations but with no overall significant difference between races.  Multivariate regression models were created to adjust for potential confounders.

In unadjusted analysis, African American patients had more cardiac arrests, invasive mechanical ventilation, tracheostomies, acute kidney injuries, and longer hospital stays compared with Caucasians.  After the adjustment for differences in age, gender, comorbidities, hospital location/teaching status, and socio-economic factors, all differences were significantly reduced or eliminated. The adjusted risk was lower in African Americans compared with Caucasians, for cardiogenic shock, mechanical ventilation and intra-aortic balloon pump insertion.

The research concluded that African American patients overall have worse outcomes including longer hospitalizations, higher rates of cardiac arrests, invasive mechanical ventilation, tracheostomies, and acute kidney injury compared with Caucasians. Overall, African American patients have more in-hospital complications; however, the differences are driven by racial disparities in demographics, comorbidities, and socio-economic factors.

The team included Raja Zaghlol,MD; Ana Barac, MD; Amit K. Dey; and Sameer Desale.

ESC Heart Failure, 2020.  DOI: 10.1002/ehf2.12664

June Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in June 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. Sex-Associated Differences in Cardiac Reverse Remodeling in Patients Supported by Contemporary Left Ventricular Assist Devices
      Journal of Cardiac Failure, 2020. DOI: 10.1016/j.cardfail.2020.03.005
      Mehta N, Mazer-Amirshahi M, Schulman C, O'Connell F, Pourmand A.
    2. Differentiated Thyroid Cancer and Hashimoto Thyroiditis: Utility of the Afirma Gene Expression Classifier
      Journal of  Surgical Oncology, 2020.
      DOI: 10.1002/jso.25875
      Papoian V, Rosen JE, Lee W, Wartofsky L, Felger EA.

    3. Varying Rates of Patient Identity Verification When Using Computerized Provider Order Entry
      Journal of the American Medical Informatics Association, 2020. DOI: 10.1093/jamia/ocaa047
      Fortman E, Hettinger AZ, Howe JL, Fong A, Pruitt Z, Miller K, Ratwani RM.

    4. Racial Disparity in Postpartum Readmission Due to Hypertension Among Women With Pregnancy-Associated Hypertension
      American Journal of Perinatology, 2020. DOI: 10.1055/s-0040-1712530
      Chornock R, Iqbal SN, Kawakita T.

MedStar Investigates Point of Care Lung Ultrasound for COVID-19 Patients

Recently published research evaluated lung ultrasound findings in patients admitted to the internal medicine ward with COVID-19. “Point-of-Care Lung Ultrasound Findings in Patients with Novel Coronavirus Disease (COVID-19) Pneumonia” was published in The American Journal of Tropical Medicine and Hygiene. The study sought to diagnose and monitor patients who received point-of-care ultrasound and assess the findings.

The research was led by Kosuke Yasukawa from the Department of Medicine at MedStar Washington Hospital Center, in collaboration with Taro Minami from Care New England Medical Group and The Warren Alpert Medical School of Brown University.

Patients with COVID-19 typically present with bilateral multilobar ground-glass characteristics. Chest CT has been used in the diagnosis and management of patients with COVID-19. However, CT is not always readily available and the disinfection of CT machine after the use of a patient with COVID-19 may result in a delay of care for other patients requiring CT examination. While the utility of point-of-care ultrasound has been suggested, detailed descriptions of lung ultrasound findings are not available.

The research team retrospectively evaluated lung ultrasound images of 10 patients who received point-of-care ultrasound and were diagnosed with COVID-19. The images were stored and reviewed to determine demographics, comorbidities, laboratory, and radiographic findings. The findings showed that characteristic glass rockets with or without the Birolleau variant (white lung) were present in all 10 patients. One patient required transfer to intermediate care unit, and another patient required transfer to intensive care unit. Four of the patients required administration of oxygen via a non-rebreather mask. Abnormal lung ultrasound findings were detected in all of the patients. Two patients had septal rockets and small subpleural consolidations were detected in five patients. Although glass rockets and the Birolleau variant can be seen in patients with cardiogenic pulmonary edema, none of the patients were diagnosed with decompensated congestive heart failure.

The results found confluent B lines and thick, irregular pleural lines present in all patients evaluated. The glass rockets, confluent B lines, thick irregular pleural lines, and subpleural consolidations are likely not specific to COVID-19. However, these findings can be an aid for diagnosis during the COVID-19 pandemic when pretest probability is high.

The American Journal of Tropical Medicine and Hygiene, 2020. DOI: 10.4269/ajtmh.20-0280





Collaborative Research from MedStar Investigators Evaluates Surgical Outcomes of Minimally Invasive Surgery for Colorectal Cancer

Recently published collaborative research examined temporal trends and surgical outcomes of minimally invasive surgery approaches for colorectal cancer by hospital type. “Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes” was published in the Journal of Surgical Research. The study sought to assess these relationships to improve access to high-quality surgical care for CRC patients.

The study collected data from the National Cancer Database which organizes oncology data from more than 1500 accredited cancer facilities across the United States and Puerto Rico. The main outcome variable was the performance of minimally invasive surgery for the associated cancer type. Secondary outcome variables included surgical margin, conversion to open, length of stay, 30-day unanticipated readmission rate, 30-day mortality, 90-day mortality, and overall survival. The main independent variable was hospital type and facility-level variables included location by US region, center type, and average center volume.

The results of the study found that of 234, 935 cases, 48.5% of colorectal cancer surgeries were performed in comprehensive community hospitals, 28% in academic, 12.5% in community, and 11.1% in integrated networks. Many procedures performed in community hospitals were open, while all other hospital types primarily performed minimally invasive surgery. The percentage of robotic surgeries was highest in academic hospitals (7.9%) and lowest in community centers (3.3%).

The study findings showed rates of MIS utilization overall (40.1%), as well as for laparoscopic (36.8%) and robotic (3.3%) procedures specifically, were lowest in community hospitals compared with comprehensive community (46.2% laparoscopic; 5.7% robotic), integrated network (47.7% laparoscopic; 6.8% robotic), and academic (46.3% laparoscopic; 7.9% robotic) centers.

MIS utilization rates varied substantially by hospital type for both the laparoscopic and robotic approaches however were generally lower at community centers for both cancer types. Also, compared with laparoscopic colon surgery at academic centers, community centers treated lower grade tumors with higher 30-day and 90-day mortality. In conclusion, “Future research and healthcare policy must address these trends at the community level to facilitate safe, effective access to these techniques across the US.”

This research was supported by a grant from the Georgetown Howard Universities Center for Clinical and Translational Science and The Lee Folger Foundation.

The research team included researchers from the MedStar-Georgetown Surgical Outcomes Research Center, MedStar Health Research Institute, and MedStar-Georgetown University Hospital: Anthony M. Villano MD, Alexander Zeymo MS, Brenna K. Houlihan MD, Mohammed Bayasi MD, Waddah B. Al-Refaie MD, FACS and Kitty S. Chan PhD.

Journal of Surgical Research, 2020. DOI: 10.1093/jbcr/irz168






KL2 Junior Faculty Scholars Program: Application Deadline is Extended

Due to the unprecedented COVID-19 pandemic, GHUCCTS has reconsidered their application, selection, and appointment cycle for new KL2 scholars. Most current KL2 scholars, nationally, have been unable to make significant research progress due to practical and institutional restrictions, despite continued KL2 support. We want to make sure that our next KL2 scholars have the best opportunity to benefit fully from their new awards.

Final evaluation of previously-submitted applications has been deferred and the call for new KL2 applications has been reopened. Projects that are novel, inter-or multi-disciplinary and collaborative will be favored. The KL2 scholars will be awarded up to $90, 000 salary support and $40,000 project support per year (for up to three years). 

The 2020 application deadline has been extended to July 6, 2020 and an anticipated appointment date no earlier than September 2020. 

Who is eligible: Junior Faculty with a full-time or equivalent appointment at a GHUCCTS institution (Georgetown University, Howard University, or MedStar Health) at the time of award activation. Scholars must devote 75% effort to the program for three yearsscholars must be US Citizens, Non-citizen Nationals, or Permanent Residents. Individuals who were, or currently are Principal Investigator of NIH R01, P01 or P50 subprojects, or individual K (e.g., K01, K08, K22, K23) grant ARE NOT eligible; current/former PIs of non-NIH peer reviewed research grants >$100k annual direct costs are ineligible.

Learn more about the program and applicatation requirements on the GHUCCTS website.

QUESTIONS? Contact the Executive Committee:
Jason G. Umans, MD, PhD [email protected]
Charles Howell, MD [email protected]
Kathryn Sandberg, PhD [email protected]

Congratulations to the 2020 Summer Research Scholars at MedStar Health

Every year, MedStar Health awards scholarships to approximately 30 first-year Georgetown University medical students in order to pursue research during the summer. For seven weeks, each summer scholar works under the direction of a MedStar Health physician-investigator to conduct research in a specific area. These scholars are housed at various departments throughout the MedStar system and their experience has been tailored to work remotely given the COVID19 pandemic.

Congratulations to the Class of 2023 Scholarship Recipients. Best of luck with your research!

MedStar Health Research Institute

Recipient

Research Area

Mentor(s)

Matthew Sheridan

Quality Improvement

Raj Ratwani

GiGi Yip

Quality Improvement

Raj Ratwani, PhD

MedStar Georgetown University Hospital

Recipient

Research Area

Mentor(s)

Peter Rakita

Mental & Behavioral Health

Matthew Biel, MD

Alice Kim

David Thomas

General Surgery/Surgery Education

Shimae Fitzgibbons/John Lazar

Ankit Misha

Surgical Oncology

Waddah Al-Refaie

Cupeil (Kevin) Choi

Radiation Oncology

Keith Unger

MedStar Washington Hospital Center

Recipient

Research Area

Mentor(s)

Emily Kim

Burn Surgery

Laura Johnson

Daniel Childers

Vascular Surgery

Steven Abramowitz

Aisha Inuwa

Grant Wilhelm

OB/GYN, HIV and Pregnancy

Rachel Scott

Kira Chandran

Nikash Shankar

Emergency Medicine

Mary Ann Amirshahi

Sadhana Sathi

Endocrine Surgery

Victoria Lai

James Severin

Ethics

Ben Krohmal

Matthew Cabrera

Meghan Chin

Surgical Critical Care

Seife Yohannes

Michael Hammer

Josh Kang

Clark Pitcher

Anna Hogan

Erin Rachel Vaughan

Palliative Care

Hunter Groinger

MedStar Institute for Innovation (MI2)

Recipient

Research Area

Mentor(s)

Elizabeth Duquette

Human Factors Engineering

Kristen Miller

MedStar Georgetown Pediatrics at Tenleytown

Recipient

Research Area

Mentor(s)

Aditi Gadre

Pediatrics

Elizabeth Chawla

MedStar Union Memorial Hospital

Recipient

Research Area

Mentor(s)

Daniel Kim

Medicine

Stephanie Detterlne/Christopher Haas

Joshua Fallentine

Sports Medicine

Andy Lincoln

Eric Nieto

Orthopaedics (Foot & Ankle)

Jason Wisbeck

Madeline Walsh

Endocrinology

Pamela Schroeder

Gianna Guarino

Eliana Schaefer

Caroline Wu

The Curtis National Hand Center

Avi Giladi

Caleb Grieme

Nijo Abraham

Orthopaedics (Total JoilOVELY*0207nt)

Henry Boucher

Aman Chopra

Orthopaedics (Shoulder)

Anand Muthi

MedStar Franklin Square Medical Center

Recipient

Research Area

Mentor(s)

Stephanie Michales

Alexandra Eckert

Family Medicine

Nacny Barr

MedStar Good Samaritan Hospital

Recipient

Research Area

Mentor(s)

Krytal Henderson

Medicine

David Weissman






May Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in April 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. E-Cigarettes, Vaping Devices, and Acute Lung Injury
    Respiratory Care, 2020. DOI: 10.4187/respcare.07733
    Cobb NK, Solanki JN.

  2. Pharmacogenetics in Practice: Estimating the Clinical Actionability of Pharmacogenetic Testing in Perioperative and Ambulatory Settings
    Clinical and Translational Science, 2020DOI: 10.1111/cts.12748
    Smith DM, Peshkin BN, Springfield TB, Brown RP, Hwang E, Kmiecik S, Shapiro R, Eldadah Z, Lundergan C, McAlduff J, Levin B, Swain SM.
  3. The Role of MRI in the Diagnosis of Pelvic Floor Disorders
    Female Urology, 2020. DOI: 10.1007/s11934-020-00981-4
    Fitzgerald J, Richter LA.

  4. COVID-19 (SARS-Cov-2) and the Heart - An Ominous Association
    Cardiovascular Revascularization Medicine, 2020. DOI: 10.1016/j.carrev.2020.05.009
    Khalid N, Chen Y, Case BC, Shlofmitz E, Wermers JP, Rogers T, Ben-Dor I, Waksman R.

 






April Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in April 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.

  1. Pertuzumab, Trastuzumab, and Docetaxel for HER2-positive Metastatic Breast Cancer (CLEOPATRA): End-Of-Study Results From a Double-Blind, Randomised, Placebo-Controlled, Phase 3 Study
    The Lancet Oncology, 2020. DOI: 1016/j.ajem.2020.04.035
    Swain SM, Miles D, Kim SB, Im YH, Im SA, Semiglazov V, Ciruelos E, Schneeweiss A, Loi S, Monturus E, Clark E, Knott A, Restuccia E, Benyunes MC, Cortés J; CLEOPATRA study group.
  1. Outcomes of the Medial Femoral Trochlea Osteochondral Free Flap for Proximal Scaphoid Reconstruction
    Journal of Hand Surgery, 2020. DOI: 10.1016/j.jhsa.2019.08.008
    Pet MA, Assi PE, Yousaf IS, Giladi AM, Higgins JP.
  1. MitraClip 30-day Readmissions and Impact of Early Discharge: An Analysis From the Nationwide Readmissions Database 2016
    Cardiovascular Revascularization Medicine, 2020. DOI: 1016/j.carrev.2020.04.004
    Case BC, Yerasi C, Forrestal BJ, Wang Y, Musallam A, Hahm J, Torguson R, Ben-Dor I, Satler LF, Rogers T, Waksman R.
  1. A Philosophical Approach to the Rehabilitation of the Patient with Persistent Pain
    American Journal of Hypnosis, 2020. DOI: 1080/00029157.2019.1709152
    Appel PR.
  1. Timing of Intervention May Influence Outcomes in Blunt Injury to the Carotid Artery
    Journal of Vascular Surgery, 2020. DOI: 1016/j.jvs.2019.05.059
    Blitzer DN, Ottochian M, O'Connor JV, Feliciano DV, Morrison JJ, DuBose JJ, Scalea TM.





MedStar Investigators Identify Ten Best Practices for Improving Emergency Medicine Provider-Nurse Communication

Researchers at MedStar Health sought to understand how communication between emergency medicine (EM) providers plays a critical role in delivering safe and effective care to patients. “Ten Best Practices for Improving Emergency Medicine Provider-Nurse Communication” led by A. Zachary Hettinger, MD, MS, from the MedStar Health National Center for Human Factors in Healthcare was published in The Journal of Emergency Medicine. This study identified communication needs of emergency medicine nurses and physicians, in particular, what information should be conveyed, by whom and the most appropriate time to convey the information based on the clinical scenario.

The research used semi-structured focus groups and interviews to identify communication strategies and barriers associated with information sharing in emergency medicine. Nine EM nurses, eight EM attending physicians, and four EM resident physicians participated in five focus groups and one interview to address questions regarding how EM personnel use and share information about patients and clinical work, what information tends to be exchanged, and what additional information would be helpful to share.

The interview sessions were audio recorded and transcripts were analyzed using a concept mapping approach. Eleven maps were developed to describe the role communication plays in patient outcomes comprised of: categories of information physicians needed from nurses and vice versa; methods of communication that could be utilized; barriers or obstacles to effective communication; strategies to enhance or ensure effective communication; and environmental or situational factors that impact communication.

Participants described several communication-enhancing strategies and the research team produced ten strategies to help support effective nurse-physician communication. These strategies include:

  1. Communicate diagnostic assessment, plan of care and, especially, disposition plan to other team members as early as possible. Update the team of any changes to the plan.
  2. Communicate pending tasks/steps in the patient’s care as well as information regarding changes or holdups to tasks or orders.
  3. Communicate details regarding proactive diagnostic testing and therapeutic interventions.
  4. Don’t assume everyone has a shared understanding: recognized that you might have unique access to information and make sure that it is shared in a timely manner.
  5. Notify providers of any critical or unexpected changes in vital signs or patient status.
  6. Do not assume electronic orders substitute for verbal communication
  7. Use asynchronous communication for lower priority items to aid in prioritization.
  8. Adapt communication strategies based on team members’ experience level and existing relationships.
  9. Adapt communication strategies to the physical layout of the ED, especially in those facilities where nurses and physicians may have workstations out of sight from one another or where it is not obvious which staff members are on different care teams
  10. Use strategies that exploit provider experience level regardless of role hierarchy.

The key findings of this study help provide insight on how to improve communication and patient care within the EM department. While the information needed by physicians and nurses was similar, discrepancies in knowledge occurred from timing of when a patient or family member was spoken to; differential access times to the EHR; complexities in information sharing among trainees, nurses, and physicians; or because each role may have had unique opportunities to access information.

This research was supported by the Agency for Healthcare Research and Quality, United States (R01HS022542).

The research team included A. Zachary Hettinger, MD, MS; Natalie Benda, PhD; Daniel Hoffman, BS; Akhila Iyer, MS; Ella Franklin, MSN, RN; R. J. Fairbanks, MD, MS from MedStar Health National Center for Human Factors in Healthcare in collaboration with researchers from Roth Cognitive Engineering; Department of Emergency Medicine, University of Florida, Jacksonville Medical Center; Department of Emergency Medicine, Georgetown University School of Medicine; and the Department of Industrial and Systems Engineering, University at Buffalo, The State University of New York.

The Journal of Emergency Medicine, 2019. DOI: 10.1016/j.jemermed.2019.10.035