Brian T. Garibaldi’s research while affiliated with Northwestern University and other places

Background: Few studies have examined internal medicine residents’ performance using cardiovascular point of care ultrasound (POCUS). Methods: From 2019 to 2022, first-year residents from two academic medical centers in Baltimore participated in the Assessment of Examination and Communication Skills (APECS). Interns examined a single patient with aortic insufficiency and were assessed on physical exam and POCUS technique, identifying physical exam and POCUS findings, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam and POCUS exam technique and in identifying correct findings. Results: Fifty-three first-year residents (interns) performed a cardiovascular POCUS exam. Of these, 44 (83%) scored either “unsatisfactory” or “borderline” on their POCUS technique with a mean score of 29.5 (out of 100). Seventeen (32%) interns were able to correctly obtain a parasternal-long axis (PLAX) view with only 26 (52%) attempting an apical four-chamber (AP4) or subcostal (SUBC) view. Of the 11 participants who correctly obtained both PLAX and parasternal-short views (PSAX), 10 were able to properly identify a normal ejection fraction and the absence of a pericardial effusion. POCUS technique was statistically significantly associated with physical exam technique, identifying the correct POCUS findings, and generating a correct differential diagnosis (r=0.46, p<0.01; r=0.41, p=<0.01; r=0.60, p=<0.01, respectively). Conclusion: Internal medicine interns showed variable skill in performing and interpreting a cardiovascular POCUS exam. Further emphasis on teaching cardiovascular POCUS skills would likely increase ability to identify relevant cardiovascular findings and improve patient care.

B-cell depletion therapy is employed in a variety of clinical contexts from auto-immune diseases to malignancy. Prior research on patients with prior B-cell depletion treatment has suggested a mortality risk in patients hospitalized with COVID-19 however previous case–control studies have differed in their methods of patient comparison. Patients previously treated with B-cell-depletion hospitalized with COVID-19 were compared to matched controls in the Johns Hopkins Health System between March 1, 2020 and November 30, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes included time to severe illness or death and time to clinical improvement. To eliminate bias due to imbalanced covariates, each patient who had previously received B-cell depletion therapy was matched with patients who had not received therapy based on age, sex, race, WHO severity score, admission date, COVID-19 specific treatment, and vaccination status. Propensity scores were calculated from a multivariable logistic regression model and performed on the matched sets, using B-cell depletion as the outcome, where the propensity score was the probability of receiving B-cell depletion therapy. The propensity score included matched covariates as well as smoking status, medical comorbidities, and vaccination status. Cox proportional-hazards regression models were applied on the matched sets to perform time to death, time to severe illness or death, and time to clinical improvement analyses. 50 patients were identified who had received B-cell depletion therapy and were compared to 186 matched controls. Patients treated with B-cell depletion experienced 30-day mortality of 6.0% compared to 3.8% in controls, adjusted hazard ratio (aHR) 1.45 (95% CI 0.30 to 6.95). B-cell-depleted patients experienced a longer time to clinical improvement, aHR 0.65 (95% CI 0.45–0.94). In this cohort, patients treated with B-cell depletion experienced a higher mortality rate compared to matched controls however this was not statistically significant. This group also experienced a prolonged time to clinical improvement based on WHO severity score.

Study Design Retrospective cohort study. Objective To characterize variation in dexamethasone and remdesivir use over time among hospitals. Background Little is known about hospital-level variation in COVID-19 drug treatments in a large and diverse network in the United States. Methods We selected individuals hospitalized with COVID-19 across 163 hospitals between February 23, 2020 and October 31, 2021 from using the HCA CHARGE, an electronic health record repository from a network of community health care facilities in the United States. We quantified receipt of dexamethasone, remdesivir, and combined use of dexamethasone and remdesivir during the hospital stay. We used 2-level logistic regression models to determine the intraclass correlation coefficient (ICC) at the hospital level, adjusting for patient and hospital characteristics. The ICC shows the proportion of total variation in drug use accounted for by hospitals. Results Among 161,667 individuals hospitalized with COVID-19, 73.0% were treated with dexamethasone, 49.1% with remdesivir, and 45.0% with both dexamethasone and remdesivir. The proportion of variation in dexamethasone use was 12.7% (adjusted ICC: 0.127), 8.5% for remdesivir, and 11.3% for combined drug use, indicating low interhospital variation. In the fully adjusted models, between-facility variation in dexamethasone use declined from 34.1% in February–March 2020 to 11.3% in January–March 2021 and then increased to 17.3% in July–October 2021. The variation in remdesivir use remained relatively stable during the study period. Conclusions During the first 2 years of the pandemic, there was relatively consistent use of dexamethasone and remdesivir across the hospitals examined. Consistent adoption and implementation of treatment guidelines across the hospitals examined may have led to a decrease in variation in drug usage over time.

Background Patients with diabetes have higher mortality from COVID-19 compared to the general population. Dexamethasone, a potent glucocorticoid used for moderate to severe COVID-19, can worsen hyperglycemia in patients with diabetes, potentially leading to worse outcomes. The efficacy and safety of use of dexamethasone for COVID-19 in patients with diabetes needs further evaluation. Objective The study aimed to assess the efficacy and safety of dexamethasone in patients with diabetes hospitalized for COVID-19 infection. Design This retrospective study analyzed data from 5 hospitals in the Johns Hopkins Health System collected between March 3, 2020, and June 25, 2022. Propensity score matching was applied to a cohort of patients with diabetes who received dexamethasone and those who did not (controls), and outcomes were compared using Cox proportional hazards regression models. Outcomes The primary outcome was time to death within 28 days. The secondary outcome was time to clinical improvement. Additional outcomes included the incidence of hyperglycemic emergencies and subgroup analysis of primary outcomes by clinical severity. Results Out of 10,329 patients admitted for COVID-19, 3679 had diabetes, and 2361 met the inclusion criteria. After propensity score matching, 529 patients were analyzed in each group. Survival rates between the dexamethasone and control groups during the 0- to 6-day and 7- to 28-day periods and time to clinical improvement at 28 days did not differ significantly. There was no difference in the incidence of diabetic ketoacidosis or hyperosmolar hyperglycemic state between the groups. Conclusion Dexamethasone treatment did not significantly improve survival or time to clinical improvement in patients with diabetes and COVID-19 infection. Further prospective studies are needed to confirm these findings and determine potential mechanisms.

In response to the growing number of outbreaks of emerging infectious diseases, the US Administration for Strategic Preparedness and Response (ASPR) has embarked on a plan to improve and expand special pathogen patient care capabilities. To achieve this, ASPR is developing a coordinated network of Regional Emerging Special Pathogen Treatment Centers (RESPTCs) to serve as state-of-the-art facilities staffed by a highly trained workforce to care for and manage special pathogen patients across the lifespan. The RESPTC network represents the operational arm of a broader US National Special Pathogen System of care to prevent and prepare for the next infectious disease outbreak. RESPTCs are strategically located in every region across the country and form a network linking local and regional healthcare partners to enhance national preparedness through training in best practices for detection, isolation, and treatment of individuals suspected of or known to be infected with a special pathogen. This local, regional, and national network is also designed to lead a coordinated response that includes the dissemination of accurate and trustworthy information to responders and the public. The overarching goal of the RESPTCs is to serve as a valuable resource for clinical care, training, and material support to meet current and future major infectious diseases challenges. In this case study, 2 new RESPTCs, MedStar Washington Hospital Center and the University of North Carolina, describe their experiences related to designing a biocontainment unit, creating clinical teams, building staff resiliency, receiving mentoring from regional RESPTC partners, and developing opportunities for innovation.

Introduction In the USA, minoritised communities (racial and ethnic) have suffered disproportionately from COVID-19 compared with non-Hispanic white communities. In a large cohort of patients hospitalised for COVID-19 in a healthcare system spanning five adult hospitals, we analysed outcomes of patients based on race and ethnicity. Methods This was a retrospective cohort analysis of patients 18 years or older admitted to five hospitals in the mid-Atlantic area between 4 March 2020 and 27 May 2022 with confirmed COVID-19. Participants were divided into four groups based on their race/ethnicity: non-Hispanic black, non-Hispanic white, Latinx and other. Propensity score weighted generalised linear models were used to assess the association between race/ethnicity and the primary outcome of in-hospital mortality. Results Of the 9651 participants in the cohort, more than half were aged 18–64 years old (56%) and 51% of the cohort were females. Non-Hispanic white patients had higher mortality (p<0.001) and longer hospital length-of-stay (p<0.001) than Latinx and non-Hispanic black patients. Discussion In this large multihospital cohort of patients admitted with COVID-19, non-Hispanic black and Hispanic patients did not have worse outcomes than white patients. Such findings likely reflect how the complex range of factors that resulted in a life-threatening and disproportionate impact of incidence on certain vulnerable populations by COVID-19 in the community was offset through admission at well-resourced hospitals and healthcare systems. However, there continues to remain a need for efforts to address the significant pre-existing race and ethnicity inequities highlighted by the COVID-19 pandemic to be better prepared for future public health emergencies.