Graduate

• Improving Central Venous Catheter Maintenance in the Home Setting

  THE TEAM

  Student Team:Matthew Hill, Bonolo Mathekga, Mete Morris, Melissa Schweizer, Collin Shale, Digvijay Singh

  Advisors:MiKaela Olsen, MSN; Cliff Weiss, MD; David Hirsch, MSN; Swapna Kakani; Emily Levy; Yushi Yang, PhD; Trish Brown, LDN
  Sponsors: Becton Dickinson Medical Delivery Solutions: Pratik Patel; Erik Witt, MD, PhD; Matthew Oshinski; Maarten Brand

  ABSTRACT

  The use of central venous catheters (CVCs) is pivotal for the delivery of life-saving and life-sustaining medications to patients requiring high-flow therapies or vesicant drugs. As with any vascular access device, the same pathway that is used to deliver these therapies can also introduce pathogens into the bloodstream causing life-threatening infections.

  While multiple standards and intervention bundles have been championed to reduce the incidence of these central line associated bloodstream infections (CLABSIs) in inpatient settings, little attention has been paid to the use of CVCs in home-based therapies. The resulting reality is that the 525,000 patients receiving outpatient parenteral antibiotic (OPAT) or home parenteral nutrition (HPN) therapies must perform central line maintenance, a task normally performed by trained medical professionals, by themselves with minimal training and education.

  OPAT and HPN patients specifically are at risk for CLABSIs as they tend to have a longer indwelling time for their lines ranging from 20-300 days at a time. Our team is developing solutions to increase compliance with central line maintenance in the home setting by addressing the three major challenges faced by stakeholders: (1) Limited training received by patients prior to expectation to perform maintenance tasks normally done by a professional nurse, (2) inconsistent surveillance of patient central line maintenance compliance to identify and intervene with non-compliant patients before adverse events occur, and (3) Complex and non-standardized maintenance procedures that make it difficult for patients and caregivers to perform consistent and proper maintenance procedures. The team is developing solutions that are addressing these pertinent issues that home infusion patients face, with the goal of keeping discharged patients out of the hospital. There is an increasing push for infusion care to move toward the home setting, and we are designing our solution to improve patient outcomes in a rapidly growing space.

• TB-D: Improving Differential Diagnosis for Childhood Tuberculosis

  THE TEAM

  Student Team: Matthew Hill, Bonolo Mathekga, Mete Morris, Melissa Schweizer, Collin Shale, Digvijay Singh

  Advisors: Soumyadipta Acharya, MD, MSE, PhD; Sylvia Hinrichsen, MD, PhD; Jonathan Golub, PhD, MPH; Neil Martinson, MBBCH, DCH, MFGP, MPH; Gavin Churchyard, MBBCH, FCP (SA), MMed, PhD

  ABSTRACT

  Each year, it is estimated that over one million children are infected with active tuberculosis (TB) resulting in over 233,000 deaths. Of these deaths, it is also estimated that 96% occur in children that were never treated for TB. Diagnostic testing used for adult tuberculosis has reduced sensitivity in children less than five years of age, and the clinical symptoms and signs of childhood TB overlap with many other childhood diseases. In Sub-Saharan Africa, this problem is further complicated by the current HIV epidemic as children with both HIV and TB are at risk of developing extrapulmonary TB. Childhood TB is specifically difficult to differentiate from other lower respiratory tract infections (LRTIs) in children with recent evidence indicating that childhood TB is especially missed in children presenting with symptoms of acute pneumonia.

  TB-D is researching and developing a solution to assist healthcare providers in correctly differentiating childhood TB from other LRTIs. In the SubSaharan Africa context specifically, healthcare providers rely on patient history and clinical investigations in order to determine how likely a child is to have TB. Depending on the level of suspicion, healthcare providers will order diagnostic testing for children or even begin empirical treatment; however, when healthcare providers suspect a different LRTI, they may begin treatment for the wrong LRTI. This improper diagnosis leads to diagnostic delay for children with TB along with lost follow-up among children that seek alternate care sources. TB-D is developing a solution that will assist healthcare providers in correctly suspecting TB within children, resulting in increased detection and treatment of childhood TB.

  Our team has conducted observations across multiple levels of care in South Africa in order to validate the need and assess current provider practices for investigating children with LRTIs. Healthcare providers across primary, outpatient, and inpatient care have confirmed the current difficulties with differentiating childhood TB from other LRTIs. Moving forward, the team will be focused on testing prototypes with users and validating the efficacy of our design in precisely identifying children with TB.

• ForSight Innovation: Enabling Equitable Outcomes in Cataract Surgery

  THE TEAM

  Student Team: Nick Calafat, Daniel Myers, Namratha Potharaj, Brittany Reed, Joshua de Souza, Krithik Srithar

  Advisors: Soumyadipta Acharya, MSE, MD, PhD; Youseph Yazdi, PhD, MBA; Aditya Polsani, BDS, MS; Kunal Parikh, PhD; R.D. Ravindran, PhD; John Sheets, PhD; Martin Spencer, PhD; Thulasiraj Ravilla, MBA; Zervin Baam, PhD; Balaji Velayeutham, PhD; Samuel Yiu, MD, PhD; David Friedman, MD, PhD, MPH; Katie Solley

  ABSTRACT

  Approximately 94 million people worldwide have impaired vision due to cataract, with a disproportionate number living in low- and middleincome countries (LMICs). Despite a continuous rise in cataract surgical rates, there remains a backlog of up to 16 million individuals awaiting surgery. To tackle the backlog of cataract surgeries, institutions like the Aravind Eye Care System in Madurai, India, provide high surgical throughput (>300 surgeries/ day) and subsidized care for patients of low socioeconomic status. Manual Small Incision Cataract Surgery (MSICS) has become the standard of care throughout LMICs and is a safe and effective surgery that meets the cost and time demands of a high-volume eye care center. In comparison to the goldstandard phacoemulsification (phaco) procedure, which is more widely used in developed countries, MSICS can be performed twice as fast and at a quarter of the cost. However, MSICS leads to significant rates of surgically induced astigmatism (SIA), resulting in impaired postoperative visual acuity. Additionally, MSICS patients require twice the time to recover after surgery in comparison to phaco patients. This results in a loss of income for patients who are often the sole breadwinners for their families.

  Through 100+ surgical observations and 35+ interviews with cataract surgeons at Aravind and the Johns Hopkins Wilmer Eye Institute, our team identified the primary root cause of poor MSICS patient outcomes to be the size of the surgical incision. While phaco uses ultrasonic energy to fragment and remove the cataract through a 2-3mm incision, MSICS requires a much larger 6-8mm incision to remove the cataract as a whole. Working side-by-side with experts at Aravind and Wilmer, our team has developed a surgical device capable extracting a cataract through a smaller incision while maintaining the time- and cost-efficiency of MSICS. Our solution translates the best qualities of phaco into a technology that is suitable for high-volume eyecare systems, thus enabling equitable patient outcomes independent of socioeconomic status.

• DelTect: Predicting Postoperative Delirium in the ICU

  THE TEAM

  Student Team: Nick Calafat, Daniel Myers, Namratha Potharaj, Brittany Reed, Joshua de Souza, Krithik Srithar

  Advisors: Soumyadipta Acharya, MSE, MD, PhD; Youseph Yazdi, PhD, MBA; Aditya Polsani, BDS, MS; Robert Stevens, MD, FCCM; David Giarracco, BS, MA; Michael Mestek, PhD; Cole Confer, MBA; Katie Solley

  Sponsor: Medtronic Minimally Invasive Therapies

  ABSTRACT

  Each year, up to 50% of the 16 million surgical patients who are at least 65 years of age develop postoperative delirium (POD) during their hospital stay. POD is a neurological condition that describes a change in the patient’s mental status from their presurgical baseline that is independent of any preexisting neurocognitive disorder. It is characterized by inattention, disorientation, memory problems, disorganized thought, and perceptual disturbances. Multiple studies have associated POD with increased length of hospital stay, greater rates of institutional placement upon discharge, and longterm cognitive decline. Given that these effects are more pronounced with a longer duration of delirium, early and effective treatment is a high priority.

  Despite the prevalence of POD and availability of screening tools, POD goes undiagnosed in up to 70% of all cases. Key stakeholder feedback suggests this widespread under-diagnosis is explained by the inadequacy and subjectivity of current behavioral screening tools. Nurses, who are the primary administrators of these screening tools, are often unable to identify subtle symptoms of delirium. Strong evidence shows that preventive interventions prior to clinical emergence of symptoms are highly effective in reducing the incidence and severity of delirium. However, there is wide under-implementation of preventive strategies due to a lack of monitoring solutions that can accurately predict the onset of delirium.

  DelTect is a bedside monitor, used in the immediate postoperative space to assess a patient’s risk for developing delirium. The team has developed a novel algorithm based on physiological precursors to predict delirium independent of clinically observable symptoms. DelTect will empower heavily burdened nurses to allocate resources and attention to high risk patients. By enabling better management of delirium, DelTect aims to reduce length of hospital stay, institutional placement, and long-term cognitive impairment.

• OxyGen: Portable Oxygen Supplementation

  THE TEAM

  Student Team: Ana Ainechi, Jessica Dakkak, Brice Dudley, Moriah Mattson, Jonathan Smith, Wilson Tang

  Advisors: Sonye Danoff, MD, PhD; Stephen Mathai, MD, MHS; Meredith McCormack, MD, MHS; Soumyadipta Acharya, MSE, MD, PhD; Youseph Yazdi, PhD, MBA; Ashish Nimgaonkar, MD; Robert Storey; Lawrence Aronhime, MS, MBA; Laura Scavo, MS

  ABSTRACT

  Approximately 2.1 million patients in the United States require portable oxygen therapy to treat their respiratory diseases. Patients choose from portable oxygen tanks that hold compressed gaseous O2 or portable oxygen concentrators (POCs) that concentrate oxygen from ambient air. While oxygen tanks are mobile and do not require batteries, they contain a finite amount of oxygen, are cumbersome, heavy, and difficult to maneuver. POCs are smaller, lighter, and the gold standard for portability; however, they have a limited battery life and can only provide support to patients requiring low amounts of oxygen (1-3L/min). This automatically disqualifies 20% of patients from using POCs due to their oxygen requirements.

  The technological limitations of current offerings lead to reduced mobility, initiating a vicious cycle of social isolation, depression, and poor quality of life. As flow rates increase and mobility drops, patients rapidly progress towards becoming completely homebound. With the increasing prevalence of respiratory diseases and the clinical urgency for greater mobility, a longer lasting portable treatment is imperative.

  We are developing a POC that uses respiratory support mechanisms developed for the intensive care unit to increase the efficiency and lifespan of portable oxygen devices. Our goal is to expand the technologies of current POCs beyond the 3L/min barrier to improve patient mobility and quality of life.

• Bronchoscopic Interventions for Emphysema

  THE TEAM

  Student Team: Ana Ainechi, Jessica Dakkak, Brice Dudley, Moriah Mattson, Jonathan Smith, Wilson Tang

  Advisors: Hans Lee, MD; William Krimsky, MD; Soumyadipta Acharya, MSE, MD, PhD; Youseph Yazdi, PhD, MBA; Cliff Weiss, MD

  Sponsor: Coridea/EOLO Medical: Howard Levin, MD; Mark Gelfand; Zoar Engelman, PhD; Anisha Bapna; Don Tanaka; Ary Chermorovsky; Angela Yang

  ABSTRACT

  Emphysema is a lung disease caused by chronic inhalation of irritants and characterized by the destruction of alveolar walls, loss of tissue elasticity, abnormal and irreversible hyperinflation of the lung, and difficulty breathing. As a consequence of alveolar destruction and in addition to the loss of gas exchange, emphysematous regions of the lung trap air and expand, crowding out healthy portions of the lung and reducing the patient’s overall expiratory capacity.

  While there is no cure for emphysema, a class of minimally invasive therapies called bronchoscopic lung volume reduction (BLVR) is being developed. BLVR techniques are based on the proven theory that reducing the volume of the diseased portion of the lung will allow expansion and increased ventilation of the remaining healthy portions. Despite their promise, these therapies have found only moderate success in restoring respiratory capacity due to certain anatomical variations common in emphysema. These variations generate a phenomenon called collateral ventilation, which renders the best treatments ineffective for up to 75% of the more than 75 million emphysema patients worldwide.

  Our team is working to develop multiple bronchoscopic interventions that mitigate the effects of collateral ventilation to expand the treatable population of emphysema patients.

• NeMo: Empowering Mothers for Early Detection of Neonatal Illness

  THE TEAM

  Student Team: Anthony Ho, Shababa Matin, Natalie Ng, Madison Vanosdoll, Allison Wallingford, Ryan Xu

  Advisors: Soumyadipta Acharya, MSE, MD, PhD; Christopher Golden, MD; Alain Labrique, PhD; Peter Waiswa, MPH, PhD; Moses Kyangwa; Azadeh Farzin, MD

  ABSTRACT

  Each year, 3.3 million newborns die in the first 28 days following birth, with 75% of these deaths occurring in the first seven days of life. A majority of these deaths occur within homes in low-resource settings, largely due to preventable causes such as pneumonia, sepsis, and other illnesses. Healthcare systems in low-resource settings often rely on volunteer community health workers (CHWs) to visit newborns in rural villages in the first week of life for triage. CHWs triage newborns based on the World Health Organization’s established Integrated Management of Newborn and Childhood Illness (IMNCI) danger signs: difficulty breastfeeding, convulsions, chest indrawing, movement only when stimulated, respiratory rate greater than 60 breaths per minute, temperature higher than 37.5 ˚C, and temperature less than 35.5 ˚C. The number of CHWs, however, remains woefully inadequate and thus infants with signs of illness are often identified too late to impact survival. Although effective identification of these signs at the community level can intercept illness and incite care-seeking behavior capable of impacting child mortality, the tools and training needed to assess quantitative and qualitative indicators of illness are lacking in low-income settings.

  Therefore, our team has developed the NeMo system, a two-part neonatal monitoring system designed to empower mothers, regardless of literacy, to effectively identify danger signs in their newborns and guide them to take appropriate and timely action to seek care outside the home. This system is comprised of a low-cost wearable band that measures the newborn’s respiratory rate and temperature and is paired with a smartphone application that guides the mother through the qualitative danger signs. Our team has travelled to Uganda to validate the usability of this system and tailor-fitted the NeMo system to the end user. Currently, the NeMo system is undergoing validation testing in the Johns Hopkins Nursery where data collection enables breath-by-breath analysis to iteratively improve the respiratory rate algorithm’s overall sensitivity and specificity. The team will return to Uganda to perform an acceptability study where mothers will be observed under the intended use case to study barriers of adoptions and behavior change triggered by the NeMo system.

• Minimally Invasive Dynamic Stabilization of Lumbar Facets for Reduction in Low Back Pain

  THE TEAM

  Student Team: Anthony Ho, Shababa Matin, Natalie Ng, Madison Vanosdoll, Allison Wallingford, Ryan Xu

  Advisors: Sheng-Fu Larry Lo, MD, MHS; Amit Jain, MD; Allan Belzberg, MD; Amanda Buxton, PhD; Matt Dreher, PhD; Clifford Weiss, MD

  Sponsor: BTG

  ABSTRACT

  At any given time, one in ten Americans suffer from lower back pain, and it is estimated that approximately 31% of this is attributed to the facet. The facet is a gliding synovial joint that works to limit motion and support the axial loads of the body. Patients typically experience facetmediated lumbar pain secondary to conditions such as age-related degeneration, trauma, or spinal deformities. Pathophysiologic changes accompanying degeneration of the facet joint can include the following: increased loading, wear of the cartilage surface, painful bone-on-bone contact, micromotion and prolonged inflammation.

  Patients who exhaust conservative treatment can receive radiofrequency ablation (RFA) of the peripheral nerve to prevent transmission of pain signals. RFA, however, only provides relief for a limited duration and has decreased efficacy in repeat procedures. The only remaining option for patients is spinal fusion, an extremely invasive procedure that limits the normal motion of the body and has poor long-term outcomes. Therefore, patients experiencing facet-mediated pain need a minimally invasive treatment option to fill the therapeutic gap between non-operative treatments and invasive surgical intervention.

  While other solutions exist to address this gap in care, all of these options are addressed towards surgeons who have little incentive to use these products over performing spinal fusion because open surgery is still required. Therefore, we have designed our solution to be targeted towards the skillsets of interventionalists. Our goal is to provide patients with longer and greater pain relief than the current standard without the need for invasive surgery.

  To this end, our team has developed ZyGuard, a two-part system comprised of a catheter-based delivery system and an injectable implant. The flexible spacer works to prevent the painful bone-on-bone contact while maintaining a healthy range of motion of the facet. The delivery system enables interventionalists to access the degenerated facet, appropriately re-establish the intra-articular space, and deploy the injectable implant. Our team believes that this two-part ZyGuard system will revolutionize treatment of low back pain.