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OCTOBER 28 - NOVEMBER 3, 2020 • PROFILES IN MEDICINE

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Northwell Health Creates COVID-19 Predictive Tool What this new tool means for hospitals and COVID-19 patients BY EMILY SAUCHELLI esauchelli@antonnews.com

orthwell Health has created the first-of-its-kind COVID-19 predictive tool. The head of the team who created this new endeavor is Paul Lambson, corporate director of consumer insights and analytics at Northwell Health. The thought of creating a resource to help combat COVID-19 was brought to Lambson’s attention in the earlier months of the pandemic by a Northwell physician. “I was approached by one of the doctors in Northwell, who in normal times was actually not a practicing doctor, but an administrator,” Lambson explained. “During COVID-19, he got called back during the first wave—March, April, May time. He got called back in the front line and was working in the pediatric ICU. When things calmed down in June, he came to me and we worked on a couple of things. He explained to me how desperate it was for him to be on the front lines, how the suffering [is unlike anything he’s ever] seen and working with pregnant mothers who had COVID-19 and working through their delivery.” Lambson said the basis of this project is centered around Northwell Health’s website traffic—specifically where patients were clicking in regard to their searches. “We talked about search trends,” he said. “Google had a flu predictor based on what people’s search terms were. Me and my team took that back. Our imperative was, we need to use whatever data that we have to try to find some way to help the health system prepare for a spike.” Lambson adds that there was not much clinical data—measurements and determinants of health—to work with, so the team had to come up with new methods to find a pattern that worked as a form of prediction. “We categorized the website into a bunch of different ways that someone would interact with our system,” he said. “So, people request appointments, they looked at doctor’s profiles. They will find a number to call. We look at it as, what actions did they take or what kind of ways they’re using the website. So, we categorize the website

into these—we eventually used 15 of them—distinct categories. Then, we use machine learning algorithms to test it against whether it could predict COVID-19 diagnoses in our system. Then once we knew the ones we liked we immediately had to test—how far in advance should we be on the testing? Two weeks seemed to have the best relationship. COVID-19 diagnoses have a very day of week dependent nature. Then we refined the model and ran it through a couple different types of machine learning algorithms.” Lambson said the predictions are made through the use of monitoring Northwell Health’s website. “At the end of the day, we get a tally of how many people look for doctors, how many people look for wait times, how many people requested an appointment and all kinds of things,” he said. “We saw that more people than usual decided to request an appointment, less people than usual decided to look at wait times, for example. There’s 15 categories to an equation or an algorithm that we have trained and built with previous data and that will tell us this—that two weeks from today, we expect the COVID-19 cases in our hospitals to be at this level.”

In addition to the website traffic, there is clinical information that is used, in addition, as a way to monitor the COVID-19 trends. “The hospital has a suite of tools,” Lambson said. “The departments that are not mine are monitoring a lot of vital signs and oxygen saturation levels—and a lot of things that come from hospital settings—those go into the monitoring suite that the system uses. This algorithm goes into a dashboard that is basically a line chart that shows the trend we’ve been seeing in COVID-19 cases per day. Then it shows a forecast of what the next two weeks look like.” According to Lambson, the dashboard does not predict the number of people who are hospitalized, but rather the number of people who test positive for COVID-19 whether they are in an in-patient or out-patient setting. Lambson and the Northwell Health team are grateful to be able to share this new tool with other hospitals across the country. “It was so important for us—for me, personally— to share this code as wide as we can,” he explained. “We felt it was important to share our knowledge with the global domain of knowledge to hopefully fast track

Paul Lambson

(Photo courtesy of Northwell Health)

and advance. We did this, which might mean some researcher at Johns Hopkins or Children’s National will come up with some other relationship there—that we hadn’t thought of—that would forward us. That would advance us even more.” For health systems interested in learning more about Northwell’s COVID-19 predictive dashboard, visit www.github.com/northwell-health/ covid-web-data-predictor.

Northwell Health frontline staff will have advance warning of the next COVID-19 surge thanks to its new predictive dashboard. (Photo courtesy of Northwell Health)

OCTOBER 28 - NOVEMBER 3, 2020 • PROFILES IN MEDICINE

Diagnosed With Breast Cancer While Pregnant A look inside the process of treatment and diagnosis BY EMILY SAUCHELLI esauchelli@antonnews.com

Breast cancer alone is a struggle for any woman. However, being pregnant and finding out you have breast cancer is a whole other struggle that can be met with fear and uncertainty. Dr. Ruby Sharma is a medical oncologist at Northwell Health, who shares her insight into the different treatment options and resources women have.

Q A

What is the first step in treating Is being pregnant and having a woman who is pregnant breast cancer simultaneously a and has breast cancer? rare occurrence? I just saw one patient this mornYes, it is. It is relatively uncoming, and it’s still very fresh in my mon. Breast cancer occurs in mind. A woman who is pregnant and about one and 3,000 pregnancies. The gets a cancer diagnosis is going numbers have gone up in the through a roller coaster of last decade or so because, emotions. She’s excited more women are delaying about the pregnancy, childbearing. More but at the same time, women are getting she was very scared pregnant in their late about cancer. The 30s and 40s. We’re gofirst thing that I do ing to see more breast when I meet with the cancer because the risk patient and their family of breast cancer increases is to provide reassurance. with age. Dr. Ruby Sharma I tell the family that breast If a woman has breast courtesy of cancer can be treated safely (Photo cancer while they’re Northwell Health) during pregnancy, and terpregnant, are there ways to mination is not needed. Termination be able to breastfeed? of pregnancy has not been shown Only in some cases and only for to improve outcome. The first thing a short period of time. Most pathat I tell my patients is that they can tients who are diagnosed with cancer, continue with the pregnancy and can do need additional treatment after get safely treated, and I reassure them surgery to prevent the cancer from and they feel relieved. It takes a lot of coming back. Often these treatments anxiety away from them. include chemotherapy or hormonal Can you go into more detail therapy. These cancer medicines about how it felt to discuss can enter the breast milk and can be with your patient? Usually, these are young patients. They don’t go for mammograms. In terms of how they are diagnosed, either the patient herself would feel something in the breast. Pregnant breasts are very small and tender. It’s hard to feel a mass, but if a patient ever feels a mass, they really should get it investigated. They should not ignore it. So, in this case, the obstetrics and gynecology doctor felt a mass and sent her for imaging. But of course, patients are somewhat devastated when they get the news. So, [this patient] was very emotional this morning. She actually works in health care, so she kind of knows what is involved. She was overwhelmed. I spent a good five to 10 minutes of reassuring the family—and not just the patient, the whole family—and to tell them that they will be okay. Monter Cancer Center

Q A

(Photo courtesy of Northwell Health)

passed on to the baby. In most cases, breastfeeding is not recommended when a patient is on cancer medications. But, there’s often a two-week time window between delivery and starting cancer treatment.

Q A

What are ways to protect the baby other than the placenta? We avoid any imaging that involves radiation. For example, a CT scan or a PET scan is not done in a pregnant patient, which we would do otherwise in our cancer patients. But, other imaging studies like a mammogram, a sonogram, they’re okay, but we do use abdominal shield to protect the baby. In some cases, if we need an MRI, that can be done without contrast. First trimester is when the baby is actually being formed—the organs are all forming. So, that’s when we avoid any treatment. But in second and third trimester, that’s the period of fetal growth. So, we give treatments that are necessary—whether it’s surgery or chemotherapy. The patient is followed by high risk OBGYN doctors, and they monitor physical growth and development after every chemotherapy cycle.

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What advice can you give women who are going through this process? Breast cancer diagnoses are very complex. It definitely

needs to be treated at a center with a team of experts who specialize in cancer treatment as well as high-risk pregnancy issues. I think the other biggest thing is that termination of pregnancy is not necessary in most cases. Often time people don’t realize that. They come to me saying ‘we were told that we have to terminate the baby to go ahead with cancer treatment.’ When I tell them that termination is not necessary they feel very relieved. It’s important for people to understand that pregnant patients can safely get treatment for breast cancer, and they can continue their pregnancy. Most patients are cancer free after completing their treatment, and they’re able to have a happy and a healthy baby. In terms of outcome or prognosis—if the cancer is treated appropriately, the prognosis or outcome is very good. Dr. Ruby Sharma’s is a medical oncologist at The Monter Center, within The Center for Advanced Medicine, part of Northwell Health’s Cancer Institute. The Monter Center is located in New Hyde Park. To learn more about Northwell Health’s Cancer Institute, visit www.northwell.edu/cancer-institute. To read a longer version of this story, visit www.longislandweekly. com.

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PROFILES IN MEDICINE • OCTOBER 28 - NOVEMBER 3, 2020

Feinstein Institutes Have A Breakthrough

Researchers find effective COVID-19 ‘cytokine storm’ treatment

ome immune systems have responded to COVID-19 infections by going into overdrive, resulting in an overzealous inflammatory response referred to as a cytokine storm. In a retrospective study of nearly 6,000 patients, researchers from the Feinstein Institutes for Medical Research and Northwell COVID-19 Research Consortium have identified the most effective immunomodulatory therapies to treat patients with evidence of this cytokine storm and improve patient survival. A multidisciplinary team of investigators, led by Negin Hajizadeh, a pulmonary and critical care physician, and associate professor at the Feinstein Institutes, analyzed the electronic health records of hospitalized COVID-19 patients across 12 of Northwell Health hospitals—New York State’s largest health system—between March 1 and April 24. The results were published in CHEST, by Sonali Narain, assistant professor at the Feinstein Institutes, corresponding author, and team. Patients were divided into one of six groups; no immunomodulatory

more than 65 percent had never smoked. Contradictory to previous reports, the black population was associated with better survival compared to white patients. Additionally, the most common comorbidities across the groups of patients that experienced a cytokine storm include: • Hypertension (44-59 percent) • Diabetes (32-46 percent) • Cardiovascular disease (5-14 percent) • Chronic kidney disease (5-12 percent) • Cancer (5-11 percent) The Feinstein Institutes for Medical Research is located on Northern Boule• Asthma (3-12 percent) vard in Manhasset. (Photo courtesy Feinstein Institutes for Medical Research) “Dr. Hajizadeh’s major COVID-19 treatment (standard of care), patients “Cytokine storms are a hallmark for research study gives timely and crucial who received intravenous corticomany COVID-19 patients and are asso- new knowledge about using currently steroids, anti-interleukin 6 antibody ciated with the most severe form of this available anti-inflammatory drugs,” therapy (tocilizumab) or anti-interleu- illness,” Dr. Hajizadeh, associate profes- Dr. Kevin J. Tracey, president and kin-1 therapy (anakinra) alone or in sor at the Zucker School of Medicine chief executive officer of the Feinstein combination with corticosteroids. at Hofstra/Northwell and co-senior Institutes said in a statement. “This The results show that the most effec- author on the paper said. “Our findings information will help others save lives.” tive treatment was the combination of suggest that with the intervention The researchers hope that the findcorticosteroids—such as dexamethaof certain drugs like corticosteroids, ings are useful for frontline providers to sone with tocilizumab when compared we can battle the cytokine storm and care for severely ill COVID-19 patients to standard of care. Additionally, there improve outcomes to the point that we and to aid in the future design of large was an improvement if corticosteroids believe we have found a new standard randomized controlled clinical trials, of care for seriously ill patients.” were used alone, or in combination the gold standard of medical research. Overall, there were twice as many with tocilizumab or anakinra when —Submitted by The Feinstein Institutes males as females in the cohorts, and compared with standard of care. for Medical Research

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What To Know About Gynecological Cancer A look inside resources and symptoms

BY EMILY SAUCHELLI Esauchelli@antonnews.com

According to Dr. Eva Chalas, gynecological cancer is a condition that is very common. Chalas specializes in gynecologic oncology at NYU Winthrop Hospital’s Perlmutter Cancer Center. She said there are ways women can learn about the disease through knowledge and shared details on how she ended up in this profession.

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What is gynecological cancer composed of? Basically, it’s malignancy that arises in the female genital track. It could be from the external going external—the vulva, fallopian tubes and ovaries, and sometimes the abdominal cavity, which is called peritoneal cancer.

Q A

What are the symptoms of gynecological cancer that women should look out for? Gynecological cancers can occur at any age, however there far more common after menopause then before. They’re typically, most of the women in their 50s to 80s, and rarely also 90s. If you think something is wrong, you should have it investigated. I think most women know their bodies. Sometimes people ignore symptoms. So, if we go from outside in on the vulva, the most common symptom of, malignancy, is either itching or presence of a lump, or an ulcer that’s not healing. Those are obviously concerns. Any kind of bleeding—that’s outside of the norm. Certainly, bleeding after menopause is completely outside of the norm. Sometimes women think they just haven’t gone through their changes, and they feel like that’s normal or they talk to their friends and they said, ‘yeah had some spotting.’ In general, it’s considered abnormal. That could be a sign of cervical cancer. Then of course, the presence of any kind of a mass or lump in your belly, is something that needs to be investigated. Ovarian cancer can present with bloating—feeling of fullness. You don’t have much of an appetite. You eat something and you’re full quickly. Most women are pretty much aware of those kind of symptoms, which may come just as a part of the norm.

Dr. Eva Chalas. (Photo courtesy of NYU Winthrop) Eating something that’s gassy, [the result is] you get a little bloated. This is something that doesn’t go away—it basically progresses. It’s not one meal that caused it. It’s happened several times in the course of a month, and maybe it’s happening more frequently. Those are all things that women should be aware of and investigate.

After a woman finds out she has a symptom, when should she get checked?

The sooner the better. Obviously, if there’s a problem, the sooner you’re on top of it, the less of a problem they come. Sadly—for things like ovarian, fallopian tube and peritoneal cancers—many of the symptoms I described actually occur as part of late disease, meaning already advanced. The cancer has already spread. That’s the unfortunate thing. Sadly, there’s also no way to screen for these. I think the most important thing is if you think something is wrong, seek help quickly. One of the things that people do is they’ll call the doctor’s office and say, ‘I need to be seen,’ but they don’t make it clear that it’s an urgent situation or that they’re very concerned. So, the front desk staff usually is the one that decides how quickly you can get in based on your symptoms. So, if the woman is concerned, they may want to insist on speaking with either one of the providers, like a nurse practitioner or physician’s assistant (PA) to say, ‘I’m concerned about these symptoms. How fast do I need to be seen?’ or to speak with the physician directly. Let’s say you have abnormal bleeding. If you think that something is wrong, don’t wait for three months

to make an appointment. Don’t accept an appointment in three months. It’s best to say, ‘I need to be seen urgently because I think this is a problem.’

Q A

What made you want to go into medicine as gynecological cancer specialist? I think it’s two things. One is, the person who was a gynecological oncologist during my residency was a very inspiring individual. The patients were very inspiring. It was a pleasure to work with them and try to do our best to help them. Also, the drive. I think everyone likes to try to help people. The fact that people appreciate that is a big plus. I think it was a combination of all those efforts—the mentorship and also the interactions with the patients.

Q A

How did you being hospitalized as a child affect you wanting to go into medicine? I was about 10 years old. I got sick, when we were on vacation in Yugoslavia, and my parents rushed me home. I got into the hospital and they discovered that I had a very severe kidney infection. The pediatrician who took care of me really did a great job. I knew I was very sick, and they helped me and I enjoyed the environment. Despite the fact that it was a hospital and I was 10 years old, I thought it was incredible what they did for kids. I think that [experience] nurtured my love of medicine or started my love of medicine. I volunteered in the hospital when I was in college. I was impressed by what people do to help others and really became single minded about a profession in medicine—choosing obstetrics and gynecology. Dr. Eva Chalas is the physician director of the Perlmutter Cancer Center at NYU Winthrop Hospital. She is also a professor and the vice chair of NYU Long Island School of Medicine. To learn more about the Perlmutter Cancer Center, visit www.nyulangone.org/locations/ perlmutter-cancer-center.

To read a longer version of this Dr. Eva Chalas discusses the robust expansion and growth of cancer services story, visit www.longislandweekly. com at NYU Winthrop Hospital. (Photo courtesy of NYU Winthrop Hospital)

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Saturday, November 14, 2020 10:00am – 11:30am Eastern

Director, NYU Langone Arena Oncology Clinical Professor, NYU Health Medical College President and Director of Research Sass Foundation for Medical Research Lake Success, NY

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Eileen Krim, MD, FACOG

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