Federal Practitioner

ANSWER

The correct answer is granuloma annulare (GA; choice “a”).

DISCUSSION

One of the most difficult concepts to grasp in dermatologic diagnosis is that almost all lesions and conditions—even the most common—have a broad range of morphologic presentations. These will often differ from the textbook photos. In this digital age, a simple Internet search will provide many results showing a diverse morphologic spectrum for many diseases, conditions, and lesions.

GA is a good example of how the presentation can vary. It has raised rolled margins and delled (gently concave) centers. The brownish red color is typical, but this patient showed a deeper red than most cases of GA. Occasionally, the red color is even deeper, with large patches of darkened skin and no palpable component.

Unfortunately, the misdiagnosis of fungal infection in this patient is typical. But dermatophytosis (otherwise known as “ringworm”)—the most common fungal skin infection—involves the epidermis. This means the patient would have scaly skin, probably with a well-defined margin—factors missing in this case. In addition, this patient reported no contact with sources of infection: animals, children, or immunosuppressive agents.

Ultimately, the most basic information that this patient's past providers neglected was a differential diagnosis. By establishing a differential, there was a clear decision to biopsy, which not only revealed the correct diagnosis but effectively ruled out the other options.

In defense of the patient’s other providers, I must admit that as a young primary care provider, I made this same mistake for exactly the same reasons.

TREATMENT

Most cases of GA are mild and self-limited, requiring no treatment. This is fortunate because no effective treatment exists. Topical steroids and cryotherapy will lighten the lesion, but GA nearly always resolves on its own.

ANSWER

The correct answer is granuloma annulare (GA; choice “a”).

DISCUSSION

One of the most difficult concepts to grasp in dermatologic diagnosis is that almost all lesions and conditions—even the most common—have a broad range of morphologic presentations. These will often differ from the textbook photos. In this digital age, a simple Internet search will provide many results showing a diverse morphologic spectrum for many diseases, conditions, and lesions.

GA is a good example of how the presentation can vary. It has raised rolled margins and delled (gently concave) centers. The brownish red color is typical, but this patient showed a deeper red than most cases of GA. Occasionally, the red color is even deeper, with large patches of darkened skin and no palpable component.

Unfortunately, the misdiagnosis of fungal infection in this patient is typical. But dermatophytosis (otherwise known as “ringworm”)—the most common fungal skin infection—involves the epidermis. This means the patient would have scaly skin, probably with a well-defined margin—factors missing in this case. In addition, this patient reported no contact with sources of infection: animals, children, or immunosuppressive agents.

Ultimately, the most basic information that this patient's past providers neglected was a differential diagnosis. By establishing a differential, there was a clear decision to biopsy, which not only revealed the correct diagnosis but effectively ruled out the other options.

In defense of the patient’s other providers, I must admit that as a young primary care provider, I made this same mistake for exactly the same reasons.

TREATMENT

Most cases of GA are mild and self-limited, requiring no treatment. This is fortunate because no effective treatment exists. Topical steroids and cryotherapy will lighten the lesion, but GA nearly always resolves on its own.

ANSWER

The correct answer is granuloma annulare (GA; choice “a”).

DISCUSSION

One of the most difficult concepts to grasp in dermatologic diagnosis is that almost all lesions and conditions—even the most common—have a broad range of morphologic presentations. These will often differ from the textbook photos. In this digital age, a simple Internet search will provide many results showing a diverse morphologic spectrum for many diseases, conditions, and lesions.

GA is a good example of how the presentation can vary. It has raised rolled margins and delled (gently concave) centers. The brownish red color is typical, but this patient showed a deeper red than most cases of GA. Occasionally, the red color is even deeper, with large patches of darkened skin and no palpable component.

Unfortunately, the misdiagnosis of fungal infection in this patient is typical. But dermatophytosis (otherwise known as “ringworm”)—the most common fungal skin infection—involves the epidermis. This means the patient would have scaly skin, probably with a well-defined margin—factors missing in this case. In addition, this patient reported no contact with sources of infection: animals, children, or immunosuppressive agents.

Ultimately, the most basic information that this patient's past providers neglected was a differential diagnosis. By establishing a differential, there was a clear decision to biopsy, which not only revealed the correct diagnosis but effectively ruled out the other options.

In defense of the patient’s other providers, I must admit that as a young primary care provider, I made this same mistake for exactly the same reasons.

TREATMENT

Most cases of GA are mild and self-limited, requiring no treatment. This is fortunate because no effective treatment exists. Topical steroids and cryotherapy will lighten the lesion, but GA nearly always resolves on its own.

After initial promising interim results on Nov. 9, Pfizer and BioNTech today announced that their mRNA vaccine, in development to prevent COVID-19, is 95% effective.

Final analysis of the randomized, phase 3 study of more than 43,000 people yielded 170 confirmed cases of COVID-19 – with 162 positive cases in the placebo group versus 8 in the BNT162b2 vaccine group.

Researchers reported 10 severe cases of COVID-19 in the trial, 9 of which occurred in the placebo group.

The study was ethnically diverse, and results were consistent across gender and age groups, with a 94% efficacy reported among participants aged older than 65 years.

Pfizer plans to file for an emergency-use authorization with the Food and Drug Administration “within days,” having now met all the FDA data endpoints, according to a news release from the two companies.

The vaccine was well tolerated with no serious safety concerns, the company stated. Two grade 3 adverse events were reported – fatigue in 3.8% of participants and headache in 2%.

The 95% efficacy places the Pfizer vaccine in the same neighborhood as the interim results of the Moderna vaccine, reported at 94.5%. Both products are two-dose mRNA vaccines.

As of Nov. 13, of 43,661 total participants in the Pfizer vaccine phase 3 trial, 41,135 received a second dose. The final results are based on two outcomes measured 7 days after the second dose: vaccine efficacy in people without prior SARS-CoV-2 infection as well as a secondary outcome in people both with and without prior SARS-CoV-2 infection.

The 95% vaccine efficacy was statistically significant, compared with placebo (P < .0001).
 

‘Historic 8-month journey’

The BNT162b2 vaccine candidate is a joint effort between Pfizer and BioNTech. “The study results mark an important step in this historic 8-month journey to bring forward a vaccine capable of helping to end this devastating pandemic,” Albert Bourla, DVM, PhD, Pfizer chairman and CEO, said in a statement. “With hundreds of thousands of people around the globe infected every day, we urgently need to get a safe and effective vaccine to the world.”

Ugur Sahin, MD, PhD, cofounder and CEO of BioNTech, added, “we are grateful that the first global trial to reach the final efficacy analysis mark indicates that a high rate of protection against COVID-19 can be achieved very fast after the first 30-mcg dose, underscoring the power of BNT162 in providing early protection.”

The two companies expect to produce up to 50 million vaccine doses in 2020 for global distribution. Projections for 2021 include up to 1.3 billion doses.

The companies also designed temperature-controlled thermal shipping containers with dry ice to maintain the required, approximate –70° C (–94° F) conditions. Clinicians can use the containers as temporary storage units for up to 15 days by replacing the dry ice.

This article first appeared on Medscape.com.

After initial promising interim results on Nov. 9, Pfizer and BioNTech today announced that their mRNA vaccine, in development to prevent COVID-19, is 95% effective.

Final analysis of the randomized, phase 3 study of more than 43,000 people yielded 170 confirmed cases of COVID-19 – with 162 positive cases in the placebo group versus 8 in the BNT162b2 vaccine group.

Researchers reported 10 severe cases of COVID-19 in the trial, 9 of which occurred in the placebo group.

The study was ethnically diverse, and results were consistent across gender and age groups, with a 94% efficacy reported among participants aged older than 65 years.

Pfizer plans to file for an emergency-use authorization with the Food and Drug Administration “within days,” having now met all the FDA data endpoints, according to a news release from the two companies.

The vaccine was well tolerated with no serious safety concerns, the company stated. Two grade 3 adverse events were reported – fatigue in 3.8% of participants and headache in 2%.

The 95% efficacy places the Pfizer vaccine in the same neighborhood as the interim results of the Moderna vaccine, reported at 94.5%. Both products are two-dose mRNA vaccines.

As of Nov. 13, of 43,661 total participants in the Pfizer vaccine phase 3 trial, 41,135 received a second dose. The final results are based on two outcomes measured 7 days after the second dose: vaccine efficacy in people without prior SARS-CoV-2 infection as well as a secondary outcome in people both with and without prior SARS-CoV-2 infection.

The 95% vaccine efficacy was statistically significant, compared with placebo (P < .0001).
 

‘Historic 8-month journey’

The BNT162b2 vaccine candidate is a joint effort between Pfizer and BioNTech. “The study results mark an important step in this historic 8-month journey to bring forward a vaccine capable of helping to end this devastating pandemic,” Albert Bourla, DVM, PhD, Pfizer chairman and CEO, said in a statement. “With hundreds of thousands of people around the globe infected every day, we urgently need to get a safe and effective vaccine to the world.”

Ugur Sahin, MD, PhD, cofounder and CEO of BioNTech, added, “we are grateful that the first global trial to reach the final efficacy analysis mark indicates that a high rate of protection against COVID-19 can be achieved very fast after the first 30-mcg dose, underscoring the power of BNT162 in providing early protection.”

The two companies expect to produce up to 50 million vaccine doses in 2020 for global distribution. Projections for 2021 include up to 1.3 billion doses.

The companies also designed temperature-controlled thermal shipping containers with dry ice to maintain the required, approximate –70° C (–94° F) conditions. Clinicians can use the containers as temporary storage units for up to 15 days by replacing the dry ice.

This article first appeared on Medscape.com.

After initial promising interim results on Nov. 9, Pfizer and BioNTech today announced that their mRNA vaccine, in development to prevent COVID-19, is 95% effective.

Final analysis of the randomized, phase 3 study of more than 43,000 people yielded 170 confirmed cases of COVID-19 – with 162 positive cases in the placebo group versus 8 in the BNT162b2 vaccine group.

Researchers reported 10 severe cases of COVID-19 in the trial, 9 of which occurred in the placebo group.

The study was ethnically diverse, and results were consistent across gender and age groups, with a 94% efficacy reported among participants aged older than 65 years.

Pfizer plans to file for an emergency-use authorization with the Food and Drug Administration “within days,” having now met all the FDA data endpoints, according to a news release from the two companies.

The vaccine was well tolerated with no serious safety concerns, the company stated. Two grade 3 adverse events were reported – fatigue in 3.8% of participants and headache in 2%.

The 95% efficacy places the Pfizer vaccine in the same neighborhood as the interim results of the Moderna vaccine, reported at 94.5%. Both products are two-dose mRNA vaccines.

As of Nov. 13, of 43,661 total participants in the Pfizer vaccine phase 3 trial, 41,135 received a second dose. The final results are based on two outcomes measured 7 days after the second dose: vaccine efficacy in people without prior SARS-CoV-2 infection as well as a secondary outcome in people both with and without prior SARS-CoV-2 infection.

The 95% vaccine efficacy was statistically significant, compared with placebo (P < .0001).
 

‘Historic 8-month journey’

The BNT162b2 vaccine candidate is a joint effort between Pfizer and BioNTech. “The study results mark an important step in this historic 8-month journey to bring forward a vaccine capable of helping to end this devastating pandemic,” Albert Bourla, DVM, PhD, Pfizer chairman and CEO, said in a statement. “With hundreds of thousands of people around the globe infected every day, we urgently need to get a safe and effective vaccine to the world.”

Ugur Sahin, MD, PhD, cofounder and CEO of BioNTech, added, “we are grateful that the first global trial to reach the final efficacy analysis mark indicates that a high rate of protection against COVID-19 can be achieved very fast after the first 30-mcg dose, underscoring the power of BNT162 in providing early protection.”

The two companies expect to produce up to 50 million vaccine doses in 2020 for global distribution. Projections for 2021 include up to 1.3 billion doses.

The companies also designed temperature-controlled thermal shipping containers with dry ice to maintain the required, approximate –70° C (–94° F) conditions. Clinicians can use the containers as temporary storage units for up to 15 days by replacing the dry ice.

This article first appeared on Medscape.com.

A “hospital at home” (HaH) program at Atrium Health, a large integrated delivery system in the Southeast, expanded its hospital capacity during the early phase of the COVID-19 pandemic by providing hospital-level acute care to COVID-19 patients at home, according to a new study in Annals of Internal Medicine.

“Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond,” wrote Kranthi Sitammagari, MD, from the Atrium Health Hospitalist Group, Monroe, N.C., and colleagues.

Whereas most previous HaH programs have relied on visiting nurses and physicians, the new study uses telemedicine to connect with patients. Advocate Health Care researchers published the only other study using the telemedicine-powered model in 2015.

The new Atrium Health study evaluated 1,477 patients who received care in the HaH program between March 23 and May 7 of this year after having been diagnosed with COVID-19. The program provided home monitoring and hospital-level care in a home-based virtual observation unit (VOU) and a virtual acute care unit (VACU).

Patients were tested for the virus in Atrium emergency departments, primary care clinics, urgent care centers, and external testing sites. Those who tested positive were invited to be cared for either in the VOU, if they had mild to moderate symptoms, or in the VACU, if they were sick enough to be admitted to the hospital.
 

Patients hop onboard

Nearly all COVID-positive patients tested in these sites agreed to be admitted to the hospital at home, coauthor Stephanie Murphy, DO, medical director of the Atrium Health HaH program, said in an interview.

Patients with moderate symptoms were glad to be monitored at home, she said. When they got to the point where the nurse supervising their care felt they needed escalation to acute care, they were asked whether they wanted to continue to be cared for at home. Most opted to stay home rather than be admitted to the hospital, where their loved ones couldn’t visit them.

Low-acuity patients in the VOU received daily telemonitoring by a nurse to identify disease progression and escalate care as needed. For those who required more care and were admitted to the VACU, a team of paramedics and registered nurses (RNs; mobile clinicians) visited the patient’s home within 24 hours, setting up a hospital bed, other necessary medical equipment, videoconferencing gear, and a remote-monitoring kit that included a blood pressure cuff, a pulse oximeter, and a thermometer.

Dedicated hospitalists and nurses managed patients with 24/7 coverage and monitoring, bringing in other specialties as needed for virtual consults. Mobile clinician and virtual provider visits continued daily until a patient’s condition improved to the point where they could be deescalated back to the VOU. After that, patients received mobile app-driven symptom monitoring and telephone follow-up with a nurse until they got better.
 

Few patients go to hospital

Overall, patients had a median length of stay of 11 days in the VOU or the VACU or both. The vast majority, 1,293 patients (88%), received care in the VOU only. In that cohort, just 40 patients (3%) required hospitalization in an Atrium facility. Sixteen of those patients spent time in an ICU, seven required ventilator support, and two died in the hospital.

A total of 184 patients (12%) were admitted to the VACU. Twenty-one (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted to a conventional hospital. Of the latter patients, 10 were admitted to an ICU, one required a ventilator, and none died in the hospital.

Dr. Sitammagari, a hospitalist and comedical director for quality at Atrium Health, told this news organization that, overall, the outcomes for patients in the system’s HaH were comparable to those seen in the literature among other COVID-19 cohorts.
 

Augmenting hospital capacity

The authors note that treating the 160 VACU patients within the HaH saved hospital beds for other patients. The HaH maintained a consistent census of between 20 and 30 patients for the first 6 weeks as COVID-19 cases spread.

Since last spring, Dr. Murphy said, the Atrium HaH’s daily census has grown to between 30 and 45 patients. “We could absorb 50 patients if our hospitals required it.”

How much capacity does that add to Atrium Health? While there are 50 hospitals in the health system, the HaH was set up mainly to care for COVID-19 patients who would otherwise have been admitted to the 10 acute-care hospitals in the Charlotte, N.C., area. In the 4 weeks ending Nov. 16, these facilities carried an average daily census of around 160 COVID-19 patients, Dr. Murphy noted. “During that time, the Atrium Health HaH has carried, on average, about 20%-25% of that census.”

If the pandemic were to overwhelm area hospitals, she added, “the structure would support flexing up our staffing and supplies to expand to crisis capacity,” which could be up to 200 patients a day.

For the nurses who make most of the phone calls to patients, patients average about 12 to 15 per RN, Dr. Murphy said, and there’s one mobile clinician for every six to nine patients. That’s pretty consistent with the staffing on med-surg floors in hospitals, she said.

The physicians in the program include hospitalists dedicated to telemedicine and some doctors who can’t work in the regular hospital because they’re immunocompromised. The physicians round virtually, covering 12-17 HaH patients per day, according to Dr. Murphy.
 

Prior planning paid off

Unlike some other health care systems that have launched HaH programs with the aid of outside vendors, Atrium Health developed its own HaH and brought it online just 2 weeks after deciding to launch the program. Atrium was able to do this, Dr. Sitammagari explained, because before the pandemic its hospitalist program was already developing an HaH model to improve the care of high-risk patients after hospital discharge to prevent readmission.

While Atrium’s electronic health record system wasn’t designed for hospital at home, its health information technology department and clinicians collaborated in rewriting some of the workflows and order sets in the EHR. For example, they set up a nursing questionnaire to administer after VACU admission, and they created another form for automatic admission to the HaH after a patient tested positive for COVID-19. Atrium staff also modified a patient-doctor communications app to help clinicians monitor HaH patients, Dr. Murphy noted.

Other hospital systems have gotten up to speed on HaH pretty quickly by using platforms supplied by outside vendors. Adventist Health in Los Angeles, for example, started admitting patients to its hospital at home just a month after approaching a vendor called Medically Home.
 

COVID vs. non-COVID patients

Atrium’s decision to focus its HaH effort on COVID-19 patients is unusual among the small but growing number of health systems that have adopted the HaH model to increase their capacity. (Atrium is now transferring some hospitalized patients with other conditions to its HaH, but is still focusing mainly on COVID-19 in its HaH program.)

Bruce Leff, MD, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, Baltimore, a leading expert on the HaH model, agrees that it can increase hospital capacity significantly.

Dr. Leff praised the Atrium Health study. “It proves that within an integrated delivery system you can quickly deploy and implement a virtual hospital in the specific-use case of COVID, and help patients and help the system at scale,” he said. “They took a bunch of people into the virtual observation unit and thereby kept people from overwhelming their [emergency department] and treated those people safely at home.”

Dr. Leff had no problem with Atrium’s focus on patients with COVID-19 rather than other conditions. “My guess is that they have the ability to take what they developed and apply it to other conditions. Once you have the ability to do acute care at home, you can do a lot at home.”

The biggest barrier to the spread of hospital at home remains the lack of insurer coverage. Dr. Murphy said that health plans are covering virtual physician consultations with patients in the HaH, as well as some other bits and pieces, but not the entire episode of acute care.

Dr. Leff believes that this will start changing soon. COVID-19 has altered the attitudes of physicians and hospitals toward telehealth, he noted, “and it has moved policy makers and payers to start thinking about the new models – home-based care in general and hospital at home in particular. For the first time in 25 years, payers are starting to get interested.”

Most of the authors are employees of Atrium Health. In addition, one coauthor reports being the cofounder of a digital health company, iEnroll, and receiving grants from The Heineman Foundation. Dr. Leff is an advisor to Medically Home, which provides support to hospital at home programs.

A version of this article originally appeared on Medscape.com.

A “hospital at home” (HaH) program at Atrium Health, a large integrated delivery system in the Southeast, expanded its hospital capacity during the early phase of the COVID-19 pandemic by providing hospital-level acute care to COVID-19 patients at home, according to a new study in Annals of Internal Medicine.

“Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond,” wrote Kranthi Sitammagari, MD, from the Atrium Health Hospitalist Group, Monroe, N.C., and colleagues.

Whereas most previous HaH programs have relied on visiting nurses and physicians, the new study uses telemedicine to connect with patients. Advocate Health Care researchers published the only other study using the telemedicine-powered model in 2015.

The new Atrium Health study evaluated 1,477 patients who received care in the HaH program between March 23 and May 7 of this year after having been diagnosed with COVID-19. The program provided home monitoring and hospital-level care in a home-based virtual observation unit (VOU) and a virtual acute care unit (VACU).

Patients were tested for the virus in Atrium emergency departments, primary care clinics, urgent care centers, and external testing sites. Those who tested positive were invited to be cared for either in the VOU, if they had mild to moderate symptoms, or in the VACU, if they were sick enough to be admitted to the hospital.
 

Patients hop onboard

Nearly all COVID-positive patients tested in these sites agreed to be admitted to the hospital at home, coauthor Stephanie Murphy, DO, medical director of the Atrium Health HaH program, said in an interview.

Patients with moderate symptoms were glad to be monitored at home, she said. When they got to the point where the nurse supervising their care felt they needed escalation to acute care, they were asked whether they wanted to continue to be cared for at home. Most opted to stay home rather than be admitted to the hospital, where their loved ones couldn’t visit them.

Low-acuity patients in the VOU received daily telemonitoring by a nurse to identify disease progression and escalate care as needed. For those who required more care and were admitted to the VACU, a team of paramedics and registered nurses (RNs; mobile clinicians) visited the patient’s home within 24 hours, setting up a hospital bed, other necessary medical equipment, videoconferencing gear, and a remote-monitoring kit that included a blood pressure cuff, a pulse oximeter, and a thermometer.

Dedicated hospitalists and nurses managed patients with 24/7 coverage and monitoring, bringing in other specialties as needed for virtual consults. Mobile clinician and virtual provider visits continued daily until a patient’s condition improved to the point where they could be deescalated back to the VOU. After that, patients received mobile app-driven symptom monitoring and telephone follow-up with a nurse until they got better.
 

Few patients go to hospital

Overall, patients had a median length of stay of 11 days in the VOU or the VACU or both. The vast majority, 1,293 patients (88%), received care in the VOU only. In that cohort, just 40 patients (3%) required hospitalization in an Atrium facility. Sixteen of those patients spent time in an ICU, seven required ventilator support, and two died in the hospital.

A total of 184 patients (12%) were admitted to the VACU. Twenty-one (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted to a conventional hospital. Of the latter patients, 10 were admitted to an ICU, one required a ventilator, and none died in the hospital.

Dr. Sitammagari, a hospitalist and comedical director for quality at Atrium Health, told this news organization that, overall, the outcomes for patients in the system’s HaH were comparable to those seen in the literature among other COVID-19 cohorts.
 

Augmenting hospital capacity

The authors note that treating the 160 VACU patients within the HaH saved hospital beds for other patients. The HaH maintained a consistent census of between 20 and 30 patients for the first 6 weeks as COVID-19 cases spread.

Since last spring, Dr. Murphy said, the Atrium HaH’s daily census has grown to between 30 and 45 patients. “We could absorb 50 patients if our hospitals required it.”

How much capacity does that add to Atrium Health? While there are 50 hospitals in the health system, the HaH was set up mainly to care for COVID-19 patients who would otherwise have been admitted to the 10 acute-care hospitals in the Charlotte, N.C., area. In the 4 weeks ending Nov. 16, these facilities carried an average daily census of around 160 COVID-19 patients, Dr. Murphy noted. “During that time, the Atrium Health HaH has carried, on average, about 20%-25% of that census.”

If the pandemic were to overwhelm area hospitals, she added, “the structure would support flexing up our staffing and supplies to expand to crisis capacity,” which could be up to 200 patients a day.

For the nurses who make most of the phone calls to patients, patients average about 12 to 15 per RN, Dr. Murphy said, and there’s one mobile clinician for every six to nine patients. That’s pretty consistent with the staffing on med-surg floors in hospitals, she said.

The physicians in the program include hospitalists dedicated to telemedicine and some doctors who can’t work in the regular hospital because they’re immunocompromised. The physicians round virtually, covering 12-17 HaH patients per day, according to Dr. Murphy.
 

Prior planning paid off

Unlike some other health care systems that have launched HaH programs with the aid of outside vendors, Atrium Health developed its own HaH and brought it online just 2 weeks after deciding to launch the program. Atrium was able to do this, Dr. Sitammagari explained, because before the pandemic its hospitalist program was already developing an HaH model to improve the care of high-risk patients after hospital discharge to prevent readmission.

While Atrium’s electronic health record system wasn’t designed for hospital at home, its health information technology department and clinicians collaborated in rewriting some of the workflows and order sets in the EHR. For example, they set up a nursing questionnaire to administer after VACU admission, and they created another form for automatic admission to the HaH after a patient tested positive for COVID-19. Atrium staff also modified a patient-doctor communications app to help clinicians monitor HaH patients, Dr. Murphy noted.

Other hospital systems have gotten up to speed on HaH pretty quickly by using platforms supplied by outside vendors. Adventist Health in Los Angeles, for example, started admitting patients to its hospital at home just a month after approaching a vendor called Medically Home.
 

COVID vs. non-COVID patients

Atrium’s decision to focus its HaH effort on COVID-19 patients is unusual among the small but growing number of health systems that have adopted the HaH model to increase their capacity. (Atrium is now transferring some hospitalized patients with other conditions to its HaH, but is still focusing mainly on COVID-19 in its HaH program.)

Bruce Leff, MD, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, Baltimore, a leading expert on the HaH model, agrees that it can increase hospital capacity significantly.

Dr. Leff praised the Atrium Health study. “It proves that within an integrated delivery system you can quickly deploy and implement a virtual hospital in the specific-use case of COVID, and help patients and help the system at scale,” he said. “They took a bunch of people into the virtual observation unit and thereby kept people from overwhelming their [emergency department] and treated those people safely at home.”

Dr. Leff had no problem with Atrium’s focus on patients with COVID-19 rather than other conditions. “My guess is that they have the ability to take what they developed and apply it to other conditions. Once you have the ability to do acute care at home, you can do a lot at home.”

The biggest barrier to the spread of hospital at home remains the lack of insurer coverage. Dr. Murphy said that health plans are covering virtual physician consultations with patients in the HaH, as well as some other bits and pieces, but not the entire episode of acute care.

Dr. Leff believes that this will start changing soon. COVID-19 has altered the attitudes of physicians and hospitals toward telehealth, he noted, “and it has moved policy makers and payers to start thinking about the new models – home-based care in general and hospital at home in particular. For the first time in 25 years, payers are starting to get interested.”

Most of the authors are employees of Atrium Health. In addition, one coauthor reports being the cofounder of a digital health company, iEnroll, and receiving grants from The Heineman Foundation. Dr. Leff is an advisor to Medically Home, which provides support to hospital at home programs.

A version of this article originally appeared on Medscape.com.

A “hospital at home” (HaH) program at Atrium Health, a large integrated delivery system in the Southeast, expanded its hospital capacity during the early phase of the COVID-19 pandemic by providing hospital-level acute care to COVID-19 patients at home, according to a new study in Annals of Internal Medicine.

“Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond,” wrote Kranthi Sitammagari, MD, from the Atrium Health Hospitalist Group, Monroe, N.C., and colleagues.

Whereas most previous HaH programs have relied on visiting nurses and physicians, the new study uses telemedicine to connect with patients. Advocate Health Care researchers published the only other study using the telemedicine-powered model in 2015.

The new Atrium Health study evaluated 1,477 patients who received care in the HaH program between March 23 and May 7 of this year after having been diagnosed with COVID-19. The program provided home monitoring and hospital-level care in a home-based virtual observation unit (VOU) and a virtual acute care unit (VACU).

Patients were tested for the virus in Atrium emergency departments, primary care clinics, urgent care centers, and external testing sites. Those who tested positive were invited to be cared for either in the VOU, if they had mild to moderate symptoms, or in the VACU, if they were sick enough to be admitted to the hospital.
 

Patients hop onboard

Nearly all COVID-positive patients tested in these sites agreed to be admitted to the hospital at home, coauthor Stephanie Murphy, DO, medical director of the Atrium Health HaH program, said in an interview.

Patients with moderate symptoms were glad to be monitored at home, she said. When they got to the point where the nurse supervising their care felt they needed escalation to acute care, they were asked whether they wanted to continue to be cared for at home. Most opted to stay home rather than be admitted to the hospital, where their loved ones couldn’t visit them.

Low-acuity patients in the VOU received daily telemonitoring by a nurse to identify disease progression and escalate care as needed. For those who required more care and were admitted to the VACU, a team of paramedics and registered nurses (RNs; mobile clinicians) visited the patient’s home within 24 hours, setting up a hospital bed, other necessary medical equipment, videoconferencing gear, and a remote-monitoring kit that included a blood pressure cuff, a pulse oximeter, and a thermometer.

Dedicated hospitalists and nurses managed patients with 24/7 coverage and monitoring, bringing in other specialties as needed for virtual consults. Mobile clinician and virtual provider visits continued daily until a patient’s condition improved to the point where they could be deescalated back to the VOU. After that, patients received mobile app-driven symptom monitoring and telephone follow-up with a nurse until they got better.
 

Few patients go to hospital

Overall, patients had a median length of stay of 11 days in the VOU or the VACU or both. The vast majority, 1,293 patients (88%), received care in the VOU only. In that cohort, just 40 patients (3%) required hospitalization in an Atrium facility. Sixteen of those patients spent time in an ICU, seven required ventilator support, and two died in the hospital.

A total of 184 patients (12%) were admitted to the VACU. Twenty-one (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted to a conventional hospital. Of the latter patients, 10 were admitted to an ICU, one required a ventilator, and none died in the hospital.

Dr. Sitammagari, a hospitalist and comedical director for quality at Atrium Health, told this news organization that, overall, the outcomes for patients in the system’s HaH were comparable to those seen in the literature among other COVID-19 cohorts.
 

Augmenting hospital capacity

The authors note that treating the 160 VACU patients within the HaH saved hospital beds for other patients. The HaH maintained a consistent census of between 20 and 30 patients for the first 6 weeks as COVID-19 cases spread.

Since last spring, Dr. Murphy said, the Atrium HaH’s daily census has grown to between 30 and 45 patients. “We could absorb 50 patients if our hospitals required it.”

How much capacity does that add to Atrium Health? While there are 50 hospitals in the health system, the HaH was set up mainly to care for COVID-19 patients who would otherwise have been admitted to the 10 acute-care hospitals in the Charlotte, N.C., area. In the 4 weeks ending Nov. 16, these facilities carried an average daily census of around 160 COVID-19 patients, Dr. Murphy noted. “During that time, the Atrium Health HaH has carried, on average, about 20%-25% of that census.”

If the pandemic were to overwhelm area hospitals, she added, “the structure would support flexing up our staffing and supplies to expand to crisis capacity,” which could be up to 200 patients a day.

For the nurses who make most of the phone calls to patients, patients average about 12 to 15 per RN, Dr. Murphy said, and there’s one mobile clinician for every six to nine patients. That’s pretty consistent with the staffing on med-surg floors in hospitals, she said.

The physicians in the program include hospitalists dedicated to telemedicine and some doctors who can’t work in the regular hospital because they’re immunocompromised. The physicians round virtually, covering 12-17 HaH patients per day, according to Dr. Murphy.
 

Prior planning paid off

Unlike some other health care systems that have launched HaH programs with the aid of outside vendors, Atrium Health developed its own HaH and brought it online just 2 weeks after deciding to launch the program. Atrium was able to do this, Dr. Sitammagari explained, because before the pandemic its hospitalist program was already developing an HaH model to improve the care of high-risk patients after hospital discharge to prevent readmission.

While Atrium’s electronic health record system wasn’t designed for hospital at home, its health information technology department and clinicians collaborated in rewriting some of the workflows and order sets in the EHR. For example, they set up a nursing questionnaire to administer after VACU admission, and they created another form for automatic admission to the HaH after a patient tested positive for COVID-19. Atrium staff also modified a patient-doctor communications app to help clinicians monitor HaH patients, Dr. Murphy noted.

Other hospital systems have gotten up to speed on HaH pretty quickly by using platforms supplied by outside vendors. Adventist Health in Los Angeles, for example, started admitting patients to its hospital at home just a month after approaching a vendor called Medically Home.
 

COVID vs. non-COVID patients

Atrium’s decision to focus its HaH effort on COVID-19 patients is unusual among the small but growing number of health systems that have adopted the HaH model to increase their capacity. (Atrium is now transferring some hospitalized patients with other conditions to its HaH, but is still focusing mainly on COVID-19 in its HaH program.)

Bruce Leff, MD, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, Baltimore, a leading expert on the HaH model, agrees that it can increase hospital capacity significantly.

Dr. Leff praised the Atrium Health study. “It proves that within an integrated delivery system you can quickly deploy and implement a virtual hospital in the specific-use case of COVID, and help patients and help the system at scale,” he said. “They took a bunch of people into the virtual observation unit and thereby kept people from overwhelming their [emergency department] and treated those people safely at home.”

Dr. Leff had no problem with Atrium’s focus on patients with COVID-19 rather than other conditions. “My guess is that they have the ability to take what they developed and apply it to other conditions. Once you have the ability to do acute care at home, you can do a lot at home.”

The biggest barrier to the spread of hospital at home remains the lack of insurer coverage. Dr. Murphy said that health plans are covering virtual physician consultations with patients in the HaH, as well as some other bits and pieces, but not the entire episode of acute care.

Dr. Leff believes that this will start changing soon. COVID-19 has altered the attitudes of physicians and hospitals toward telehealth, he noted, “and it has moved policy makers and payers to start thinking about the new models – home-based care in general and hospital at home in particular. For the first time in 25 years, payers are starting to get interested.”

Most of the authors are employees of Atrium Health. In addition, one coauthor reports being the cofounder of a digital health company, iEnroll, and receiving grants from The Heineman Foundation. Dr. Leff is an advisor to Medically Home, which provides support to hospital at home programs.

A version of this article originally appeared on Medscape.com.

The current COVID-19 pandemic has afflicted over 44 million individuals across the planet and been responsible for over 1 million deaths, particularly in high-risk populations. As a result of the overall advanced age, frailty and pre-existing comorbidities of patients with MDS, SARS-Cov2 was feared to be particularly dangerous in this patient population. A recent study by Mossuto et al describes the outcomes of patients with MDS with SARS-CoV-2 infection during the Coronavirus outbreak in Italy. Among a total of 5326 patients with MDS followed during the study period, 63 (1.18%) had confirmed SARS-CoV-2 infection. With a median age of 73 years, the mortality rate among these patients was 52% compared to that of the non-MDS population (24%), and was particularly high on male MDS patients (73% of total deaths). Respiratory failure was the cause of death in all the MDS patients with ARDS in 50% of deceased patients, and with majority of patients who were able to recover having lower risk IPSS-R categories. Interestingly, no differences in mortality or severity of infection were observed based on the type of therapy received for their MDS. These findings are not surprising given the underlying inflammation and immunosuppression in patients with MDS. Until the development of COVID-19 vaccines has been completed, identification of high-risk populations and specific guidelines for the management of SARS-CoV-2 infection in patients with MDS remains of paramount importance.

Clonal hematopoiesis is a known cardiovascular risk factor which has been associated with increased risk of cardiac and cerebrovascular events. Recent studies have also associated MDS with higher than expected cardiovascular comorbidities and cardiovascular-related deaths. In accordance to prior publications by Naqvi et al, a recent study by Faber et al retrospectively evaluated 236 MDS patients and studied the associations of somatic mutations with cardiovascular risk. Overall, the authors observed that 27% of patients in their study population developed vascular event, and that ASXL1 mutations were predictive of vascular disease by multivariate analysis (with an odds ratio of 4.2). This data further supports the biological connection between comorbidities and hematopoietic clonal disorders, the role of inflammaging and the need to maximize cardiovascular risk factor care in patients with MDS and develop specific therapies targeting both the disease biology and the underlying mechanisms leading to increased cardiovascular risk.

Guillermo Montalban Bravo, MD
Assistant Professor, Department of Leukemia, Division of Cancer Medicine
MD Anderson Cancer Center, Houston, TX

The current COVID-19 pandemic has afflicted over 44 million individuals across the planet and been responsible for over 1 million deaths, particularly in high-risk populations. As a result of the overall advanced age, frailty and pre-existing comorbidities of patients with MDS, SARS-Cov2 was feared to be particularly dangerous in this patient population. A recent study by Mossuto et al describes the outcomes of patients with MDS with SARS-CoV-2 infection during the Coronavirus outbreak in Italy. Among a total of 5326 patients with MDS followed during the study period, 63 (1.18%) had confirmed SARS-CoV-2 infection. With a median age of 73 years, the mortality rate among these patients was 52% compared to that of the non-MDS population (24%), and was particularly high on male MDS patients (73% of total deaths). Respiratory failure was the cause of death in all the MDS patients with ARDS in 50% of deceased patients, and with majority of patients who were able to recover having lower risk IPSS-R categories. Interestingly, no differences in mortality or severity of infection were observed based on the type of therapy received for their MDS. These findings are not surprising given the underlying inflammation and immunosuppression in patients with MDS. Until the development of COVID-19 vaccines has been completed, identification of high-risk populations and specific guidelines for the management of SARS-CoV-2 infection in patients with MDS remains of paramount importance.

Clonal hematopoiesis is a known cardiovascular risk factor which has been associated with increased risk of cardiac and cerebrovascular events. Recent studies have also associated MDS with higher than expected cardiovascular comorbidities and cardiovascular-related deaths. In accordance to prior publications by Naqvi et al, a recent study by Faber et al retrospectively evaluated 236 MDS patients and studied the associations of somatic mutations with cardiovascular risk. Overall, the authors observed that 27% of patients in their study population developed vascular event, and that ASXL1 mutations were predictive of vascular disease by multivariate analysis (with an odds ratio of 4.2). This data further supports the biological connection between comorbidities and hematopoietic clonal disorders, the role of inflammaging and the need to maximize cardiovascular risk factor care in patients with MDS and develop specific therapies targeting both the disease biology and the underlying mechanisms leading to increased cardiovascular risk.

Guillermo Montalban Bravo, MD
Assistant Professor, Department of Leukemia, Division of Cancer Medicine
MD Anderson Cancer Center, Houston, TX

The current COVID-19 pandemic has afflicted over 44 million individuals across the planet and been responsible for over 1 million deaths, particularly in high-risk populations. As a result of the overall advanced age, frailty and pre-existing comorbidities of patients with MDS, SARS-Cov2 was feared to be particularly dangerous in this patient population. A recent study by Mossuto et al describes the outcomes of patients with MDS with SARS-CoV-2 infection during the Coronavirus outbreak in Italy. Among a total of 5326 patients with MDS followed during the study period, 63 (1.18%) had confirmed SARS-CoV-2 infection. With a median age of 73 years, the mortality rate among these patients was 52% compared to that of the non-MDS population (24%), and was particularly high on male MDS patients (73% of total deaths). Respiratory failure was the cause of death in all the MDS patients with ARDS in 50% of deceased patients, and with majority of patients who were able to recover having lower risk IPSS-R categories. Interestingly, no differences in mortality or severity of infection were observed based on the type of therapy received for their MDS. These findings are not surprising given the underlying inflammation and immunosuppression in patients with MDS. Until the development of COVID-19 vaccines has been completed, identification of high-risk populations and specific guidelines for the management of SARS-CoV-2 infection in patients with MDS remains of paramount importance.

Clonal hematopoiesis is a known cardiovascular risk factor which has been associated with increased risk of cardiac and cerebrovascular events. Recent studies have also associated MDS with higher than expected cardiovascular comorbidities and cardiovascular-related deaths. In accordance to prior publications by Naqvi et al, a recent study by Faber et al retrospectively evaluated 236 MDS patients and studied the associations of somatic mutations with cardiovascular risk. Overall, the authors observed that 27% of patients in their study population developed vascular event, and that ASXL1 mutations were predictive of vascular disease by multivariate analysis (with an odds ratio of 4.2). This data further supports the biological connection between comorbidities and hematopoietic clonal disorders, the role of inflammaging and the need to maximize cardiovascular risk factor care in patients with MDS and develop specific therapies targeting both the disease biology and the underlying mechanisms leading to increased cardiovascular risk.

Guillermo Montalban Bravo, MD
Assistant Professor, Department of Leukemia, Division of Cancer Medicine
MD Anderson Cancer Center, Houston, TX

Key clinical point: Gene mutations involving ASXL1 were significantly associated with increased risk of vascular events in adults with myelodysplastic syndrome, but Trisomy 8 appeared to have a protective effect.

Major finding: Overall, the incidence of vascular disease in the study population was 27%; mutations in the ASXL1 in particular were significant predictors of vascular disease in multivariate analysis (odds ratio 4.2); however, both elevated ferritin and Trisomy 8 were significantly associated with a lower risk of vascular disease in low-risk MDS patients (P = .043 and P = .036, respectively).

Study details: The data come from a retrospective analysis of 236 MDS patients aged 18 years and older who were seen and treated at a single center between 2010 and 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.  

Citation: Faber MG et al. eJHaem. 2020 Sept 28. doi: 10.1002/jha2.101.

Key clinical point: Gene mutations involving ASXL1 were significantly associated with increased risk of vascular events in adults with myelodysplastic syndrome, but Trisomy 8 appeared to have a protective effect.

Major finding: Overall, the incidence of vascular disease in the study population was 27%; mutations in the ASXL1 in particular were significant predictors of vascular disease in multivariate analysis (odds ratio 4.2); however, both elevated ferritin and Trisomy 8 were significantly associated with a lower risk of vascular disease in low-risk MDS patients (P = .043 and P = .036, respectively).

Study details: The data come from a retrospective analysis of 236 MDS patients aged 18 years and older who were seen and treated at a single center between 2010 and 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.  

Citation: Faber MG et al. eJHaem. 2020 Sept 28. doi: 10.1002/jha2.101.

Key clinical point: Gene mutations involving ASXL1 were significantly associated with increased risk of vascular events in adults with myelodysplastic syndrome, but Trisomy 8 appeared to have a protective effect.

Major finding: Overall, the incidence of vascular disease in the study population was 27%; mutations in the ASXL1 in particular were significant predictors of vascular disease in multivariate analysis (odds ratio 4.2); however, both elevated ferritin and Trisomy 8 were significantly associated with a lower risk of vascular disease in low-risk MDS patients (P = .043 and P = .036, respectively).

Study details: The data come from a retrospective analysis of 236 MDS patients aged 18 years and older who were seen and treated at a single center between 2010 and 2018.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.  

Citation: Faber MG et al. eJHaem. 2020 Sept 28. doi: 10.1002/jha2.101.

Key clinical point: Myelodysplastic syndrome patients who had a slower luspatercept apparent clearance (CL/F) were more likely to achieve erythroid responses, suggesting potential as an early efficacy marker.

Major finding: Luspatercept given over a dose range of 0.125 mg/kg-1.75 mg/kg yielded linear and time-invariant pharmacokinetics when given to MDS patients with anemia subcutaneously once every 3 weeks; the odds of transfusion independence at a minimum of 8 weeks increased with time-averaged exposure and plateaued at 1.0 mg/kg-1.75 mg/kg.

Study details: The data come from a review of several studies including 260 adults with anemia caused by myelodysplastic syndromes.

Disclosures: The studies in the review were funded by Bristol Myers Squibb or Acceleron. Lead author Dr. Chen and several coauthors are employees of Bristol Myers Squibb.

Citation: Chen N et al. CPT Pharmacometrics Syst Pharmacol. 2020 June 30. doi: 10.1002/psp4.12521.

Key clinical point: Myelodysplastic syndrome patients who had a slower luspatercept apparent clearance (CL/F) were more likely to achieve erythroid responses, suggesting potential as an early efficacy marker.

Major finding: Luspatercept given over a dose range of 0.125 mg/kg-1.75 mg/kg yielded linear and time-invariant pharmacokinetics when given to MDS patients with anemia subcutaneously once every 3 weeks; the odds of transfusion independence at a minimum of 8 weeks increased with time-averaged exposure and plateaued at 1.0 mg/kg-1.75 mg/kg.

Study details: The data come from a review of several studies including 260 adults with anemia caused by myelodysplastic syndromes.

Disclosures: The studies in the review were funded by Bristol Myers Squibb or Acceleron. Lead author Dr. Chen and several coauthors are employees of Bristol Myers Squibb.

Citation: Chen N et al. CPT Pharmacometrics Syst Pharmacol. 2020 June 30. doi: 10.1002/psp4.12521.

Key clinical point: Myelodysplastic syndrome patients who had a slower luspatercept apparent clearance (CL/F) were more likely to achieve erythroid responses, suggesting potential as an early efficacy marker.

Major finding: Luspatercept given over a dose range of 0.125 mg/kg-1.75 mg/kg yielded linear and time-invariant pharmacokinetics when given to MDS patients with anemia subcutaneously once every 3 weeks; the odds of transfusion independence at a minimum of 8 weeks increased with time-averaged exposure and plateaued at 1.0 mg/kg-1.75 mg/kg.

Study details: The data come from a review of several studies including 260 adults with anemia caused by myelodysplastic syndromes.

Disclosures: The studies in the review were funded by Bristol Myers Squibb or Acceleron. Lead author Dr. Chen and several coauthors are employees of Bristol Myers Squibb.

Citation: Chen N et al. CPT Pharmacometrics Syst Pharmacol. 2020 June 30. doi: 10.1002/psp4.12521.

Key clinical point: Approximately half of transfusion-dependent MDS patients said they had not discussed ways to reduce the need for transfusions with their doctors and 74% said there were no alternatives to blood transfusions.

Major finding: Among adults with MDS, those with disease duration less than 5 years cited transfusion reactions as their greatest concern; those with longer disease duration cited iron overload. However, a majority of 71% of the patients ranked their quality of life as good or excellent. MDS physicians reported that they would be most likely to offer blood transfusions as primary therapy to patients who were older than 80 years, frail, had lower risk MDS, or had other significant comorbidities.

Study details: The data come from a pair of cross-sectional surveys including 157 myelodysplastic syndrome (MDS) patients and 109 MDS physicians.

Disclosures: The study was supported by the Aplastic Anemia and MDS International Foundation through a grant from Celgene. Lead author Dr. King was supported in part by The Maren Research Award Scholarship through the University of Florida.

Citation: King D et al. Leuk Res. 2020 July 15. doi: 10.1016/j.leukres.2020.106425.

Key clinical point: Approximately half of transfusion-dependent MDS patients said they had not discussed ways to reduce the need for transfusions with their doctors and 74% said there were no alternatives to blood transfusions.

Major finding: Among adults with MDS, those with disease duration less than 5 years cited transfusion reactions as their greatest concern; those with longer disease duration cited iron overload. However, a majority of 71% of the patients ranked their quality of life as good or excellent. MDS physicians reported that they would be most likely to offer blood transfusions as primary therapy to patients who were older than 80 years, frail, had lower risk MDS, or had other significant comorbidities.

Study details: The data come from a pair of cross-sectional surveys including 157 myelodysplastic syndrome (MDS) patients and 109 MDS physicians.

Disclosures: The study was supported by the Aplastic Anemia and MDS International Foundation through a grant from Celgene. Lead author Dr. King was supported in part by The Maren Research Award Scholarship through the University of Florida.

Citation: King D et al. Leuk Res. 2020 July 15. doi: 10.1016/j.leukres.2020.106425.

Key clinical point: Approximately half of transfusion-dependent MDS patients said they had not discussed ways to reduce the need for transfusions with their doctors and 74% said there were no alternatives to blood transfusions.

Major finding: Among adults with MDS, those with disease duration less than 5 years cited transfusion reactions as their greatest concern; those with longer disease duration cited iron overload. However, a majority of 71% of the patients ranked their quality of life as good or excellent. MDS physicians reported that they would be most likely to offer blood transfusions as primary therapy to patients who were older than 80 years, frail, had lower risk MDS, or had other significant comorbidities.

Study details: The data come from a pair of cross-sectional surveys including 157 myelodysplastic syndrome (MDS) patients and 109 MDS physicians.

Disclosures: The study was supported by the Aplastic Anemia and MDS International Foundation through a grant from Celgene. Lead author Dr. King was supported in part by The Maren Research Award Scholarship through the University of Florida.

Citation: King D et al. Leuk Res. 2020 July 15. doi: 10.1016/j.leukres.2020.106425.

Key clinical point: Bronchoscopy was safe for most patients with malignant hematologic disorders with careful monitoring and use of sedatives, particularly midazolam.

Major finding: A total of 12 out of 272 patients (3.8%) experienced prolonged oxygen desaturation; 7 of these recovered and 5 died from lung lesion deterioration. However, midazolam reduced the risk of prolonged oxygen desaturation in the study population.

Study details: The data come from a review of 316 bronchoscopies in 282 adults with malignant hematologic disorders and pulmonary infiltrates who were treated at a single center.

Disclosures: Lead author Dr. Uruga disclosed grant support from Okinaka Memorial Institute for Medical Research.

Citation: Uruga H et al. BMC Pulm Med. 2020 Sep 11. doi: 10.1186/s12890-020-01283-8.

Key clinical point: Bronchoscopy was safe for most patients with malignant hematologic disorders with careful monitoring and use of sedatives, particularly midazolam.

Major finding: A total of 12 out of 272 patients (3.8%) experienced prolonged oxygen desaturation; 7 of these recovered and 5 died from lung lesion deterioration. However, midazolam reduced the risk of prolonged oxygen desaturation in the study population.

Study details: The data come from a review of 316 bronchoscopies in 282 adults with malignant hematologic disorders and pulmonary infiltrates who were treated at a single center.

Disclosures: Lead author Dr. Uruga disclosed grant support from Okinaka Memorial Institute for Medical Research.

Citation: Uruga H et al. BMC Pulm Med. 2020 Sep 11. doi: 10.1186/s12890-020-01283-8.

Key clinical point: Bronchoscopy was safe for most patients with malignant hematologic disorders with careful monitoring and use of sedatives, particularly midazolam.

Major finding: A total of 12 out of 272 patients (3.8%) experienced prolonged oxygen desaturation; 7 of these recovered and 5 died from lung lesion deterioration. However, midazolam reduced the risk of prolonged oxygen desaturation in the study population.

Study details: The data come from a review of 316 bronchoscopies in 282 adults with malignant hematologic disorders and pulmonary infiltrates who were treated at a single center.

Disclosures: Lead author Dr. Uruga disclosed grant support from Okinaka Memorial Institute for Medical Research.

Citation: Uruga H et al. BMC Pulm Med. 2020 Sep 11. doi: 10.1186/s12890-020-01283-8.

Key clinical point: Adults with end-stage renal disease who underwent dialysis for at least six months were at significantly increased risk for MDS compared with healthy controls.

Major finding: Patients with chronic renal failure who underwent dialysis were significantly more likely to develop myelodysplastic syndrome compared to healthy controls (subdistribution hazard ratio 1.60); older age also was significantly associated with increased MDS risk (sHR 1.03).

Study details: The data come from a study of 74,712 adults with chronic renal failure diagnoses between 1997 and 2013 who underwent dialysis, and matched controls. Participants were follow from index date to the first occurrence of MDS, withdrawal from the NHI program, or the last day of 2013.

Disclosures: The study used the National Health Insurance Research Database established by the National Health Research Institutes with the authorization of the Bureau of National Health Insurance, Ministry of Health and Welfare of Taiwan. The researchers had no financial conflicts to disclose.

Citation: Chang M-Y et al. Sci Rep. 2020 Sept 23. doi: 10.1038/s41598-020-72568-5.

Key clinical point: Adults with end-stage renal disease who underwent dialysis for at least six months were at significantly increased risk for MDS compared with healthy controls.

Major finding: Patients with chronic renal failure who underwent dialysis were significantly more likely to develop myelodysplastic syndrome compared to healthy controls (subdistribution hazard ratio 1.60); older age also was significantly associated with increased MDS risk (sHR 1.03).

Study details: The data come from a study of 74,712 adults with chronic renal failure diagnoses between 1997 and 2013 who underwent dialysis, and matched controls. Participants were follow from index date to the first occurrence of MDS, withdrawal from the NHI program, or the last day of 2013.

Disclosures: The study used the National Health Insurance Research Database established by the National Health Research Institutes with the authorization of the Bureau of National Health Insurance, Ministry of Health and Welfare of Taiwan. The researchers had no financial conflicts to disclose.

Citation: Chang M-Y et al. Sci Rep. 2020 Sept 23. doi: 10.1038/s41598-020-72568-5.

Key clinical point: Adults with end-stage renal disease who underwent dialysis for at least six months were at significantly increased risk for MDS compared with healthy controls.

Major finding: Patients with chronic renal failure who underwent dialysis were significantly more likely to develop myelodysplastic syndrome compared to healthy controls (subdistribution hazard ratio 1.60); older age also was significantly associated with increased MDS risk (sHR 1.03).

Study details: The data come from a study of 74,712 adults with chronic renal failure diagnoses between 1997 and 2013 who underwent dialysis, and matched controls. Participants were follow from index date to the first occurrence of MDS, withdrawal from the NHI program, or the last day of 2013.

Disclosures: The study used the National Health Insurance Research Database established by the National Health Research Institutes with the authorization of the Bureau of National Health Insurance, Ministry of Health and Welfare of Taiwan. The researchers had no financial conflicts to disclose.

Citation: Chang M-Y et al. Sci Rep. 2020 Sept 23. doi: 10.1038/s41598-020-72568-5.