Mary Ann Moon

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Delirium is common but underrecognized in hospitalized patients, "a neglected condition relative to its frequency and serious consequences," and approximately one-third of cases are preventable, according to a report in the June 7 Annals of Internal Medicine.

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has released a new clinical guideline for preventing delirium, which lists 13 recommendations that "could probably be easily accommodated in current care without incurring high costs." On the contrary, preventing delirium in hospitalized patients is expected to markedly cut health care costs, as well as to improve quality-adjusted life-year gains, compared with usual care, said Rachel O’Mahony, Ph.D., of the National Clinical Guideline Centre at the Royal College of Physicians, London, and her associates.

A multidisciplinary group of experts, including physicians, psychiatrists, specialist nurses, a home care manager, and patient representatives, reviewed the literature to find which prevention strategies were effective to compile the guidelines.

No single intervention was identified that significantly reduced hospital stay, placement in long-term care facilities, mortality, or duration or severity of delirium. Instead, multicomponent interventions provided the strongest evidence of improving these factors.

The recommendations include:

1. Avoid changes in patient surroundings to prevent confusion and disorientation. This includes avoiding unnecessary room changes as well as changes in the personnel who provide care.

   "Several moves within an acute care hospital are now common ... [from] emergency department to assessment unit to acute care ward and sometimes to post-acute care ward.

   "Moving could make it difficult for a sick person on the brink of a delirium episode to maintain his or her orientation and contact with reality," Dr. O’Mahony and her colleagues said (Ann. Intern. Med. 2011;154:746-51).

2. Provide appropriate lighting, clear signage, an easily visible 24-hour clock (to distinguish day from night in rooms without windows), and a calendar to help patients stay oriented to time and place.
   
   
3. Reorient patients by explaining where they are and what your role is.
   
   
4. Provide cognitively stimulating activities, such as encouraging patients to reminisce and facilitating visits from family and friends.
   
   
5. Address dehydration and constipation, with intravenous fluids, if necessary, and manage fluid balance in patients with relevant comorbidities such as heart failure or kidney disease.
   
   
6. Assess for hypoxia and optimize oxygen saturation.
   
   
7. Actively assess for infection and treat it; employ infection-control procedures; and avoid unnecessary catheterization.

   The presence of a bladder catheter is a known risk factor for delirium, the researchers noted.

8. Address immobility by encouraging patients to walk as soon as possible, providing appropriate walking aids and ensuring they are available at all times, and encouraging range-of-motion exercises.
   
   
9. Assess for pain, attending to nonverbal signs of pain, and manage it.

   Although some clinicians are leery of inducing confusion by providing painkillers, pain itself is an independent risk factor for delirium, the investigators said.

10. Review both the type and the number of medications.
    
    
11. Address poor nutrition, and make sure that dentures fit properly in patients who have them.
    
    
12. Address sensory impairment and resolve any reversible causes such as impacted ear wax or need for visual or hearing aids. Ensure such aids are in good working order.
    
    
13. Promote good sleep patterns by avoiding procedures and minimizing ambient noise during sleeping hours.

"Some of these components are provided to some patients some of the time, but prevention of delirium requires that we do all of these things all the time to all of the patients who are at risk," Dr. O’Mahony and her associates said.

"It makes sense" to target these interventions to patients at highest risk of developing delirium. There are four such easy-to-identify groups, each with a greater than fivefold increase in risk for delirium: patients aged 65 [years] and older, patients with preexisting cognitive impairment, patients with severe illness, and patients with hip fracture, they noted.

"This enhanced approach goes beyond well-trained and prepared staff. It requires a health care system ... that supports comprehensive and reliable delivery of specific tasks," they researchers added.

The guideline was supported by the National Clinical Guideline Centre at the Royal College of Physicians; the U.K. Cochrane Centre and KSG-Trans; and the Bradford Institute for Health Research. None of the authors reported having any relevant conflicts of interest.

The full version of the guideline, including details about the methods used in its development, is available online. A synopsis is available at Annals of Internal Medicine.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

Adding narrow-band imaging and autofluorescence imaging to high-resolution endoscopy – a combination known as endoscopic trimodal imaging – doesn’t improve the detection of colonic adenomas in routine clinical practice, compared with standard video endoscopy, Dr. Teaco Kuiper and colleagues reported in the June issue of Gastroenterology.

This result is somewhat surprising. Not only does endoscopic trimodal imaging (ETMI) involve newer technology specifically designed to improve detection and differentiation of gastrointestinal lesions, but in this study it also entailed a significantly longer time for inspection of the colon, "which is known to positively influence adenoma detection rate," wrote Dr. Kuiper of the University of Amsterdam and associates (Gastroenterology 2011 June [doi:10.1053/j.gastro.2011.03.008]).

Nevertheless, a colonoscopy involving an initial pass with a high-resolution endoscope yielded nearly the same detection rate as did an initial pass with a standard video endoscope, and a second pass adding narrow-band imaging (NBI) and autofluorescence imaging (AFI) to the high-resolution endoscopy yielded nearly the same detection rate as did a second pass with a standard video endoscope, the researchers said.

They assessed the value of various endoscopic imaging techniques in routine clinical practice because until now, "nearly all studies evaluating narrow-band imaging and autofluorescence imaging have been performed in expert centers. As a consequence, these studies often include a selected patient population and are performed by a small number of endoscopists with extensive experience in advanced clinical imaging," they noted.

"There is a need to ascertain if these new imaging techniques improve detection and differentiation of colonic lesions in the community and nonspecialised settings."

Dr. Kuiper and colleagues compared ETMI with standard video endoscopy at six nonacademic medical centers in the Amsterdam region over a 3-year period. The study included unselected patients scheduled for routine surveillance colonoscopy, and all the procedures were performed by eight endoscopists with experience in regular (but not advanced) clinical imaging, with more than 2,000 colonoscopies each.

The study subjects were adults undergoing colonoscopy because of a history of adenomatous polyps, colorectal cancer for which partial colectomy had been performed, hereditary nonpolyposis colorectal cancer, or a family history of colorectal cancer. They were randomly assigned to undergo either ETMI (118 patients) or standard video endoscopy (116 patients) under conscious sedation. Only patients with adequate bowel preparation to achieve adequate imaging were included in the study.

In the ETMI group, patients underwent a first-pass inspection with high-resolution endoscopy alone followed by a second pass with autofluorescence imaging and narrow-band imaging. To make the control procedure closely resemble this approach, patients in the control group underwent a first-pass inspection with standard video endoscopy immediately followed by a second pass with the same standard video endoscopy.

The mean inspection time was significantly longer with ETMI during both the first pass (7.06 minutes) and second pass (7.34 minutes) than with standard video endoscopy (6.18 minutes and 6.06 minutes).

The primary outcome measure was the mean number of adenomas detected by the two methods. By this measure, trimodal imaging detected 1.03 adenomas and standard imaging detected 0.97, a nonsignificant difference.

A total of 87 adenomas were detected during the first pass with high-resolution endoscopy, including 46 advanced adenomas. In the control group, 79 adenomas were detected during the first pass with standard endoscopy, including 33 advanced adenomas. These rates were not significantly different.

A total of 34 adenomas were detected during the second pass with autofluorescence imaging and narrow-band imaging added to high-resolution endoscopy, including 12 that were advanced. In the control group, an additional 33 adenomas were detected during the second pass with standard endoscopy, including 14 advanced adenomas. These rates also were not significantly different.

Nine patients had adenomas that were detected only during the second pass with autofluorescence imaging and narrow-band imaging. Similarly, 9 patients in the control group had adenomas that were detected only during the second pass with standard endoscopy.

The adenoma miss rate was 28% after the second pass in the trimodal imaging group, and the miss rate of advanced adenomas was 21%. The corresponding miss rates in the control group were 29% and 30%.

These miss rates were substantial and much higher than has been reported in the literature, despite the fact that patients with poor bowel preparation were excluded and that inspection time was longer than 6 minutes in most cases. These rates are high in comparison to those in clinical trials, but may well reflect the typical rates in true day-to-day practice, Dr. Kuiper and colleagues said.

In this study, autofluorescence imaging had a sensitivity of 87%, and narrow-band imaging had a sensitivity of 90%. These rates are "clinically unacceptable, as approximately 10% of all adenomas would be left in situ," the researchers noted.

The specificity of both techniques was even poorer.

Taken together, the findings indicate that the accuracy of these new modalities in nonexpert settings is "insufficient for clinical use," they added.

Dr. Kuiper and associates reported ties to Olympus Medical, Astra Zeneca, and Cook Medical.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.

The use of telemedicine to link primary caregivers to the specialized medical resources of an academic medical center proved to be extremely effective for treating chronic hepatitis C in rural and underserved regions, according to a report published online June 1 in the New England Journal of Medicine.

In a prospective cohort study involving 407 HCV patients who had never received treatment for the disease, the proportion of patients who achieved a sustained virologic response to therapy was no different between the 261 treated at remote sites using the Extension for Community Healthcare Outcomes (ECHO) model and the 146 who were treated at a university HCV clinic, said Dr. Sanjeev Arora of the University of New Mexico, Albuquerque, and his associates.

The treatment response was not only equivalent between the two study groups, it also was equivalent to that reported in controlled trials of HCV therapy, even though the ECHO patients in this study were impoverished minorities. "By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the investigators said.

"ECHO represents a needed change from the conventional approaches in which specialized care and expertise are available only at academic medical centers in urban areas," they noted.

At present, "very few persons with chronic HCV infection are receiving treatment," and it is estimated that under the conventional approach, therapy will prevent "only 14% of potential liver-related deaths caused by HCV infection between 2002 and 2030," Dr. Arora and his colleagues said.

"Community-based health centers are often the most culturally appropriate and accessible choices for care, particularly in rural areas, and providers at these centers can establish trust through ongoing relationships with patients. Therefore, these centers can be ideal places to provide complex care for HCV infection, if they have access to the needed expertise," said Dr. Arora, who is also director of the ECHO Project at the university, and his associates.

The ECHO program began in 2003 and involves 16 community sites and 5 prisons. It provides weekly HCV clinics via video conferencing or teleconferencing in which primary care providers at these sites present cases to, and ask questions of, hepatology, infectious disease, psychiatry, and pharmacology specialists at the university. "These case-based discussions are supplemented with short didactic presentations by interdisciplinary experts to improve content knowledge" and teach skills, the investigators wrote.

Dr. Arora and his associates assessed treatment outcomes in patients who were initially treated in 2004-2008 and followed through the end of 2009. The primary end point was the rate of sustained virologic response 24 weeks after the conclusion of treatment.

This rate was 58.2% at the ECHO sites, which was not significantly different from the 57.5% rate at the university clinic.

These rates are similar to those reported in licensing trials of peginterferon and ribavirin.

Nearly twice as many patients at the university clinic (13.7%) as in the ECHO program (6.9%) developed serious adverse events, and more than twice as many (8.9% vs. 4.2%) developed a serious adverse event necessitating termination of treatment, the researchers said (N. Engl. J. Med. 2011 June 1 [doi:10.1056/NEJMoa1009370]).

The findings demonstrate that chronic HCV infection, a complex disease, "can be managed as effectively at a center that uses the ECHO model as at an academic medical center," Dr. Arora and his associates wrote. It is likely that the ECHO program accomplished this by facilitating more clinician visits; greater adherence to treatment; closer assessment of lab test results; and better, more timely management of side effects.

The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the New Mexico Department of Health, and the New Mexico State Legislature. Dr. Arora reported ties to ZymoGenetics, Genentech, Vertex Pharmaceuticals, Tibotec, Human Genome Sciences, Wyeth, and Schering-Plough.