Patrice Wendling

CHICAGO — Designating a hospitalist to manage patients boarded in the emergency department enhances patient care and safety and has the potential to affect hospital length of stay, according to a pilot study presented at the annual meeting of the Society of Hospital Medicine.

A total of 4,363 patients were admitted during a 3-month period to the medicine service of a 1,121-bed, acute-care teaching hospital, of whom 3,555 qualified as boarders based on an ED stay of 2 hours or more. There was an average of 29 boarders per 24 hours, with a mean boarding time of 440 minutes.

A full-time hospitalist was on duty from 8 a.m. to 6 p.m. weekdays, and evaluated 634 of the boarders, averaging 8 per day.

The role of the hospitalist was to round on all medicine patients and to focus on patient safety, said Dr. Alan S. Briones, an internist at Mount Sinai Hospital and the Mount Sinai School of Medicine, New York. The hospitalist addressed any changes in patient status or stability and informed the primary teams, and ensured that vital home and hospital medications were administered and reconciled with inpatient orders.

Hospitalists acted on laboratory results for 472 (74.4%) boarded patients and followed up on medication orders for 506 (80%) of them.

Hospitalists discharged 46 (7.3%) patients or 1.3% of all ED boarders, and downgraded telemetry for 61 (9.6%) patients or 1.7% of all ED boarders.

“Designating a full-time hospitalist to care for admitted patients has the potential to impact ED throughput and hospital length of stay, as demonstrated by our discharge rate and our [telemetry] downgrade rate,” Dr. Briones said.

He noted that prolonged ED length of stay is the most frequent reason for overcrowding and that an estimated one-third of American hospitals experience ED overcrowding on a daily basis. He described Mount Sinai Hospital as experiencing periodic “moderate to severe” episodes of ED overcrowding.

“A 5% increase in hospital occupancy or census can cause a 14-hour delay time in the ED or holding time,” Dr. Briones said. “Overcrowding has important consequences on physician and patient satisfaction and quality of care.”

The researchers are further evaluating the data to determine the broader impact of the program on hospital length of stay and ED diversion rates.

The investigators reported no conflicts of interest.

CHICAGO — Designating a hospitalist to manage patients boarded in the emergency department enhances patient care and safety and has the potential to affect hospital length of stay, according to a pilot study presented at the annual meeting of the Society of Hospital Medicine.

A total of 4,363 patients were admitted during a 3-month period to the medicine service of a 1,121-bed, acute-care teaching hospital, of whom 3,555 qualified as boarders based on an ED stay of 2 hours or more. There was an average of 29 boarders per 24 hours, with a mean boarding time of 440 minutes.

A full-time hospitalist was on duty from 8 a.m. to 6 p.m. weekdays, and evaluated 634 of the boarders, averaging 8 per day.

The role of the hospitalist was to round on all medicine patients and to focus on patient safety, said Dr. Alan S. Briones, an internist at Mount Sinai Hospital and the Mount Sinai School of Medicine, New York. The hospitalist addressed any changes in patient status or stability and informed the primary teams, and ensured that vital home and hospital medications were administered and reconciled with inpatient orders.

Hospitalists acted on laboratory results for 472 (74.4%) boarded patients and followed up on medication orders for 506 (80%) of them.

Hospitalists discharged 46 (7.3%) patients or 1.3% of all ED boarders, and downgraded telemetry for 61 (9.6%) patients or 1.7% of all ED boarders.

“Designating a full-time hospitalist to care for admitted patients has the potential to impact ED throughput and hospital length of stay, as demonstrated by our discharge rate and our [telemetry] downgrade rate,” Dr. Briones said.

He noted that prolonged ED length of stay is the most frequent reason for overcrowding and that an estimated one-third of American hospitals experience ED overcrowding on a daily basis. He described Mount Sinai Hospital as experiencing periodic “moderate to severe” episodes of ED overcrowding.

“A 5% increase in hospital occupancy or census can cause a 14-hour delay time in the ED or holding time,” Dr. Briones said. “Overcrowding has important consequences on physician and patient satisfaction and quality of care.”

The researchers are further evaluating the data to determine the broader impact of the program on hospital length of stay and ED diversion rates.

The investigators reported no conflicts of interest.

CHICAGO — Designating a hospitalist to manage patients boarded in the emergency department enhances patient care and safety and has the potential to affect hospital length of stay, according to a pilot study presented at the annual meeting of the Society of Hospital Medicine.

A total of 4,363 patients were admitted during a 3-month period to the medicine service of a 1,121-bed, acute-care teaching hospital, of whom 3,555 qualified as boarders based on an ED stay of 2 hours or more. There was an average of 29 boarders per 24 hours, with a mean boarding time of 440 minutes.

A full-time hospitalist was on duty from 8 a.m. to 6 p.m. weekdays, and evaluated 634 of the boarders, averaging 8 per day.

The role of the hospitalist was to round on all medicine patients and to focus on patient safety, said Dr. Alan S. Briones, an internist at Mount Sinai Hospital and the Mount Sinai School of Medicine, New York. The hospitalist addressed any changes in patient status or stability and informed the primary teams, and ensured that vital home and hospital medications were administered and reconciled with inpatient orders.

Hospitalists acted on laboratory results for 472 (74.4%) boarded patients and followed up on medication orders for 506 (80%) of them.

Hospitalists discharged 46 (7.3%) patients or 1.3% of all ED boarders, and downgraded telemetry for 61 (9.6%) patients or 1.7% of all ED boarders.

“Designating a full-time hospitalist to care for admitted patients has the potential to impact ED throughput and hospital length of stay, as demonstrated by our discharge rate and our [telemetry] downgrade rate,” Dr. Briones said.

He noted that prolonged ED length of stay is the most frequent reason for overcrowding and that an estimated one-third of American hospitals experience ED overcrowding on a daily basis. He described Mount Sinai Hospital as experiencing periodic “moderate to severe” episodes of ED overcrowding.

“A 5% increase in hospital occupancy or census can cause a 14-hour delay time in the ED or holding time,” Dr. Briones said. “Overcrowding has important consequences on physician and patient satisfaction and quality of care.”

The researchers are further evaluating the data to determine the broader impact of the program on hospital length of stay and ED diversion rates.

The investigators reported no conflicts of interest.

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD

CHICAGO — A hospitalist-run geriatrics service significantly improved the recognition and treatment of functional and cognitive status abnormalities in a retrospective analysis of 217 elderly inpatients.

Documentation and treatment of abnormal functional status was reported in 69% of patients assigned to an acute care for the elderly (ACE) service vs. 36% of those who received usual care. For abnormal cognitive status, the corresponding results were 56% vs. 40%.

There was a trend favoring ACE for the identification and treatment of delirium (27% vs. 17%), although neither model was outstanding, particularly with regard to hypoactive delirium, geriatrician and hospitalist Dr. Heidi Wald said at the annual meeting of the Society of Hospital Medicine.

There were no differences in use of sleep aids, physical restraints, or documentation of code status, although ACE patients had a significantly higher rate of do-not-resuscitate orders, compared with usual care patients (39% vs. 25%).

ACE and usual care patients had similar lengths of stay (mean 3.4 days vs. 3.1 days), although 30-day admission rates were slightly higher with ACE (12.3% vs. 9.5%).

Notably, mean hospital charges were not significantly higher with ACE, at $24,617 vs. $21,488 for usual care, said Dr. Wald, of the University of Colorado at Denver Health Sciences Center in Aurora.

“Existing resources can be leveraged to improve geriatric care,” she said.

ACE units have been shown to improve functional outcomes in vulnerable hospitalized elders, but widespread adoption has been slow because of the need for and cost of a dedicated unit staffed by geriatricians and geriatric nurses.

Dr. Wald described the ACE service, now in its third year at her institution, as a hybrid between a general medical inpatient service and a traditional ACE unit. Key components include a core group of hospitalists with an interest in geriatric medicine, interdisciplinary rounds, a novel educational curriculum, and a standardized geriatric assessment approach. Patients are treated on a single medical inpatient unit when possible, something that occurred with two-thirds of ACE patients in the analysis.

In all, 122 patients were assigned to ACE and 95 to usual care during the study period of Nov. 1, 2007, to April 15, 2008. Their mean age was 80.5 years, slightly more than half were female, and the primary ICD-9 code was pulmonary disease in 28% of patients.

Dr. Wald observed that one of the keys to sustaining an ACE service is having a dedicated nursing staff, as many of the quality indicators for geriatric patients are nursing sensitive.

“Nursing staff loved this model and are very interested in increasing their nursing education around geriatric issues, and [are] happy to have a core group of physicians to work with on this,” she said.

The researchers disclosed no conflicts of interest.

'Existing resources can be leveraged to improve geriatric care.' DR. WALD

CHICAGO — A novel mobile service that provides acute care for the elderly reduced hospital length of stay and costs with no change in in-hospital mortality or readmission rates when compared with more traditional services in a retrospective study.

Traditional acute care for the elderly (ACE) units, which have been shown to improve functional outcomes without increased costs or changes in length of stay, are limited to caring for patients in a fixed hospital unit, geriatrician Dr. Jeffrey Farber noted at the annual meeting of the American Geriatrics Society.

In contrast, a mobile acute care for the elderly (MACE) service follows patients no matter where they are in the hospital. The multidisciplinary MACE team includes a geriatrics attending and a geriatrics fellow, a social worker, and a nurse coordinator. The service focuses on early discharge from units when indicated, shares information collected via postdischarge telephone calls with outpatient physicians, and enters that follow-up information into the patient's electronic medical record.

The retrospective study at Mount Sinai Medical Center, New York, compared outcomes of patients on the MACE service with matched control patients admitted to general medical services and with patients admitted to an ACE unit during the prior year. Three-fourths of the patients were women; their mean age was 82 years in the ACE unit, 83 years on the MACE service, and 81 years among the controls. All patients had an average comorbidity score of 3 using the Elixhauser method, with hypertension being the most common condition (range 53%-60%), followed by congestive heart failure (22%-27%) and diabetes (22%-29%).

For 543 patients on the MACE service, the mean length of stay (5.9 days) was significantly lower than in 450 patients admitted to the ACE unit (8.3 days), said Dr. Farber, director of Mount Sinai's acute care for the elderly service.

Total costs were significantly lower with MACE ($10,518) than in the ACE unit ($14,164), as were direct costs ($4,882 vs. $6,367) and pharmaceutical costs ($631 vs. $961).

Comparing MACE with ACE, rates were similar for in-hospital mortality (4.4% vs. 4.9%), 7-day readmission (3.9% vs. 4.9%), and 30-day readmission (20.6% vs. 20.9%), he said.

Similar results were observed when 516 patients on the MACE service were compared with 3,168 propensity-score matched controls who received traditional care via general medical services. Patients on MACE had significantly lower mean length of stay (5.8 vs. 6.8 days) and total costs ($10,346 vs. $14,145) versus controls. Rates were similar for in-hospital mortality (4.5% vs. 5.0%), 7-day readmission (3.9% vs. 5.6%), and 30-day readmission (20.9% vs. 19.6%).

“We don't know which of the components of this model are driving these results,” Dr. Farber said.

The focus on early discharge and early family meetings involving the MACE social worker and nurse coordinator may be driving the reduced length of stay, while reduced costs might be related to the more geriatric hospitalist nature of the service delivered by fewer physicians.

Because a MACE service does not require structural changes to a hospital or additional beds, there is the potential for wider adoption of such a service than a traditional ACE unit, Dr. Farber said.

Dr. Farber reported that he is supported by an academic career award from the Health Resources and Services Administration. The authors reported no conflicts of interest or study funding.

CHICAGO — A novel mobile service that provides acute care for the elderly reduced hospital length of stay and costs with no change in in-hospital mortality or readmission rates when compared with more traditional services in a retrospective study.

Traditional acute care for the elderly (ACE) units, which have been shown to improve functional outcomes without increased costs or changes in length of stay, are limited to caring for patients in a fixed hospital unit, geriatrician Dr. Jeffrey Farber noted at the annual meeting of the American Geriatrics Society.

In contrast, a mobile acute care for the elderly (MACE) service follows patients no matter where they are in the hospital. The multidisciplinary MACE team includes a geriatrics attending and a geriatrics fellow, a social worker, and a nurse coordinator. The service focuses on early discharge from units when indicated, shares information collected via postdischarge telephone calls with outpatient physicians, and enters that follow-up information into the patient's electronic medical record.

The retrospective study at Mount Sinai Medical Center, New York, compared outcomes of patients on the MACE service with matched control patients admitted to general medical services and with patients admitted to an ACE unit during the prior year. Three-fourths of the patients were women; their mean age was 82 years in the ACE unit, 83 years on the MACE service, and 81 years among the controls. All patients had an average comorbidity score of 3 using the Elixhauser method, with hypertension being the most common condition (range 53%-60%), followed by congestive heart failure (22%-27%) and diabetes (22%-29%).

For 543 patients on the MACE service, the mean length of stay (5.9 days) was significantly lower than in 450 patients admitted to the ACE unit (8.3 days), said Dr. Farber, director of Mount Sinai's acute care for the elderly service.

Total costs were significantly lower with MACE ($10,518) than in the ACE unit ($14,164), as were direct costs ($4,882 vs. $6,367) and pharmaceutical costs ($631 vs. $961).

Comparing MACE with ACE, rates were similar for in-hospital mortality (4.4% vs. 4.9%), 7-day readmission (3.9% vs. 4.9%), and 30-day readmission (20.6% vs. 20.9%), he said.

Similar results were observed when 516 patients on the MACE service were compared with 3,168 propensity-score matched controls who received traditional care via general medical services. Patients on MACE had significantly lower mean length of stay (5.8 vs. 6.8 days) and total costs ($10,346 vs. $14,145) versus controls. Rates were similar for in-hospital mortality (4.5% vs. 5.0%), 7-day readmission (3.9% vs. 5.6%), and 30-day readmission (20.9% vs. 19.6%).

“We don't know which of the components of this model are driving these results,” Dr. Farber said.

The focus on early discharge and early family meetings involving the MACE social worker and nurse coordinator may be driving the reduced length of stay, while reduced costs might be related to the more geriatric hospitalist nature of the service delivered by fewer physicians.

Because a MACE service does not require structural changes to a hospital or additional beds, there is the potential for wider adoption of such a service than a traditional ACE unit, Dr. Farber said.

Dr. Farber reported that he is supported by an academic career award from the Health Resources and Services Administration. The authors reported no conflicts of interest or study funding.

CHICAGO — A novel mobile service that provides acute care for the elderly reduced hospital length of stay and costs with no change in in-hospital mortality or readmission rates when compared with more traditional services in a retrospective study.

Traditional acute care for the elderly (ACE) units, which have been shown to improve functional outcomes without increased costs or changes in length of stay, are limited to caring for patients in a fixed hospital unit, geriatrician Dr. Jeffrey Farber noted at the annual meeting of the American Geriatrics Society.

In contrast, a mobile acute care for the elderly (MACE) service follows patients no matter where they are in the hospital. The multidisciplinary MACE team includes a geriatrics attending and a geriatrics fellow, a social worker, and a nurse coordinator. The service focuses on early discharge from units when indicated, shares information collected via postdischarge telephone calls with outpatient physicians, and enters that follow-up information into the patient's electronic medical record.

The retrospective study at Mount Sinai Medical Center, New York, compared outcomes of patients on the MACE service with matched control patients admitted to general medical services and with patients admitted to an ACE unit during the prior year. Three-fourths of the patients were women; their mean age was 82 years in the ACE unit, 83 years on the MACE service, and 81 years among the controls. All patients had an average comorbidity score of 3 using the Elixhauser method, with hypertension being the most common condition (range 53%-60%), followed by congestive heart failure (22%-27%) and diabetes (22%-29%).

For 543 patients on the MACE service, the mean length of stay (5.9 days) was significantly lower than in 450 patients admitted to the ACE unit (8.3 days), said Dr. Farber, director of Mount Sinai's acute care for the elderly service.

Total costs were significantly lower with MACE ($10,518) than in the ACE unit ($14,164), as were direct costs ($4,882 vs. $6,367) and pharmaceutical costs ($631 vs. $961).

Comparing MACE with ACE, rates were similar for in-hospital mortality (4.4% vs. 4.9%), 7-day readmission (3.9% vs. 4.9%), and 30-day readmission (20.6% vs. 20.9%), he said.

Similar results were observed when 516 patients on the MACE service were compared with 3,168 propensity-score matched controls who received traditional care via general medical services. Patients on MACE had significantly lower mean length of stay (5.8 vs. 6.8 days) and total costs ($10,346 vs. $14,145) versus controls. Rates were similar for in-hospital mortality (4.5% vs. 5.0%), 7-day readmission (3.9% vs. 5.6%), and 30-day readmission (20.9% vs. 19.6%).

“We don't know which of the components of this model are driving these results,” Dr. Farber said.

The focus on early discharge and early family meetings involving the MACE social worker and nurse coordinator may be driving the reduced length of stay, while reduced costs might be related to the more geriatric hospitalist nature of the service delivered by fewer physicians.

Because a MACE service does not require structural changes to a hospital or additional beds, there is the potential for wider adoption of such a service than a traditional ACE unit, Dr. Farber said.

Dr. Farber reported that he is supported by an academic career award from the Health Resources and Services Administration. The authors reported no conflicts of interest or study funding.

CHICAGO — Hospitalists looking to improve handoffs during transitions of care and reduce downstream errors may find inspiration at their local Starbucks.

By repeating your order for a triple tall, nonfat, no-whip peppermint mocha, Starbucks is using the simple “read-back” strategy to ensure accuracy.

“In business and restaurants, they have to get the order right or you won't go back,” Dr. Vineet Arora explained during a session on handoff best practices at the annual meeting of the Society of Hospital Medicine (SHM). “And in medicine we have a culture of errors.”

Communication problems have been identified as the primary cause of nearly two-thirds of hospital sentinel events. A study at Chicago's Northwestern Memorial Hospital of telephone read-back of 822 lab results showed that using the strategy took only an additional 12.8 seconds per call and identified 29 errors, including 10 instances in which the patient's name was incorrect, she said (Am. J. Clin. Pathol. 2004;121:790-1).

In recent years, organizations such as the SHM, World Health Organization, Institute of Medicine, and the Joint Commission have focused on the need to improve handoffs of care. Dr. Arora, assistant dean at the University of Chicago Pritzker School of Medicine, and her colleagues advocate a competency-based approach focused on improving communication and professionalism (Qual. Saf. Health Care 2008;17:11-4).

“Handoffs are more than just a transfer of content, but also a transfer of professional responsibility,” she said. “Every patient is your patient.”

Dr. Arora and her colleagues are developing handoff training programs, which are not commonly used.

The SHM recommends that a formal handoff plan be instituted at the end of a shift or change in service, Dr. Arora said, and the plan should include time during shifts dedicated for verbal exchange of information, a template or technology solution to be used for tracking patient information, and training for new users on handoff expectations.

Although information technology can advance communication, it cannot replace it, Dr. Arora cautioned. In one study, replacing a telephone call for critical lab values with a computerized reporting system and no verbal communication resulted in 45% of 3,228 urgent lab results not being read by a clinician (BMJ 2001;322:1101-3).

Precise language is essential, she said, citing a common scenario in which a nurse calls because the patient wants to know if they can eat, but the chart says “patient is NPO for surgery tomorrow.” To avoid confusion, use exact dates instead of terms like today, tomorrow, or yesterday, and state exactly what procedure is planned, she advised.

A verbal handoff also should provide anticipatory guidance and identify tasks that need to be done, she said. Both should be accompanied by a plan and the rationale behind it. For example, a chart that simply says “check BMP at 8 p.m.” doesn't explain what the physician is looking for or what staff should do if that basic metabolic panel reports an abnormality. Before a handoff, hospitalists should also examine the chart for critical omissions, such as “do not resuscitate” status.

Dr. Arora has received consultant or speakers fees related to her work on handoffs from the Illinois Hospital Association, Michigan Health and Hospital Association, Delmarva Foundation/Maryland Patient Safety Learning Center, Clarity Group, MacNeal Hospital, and HCPro.

CHICAGO — Hospitalists looking to improve handoffs during transitions of care and reduce downstream errors may find inspiration at their local Starbucks.

By repeating your order for a triple tall, nonfat, no-whip peppermint mocha, Starbucks is using the simple “read-back” strategy to ensure accuracy.

“In business and restaurants, they have to get the order right or you won't go back,” Dr. Vineet Arora explained during a session on handoff best practices at the annual meeting of the Society of Hospital Medicine (SHM). “And in medicine we have a culture of errors.”

Communication problems have been identified as the primary cause of nearly two-thirds of hospital sentinel events. A study at Chicago's Northwestern Memorial Hospital of telephone read-back of 822 lab results showed that using the strategy took only an additional 12.8 seconds per call and identified 29 errors, including 10 instances in which the patient's name was incorrect, she said (Am. J. Clin. Pathol. 2004;121:790-1).

In recent years, organizations such as the SHM, World Health Organization, Institute of Medicine, and the Joint Commission have focused on the need to improve handoffs of care. Dr. Arora, assistant dean at the University of Chicago Pritzker School of Medicine, and her colleagues advocate a competency-based approach focused on improving communication and professionalism (Qual. Saf. Health Care 2008;17:11-4).

“Handoffs are more than just a transfer of content, but also a transfer of professional responsibility,” she said. “Every patient is your patient.”

Dr. Arora and her colleagues are developing handoff training programs, which are not commonly used.

The SHM recommends that a formal handoff plan be instituted at the end of a shift or change in service, Dr. Arora said, and the plan should include time during shifts dedicated for verbal exchange of information, a template or technology solution to be used for tracking patient information, and training for new users on handoff expectations.

Although information technology can advance communication, it cannot replace it, Dr. Arora cautioned. In one study, replacing a telephone call for critical lab values with a computerized reporting system and no verbal communication resulted in 45% of 3,228 urgent lab results not being read by a clinician (BMJ 2001;322:1101-3).

Precise language is essential, she said, citing a common scenario in which a nurse calls because the patient wants to know if they can eat, but the chart says “patient is NPO for surgery tomorrow.” To avoid confusion, use exact dates instead of terms like today, tomorrow, or yesterday, and state exactly what procedure is planned, she advised.

A verbal handoff also should provide anticipatory guidance and identify tasks that need to be done, she said. Both should be accompanied by a plan and the rationale behind it. For example, a chart that simply says “check BMP at 8 p.m.” doesn't explain what the physician is looking for or what staff should do if that basic metabolic panel reports an abnormality. Before a handoff, hospitalists should also examine the chart for critical omissions, such as “do not resuscitate” status.

Dr. Arora has received consultant or speakers fees related to her work on handoffs from the Illinois Hospital Association, Michigan Health and Hospital Association, Delmarva Foundation/Maryland Patient Safety Learning Center, Clarity Group, MacNeal Hospital, and HCPro.

CHICAGO — Hospitalists looking to improve handoffs during transitions of care and reduce downstream errors may find inspiration at their local Starbucks.

By repeating your order for a triple tall, nonfat, no-whip peppermint mocha, Starbucks is using the simple “read-back” strategy to ensure accuracy.

“In business and restaurants, they have to get the order right or you won't go back,” Dr. Vineet Arora explained during a session on handoff best practices at the annual meeting of the Society of Hospital Medicine (SHM). “And in medicine we have a culture of errors.”

Communication problems have been identified as the primary cause of nearly two-thirds of hospital sentinel events. A study at Chicago's Northwestern Memorial Hospital of telephone read-back of 822 lab results showed that using the strategy took only an additional 12.8 seconds per call and identified 29 errors, including 10 instances in which the patient's name was incorrect, she said (Am. J. Clin. Pathol. 2004;121:790-1).

In recent years, organizations such as the SHM, World Health Organization, Institute of Medicine, and the Joint Commission have focused on the need to improve handoffs of care. Dr. Arora, assistant dean at the University of Chicago Pritzker School of Medicine, and her colleagues advocate a competency-based approach focused on improving communication and professionalism (Qual. Saf. Health Care 2008;17:11-4).

“Handoffs are more than just a transfer of content, but also a transfer of professional responsibility,” she said. “Every patient is your patient.”

Dr. Arora and her colleagues are developing handoff training programs, which are not commonly used.

The SHM recommends that a formal handoff plan be instituted at the end of a shift or change in service, Dr. Arora said, and the plan should include time during shifts dedicated for verbal exchange of information, a template or technology solution to be used for tracking patient information, and training for new users on handoff expectations.

Although information technology can advance communication, it cannot replace it, Dr. Arora cautioned. In one study, replacing a telephone call for critical lab values with a computerized reporting system and no verbal communication resulted in 45% of 3,228 urgent lab results not being read by a clinician (BMJ 2001;322:1101-3).

Precise language is essential, she said, citing a common scenario in which a nurse calls because the patient wants to know if they can eat, but the chart says “patient is NPO for surgery tomorrow.” To avoid confusion, use exact dates instead of terms like today, tomorrow, or yesterday, and state exactly what procedure is planned, she advised.

A verbal handoff also should provide anticipatory guidance and identify tasks that need to be done, she said. Both should be accompanied by a plan and the rationale behind it. For example, a chart that simply says “check BMP at 8 p.m.” doesn't explain what the physician is looking for or what staff should do if that basic metabolic panel reports an abnormality. Before a handoff, hospitalists should also examine the chart for critical omissions, such as “do not resuscitate” status.

Dr. Arora has received consultant or speakers fees related to her work on handoffs from the Illinois Hospital Association, Michigan Health and Hospital Association, Delmarva Foundation/Maryland Patient Safety Learning Center, Clarity Group, MacNeal Hospital, and HCPro.

CHICAGO — Not quite half of 785 hospitalized pediatric patients were overweight or obese, and psychiatric diagnoses affected almost a quarter of those children and teens, according to a chart review.

Overall, 102 (13%) children were overweight based on a body mass index percentage of 85%-95%, and another 227 (29%) were obese based on a BMI percentage greater than 95%, for a total of 42%, Dr. Marsha Medows and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

Obesity was recognized as a diagnosis or problem in only 23% of the 227 obese children.

Failure to diagnose obesity and overweight in children represents an important missed opportunity to intervene, according to the investigators. Childhood obesity confers a substantial risk of adult obesity, lifelong health risks, and social and economic disadvantages.

Providers might not diagnose, counsel, or treat their obese patients because of concerns related to societal stigma and effectiveness of treatment, Dr. Medows of the department of pediatrics at New York University Langone Medical Center said in an interview.

“The social stigma is real, but so are the threats to health status that obesity poses,” she said. “Providers, recognizing this negative view of obesity, need to be empathic in their discussions regarding weight management.”

Psychiatric illness was significantly more common in obese/overweight children (24%), compared with those without a weight problem (7%). There were no differences in diagnoses of respiratory illness, skin and soft-tissue infections, or diabetes.

“Obese children are at significantly higher risk for experiencing poor psychological well-being,” Dr. Medows said. “Many studies have not determined if depression is a consequence of obesity or if depression predisposes to obesity. Bipolar disorder and schizophrenia are independent risk factors for obesity.”

The medical center is in the process of changing its computer system to automatically flag overweight/obese BMI and place these patients on the problem list. When obesity was recognized as a problem in the study, the primary care physician was contacted regarding referral of the patient to the obesity clinic.

The chart review included children (60% male), aged 6 months to 18 years (mean, 8.5 years), who were hospitalized during a 15-month period at an urban community hospital. Diabetes was present in 1.4% of patients, but the prevalence was not different between those with or without a weight problem.

The investigators reported no conflicts of interest.

CHICAGO — Not quite half of 785 hospitalized pediatric patients were overweight or obese, and psychiatric diagnoses affected almost a quarter of those children and teens, according to a chart review.

Overall, 102 (13%) children were overweight based on a body mass index percentage of 85%-95%, and another 227 (29%) were obese based on a BMI percentage greater than 95%, for a total of 42%, Dr. Marsha Medows and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

Obesity was recognized as a diagnosis or problem in only 23% of the 227 obese children.

Failure to diagnose obesity and overweight in children represents an important missed opportunity to intervene, according to the investigators. Childhood obesity confers a substantial risk of adult obesity, lifelong health risks, and social and economic disadvantages.

Providers might not diagnose, counsel, or treat their obese patients because of concerns related to societal stigma and effectiveness of treatment, Dr. Medows of the department of pediatrics at New York University Langone Medical Center said in an interview.

“The social stigma is real, but so are the threats to health status that obesity poses,” she said. “Providers, recognizing this negative view of obesity, need to be empathic in their discussions regarding weight management.”

Psychiatric illness was significantly more common in obese/overweight children (24%), compared with those without a weight problem (7%). There were no differences in diagnoses of respiratory illness, skin and soft-tissue infections, or diabetes.

“Obese children are at significantly higher risk for experiencing poor psychological well-being,” Dr. Medows said. “Many studies have not determined if depression is a consequence of obesity or if depression predisposes to obesity. Bipolar disorder and schizophrenia are independent risk factors for obesity.”

The medical center is in the process of changing its computer system to automatically flag overweight/obese BMI and place these patients on the problem list. When obesity was recognized as a problem in the study, the primary care physician was contacted regarding referral of the patient to the obesity clinic.

The chart review included children (60% male), aged 6 months to 18 years (mean, 8.5 years), who were hospitalized during a 15-month period at an urban community hospital. Diabetes was present in 1.4% of patients, but the prevalence was not different between those with or without a weight problem.

The investigators reported no conflicts of interest.

CHICAGO — Not quite half of 785 hospitalized pediatric patients were overweight or obese, and psychiatric diagnoses affected almost a quarter of those children and teens, according to a chart review.

Overall, 102 (13%) children were overweight based on a body mass index percentage of 85%-95%, and another 227 (29%) were obese based on a BMI percentage greater than 95%, for a total of 42%, Dr. Marsha Medows and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

Obesity was recognized as a diagnosis or problem in only 23% of the 227 obese children.

Failure to diagnose obesity and overweight in children represents an important missed opportunity to intervene, according to the investigators. Childhood obesity confers a substantial risk of adult obesity, lifelong health risks, and social and economic disadvantages.

Providers might not diagnose, counsel, or treat their obese patients because of concerns related to societal stigma and effectiveness of treatment, Dr. Medows of the department of pediatrics at New York University Langone Medical Center said in an interview.

“The social stigma is real, but so are the threats to health status that obesity poses,” she said. “Providers, recognizing this negative view of obesity, need to be empathic in their discussions regarding weight management.”

Psychiatric illness was significantly more common in obese/overweight children (24%), compared with those without a weight problem (7%). There were no differences in diagnoses of respiratory illness, skin and soft-tissue infections, or diabetes.

“Obese children are at significantly higher risk for experiencing poor psychological well-being,” Dr. Medows said. “Many studies have not determined if depression is a consequence of obesity or if depression predisposes to obesity. Bipolar disorder and schizophrenia are independent risk factors for obesity.”

The medical center is in the process of changing its computer system to automatically flag overweight/obese BMI and place these patients on the problem list. When obesity was recognized as a problem in the study, the primary care physician was contacted regarding referral of the patient to the obesity clinic.

The chart review included children (60% male), aged 6 months to 18 years (mean, 8.5 years), who were hospitalized during a 15-month period at an urban community hospital. Diabetes was present in 1.4% of patients, but the prevalence was not different between those with or without a weight problem.

The investigators reported no conflicts of interest.

CHICAGO — As in outpatients, cystatin C levels appear to offer additional prognostic information in patients admitted with heart failure exacerbations, according to an analysis of 240 consecutive inpatients.

There was no significant association between cystatin C levels on admission and the study's primary end point of length of hospitalization.

However, cystatin C was more predictive of all-cause mortality and the combined end point of readmission or death than was creatinine, Dr. Daniel J. Brotman and his colleagues reported in a poster at the annual meeting of the Society of Hospital Medicine.

Patients in the highest quartile of cystatin C (mean 2.44 mg/L) were at significantly increased risk of death (hazard ratio 2.07) and of readmission or death (HR 1.61) during the first year after admission, compared with those in the lower three cystatin C quartiles (mean 0.66-1.43 mg/L).

The association between cystatin C and the risk of readmission or death remained significant on multivariate analysis after adjustment for age, race, gender, and creatinine level (HR 1.65), according to Dr. Brotman, director of the hospitalists program at Johns Hopkins Hospital in Baltimore. The relationship also remained significant when ejection fraction was included in the model.

Cystatin C level has been shown to be a stronger predictor of the risk of death and cardiovascular events in elderly patients, compared with creatinine level (N. Engl. J. Med. 2005;352:2049-60). Accumulating evidence also supports its use as an alternative and more sensitive endogenous marker, compared with serum creatinine, for the estimation of glomerular filtration rate.

In the current analysis, there was a trend toward increased risk of readmission or death (HR 1.44) for patients in the top quartile of creatinine (mean 2.0 mg/dL), compared with those in the lower three creatinine quartiles (1.0-1.3 mg/dL), but this difference did not reach statistical significance.

The combination of cystatin C and creatinine, however, was significantly more predictive of the combined end point of readmission or death than was either variable alone (HR 1.81).

“We are looking into whether serial changes in this biomarker during the course of hospitalization will have any potential clinical utility,” Dr. Brotman said in an interview.

Clinical application is currently limited, as most laboratories do not routinely test for cystatin C.

Dr. Brotman disclosed receiving research funding from Siemens Healthcare Diagnostics Inc., serving on the hospitalist leadership panel for Quantia Communications LLC, and being on the advisory boards of several pharmaceutical companies.

CHICAGO — As in outpatients, cystatin C levels appear to offer additional prognostic information in patients admitted with heart failure exacerbations, according to an analysis of 240 consecutive inpatients.

There was no significant association between cystatin C levels on admission and the study's primary end point of length of hospitalization.

However, cystatin C was more predictive of all-cause mortality and the combined end point of readmission or death than was creatinine, Dr. Daniel J. Brotman and his colleagues reported in a poster at the annual meeting of the Society of Hospital Medicine.

Patients in the highest quartile of cystatin C (mean 2.44 mg/L) were at significantly increased risk of death (hazard ratio 2.07) and of readmission or death (HR 1.61) during the first year after admission, compared with those in the lower three cystatin C quartiles (mean 0.66-1.43 mg/L).

The association between cystatin C and the risk of readmission or death remained significant on multivariate analysis after adjustment for age, race, gender, and creatinine level (HR 1.65), according to Dr. Brotman, director of the hospitalists program at Johns Hopkins Hospital in Baltimore. The relationship also remained significant when ejection fraction was included in the model.

Cystatin C level has been shown to be a stronger predictor of the risk of death and cardiovascular events in elderly patients, compared with creatinine level (N. Engl. J. Med. 2005;352:2049-60). Accumulating evidence also supports its use as an alternative and more sensitive endogenous marker, compared with serum creatinine, for the estimation of glomerular filtration rate.

In the current analysis, there was a trend toward increased risk of readmission or death (HR 1.44) for patients in the top quartile of creatinine (mean 2.0 mg/dL), compared with those in the lower three creatinine quartiles (1.0-1.3 mg/dL), but this difference did not reach statistical significance.

The combination of cystatin C and creatinine, however, was significantly more predictive of the combined end point of readmission or death than was either variable alone (HR 1.81).

“We are looking into whether serial changes in this biomarker during the course of hospitalization will have any potential clinical utility,” Dr. Brotman said in an interview.

Clinical application is currently limited, as most laboratories do not routinely test for cystatin C.

Dr. Brotman disclosed receiving research funding from Siemens Healthcare Diagnostics Inc., serving on the hospitalist leadership panel for Quantia Communications LLC, and being on the advisory boards of several pharmaceutical companies.

CHICAGO — As in outpatients, cystatin C levels appear to offer additional prognostic information in patients admitted with heart failure exacerbations, according to an analysis of 240 consecutive inpatients.

There was no significant association between cystatin C levels on admission and the study's primary end point of length of hospitalization.

However, cystatin C was more predictive of all-cause mortality and the combined end point of readmission or death than was creatinine, Dr. Daniel J. Brotman and his colleagues reported in a poster at the annual meeting of the Society of Hospital Medicine.

Patients in the highest quartile of cystatin C (mean 2.44 mg/L) were at significantly increased risk of death (hazard ratio 2.07) and of readmission or death (HR 1.61) during the first year after admission, compared with those in the lower three cystatin C quartiles (mean 0.66-1.43 mg/L).

The association between cystatin C and the risk of readmission or death remained significant on multivariate analysis after adjustment for age, race, gender, and creatinine level (HR 1.65), according to Dr. Brotman, director of the hospitalists program at Johns Hopkins Hospital in Baltimore. The relationship also remained significant when ejection fraction was included in the model.

Cystatin C level has been shown to be a stronger predictor of the risk of death and cardiovascular events in elderly patients, compared with creatinine level (N. Engl. J. Med. 2005;352:2049-60). Accumulating evidence also supports its use as an alternative and more sensitive endogenous marker, compared with serum creatinine, for the estimation of glomerular filtration rate.

In the current analysis, there was a trend toward increased risk of readmission or death (HR 1.44) for patients in the top quartile of creatinine (mean 2.0 mg/dL), compared with those in the lower three creatinine quartiles (1.0-1.3 mg/dL), but this difference did not reach statistical significance.

The combination of cystatin C and creatinine, however, was significantly more predictive of the combined end point of readmission or death than was either variable alone (HR 1.81).

“We are looking into whether serial changes in this biomarker during the course of hospitalization will have any potential clinical utility,” Dr. Brotman said in an interview.

Clinical application is currently limited, as most laboratories do not routinely test for cystatin C.

Dr. Brotman disclosed receiving research funding from Siemens Healthcare Diagnostics Inc., serving on the hospitalist leadership panel for Quantia Communications LLC, and being on the advisory boards of several pharmaceutical companies.

CHICAGO — Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (The video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of a video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internist with Massachusetts General Hospital and Harvard University, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a ninth-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advance care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates.

The study was sponsored by the Alzheimer's Association, John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

CHICAGO — Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (The video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of a video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internist with Massachusetts General Hospital and Harvard University, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a ninth-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advance care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates.

The study was sponsored by the Alzheimer's Association, John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

CHICAGO — Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (The video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of a video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internist with Massachusetts General Hospital and Harvard University, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a ninth-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advance care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates.

The study was sponsored by the Alzheimer's Association, John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

CHICAGO — A brief exercise program reduced agitated behavior in a pilot study of 50 nursing home residents with severe cognitive impairment.

Several other studies have shown that exercise programs can reduce agitation and depression, and improve the ability to perform activities of daily living.

The current study involved 30 minutes of supervised exercise for 3 days per week for 3 weeks. Residents of locked special needs units at two nursing homes walked outdoors for 15 minutes in large groups and did 5 minutes each of weight lifting, sitting and standing, and throwing a beach ball in small groups.

At baseline, the residents' mean St. Louis Mental Status Examination score was 1.45 on a 30-point scale, with a score of 30 indicating full cognitive faculty.

Mean Pittsburgh Agitation Scale (PAS) scores improved significantly from 5.8 at baseline to 4.5 post intervention on a 16-point scale, with 0 meaning no agitation, Edris Aman reported at the annual meeting of the American Geriatrics Society.

Those categorized with the highest PAS scores at baseline had the largest reductions in PAS scores, falling from a mean score of 9.1 to 6.1.

An audience member asked how a 3-point drop in PAS score would translate clinically and if exercise influenced psychotropic use.

“When you have a structured exercise program it seems like it kind of changes the way they think, especially when they interact one-on-one” said Mr. Aman, a medical student at St. Louis University School of Medicine in Missouri. “A lot of times in the locked units, a lot of the nurses leave the residents alone because it's much easier to deal with agitated patients if they're quiet, sitting alone.

“I feel like the continuity, where they'd see one person 3 days a week who's talking with them, really helps the resident,” he said.

Continuous activity programming, in which residents are engaged in meaningful activities like exercise or casual conversation whenever they are in the main activity area, has been shown to reduce the number of days with agitation and psychoactive medication use and improve sleep in two dementia special care units (J. Am. Med. Dir. Assoc. 2006;7:426-31).

Mr. Aman said that anecdotally nurses reported that after a week of exercising, patients who were previously up all night began sleeping through the night and remaining awake during the day. He theorized that exercise could be used at times in place of psychotropics, but said that medication use was not specifically evaluated in the study and that further research is needed.

When asked how he was able to get patients with such poor mental status to exercise, Mr. Aman said that it wasn't difficult to get patients to go outdoors because they wanted to join the group, but that at times he had to passively guide a patient's arm to get them to understand a specific exercise pattern.

“If you're enthusiastic and really happy, they will actually do what you want,” he said. “The biggest problem I had was getting them to exercise the first time. Once they exercised once, it was easy.”

Mr. Aman reported no conflicts of interest. The study was funded by a grant from the American Foundation for Aging Research.

Mean Pittsburgh Agitation Scale scores improved significantly with exercise. ©PhotoDisc, Inc.

CHICAGO — A brief exercise program reduced agitated behavior in a pilot study of 50 nursing home residents with severe cognitive impairment.

Several other studies have shown that exercise programs can reduce agitation and depression, and improve the ability to perform activities of daily living.

The current study involved 30 minutes of supervised exercise for 3 days per week for 3 weeks. Residents of locked special needs units at two nursing homes walked outdoors for 15 minutes in large groups and did 5 minutes each of weight lifting, sitting and standing, and throwing a beach ball in small groups.

At baseline, the residents' mean St. Louis Mental Status Examination score was 1.45 on a 30-point scale, with a score of 30 indicating full cognitive faculty.

Mean Pittsburgh Agitation Scale (PAS) scores improved significantly from 5.8 at baseline to 4.5 post intervention on a 16-point scale, with 0 meaning no agitation, Edris Aman reported at the annual meeting of the American Geriatrics Society.

Those categorized with the highest PAS scores at baseline had the largest reductions in PAS scores, falling from a mean score of 9.1 to 6.1.

An audience member asked how a 3-point drop in PAS score would translate clinically and if exercise influenced psychotropic use.

“When you have a structured exercise program it seems like it kind of changes the way they think, especially when they interact one-on-one” said Mr. Aman, a medical student at St. Louis University School of Medicine in Missouri. “A lot of times in the locked units, a lot of the nurses leave the residents alone because it's much easier to deal with agitated patients if they're quiet, sitting alone.

“I feel like the continuity, where they'd see one person 3 days a week who's talking with them, really helps the resident,” he said.

Continuous activity programming, in which residents are engaged in meaningful activities like exercise or casual conversation whenever they are in the main activity area, has been shown to reduce the number of days with agitation and psychoactive medication use and improve sleep in two dementia special care units (J. Am. Med. Dir. Assoc. 2006;7:426-31).

Mr. Aman said that anecdotally nurses reported that after a week of exercising, patients who were previously up all night began sleeping through the night and remaining awake during the day. He theorized that exercise could be used at times in place of psychotropics, but said that medication use was not specifically evaluated in the study and that further research is needed.

When asked how he was able to get patients with such poor mental status to exercise, Mr. Aman said that it wasn't difficult to get patients to go outdoors because they wanted to join the group, but that at times he had to passively guide a patient's arm to get them to understand a specific exercise pattern.

“If you're enthusiastic and really happy, they will actually do what you want,” he said. “The biggest problem I had was getting them to exercise the first time. Once they exercised once, it was easy.”

Mr. Aman reported no conflicts of interest. The study was funded by a grant from the American Foundation for Aging Research.

Mean Pittsburgh Agitation Scale scores improved significantly with exercise. ©PhotoDisc, Inc.

CHICAGO — A brief exercise program reduced agitated behavior in a pilot study of 50 nursing home residents with severe cognitive impairment.

Several other studies have shown that exercise programs can reduce agitation and depression, and improve the ability to perform activities of daily living.

The current study involved 30 minutes of supervised exercise for 3 days per week for 3 weeks. Residents of locked special needs units at two nursing homes walked outdoors for 15 minutes in large groups and did 5 minutes each of weight lifting, sitting and standing, and throwing a beach ball in small groups.

At baseline, the residents' mean St. Louis Mental Status Examination score was 1.45 on a 30-point scale, with a score of 30 indicating full cognitive faculty.

Mean Pittsburgh Agitation Scale (PAS) scores improved significantly from 5.8 at baseline to 4.5 post intervention on a 16-point scale, with 0 meaning no agitation, Edris Aman reported at the annual meeting of the American Geriatrics Society.

Those categorized with the highest PAS scores at baseline had the largest reductions in PAS scores, falling from a mean score of 9.1 to 6.1.

An audience member asked how a 3-point drop in PAS score would translate clinically and if exercise influenced psychotropic use.

“When you have a structured exercise program it seems like it kind of changes the way they think, especially when they interact one-on-one” said Mr. Aman, a medical student at St. Louis University School of Medicine in Missouri. “A lot of times in the locked units, a lot of the nurses leave the residents alone because it's much easier to deal with agitated patients if they're quiet, sitting alone.

“I feel like the continuity, where they'd see one person 3 days a week who's talking with them, really helps the resident,” he said.

Continuous activity programming, in which residents are engaged in meaningful activities like exercise or casual conversation whenever they are in the main activity area, has been shown to reduce the number of days with agitation and psychoactive medication use and improve sleep in two dementia special care units (J. Am. Med. Dir. Assoc. 2006;7:426-31).

Mr. Aman said that anecdotally nurses reported that after a week of exercising, patients who were previously up all night began sleeping through the night and remaining awake during the day. He theorized that exercise could be used at times in place of psychotropics, but said that medication use was not specifically evaluated in the study and that further research is needed.

When asked how he was able to get patients with such poor mental status to exercise, Mr. Aman said that it wasn't difficult to get patients to go outdoors because they wanted to join the group, but that at times he had to passively guide a patient's arm to get them to understand a specific exercise pattern.

“If you're enthusiastic and really happy, they will actually do what you want,” he said. “The biggest problem I had was getting them to exercise the first time. Once they exercised once, it was easy.”

Mr. Aman reported no conflicts of interest. The study was funded by a grant from the American Foundation for Aging Research.

Mean Pittsburgh Agitation Scale scores improved significantly with exercise. ©PhotoDisc, Inc.

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.