Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Gender identity typically develops in early childhood, and by age 4 years, most children consistently refer to themselves as a girl or a boy.¹ For the majority of children, natal sex or sex assigned at birth, aligns with gender identity (a person’s innate sense of feeling male, female, or somewhere in between). However, this is not always the case. Gender identity can be understood as a spectrum with youth identifying as a gender that aligns with their natal sex (cisgender), is opposite of their natal sex (transgender), no gender (agender), or somewhere in between (genderqueer). The distress that can result from an incongruence between natal sex and gender identity is called gender dysphoria. Youth with gender dysphoria are at increased risk for a number of conditions, including suicide and self-harm. Early identification and appropriate care of these youth can reduce these risks. This month’s column will briefly review assessment of these youth in the pediatric setting.

Many youth who have a gender-nonconforming identity in childhood will not go on to have one in adulthood.^2,3 Those who have a consistent, insistent, and persistent nonconforming identity are more likely to have this identity persist into adulthood. Youth who experience increased gender dysphoria with the onset of puberty rarely have this subside.

As it can be difficult to predict the trajectory of gender identity from childhood to adolescence, the approach to the prepubertal and pubertal gender nonconforming patient is different. It is important to note that research suggests that gender identity is innate and cannot be changed with interventions. The goals of care for gender-nonconforming (GN) youth include providing a safe environment where youth can explore their identities, and individualizing treatment to meet the needs of each patient and family.

Care for prepubertal GN youth

For parents:

Have you noticed, or are you concerned about your child’s:

• Preference or rejection of particular toys/games?

• Hair and clothing preferences or rejections?

• Preferred (if any) gender of playmates?

Has your child ever expressed:

• A desire to be or insistence that they are the other gender?

• A dislike of their sexual anatomy?

• A desire for primary (penis, vagina) or secondary (periods, facial hair) sex characteristics of the other gender?

Are you concerned about bullying ?

Do you have any concerns about your child’s mood or concerns for self-harm?

For children:

• Do you feel more like a girl, boy, neither, both?

• How would you like to play, cut your hair, dress?

• What name or pronoun (she for girl, he for boy) fits you?⁴

The goal for prepubertal youth with nonconforming identities is to ensure that they are safe at home, school, and at play. Some youth may express a desire to “transition” or live as their identified gender by changing their name and dressing as their identified gender. Some youth and families may choose to transition only in certain settings (at home, but not at school). Some youth and families may want a safe space where the child can grow, develop, and continue to explore their identity without transitioning. Mental health providers trained in the care of GN youth can help patients and families decide if transition is appropriate for them and support them with the process and timing of transitioning. For youth who experience depression, anxiety, bullying, or thoughts of self-harm related to their gender identity, care by an experienced mental health provider is essential. It is important to recognize that each patient and family will need an individualized approach based on their needs.

Care for pubertal GN youth

©Olga Ekaterincheva/Thinkstock

The development of secondary sex characteristics can be particularly distressing for GN youth. Some youth may first experience gender dysphoria at this time. This distress combined with the psychosocial stressors of adolescent development can lead to depression, anxiety, suicidal ideation, self-harm, and other risk taking behaviors. Visits with pubertal GN youth, as with any adolescent, should include confidential time alone with the medical provider to discuss any concerns. Youth should be informed that information will be kept confidential, but parents will need to be notified of any safety concerns (such as suicidality or self-harm). As with prepubertal youth, a history related to hair and clothing preferences; distress related to genital anatomy; and the desire to be the other gender should be obtained. A pubertal history and any related symptoms of distress also should be obtained.

DO

• Ask preferred name and pronoun.

• Perform confidential strength and risk assessment.

• Assess for family and social support.

• Refer to appropriate mental health and transgender providers.

DON’T

• Assume names and pronouns.

• Interview patient only with parent in the room.

• Disclose identity without patient consent.

• Dismiss parents as sources of support.

• Refer for reparative therapy.⁴

Youth who are suspected to have a diagnosis of gender dysphoria should be referred to mental health and medical providers with experience caring for transgender youth. These specialists can work with patients and families, and determine when and if youth are eligible for puberty blocking therapy with GnRH analogues and/or hormone therapy. GnRH analogues, if appropriate, can be prescribed after patients have reached sexual maturity rating stage 2. The rationale for this treatment is to prevent the development of unwanted secondary sex characteristics while giving the youth a chance to continue with psychotherapy and explore their gender identity.⁵ Hormone therapy, if appropriate, can be prescribed a few years later under the care of a transgender specialist and mental health provider.

Summary

It is normal to experiment with gender roles and expression in childhood. Providing a safe space to do this is important.

Individuals who have a persistent, consistent, and insistent gender-nonconforming identification and who have increased distress with puberty are unlikely to have this subside.

Pediatricians can assess for gender dysphoria and screen for related mood disorders and behaviors in the primary care setting. Appropriate referral to trained professionals is important.

Care should be individualized and focused on the health and safety of the patient.

Resources

For health care professionals

• World Professional Association for Transgender Health: Standards of care on care of transgender patients and provider directory. www.wpath.org• Physicians for Reproductive Health’s adolescent reproductive and sexual health education program (ARSHEP): Best practices for adolescent and reproductive health: Module on caring for transgender adolescent patients. prh.org/teen-reproductive-health/arshep-downloads/

For patients and families

• Family Acceptance Project: familyproject.sfsu.edu/

• Healthychildren.org: Parenting website supported by the American Academy of Pediatrics. Links to articles on gender nonconforming and transgender children; gender identity development in children. www.healthychildren.org

References

1. Caring for Your School Age Child: Ages 5-12 by the American Academy of Pediatrics (New York: Bantam Books, 1995).

2. Dev Psychol. 2008 Jan;44(1):34-45.

3. J Am Acad Child and Adolesc Psychiatry. 2008;47(12):1413-23

4. Caring for Transgender Adolescent Patients. Physicians for Reproductive Health’s Adolescent Reproductive and Sexual Health Education Program (ARSHEP): Best practices for adolescent and reproductive health: prh.org/teen-reproductive-health/arshep-downloads/

5. World Professional Association of Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Edition (International Journal of Transgenderism. 2011;13:165-232)

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

SNOWMASS, COLO. – Since the 2011 release of the current American College of Cardiology/American Heart Association guidelines on hypertrophic cardiomyopathy, several new evidence-based tools have emerged as being helpful in decision making regarding which patients should receive an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death, Dr. Rick A. Nishimura said at the annual Cardiovascular Conference at Snowmass.

These three tools – gadolinium-enhanced cardiovascular magnetic resonance imaging, a novel European risk score calculator, and a new appreciation of the importance of age-related risk – are most useful in the many cases of hypertrophic cardiomyopathy (HCM) where the cardiologist is on the fence regarding ICD placement because the patient doesn’t clearly meet the conventional major criteria for an ICD, according to Dr. Nishimura, professor of medicine at the Mayo Clinic in Rochester, Minn.

Dr. Nishimura, a member of the writing panel for the current guidelines (Circulation. 2011 Dec 13;124[24]:2761-96), predicted these tools will be incorporated into the next iteration of the HCM guidelines.

Notably absent from Dr. Nishimura’s list of useful tools was genetic testing for assessment of SCD risk in a patient with HCM.

“You should not spend $6,000 to do a genetic study to try to predict who’s at risk for sudden death. It turns out that most mutations are neither inherently benign nor malignant. High-risk mutations come from high-risk families, so you can do just as well by taking a family history,” according to the cardiologist.

Dr. Nishimura explained that the clinical dilemma in trying to evaluate SCD risk in a patient who presents with HCM is that the overall risk is quite low – probably 1% or less per year in the total HCM population – yet HCM is the number-one cause of SCD in younger patients. And it can occur unpredictably years or decades after diagnosis of HCM.

While ICDs are of proven effectiveness in preventing SCD in patients with HCM, reliance solely upon the conventional risk predictors to identify those who should get a device is clearly inadequate. Those criteria have a positive predictive accuracy of less than 15%; in other words, roughly 85% of HCM patients who get an ICD never receive an appropriate, life-saving shock, Dr. Nishimura said.

“We have a lot of work left to do in order to better identify these patients. In our own data from the Mayo Clinic, 20%-25% of patients have inappropriate ICD shocks despite efforts to program the device to prevent such shocks. That’s especially common in younger, active patients with HCM, and when it occurs patients find it absolutely devastating,” according to the cardiologist.

As stated in the current guidelines, the established SCD risk factors that provide a strong indication for an ICD in a patient with HCM are prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. Additionally, risk factors which, in Dr. Nishimura’s view, probably warrant insertion of an ICD and, at the very least should trigger a physician-patient discussion about the risks and benefits of preventive device therapy, include a family history of HCM-related sudden death in a first-degree relative, massive left ventricular (LV) hypertrophy as defined by a maximum wall thickness of at least 30 mm, and recent unexplained syncope inconsistent with neurocardiogenic origin.

Less potent risk predictors where savvy clinical judgment becomes imperative include nonsustained ventricular tachycardia on 24-hour Holter monitoring, a hypotensive blood pressure response to exercise, and an increased LV wall thickness in a younger patient that doesn’t rise to the 30-mm standard. These are situations where gadolinium-enhanced MRI, consideration of patient age, and the European risk scoring system can help in the decision-making process, he said.

Gadolinium-enhanced MRI: Contrast-enhanced cardiovascular MRI with late gadolinium enhancement has emerged as a reliable marker of the myocyte disarray and interstitial fibrosis which serves as a substrate for ventricular arrhythmias. In a recent study of 1,293 HCM patients followed for a median of 3.3 years, the incidence of SCD events increased progressively with the extent of late gadolinium enhancement. Extensive late gadolinium enhancement, defined as involving at least 15% of LV mass, was associated with a doubled risk of SCD events in patients otherwise considered at low risk (Circulation. 2014 Aug 5;130[6]:484-95).

“This is probably going to become one of the key markers that can help you when you’re on the fence as to whether or not to put in an ICD. We’re getting MRIs with gadolinium now in all of our HCM patients. What matters is not gadolinium enhancement at the insertion of the left ventricle into the septum – a lot of people have that – but diffuse gadolinium enhancement throughout the septum,” Dr. Nishimura said.

Because SCD risk increases linearly with greater maximal LV wall thickness, gadolinium-enhanced MRI is particularly helpful in assessing risk in a younger patient with a maximal LV wall thickness of, say, 26 mm, he added.

Age: A study by led by Dr. Barry J. Maron, the cochair of the 2011 guideline committee and director of the HCM center at the Minneapolis Heart Institute, provides a new understanding that prophylactic ICD implantation is not warranted in patients with HCM who present at age 60 or older. In their study of 428 consecutive patients presenting with HCM at age 60 or above, the investigators found during 5.8 years of follow-up that the incidence of arrhythmic sudden death events was just 0.2% per year (Circulation. 2013 Feb 5;127[5]:585-93).

“They’ve shown that if you look at patients age 60 or above who have HCM, the risk of sudden cardiac death is almost nonexistent. That’s incredibly important to remember. Sudden death is something that’s going to happen in the younger population, under age 30,” Dr. Nishimura emphasized.

European SCD risk prediction tool: This tool was hailed as a major advance in the current European Society of Cardiology guidelines on HCM (Eur Heart J. 2014;35:2733-2779). The tool was incorporated into the guidelines. It is also available as a smartphone app.

The risk prediction tool (Eur Heart J. 2014 Aug 7;35[30]:2010-20) is a complex equation that incorporates seven predictive factors: age, maximal LV wall thickness, left atrial diameter, LV outflow tract gradient, family history of SCD, nonsustained VT, and unexplained syncope. After input on these seven factors, the equation spits out an individual’s estimated 5-year SCD risk. Based on the study of 3,675 consecutive HCM patients with a median 5.7 years of follow-up that was used to develop the risk equation, the current ESC guidelines state that an ICD is not warranted in HCM patients with a 5-year risk below 4%, device implantation should be considered in those whose risk is 4%-6%, and an ICD should be even more strongly considered in patients with a 5-year risk in excess of 6%.

“A lot of people across the pond are using this risk score. But there are some problems with it,” according to Dr. Nishimura.

In his view, it “doesn’t make much sense” to include left ventricular outflow tract gradient or left atrial diameter in the risk equation. Nor is unexplained syncope carefully defined. Also, the equation would be improved by incorporation of late gadolinium enhancement on MRI, left ventricular dysfunction, and presence or absence of apical aneurysm as predictive variables. But on the plus side, the European equation treats maximal LV wall thickness as a continuous variable, which is more appropriate than the single 30-mm cutoff used in the ACC/AHA guidelines.

The biggest limitation of the European prognostic score, however, is that it hasn’t yet been validated in an independent patient cohort, Dr. Nishimura said. He noted that when Dr. Maron and coworkers recently applied the European SCD risk equation retrospectively to 1,629 consecutive U.S. patients with HCM, the investigators concluded that the risk equation proved unreliable for prediction of future SCD events. Fifty-nine percent of patients who got an appropriate ICD shock or experienced SCD were misclassified as low risk and hence would not have received an ICD under the European guidelines (Am J Cardiol. 2015 Sep 1;116[5]:757-64).

Nonetheless, because of the limited predictive accuracy of today’s standard methods of assessing SCD risk, Dr. Nishimura considers application of the European risk score to be “reasonable” in HCM patients who don’t have any of the strong indications for an ICD.

“If it comes up with an estimated 5-year risk greater than 6%, I think it’s very reasonable to consider implantation of an ICD,” he said.

Dr. Nishimura observed that in addition to assessing SCD risk, cardiologists have two other separate essential tasks when a patient presents with HCM. One is to screen and counsel the first-degree relatives. The other is to determine whether a left ventricular outflow tract obstruction is present in a symptomatic patient and, if so, to improve symptoms by treating the associated hemodynamic abnormalities medically and if need be by septal ablation or septal myectomy.

He reported having no financial conflicts of interest regarding his presentation.

bjancin@frontlinemedcom.com

SNOWMASS, COLO. – Since the 2011 release of the current American College of Cardiology/American Heart Association guidelines on hypertrophic cardiomyopathy, several new evidence-based tools have emerged as being helpful in decision making regarding which patients should receive an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death, Dr. Rick A. Nishimura said at the annual Cardiovascular Conference at Snowmass.

These three tools – gadolinium-enhanced cardiovascular magnetic resonance imaging, a novel European risk score calculator, and a new appreciation of the importance of age-related risk – are most useful in the many cases of hypertrophic cardiomyopathy (HCM) where the cardiologist is on the fence regarding ICD placement because the patient doesn’t clearly meet the conventional major criteria for an ICD, according to Dr. Nishimura, professor of medicine at the Mayo Clinic in Rochester, Minn.

Dr. Nishimura, a member of the writing panel for the current guidelines (Circulation. 2011 Dec 13;124[24]:2761-96), predicted these tools will be incorporated into the next iteration of the HCM guidelines.

Notably absent from Dr. Nishimura’s list of useful tools was genetic testing for assessment of SCD risk in a patient with HCM.

“You should not spend $6,000 to do a genetic study to try to predict who’s at risk for sudden death. It turns out that most mutations are neither inherently benign nor malignant. High-risk mutations come from high-risk families, so you can do just as well by taking a family history,” according to the cardiologist.

Dr. Nishimura explained that the clinical dilemma in trying to evaluate SCD risk in a patient who presents with HCM is that the overall risk is quite low – probably 1% or less per year in the total HCM population – yet HCM is the number-one cause of SCD in younger patients. And it can occur unpredictably years or decades after diagnosis of HCM.

While ICDs are of proven effectiveness in preventing SCD in patients with HCM, reliance solely upon the conventional risk predictors to identify those who should get a device is clearly inadequate. Those criteria have a positive predictive accuracy of less than 15%; in other words, roughly 85% of HCM patients who get an ICD never receive an appropriate, life-saving shock, Dr. Nishimura said.

“We have a lot of work left to do in order to better identify these patients. In our own data from the Mayo Clinic, 20%-25% of patients have inappropriate ICD shocks despite efforts to program the device to prevent such shocks. That’s especially common in younger, active patients with HCM, and when it occurs patients find it absolutely devastating,” according to the cardiologist.

As stated in the current guidelines, the established SCD risk factors that provide a strong indication for an ICD in a patient with HCM are prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. Additionally, risk factors which, in Dr. Nishimura’s view, probably warrant insertion of an ICD and, at the very least should trigger a physician-patient discussion about the risks and benefits of preventive device therapy, include a family history of HCM-related sudden death in a first-degree relative, massive left ventricular (LV) hypertrophy as defined by a maximum wall thickness of at least 30 mm, and recent unexplained syncope inconsistent with neurocardiogenic origin.

Less potent risk predictors where savvy clinical judgment becomes imperative include nonsustained ventricular tachycardia on 24-hour Holter monitoring, a hypotensive blood pressure response to exercise, and an increased LV wall thickness in a younger patient that doesn’t rise to the 30-mm standard. These are situations where gadolinium-enhanced MRI, consideration of patient age, and the European risk scoring system can help in the decision-making process, he said.

Gadolinium-enhanced MRI: Contrast-enhanced cardiovascular MRI with late gadolinium enhancement has emerged as a reliable marker of the myocyte disarray and interstitial fibrosis which serves as a substrate for ventricular arrhythmias. In a recent study of 1,293 HCM patients followed for a median of 3.3 years, the incidence of SCD events increased progressively with the extent of late gadolinium enhancement. Extensive late gadolinium enhancement, defined as involving at least 15% of LV mass, was associated with a doubled risk of SCD events in patients otherwise considered at low risk (Circulation. 2014 Aug 5;130[6]:484-95).

“This is probably going to become one of the key markers that can help you when you’re on the fence as to whether or not to put in an ICD. We’re getting MRIs with gadolinium now in all of our HCM patients. What matters is not gadolinium enhancement at the insertion of the left ventricle into the septum – a lot of people have that – but diffuse gadolinium enhancement throughout the septum,” Dr. Nishimura said.

Because SCD risk increases linearly with greater maximal LV wall thickness, gadolinium-enhanced MRI is particularly helpful in assessing risk in a younger patient with a maximal LV wall thickness of, say, 26 mm, he added.

Age: A study by led by Dr. Barry J. Maron, the cochair of the 2011 guideline committee and director of the HCM center at the Minneapolis Heart Institute, provides a new understanding that prophylactic ICD implantation is not warranted in patients with HCM who present at age 60 or older. In their study of 428 consecutive patients presenting with HCM at age 60 or above, the investigators found during 5.8 years of follow-up that the incidence of arrhythmic sudden death events was just 0.2% per year (Circulation. 2013 Feb 5;127[5]:585-93).

“They’ve shown that if you look at patients age 60 or above who have HCM, the risk of sudden cardiac death is almost nonexistent. That’s incredibly important to remember. Sudden death is something that’s going to happen in the younger population, under age 30,” Dr. Nishimura emphasized.

European SCD risk prediction tool: This tool was hailed as a major advance in the current European Society of Cardiology guidelines on HCM (Eur Heart J. 2014;35:2733-2779). The tool was incorporated into the guidelines. It is also available as a smartphone app.

The risk prediction tool (Eur Heart J. 2014 Aug 7;35[30]:2010-20) is a complex equation that incorporates seven predictive factors: age, maximal LV wall thickness, left atrial diameter, LV outflow tract gradient, family history of SCD, nonsustained VT, and unexplained syncope. After input on these seven factors, the equation spits out an individual’s estimated 5-year SCD risk. Based on the study of 3,675 consecutive HCM patients with a median 5.7 years of follow-up that was used to develop the risk equation, the current ESC guidelines state that an ICD is not warranted in HCM patients with a 5-year risk below 4%, device implantation should be considered in those whose risk is 4%-6%, and an ICD should be even more strongly considered in patients with a 5-year risk in excess of 6%.

“A lot of people across the pond are using this risk score. But there are some problems with it,” according to Dr. Nishimura.

In his view, it “doesn’t make much sense” to include left ventricular outflow tract gradient or left atrial diameter in the risk equation. Nor is unexplained syncope carefully defined. Also, the equation would be improved by incorporation of late gadolinium enhancement on MRI, left ventricular dysfunction, and presence or absence of apical aneurysm as predictive variables. But on the plus side, the European equation treats maximal LV wall thickness as a continuous variable, which is more appropriate than the single 30-mm cutoff used in the ACC/AHA guidelines.

The biggest limitation of the European prognostic score, however, is that it hasn’t yet been validated in an independent patient cohort, Dr. Nishimura said. He noted that when Dr. Maron and coworkers recently applied the European SCD risk equation retrospectively to 1,629 consecutive U.S. patients with HCM, the investigators concluded that the risk equation proved unreliable for prediction of future SCD events. Fifty-nine percent of patients who got an appropriate ICD shock or experienced SCD were misclassified as low risk and hence would not have received an ICD under the European guidelines (Am J Cardiol. 2015 Sep 1;116[5]:757-64).

Nonetheless, because of the limited predictive accuracy of today’s standard methods of assessing SCD risk, Dr. Nishimura considers application of the European risk score to be “reasonable” in HCM patients who don’t have any of the strong indications for an ICD.

“If it comes up with an estimated 5-year risk greater than 6%, I think it’s very reasonable to consider implantation of an ICD,” he said.

Dr. Nishimura observed that in addition to assessing SCD risk, cardiologists have two other separate essential tasks when a patient presents with HCM. One is to screen and counsel the first-degree relatives. The other is to determine whether a left ventricular outflow tract obstruction is present in a symptomatic patient and, if so, to improve symptoms by treating the associated hemodynamic abnormalities medically and if need be by septal ablation or septal myectomy.

He reported having no financial conflicts of interest regarding his presentation.

bjancin@frontlinemedcom.com

SNOWMASS, COLO. – Since the 2011 release of the current American College of Cardiology/American Heart Association guidelines on hypertrophic cardiomyopathy, several new evidence-based tools have emerged as being helpful in decision making regarding which patients should receive an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death, Dr. Rick A. Nishimura said at the annual Cardiovascular Conference at Snowmass.

These three tools – gadolinium-enhanced cardiovascular magnetic resonance imaging, a novel European risk score calculator, and a new appreciation of the importance of age-related risk – are most useful in the many cases of hypertrophic cardiomyopathy (HCM) where the cardiologist is on the fence regarding ICD placement because the patient doesn’t clearly meet the conventional major criteria for an ICD, according to Dr. Nishimura, professor of medicine at the Mayo Clinic in Rochester, Minn.

Dr. Nishimura, a member of the writing panel for the current guidelines (Circulation. 2011 Dec 13;124[24]:2761-96), predicted these tools will be incorporated into the next iteration of the HCM guidelines.

Notably absent from Dr. Nishimura’s list of useful tools was genetic testing for assessment of SCD risk in a patient with HCM.

“You should not spend $6,000 to do a genetic study to try to predict who’s at risk for sudden death. It turns out that most mutations are neither inherently benign nor malignant. High-risk mutations come from high-risk families, so you can do just as well by taking a family history,” according to the cardiologist.

Dr. Nishimura explained that the clinical dilemma in trying to evaluate SCD risk in a patient who presents with HCM is that the overall risk is quite low – probably 1% or less per year in the total HCM population – yet HCM is the number-one cause of SCD in younger patients. And it can occur unpredictably years or decades after diagnosis of HCM.

While ICDs are of proven effectiveness in preventing SCD in patients with HCM, reliance solely upon the conventional risk predictors to identify those who should get a device is clearly inadequate. Those criteria have a positive predictive accuracy of less than 15%; in other words, roughly 85% of HCM patients who get an ICD never receive an appropriate, life-saving shock, Dr. Nishimura said.

“We have a lot of work left to do in order to better identify these patients. In our own data from the Mayo Clinic, 20%-25% of patients have inappropriate ICD shocks despite efforts to program the device to prevent such shocks. That’s especially common in younger, active patients with HCM, and when it occurs patients find it absolutely devastating,” according to the cardiologist.

As stated in the current guidelines, the established SCD risk factors that provide a strong indication for an ICD in a patient with HCM are prior documented cardiac arrest, ventricular fibrillation, or hemodynamically significant ventricular tachycardia. Additionally, risk factors which, in Dr. Nishimura’s view, probably warrant insertion of an ICD and, at the very least should trigger a physician-patient discussion about the risks and benefits of preventive device therapy, include a family history of HCM-related sudden death in a first-degree relative, massive left ventricular (LV) hypertrophy as defined by a maximum wall thickness of at least 30 mm, and recent unexplained syncope inconsistent with neurocardiogenic origin.

Less potent risk predictors where savvy clinical judgment becomes imperative include nonsustained ventricular tachycardia on 24-hour Holter monitoring, a hypotensive blood pressure response to exercise, and an increased LV wall thickness in a younger patient that doesn’t rise to the 30-mm standard. These are situations where gadolinium-enhanced MRI, consideration of patient age, and the European risk scoring system can help in the decision-making process, he said.

Gadolinium-enhanced MRI: Contrast-enhanced cardiovascular MRI with late gadolinium enhancement has emerged as a reliable marker of the myocyte disarray and interstitial fibrosis which serves as a substrate for ventricular arrhythmias. In a recent study of 1,293 HCM patients followed for a median of 3.3 years, the incidence of SCD events increased progressively with the extent of late gadolinium enhancement. Extensive late gadolinium enhancement, defined as involving at least 15% of LV mass, was associated with a doubled risk of SCD events in patients otherwise considered at low risk (Circulation. 2014 Aug 5;130[6]:484-95).

“This is probably going to become one of the key markers that can help you when you’re on the fence as to whether or not to put in an ICD. We’re getting MRIs with gadolinium now in all of our HCM patients. What matters is not gadolinium enhancement at the insertion of the left ventricle into the septum – a lot of people have that – but diffuse gadolinium enhancement throughout the septum,” Dr. Nishimura said.

Because SCD risk increases linearly with greater maximal LV wall thickness, gadolinium-enhanced MRI is particularly helpful in assessing risk in a younger patient with a maximal LV wall thickness of, say, 26 mm, he added.

Age: A study by led by Dr. Barry J. Maron, the cochair of the 2011 guideline committee and director of the HCM center at the Minneapolis Heart Institute, provides a new understanding that prophylactic ICD implantation is not warranted in patients with HCM who present at age 60 or older. In their study of 428 consecutive patients presenting with HCM at age 60 or above, the investigators found during 5.8 years of follow-up that the incidence of arrhythmic sudden death events was just 0.2% per year (Circulation. 2013 Feb 5;127[5]:585-93).

“They’ve shown that if you look at patients age 60 or above who have HCM, the risk of sudden cardiac death is almost nonexistent. That’s incredibly important to remember. Sudden death is something that’s going to happen in the younger population, under age 30,” Dr. Nishimura emphasized.

European SCD risk prediction tool: This tool was hailed as a major advance in the current European Society of Cardiology guidelines on HCM (Eur Heart J. 2014;35:2733-2779). The tool was incorporated into the guidelines. It is also available as a smartphone app.

The risk prediction tool (Eur Heart J. 2014 Aug 7;35[30]:2010-20) is a complex equation that incorporates seven predictive factors: age, maximal LV wall thickness, left atrial diameter, LV outflow tract gradient, family history of SCD, nonsustained VT, and unexplained syncope. After input on these seven factors, the equation spits out an individual’s estimated 5-year SCD risk. Based on the study of 3,675 consecutive HCM patients with a median 5.7 years of follow-up that was used to develop the risk equation, the current ESC guidelines state that an ICD is not warranted in HCM patients with a 5-year risk below 4%, device implantation should be considered in those whose risk is 4%-6%, and an ICD should be even more strongly considered in patients with a 5-year risk in excess of 6%.

“A lot of people across the pond are using this risk score. But there are some problems with it,” according to Dr. Nishimura.

In his view, it “doesn’t make much sense” to include left ventricular outflow tract gradient or left atrial diameter in the risk equation. Nor is unexplained syncope carefully defined. Also, the equation would be improved by incorporation of late gadolinium enhancement on MRI, left ventricular dysfunction, and presence or absence of apical aneurysm as predictive variables. But on the plus side, the European equation treats maximal LV wall thickness as a continuous variable, which is more appropriate than the single 30-mm cutoff used in the ACC/AHA guidelines.

The biggest limitation of the European prognostic score, however, is that it hasn’t yet been validated in an independent patient cohort, Dr. Nishimura said. He noted that when Dr. Maron and coworkers recently applied the European SCD risk equation retrospectively to 1,629 consecutive U.S. patients with HCM, the investigators concluded that the risk equation proved unreliable for prediction of future SCD events. Fifty-nine percent of patients who got an appropriate ICD shock or experienced SCD were misclassified as low risk and hence would not have received an ICD under the European guidelines (Am J Cardiol. 2015 Sep 1;116[5]:757-64).

Nonetheless, because of the limited predictive accuracy of today’s standard methods of assessing SCD risk, Dr. Nishimura considers application of the European risk score to be “reasonable” in HCM patients who don’t have any of the strong indications for an ICD.

“If it comes up with an estimated 5-year risk greater than 6%, I think it’s very reasonable to consider implantation of an ICD,” he said.

Dr. Nishimura observed that in addition to assessing SCD risk, cardiologists have two other separate essential tasks when a patient presents with HCM. One is to screen and counsel the first-degree relatives. The other is to determine whether a left ventricular outflow tract obstruction is present in a symptomatic patient and, if so, to improve symptoms by treating the associated hemodynamic abnormalities medically and if need be by septal ablation or septal myectomy.

He reported having no financial conflicts of interest regarding his presentation.

bjancin@frontlinemedcom.com

SAN DIEGO – In the setting of traumatic brain injury, increases in systolic blood pressure after the nadir are independently associated with improved survival in hypotensive patients.

In addition, even substantial blood pressure increases do not seem to harm normotensive patients. These findings come from a subanalysis of the ongoing National Institutes of Health–funded Excellence in Prehospital Injury Care (EPIC) TBI study.

“Very little is known about the patterns of blood pressure in traumatic brain injury in the field,” principal investigator Dr. Daniel W. Spaite said at the annual meeting of the National Association of EMS Physicians. “For instance, nobody knows whether it’s better to have your blood pressure increasing, stable, or decreasing in the field with regard to outcome, especially mortality. Typical studies that do have EMS data linked only have a single blood pressure measurement documented, so there’s no knowledge of trends in EMS blood pressure in TBI.”

Dr. Spaite, professor and Virginia Piper Endowed Chair of Emergency Medicine at the University of Arizona, Tucson, and his colleagues evaluated the association between mortality and increases in prehospital systolic blood pressure after the lowest recorded measurement in major TBI patients who are part of the EPIC study – the statewide implementation of TBI guidelines from the Brain Trauma Foundation and the NAEMSP. Data sources include the Arizona State Trauma Registry, which has comprehensive hospital outcome data. “The cases are then linked and the EMS patient care reports are carefully abstracted by the EPIC data team,” Dr. Spaite explained. “This included major TBI (which is, clinically, both moderate and severe) and all patients whose lowest systolic BP was between 40 and 300 mm Hg.”

The researchers used logistic regression to examine the association between the increase in EMS systolic blood pressure (SBP) after the lowest EMS blood pressure and its association with adjusted probability of death. They then partitioned the study population into four cohorts based on each patient’s prehospital systolic BP (40-89 mm Hg, 90-139 mm Hg, 140-159 mm Hg, and 160-300 mm Hg). In each cohort, they identified the independent association between the magnitude of increase in SBP and the adjusted probability of death.

Dr. Spaite reported findings from 14,567 TBI patients. More than two-thirds (68%) were male, and their mean age was 45 years. The researchers observed that, in the hypotensive cohort, mortality dropped significantly if the SBP increased after the lowest SBP. “Improvements were dramatic with increases of 40-80 mm Hg,” he said. In the normotensive group, increases in SBP were associated with very slight reductions in mortality. Even large increases in SBP, such as in the range of 70-90 mm Hg, did not appear to be detrimental.

In the mildly hypertensive group, large systolic increases were associated with higher mortality. “Interestingly, even if your lowest [SBP] is between 140 and 159 mm Hg, until you get above an increase of 40 mm Hg above that, you don’t start seeing increases in mortality,” Dr. Spaite said. In the severely hypertensive group, mortality was higher with any subsequent increase in SBP, “which doesn’t surprise any of us,” he said. “It’s dramatically higher if the increase is large.”

Dr. Spaite emphasized that the current analysis is based on observational data, “so this does not prove that treating hypotension improves outcome. … That direct question is part of the EPIC study itself and awaits the final analysis, hopefully in mid-2017. This is the first large report of blood pressure trends in the prehospital management of TBI.”

He concluded that the current findings in the hypotensive and normotensive cohorts “support guideline recommendations for restoring and optimizing cerebral perfusion in EMS traumatic brain injury management. What is fascinating about the literature is that the focus in TBI has always been on hypotension, but there’s very little information about what’s the best or the optimal blood pressure.”

EPIC is funded by the National Institutes of Health. Dr. Spaite reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – In the setting of traumatic brain injury, increases in systolic blood pressure after the nadir are independently associated with improved survival in hypotensive patients.

In addition, even substantial blood pressure increases do not seem to harm normotensive patients. These findings come from a subanalysis of the ongoing National Institutes of Health–funded Excellence in Prehospital Injury Care (EPIC) TBI study.

“Very little is known about the patterns of blood pressure in traumatic brain injury in the field,” principal investigator Dr. Daniel W. Spaite said at the annual meeting of the National Association of EMS Physicians. “For instance, nobody knows whether it’s better to have your blood pressure increasing, stable, or decreasing in the field with regard to outcome, especially mortality. Typical studies that do have EMS data linked only have a single blood pressure measurement documented, so there’s no knowledge of trends in EMS blood pressure in TBI.”

Dr. Spaite, professor and Virginia Piper Endowed Chair of Emergency Medicine at the University of Arizona, Tucson, and his colleagues evaluated the association between mortality and increases in prehospital systolic blood pressure after the lowest recorded measurement in major TBI patients who are part of the EPIC study – the statewide implementation of TBI guidelines from the Brain Trauma Foundation and the NAEMSP. Data sources include the Arizona State Trauma Registry, which has comprehensive hospital outcome data. “The cases are then linked and the EMS patient care reports are carefully abstracted by the EPIC data team,” Dr. Spaite explained. “This included major TBI (which is, clinically, both moderate and severe) and all patients whose lowest systolic BP was between 40 and 300 mm Hg.”

The researchers used logistic regression to examine the association between the increase in EMS systolic blood pressure (SBP) after the lowest EMS blood pressure and its association with adjusted probability of death. They then partitioned the study population into four cohorts based on each patient’s prehospital systolic BP (40-89 mm Hg, 90-139 mm Hg, 140-159 mm Hg, and 160-300 mm Hg). In each cohort, they identified the independent association between the magnitude of increase in SBP and the adjusted probability of death.

Dr. Spaite reported findings from 14,567 TBI patients. More than two-thirds (68%) were male, and their mean age was 45 years. The researchers observed that, in the hypotensive cohort, mortality dropped significantly if the SBP increased after the lowest SBP. “Improvements were dramatic with increases of 40-80 mm Hg,” he said. In the normotensive group, increases in SBP were associated with very slight reductions in mortality. Even large increases in SBP, such as in the range of 70-90 mm Hg, did not appear to be detrimental.

In the mildly hypertensive group, large systolic increases were associated with higher mortality. “Interestingly, even if your lowest [SBP] is between 140 and 159 mm Hg, until you get above an increase of 40 mm Hg above that, you don’t start seeing increases in mortality,” Dr. Spaite said. In the severely hypertensive group, mortality was higher with any subsequent increase in SBP, “which doesn’t surprise any of us,” he said. “It’s dramatically higher if the increase is large.”

Dr. Spaite emphasized that the current analysis is based on observational data, “so this does not prove that treating hypotension improves outcome. … That direct question is part of the EPIC study itself and awaits the final analysis, hopefully in mid-2017. This is the first large report of blood pressure trends in the prehospital management of TBI.”

He concluded that the current findings in the hypotensive and normotensive cohorts “support guideline recommendations for restoring and optimizing cerebral perfusion in EMS traumatic brain injury management. What is fascinating about the literature is that the focus in TBI has always been on hypotension, but there’s very little information about what’s the best or the optimal blood pressure.”

EPIC is funded by the National Institutes of Health. Dr. Spaite reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – In the setting of traumatic brain injury, increases in systolic blood pressure after the nadir are independently associated with improved survival in hypotensive patients.

In addition, even substantial blood pressure increases do not seem to harm normotensive patients. These findings come from a subanalysis of the ongoing National Institutes of Health–funded Excellence in Prehospital Injury Care (EPIC) TBI study.

“Very little is known about the patterns of blood pressure in traumatic brain injury in the field,” principal investigator Dr. Daniel W. Spaite said at the annual meeting of the National Association of EMS Physicians. “For instance, nobody knows whether it’s better to have your blood pressure increasing, stable, or decreasing in the field with regard to outcome, especially mortality. Typical studies that do have EMS data linked only have a single blood pressure measurement documented, so there’s no knowledge of trends in EMS blood pressure in TBI.”

Dr. Spaite, professor and Virginia Piper Endowed Chair of Emergency Medicine at the University of Arizona, Tucson, and his colleagues evaluated the association between mortality and increases in prehospital systolic blood pressure after the lowest recorded measurement in major TBI patients who are part of the EPIC study – the statewide implementation of TBI guidelines from the Brain Trauma Foundation and the NAEMSP. Data sources include the Arizona State Trauma Registry, which has comprehensive hospital outcome data. “The cases are then linked and the EMS patient care reports are carefully abstracted by the EPIC data team,” Dr. Spaite explained. “This included major TBI (which is, clinically, both moderate and severe) and all patients whose lowest systolic BP was between 40 and 300 mm Hg.”

The researchers used logistic regression to examine the association between the increase in EMS systolic blood pressure (SBP) after the lowest EMS blood pressure and its association with adjusted probability of death. They then partitioned the study population into four cohorts based on each patient’s prehospital systolic BP (40-89 mm Hg, 90-139 mm Hg, 140-159 mm Hg, and 160-300 mm Hg). In each cohort, they identified the independent association between the magnitude of increase in SBP and the adjusted probability of death.

Dr. Spaite reported findings from 14,567 TBI patients. More than two-thirds (68%) were male, and their mean age was 45 years. The researchers observed that, in the hypotensive cohort, mortality dropped significantly if the SBP increased after the lowest SBP. “Improvements were dramatic with increases of 40-80 mm Hg,” he said. In the normotensive group, increases in SBP were associated with very slight reductions in mortality. Even large increases in SBP, such as in the range of 70-90 mm Hg, did not appear to be detrimental.

In the mildly hypertensive group, large systolic increases were associated with higher mortality. “Interestingly, even if your lowest [SBP] is between 140 and 159 mm Hg, until you get above an increase of 40 mm Hg above that, you don’t start seeing increases in mortality,” Dr. Spaite said. In the severely hypertensive group, mortality was higher with any subsequent increase in SBP, “which doesn’t surprise any of us,” he said. “It’s dramatically higher if the increase is large.”

Dr. Spaite emphasized that the current analysis is based on observational data, “so this does not prove that treating hypotension improves outcome. … That direct question is part of the EPIC study itself and awaits the final analysis, hopefully in mid-2017. This is the first large report of blood pressure trends in the prehospital management of TBI.”

He concluded that the current findings in the hypotensive and normotensive cohorts “support guideline recommendations for restoring and optimizing cerebral perfusion in EMS traumatic brain injury management. What is fascinating about the literature is that the focus in TBI has always been on hypotension, but there’s very little information about what’s the best or the optimal blood pressure.”

EPIC is funded by the National Institutes of Health. Dr. Spaite reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

The use of endoscopic mucosal resection (EMR) before radiofrequency ablation significantly reduced the risk for treatment failure among patients with Barrett’s esophagus–associated intramucosal adenocarcinoma (IMC) and dysplasia, according to new data published in the American Journal of Surgical Pathology.

Complete eradication of IMC/dysplasia on the first follow-up endoscopy after treatment was achieved in 86% of patients, while durable eradication, defined as a complete recurrence that persisted until the last follow-up, was achieved in 78% of patients. However, there was significant variation between the different study sites (P = .03) and outcomes were significantly impacted by the baseline extent of IMC and the use of EMR prior to radiofrequency ablation (RFA) therapy.

In addition, almost a quarter of all patients developed treatment-related strictures, usually in the setting of multiple EMRs, and recurrence occurred as a malignant stricture in one patient.

Radiofrequency ablation used with or without EMR, is a safe, effective, and durable treatment option for the treatment of dysplasia associated with Barrett’s esophagus. However, studies that have assessed the predictors of treatment failure in Barrett’s esophagus-associated intramucosal adenocarcinoma (IMC) are limited.

In this study, Dr. Agoston T. Agoston of the department of pathology at Brigham and Women’s Hospital, Boston, and his colleagues investigated the rate of Barrett’s esophagus–associated IMC eradication when using RFA, with or without EMR, in a multicenter setting. In addition, they attempted to identify clinical and pathologic predictors of treatment failure.

“We anticipate that these data will have significant implications for a personalized treatment approach to patients with BE [Barrett’s esophagus]–associated IMC,” wrote the authors.

They conducted a retrospective review of medical records from four tertiary care academic medical centers, and identified 78 patients who underwent RFA with or without EMR as the primary treatment for biopsy-proven IMC.

Some notable baseline differences were observed in patient characteristics at the different study sites, including baseline Barrett’s esophagus segment length (P = .06), baseline nodularity (P = .08), and percentage of tissue involved by IMC at pretreatment endoscopy and biopsy (P = .01).

Over a mean follow-up time of 26.4 months (range, 2-116 months), 86% of patients achieved complete eradication and 78% durable eradication of IMC/dysplasia.

Within the cohort, 11 patients failed to achieve complete eradication, and of the 67 patients who initially did, 6 patients (9.0%) had a subsequent recurrence of neoplasia (3.91 recurrences per 100 patient-years). This extrapolated to an overall rate of 22% for treatment failure (17/78 patients). Of the 17 patients who failed the treatment, 3 subsequently underwent esophagectomy, 1 received palliative measures in the setting of advanced neurological disease, and 1 patient is currently undergoing a repeat ablation procedure with curative intent.

Dr. Agoston and his team also identified 2 clinicopathologic factors that were significantly associated with treatment failure, and both remained significant on univariate and multivariate analysis. The first was that the use of EMR prior to RFA was associated with a significantly reduced risk for treatment failure (hazard ratio, 0.15; 95% confidence interval, 0.05-0.48; P = .001), and the second was that the extent of IMC involving at least 50% of the columnar metaplastic area was associated with a significantly increased risk for treatment failure (HR, 4.24; 95% CI, 1.53-11.7; P = .005).

They also observed similar results when the analysis of extent of IMC as a predictor was restricted to a subset of 43 cases in which the diagnosis of IMC was made on EMR specimens only (HR, 10.8; 95% CI, 2.30-50.8; P = .003).

“In conclusion, we have identified endoscopic and pathologic factors associated with treatment success in patients with BE-associated IMC treated with RFA with or without EMR,” they wrote. “Utilization of these predictors can help in identifying patients with a high probability of success and also those patients with a higher risk for treatment failure for whom a more aggressive initial approach may be justified” (Am J Surg Pathol. 2015 Dec 5. doi: 10.1097/PAS.0000000000000566).

Dr. Rothstein and Dr. Abrams have received research support previously from Barrx/ Covidien and C2 Therapeutics/Covidien, respectively. None of the other authors reported significant conflicts of interest.

ginews@gastro.org

The use of endoscopic mucosal resection (EMR) before radiofrequency ablation significantly reduced the risk for treatment failure among patients with Barrett’s esophagus–associated intramucosal adenocarcinoma (IMC) and dysplasia, according to new data published in the American Journal of Surgical Pathology.

Complete eradication of IMC/dysplasia on the first follow-up endoscopy after treatment was achieved in 86% of patients, while durable eradication, defined as a complete recurrence that persisted until the last follow-up, was achieved in 78% of patients. However, there was significant variation between the different study sites (P = .03) and outcomes were significantly impacted by the baseline extent of IMC and the use of EMR prior to radiofrequency ablation (RFA) therapy.

In addition, almost a quarter of all patients developed treatment-related strictures, usually in the setting of multiple EMRs, and recurrence occurred as a malignant stricture in one patient.

Radiofrequency ablation used with or without EMR, is a safe, effective, and durable treatment option for the treatment of dysplasia associated with Barrett’s esophagus. However, studies that have assessed the predictors of treatment failure in Barrett’s esophagus-associated intramucosal adenocarcinoma (IMC) are limited.

In this study, Dr. Agoston T. Agoston of the department of pathology at Brigham and Women’s Hospital, Boston, and his colleagues investigated the rate of Barrett’s esophagus–associated IMC eradication when using RFA, with or without EMR, in a multicenter setting. In addition, they attempted to identify clinical and pathologic predictors of treatment failure.

“We anticipate that these data will have significant implications for a personalized treatment approach to patients with BE [Barrett’s esophagus]–associated IMC,” wrote the authors.

They conducted a retrospective review of medical records from four tertiary care academic medical centers, and identified 78 patients who underwent RFA with or without EMR as the primary treatment for biopsy-proven IMC.

Some notable baseline differences were observed in patient characteristics at the different study sites, including baseline Barrett’s esophagus segment length (P = .06), baseline nodularity (P = .08), and percentage of tissue involved by IMC at pretreatment endoscopy and biopsy (P = .01).

Over a mean follow-up time of 26.4 months (range, 2-116 months), 86% of patients achieved complete eradication and 78% durable eradication of IMC/dysplasia.

Within the cohort, 11 patients failed to achieve complete eradication, and of the 67 patients who initially did, 6 patients (9.0%) had a subsequent recurrence of neoplasia (3.91 recurrences per 100 patient-years). This extrapolated to an overall rate of 22% for treatment failure (17/78 patients). Of the 17 patients who failed the treatment, 3 subsequently underwent esophagectomy, 1 received palliative measures in the setting of advanced neurological disease, and 1 patient is currently undergoing a repeat ablation procedure with curative intent.

Dr. Agoston and his team also identified 2 clinicopathologic factors that were significantly associated with treatment failure, and both remained significant on univariate and multivariate analysis. The first was that the use of EMR prior to RFA was associated with a significantly reduced risk for treatment failure (hazard ratio, 0.15; 95% confidence interval, 0.05-0.48; P = .001), and the second was that the extent of IMC involving at least 50% of the columnar metaplastic area was associated with a significantly increased risk for treatment failure (HR, 4.24; 95% CI, 1.53-11.7; P = .005).

They also observed similar results when the analysis of extent of IMC as a predictor was restricted to a subset of 43 cases in which the diagnosis of IMC was made on EMR specimens only (HR, 10.8; 95% CI, 2.30-50.8; P = .003).

“In conclusion, we have identified endoscopic and pathologic factors associated with treatment success in patients with BE-associated IMC treated with RFA with or without EMR,” they wrote. “Utilization of these predictors can help in identifying patients with a high probability of success and also those patients with a higher risk for treatment failure for whom a more aggressive initial approach may be justified” (Am J Surg Pathol. 2015 Dec 5. doi: 10.1097/PAS.0000000000000566).

Dr. Rothstein and Dr. Abrams have received research support previously from Barrx/ Covidien and C2 Therapeutics/Covidien, respectively. None of the other authors reported significant conflicts of interest.

ginews@gastro.org

The use of endoscopic mucosal resection (EMR) before radiofrequency ablation significantly reduced the risk for treatment failure among patients with Barrett’s esophagus–associated intramucosal adenocarcinoma (IMC) and dysplasia, according to new data published in the American Journal of Surgical Pathology.

Complete eradication of IMC/dysplasia on the first follow-up endoscopy after treatment was achieved in 86% of patients, while durable eradication, defined as a complete recurrence that persisted until the last follow-up, was achieved in 78% of patients. However, there was significant variation between the different study sites (P = .03) and outcomes were significantly impacted by the baseline extent of IMC and the use of EMR prior to radiofrequency ablation (RFA) therapy.

In addition, almost a quarter of all patients developed treatment-related strictures, usually in the setting of multiple EMRs, and recurrence occurred as a malignant stricture in one patient.

Radiofrequency ablation used with or without EMR, is a safe, effective, and durable treatment option for the treatment of dysplasia associated with Barrett’s esophagus. However, studies that have assessed the predictors of treatment failure in Barrett’s esophagus-associated intramucosal adenocarcinoma (IMC) are limited.

In this study, Dr. Agoston T. Agoston of the department of pathology at Brigham and Women’s Hospital, Boston, and his colleagues investigated the rate of Barrett’s esophagus–associated IMC eradication when using RFA, with or without EMR, in a multicenter setting. In addition, they attempted to identify clinical and pathologic predictors of treatment failure.

“We anticipate that these data will have significant implications for a personalized treatment approach to patients with BE [Barrett’s esophagus]–associated IMC,” wrote the authors.

They conducted a retrospective review of medical records from four tertiary care academic medical centers, and identified 78 patients who underwent RFA with or without EMR as the primary treatment for biopsy-proven IMC.

Some notable baseline differences were observed in patient characteristics at the different study sites, including baseline Barrett’s esophagus segment length (P = .06), baseline nodularity (P = .08), and percentage of tissue involved by IMC at pretreatment endoscopy and biopsy (P = .01).

Over a mean follow-up time of 26.4 months (range, 2-116 months), 86% of patients achieved complete eradication and 78% durable eradication of IMC/dysplasia.

Within the cohort, 11 patients failed to achieve complete eradication, and of the 67 patients who initially did, 6 patients (9.0%) had a subsequent recurrence of neoplasia (3.91 recurrences per 100 patient-years). This extrapolated to an overall rate of 22% for treatment failure (17/78 patients). Of the 17 patients who failed the treatment, 3 subsequently underwent esophagectomy, 1 received palliative measures in the setting of advanced neurological disease, and 1 patient is currently undergoing a repeat ablation procedure with curative intent.

Dr. Agoston and his team also identified 2 clinicopathologic factors that were significantly associated with treatment failure, and both remained significant on univariate and multivariate analysis. The first was that the use of EMR prior to RFA was associated with a significantly reduced risk for treatment failure (hazard ratio, 0.15; 95% confidence interval, 0.05-0.48; P = .001), and the second was that the extent of IMC involving at least 50% of the columnar metaplastic area was associated with a significantly increased risk for treatment failure (HR, 4.24; 95% CI, 1.53-11.7; P = .005).

They also observed similar results when the analysis of extent of IMC as a predictor was restricted to a subset of 43 cases in which the diagnosis of IMC was made on EMR specimens only (HR, 10.8; 95% CI, 2.30-50.8; P = .003).

“In conclusion, we have identified endoscopic and pathologic factors associated with treatment success in patients with BE-associated IMC treated with RFA with or without EMR,” they wrote. “Utilization of these predictors can help in identifying patients with a high probability of success and also those patients with a higher risk for treatment failure for whom a more aggressive initial approach may be justified” (Am J Surg Pathol. 2015 Dec 5. doi: 10.1097/PAS.0000000000000566).

Dr. Rothstein and Dr. Abrams have received research support previously from Barrx/ Covidien and C2 Therapeutics/Covidien, respectively. None of the other authors reported significant conflicts of interest.

ginews@gastro.org

By Sarah E. Streett, M.D., Chair, AGA Practice Management and Economics Committee, and Joel V. Brill, M.D., AGAF, AGA CPT Advisor

Have you taken steps to ensure that your practice will have a successful 2016? Here are six resolutions from AGA to help you improve your practice and prepare for the changing health-care environment.

1. Avoid penalties. Failing to demonstrate meaningful use with your electronic health records or failing to participate in the Physician Quality Reporting System (PQRS) during 2016 will cost you in 2018. Stay up to date with the latest requirements. AGA can help you meet PQRS and avoid penalties with the Digestive Health Recognition Program.™

2. Prepare for reimbursement cuts.

Evaluate the operations of your practice to minimize waste, excess expense, and rework due to mistakes. Efficiency will become crucial to your success as reimbursement rates to physicians and ASCs for colonoscopy procedures decline. You can also find helpful hints for efficiency and quality of care from NIH and HHS.

Review your commercial contracts. With reimbursement decreasing each year, protect yourself now by renegotiating multi-year contract rates with payors based on the 2015 fee schedule.

3. Be sure you’re up to date on your CPT coding. Did you know that AGA members can get two free coding/billing questions answered every 30 days? Visit the AGA Coding and Billing Corner and get started today at www.gastro.org/practice-management/coding/coding-billing-corner.

4. Increase efficiency and efficacy to increase impact for patients. Ensure your practice is conducive to a positive patient experience. In the new health-care landscape, it is crucial that you not only provide top-notch patient care, but also an overall positive patient experience.

5. Utilize the patient census in your practice. Think about strategizing with your patient census to maintain your position as a viable health-care business. Which payors are most beneficial to your practice? Who owns your referral sources?

6. Know how to make the Affordable Care Act work for your practice. Effective Dec. 23, 2015, commercial payors (but not Medicare) are required to cover a pre-procedure consultation prior to a screening colonoscopy, as well as the pathology resulting from the screening colonoscopy procedure, without patient financial responsibility. Make sure that your billers and referring physicians are familiar with the new regulations.

By Sarah E. Streett, M.D., Chair, AGA Practice Management and Economics Committee, and Joel V. Brill, M.D., AGAF, AGA CPT Advisor

Have you taken steps to ensure that your practice will have a successful 2016? Here are six resolutions from AGA to help you improve your practice and prepare for the changing health-care environment.

1. Avoid penalties. Failing to demonstrate meaningful use with your electronic health records or failing to participate in the Physician Quality Reporting System (PQRS) during 2016 will cost you in 2018. Stay up to date with the latest requirements. AGA can help you meet PQRS and avoid penalties with the Digestive Health Recognition Program.™

2. Prepare for reimbursement cuts.

Evaluate the operations of your practice to minimize waste, excess expense, and rework due to mistakes. Efficiency will become crucial to your success as reimbursement rates to physicians and ASCs for colonoscopy procedures decline. You can also find helpful hints for efficiency and quality of care from NIH and HHS.

Review your commercial contracts. With reimbursement decreasing each year, protect yourself now by renegotiating multi-year contract rates with payors based on the 2015 fee schedule.

3. Be sure you’re up to date on your CPT coding. Did you know that AGA members can get two free coding/billing questions answered every 30 days? Visit the AGA Coding and Billing Corner and get started today at www.gastro.org/practice-management/coding/coding-billing-corner.

4. Increase efficiency and efficacy to increase impact for patients. Ensure your practice is conducive to a positive patient experience. In the new health-care landscape, it is crucial that you not only provide top-notch patient care, but also an overall positive patient experience.

5. Utilize the patient census in your practice. Think about strategizing with your patient census to maintain your position as a viable health-care business. Which payors are most beneficial to your practice? Who owns your referral sources?

6. Know how to make the Affordable Care Act work for your practice. Effective Dec. 23, 2015, commercial payors (but not Medicare) are required to cover a pre-procedure consultation prior to a screening colonoscopy, as well as the pathology resulting from the screening colonoscopy procedure, without patient financial responsibility. Make sure that your billers and referring physicians are familiar with the new regulations.

By Sarah E. Streett, M.D., Chair, AGA Practice Management and Economics Committee, and Joel V. Brill, M.D., AGAF, AGA CPT Advisor

Have you taken steps to ensure that your practice will have a successful 2016? Here are six resolutions from AGA to help you improve your practice and prepare for the changing health-care environment.

1. Avoid penalties. Failing to demonstrate meaningful use with your electronic health records or failing to participate in the Physician Quality Reporting System (PQRS) during 2016 will cost you in 2018. Stay up to date with the latest requirements. AGA can help you meet PQRS and avoid penalties with the Digestive Health Recognition Program.™

2. Prepare for reimbursement cuts.

Evaluate the operations of your practice to minimize waste, excess expense, and rework due to mistakes. Efficiency will become crucial to your success as reimbursement rates to physicians and ASCs for colonoscopy procedures decline. You can also find helpful hints for efficiency and quality of care from NIH and HHS.

Review your commercial contracts. With reimbursement decreasing each year, protect yourself now by renegotiating multi-year contract rates with payors based on the 2015 fee schedule.

3. Be sure you’re up to date on your CPT coding. Did you know that AGA members can get two free coding/billing questions answered every 30 days? Visit the AGA Coding and Billing Corner and get started today at www.gastro.org/practice-management/coding/coding-billing-corner.

4. Increase efficiency and efficacy to increase impact for patients. Ensure your practice is conducive to a positive patient experience. In the new health-care landscape, it is crucial that you not only provide top-notch patient care, but also an overall positive patient experience.

5. Utilize the patient census in your practice. Think about strategizing with your patient census to maintain your position as a viable health-care business. Which payors are most beneficial to your practice? Who owns your referral sources?

6. Know how to make the Affordable Care Act work for your practice. Effective Dec. 23, 2015, commercial payors (but not Medicare) are required to cover a pre-procedure consultation prior to a screening colonoscopy, as well as the pathology resulting from the screening colonoscopy procedure, without patient financial responsibility. Make sure that your billers and referring physicians are familiar with the new regulations.

Clinical practice guidelines are critical to reducing physician variation and providing high-quality patient care. In 2015, AGA issued six clinical practice guidelines, all published in Gastroenterology, offering current, evidence-based point-of-care recommendations to guide physicians at the bedside.

To view all of AGA’s clinical practice guidelines, as well as accompanying clinical decision support tools and patient guideline summaries, visit www.gastro.org/guidelines.

1. Medical Management of Microscopic Colitis (November 2015): In patients with symptomatic microscopic colitis, AGA recommends first-line treatment with budesonide for induction and, when appropriate, maintenance therapy.

2. Management of Acute Diverticulitis (October 2015): This guideline suggests that antibiotics be used selectively, rather than routinely, in patients with acute diverticulitis.  

3. Role of Upper GI Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions (August 2015):  AGA recommends against obtaining endoscopic biopsy of a normal-appearing esophagus in patients with dyspepsia, regardless of immune status, providing evidence that this alone would have no added value.

4. Diagnosis and Management of Lynch Syndrome (July 2015): All colorectal cancer patients should undergo tumor testing to see if they carry Lynch syndrome, according to this AGA guideline.

5. Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts (April 2015): This guideline changes clinical practice by recommending a 2-year screening interval for asymptomatic pancreatic cysts of any size and stopping surveillance after 5 years if there is no change.

6. Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Drug Therapy (January 2015): Preventing HBV reactivation in patients on long-term immunosuppressive therapy involves screening those at risk, identifying patients based on HBV serologic status and the type of immunosuppression, and considering prophylaxis with anti–hepatitis B therapeutics; all three steps are detailed in this guideline.

Clinical practice guidelines are critical to reducing physician variation and providing high-quality patient care. In 2015, AGA issued six clinical practice guidelines, all published in Gastroenterology, offering current, evidence-based point-of-care recommendations to guide physicians at the bedside.

To view all of AGA’s clinical practice guidelines, as well as accompanying clinical decision support tools and patient guideline summaries, visit www.gastro.org/guidelines.

1. Medical Management of Microscopic Colitis (November 2015): In patients with symptomatic microscopic colitis, AGA recommends first-line treatment with budesonide for induction and, when appropriate, maintenance therapy.

2. Management of Acute Diverticulitis (October 2015): This guideline suggests that antibiotics be used selectively, rather than routinely, in patients with acute diverticulitis.  

3. Role of Upper GI Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions (August 2015):  AGA recommends against obtaining endoscopic biopsy of a normal-appearing esophagus in patients with dyspepsia, regardless of immune status, providing evidence that this alone would have no added value.

4. Diagnosis and Management of Lynch Syndrome (July 2015): All colorectal cancer patients should undergo tumor testing to see if they carry Lynch syndrome, according to this AGA guideline.

5. Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts (April 2015): This guideline changes clinical practice by recommending a 2-year screening interval for asymptomatic pancreatic cysts of any size and stopping surveillance after 5 years if there is no change.

6. Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Drug Therapy (January 2015): Preventing HBV reactivation in patients on long-term immunosuppressive therapy involves screening those at risk, identifying patients based on HBV serologic status and the type of immunosuppression, and considering prophylaxis with anti–hepatitis B therapeutics; all three steps are detailed in this guideline.

Clinical practice guidelines are critical to reducing physician variation and providing high-quality patient care. In 2015, AGA issued six clinical practice guidelines, all published in Gastroenterology, offering current, evidence-based point-of-care recommendations to guide physicians at the bedside.

To view all of AGA’s clinical practice guidelines, as well as accompanying clinical decision support tools and patient guideline summaries, visit www.gastro.org/guidelines.

1. Medical Management of Microscopic Colitis (November 2015): In patients with symptomatic microscopic colitis, AGA recommends first-line treatment with budesonide for induction and, when appropriate, maintenance therapy.

2. Management of Acute Diverticulitis (October 2015): This guideline suggests that antibiotics be used selectively, rather than routinely, in patients with acute diverticulitis.  

3. Role of Upper GI Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions (August 2015):  AGA recommends against obtaining endoscopic biopsy of a normal-appearing esophagus in patients with dyspepsia, regardless of immune status, providing evidence that this alone would have no added value.

4. Diagnosis and Management of Lynch Syndrome (July 2015): All colorectal cancer patients should undergo tumor testing to see if they carry Lynch syndrome, according to this AGA guideline.

5. Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts (April 2015): This guideline changes clinical practice by recommending a 2-year screening interval for asymptomatic pancreatic cysts of any size and stopping surveillance after 5 years if there is no change.

6. Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Drug Therapy (January 2015): Preventing HBV reactivation in patients on long-term immunosuppressive therapy involves screening those at risk, identifying patients based on HBV serologic status and the type of immunosuppression, and considering prophylaxis with anti–hepatitis B therapeutics; all three steps are detailed in this guideline.

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit.

• Giving now or later. Any charitable gift can be made in honor or memory of someone.

• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.

• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A bequest gift of $50,000 or more qualifies for membership in the AGA Legacy Society.

• Named funds. A named fund, which can be named to honor or memorialize a loved one, can be established with a minimum gift of $100,000 over the course of 5 years or through an estate gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a fund. Donors receive a tax deduction at the time a fund is established and when additional contributions are made to the fund. Because the principal remains intact, the fund will support our mission in perpetuity. The larger the fund, the more impact it has on the program it is designed to benefit.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Stacey Hinton Tuneski at 301-222-4005 or stuneski@gastro.org.

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit.

• Giving now or later. Any charitable gift can be made in honor or memory of someone.

• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.

• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A bequest gift of $50,000 or more qualifies for membership in the AGA Legacy Society.

• Named funds. A named fund, which can be named to honor or memorialize a loved one, can be established with a minimum gift of $100,000 over the course of 5 years or through an estate gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a fund. Donors receive a tax deduction at the time a fund is established and when additional contributions are made to the fund. Because the principal remains intact, the fund will support our mission in perpetuity. The larger the fund, the more impact it has on the program it is designed to benefit.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Stacey Hinton Tuneski at 301-222-4005 or stuneski@gastro.org.

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit.

• Giving now or later. Any charitable gift can be made in honor or memory of someone.

• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.

• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A bequest gift of $50,000 or more qualifies for membership in the AGA Legacy Society.

• Named funds. A named fund, which can be named to honor or memorialize a loved one, can be established with a minimum gift of $100,000 over the course of 5 years or through an estate gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a fund. Donors receive a tax deduction at the time a fund is established and when additional contributions are made to the fund. Because the principal remains intact, the fund will support our mission in perpetuity. The larger the fund, the more impact it has on the program it is designed to benefit.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Stacey Hinton Tuneski at 301-222-4005 or stuneski@gastro.org.

Physician entrepreneurs and innovators are invited to apply for the Shark Tank session at the 2016 AGA Tech Summit. Selected participants will receive valuable feedback from a panel of business development leaders, investors, established entrepreneurs, and other strategic partners.

Each participant will be given 5 minutes to present their GI-related innovation or technology. Selection is competitive and is limited to only five slots. Applications must be received no later than Feb. 16, 2016. If an applicant is selected, registration fees will be waived. However, participants will be responsible for their own travel and lodging costs.

Apply for the Shark Tank today at www.gastro.org/techsummit.

The AGA Tech Summit was developed in collaboration with the Society of American Gastrointestinal and Endoscopic Surgeons.

Physician entrepreneurs and innovators are invited to apply for the Shark Tank session at the 2016 AGA Tech Summit. Selected participants will receive valuable feedback from a panel of business development leaders, investors, established entrepreneurs, and other strategic partners.

Each participant will be given 5 minutes to present their GI-related innovation or technology. Selection is competitive and is limited to only five slots. Applications must be received no later than Feb. 16, 2016. If an applicant is selected, registration fees will be waived. However, participants will be responsible for their own travel and lodging costs.

Apply for the Shark Tank today at www.gastro.org/techsummit.

The AGA Tech Summit was developed in collaboration with the Society of American Gastrointestinal and Endoscopic Surgeons.

Physician entrepreneurs and innovators are invited to apply for the Shark Tank session at the 2016 AGA Tech Summit. Selected participants will receive valuable feedback from a panel of business development leaders, investors, established entrepreneurs, and other strategic partners.

Each participant will be given 5 minutes to present their GI-related innovation or technology. Selection is competitive and is limited to only five slots. Applications must be received no later than Feb. 16, 2016. If an applicant is selected, registration fees will be waived. However, participants will be responsible for their own travel and lodging costs.

Apply for the Shark Tank today at www.gastro.org/techsummit.

The AGA Tech Summit was developed in collaboration with the Society of American Gastrointestinal and Endoscopic Surgeons.

Early bird registration (www.xpressreg.net/register/ddwk0516/attendee/landing.asp?hkey=&ea=&sc=&iq) and housing for Digestive Disease Week® (DDW) 2016 are now open. Register by April 6 to save at least $75 on your registration, receive additional discounts on the sponsoring societies’ courses, and book your hotel.

DDW On Demand (www.ddw.org/attendees/maximize-your-experience/ddw-on-demand), an online-only library that will include nearly 450 hours of nonticketed presentations from DDW 2016, is once again included in the cost of registration.

Registration is also now open for the 2016 AGA Postgraduate Course: Cognitive and Technical Skills for the Gastroenterologist. The course, which is scheduled for May 21 and 22,  features six general sessions, 13 clinical challenge sessions, and 12 lunch breakout sessions that will teach you critical updates for 2016. This live activity will be eligible for a maximum of 11.5 AMA PRA Category 1 Credits™.

Additional details, including the program agenda and learning objectives, are available online at www. gastro.org/in-person/2015/10/27/2016-aga-postgraduate-course.

Early bird registration (www.xpressreg.net/register/ddwk0516/attendee/landing.asp?hkey=&ea=&sc=&iq) and housing for Digestive Disease Week® (DDW) 2016 are now open. Register by April 6 to save at least $75 on your registration, receive additional discounts on the sponsoring societies’ courses, and book your hotel.

DDW On Demand (www.ddw.org/attendees/maximize-your-experience/ddw-on-demand), an online-only library that will include nearly 450 hours of nonticketed presentations from DDW 2016, is once again included in the cost of registration.

Registration is also now open for the 2016 AGA Postgraduate Course: Cognitive and Technical Skills for the Gastroenterologist. The course, which is scheduled for May 21 and 22,  features six general sessions, 13 clinical challenge sessions, and 12 lunch breakout sessions that will teach you critical updates for 2016. This live activity will be eligible for a maximum of 11.5 AMA PRA Category 1 Credits™.

Additional details, including the program agenda and learning objectives, are available online at www. gastro.org/in-person/2015/10/27/2016-aga-postgraduate-course.

Early bird registration (www.xpressreg.net/register/ddwk0516/attendee/landing.asp?hkey=&ea=&sc=&iq) and housing for Digestive Disease Week® (DDW) 2016 are now open. Register by April 6 to save at least $75 on your registration, receive additional discounts on the sponsoring societies’ courses, and book your hotel.

DDW On Demand (www.ddw.org/attendees/maximize-your-experience/ddw-on-demand), an online-only library that will include nearly 450 hours of nonticketed presentations from DDW 2016, is once again included in the cost of registration.

Registration is also now open for the 2016 AGA Postgraduate Course: Cognitive and Technical Skills for the Gastroenterologist. The course, which is scheduled for May 21 and 22,  features six general sessions, 13 clinical challenge sessions, and 12 lunch breakout sessions that will teach you critical updates for 2016. This live activity will be eligible for a maximum of 11.5 AMA PRA Category 1 Credits™.

Additional details, including the program agenda and learning objectives, are available online at www. gastro.org/in-person/2015/10/27/2016-aga-postgraduate-course.