Commentary

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.