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.

[email protected]

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.

[email protected]

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.

[email protected]

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.

[email protected]

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.

[email protected]

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.

[email protected]

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 [email protected].

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 [email protected].

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 [email protected].

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.

Blood samples

Photo by William Weinert

A test measuring minimal residual disease (MRD) can help predict relapse in patients with acute myeloid leukemia (AML), according to a study published in NEJM.

Investigators used the test to detect MRD in samples from patients with NPM1-mutated AML who were deemed standard-risk by conventional methods.

The team said the presence of MRD after treatment provided powerful prognostic information independent of other risk factors.

“What we have been able to identify is a group of patients who otherwise would be thought to do quite well, who, in fact, have a very poor prognosis, and who are not well served currently,” said study author Robert Hills, DPhil, of Cardiff University School of Medicine in the UK.

“This opens up the exciting prospect that we can do the same for other groups of patients as well.”

For this study, Dr Hills and his colleagues used a reverse-transcriptase quantitative polymerase-chain-reaction assay to detect MRD in 2569 samples (902 bone marrow samples and 1667 peripheral blood samples) from 346 patients with NPM1-mutated AML.

The patients had received 2 cycles of chemotherapy as part of the National Cancer Research Institute AML17 trial. They were treated at centers in the UK, Denmark, and New Zealand. All patients were shown to be at standard risk of relapse using conventional tests.

The investigators found that NPM1-mutated transcripts persisted in the blood of 15% of patients after the second cycle of chemotherapy.

This finding was associated with a greater risk of relapse after 3 years of follow-up.

Eighty-two percent of patients with NPM1-mutated transcripts had relapsed within 3 years, compared to 30% of patients who had no detectable NPM1. The hazard ratio was 4.80 (P<0.001).

Patients with traces of NPM1 also had a lower rate of survival—24%, compared to 75% for patients without detectable NPM1. The hazard ratio was 4.38 (P<0.001).

In multivariate analysis, the presence of MRD was the only significant prognostic factor for relapse or death. The hazard ratios were 5.09 and 4.84, respectively (P<0.001 for both).

The investigators validated these findings in a cohort of 91 patients with NPM1-mutated AML.

The presence of MRD in the blood of these patients was associated with a higher cumulative incidence of relapse—70% vs 31% (P=0.001)—and a lower rate of survival—40% vs 87% (P=0.001)—at 2 years.

The investigators also found that, with sequential monitoring of MRD, a rising level of NPM1-mutated transcripts could predict relapse.

“Conventional methods for guiding treatment for this aggressive type of leukemia are inadequate,” said study author David Grimwade, PhD, of King’s College London in the UK.

“The MRD test is an invaluable tool to assess treatment response and identify those patients for whom chemotherapy is not sufficient and require stem cell transplantation or new treatments.”

Blood samples

Photo by William Weinert

A test measuring minimal residual disease (MRD) can help predict relapse in patients with acute myeloid leukemia (AML), according to a study published in NEJM.

Investigators used the test to detect MRD in samples from patients with NPM1-mutated AML who were deemed standard-risk by conventional methods.

The team said the presence of MRD after treatment provided powerful prognostic information independent of other risk factors.

“What we have been able to identify is a group of patients who otherwise would be thought to do quite well, who, in fact, have a very poor prognosis, and who are not well served currently,” said study author Robert Hills, DPhil, of Cardiff University School of Medicine in the UK.

“This opens up the exciting prospect that we can do the same for other groups of patients as well.”

For this study, Dr Hills and his colleagues used a reverse-transcriptase quantitative polymerase-chain-reaction assay to detect MRD in 2569 samples (902 bone marrow samples and 1667 peripheral blood samples) from 346 patients with NPM1-mutated AML.

The patients had received 2 cycles of chemotherapy as part of the National Cancer Research Institute AML17 trial. They were treated at centers in the UK, Denmark, and New Zealand. All patients were shown to be at standard risk of relapse using conventional tests.

The investigators found that NPM1-mutated transcripts persisted in the blood of 15% of patients after the second cycle of chemotherapy.

This finding was associated with a greater risk of relapse after 3 years of follow-up.

Eighty-two percent of patients with NPM1-mutated transcripts had relapsed within 3 years, compared to 30% of patients who had no detectable NPM1. The hazard ratio was 4.80 (P<0.001).

Patients with traces of NPM1 also had a lower rate of survival—24%, compared to 75% for patients without detectable NPM1. The hazard ratio was 4.38 (P<0.001).

In multivariate analysis, the presence of MRD was the only significant prognostic factor for relapse or death. The hazard ratios were 5.09 and 4.84, respectively (P<0.001 for both).

The investigators validated these findings in a cohort of 91 patients with NPM1-mutated AML.

The presence of MRD in the blood of these patients was associated with a higher cumulative incidence of relapse—70% vs 31% (P=0.001)—and a lower rate of survival—40% vs 87% (P=0.001)—at 2 years.

The investigators also found that, with sequential monitoring of MRD, a rising level of NPM1-mutated transcripts could predict relapse.

“Conventional methods for guiding treatment for this aggressive type of leukemia are inadequate,” said study author David Grimwade, PhD, of King’s College London in the UK.

“The MRD test is an invaluable tool to assess treatment response and identify those patients for whom chemotherapy is not sufficient and require stem cell transplantation or new treatments.”

Blood samples

Photo by William Weinert

A test measuring minimal residual disease (MRD) can help predict relapse in patients with acute myeloid leukemia (AML), according to a study published in NEJM.

Investigators used the test to detect MRD in samples from patients with NPM1-mutated AML who were deemed standard-risk by conventional methods.

The team said the presence of MRD after treatment provided powerful prognostic information independent of other risk factors.

“What we have been able to identify is a group of patients who otherwise would be thought to do quite well, who, in fact, have a very poor prognosis, and who are not well served currently,” said study author Robert Hills, DPhil, of Cardiff University School of Medicine in the UK.

“This opens up the exciting prospect that we can do the same for other groups of patients as well.”

For this study, Dr Hills and his colleagues used a reverse-transcriptase quantitative polymerase-chain-reaction assay to detect MRD in 2569 samples (902 bone marrow samples and 1667 peripheral blood samples) from 346 patients with NPM1-mutated AML.

The patients had received 2 cycles of chemotherapy as part of the National Cancer Research Institute AML17 trial. They were treated at centers in the UK, Denmark, and New Zealand. All patients were shown to be at standard risk of relapse using conventional tests.

The investigators found that NPM1-mutated transcripts persisted in the blood of 15% of patients after the second cycle of chemotherapy.

This finding was associated with a greater risk of relapse after 3 years of follow-up.

Eighty-two percent of patients with NPM1-mutated transcripts had relapsed within 3 years, compared to 30% of patients who had no detectable NPM1. The hazard ratio was 4.80 (P<0.001).

Patients with traces of NPM1 also had a lower rate of survival—24%, compared to 75% for patients without detectable NPM1. The hazard ratio was 4.38 (P<0.001).

In multivariate analysis, the presence of MRD was the only significant prognostic factor for relapse or death. The hazard ratios were 5.09 and 4.84, respectively (P<0.001 for both).

The investigators validated these findings in a cohort of 91 patients with NPM1-mutated AML.

The presence of MRD in the blood of these patients was associated with a higher cumulative incidence of relapse—70% vs 31% (P=0.001)—and a lower rate of survival—40% vs 87% (P=0.001)—at 2 years.

The investigators also found that, with sequential monitoring of MRD, a rising level of NPM1-mutated transcripts could predict relapse.

“Conventional methods for guiding treatment for this aggressive type of leukemia are inadequate,” said study author David Grimwade, PhD, of King’s College London in the UK.

“The MRD test is an invaluable tool to assess treatment response and identify those patients for whom chemotherapy is not sufficient and require stem cell transplantation or new treatments.”

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?

Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.

Study design: Retrospective cohort.

Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.

Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.

This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.

Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.