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Eileen Metzger Bulger, MD, FACS, is new Chair of the ACS Committee on Trauma
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.
“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.
A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
Recognized leadership
Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.
Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Traum
The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.
Bipartisan Budget Act of 2018 addresses ACS priorities
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.
The law addresses several other ACS priorities, including:
The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care
The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices
Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board
For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].
ACS delegation shapes policy at AMA HOD meeting
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.
The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
ACS cosponsored issues
The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.
Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.
Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.
Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
Other HOD-adopted resolutions of interest
BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.
Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.
Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.
Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
Surgical caucus
In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
Leadership transition
After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
Next meeting
The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
ACS Delegation at the AMA HOD
John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL
Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH
Jacob Moalem, MD, FACS, general surgery, Rochester, NY
Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents
Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA
Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).
Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.
Register for an upcoming 2018 ACS General Surgery Coding Workshop
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail
Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.
During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.
The ACS will offer the following five remaining coding workshops in 2018:
Chicago, IL, April 12–13
New York, NY, May 17–19
Nashville, TN, August 9–10
Chicago, IL, November 1–3
The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.
Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail
ACS-COSECSA Women Scholars Program now accepting applications
To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession.
The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS. Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director. Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee.
Applications are due no later than April 1. Contact [email protected] with any questions.
To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession.
The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS. Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director. Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee.
Applications are due no later than April 1. Contact [email protected] with any questions.
To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession.
The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS. Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director. Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee.
Applications are due no later than April 1. Contact [email protected] with any questions.
In myeloma, third ASCT is a viable option
A third autologous stem cell transplantation (ASCT) is feasible and provides clinical benefit to patients with relapsed multiple myeloma, according to findings from a retrospective study.
The benefits appear to be most pronounced in patients who had a long duration of response to the previous ASCT, the researchers wrote in Biology of Blood and Marrow Transplantation.
“A salvage third ASCT is of value for patients with relapsed multiple myeloma,” Laurent Garderet, MD, of the department of hematology, Hôpital Saint Antoine, Paris, and coauthors wrote in the report.
A third transplantation is most commonly used in patients who relapse following tandem ASCT. Less often, it is done in patients who receive upfront ASCT, relapse, undergo a second ASCT, and relapse again.
“The first scenario gives much better results, due in part to a better remission status at the third ASCT with no signs of increased [second primary malignancy],” the researchers wrote.
In that group, median overall survival was greater than 5 years if the relapse occurred 3 years or more after the initial tandem ASCT, study results show.
The retrospective analysis, based on European Society for Blood and Marrow Transplantation data, included 570 patients who had undergone a third ASCT between 1997 and 2010. Of that group, 482 patients (81%) received the third transplantation after tandem ASCT and subsequent relapse, and 88 (15%) received it after second relapse.
After third ASCT, overall survival was 33 months in the larger tandem transplant group with 61 months of follow-up, and 15 months in the smaller group of patients who received two salvage ASCTs after 48 months of follow-up.
Median progression-free survival was 13 and 8 months for the tandem ASCT and two-salvage–ASCT groups, respectively, while 100-day nonrelapse mortality was 4% and 7%, respectively.
For both groups, better outcomes were associated with longer duration of remission after the second ASCT, the researchers reported.
Moreover, the time from second ASCT to relapse was the only favorable prognostic factor associated with survival after third ASCT in a multivariate analysis of the patients who relapsed following tandem transplant. The hazard ratio for relapse occurring between 18 and 36 months vs. within 18 months was 0.62 (95% confidence interval, 0.47-0.82; P = .01); for relapse after 36 months, the HR was 0.35 (95% CI, 0.25-0.49; P less than .001).
The researchers acknowledged that, beyond transplant, treatment of myeloma has changed substantially in recent years and could change the clinical picture for patients undergoing a third ASCT.
“The availability of novel agents may further improve the response to a third ASCT, rather than impairing its usefulness in the salvage setting, by enhancing the depth of response before ASCT, which could result in improved durability of the outcome,” they wrote.
The researchers reported having no financial disclosures related to this study.
SOURCE: Garderet L et al. Biol Blood Marrow Transplant. 2018 Feb 3. doi: 10.1016/j.bbmt.2018.01.035.
A third autologous stem cell transplantation (ASCT) is feasible and provides clinical benefit to patients with relapsed multiple myeloma, according to findings from a retrospective study.
The benefits appear to be most pronounced in patients who had a long duration of response to the previous ASCT, the researchers wrote in Biology of Blood and Marrow Transplantation.
“A salvage third ASCT is of value for patients with relapsed multiple myeloma,” Laurent Garderet, MD, of the department of hematology, Hôpital Saint Antoine, Paris, and coauthors wrote in the report.
A third transplantation is most commonly used in patients who relapse following tandem ASCT. Less often, it is done in patients who receive upfront ASCT, relapse, undergo a second ASCT, and relapse again.
“The first scenario gives much better results, due in part to a better remission status at the third ASCT with no signs of increased [second primary malignancy],” the researchers wrote.
In that group, median overall survival was greater than 5 years if the relapse occurred 3 years or more after the initial tandem ASCT, study results show.
The retrospective analysis, based on European Society for Blood and Marrow Transplantation data, included 570 patients who had undergone a third ASCT between 1997 and 2010. Of that group, 482 patients (81%) received the third transplantation after tandem ASCT and subsequent relapse, and 88 (15%) received it after second relapse.
After third ASCT, overall survival was 33 months in the larger tandem transplant group with 61 months of follow-up, and 15 months in the smaller group of patients who received two salvage ASCTs after 48 months of follow-up.
Median progression-free survival was 13 and 8 months for the tandem ASCT and two-salvage–ASCT groups, respectively, while 100-day nonrelapse mortality was 4% and 7%, respectively.
For both groups, better outcomes were associated with longer duration of remission after the second ASCT, the researchers reported.
Moreover, the time from second ASCT to relapse was the only favorable prognostic factor associated with survival after third ASCT in a multivariate analysis of the patients who relapsed following tandem transplant. The hazard ratio for relapse occurring between 18 and 36 months vs. within 18 months was 0.62 (95% confidence interval, 0.47-0.82; P = .01); for relapse after 36 months, the HR was 0.35 (95% CI, 0.25-0.49; P less than .001).
The researchers acknowledged that, beyond transplant, treatment of myeloma has changed substantially in recent years and could change the clinical picture for patients undergoing a third ASCT.
“The availability of novel agents may further improve the response to a third ASCT, rather than impairing its usefulness in the salvage setting, by enhancing the depth of response before ASCT, which could result in improved durability of the outcome,” they wrote.
The researchers reported having no financial disclosures related to this study.
SOURCE: Garderet L et al. Biol Blood Marrow Transplant. 2018 Feb 3. doi: 10.1016/j.bbmt.2018.01.035.
A third autologous stem cell transplantation (ASCT) is feasible and provides clinical benefit to patients with relapsed multiple myeloma, according to findings from a retrospective study.
The benefits appear to be most pronounced in patients who had a long duration of response to the previous ASCT, the researchers wrote in Biology of Blood and Marrow Transplantation.
“A salvage third ASCT is of value for patients with relapsed multiple myeloma,” Laurent Garderet, MD, of the department of hematology, Hôpital Saint Antoine, Paris, and coauthors wrote in the report.
A third transplantation is most commonly used in patients who relapse following tandem ASCT. Less often, it is done in patients who receive upfront ASCT, relapse, undergo a second ASCT, and relapse again.
“The first scenario gives much better results, due in part to a better remission status at the third ASCT with no signs of increased [second primary malignancy],” the researchers wrote.
In that group, median overall survival was greater than 5 years if the relapse occurred 3 years or more after the initial tandem ASCT, study results show.
The retrospective analysis, based on European Society for Blood and Marrow Transplantation data, included 570 patients who had undergone a third ASCT between 1997 and 2010. Of that group, 482 patients (81%) received the third transplantation after tandem ASCT and subsequent relapse, and 88 (15%) received it after second relapse.
After third ASCT, overall survival was 33 months in the larger tandem transplant group with 61 months of follow-up, and 15 months in the smaller group of patients who received two salvage ASCTs after 48 months of follow-up.
Median progression-free survival was 13 and 8 months for the tandem ASCT and two-salvage–ASCT groups, respectively, while 100-day nonrelapse mortality was 4% and 7%, respectively.
For both groups, better outcomes were associated with longer duration of remission after the second ASCT, the researchers reported.
Moreover, the time from second ASCT to relapse was the only favorable prognostic factor associated with survival after third ASCT in a multivariate analysis of the patients who relapsed following tandem transplant. The hazard ratio for relapse occurring between 18 and 36 months vs. within 18 months was 0.62 (95% confidence interval, 0.47-0.82; P = .01); for relapse after 36 months, the HR was 0.35 (95% CI, 0.25-0.49; P less than .001).
The researchers acknowledged that, beyond transplant, treatment of myeloma has changed substantially in recent years and could change the clinical picture for patients undergoing a third ASCT.
“The availability of novel agents may further improve the response to a third ASCT, rather than impairing its usefulness in the salvage setting, by enhancing the depth of response before ASCT, which could result in improved durability of the outcome,” they wrote.
The researchers reported having no financial disclosures related to this study.
SOURCE: Garderet L et al. Biol Blood Marrow Transplant. 2018 Feb 3. doi: 10.1016/j.bbmt.2018.01.035.
FROM BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION
Key clinical point:
Major finding: Relapse-free interval was a favorable prognostic factor and significantly correlated with overall survival (P less than .001) in patients who underwent a third ASCT.
Study details: A retrospective analysis of European Society for Blood and Marrow Transplantation data including 570 patients who had undergone a third ASCT between 1997 and 2010.
Disclosures: The study authors reported having no financial disclosures related to the study.
Source: Garderet L et al. Biol Blood Marrow Transplant. 2018 Feb 3. doi: 10.1016/j.bbmt.2018.01.035.
Variants in one gene account for 7% of juvenile myoclonic epilepsy cases
An extremely rare genetic variant that affects the maturation, migration, and death of neurons appears to be responsible for about 7% of cases of juvenile myoclonic epilepsy.
Variants of the intestinal-cell kinase gene (ICK) occurred in 12 members of a family affected by the disorder and were confirmed in 22 of 310 additional patients, Julia N. Bailey, PhD, of the University of California, Los Angeles, and her colleagues reported in the March 15 issue of the New England Journal of Medicine.
“We report striking variation with respect to epilepsy phenotypes both within and among families,” the team wrote. “Of 34 affected nonproband family members, 5 (15%) had juvenile myoclonic epilepsy, 10 (29%) had myoclonic-tonic-clonic seizures, 4 (12%) had pyknoleptic petit mal seizures alone or with myoclonic-tonic-clonic seizures, 4 (12%) had febrile seizures alone or with absence seizures or myoclonias, and 11 (32%) were clinically asymptomatic but had polyspikes or focal spikes on EEG. These results strongly suggest that ICK is pleiotropic ... and that epistatic loci with different genes are present in affected family members and interact with ICK and contribute to pleiotropism and clinical heterogeneity.”
Despite the misnomer of intestinal-cell kinase, ICK “is ubiquitous and is expressed in all tissues,” senior study author Antonio Delgado-Escueta, MD, professor of neurology at UCLA, noted in an interview. He said the brain dysplasia, or microdysgenesis, that occurs in patients with juvenile myoclonic epilepsy (JME) “is very subtle, diagnosed mainly microscopically, and has neuronal cells that migrated from periventricular zones to the wrong places in wrong layers of the cortical gray matter and even the white matter of the brain. The cells can also be abnormally large and bunch up as a thicker gray matter. On voxel-based brain MRI ... focal thickenings of these abnormally migrated cells can also be partly explained by decreased pruning of cells and circuits (apoptosis).”
The gene encoding for ICK is located close to EFHC1 on chromosome 6p12. EFHC1, which encodes for a calcium-binging protein, has been implicated in JME. Dr. Bailey and her colleagues examined whether several genes in close proximity to EFHC1 also influenced that risk.
The investigators drew data from the GENESS (Genetic Epilepsies Studies) consortium, which has study sites in the United States, Mexico, Honduras, Brazil, and Japan. The current study from the databank analyzed information from 334 families with genetic generalized epilepsies. Among these, 310 patients had adolescent-onset myoclonic seizures and polyspike waves, or had a diagnosis of JME.
The team first performed an exome-wide analysis of four affected members of a large family with genetic JME. They observed the same variants in all four patients, then ran the screen in all 37 family members. Next, they screened these candidate genes in all 334 of the GENESS families and calculated risk scores for JME.
A linkage analysis confirmed two candidate genes on chromosome 6p12.1. Further analyses pinpointed a single variant: K305T on the ICK gene. This was present in each of the 12 affected members and 3 unaffected members of the initial family examined. Of those affected, three had JME, two had myoclonic-tonic-clonic convulsions only, two had febrile convulsions plus childhood absence seizures or neonatal myoclonus, one had febrile convulsions only, and four had polyspikes on EEG and were clinically asymptomatic.
“These results genetically implicated K305T as an autosomal dominant, possibly disease-causing trait,” the authors noted.
ICK variants were also present in 24 of the 310 database patients who had JME (8%). Of these, nine belonged to families with other affected members. The team tested 24 ICK variants for pathogenicity and determined that 13 exerted significant JME risk, with odds ratios exceeding 5.0.
When the team looked for these 24 variants in the Genome Aggregation Database (gnomAD), the found that 12 were present but extremely rare, and 8 were absent. They also found an additional ICK variant in a Mexican patient who was in gnomAD. Interestingly, that variant was a benign polymorphism in Africans.
Dr. Bailey and her colleagues thus concluded that 21 ICK variants accounted for 7% of the JME among the 310 cases examined.
The team also conducted a series of in vitro and in vivo mouse experiments. They determined that ICK variants impaired the migration of neuronal progenitor cells and lowered their mitotic index. ICK transgenic mice under light sedation displayed muscle movements similar to human myoclonic seizures that occur upon awakening. These mice also displayed diffuse polyspike brain waves on EEG recordings.
“The data we obtained through the use of electroporated slices of mouse brain support the conclusion that those pathogenic variants in ICK cause 7% of cases of juvenile myoclonic epilepsy by disrupting mitosis, neuroblast migration, and apoptosis,” they concluded.
The study was funded by a number of private and public grants from within the United States and other countries. Several authors are coholders of patents on EFHC1-based diagnostic and therapeutics that have been licensed to Athena Diagnostics. Several authors also reported receiving honoraria from various pharmaceutical companies.
SOURCE: Bailey J et al. N Engl J Med. 2018;378:1018-28
An extremely rare genetic variant that affects the maturation, migration, and death of neurons appears to be responsible for about 7% of cases of juvenile myoclonic epilepsy.
Variants of the intestinal-cell kinase gene (ICK) occurred in 12 members of a family affected by the disorder and were confirmed in 22 of 310 additional patients, Julia N. Bailey, PhD, of the University of California, Los Angeles, and her colleagues reported in the March 15 issue of the New England Journal of Medicine.
“We report striking variation with respect to epilepsy phenotypes both within and among families,” the team wrote. “Of 34 affected nonproband family members, 5 (15%) had juvenile myoclonic epilepsy, 10 (29%) had myoclonic-tonic-clonic seizures, 4 (12%) had pyknoleptic petit mal seizures alone or with myoclonic-tonic-clonic seizures, 4 (12%) had febrile seizures alone or with absence seizures or myoclonias, and 11 (32%) were clinically asymptomatic but had polyspikes or focal spikes on EEG. These results strongly suggest that ICK is pleiotropic ... and that epistatic loci with different genes are present in affected family members and interact with ICK and contribute to pleiotropism and clinical heterogeneity.”
Despite the misnomer of intestinal-cell kinase, ICK “is ubiquitous and is expressed in all tissues,” senior study author Antonio Delgado-Escueta, MD, professor of neurology at UCLA, noted in an interview. He said the brain dysplasia, or microdysgenesis, that occurs in patients with juvenile myoclonic epilepsy (JME) “is very subtle, diagnosed mainly microscopically, and has neuronal cells that migrated from periventricular zones to the wrong places in wrong layers of the cortical gray matter and even the white matter of the brain. The cells can also be abnormally large and bunch up as a thicker gray matter. On voxel-based brain MRI ... focal thickenings of these abnormally migrated cells can also be partly explained by decreased pruning of cells and circuits (apoptosis).”
The gene encoding for ICK is located close to EFHC1 on chromosome 6p12. EFHC1, which encodes for a calcium-binging protein, has been implicated in JME. Dr. Bailey and her colleagues examined whether several genes in close proximity to EFHC1 also influenced that risk.
The investigators drew data from the GENESS (Genetic Epilepsies Studies) consortium, which has study sites in the United States, Mexico, Honduras, Brazil, and Japan. The current study from the databank analyzed information from 334 families with genetic generalized epilepsies. Among these, 310 patients had adolescent-onset myoclonic seizures and polyspike waves, or had a diagnosis of JME.
The team first performed an exome-wide analysis of four affected members of a large family with genetic JME. They observed the same variants in all four patients, then ran the screen in all 37 family members. Next, they screened these candidate genes in all 334 of the GENESS families and calculated risk scores for JME.
A linkage analysis confirmed two candidate genes on chromosome 6p12.1. Further analyses pinpointed a single variant: K305T on the ICK gene. This was present in each of the 12 affected members and 3 unaffected members of the initial family examined. Of those affected, three had JME, two had myoclonic-tonic-clonic convulsions only, two had febrile convulsions plus childhood absence seizures or neonatal myoclonus, one had febrile convulsions only, and four had polyspikes on EEG and were clinically asymptomatic.
“These results genetically implicated K305T as an autosomal dominant, possibly disease-causing trait,” the authors noted.
ICK variants were also present in 24 of the 310 database patients who had JME (8%). Of these, nine belonged to families with other affected members. The team tested 24 ICK variants for pathogenicity and determined that 13 exerted significant JME risk, with odds ratios exceeding 5.0.
When the team looked for these 24 variants in the Genome Aggregation Database (gnomAD), the found that 12 were present but extremely rare, and 8 were absent. They also found an additional ICK variant in a Mexican patient who was in gnomAD. Interestingly, that variant was a benign polymorphism in Africans.
Dr. Bailey and her colleagues thus concluded that 21 ICK variants accounted for 7% of the JME among the 310 cases examined.
The team also conducted a series of in vitro and in vivo mouse experiments. They determined that ICK variants impaired the migration of neuronal progenitor cells and lowered their mitotic index. ICK transgenic mice under light sedation displayed muscle movements similar to human myoclonic seizures that occur upon awakening. These mice also displayed diffuse polyspike brain waves on EEG recordings.
“The data we obtained through the use of electroporated slices of mouse brain support the conclusion that those pathogenic variants in ICK cause 7% of cases of juvenile myoclonic epilepsy by disrupting mitosis, neuroblast migration, and apoptosis,” they concluded.
The study was funded by a number of private and public grants from within the United States and other countries. Several authors are coholders of patents on EFHC1-based diagnostic and therapeutics that have been licensed to Athena Diagnostics. Several authors also reported receiving honoraria from various pharmaceutical companies.
SOURCE: Bailey J et al. N Engl J Med. 2018;378:1018-28
An extremely rare genetic variant that affects the maturation, migration, and death of neurons appears to be responsible for about 7% of cases of juvenile myoclonic epilepsy.
Variants of the intestinal-cell kinase gene (ICK) occurred in 12 members of a family affected by the disorder and were confirmed in 22 of 310 additional patients, Julia N. Bailey, PhD, of the University of California, Los Angeles, and her colleagues reported in the March 15 issue of the New England Journal of Medicine.
“We report striking variation with respect to epilepsy phenotypes both within and among families,” the team wrote. “Of 34 affected nonproband family members, 5 (15%) had juvenile myoclonic epilepsy, 10 (29%) had myoclonic-tonic-clonic seizures, 4 (12%) had pyknoleptic petit mal seizures alone or with myoclonic-tonic-clonic seizures, 4 (12%) had febrile seizures alone or with absence seizures or myoclonias, and 11 (32%) were clinically asymptomatic but had polyspikes or focal spikes on EEG. These results strongly suggest that ICK is pleiotropic ... and that epistatic loci with different genes are present in affected family members and interact with ICK and contribute to pleiotropism and clinical heterogeneity.”
Despite the misnomer of intestinal-cell kinase, ICK “is ubiquitous and is expressed in all tissues,” senior study author Antonio Delgado-Escueta, MD, professor of neurology at UCLA, noted in an interview. He said the brain dysplasia, or microdysgenesis, that occurs in patients with juvenile myoclonic epilepsy (JME) “is very subtle, diagnosed mainly microscopically, and has neuronal cells that migrated from periventricular zones to the wrong places in wrong layers of the cortical gray matter and even the white matter of the brain. The cells can also be abnormally large and bunch up as a thicker gray matter. On voxel-based brain MRI ... focal thickenings of these abnormally migrated cells can also be partly explained by decreased pruning of cells and circuits (apoptosis).”
The gene encoding for ICK is located close to EFHC1 on chromosome 6p12. EFHC1, which encodes for a calcium-binging protein, has been implicated in JME. Dr. Bailey and her colleagues examined whether several genes in close proximity to EFHC1 also influenced that risk.
The investigators drew data from the GENESS (Genetic Epilepsies Studies) consortium, which has study sites in the United States, Mexico, Honduras, Brazil, and Japan. The current study from the databank analyzed information from 334 families with genetic generalized epilepsies. Among these, 310 patients had adolescent-onset myoclonic seizures and polyspike waves, or had a diagnosis of JME.
The team first performed an exome-wide analysis of four affected members of a large family with genetic JME. They observed the same variants in all four patients, then ran the screen in all 37 family members. Next, they screened these candidate genes in all 334 of the GENESS families and calculated risk scores for JME.
A linkage analysis confirmed two candidate genes on chromosome 6p12.1. Further analyses pinpointed a single variant: K305T on the ICK gene. This was present in each of the 12 affected members and 3 unaffected members of the initial family examined. Of those affected, three had JME, two had myoclonic-tonic-clonic convulsions only, two had febrile convulsions plus childhood absence seizures or neonatal myoclonus, one had febrile convulsions only, and four had polyspikes on EEG and were clinically asymptomatic.
“These results genetically implicated K305T as an autosomal dominant, possibly disease-causing trait,” the authors noted.
ICK variants were also present in 24 of the 310 database patients who had JME (8%). Of these, nine belonged to families with other affected members. The team tested 24 ICK variants for pathogenicity and determined that 13 exerted significant JME risk, with odds ratios exceeding 5.0.
When the team looked for these 24 variants in the Genome Aggregation Database (gnomAD), the found that 12 were present but extremely rare, and 8 were absent. They also found an additional ICK variant in a Mexican patient who was in gnomAD. Interestingly, that variant was a benign polymorphism in Africans.
Dr. Bailey and her colleagues thus concluded that 21 ICK variants accounted for 7% of the JME among the 310 cases examined.
The team also conducted a series of in vitro and in vivo mouse experiments. They determined that ICK variants impaired the migration of neuronal progenitor cells and lowered their mitotic index. ICK transgenic mice under light sedation displayed muscle movements similar to human myoclonic seizures that occur upon awakening. These mice also displayed diffuse polyspike brain waves on EEG recordings.
“The data we obtained through the use of electroporated slices of mouse brain support the conclusion that those pathogenic variants in ICK cause 7% of cases of juvenile myoclonic epilepsy by disrupting mitosis, neuroblast migration, and apoptosis,” they concluded.
The study was funded by a number of private and public grants from within the United States and other countries. Several authors are coholders of patents on EFHC1-based diagnostic and therapeutics that have been licensed to Athena Diagnostics. Several authors also reported receiving honoraria from various pharmaceutical companies.
SOURCE: Bailey J et al. N Engl J Med. 2018;378:1018-28
FROM NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point:
Major finding: ICK variants account for 7% of JME cases.
Study details: Genetic studies comprising one family and 310 epilepsy cases in a database.
Disclosures: The study was funded by a number of private and public grants from within the United States and other countries. Several authors are coholders of patents on EFHC1-based diagnostic and therapeutics that have been licensed to Athena Diagnostics. Several authors also reported receiving honoraria from various pharmaceutical companies.
Source: Bailey J et al. N Engl J Med. 2018;378:1018-28.
Vaccine priming determines teen susceptibility to pertussis
It is the initial type of pertussis vaccine given in infancy – acellular or whole cell – that primes the immune system and determines how soon adolescents become susceptible to pertussis, regardless of later acellular booster vaccination, noted the authors of a new study.
The IgG4 subclass proportion for IgG4-specific antibodies remained lower in patients who had whole-cell pertussis (wP) priming in infancy, even though they had received acellular pertussis booster vaccinations at ages 4 and 9 years, compared with patients who underwent acellular pertussis (aP) priming in infancy. This was true for all vaccine antigens, other than filamentous hemagglutinin and tetanus, 1 year after the preadolescent booster, noted researcher Saskia van der Lee of the National Institute for Public Health and the Environment, Bilthoven, The Netherlands, and her associates.
“ compared to aP-primed children, even after booster vaccinations. This is in line with epidemiological data indicating that adolescents, after aP vaccination in infancy, are more susceptible to pertussis, compared with wP-primed adolescents, though wP-primed individuals become also susceptible over time,” the researchers said.
In addition, children primed with DTwP vaccines have a more Th1-skewed response for pertussis vaccine antigens after receiving a DTap booster vaccine or clinical infection with Bordetella pertussis, whereas children primed with DTaP have a more mixed pertussis-specific Th1/Th2 response, the researchers said. So “new adjuvants that skew the immune response towards a Th1 profile are desired” for better protection against pertussis over time.
SOURCE: van der Lee S et al. Vaccine. 2018 Jan 4;36(2):220-6.
It is the initial type of pertussis vaccine given in infancy – acellular or whole cell – that primes the immune system and determines how soon adolescents become susceptible to pertussis, regardless of later acellular booster vaccination, noted the authors of a new study.
The IgG4 subclass proportion for IgG4-specific antibodies remained lower in patients who had whole-cell pertussis (wP) priming in infancy, even though they had received acellular pertussis booster vaccinations at ages 4 and 9 years, compared with patients who underwent acellular pertussis (aP) priming in infancy. This was true for all vaccine antigens, other than filamentous hemagglutinin and tetanus, 1 year after the preadolescent booster, noted researcher Saskia van der Lee of the National Institute for Public Health and the Environment, Bilthoven, The Netherlands, and her associates.
“ compared to aP-primed children, even after booster vaccinations. This is in line with epidemiological data indicating that adolescents, after aP vaccination in infancy, are more susceptible to pertussis, compared with wP-primed adolescents, though wP-primed individuals become also susceptible over time,” the researchers said.
In addition, children primed with DTwP vaccines have a more Th1-skewed response for pertussis vaccine antigens after receiving a DTap booster vaccine or clinical infection with Bordetella pertussis, whereas children primed with DTaP have a more mixed pertussis-specific Th1/Th2 response, the researchers said. So “new adjuvants that skew the immune response towards a Th1 profile are desired” for better protection against pertussis over time.
SOURCE: van der Lee S et al. Vaccine. 2018 Jan 4;36(2):220-6.
It is the initial type of pertussis vaccine given in infancy – acellular or whole cell – that primes the immune system and determines how soon adolescents become susceptible to pertussis, regardless of later acellular booster vaccination, noted the authors of a new study.
The IgG4 subclass proportion for IgG4-specific antibodies remained lower in patients who had whole-cell pertussis (wP) priming in infancy, even though they had received acellular pertussis booster vaccinations at ages 4 and 9 years, compared with patients who underwent acellular pertussis (aP) priming in infancy. This was true for all vaccine antigens, other than filamentous hemagglutinin and tetanus, 1 year after the preadolescent booster, noted researcher Saskia van der Lee of the National Institute for Public Health and the Environment, Bilthoven, The Netherlands, and her associates.
“ compared to aP-primed children, even after booster vaccinations. This is in line with epidemiological data indicating that adolescents, after aP vaccination in infancy, are more susceptible to pertussis, compared with wP-primed adolescents, though wP-primed individuals become also susceptible over time,” the researchers said.
In addition, children primed with DTwP vaccines have a more Th1-skewed response for pertussis vaccine antigens after receiving a DTap booster vaccine or clinical infection with Bordetella pertussis, whereas children primed with DTaP have a more mixed pertussis-specific Th1/Th2 response, the researchers said. So “new adjuvants that skew the immune response towards a Th1 profile are desired” for better protection against pertussis over time.
SOURCE: van der Lee S et al. Vaccine. 2018 Jan 4;36(2):220-6.
FROM VACCINE
Congenital Heart Disease Is Associated With a Higher Risk of Dementia
Congenital heart disease (CHD) is associated with an increased risk of dementia, especially early onset dementia, according to research published online ahead of print February 12 in Circulation. A particularly increased risk of dementia was observed among middle-aged adults with CHD and signs of early onset dementia, the authors noted.
“These results support the importance of understanding the risk of adverse long-term neurologic outcomes in the growing and aging population with CHD,” said Carina N. Bagge, a medical student at Aarhus University Hospital in Aarhus, Denmark, and colleagues. 
Examining Dementia Risk in Patients With CHD
CHD occurs in six to 10 per 1,000 live births and represents the most common group of congenital defects. Dementia is the sixth most common cause of death in the United States. Although neurodevelopmental deficits among infants and children with CHD are well studied, research on long-term neurologic outcomes in adults with CHD is limited. Based on the increased incidence of neurodevelopmental impairments and associated risk factors for dementia among patients with CHD, Ms. Bagge and colleagues hypothesized that the risk of dementia is higher in adults with CHD than in the general population.
To test this hypothesis, the authors performed a nationwide, population-based cohort study in Denmark using linked medical registries that included data from all Danish hospitals. They identified all adults who received a diagnosis of CHD between 1963 and 1974 (before age 15) and between 1977 and 2012 (at any age). For each patient with CHD, 10 individuals from the general population were matched by sex and birth year,
The primary outcome was a first-time hospital diagnosis of all-cause dementia in the inpatient or outpatient clinic setting. Investigators categorized dementia diagnoses as Alzheimer’s disease, vascular dementia, or other dementias.
CHD Severity Correlated With Increased Risk of Dementia
The investigators identified 10,632 adults with CHD and 103,403 adults from the general population;46% were male in both cohorts. The cumulative incidence of dementia was 4% at age 80 in both cohorts. The overall hazard ratio (HR) of dementia was 1.6 among adults with CHD, compared with the general population. The HR of dementia was 1.4 among patients with CHD without extracardiac defects, 1.5 among patients with mild-to-moderate CHD, and 2.0 for patients with severe CHD, including univentricular hearts. Finally, the HR for early-onset dementia (ie, onset younger than age 65) was 2.6, and the HR for late-onset dementia was 1.3 among patients with CHD.
“These results cannot be directly applied to young adults diagnosed with CHD in the present eras. However, it is important to recognize healthcare needs and risk factors affecting the larger number of middle-aged and older adults currently living with CHD,” said Ms. Bagge and colleagues.
—Erica Tricarico
Suggested Reading
Bagge CN, Henderson VW, Laursen HB, et al. Risk of dementia in adults with congenital heart disease: population-based cohort study. Circulation. 2018 Feb 12 [Epub ahead of print].
Congenital heart disease (CHD) is associated with an increased risk of dementia, especially early onset dementia, according to research published online ahead of print February 12 in Circulation. A particularly increased risk of dementia was observed among middle-aged adults with CHD and signs of early onset dementia, the authors noted.
“These results support the importance of understanding the risk of adverse long-term neurologic outcomes in the growing and aging population with CHD,” said Carina N. Bagge, a medical student at Aarhus University Hospital in Aarhus, Denmark, and colleagues.
Examining Dementia Risk in Patients With CHD
CHD occurs in six to 10 per 1,000 live births and represents the most common group of congenital defects. Dementia is the sixth most common cause of death in the United States. Although neurodevelopmental deficits among infants and children with CHD are well studied, research on long-term neurologic outcomes in adults with CHD is limited. Based on the increased incidence of neurodevelopmental impairments and associated risk factors for dementia among patients with CHD, Ms. Bagge and colleagues hypothesized that the risk of dementia is higher in adults with CHD than in the general population.
To test this hypothesis, the authors performed a nationwide, population-based cohort study in Denmark using linked medical registries that included data from all Danish hospitals. They identified all adults who received a diagnosis of CHD between 1963 and 1974 (before age 15) and between 1977 and 2012 (at any age). For each patient with CHD, 10 individuals from the general population were matched by sex and birth year,
The primary outcome was a first-time hospital diagnosis of all-cause dementia in the inpatient or outpatient clinic setting. Investigators categorized dementia diagnoses as Alzheimer’s disease, vascular dementia, or other dementias.
CHD Severity Correlated With Increased Risk of Dementia
The investigators identified 10,632 adults with CHD and 103,403 adults from the general population;46% were male in both cohorts. The cumulative incidence of dementia was 4% at age 80 in both cohorts. The overall hazard ratio (HR) of dementia was 1.6 among adults with CHD, compared with the general population. The HR of dementia was 1.4 among patients with CHD without extracardiac defects, 1.5 among patients with mild-to-moderate CHD, and 2.0 for patients with severe CHD, including univentricular hearts. Finally, the HR for early-onset dementia (ie, onset younger than age 65) was 2.6, and the HR for late-onset dementia was 1.3 among patients with CHD.
“These results cannot be directly applied to young adults diagnosed with CHD in the present eras. However, it is important to recognize healthcare needs and risk factors affecting the larger number of middle-aged and older adults currently living with CHD,” said Ms. Bagge and colleagues.
—Erica Tricarico
Suggested Reading
Bagge CN, Henderson VW, Laursen HB, et al. Risk of dementia in adults with congenital heart disease: population-based cohort study. Circulation. 2018 Feb 12 [Epub ahead of print].
Congenital heart disease (CHD) is associated with an increased risk of dementia, especially early onset dementia, according to research published online ahead of print February 12 in Circulation. A particularly increased risk of dementia was observed among middle-aged adults with CHD and signs of early onset dementia, the authors noted.
“These results support the importance of understanding the risk of adverse long-term neurologic outcomes in the growing and aging population with CHD,” said Carina N. Bagge, a medical student at Aarhus University Hospital in Aarhus, Denmark, and colleagues.
Examining Dementia Risk in Patients With CHD
CHD occurs in six to 10 per 1,000 live births and represents the most common group of congenital defects. Dementia is the sixth most common cause of death in the United States. Although neurodevelopmental deficits among infants and children with CHD are well studied, research on long-term neurologic outcomes in adults with CHD is limited. Based on the increased incidence of neurodevelopmental impairments and associated risk factors for dementia among patients with CHD, Ms. Bagge and colleagues hypothesized that the risk of dementia is higher in adults with CHD than in the general population.
To test this hypothesis, the authors performed a nationwide, population-based cohort study in Denmark using linked medical registries that included data from all Danish hospitals. They identified all adults who received a diagnosis of CHD between 1963 and 1974 (before age 15) and between 1977 and 2012 (at any age). For each patient with CHD, 10 individuals from the general population were matched by sex and birth year,
The primary outcome was a first-time hospital diagnosis of all-cause dementia in the inpatient or outpatient clinic setting. Investigators categorized dementia diagnoses as Alzheimer’s disease, vascular dementia, or other dementias.
CHD Severity Correlated With Increased Risk of Dementia
The investigators identified 10,632 adults with CHD and 103,403 adults from the general population;46% were male in both cohorts. The cumulative incidence of dementia was 4% at age 80 in both cohorts. The overall hazard ratio (HR) of dementia was 1.6 among adults with CHD, compared with the general population. The HR of dementia was 1.4 among patients with CHD without extracardiac defects, 1.5 among patients with mild-to-moderate CHD, and 2.0 for patients with severe CHD, including univentricular hearts. Finally, the HR for early-onset dementia (ie, onset younger than age 65) was 2.6, and the HR for late-onset dementia was 1.3 among patients with CHD.
“These results cannot be directly applied to young adults diagnosed with CHD in the present eras. However, it is important to recognize healthcare needs and risk factors affecting the larger number of middle-aged and older adults currently living with CHD,” said Ms. Bagge and colleagues.
—Erica Tricarico
Suggested Reading
Bagge CN, Henderson VW, Laursen HB, et al. Risk of dementia in adults with congenital heart disease: population-based cohort study. Circulation. 2018 Feb 12 [Epub ahead of print].
Personalizing Seizure Mapping with a Computer Algorithm
A software algorithm has the potential to increase the likelihood of achieving freedom from seizures after epilepsy surgery suggests an analysis of 3 illustrative case studies.
- Researchers from the University of South Florida created the algorithm to individualize the mapping of patients’ epilepsy networks.
- The computer program combines noninvasive EEG source localization with nonconcurrent resting state functional MRI.
- Investigators used scalp EEG and resting state fMRI to gather data on a healthy control subject, a patient with right temporal lobe epilepsy (TLE), and one with bitemporal seizure onset.
- Results from the healthy subject found symmetrical global connectivity.
- The patient with right TLE had asymmetry in global connectivity and very little connectivity ipsolaterial to the epileptogenic cortex.
- The patient who had bitemporal lobe epilepsy had symmetrical global connectivity and a network of correlating activity in the cortex that was localized in the epileptogenic tissue of both temporal lobes.
Neal EG, Maciver S, Vale FL. Multimodal, noninvasive seizure network mapping software: A novel tool for preoperative epilepsy evaluation. Epilepsy Behav. 2018; 81:25-32. https://doi.org/10.1016/j.yebeh.2018.01.033
A software algorithm has the potential to increase the likelihood of achieving freedom from seizures after epilepsy surgery suggests an analysis of 3 illustrative case studies.
- Researchers from the University of South Florida created the algorithm to individualize the mapping of patients’ epilepsy networks.
- The computer program combines noninvasive EEG source localization with nonconcurrent resting state functional MRI.
- Investigators used scalp EEG and resting state fMRI to gather data on a healthy control subject, a patient with right temporal lobe epilepsy (TLE), and one with bitemporal seizure onset.
- Results from the healthy subject found symmetrical global connectivity.
- The patient with right TLE had asymmetry in global connectivity and very little connectivity ipsolaterial to the epileptogenic cortex.
- The patient who had bitemporal lobe epilepsy had symmetrical global connectivity and a network of correlating activity in the cortex that was localized in the epileptogenic tissue of both temporal lobes.
Neal EG, Maciver S, Vale FL. Multimodal, noninvasive seizure network mapping software: A novel tool for preoperative epilepsy evaluation. Epilepsy Behav. 2018; 81:25-32. https://doi.org/10.1016/j.yebeh.2018.01.033
A software algorithm has the potential to increase the likelihood of achieving freedom from seizures after epilepsy surgery suggests an analysis of 3 illustrative case studies.
- Researchers from the University of South Florida created the algorithm to individualize the mapping of patients’ epilepsy networks.
- The computer program combines noninvasive EEG source localization with nonconcurrent resting state functional MRI.
- Investigators used scalp EEG and resting state fMRI to gather data on a healthy control subject, a patient with right temporal lobe epilepsy (TLE), and one with bitemporal seizure onset.
- Results from the healthy subject found symmetrical global connectivity.
- The patient with right TLE had asymmetry in global connectivity and very little connectivity ipsolaterial to the epileptogenic cortex.
- The patient who had bitemporal lobe epilepsy had symmetrical global connectivity and a network of correlating activity in the cortex that was localized in the epileptogenic tissue of both temporal lobes.
Neal EG, Maciver S, Vale FL. Multimodal, noninvasive seizure network mapping software: A novel tool for preoperative epilepsy evaluation. Epilepsy Behav. 2018; 81:25-32. https://doi.org/10.1016/j.yebeh.2018.01.033