Expert Commentary

HOUSTON– In central Virginia, where IgE-mediated delayed allergic reactions to red meat have become the most common cause of anaphylaxis in adults, physicians have taken to looking for what they call the ‘Mossy Oak sign.’

“If a patient shows up in a blaze-orange cap and hunter’s camouflage fatigues, an allergy fellow will tell me, ‘There’s a positive Mossy Oak sign in room 2,’ and I know that probably means the patient has delayed anaphylaxis to alpha-gal,” Dr. Scott P. Commins said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Courtesy CDC

Alpha-gal is short for galactose-alpha-1,3,-galactose, an oligosaccharide present on thyroglobulin and other tissues in nonprimate mammals. It’s not normally present in humans, but when a lone star tick (Amblyomma americanum) that has fed on a nonprimate mammal bites a human, the alpha-gal is transferred, eliciting serum IgE antibodies.

Mossy Oak is a popular brand of hunter’s camouflage clothing. A positive Mossy Oak sign is useful in clinical practice because a patient who presents to a medical clinic dressed in hunting regalia is someone who spends a lot of time outdoors in the woods and fields where ticks lurk. He’s also typically someone who enjoys eating red meat. And whether it’s venison, beef, pork, lamb, goat, or bison, it contains alpha-gal. The result, in a patient who’s been primed via tick bite, can be a life-threatening anaphylactic or urticarial reaction arising 3-6 hours later, explained Dr. Commins, an allergist at the University of Virginia, Charlottesville.

He and his coinvestigators have played a central role in the still-unfolding story of this novel disease involving late-onset anaphylaxis to mammalian meat. Dr. Commins was the lead author of the paper that first described the syndrome (J. Allergy Clin. Immunol. 2009;123:426-33), as well as a subsequent paper that established the lone star tick as the culprit, making this syndrome the first known example of a response to an ectoparasite giving rise to a serious form of food allergy (J. Allergy Clin. Immunol. 2011;127:1286-93). More recently, the investigators have shown that alpha-gal-specific IgE does not cause or worsen asthma (Am. J. Respir. Crit. Care Med. 2012;185:723-30).

In a wide-ranging talk, Dr. Commins addressed the diagnosis and management of delayed anaphylaxis to red meat. He also touched upon some provocative emerging issues, including the possible risks posed by placing a porcine heart valve or bioprosthetic ligament in a patient with serum IgE antibodies to alpha-gal.

Bruce Jancin/Frontline Medical News

The investigators stumbled upon the phenomenon of tick-transmitted delayed anaphylaxis to red meat while they were trying to unravel the explanation for the markedly regional occurrence of IgE-mediated hypersensitivity reactions to the chimeric monoclonal antibody cetuximab (Erbitux) previously reported in the oncology literature (J. Clin. Oncol. 2007;25:3644-8). Dr. Commins and his colleagues realized that the same southeastern and south-central states where reactions to the initial infusion of cetuximab were concentrated were the states where the lone star tick abounds.

Incidentally, scientists at the Centers for Disease Control and Prevention follow the lone star tick closely because it is the primary vector for ehrlichiosis. CDC researchers say the tick’s range is steadily expanding and now includes 28 states, with New York’s Long Island a hot spot.

There is no public health requirement to report serum IgE-mediated delayed reactions to red meat, so the exact number of affected patients is unknown. But it’s clear that many thousands of individuals are affected, and estimates are being revised upward as the novel syndrome becomes more widely known. The disorder is common in Europe and Australia as well.

Classically, IgE-mediated anaphylactic reactions occur within 5-30 minutes after exposure to the offending agent. Thus, the 3- to 6-hour delay in symptom onset in patients with a reaction to the alpha-gal in red meat is remarkable; the explanation for the time lag remains unclear.

Dr. Commins and others have shown that individuals with serum IgE antibodies to alpha-gal also typically have serum IgE antibodies to cat, dog, beef, and pork, but not to egg, peanut, chicken, fish, or house dust mite.

Diagnosis of IgE-mediated urticarial or anaphylactic reactions to mammalian meat is made on the basis of the presence of serum IgE antibodies to alpha-gal. Dr. Commins recommended considering the diagnosis and ordering the blood test in the setting of new-onset anaphylaxis in a patient who enjoys hunting or other outdoor activities in a state where the lone star tick is found, particularly if the symptoms occur at night, hours after a big meat-heavy meal. A history of recent or persistent tick bites is an obvious clue.

“Also, it’s striking how many patients develop palmar erythema and itching during an episode. Not all report it, but when they do it’s usually a pretty good giveaway that they might have IgE to alpha-gal,” according to the allergist.

He added that it’s entirely reasonable to order a screening test for IgE to alpha-gal in patients in lone star tick–abiding states whose anaphylactic reactions seem to occur randomly without an apparent trigger.

Dr. Commins and his coinvestigators have assembled a database of roughly 500 of their patients with IgE to alpha-gal, about half of whom have a history of atopy. The investigators have found that an individual’s atopic status has no bearing on IgE antibody titer or the severity of the delayed reactions. Moreover, neither the alpha-gal IgE antibody level, the ratio of alpha-gal-specific IgE to total IgE, nor IgG antibodies correlate with reaction severity, he continued.

Based upon their study of 45 affected children, Dr. Commins and coworkers concluded that the clinical presentation and serum IgE pattern are the same as in adults (Pediatrics 2013 May [doi:10.1542/peds.2012-2585]). Since that publication, however, the investigators have realized there is a subgroup of affected teenagers who present with GI symptoms, he added.

Turning to disease management, Dr. Commins said he advocates an avoidance diet that eliminates mammalian meats, rich desserts, and super-premium ice cream.

“I also counsel patients to avoid broths, gravies, and anything that might be a mystery sauce,” he said. “You’d be surprised at how many people with alpha-gal order chicken at a Mexican restaurant thinking that they’re doing the right thing and end up reacting. I don’t know exactly why it happens, so I just say ‘avoid mystery sauces.’ Dairy and cheese are actually fairly well tolerated, although soft cheeses, like brie, can cause a reaction.”

Reactions are inconsistent, and symptoms can vary from episode to episode. Cofactors are a concern, with exercise and alcohol tending to make patients more sensitive to an alpha-gal exposure. The degree of risk posed by vaccines containing gelatin constitutes an emerging and unresolved issue.

“We’ve heard of several reactions to the shingles vaccine because of the gelatin, and the MMR vaccine is also on the radar,” Dr. Commins said.

Implantation of porcine bioprosthetic heart valves in patients with serum IgE antibodies to alpha-gal has been associated with reports of early valve failure; all bioprosthetic valves contain alpha-gal unless they’ve been decellularized. In addition, Dr. Commins is familiar with a case at another university in which three separate attempts to place a bioprosthetic ligament during repeated arthroscopic knee surgeries failed in a patient who had a “screamingly high” level of IgE to alpha-gal.

“I think this bioprosthesis issue is yet to be resolved,” he added.

One audience member, a Texas allergist, said she has a lot of trouble convincing her patients who are avid hunters to give up eating red meats. Dr. Commins said he faces the same issue.

“There is a recalcitrant group that just wants to eat a side of beef every day. I tell them if you’re not going to be on an avoidance diet, at least avoid the fattier cuts and don’t eat tremendous amounts. We believe that the antigen is possibly a glycolipid. Those cuts of meat that are high in fat are the ones patients tell us over and over again give them the worst reactions,” he said.

“The inconsistency of the allergic reactions keeps some patients from taking this disease seriously,” the allergist added. “What eventually happens for some patients is they end up having a really bad reaction. And then that convinces them.”

He monitors affected patients’ alpha-gal IgE levels over time. If and when the IgE becomes negative, he recommends a food challenge test. The patient comes in at 8 a.m., eats three pork sausage patties, and spends the day under observation at the clinic, walking the stairs periodically since exercise is a cofactor. If the challenge goes off without a hitch, the patient is free to go home at 4 or 5 p.m. In the past, that was the patient’s ticket to clearance to safely eat a big meat meal with alcohol, but Dr. Commins has pulled back of late from that recommendation.

“We believe that additional tick bites can make the allergy come back. So if someone passes a challenge in October and then the following spring gets more tick bites, you may have set them up to have a reaction because you’ve told them they can eat meat again. So the utility of a negative food challenge is unclear unless you’re pretty confident a patient is not going to have more tick bites,” he explained.

Dr. Commins reported receiving research grants from the National Institutes of Health to conduct his studies on delayed anaphylactic reactions to red meat. He serves on speakers bureaus for Genentech and Teva.

[email protected]

HOUSTON– In central Virginia, where IgE-mediated delayed allergic reactions to red meat have become the most common cause of anaphylaxis in adults, physicians have taken to looking for what they call the ‘Mossy Oak sign.’

“If a patient shows up in a blaze-orange cap and hunter’s camouflage fatigues, an allergy fellow will tell me, ‘There’s a positive Mossy Oak sign in room 2,’ and I know that probably means the patient has delayed anaphylaxis to alpha-gal,” Dr. Scott P. Commins said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Courtesy CDC

Alpha-gal is short for galactose-alpha-1,3,-galactose, an oligosaccharide present on thyroglobulin and other tissues in nonprimate mammals. It’s not normally present in humans, but when a lone star tick (Amblyomma americanum) that has fed on a nonprimate mammal bites a human, the alpha-gal is transferred, eliciting serum IgE antibodies.

Mossy Oak is a popular brand of hunter’s camouflage clothing. A positive Mossy Oak sign is useful in clinical practice because a patient who presents to a medical clinic dressed in hunting regalia is someone who spends a lot of time outdoors in the woods and fields where ticks lurk. He’s also typically someone who enjoys eating red meat. And whether it’s venison, beef, pork, lamb, goat, or bison, it contains alpha-gal. The result, in a patient who’s been primed via tick bite, can be a life-threatening anaphylactic or urticarial reaction arising 3-6 hours later, explained Dr. Commins, an allergist at the University of Virginia, Charlottesville.

He and his coinvestigators have played a central role in the still-unfolding story of this novel disease involving late-onset anaphylaxis to mammalian meat. Dr. Commins was the lead author of the paper that first described the syndrome (J. Allergy Clin. Immunol. 2009;123:426-33), as well as a subsequent paper that established the lone star tick as the culprit, making this syndrome the first known example of a response to an ectoparasite giving rise to a serious form of food allergy (J. Allergy Clin. Immunol. 2011;127:1286-93). More recently, the investigators have shown that alpha-gal-specific IgE does not cause or worsen asthma (Am. J. Respir. Crit. Care Med. 2012;185:723-30).

In a wide-ranging talk, Dr. Commins addressed the diagnosis and management of delayed anaphylaxis to red meat. He also touched upon some provocative emerging issues, including the possible risks posed by placing a porcine heart valve or bioprosthetic ligament in a patient with serum IgE antibodies to alpha-gal.

Bruce Jancin/Frontline Medical News

The investigators stumbled upon the phenomenon of tick-transmitted delayed anaphylaxis to red meat while they were trying to unravel the explanation for the markedly regional occurrence of IgE-mediated hypersensitivity reactions to the chimeric monoclonal antibody cetuximab (Erbitux) previously reported in the oncology literature (J. Clin. Oncol. 2007;25:3644-8). Dr. Commins and his colleagues realized that the same southeastern and south-central states where reactions to the initial infusion of cetuximab were concentrated were the states where the lone star tick abounds.

Incidentally, scientists at the Centers for Disease Control and Prevention follow the lone star tick closely because it is the primary vector for ehrlichiosis. CDC researchers say the tick’s range is steadily expanding and now includes 28 states, with New York’s Long Island a hot spot.

There is no public health requirement to report serum IgE-mediated delayed reactions to red meat, so the exact number of affected patients is unknown. But it’s clear that many thousands of individuals are affected, and estimates are being revised upward as the novel syndrome becomes more widely known. The disorder is common in Europe and Australia as well.

Classically, IgE-mediated anaphylactic reactions occur within 5-30 minutes after exposure to the offending agent. Thus, the 3- to 6-hour delay in symptom onset in patients with a reaction to the alpha-gal in red meat is remarkable; the explanation for the time lag remains unclear.

Dr. Commins and others have shown that individuals with serum IgE antibodies to alpha-gal also typically have serum IgE antibodies to cat, dog, beef, and pork, but not to egg, peanut, chicken, fish, or house dust mite.

Diagnosis of IgE-mediated urticarial or anaphylactic reactions to mammalian meat is made on the basis of the presence of serum IgE antibodies to alpha-gal. Dr. Commins recommended considering the diagnosis and ordering the blood test in the setting of new-onset anaphylaxis in a patient who enjoys hunting or other outdoor activities in a state where the lone star tick is found, particularly if the symptoms occur at night, hours after a big meat-heavy meal. A history of recent or persistent tick bites is an obvious clue.

“Also, it’s striking how many patients develop palmar erythema and itching during an episode. Not all report it, but when they do it’s usually a pretty good giveaway that they might have IgE to alpha-gal,” according to the allergist.

He added that it’s entirely reasonable to order a screening test for IgE to alpha-gal in patients in lone star tick–abiding states whose anaphylactic reactions seem to occur randomly without an apparent trigger.

Dr. Commins and his coinvestigators have assembled a database of roughly 500 of their patients with IgE to alpha-gal, about half of whom have a history of atopy. The investigators have found that an individual’s atopic status has no bearing on IgE antibody titer or the severity of the delayed reactions. Moreover, neither the alpha-gal IgE antibody level, the ratio of alpha-gal-specific IgE to total IgE, nor IgG antibodies correlate with reaction severity, he continued.

Based upon their study of 45 affected children, Dr. Commins and coworkers concluded that the clinical presentation and serum IgE pattern are the same as in adults (Pediatrics 2013 May [doi:10.1542/peds.2012-2585]). Since that publication, however, the investigators have realized there is a subgroup of affected teenagers who present with GI symptoms, he added.

Turning to disease management, Dr. Commins said he advocates an avoidance diet that eliminates mammalian meats, rich desserts, and super-premium ice cream.

“I also counsel patients to avoid broths, gravies, and anything that might be a mystery sauce,” he said. “You’d be surprised at how many people with alpha-gal order chicken at a Mexican restaurant thinking that they’re doing the right thing and end up reacting. I don’t know exactly why it happens, so I just say ‘avoid mystery sauces.’ Dairy and cheese are actually fairly well tolerated, although soft cheeses, like brie, can cause a reaction.”

Reactions are inconsistent, and symptoms can vary from episode to episode. Cofactors are a concern, with exercise and alcohol tending to make patients more sensitive to an alpha-gal exposure. The degree of risk posed by vaccines containing gelatin constitutes an emerging and unresolved issue.

“We’ve heard of several reactions to the shingles vaccine because of the gelatin, and the MMR vaccine is also on the radar,” Dr. Commins said.

Implantation of porcine bioprosthetic heart valves in patients with serum IgE antibodies to alpha-gal has been associated with reports of early valve failure; all bioprosthetic valves contain alpha-gal unless they’ve been decellularized. In addition, Dr. Commins is familiar with a case at another university in which three separate attempts to place a bioprosthetic ligament during repeated arthroscopic knee surgeries failed in a patient who had a “screamingly high” level of IgE to alpha-gal.

“I think this bioprosthesis issue is yet to be resolved,” he added.

One audience member, a Texas allergist, said she has a lot of trouble convincing her patients who are avid hunters to give up eating red meats. Dr. Commins said he faces the same issue.

“There is a recalcitrant group that just wants to eat a side of beef every day. I tell them if you’re not going to be on an avoidance diet, at least avoid the fattier cuts and don’t eat tremendous amounts. We believe that the antigen is possibly a glycolipid. Those cuts of meat that are high in fat are the ones patients tell us over and over again give them the worst reactions,” he said.

“The inconsistency of the allergic reactions keeps some patients from taking this disease seriously,” the allergist added. “What eventually happens for some patients is they end up having a really bad reaction. And then that convinces them.”

He monitors affected patients’ alpha-gal IgE levels over time. If and when the IgE becomes negative, he recommends a food challenge test. The patient comes in at 8 a.m., eats three pork sausage patties, and spends the day under observation at the clinic, walking the stairs periodically since exercise is a cofactor. If the challenge goes off without a hitch, the patient is free to go home at 4 or 5 p.m. In the past, that was the patient’s ticket to clearance to safely eat a big meat meal with alcohol, but Dr. Commins has pulled back of late from that recommendation.

“We believe that additional tick bites can make the allergy come back. So if someone passes a challenge in October and then the following spring gets more tick bites, you may have set them up to have a reaction because you’ve told them they can eat meat again. So the utility of a negative food challenge is unclear unless you’re pretty confident a patient is not going to have more tick bites,” he explained.

Dr. Commins reported receiving research grants from the National Institutes of Health to conduct his studies on delayed anaphylactic reactions to red meat. He serves on speakers bureaus for Genentech and Teva.

[email protected]

HOUSTON– In central Virginia, where IgE-mediated delayed allergic reactions to red meat have become the most common cause of anaphylaxis in adults, physicians have taken to looking for what they call the ‘Mossy Oak sign.’

“If a patient shows up in a blaze-orange cap and hunter’s camouflage fatigues, an allergy fellow will tell me, ‘There’s a positive Mossy Oak sign in room 2,’ and I know that probably means the patient has delayed anaphylaxis to alpha-gal,” Dr. Scott P. Commins said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Courtesy CDC

Alpha-gal is short for galactose-alpha-1,3,-galactose, an oligosaccharide present on thyroglobulin and other tissues in nonprimate mammals. It’s not normally present in humans, but when a lone star tick (Amblyomma americanum) that has fed on a nonprimate mammal bites a human, the alpha-gal is transferred, eliciting serum IgE antibodies.

Mossy Oak is a popular brand of hunter’s camouflage clothing. A positive Mossy Oak sign is useful in clinical practice because a patient who presents to a medical clinic dressed in hunting regalia is someone who spends a lot of time outdoors in the woods and fields where ticks lurk. He’s also typically someone who enjoys eating red meat. And whether it’s venison, beef, pork, lamb, goat, or bison, it contains alpha-gal. The result, in a patient who’s been primed via tick bite, can be a life-threatening anaphylactic or urticarial reaction arising 3-6 hours later, explained Dr. Commins, an allergist at the University of Virginia, Charlottesville.

He and his coinvestigators have played a central role in the still-unfolding story of this novel disease involving late-onset anaphylaxis to mammalian meat. Dr. Commins was the lead author of the paper that first described the syndrome (J. Allergy Clin. Immunol. 2009;123:426-33), as well as a subsequent paper that established the lone star tick as the culprit, making this syndrome the first known example of a response to an ectoparasite giving rise to a serious form of food allergy (J. Allergy Clin. Immunol. 2011;127:1286-93). More recently, the investigators have shown that alpha-gal-specific IgE does not cause or worsen asthma (Am. J. Respir. Crit. Care Med. 2012;185:723-30).

In a wide-ranging talk, Dr. Commins addressed the diagnosis and management of delayed anaphylaxis to red meat. He also touched upon some provocative emerging issues, including the possible risks posed by placing a porcine heart valve or bioprosthetic ligament in a patient with serum IgE antibodies to alpha-gal.

Bruce Jancin/Frontline Medical News

The investigators stumbled upon the phenomenon of tick-transmitted delayed anaphylaxis to red meat while they were trying to unravel the explanation for the markedly regional occurrence of IgE-mediated hypersensitivity reactions to the chimeric monoclonal antibody cetuximab (Erbitux) previously reported in the oncology literature (J. Clin. Oncol. 2007;25:3644-8). Dr. Commins and his colleagues realized that the same southeastern and south-central states where reactions to the initial infusion of cetuximab were concentrated were the states where the lone star tick abounds.

Incidentally, scientists at the Centers for Disease Control and Prevention follow the lone star tick closely because it is the primary vector for ehrlichiosis. CDC researchers say the tick’s range is steadily expanding and now includes 28 states, with New York’s Long Island a hot spot.

There is no public health requirement to report serum IgE-mediated delayed reactions to red meat, so the exact number of affected patients is unknown. But it’s clear that many thousands of individuals are affected, and estimates are being revised upward as the novel syndrome becomes more widely known. The disorder is common in Europe and Australia as well.

Classically, IgE-mediated anaphylactic reactions occur within 5-30 minutes after exposure to the offending agent. Thus, the 3- to 6-hour delay in symptom onset in patients with a reaction to the alpha-gal in red meat is remarkable; the explanation for the time lag remains unclear.

Dr. Commins and others have shown that individuals with serum IgE antibodies to alpha-gal also typically have serum IgE antibodies to cat, dog, beef, and pork, but not to egg, peanut, chicken, fish, or house dust mite.

Diagnosis of IgE-mediated urticarial or anaphylactic reactions to mammalian meat is made on the basis of the presence of serum IgE antibodies to alpha-gal. Dr. Commins recommended considering the diagnosis and ordering the blood test in the setting of new-onset anaphylaxis in a patient who enjoys hunting or other outdoor activities in a state where the lone star tick is found, particularly if the symptoms occur at night, hours after a big meat-heavy meal. A history of recent or persistent tick bites is an obvious clue.

“Also, it’s striking how many patients develop palmar erythema and itching during an episode. Not all report it, but when they do it’s usually a pretty good giveaway that they might have IgE to alpha-gal,” according to the allergist.

He added that it’s entirely reasonable to order a screening test for IgE to alpha-gal in patients in lone star tick–abiding states whose anaphylactic reactions seem to occur randomly without an apparent trigger.

Dr. Commins and his coinvestigators have assembled a database of roughly 500 of their patients with IgE to alpha-gal, about half of whom have a history of atopy. The investigators have found that an individual’s atopic status has no bearing on IgE antibody titer or the severity of the delayed reactions. Moreover, neither the alpha-gal IgE antibody level, the ratio of alpha-gal-specific IgE to total IgE, nor IgG antibodies correlate with reaction severity, he continued.

Based upon their study of 45 affected children, Dr. Commins and coworkers concluded that the clinical presentation and serum IgE pattern are the same as in adults (Pediatrics 2013 May [doi:10.1542/peds.2012-2585]). Since that publication, however, the investigators have realized there is a subgroup of affected teenagers who present with GI symptoms, he added.

Turning to disease management, Dr. Commins said he advocates an avoidance diet that eliminates mammalian meats, rich desserts, and super-premium ice cream.

“I also counsel patients to avoid broths, gravies, and anything that might be a mystery sauce,” he said. “You’d be surprised at how many people with alpha-gal order chicken at a Mexican restaurant thinking that they’re doing the right thing and end up reacting. I don’t know exactly why it happens, so I just say ‘avoid mystery sauces.’ Dairy and cheese are actually fairly well tolerated, although soft cheeses, like brie, can cause a reaction.”

Reactions are inconsistent, and symptoms can vary from episode to episode. Cofactors are a concern, with exercise and alcohol tending to make patients more sensitive to an alpha-gal exposure. The degree of risk posed by vaccines containing gelatin constitutes an emerging and unresolved issue.

“We’ve heard of several reactions to the shingles vaccine because of the gelatin, and the MMR vaccine is also on the radar,” Dr. Commins said.

Implantation of porcine bioprosthetic heart valves in patients with serum IgE antibodies to alpha-gal has been associated with reports of early valve failure; all bioprosthetic valves contain alpha-gal unless they’ve been decellularized. In addition, Dr. Commins is familiar with a case at another university in which three separate attempts to place a bioprosthetic ligament during repeated arthroscopic knee surgeries failed in a patient who had a “screamingly high” level of IgE to alpha-gal.

“I think this bioprosthesis issue is yet to be resolved,” he added.

One audience member, a Texas allergist, said she has a lot of trouble convincing her patients who are avid hunters to give up eating red meats. Dr. Commins said he faces the same issue.

“There is a recalcitrant group that just wants to eat a side of beef every day. I tell them if you’re not going to be on an avoidance diet, at least avoid the fattier cuts and don’t eat tremendous amounts. We believe that the antigen is possibly a glycolipid. Those cuts of meat that are high in fat are the ones patients tell us over and over again give them the worst reactions,” he said.

“The inconsistency of the allergic reactions keeps some patients from taking this disease seriously,” the allergist added. “What eventually happens for some patients is they end up having a really bad reaction. And then that convinces them.”

He monitors affected patients’ alpha-gal IgE levels over time. If and when the IgE becomes negative, he recommends a food challenge test. The patient comes in at 8 a.m., eats three pork sausage patties, and spends the day under observation at the clinic, walking the stairs periodically since exercise is a cofactor. If the challenge goes off without a hitch, the patient is free to go home at 4 or 5 p.m. In the past, that was the patient’s ticket to clearance to safely eat a big meat meal with alcohol, but Dr. Commins has pulled back of late from that recommendation.

“We believe that additional tick bites can make the allergy come back. So if someone passes a challenge in October and then the following spring gets more tick bites, you may have set them up to have a reaction because you’ve told them they can eat meat again. So the utility of a negative food challenge is unclear unless you’re pretty confident a patient is not going to have more tick bites,” he explained.

Dr. Commins reported receiving research grants from the National Institutes of Health to conduct his studies on delayed anaphylactic reactions to red meat. He serves on speakers bureaus for Genentech and Teva.

[email protected]

The Fairfax Family Practice Comprehensive Concussion Center is an example of what dedicated physicians can accomplish when they undertake to improve upon an accepted medical approach to a health problem because it falls far short of effective. The concussion center’s hall wall is adorned with a broad and colorful sign autographed by scores of patients – many of them student-athletes – who have been cleared to return to their sports and activities and to lives free of restrictions and struggle following concussion.

Dr. Garry W.K. Ho, the double-credentialed family practice and sports medicine physician who directs the 2-year-old concussion center in Fairfax, Va., takes pride in the skills his team has acquired to facilitate these recoveries.

He and his colleagues within the practice’s sports medicine division established the center, teaming up with several certified athletic trainers, to meet what they saw as a growing, urgent need: to help concussed patients who were taking longer than the oft-mentioned 7-10 days or 2 weeks to heal.

Christine Kilgore/Frontline Medical Media

“While many of the people we’d been treating in the clinic with typical 15- to 30-minute appointments and relatively simple follow-up were able to get better, there was clearly a subset of the population that was more complicated and needed a more dedicated, multidimensional approach,” Dr. Ho said.

Findings from a growing number of studies have shown that concussions can involve a vast array of deficits – problems with the vestibular and vision systems, for example – and that a more comprehensive initial evaluation and a multipronged approach to management could shorten recovery time for any individual with the brain injury, he said.

“We’d started to realize how much patients can benefit from new and creative approaches,” said Dr. Ho. “We were also appreciating that no one person can own this disorder. You can’t say that only the neurologist can treat a concussion, or only the family physician or sports medicine physician.

‘Silent epidemic’

A small but growing number of concussion-care programs and clinics are being established across the country. Most often, the programs are incorporated into hospitals and sports medicine clinics. But some, like the program Dr. Ho leads, are embedded within larger primary care practices with a sports medicine component.

And, in other traditional family practices, some physicians are deepening their knowledge of concussions and building the networks necessary for managing prolonged impairment.

“If we have a good understanding of brain injury, we can often facilitate recovery and help [our patients] get back on track seamlessly,” said Dr. Rebecca Jaffe, a family physician in Wilmington, Del. “And when recovery is protracted, when issues don’t resolve in 2-3 weeks, there’s often more to the situation than is initially apparent, and it’s often better that we have a team of individuals who can help us.”

According to the Institute of Medicine (IOM), there are not enough data for an accurate estimate of the incidence of sports-related concussions in youth (Institute of Medicine and National Research Council. 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, D.C.: The National Academies Press.)

But among high school athletes, an increase in concussions has been documented in several emergency department studies and other longitudinal studies published over the past 7-8 years. Most recently, the first national study to look at trends among high school athletes showed the numbers of concussions reported by certified athletic trainers increasing from 0.23/1,000 athlete-exposures in the 2005-2006 academic year to 0.51/1,000 in the 2011-2012 academic year (Am. J. Sports Med. 2014;42:1710-5).

Experts attribute such increases largely to improved awareness and new state laws. The Centers for Disease Control and Prevention’s launched its “Heads Up” educational program in 2004, for instance. And as of last year, every state and the District of Columbia had enacted at least one law to protect young athletes with concussions.

State concussion laws vary, but most require that parents, athletes, and coaches be educated about concussions, and that athletes with suspected concussions be evaluated and cleared by a health care professional with knowledge in concussions before returning to play.

It is likely, some experts say, that the upward curve is leveling off with improved awareness and diagnosis. But with such improvements there lurks a void of data on concussions in youth outside the realm of high school sports. And, according to the 2014 IOM report, the acute and long-term health threat from concussions is “not fully appreciated or acted upon” in many settings. “Kids are getting removed from play more frequently, but then it’s not really clear what anyone should do after that,” said Dr. Shireen Atabaki, an emergency medicine specialist at Children’s National Medical Center in Washington, who is leading several national initiatives to improve concussion care.

Too often, concussed children and teens receive little besides unnecessary CT scans in emergency departments and concussions go undiagnosed. And when concussions are diagnosed, discharge instructions are poor and “kids are sent out into a no-man’s land” where recovery is often poorly managed, she said.

When Dr. Ho and his colleagues opened their concussion center in March 2013, they began seeing patients who remained symptomatic after concussions that had occurred 6-12 months ago, and longer. “It was almost like a silent epidemic,” he said. “We had one young woman who’d been injured in her senior year of high school and was still symptomatic after 2 years.”

To build the program at Fairfax Family Practice, Dr. Ho and his colleagues, Dr. Thomas Howard and Dr. Marc Childress (who, like Dr. Ho, are board certified in sports medicine as well as family medicine), capitalized on what they saw as a valuable synergy with high school athletic trainers.

Dr. Ho had worked closely with athletic trainers as a volunteer medical adviser to the Fairfax County Public School System’s athletic training program, which provides care to student-athletes in 25 high schools. He drew on his relationships to recruit three athletic trainers who were at transition points in their careers and who had both experience and “passion” in the treatment of concussions.

One of them, Jon Almquist, VATL, ATC, had led the development of return-to-learn protocols and other management practices for the high schools. He had also partnered with investigators at MedStar Health Research Institute in Baltimore on research that documented a 4.2-fold increase in concussions among the school system’s high school athletes between 1997 and 2008 (Am. J. Sports Med. 2011;39:958-63).

More surprising than this increase, however, were some data collected after the study period ended. When Mr. Almquist looked at recovery times for the concussions reported between 2011 and 2013, he found that about 25% of concussions took 30 days or longer to recover – a portion greater than he’d seen anywhere in the literature.

According to the 2014 IOM report, youth athletes typically recover from a concussion within 2 weeks of the injury, but in 10-20% of cases the symptoms persist for a number of weeks, months, or even years.

“Families would come to us for advice,” Mr. Almquist recalled. Other than referring them to the University of Pittsburgh Medical Center’s (UPMC) Sports Medicine Concussion Program, there were few local providers whom they believed offered comprehensive care and had experience with prolonged impairment.

Mr. Almquist and his fellow athletic trainers, and Dr. Ho and his physician colleagues, all had been following developments at UPMC’s Sports Medicine Concussion Program since it was established in 2000. The program had evolved to assess and manage diverse facets of concussions, including vision, vestibular, exertion, and medication components—not all of which are fully addressed in clinical practice guidelines and position statements. By 2010, the program was drawing 10,000 patients a year.

Care at UPMC is guided by a clinical neuropsychologist who assesses head injuries and then refers patients on as needed to other members of the team – like a neurovestibular expert for vestibular assessment and therapy, a neuro-optometrist for vision therapy, a physical therapist for exertion training, or a sports medicine physician for medication.

In planning their own concussion center, Dr. Ho and his team visited various programs in the country but homed in on UPMC. They decided to mimic several aspects of UPMC’s approach by providing comprehensive and individualized care, and by having the certified athletic trainers serve as the “quarterbacks.”

“The athletic trainer in our center does all the symptom inventories and history taking, a concussion-focused physical exam, vestibular-ocular-motor screening, and neurocognitive tests if appropriate,” said Dr. Ho.

Dr. Ho or one of his sports medicine physician colleagues then discusses results with the athletic trainer and completes the patient visit – with the trainer – by asking any necessary follow-up questions, probing further with additional evaluation, and writing medication prescriptions when appropriate.

Throughout the course of care – visits occur weekly to monthly and often last 30-90 minutes – the athletic trainer and physician work together on clinical issues such as sleep and mental health and on subtyping headaches (cognitive fatigue, cervicogenic, or migrainelike) and “determining where the headaches lie relative to other areas of dysfunction,” said Dr. Ho.

Much of the individualized counseling, monitoring, and coordination that’s required to address sleep hygiene, rest, nutrition, and graded return to physical and cognitive activity can be led by the athletic trainer, he said.

For the first year or so, patients were referred out for such special services as vision or vestibular therapy. But there were problems with this approach: One frequent issue was poor insurance coverage for these therapies. Another was the stress involved in getting to additional appointments on Fairfax’s congested roads. “Traffic and busy environments aren’t always tolerable for a concussed patient,” Dr. Ho said.

Dr. Ho searched the Internet, worked the phone, read the neuro-optometry and vestibular therapy literature, and attended conferences to learn what kinds of therapeutic exercises they could integrate into office visits and take-home care plans. Dr. Ho said he was “surprised at how willing some of [their] colleagues were to give us some basic skills” to help patients who “don’t all need the Cadillac version” of therapy.

About the same time they integrated basic vision and vestibular therapy, they also revamped their billing strategy, moving away from the use of prolonged service billing codes, which Dr. Ho said were frequently denied on the first submission, to using separate codes for the encounter, therapeutic exercise (which encompasses vision therapy and vestibular therapy), and various physical tests.

Concussion care networks

Fairfax Family Practice is not the only practice to center its concussion program on physician-athletic trainer partnerships. Carolina Family Practice and Sports Medicine, a 12-provider practice with three offices in and around Raleigh, N.C., took a similar approach when it established its concussion clinic in 2008.

“Concussion is the ultimate example of an injury that benefits from a team approach,” said Dr. Josh Bloom, medical director of the Carolina Sports Concussion Clinic that is embedded into the practice. “And it’s the one injury – the only injury in sports medicine – where the standard of care calls for the injury to be 100% resolved prior to being cleared to return to play.”

Dr. Jaffe, the family physician in Delaware, said she is fortunate to have a neuro-optometrist practicing in the medical building where her three-physician family practice resides, and a concussion care team in the nearby Nemours/Alfred I. Dupont Hospital for Children, also in Wilmington.

Someday, she and others hope, physicians who see patients soon after injury will have tools to better predict clinical trajectories and identify who could benefit from earlier referral to a “more sophisticated team.”

For now, Dr. Jaffe said, she seeks assistance when headache and initial symptoms persist after 2-3 weeks or when their symptoms “seem out of proportion to the incident.”

Dr. Scott Ross of Novant Health Bull Run Family Medicine based in Manassas, Va., said that family physicians are well suited to guide management and should learn to evaluate each patient’s concussion-related impairments as thoroughly as possible.

About 3 years ago, he and a partner established an official “Sports Medicine and Concussion Management” service line in their practice. “We don’t have a concussion center all under one roof, but we have the knowledge, skills, and resources that we need,” he said.

This article was updated April 13, 2015.

The Fairfax Family Practice Comprehensive Concussion Center is an example of what dedicated physicians can accomplish when they undertake to improve upon an accepted medical approach to a health problem because it falls far short of effective. The concussion center’s hall wall is adorned with a broad and colorful sign autographed by scores of patients – many of them student-athletes – who have been cleared to return to their sports and activities and to lives free of restrictions and struggle following concussion.

Dr. Garry W.K. Ho, the double-credentialed family practice and sports medicine physician who directs the 2-year-old concussion center in Fairfax, Va., takes pride in the skills his team has acquired to facilitate these recoveries.

He and his colleagues within the practice’s sports medicine division established the center, teaming up with several certified athletic trainers, to meet what they saw as a growing, urgent need: to help concussed patients who were taking longer than the oft-mentioned 7-10 days or 2 weeks to heal.

Christine Kilgore/Frontline Medical Media

“While many of the people we’d been treating in the clinic with typical 15- to 30-minute appointments and relatively simple follow-up were able to get better, there was clearly a subset of the population that was more complicated and needed a more dedicated, multidimensional approach,” Dr. Ho said.

Findings from a growing number of studies have shown that concussions can involve a vast array of deficits – problems with the vestibular and vision systems, for example – and that a more comprehensive initial evaluation and a multipronged approach to management could shorten recovery time for any individual with the brain injury, he said.

“We’d started to realize how much patients can benefit from new and creative approaches,” said Dr. Ho. “We were also appreciating that no one person can own this disorder. You can’t say that only the neurologist can treat a concussion, or only the family physician or sports medicine physician.

‘Silent epidemic’

A small but growing number of concussion-care programs and clinics are being established across the country. Most often, the programs are incorporated into hospitals and sports medicine clinics. But some, like the program Dr. Ho leads, are embedded within larger primary care practices with a sports medicine component.

And, in other traditional family practices, some physicians are deepening their knowledge of concussions and building the networks necessary for managing prolonged impairment.

“If we have a good understanding of brain injury, we can often facilitate recovery and help [our patients] get back on track seamlessly,” said Dr. Rebecca Jaffe, a family physician in Wilmington, Del. “And when recovery is protracted, when issues don’t resolve in 2-3 weeks, there’s often more to the situation than is initially apparent, and it’s often better that we have a team of individuals who can help us.”

According to the Institute of Medicine (IOM), there are not enough data for an accurate estimate of the incidence of sports-related concussions in youth (Institute of Medicine and National Research Council. 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, D.C.: The National Academies Press.)

But among high school athletes, an increase in concussions has been documented in several emergency department studies and other longitudinal studies published over the past 7-8 years. Most recently, the first national study to look at trends among high school athletes showed the numbers of concussions reported by certified athletic trainers increasing from 0.23/1,000 athlete-exposures in the 2005-2006 academic year to 0.51/1,000 in the 2011-2012 academic year (Am. J. Sports Med. 2014;42:1710-5).

Experts attribute such increases largely to improved awareness and new state laws. The Centers for Disease Control and Prevention’s launched its “Heads Up” educational program in 2004, for instance. And as of last year, every state and the District of Columbia had enacted at least one law to protect young athletes with concussions.

State concussion laws vary, but most require that parents, athletes, and coaches be educated about concussions, and that athletes with suspected concussions be evaluated and cleared by a health care professional with knowledge in concussions before returning to play.

It is likely, some experts say, that the upward curve is leveling off with improved awareness and diagnosis. But with such improvements there lurks a void of data on concussions in youth outside the realm of high school sports. And, according to the 2014 IOM report, the acute and long-term health threat from concussions is “not fully appreciated or acted upon” in many settings. “Kids are getting removed from play more frequently, but then it’s not really clear what anyone should do after that,” said Dr. Shireen Atabaki, an emergency medicine specialist at Children’s National Medical Center in Washington, who is leading several national initiatives to improve concussion care.

Too often, concussed children and teens receive little besides unnecessary CT scans in emergency departments and concussions go undiagnosed. And when concussions are diagnosed, discharge instructions are poor and “kids are sent out into a no-man’s land” where recovery is often poorly managed, she said.

When Dr. Ho and his colleagues opened their concussion center in March 2013, they began seeing patients who remained symptomatic after concussions that had occurred 6-12 months ago, and longer. “It was almost like a silent epidemic,” he said. “We had one young woman who’d been injured in her senior year of high school and was still symptomatic after 2 years.”

To build the program at Fairfax Family Practice, Dr. Ho and his colleagues, Dr. Thomas Howard and Dr. Marc Childress (who, like Dr. Ho, are board certified in sports medicine as well as family medicine), capitalized on what they saw as a valuable synergy with high school athletic trainers.

Dr. Ho had worked closely with athletic trainers as a volunteer medical adviser to the Fairfax County Public School System’s athletic training program, which provides care to student-athletes in 25 high schools. He drew on his relationships to recruit three athletic trainers who were at transition points in their careers and who had both experience and “passion” in the treatment of concussions.

One of them, Jon Almquist, VATL, ATC, had led the development of return-to-learn protocols and other management practices for the high schools. He had also partnered with investigators at MedStar Health Research Institute in Baltimore on research that documented a 4.2-fold increase in concussions among the school system’s high school athletes between 1997 and 2008 (Am. J. Sports Med. 2011;39:958-63).

More surprising than this increase, however, were some data collected after the study period ended. When Mr. Almquist looked at recovery times for the concussions reported between 2011 and 2013, he found that about 25% of concussions took 30 days or longer to recover – a portion greater than he’d seen anywhere in the literature.

According to the 2014 IOM report, youth athletes typically recover from a concussion within 2 weeks of the injury, but in 10-20% of cases the symptoms persist for a number of weeks, months, or even years.

“Families would come to us for advice,” Mr. Almquist recalled. Other than referring them to the University of Pittsburgh Medical Center’s (UPMC) Sports Medicine Concussion Program, there were few local providers whom they believed offered comprehensive care and had experience with prolonged impairment.

Mr. Almquist and his fellow athletic trainers, and Dr. Ho and his physician colleagues, all had been following developments at UPMC’s Sports Medicine Concussion Program since it was established in 2000. The program had evolved to assess and manage diverse facets of concussions, including vision, vestibular, exertion, and medication components—not all of which are fully addressed in clinical practice guidelines and position statements. By 2010, the program was drawing 10,000 patients a year.

Care at UPMC is guided by a clinical neuropsychologist who assesses head injuries and then refers patients on as needed to other members of the team – like a neurovestibular expert for vestibular assessment and therapy, a neuro-optometrist for vision therapy, a physical therapist for exertion training, or a sports medicine physician for medication.

In planning their own concussion center, Dr. Ho and his team visited various programs in the country but homed in on UPMC. They decided to mimic several aspects of UPMC’s approach by providing comprehensive and individualized care, and by having the certified athletic trainers serve as the “quarterbacks.”

“The athletic trainer in our center does all the symptom inventories and history taking, a concussion-focused physical exam, vestibular-ocular-motor screening, and neurocognitive tests if appropriate,” said Dr. Ho.

Dr. Ho or one of his sports medicine physician colleagues then discusses results with the athletic trainer and completes the patient visit – with the trainer – by asking any necessary follow-up questions, probing further with additional evaluation, and writing medication prescriptions when appropriate.

Throughout the course of care – visits occur weekly to monthly and often last 30-90 minutes – the athletic trainer and physician work together on clinical issues such as sleep and mental health and on subtyping headaches (cognitive fatigue, cervicogenic, or migrainelike) and “determining where the headaches lie relative to other areas of dysfunction,” said Dr. Ho.

Much of the individualized counseling, monitoring, and coordination that’s required to address sleep hygiene, rest, nutrition, and graded return to physical and cognitive activity can be led by the athletic trainer, he said.

For the first year or so, patients were referred out for such special services as vision or vestibular therapy. But there were problems with this approach: One frequent issue was poor insurance coverage for these therapies. Another was the stress involved in getting to additional appointments on Fairfax’s congested roads. “Traffic and busy environments aren’t always tolerable for a concussed patient,” Dr. Ho said.

Dr. Ho searched the Internet, worked the phone, read the neuro-optometry and vestibular therapy literature, and attended conferences to learn what kinds of therapeutic exercises they could integrate into office visits and take-home care plans. Dr. Ho said he was “surprised at how willing some of [their] colleagues were to give us some basic skills” to help patients who “don’t all need the Cadillac version” of therapy.

About the same time they integrated basic vision and vestibular therapy, they also revamped their billing strategy, moving away from the use of prolonged service billing codes, which Dr. Ho said were frequently denied on the first submission, to using separate codes for the encounter, therapeutic exercise (which encompasses vision therapy and vestibular therapy), and various physical tests.

Concussion care networks

Fairfax Family Practice is not the only practice to center its concussion program on physician-athletic trainer partnerships. Carolina Family Practice and Sports Medicine, a 12-provider practice with three offices in and around Raleigh, N.C., took a similar approach when it established its concussion clinic in 2008.

“Concussion is the ultimate example of an injury that benefits from a team approach,” said Dr. Josh Bloom, medical director of the Carolina Sports Concussion Clinic that is embedded into the practice. “And it’s the one injury – the only injury in sports medicine – where the standard of care calls for the injury to be 100% resolved prior to being cleared to return to play.”

Dr. Jaffe, the family physician in Delaware, said she is fortunate to have a neuro-optometrist practicing in the medical building where her three-physician family practice resides, and a concussion care team in the nearby Nemours/Alfred I. Dupont Hospital for Children, also in Wilmington.

Someday, she and others hope, physicians who see patients soon after injury will have tools to better predict clinical trajectories and identify who could benefit from earlier referral to a “more sophisticated team.”

For now, Dr. Jaffe said, she seeks assistance when headache and initial symptoms persist after 2-3 weeks or when their symptoms “seem out of proportion to the incident.”

Dr. Scott Ross of Novant Health Bull Run Family Medicine based in Manassas, Va., said that family physicians are well suited to guide management and should learn to evaluate each patient’s concussion-related impairments as thoroughly as possible.

About 3 years ago, he and a partner established an official “Sports Medicine and Concussion Management” service line in their practice. “We don’t have a concussion center all under one roof, but we have the knowledge, skills, and resources that we need,” he said.

This article was updated April 13, 2015.

The Fairfax Family Practice Comprehensive Concussion Center is an example of what dedicated physicians can accomplish when they undertake to improve upon an accepted medical approach to a health problem because it falls far short of effective. The concussion center’s hall wall is adorned with a broad and colorful sign autographed by scores of patients – many of them student-athletes – who have been cleared to return to their sports and activities and to lives free of restrictions and struggle following concussion.

Dr. Garry W.K. Ho, the double-credentialed family practice and sports medicine physician who directs the 2-year-old concussion center in Fairfax, Va., takes pride in the skills his team has acquired to facilitate these recoveries.

He and his colleagues within the practice’s sports medicine division established the center, teaming up with several certified athletic trainers, to meet what they saw as a growing, urgent need: to help concussed patients who were taking longer than the oft-mentioned 7-10 days or 2 weeks to heal.

Christine Kilgore/Frontline Medical Media

“While many of the people we’d been treating in the clinic with typical 15- to 30-minute appointments and relatively simple follow-up were able to get better, there was clearly a subset of the population that was more complicated and needed a more dedicated, multidimensional approach,” Dr. Ho said.

Findings from a growing number of studies have shown that concussions can involve a vast array of deficits – problems with the vestibular and vision systems, for example – and that a more comprehensive initial evaluation and a multipronged approach to management could shorten recovery time for any individual with the brain injury, he said.

“We’d started to realize how much patients can benefit from new and creative approaches,” said Dr. Ho. “We were also appreciating that no one person can own this disorder. You can’t say that only the neurologist can treat a concussion, or only the family physician or sports medicine physician.

‘Silent epidemic’

A small but growing number of concussion-care programs and clinics are being established across the country. Most often, the programs are incorporated into hospitals and sports medicine clinics. But some, like the program Dr. Ho leads, are embedded within larger primary care practices with a sports medicine component.

And, in other traditional family practices, some physicians are deepening their knowledge of concussions and building the networks necessary for managing prolonged impairment.

“If we have a good understanding of brain injury, we can often facilitate recovery and help [our patients] get back on track seamlessly,” said Dr. Rebecca Jaffe, a family physician in Wilmington, Del. “And when recovery is protracted, when issues don’t resolve in 2-3 weeks, there’s often more to the situation than is initially apparent, and it’s often better that we have a team of individuals who can help us.”

According to the Institute of Medicine (IOM), there are not enough data for an accurate estimate of the incidence of sports-related concussions in youth (Institute of Medicine and National Research Council. 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, D.C.: The National Academies Press.)

But among high school athletes, an increase in concussions has been documented in several emergency department studies and other longitudinal studies published over the past 7-8 years. Most recently, the first national study to look at trends among high school athletes showed the numbers of concussions reported by certified athletic trainers increasing from 0.23/1,000 athlete-exposures in the 2005-2006 academic year to 0.51/1,000 in the 2011-2012 academic year (Am. J. Sports Med. 2014;42:1710-5).

Experts attribute such increases largely to improved awareness and new state laws. The Centers for Disease Control and Prevention’s launched its “Heads Up” educational program in 2004, for instance. And as of last year, every state and the District of Columbia had enacted at least one law to protect young athletes with concussions.

State concussion laws vary, but most require that parents, athletes, and coaches be educated about concussions, and that athletes with suspected concussions be evaluated and cleared by a health care professional with knowledge in concussions before returning to play.

It is likely, some experts say, that the upward curve is leveling off with improved awareness and diagnosis. But with such improvements there lurks a void of data on concussions in youth outside the realm of high school sports. And, according to the 2014 IOM report, the acute and long-term health threat from concussions is “not fully appreciated or acted upon” in many settings. “Kids are getting removed from play more frequently, but then it’s not really clear what anyone should do after that,” said Dr. Shireen Atabaki, an emergency medicine specialist at Children’s National Medical Center in Washington, who is leading several national initiatives to improve concussion care.

Too often, concussed children and teens receive little besides unnecessary CT scans in emergency departments and concussions go undiagnosed. And when concussions are diagnosed, discharge instructions are poor and “kids are sent out into a no-man’s land” where recovery is often poorly managed, she said.

When Dr. Ho and his colleagues opened their concussion center in March 2013, they began seeing patients who remained symptomatic after concussions that had occurred 6-12 months ago, and longer. “It was almost like a silent epidemic,” he said. “We had one young woman who’d been injured in her senior year of high school and was still symptomatic after 2 years.”

To build the program at Fairfax Family Practice, Dr. Ho and his colleagues, Dr. Thomas Howard and Dr. Marc Childress (who, like Dr. Ho, are board certified in sports medicine as well as family medicine), capitalized on what they saw as a valuable synergy with high school athletic trainers.

Dr. Ho had worked closely with athletic trainers as a volunteer medical adviser to the Fairfax County Public School System’s athletic training program, which provides care to student-athletes in 25 high schools. He drew on his relationships to recruit three athletic trainers who were at transition points in their careers and who had both experience and “passion” in the treatment of concussions.

One of them, Jon Almquist, VATL, ATC, had led the development of return-to-learn protocols and other management practices for the high schools. He had also partnered with investigators at MedStar Health Research Institute in Baltimore on research that documented a 4.2-fold increase in concussions among the school system’s high school athletes between 1997 and 2008 (Am. J. Sports Med. 2011;39:958-63).

More surprising than this increase, however, were some data collected after the study period ended. When Mr. Almquist looked at recovery times for the concussions reported between 2011 and 2013, he found that about 25% of concussions took 30 days or longer to recover – a portion greater than he’d seen anywhere in the literature.

According to the 2014 IOM report, youth athletes typically recover from a concussion within 2 weeks of the injury, but in 10-20% of cases the symptoms persist for a number of weeks, months, or even years.

“Families would come to us for advice,” Mr. Almquist recalled. Other than referring them to the University of Pittsburgh Medical Center’s (UPMC) Sports Medicine Concussion Program, there were few local providers whom they believed offered comprehensive care and had experience with prolonged impairment.

Mr. Almquist and his fellow athletic trainers, and Dr. Ho and his physician colleagues, all had been following developments at UPMC’s Sports Medicine Concussion Program since it was established in 2000. The program had evolved to assess and manage diverse facets of concussions, including vision, vestibular, exertion, and medication components—not all of which are fully addressed in clinical practice guidelines and position statements. By 2010, the program was drawing 10,000 patients a year.

Care at UPMC is guided by a clinical neuropsychologist who assesses head injuries and then refers patients on as needed to other members of the team – like a neurovestibular expert for vestibular assessment and therapy, a neuro-optometrist for vision therapy, a physical therapist for exertion training, or a sports medicine physician for medication.

In planning their own concussion center, Dr. Ho and his team visited various programs in the country but homed in on UPMC. They decided to mimic several aspects of UPMC’s approach by providing comprehensive and individualized care, and by having the certified athletic trainers serve as the “quarterbacks.”

“The athletic trainer in our center does all the symptom inventories and history taking, a concussion-focused physical exam, vestibular-ocular-motor screening, and neurocognitive tests if appropriate,” said Dr. Ho.

Dr. Ho or one of his sports medicine physician colleagues then discusses results with the athletic trainer and completes the patient visit – with the trainer – by asking any necessary follow-up questions, probing further with additional evaluation, and writing medication prescriptions when appropriate.

Throughout the course of care – visits occur weekly to monthly and often last 30-90 minutes – the athletic trainer and physician work together on clinical issues such as sleep and mental health and on subtyping headaches (cognitive fatigue, cervicogenic, or migrainelike) and “determining where the headaches lie relative to other areas of dysfunction,” said Dr. Ho.

Much of the individualized counseling, monitoring, and coordination that’s required to address sleep hygiene, rest, nutrition, and graded return to physical and cognitive activity can be led by the athletic trainer, he said.

For the first year or so, patients were referred out for such special services as vision or vestibular therapy. But there were problems with this approach: One frequent issue was poor insurance coverage for these therapies. Another was the stress involved in getting to additional appointments on Fairfax’s congested roads. “Traffic and busy environments aren’t always tolerable for a concussed patient,” Dr. Ho said.

Dr. Ho searched the Internet, worked the phone, read the neuro-optometry and vestibular therapy literature, and attended conferences to learn what kinds of therapeutic exercises they could integrate into office visits and take-home care plans. Dr. Ho said he was “surprised at how willing some of [their] colleagues were to give us some basic skills” to help patients who “don’t all need the Cadillac version” of therapy.

About the same time they integrated basic vision and vestibular therapy, they also revamped their billing strategy, moving away from the use of prolonged service billing codes, which Dr. Ho said were frequently denied on the first submission, to using separate codes for the encounter, therapeutic exercise (which encompasses vision therapy and vestibular therapy), and various physical tests.

Concussion care networks

Fairfax Family Practice is not the only practice to center its concussion program on physician-athletic trainer partnerships. Carolina Family Practice and Sports Medicine, a 12-provider practice with three offices in and around Raleigh, N.C., took a similar approach when it established its concussion clinic in 2008.

“Concussion is the ultimate example of an injury that benefits from a team approach,” said Dr. Josh Bloom, medical director of the Carolina Sports Concussion Clinic that is embedded into the practice. “And it’s the one injury – the only injury in sports medicine – where the standard of care calls for the injury to be 100% resolved prior to being cleared to return to play.”

Dr. Jaffe, the family physician in Delaware, said she is fortunate to have a neuro-optometrist practicing in the medical building where her three-physician family practice resides, and a concussion care team in the nearby Nemours/Alfred I. Dupont Hospital for Children, also in Wilmington.

Someday, she and others hope, physicians who see patients soon after injury will have tools to better predict clinical trajectories and identify who could benefit from earlier referral to a “more sophisticated team.”

For now, Dr. Jaffe said, she seeks assistance when headache and initial symptoms persist after 2-3 weeks or when their symptoms “seem out of proportion to the incident.”

Dr. Scott Ross of Novant Health Bull Run Family Medicine based in Manassas, Va., said that family physicians are well suited to guide management and should learn to evaluate each patient’s concussion-related impairments as thoroughly as possible.

About 3 years ago, he and a partner established an official “Sports Medicine and Concussion Management” service line in their practice. “We don’t have a concussion center all under one roof, but we have the knowledge, skills, and resources that we need,” he said.

This article was updated April 13, 2015.

The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.

The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.

What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.

The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.

What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.

The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.

What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.

Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.

Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.

What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.

Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.

Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.

What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.

Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.

Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.

What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.

Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.

Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.

Dr. O’Gara reported no relevant financial conflicts.

[email protected]

SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.

Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.

Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.

Dr. O’Gara reported no relevant financial conflicts.

[email protected]

SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.

Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.

Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.

Dr. O’Gara reported no relevant financial conflicts.

[email protected]

Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.¹

What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.

Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.

Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.

The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.

What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.¹

What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.

Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.

Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.

The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.

What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.¹

What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.

Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.

Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.

The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.

What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]