Patient samples in outdoor courier lockboxes exposed to hot temperatures for as little as 4 hours are at risk of preanalytical error, according to results from a recent study published in the American Journal of Clinical Pathology.

“Our findings indicate that samples (centrifuged or not centrifuged) were impacted by extreme summer temperatures when stored for short periods of time inside commonly used steel lockboxes,” Joseph R. Wiencek, PhD, medical director of clinical chemistry, Vanderbilt University School of Medicine Core Laboratory in Nashville, said in an interview.

Dr. Wiencek and colleagues picked two dates during the summer of 2019 in a mid-Atlantic state to place two courier lockboxes (LabLocker-KF300) outside in hot temperatures (32º C) starting at 11 a.m., with one lockbox containing two 24-oz cold packs (Nordic NI24) and the other containing no cold packs. The researchers monitored the temperatures of each lockbox over the course of 4 hours.

Overall, eight participants had seven samples in lithium heparin drawn for two studies evaluating centrifuged or not centrifuged samples. In the first study, four participants had seven samples drawn, with one centrifuged sample serving as a control for each patient. The other six samples were wrapped in paper towels, placed in resealable plastic bags, and distributed evenly in the warm and cold lockboxes. The samples did not directly touch the cold packs in the cold lockbox. At 1 hour, 2 hours, and 4 hours, a participant’s sample was removed from each lockbox and centrifuged.

In the second study, another four participants had seven samples drawn. As in the first study, all samples were centrifuged and placed in the lockboxes. For both studies, when samples were centrifuged, plasma from samples was left on the gel barrier when analyzed for concentrations of C-reactive protein, a comprehensive metabolic panel, lactate dehydrogenase (LDH), a lipid panel, magnesium, and phosphorus (Abbott Architect c16000).

In the study of uncentrifuged samples, Dr. Wiencek and colleagues found that when the temperature outside ranged from 28.2º to 44.0º C (mean 40.4º C), the temperature of the cold lockbox was between 16.5º to 22.3º C (mean 22.3º C). The temperature ranged between 34.4º to 46.9º C (mean 42.6º C) in the warm lockbox. For centrifuged samples, the cold lockbox temperature was between 12.2º to 23.0º C (mean 18.0º C) and the warm lockbox was between 25. to 40.8º C (mean 35.2º C) when the outdoor temperature ranged from 27.2º to 46.3º C (mean 37.9º C).

The researchers also calculated the significant change limit (SCL) for each analyte in each sample, finding that aspartate aminotransferase, glucose, LDH, and potassium significantly exceeded the SCL in both the centrifuged and uncentrifuged samples, with the greatest changes seen at the 4-hour timepoint for samples in the warm lockbox (P < .05 for all).
 

Lockbox instructions are “consistently inconsistent”

In viewing instructions for lockboxes across institutions, Dr. Wiencek said the “outdoor courier lockbox instructions among private, academic and reference laboratories were consistently inconsistent.” For example, no laboratories cited time restrictions for samples in lockboxes, and their descriptions on the number of cold packs a laboratory should use and where the lockbox should be placed varied. The inconsistencies “highlighted the emergent need for standardization and guidance documents for institutions to implement,” Dr. Wiencek said.

One unanswered question is how widespread the problem is. It is unclear how many outdoor courier lockboxes are currently in use in the United States or globally; however, experts agreed it was a common occurrence, with some of the largest laboratory service providers offering outdoor courier lockboxes to their clients.

“Courier lockboxes are everywhere. All you need to do is walk around your clinics that are at your hospitals or clinics located around your grocery store to find them,” Dr. Wiencek said. “Some hang on doors, while others can be found on the ground in direct sunlight on a hot summer day.”

What’s more, institutions may not realize how leaving samples outdoors for extended periods can affect results. “Care teams are commonly unaware that samples placed in these poorly designed lockboxes can experience extreme summer or winter temperatures that may lead to incorrect results,” Dr. Wiencek said. “Healthcare providers need to understand the hidden dangers courier lockboxes have on the quality of their patient’s test results.”

Amy L. Pyle-Eilola, PhD, clinical chemistry director at Nationwide Children’s Hospital in Columbus, Ohio, said a major strength of the study by Dr. Wiencek and colleagues “is just that it was done at all.”

“I appreciate the real-world nature of this study and that it provides a snapshot of what conditions are really like in a lockbox in the summer,” she said in an interview.

In the clinical lab, receiving samples that had been sitting in a courier lockbox “is not uncommon,” Dr. Pyle-Eilola said.

“When I have encountered these situations, I have struggled to decide if it is still appropriate to run the tests. I always look to the medical literature for assistance with these situations, but there has been a paucity of information available on the impact of lockbox storage,” she explained.

The study by Dr. Wiencek and colleagues “provides some much-needed evidence for what is acceptable for lockbox storage conditions,” she said.
 

Areas of future research

Rodney E. Rohde, PhD, university distinguished chair and professor of the Clinical Laboratory Science (CLS) Program at Texas State University in San Marcos, said in an interview that the study “does a nice job of looking at multiple analytes and controlling for several variables,” but the sample size is small and the results may be difficult to generalize.

Dr. Pyle-Eilola highlighted another limitation — “a common shortcoming of these kinds of studies” — in the use of healthy donors for patient samples, which narrows the range of assay results.

“It is possible that more significant variation in results may be observed in additional analytes if the samples had higher concentrations of those analytes,” she said. “Moreover, this is clinically relevant as the samples stored in such lockboxes are not always from healthy individuals and have abnormal concentrations of analytes.”

Mario Plebani, MD, professor of clinical biochemistry and clinical molecular biology and chief of the department of laboratory medicine at University Hospital of Padova in Padova, Italy, agreed with that assessment.

“[T]he risks for errors and patient safety are higher for values near to the upper or lower reference value, and in general for samples collected in patients with particular diseases and clinical conditions,” he said in an interview.

“This paper deserves a commenting editorial to better highlight the urgent need for further studies on the same issue and in general on the risk in the pre-pre-analytical phase, including sample storage and transportation,” he noted.

Another area of future research is studying patient samples exposed to hotter or colder temperatures in outdoor courier lockboxes outside the mid-Atlantic area. “Here in Texas, temperatures can reach extreme heat levels,” Dr. Rohde said, who added that use of outdoor lockboxes is “very common in my region.”

Dr. Wiencek disclosed he has been a consultant on this research topic for Roche Diagnostics and received an honorarium for speaking on the subject from the American Association for Clinical Chemistry and American Society of Clinical Pathology. The other authors have no relevant conflict of interest. Dr. Pyle-Eilola, Dr. Rohde, and Dr. Plebani have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patient samples in outdoor courier lockboxes exposed to hot temperatures for as little as 4 hours are at risk of preanalytical error, according to results from a recent study published in the American Journal of Clinical Pathology.

“Our findings indicate that samples (centrifuged or not centrifuged) were impacted by extreme summer temperatures when stored for short periods of time inside commonly used steel lockboxes,” Joseph R. Wiencek, PhD, medical director of clinical chemistry, Vanderbilt University School of Medicine Core Laboratory in Nashville, said in an interview.

Dr. Wiencek and colleagues picked two dates during the summer of 2019 in a mid-Atlantic state to place two courier lockboxes (LabLocker-KF300) outside in hot temperatures (32º C) starting at 11 a.m., with one lockbox containing two 24-oz cold packs (Nordic NI24) and the other containing no cold packs. The researchers monitored the temperatures of each lockbox over the course of 4 hours.

Overall, eight participants had seven samples in lithium heparin drawn for two studies evaluating centrifuged or not centrifuged samples. In the first study, four participants had seven samples drawn, with one centrifuged sample serving as a control for each patient. The other six samples were wrapped in paper towels, placed in resealable plastic bags, and distributed evenly in the warm and cold lockboxes. The samples did not directly touch the cold packs in the cold lockbox. At 1 hour, 2 hours, and 4 hours, a participant’s sample was removed from each lockbox and centrifuged.

In the second study, another four participants had seven samples drawn. As in the first study, all samples were centrifuged and placed in the lockboxes. For both studies, when samples were centrifuged, plasma from samples was left on the gel barrier when analyzed for concentrations of C-reactive protein, a comprehensive metabolic panel, lactate dehydrogenase (LDH), a lipid panel, magnesium, and phosphorus (Abbott Architect c16000).

In the study of uncentrifuged samples, Dr. Wiencek and colleagues found that when the temperature outside ranged from 28.2º to 44.0º C (mean 40.4º C), the temperature of the cold lockbox was between 16.5º to 22.3º C (mean 22.3º C). The temperature ranged between 34.4º to 46.9º C (mean 42.6º C) in the warm lockbox. For centrifuged samples, the cold lockbox temperature was between 12.2º to 23.0º C (mean 18.0º C) and the warm lockbox was between 25. to 40.8º C (mean 35.2º C) when the outdoor temperature ranged from 27.2º to 46.3º C (mean 37.9º C).

The researchers also calculated the significant change limit (SCL) for each analyte in each sample, finding that aspartate aminotransferase, glucose, LDH, and potassium significantly exceeded the SCL in both the centrifuged and uncentrifuged samples, with the greatest changes seen at the 4-hour timepoint for samples in the warm lockbox (P < .05 for all).
 

Lockbox instructions are “consistently inconsistent”

In viewing instructions for lockboxes across institutions, Dr. Wiencek said the “outdoor courier lockbox instructions among private, academic and reference laboratories were consistently inconsistent.” For example, no laboratories cited time restrictions for samples in lockboxes, and their descriptions on the number of cold packs a laboratory should use and where the lockbox should be placed varied. The inconsistencies “highlighted the emergent need for standardization and guidance documents for institutions to implement,” Dr. Wiencek said.

One unanswered question is how widespread the problem is. It is unclear how many outdoor courier lockboxes are currently in use in the United States or globally; however, experts agreed it was a common occurrence, with some of the largest laboratory service providers offering outdoor courier lockboxes to their clients.

“Courier lockboxes are everywhere. All you need to do is walk around your clinics that are at your hospitals or clinics located around your grocery store to find them,” Dr. Wiencek said. “Some hang on doors, while others can be found on the ground in direct sunlight on a hot summer day.”

What’s more, institutions may not realize how leaving samples outdoors for extended periods can affect results. “Care teams are commonly unaware that samples placed in these poorly designed lockboxes can experience extreme summer or winter temperatures that may lead to incorrect results,” Dr. Wiencek said. “Healthcare providers need to understand the hidden dangers courier lockboxes have on the quality of their patient’s test results.”

Amy L. Pyle-Eilola, PhD, clinical chemistry director at Nationwide Children’s Hospital in Columbus, Ohio, said a major strength of the study by Dr. Wiencek and colleagues “is just that it was done at all.”

“I appreciate the real-world nature of this study and that it provides a snapshot of what conditions are really like in a lockbox in the summer,” she said in an interview.

In the clinical lab, receiving samples that had been sitting in a courier lockbox “is not uncommon,” Dr. Pyle-Eilola said.

“When I have encountered these situations, I have struggled to decide if it is still appropriate to run the tests. I always look to the medical literature for assistance with these situations, but there has been a paucity of information available on the impact of lockbox storage,” she explained.

The study by Dr. Wiencek and colleagues “provides some much-needed evidence for what is acceptable for lockbox storage conditions,” she said.
 

Areas of future research

Rodney E. Rohde, PhD, university distinguished chair and professor of the Clinical Laboratory Science (CLS) Program at Texas State University in San Marcos, said in an interview that the study “does a nice job of looking at multiple analytes and controlling for several variables,” but the sample size is small and the results may be difficult to generalize.

Dr. Pyle-Eilola highlighted another limitation — “a common shortcoming of these kinds of studies” — in the use of healthy donors for patient samples, which narrows the range of assay results.

“It is possible that more significant variation in results may be observed in additional analytes if the samples had higher concentrations of those analytes,” she said. “Moreover, this is clinically relevant as the samples stored in such lockboxes are not always from healthy individuals and have abnormal concentrations of analytes.”

Mario Plebani, MD, professor of clinical biochemistry and clinical molecular biology and chief of the department of laboratory medicine at University Hospital of Padova in Padova, Italy, agreed with that assessment.

“[T]he risks for errors and patient safety are higher for values near to the upper or lower reference value, and in general for samples collected in patients with particular diseases and clinical conditions,” he said in an interview.

“This paper deserves a commenting editorial to better highlight the urgent need for further studies on the same issue and in general on the risk in the pre-pre-analytical phase, including sample storage and transportation,” he noted.

Another area of future research is studying patient samples exposed to hotter or colder temperatures in outdoor courier lockboxes outside the mid-Atlantic area. “Here in Texas, temperatures can reach extreme heat levels,” Dr. Rohde said, who added that use of outdoor lockboxes is “very common in my region.”

Dr. Wiencek disclosed he has been a consultant on this research topic for Roche Diagnostics and received an honorarium for speaking on the subject from the American Association for Clinical Chemistry and American Society of Clinical Pathology. The other authors have no relevant conflict of interest. Dr. Pyle-Eilola, Dr. Rohde, and Dr. Plebani have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patient samples in outdoor courier lockboxes exposed to hot temperatures for as little as 4 hours are at risk of preanalytical error, according to results from a recent study published in the American Journal of Clinical Pathology.

“Our findings indicate that samples (centrifuged or not centrifuged) were impacted by extreme summer temperatures when stored for short periods of time inside commonly used steel lockboxes,” Joseph R. Wiencek, PhD, medical director of clinical chemistry, Vanderbilt University School of Medicine Core Laboratory in Nashville, said in an interview.

Dr. Wiencek and colleagues picked two dates during the summer of 2019 in a mid-Atlantic state to place two courier lockboxes (LabLocker-KF300) outside in hot temperatures (32º C) starting at 11 a.m., with one lockbox containing two 24-oz cold packs (Nordic NI24) and the other containing no cold packs. The researchers monitored the temperatures of each lockbox over the course of 4 hours.

Overall, eight participants had seven samples in lithium heparin drawn for two studies evaluating centrifuged or not centrifuged samples. In the first study, four participants had seven samples drawn, with one centrifuged sample serving as a control for each patient. The other six samples were wrapped in paper towels, placed in resealable plastic bags, and distributed evenly in the warm and cold lockboxes. The samples did not directly touch the cold packs in the cold lockbox. At 1 hour, 2 hours, and 4 hours, a participant’s sample was removed from each lockbox and centrifuged.

In the second study, another four participants had seven samples drawn. As in the first study, all samples were centrifuged and placed in the lockboxes. For both studies, when samples were centrifuged, plasma from samples was left on the gel barrier when analyzed for concentrations of C-reactive protein, a comprehensive metabolic panel, lactate dehydrogenase (LDH), a lipid panel, magnesium, and phosphorus (Abbott Architect c16000).

In the study of uncentrifuged samples, Dr. Wiencek and colleagues found that when the temperature outside ranged from 28.2º to 44.0º C (mean 40.4º C), the temperature of the cold lockbox was between 16.5º to 22.3º C (mean 22.3º C). The temperature ranged between 34.4º to 46.9º C (mean 42.6º C) in the warm lockbox. For centrifuged samples, the cold lockbox temperature was between 12.2º to 23.0º C (mean 18.0º C) and the warm lockbox was between 25. to 40.8º C (mean 35.2º C) when the outdoor temperature ranged from 27.2º to 46.3º C (mean 37.9º C).

The researchers also calculated the significant change limit (SCL) for each analyte in each sample, finding that aspartate aminotransferase, glucose, LDH, and potassium significantly exceeded the SCL in both the centrifuged and uncentrifuged samples, with the greatest changes seen at the 4-hour timepoint for samples in the warm lockbox (P < .05 for all).
 

Lockbox instructions are “consistently inconsistent”

In viewing instructions for lockboxes across institutions, Dr. Wiencek said the “outdoor courier lockbox instructions among private, academic and reference laboratories were consistently inconsistent.” For example, no laboratories cited time restrictions for samples in lockboxes, and their descriptions on the number of cold packs a laboratory should use and where the lockbox should be placed varied. The inconsistencies “highlighted the emergent need for standardization and guidance documents for institutions to implement,” Dr. Wiencek said.

One unanswered question is how widespread the problem is. It is unclear how many outdoor courier lockboxes are currently in use in the United States or globally; however, experts agreed it was a common occurrence, with some of the largest laboratory service providers offering outdoor courier lockboxes to their clients.

“Courier lockboxes are everywhere. All you need to do is walk around your clinics that are at your hospitals or clinics located around your grocery store to find them,” Dr. Wiencek said. “Some hang on doors, while others can be found on the ground in direct sunlight on a hot summer day.”

What’s more, institutions may not realize how leaving samples outdoors for extended periods can affect results. “Care teams are commonly unaware that samples placed in these poorly designed lockboxes can experience extreme summer or winter temperatures that may lead to incorrect results,” Dr. Wiencek said. “Healthcare providers need to understand the hidden dangers courier lockboxes have on the quality of their patient’s test results.”

Amy L. Pyle-Eilola, PhD, clinical chemistry director at Nationwide Children’s Hospital in Columbus, Ohio, said a major strength of the study by Dr. Wiencek and colleagues “is just that it was done at all.”

“I appreciate the real-world nature of this study and that it provides a snapshot of what conditions are really like in a lockbox in the summer,” she said in an interview.

In the clinical lab, receiving samples that had been sitting in a courier lockbox “is not uncommon,” Dr. Pyle-Eilola said.

“When I have encountered these situations, I have struggled to decide if it is still appropriate to run the tests. I always look to the medical literature for assistance with these situations, but there has been a paucity of information available on the impact of lockbox storage,” she explained.

The study by Dr. Wiencek and colleagues “provides some much-needed evidence for what is acceptable for lockbox storage conditions,” she said.
 

Areas of future research

Rodney E. Rohde, PhD, university distinguished chair and professor of the Clinical Laboratory Science (CLS) Program at Texas State University in San Marcos, said in an interview that the study “does a nice job of looking at multiple analytes and controlling for several variables,” but the sample size is small and the results may be difficult to generalize.

Dr. Pyle-Eilola highlighted another limitation — “a common shortcoming of these kinds of studies” — in the use of healthy donors for patient samples, which narrows the range of assay results.

“It is possible that more significant variation in results may be observed in additional analytes if the samples had higher concentrations of those analytes,” she said. “Moreover, this is clinically relevant as the samples stored in such lockboxes are not always from healthy individuals and have abnormal concentrations of analytes.”

Mario Plebani, MD, professor of clinical biochemistry and clinical molecular biology and chief of the department of laboratory medicine at University Hospital of Padova in Padova, Italy, agreed with that assessment.

“[T]he risks for errors and patient safety are higher for values near to the upper or lower reference value, and in general for samples collected in patients with particular diseases and clinical conditions,” he said in an interview.

“This paper deserves a commenting editorial to better highlight the urgent need for further studies on the same issue and in general on the risk in the pre-pre-analytical phase, including sample storage and transportation,” he noted.

Another area of future research is studying patient samples exposed to hotter or colder temperatures in outdoor courier lockboxes outside the mid-Atlantic area. “Here in Texas, temperatures can reach extreme heat levels,” Dr. Rohde said, who added that use of outdoor lockboxes is “very common in my region.”

Dr. Wiencek disclosed he has been a consultant on this research topic for Roche Diagnostics and received an honorarium for speaking on the subject from the American Association for Clinical Chemistry and American Society of Clinical Pathology. The other authors have no relevant conflict of interest. Dr. Pyle-Eilola, Dr. Rohde, and Dr. Plebani have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The tide may finally be shifting as drugs targeting specific KRAS mutations have made their way into the clinic, and there is particular excitement around the oral WEE1 inhibitor, adavosertib (AZD1775). WEE1 is a cell cycle regulatory protein and WEE1 inhibition may have increased activity in tumors with DNA repair deficiency. In a phase 2 maintenance study, Seligmann and colleagues randomized 69 patients with RAS- and TP53-mutated mCRC with stable disease or better after 16 weeks of induction chemotherapy 2:1 to receive adavosertib vs active monitoring. Median progression-free survival (mPFS) was significant improved with adavosertib (3.61 vs 1.68 months), and patients with left-sided primary tumors appears to derive more benefit. While this finding needs to be further explored in larger clinical trials, it is exciting that there may finally be a new treatment option for patients with this specific molecular subtype of mCRC.

Another maintenance mCRC trial of interest is the PANAMA trial, a phase 2 study in which 248 patients with RAS wild-type mCRC were randomized 1:1 to 5-fluorouracil/leucovorin with or without panitumumab, an anti-epidermal growth factor receptor antibody, following induction chemotherapy with 6 cycles FOLFOX/panitumumab. Modest and co-workers report that mPFS was significantly improved with continuing panitumumab in the maintenance setting (8.8 vs. 5.7 months), and there was a trend towards an overall survival benefit as well. This study further supports continuing anti-EGFR therapy with maintenance chemotherapy for patients with RAS wild-type mCRC.

Finally, in stage III CRC, there is a big movement towards using circulating tumor DNA (ctDNA) as a method to monitor disease recurrence by detecting minimal residual disease based on tumor DNA being shed into the bloodstream. Henriksen et al. evaluated 168 patients with stage III CRC who underwent surgical resection and plasma ctDNA testing using 16 patient-specific DNA variants (tumor tissue-informed testing). The rates of recurrence were much higher in patients with detectable ctDNA post-operatively and/or after the completion of adjuvant chemotherapy, whereas those patients with persistently undetectable ctDNA did not recur. ctDNA is a powerful new technology that we are still learning how to best harness in the clinic, and this study demonstrates its prognostic value and potential ability to detect recurrence prior to standard imaging surveillance. Moreover, the rate of ctDNA rise was also prognostic of survival. ctDNA testing is likely to become standard of care in the management of stage II/III colorectal cancer in the very near future, and we hope that eventually it may be able to predict who needs to receive adjuvant chemotherapy and who does not.

The tide may finally be shifting as drugs targeting specific KRAS mutations have made their way into the clinic, and there is particular excitement around the oral WEE1 inhibitor, adavosertib (AZD1775). WEE1 is a cell cycle regulatory protein and WEE1 inhibition may have increased activity in tumors with DNA repair deficiency. In a phase 2 maintenance study, Seligmann and colleagues randomized 69 patients with RAS- and TP53-mutated mCRC with stable disease or better after 16 weeks of induction chemotherapy 2:1 to receive adavosertib vs active monitoring. Median progression-free survival (mPFS) was significant improved with adavosertib (3.61 vs 1.68 months), and patients with left-sided primary tumors appears to derive more benefit. While this finding needs to be further explored in larger clinical trials, it is exciting that there may finally be a new treatment option for patients with this specific molecular subtype of mCRC.

Another maintenance mCRC trial of interest is the PANAMA trial, a phase 2 study in which 248 patients with RAS wild-type mCRC were randomized 1:1 to 5-fluorouracil/leucovorin with or without panitumumab, an anti-epidermal growth factor receptor antibody, following induction chemotherapy with 6 cycles FOLFOX/panitumumab. Modest and co-workers report that mPFS was significantly improved with continuing panitumumab in the maintenance setting (8.8 vs. 5.7 months), and there was a trend towards an overall survival benefit as well. This study further supports continuing anti-EGFR therapy with maintenance chemotherapy for patients with RAS wild-type mCRC.

Finally, in stage III CRC, there is a big movement towards using circulating tumor DNA (ctDNA) as a method to monitor disease recurrence by detecting minimal residual disease based on tumor DNA being shed into the bloodstream. Henriksen et al. evaluated 168 patients with stage III CRC who underwent surgical resection and plasma ctDNA testing using 16 patient-specific DNA variants (tumor tissue-informed testing). The rates of recurrence were much higher in patients with detectable ctDNA post-operatively and/or after the completion of adjuvant chemotherapy, whereas those patients with persistently undetectable ctDNA did not recur. ctDNA is a powerful new technology that we are still learning how to best harness in the clinic, and this study demonstrates its prognostic value and potential ability to detect recurrence prior to standard imaging surveillance. Moreover, the rate of ctDNA rise was also prognostic of survival. ctDNA testing is likely to become standard of care in the management of stage II/III colorectal cancer in the very near future, and we hope that eventually it may be able to predict who needs to receive adjuvant chemotherapy and who does not.

The tide may finally be shifting as drugs targeting specific KRAS mutations have made their way into the clinic, and there is particular excitement around the oral WEE1 inhibitor, adavosertib (AZD1775). WEE1 is a cell cycle regulatory protein and WEE1 inhibition may have increased activity in tumors with DNA repair deficiency. In a phase 2 maintenance study, Seligmann and colleagues randomized 69 patients with RAS- and TP53-mutated mCRC with stable disease or better after 16 weeks of induction chemotherapy 2:1 to receive adavosertib vs active monitoring. Median progression-free survival (mPFS) was significant improved with adavosertib (3.61 vs 1.68 months), and patients with left-sided primary tumors appears to derive more benefit. While this finding needs to be further explored in larger clinical trials, it is exciting that there may finally be a new treatment option for patients with this specific molecular subtype of mCRC.

Another maintenance mCRC trial of interest is the PANAMA trial, a phase 2 study in which 248 patients with RAS wild-type mCRC were randomized 1:1 to 5-fluorouracil/leucovorin with or without panitumumab, an anti-epidermal growth factor receptor antibody, following induction chemotherapy with 6 cycles FOLFOX/panitumumab. Modest and co-workers report that mPFS was significantly improved with continuing panitumumab in the maintenance setting (8.8 vs. 5.7 months), and there was a trend towards an overall survival benefit as well. This study further supports continuing anti-EGFR therapy with maintenance chemotherapy for patients with RAS wild-type mCRC.

Finally, in stage III CRC, there is a big movement towards using circulating tumor DNA (ctDNA) as a method to monitor disease recurrence by detecting minimal residual disease based on tumor DNA being shed into the bloodstream. Henriksen et al. evaluated 168 patients with stage III CRC who underwent surgical resection and plasma ctDNA testing using 16 patient-specific DNA variants (tumor tissue-informed testing). The rates of recurrence were much higher in patients with detectable ctDNA post-operatively and/or after the completion of adjuvant chemotherapy, whereas those patients with persistently undetectable ctDNA did not recur. ctDNA is a powerful new technology that we are still learning how to best harness in the clinic, and this study demonstrates its prognostic value and potential ability to detect recurrence prior to standard imaging surveillance. Moreover, the rate of ctDNA rise was also prognostic of survival. ctDNA testing is likely to become standard of care in the management of stage II/III colorectal cancer in the very near future, and we hope that eventually it may be able to predict who needs to receive adjuvant chemotherapy and who does not.

Patients with mild to moderate facial acne who underwent four treatments with a novel laser prototype known as Accure experienced an 82% reduction in acne lesions at 12 weeks and a 90% reduction at 12 months, a development that indicates the promise this has a treatment for acne in the future.

Currently, “there is no strong evidence that lasers are better than conventional treatments for acne,” Fernanda H. Sakamoto, MD, PhD, said during a virtual course on laser and aesthetic skin therapy. Some patients struggling with acne “search for so many different options and they end up spending a lot of money,” which, she said, includes an estimated $222 million for laser treatment alone in 2019.

Unlike other existing laser and light options for acne treatment, however, Accure is the first light-based platform to selectively target and injure sebaceous glands, the main source of sebum production and the key to a durable solution for acne. The laser, which uses a 1,726-nm wavelength, is being developed by researchers at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston and was granted the European CE mark, which allows marketing of the product in Europe, in May of 2020.

In 2012, Dr. Sakamoto, a dermatologist at the center, and her Wellman colleagues were the first to describe the use of selective photothermolysis to target sebaceous glands. “We found that the peak absorption of lipids in sebaceous glands occurs between 1,700 and 1,720 nm,” she said. “Compared to water, the contrast is not high, so for us to develop a laser that is selective for acne, we needed to develop a strong cooling system and we had to create different methods to make it more selective.” She said that it took about 10 years to develop this laser.

The latest Accure prototype features a smart laser handpiece for real time thermal monitoring and precise delivery of laser emissions. “We have developed a mathematical model which permits us to predict safe and effective treatment patterns,” Dr. Sakamoto said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “It has a unique cooling system that can control and protect the skin.”

The clinical trial for Food and Drug Administration clearance, which was delayed because of the COVID-19 pandemic, is still underway, she said, and the hope is that the laser will cleared by the FDA by next year. She and her Wellman colleagues have been working with four veteran dermatologists to conduct clinical trials of the device: Emil Tanghetti, MD, in California; Roy Geronemus, MD, in New York; Joel Cohen, MD, in Colorado; and Daniel Friedmann, MD, in Texas. As of Oct. 2, 2021, more than 50 patients were enrolled in four IRB-approved studies and an additional 30 are enrolled in a pilot facial acne trial, Dr. Sakamoto said. In the trials, patients are followed at 4, 8, 12, and 24 weeks post treatment.

Among patients enrolled in the pilot facial acne trial, researchers have observed a 100% responder rate for patients with more than five acne lesions at 4, 8, 12, and 24 weeks post treatment. The average lesion reduction at week 12 was 82% and the mean Visual Analog Scale score immediately after treatment was 2.10 out of 10. Each patient received more than 12,000 trigger pulls of energy from the device with no adverse events.

“This laser is absorbed in the near-infrared spectrum, so there is no melanin absorption,” Dr. Sakamoto explained. “It’s pretty much a color-blind laser, so we can treat darker skin types safely, with no side effects.” In other findings, researchers observed a 45% reduction in acne lesions after one treatment session, which “keeps improving over time,” she said. “At 12 weeks, we have clearance of over 80% of the lesions.”

At 12 months, they observed a 90% inflammatory lesion count reduction from baseline and a rapid response to treatment: a 73% reduction achieved after the first two treatment sessions. Histological studies revealed selective sebaceous gland destruction with no damage to the epidermis, surrounding dermis, or other follicular structures.

Dr. Sakamoto disclosed that she has received portions of patent royalties from Massachusetts General Hospital. Accure was cofounded by R. Rox Anderson, MD, the director of the Wellman Center.

[email protected]

Patients with mild to moderate facial acne who underwent four treatments with a novel laser prototype known as Accure experienced an 82% reduction in acne lesions at 12 weeks and a 90% reduction at 12 months, a development that indicates the promise this has a treatment for acne in the future.

Currently, “there is no strong evidence that lasers are better than conventional treatments for acne,” Fernanda H. Sakamoto, MD, PhD, said during a virtual course on laser and aesthetic skin therapy. Some patients struggling with acne “search for so many different options and they end up spending a lot of money,” which, she said, includes an estimated $222 million for laser treatment alone in 2019.

Unlike other existing laser and light options for acne treatment, however, Accure is the first light-based platform to selectively target and injure sebaceous glands, the main source of sebum production and the key to a durable solution for acne. The laser, which uses a 1,726-nm wavelength, is being developed by researchers at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston and was granted the European CE mark, which allows marketing of the product in Europe, in May of 2020.

In 2012, Dr. Sakamoto, a dermatologist at the center, and her Wellman colleagues were the first to describe the use of selective photothermolysis to target sebaceous glands. “We found that the peak absorption of lipids in sebaceous glands occurs between 1,700 and 1,720 nm,” she said. “Compared to water, the contrast is not high, so for us to develop a laser that is selective for acne, we needed to develop a strong cooling system and we had to create different methods to make it more selective.” She said that it took about 10 years to develop this laser.

The latest Accure prototype features a smart laser handpiece for real time thermal monitoring and precise delivery of laser emissions. “We have developed a mathematical model which permits us to predict safe and effective treatment patterns,” Dr. Sakamoto said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “It has a unique cooling system that can control and protect the skin.”

The clinical trial for Food and Drug Administration clearance, which was delayed because of the COVID-19 pandemic, is still underway, she said, and the hope is that the laser will cleared by the FDA by next year. She and her Wellman colleagues have been working with four veteran dermatologists to conduct clinical trials of the device: Emil Tanghetti, MD, in California; Roy Geronemus, MD, in New York; Joel Cohen, MD, in Colorado; and Daniel Friedmann, MD, in Texas. As of Oct. 2, 2021, more than 50 patients were enrolled in four IRB-approved studies and an additional 30 are enrolled in a pilot facial acne trial, Dr. Sakamoto said. In the trials, patients are followed at 4, 8, 12, and 24 weeks post treatment.

Among patients enrolled in the pilot facial acne trial, researchers have observed a 100% responder rate for patients with more than five acne lesions at 4, 8, 12, and 24 weeks post treatment. The average lesion reduction at week 12 was 82% and the mean Visual Analog Scale score immediately after treatment was 2.10 out of 10. Each patient received more than 12,000 trigger pulls of energy from the device with no adverse events.

“This laser is absorbed in the near-infrared spectrum, so there is no melanin absorption,” Dr. Sakamoto explained. “It’s pretty much a color-blind laser, so we can treat darker skin types safely, with no side effects.” In other findings, researchers observed a 45% reduction in acne lesions after one treatment session, which “keeps improving over time,” she said. “At 12 weeks, we have clearance of over 80% of the lesions.”

At 12 months, they observed a 90% inflammatory lesion count reduction from baseline and a rapid response to treatment: a 73% reduction achieved after the first two treatment sessions. Histological studies revealed selective sebaceous gland destruction with no damage to the epidermis, surrounding dermis, or other follicular structures.

Dr. Sakamoto disclosed that she has received portions of patent royalties from Massachusetts General Hospital. Accure was cofounded by R. Rox Anderson, MD, the director of the Wellman Center.

[email protected]

Patients with mild to moderate facial acne who underwent four treatments with a novel laser prototype known as Accure experienced an 82% reduction in acne lesions at 12 weeks and a 90% reduction at 12 months, a development that indicates the promise this has a treatment for acne in the future.

Currently, “there is no strong evidence that lasers are better than conventional treatments for acne,” Fernanda H. Sakamoto, MD, PhD, said during a virtual course on laser and aesthetic skin therapy. Some patients struggling with acne “search for so many different options and they end up spending a lot of money,” which, she said, includes an estimated $222 million for laser treatment alone in 2019.

Unlike other existing laser and light options for acne treatment, however, Accure is the first light-based platform to selectively target and injure sebaceous glands, the main source of sebum production and the key to a durable solution for acne. The laser, which uses a 1,726-nm wavelength, is being developed by researchers at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston and was granted the European CE mark, which allows marketing of the product in Europe, in May of 2020.

In 2012, Dr. Sakamoto, a dermatologist at the center, and her Wellman colleagues were the first to describe the use of selective photothermolysis to target sebaceous glands. “We found that the peak absorption of lipids in sebaceous glands occurs between 1,700 and 1,720 nm,” she said. “Compared to water, the contrast is not high, so for us to develop a laser that is selective for acne, we needed to develop a strong cooling system and we had to create different methods to make it more selective.” She said that it took about 10 years to develop this laser.

The latest Accure prototype features a smart laser handpiece for real time thermal monitoring and precise delivery of laser emissions. “We have developed a mathematical model which permits us to predict safe and effective treatment patterns,” Dr. Sakamoto said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “It has a unique cooling system that can control and protect the skin.”

The clinical trial for Food and Drug Administration clearance, which was delayed because of the COVID-19 pandemic, is still underway, she said, and the hope is that the laser will cleared by the FDA by next year. She and her Wellman colleagues have been working with four veteran dermatologists to conduct clinical trials of the device: Emil Tanghetti, MD, in California; Roy Geronemus, MD, in New York; Joel Cohen, MD, in Colorado; and Daniel Friedmann, MD, in Texas. As of Oct. 2, 2021, more than 50 patients were enrolled in four IRB-approved studies and an additional 30 are enrolled in a pilot facial acne trial, Dr. Sakamoto said. In the trials, patients are followed at 4, 8, 12, and 24 weeks post treatment.

Among patients enrolled in the pilot facial acne trial, researchers have observed a 100% responder rate for patients with more than five acne lesions at 4, 8, 12, and 24 weeks post treatment. The average lesion reduction at week 12 was 82% and the mean Visual Analog Scale score immediately after treatment was 2.10 out of 10. Each patient received more than 12,000 trigger pulls of energy from the device with no adverse events.

“This laser is absorbed in the near-infrared spectrum, so there is no melanin absorption,” Dr. Sakamoto explained. “It’s pretty much a color-blind laser, so we can treat darker skin types safely, with no side effects.” In other findings, researchers observed a 45% reduction in acne lesions after one treatment session, which “keeps improving over time,” she said. “At 12 weeks, we have clearance of over 80% of the lesions.”

At 12 months, they observed a 90% inflammatory lesion count reduction from baseline and a rapid response to treatment: a 73% reduction achieved after the first two treatment sessions. Histological studies revealed selective sebaceous gland destruction with no damage to the epidermis, surrounding dermis, or other follicular structures.

Dr. Sakamoto disclosed that she has received portions of patent royalties from Massachusetts General Hospital. Accure was cofounded by R. Rox Anderson, MD, the director of the Wellman Center.

[email protected]

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

The diagnostic performance of optical evaluation for submucosal invasive cancer (SMIC) in patients with large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may be dependent on lesion morphology. While optical evaluation featured excellent performance in the assessment of flat lesions, the assessment only featured decent performance in nodular lesions, underscoring the need for additional evaluation algorithms for these lesions.

Endoscopists rely on the accuracy of real-time optical evaluation to facilitate appropriate selection of treatment; however, in studies focusing on LNPCPs, the performance of optical evaluation is modest.

The stratification of optical evaluation by lesion morphology may enable more accurate “implementation of a selective resection algorithm by identifying lesion subgroups with accurate optical evaluation performance characteristics,” first authors Sergei Vosko, MD, and Neal Shahidi, MD, of the department of gastroenterology and hepatology, Westmead Hospital, Sydney, and colleagues wrote in Clinical Gastroenterology and Hepatology.

Given the potential importance of stratification in optical evaluation, Dr. Vosko and colleagues assessed the performance of the optical assessment modality based on lesion morphology in a prospective cohort of 1,583 LNPCPs measuring at least 20 mm in patients (median age, 69 years) referred for endoscopic resection.

In the observational cohort, centers performed optical evaluation before endoscopic resection. The optical prediction of SMIC was based on several different established features, including Kudo V pit pattern, depressed morphology, rigidity/fixation, and ulceration. The researchers calculated optical evaluation performance outcomes, which were reported by the dominant morphology, namely nodular (Paris 0–Is/0– IIaDIs) versus flat (Paris 0–IIa/0–IIb).

Across the overall cohort, the median lesion size was 35 mm. The investigators identified a total of 855 flat LNPCPs and 728 nodular LNPCPs, with 63.9% of LNPCPs considered granular. Additionally, the researchers reported submucosal invasive cancer in 146 LNPCPs (9.2%).

According to the investigators, the overall sensitivity of optical evaluation to diagnose submucosal invasive cancer was 67.1% (95% confidence interval, 59.2%-74.2%), while the overall specificity was 95.1% (95% CI, 93.9%-96.1%). The investigators reported significant differences between flat vs. nodular LNPCPs in terms of sensitivity (90.9% vs. 52.7%, respectively; P <.001) and specificity (96.3% vs. 93.7%; P =.027).

Overall, the SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). There was a significant difference in the SMIC miss rate between flat and nodular LNPCPs (0.6% vs. 5.9%, respectively; P < .001).

Independent predictors of missed SMIC on optical evaluation, as identified in the multiple logistic regression analysis, included nodular morphology (odds ratio, 7.2; 95% CI, 2.8-18.9; P < .001), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7; P =.026), and size of at least 40 mm (OR, 2.0; 95% CI, 1.0-3.8; P =.039).

Based on the findings, the researchers suggested that all flat lesions, in the absence of optical features consistent with submucosal invasive cancer, should subsequently be removed by high-quality endoscopic mucosal resection, in conjunction with the application of “site-specific modifications and ancillary techniques where needed.”

One limitation of this study is how lesion morphology was classified, which can in some cases be subjective.

The researchers added that additional refinement is required “to robustly apply a selective resection algorithm irrespective of lesion morphology” given the modest performance value of optical evaluation in nodular lesions. “Nevertheless, it is imperative that all endoscopists embrace optical evaluation in everyday clinical practice, thus harnessing its proven ability to influence resection technique selection and the associated clinical and economic ramifications,” they concluded.

The study received financial support the Cancer Institute of New South Wales, in addition to funding from the Gallipoli Medical Research Foundation. One author reported receiving research support from Olympus Medical, Cook Medical, and Boston Scientific. The remaining authors disclosed no conflicts.

The diagnostic performance of optical evaluation for submucosal invasive cancer (SMIC) in patients with large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may be dependent on lesion morphology. While optical evaluation featured excellent performance in the assessment of flat lesions, the assessment only featured decent performance in nodular lesions, underscoring the need for additional evaluation algorithms for these lesions.

Endoscopists rely on the accuracy of real-time optical evaluation to facilitate appropriate selection of treatment; however, in studies focusing on LNPCPs, the performance of optical evaluation is modest.

The stratification of optical evaluation by lesion morphology may enable more accurate “implementation of a selective resection algorithm by identifying lesion subgroups with accurate optical evaluation performance characteristics,” first authors Sergei Vosko, MD, and Neal Shahidi, MD, of the department of gastroenterology and hepatology, Westmead Hospital, Sydney, and colleagues wrote in Clinical Gastroenterology and Hepatology.

Given the potential importance of stratification in optical evaluation, Dr. Vosko and colleagues assessed the performance of the optical assessment modality based on lesion morphology in a prospective cohort of 1,583 LNPCPs measuring at least 20 mm in patients (median age, 69 years) referred for endoscopic resection.

In the observational cohort, centers performed optical evaluation before endoscopic resection. The optical prediction of SMIC was based on several different established features, including Kudo V pit pattern, depressed morphology, rigidity/fixation, and ulceration. The researchers calculated optical evaluation performance outcomes, which were reported by the dominant morphology, namely nodular (Paris 0–Is/0– IIaDIs) versus flat (Paris 0–IIa/0–IIb).

Across the overall cohort, the median lesion size was 35 mm. The investigators identified a total of 855 flat LNPCPs and 728 nodular LNPCPs, with 63.9% of LNPCPs considered granular. Additionally, the researchers reported submucosal invasive cancer in 146 LNPCPs (9.2%).

According to the investigators, the overall sensitivity of optical evaluation to diagnose submucosal invasive cancer was 67.1% (95% confidence interval, 59.2%-74.2%), while the overall specificity was 95.1% (95% CI, 93.9%-96.1%). The investigators reported significant differences between flat vs. nodular LNPCPs in terms of sensitivity (90.9% vs. 52.7%, respectively; P <.001) and specificity (96.3% vs. 93.7%; P =.027).

Overall, the SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). There was a significant difference in the SMIC miss rate between flat and nodular LNPCPs (0.6% vs. 5.9%, respectively; P < .001).

Independent predictors of missed SMIC on optical evaluation, as identified in the multiple logistic regression analysis, included nodular morphology (odds ratio, 7.2; 95% CI, 2.8-18.9; P < .001), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7; P =.026), and size of at least 40 mm (OR, 2.0; 95% CI, 1.0-3.8; P =.039).

Based on the findings, the researchers suggested that all flat lesions, in the absence of optical features consistent with submucosal invasive cancer, should subsequently be removed by high-quality endoscopic mucosal resection, in conjunction with the application of “site-specific modifications and ancillary techniques where needed.”

One limitation of this study is how lesion morphology was classified, which can in some cases be subjective.

The researchers added that additional refinement is required “to robustly apply a selective resection algorithm irrespective of lesion morphology” given the modest performance value of optical evaluation in nodular lesions. “Nevertheless, it is imperative that all endoscopists embrace optical evaluation in everyday clinical practice, thus harnessing its proven ability to influence resection technique selection and the associated clinical and economic ramifications,” they concluded.

The study received financial support the Cancer Institute of New South Wales, in addition to funding from the Gallipoli Medical Research Foundation. One author reported receiving research support from Olympus Medical, Cook Medical, and Boston Scientific. The remaining authors disclosed no conflicts.

The diagnostic performance of optical evaluation for submucosal invasive cancer (SMIC) in patients with large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may be dependent on lesion morphology. While optical evaluation featured excellent performance in the assessment of flat lesions, the assessment only featured decent performance in nodular lesions, underscoring the need for additional evaluation algorithms for these lesions.

Endoscopists rely on the accuracy of real-time optical evaluation to facilitate appropriate selection of treatment; however, in studies focusing on LNPCPs, the performance of optical evaluation is modest.

The stratification of optical evaluation by lesion morphology may enable more accurate “implementation of a selective resection algorithm by identifying lesion subgroups with accurate optical evaluation performance characteristics,” first authors Sergei Vosko, MD, and Neal Shahidi, MD, of the department of gastroenterology and hepatology, Westmead Hospital, Sydney, and colleagues wrote in Clinical Gastroenterology and Hepatology.

Given the potential importance of stratification in optical evaluation, Dr. Vosko and colleagues assessed the performance of the optical assessment modality based on lesion morphology in a prospective cohort of 1,583 LNPCPs measuring at least 20 mm in patients (median age, 69 years) referred for endoscopic resection.

In the observational cohort, centers performed optical evaluation before endoscopic resection. The optical prediction of SMIC was based on several different established features, including Kudo V pit pattern, depressed morphology, rigidity/fixation, and ulceration. The researchers calculated optical evaluation performance outcomes, which were reported by the dominant morphology, namely nodular (Paris 0–Is/0– IIaDIs) versus flat (Paris 0–IIa/0–IIb).

Across the overall cohort, the median lesion size was 35 mm. The investigators identified a total of 855 flat LNPCPs and 728 nodular LNPCPs, with 63.9% of LNPCPs considered granular. Additionally, the researchers reported submucosal invasive cancer in 146 LNPCPs (9.2%).

According to the investigators, the overall sensitivity of optical evaluation to diagnose submucosal invasive cancer was 67.1% (95% confidence interval, 59.2%-74.2%), while the overall specificity was 95.1% (95% CI, 93.9%-96.1%). The investigators reported significant differences between flat vs. nodular LNPCPs in terms of sensitivity (90.9% vs. 52.7%, respectively; P <.001) and specificity (96.3% vs. 93.7%; P =.027).

Overall, the SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). There was a significant difference in the SMIC miss rate between flat and nodular LNPCPs (0.6% vs. 5.9%, respectively; P < .001).

Independent predictors of missed SMIC on optical evaluation, as identified in the multiple logistic regression analysis, included nodular morphology (odds ratio, 7.2; 95% CI, 2.8-18.9; P < .001), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7; P =.026), and size of at least 40 mm (OR, 2.0; 95% CI, 1.0-3.8; P =.039).

Based on the findings, the researchers suggested that all flat lesions, in the absence of optical features consistent with submucosal invasive cancer, should subsequently be removed by high-quality endoscopic mucosal resection, in conjunction with the application of “site-specific modifications and ancillary techniques where needed.”

One limitation of this study is how lesion morphology was classified, which can in some cases be subjective.

The researchers added that additional refinement is required “to robustly apply a selective resection algorithm irrespective of lesion morphology” given the modest performance value of optical evaluation in nodular lesions. “Nevertheless, it is imperative that all endoscopists embrace optical evaluation in everyday clinical practice, thus harnessing its proven ability to influence resection technique selection and the associated clinical and economic ramifications,” they concluded.

The study received financial support the Cancer Institute of New South Wales, in addition to funding from the Gallipoli Medical Research Foundation. One author reported receiving research support from Olympus Medical, Cook Medical, and Boston Scientific. The remaining authors disclosed no conflicts.

An in-office age spot removal treatment known as Glacial Rx removes age spots without the risks, side effects, or limitations associated with heat-based devices, according to Arisa E. Ortiz, MD.

“What’s unique about this device is that I can see results without any downtime,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said during a virtual course on laser and aesthetic skin therapy. “Most other devices are not like that. It was well tolerated; there was minimal pain. There was no postinflammatory hyperpigmentation; it really is customizable to the patients’ needs.”

First cleared by the Food and Drug Administration in 2016 to remove benign lesions of the skin, Glacial Rx received an expanded indication in 2020 to temporarily reduce pain, swelling, and inflammation. The device, which was developed by R2 Technologies, relies on cryomodulation, a concept developed at Massachusetts General Hospital and the Wellman Center for Photomedicine, Boston, to improve skin appearance and freeze melanin at the source. “Cryomodulation pauses melanin production, but the melanocyte function is preserved, the epidermal barrier is not disrupted, and there is no persistent inflammatory response, which is key, because it decreases the risk of postinflammatory hyperpigmentation, especially in darker skin types,” Dr. Ortiz said.

Here’s how it works: The handpiece of the device is placed on top of the skin and cooling is delivered to targeted solar lentigos and other benign lesions. Ice nucleation takes place within the dendrites. As cell turnover takes place, melanin-free cells migrate upward and appear as new skin. “Clinically, this appears as clearance of the lesion,” Dr. Ortiz said.

She discussed her clinical experience treating 15 patients with a beta version of the device. Since that time, Glacial Rx was redesigned to include a smaller-tipped handpiece, easier and faster prep time, and a proprietary water-based gel to facilitate ice crystal propagation, which is applied to the targeted lesions just prior to treatment.

For the trial at UCSD, the researchers performed 29 treatment sessions on 15 patients with Fitzpatrick skin types I-IV, to gain clinical experience and evaluate the effectiveness of the device. They found that the treatment was well tolerated, with minimal discomfort. The amount of heat extracted ranged from 107 to 166 kJ/cm². No long-term dyschromia was observed, and some patients had lesion clearance after just one treatment.

“The settings are able to be titrated to where you have zero downtime, but you still get a lightening effect,” Dr. Ortiz said during the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “With other devices such as intense pulsed light, if you don’t see darkening than it probably didn’t work. With this device, you can titrate the length of the cooling and the temperature of the cooling.”

Posttreatment side effects commonly observed in the study were mild erythema, swelling, itching, and darkening. “There was minimal erythema in the higher settings, and some reports of itching and transient darkening in some of the higher settings,” she said.

Future indications for Glacial Rx may include psoriasis, acne, and rosacea. “We did try to use this for melasma,” she said. “It was effective, but I wouldn’t say it’s a cure for melasma. Melasma is very stubborn and requires a combination treatment, but it’s something we can use in our armamentarium.”

Dr. Ortiz reported having received consulting fees from R2 Technologies. She has been a paid consultant for and has received equipment from many device companies.

[email protected]

An in-office age spot removal treatment known as Glacial Rx removes age spots without the risks, side effects, or limitations associated with heat-based devices, according to Arisa E. Ortiz, MD.

“What’s unique about this device is that I can see results without any downtime,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said during a virtual course on laser and aesthetic skin therapy. “Most other devices are not like that. It was well tolerated; there was minimal pain. There was no postinflammatory hyperpigmentation; it really is customizable to the patients’ needs.”

First cleared by the Food and Drug Administration in 2016 to remove benign lesions of the skin, Glacial Rx received an expanded indication in 2020 to temporarily reduce pain, swelling, and inflammation. The device, which was developed by R2 Technologies, relies on cryomodulation, a concept developed at Massachusetts General Hospital and the Wellman Center for Photomedicine, Boston, to improve skin appearance and freeze melanin at the source. “Cryomodulation pauses melanin production, but the melanocyte function is preserved, the epidermal barrier is not disrupted, and there is no persistent inflammatory response, which is key, because it decreases the risk of postinflammatory hyperpigmentation, especially in darker skin types,” Dr. Ortiz said.

Here’s how it works: The handpiece of the device is placed on top of the skin and cooling is delivered to targeted solar lentigos and other benign lesions. Ice nucleation takes place within the dendrites. As cell turnover takes place, melanin-free cells migrate upward and appear as new skin. “Clinically, this appears as clearance of the lesion,” Dr. Ortiz said.

She discussed her clinical experience treating 15 patients with a beta version of the device. Since that time, Glacial Rx was redesigned to include a smaller-tipped handpiece, easier and faster prep time, and a proprietary water-based gel to facilitate ice crystal propagation, which is applied to the targeted lesions just prior to treatment.

For the trial at UCSD, the researchers performed 29 treatment sessions on 15 patients with Fitzpatrick skin types I-IV, to gain clinical experience and evaluate the effectiveness of the device. They found that the treatment was well tolerated, with minimal discomfort. The amount of heat extracted ranged from 107 to 166 kJ/cm². No long-term dyschromia was observed, and some patients had lesion clearance after just one treatment.

“The settings are able to be titrated to where you have zero downtime, but you still get a lightening effect,” Dr. Ortiz said during the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “With other devices such as intense pulsed light, if you don’t see darkening than it probably didn’t work. With this device, you can titrate the length of the cooling and the temperature of the cooling.”

Posttreatment side effects commonly observed in the study were mild erythema, swelling, itching, and darkening. “There was minimal erythema in the higher settings, and some reports of itching and transient darkening in some of the higher settings,” she said.

Future indications for Glacial Rx may include psoriasis, acne, and rosacea. “We did try to use this for melasma,” she said. “It was effective, but I wouldn’t say it’s a cure for melasma. Melasma is very stubborn and requires a combination treatment, but it’s something we can use in our armamentarium.”

Dr. Ortiz reported having received consulting fees from R2 Technologies. She has been a paid consultant for and has received equipment from many device companies.

[email protected]

An in-office age spot removal treatment known as Glacial Rx removes age spots without the risks, side effects, or limitations associated with heat-based devices, according to Arisa E. Ortiz, MD.

“What’s unique about this device is that I can see results without any downtime,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said during a virtual course on laser and aesthetic skin therapy. “Most other devices are not like that. It was well tolerated; there was minimal pain. There was no postinflammatory hyperpigmentation; it really is customizable to the patients’ needs.”

First cleared by the Food and Drug Administration in 2016 to remove benign lesions of the skin, Glacial Rx received an expanded indication in 2020 to temporarily reduce pain, swelling, and inflammation. The device, which was developed by R2 Technologies, relies on cryomodulation, a concept developed at Massachusetts General Hospital and the Wellman Center for Photomedicine, Boston, to improve skin appearance and freeze melanin at the source. “Cryomodulation pauses melanin production, but the melanocyte function is preserved, the epidermal barrier is not disrupted, and there is no persistent inflammatory response, which is key, because it decreases the risk of postinflammatory hyperpigmentation, especially in darker skin types,” Dr. Ortiz said.

Here’s how it works: The handpiece of the device is placed on top of the skin and cooling is delivered to targeted solar lentigos and other benign lesions. Ice nucleation takes place within the dendrites. As cell turnover takes place, melanin-free cells migrate upward and appear as new skin. “Clinically, this appears as clearance of the lesion,” Dr. Ortiz said.

She discussed her clinical experience treating 15 patients with a beta version of the device. Since that time, Glacial Rx was redesigned to include a smaller-tipped handpiece, easier and faster prep time, and a proprietary water-based gel to facilitate ice crystal propagation, which is applied to the targeted lesions just prior to treatment.

For the trial at UCSD, the researchers performed 29 treatment sessions on 15 patients with Fitzpatrick skin types I-IV, to gain clinical experience and evaluate the effectiveness of the device. They found that the treatment was well tolerated, with minimal discomfort. The amount of heat extracted ranged from 107 to 166 kJ/cm². No long-term dyschromia was observed, and some patients had lesion clearance after just one treatment.

“The settings are able to be titrated to where you have zero downtime, but you still get a lightening effect,” Dr. Ortiz said during the meeting, named “Laser & Aesthetic Skin Therapy: What’s the Truth?” sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “With other devices such as intense pulsed light, if you don’t see darkening than it probably didn’t work. With this device, you can titrate the length of the cooling and the temperature of the cooling.”

Posttreatment side effects commonly observed in the study were mild erythema, swelling, itching, and darkening. “There was minimal erythema in the higher settings, and some reports of itching and transient darkening in some of the higher settings,” she said.

Future indications for Glacial Rx may include psoriasis, acne, and rosacea. “We did try to use this for melasma,” she said. “It was effective, but I wouldn’t say it’s a cure for melasma. Melasma is very stubborn and requires a combination treatment, but it’s something we can use in our armamentarium.”

Dr. Ortiz reported having received consulting fees from R2 Technologies. She has been a paid consultant for and has received equipment from many device companies.

[email protected]

Pain is as individual as patients are, a multiple sclerosis (MS) specialist told colleagues, and one size does not fit all when it comes to treatment. Flexibility and multiple strategies are key, especially considering that pain can evolve over time because of changes in MS and related conditions.

“Pain syndromes are incredibly common. They can happen in monophasic, neurological attacks, or relapsing conditions,” neurologist Scott Newsome, DO, of Johns Hopkins University, Baltimore, said in a presentation about pain at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC). “The good news is there are a lot of things that we can do to help our patients, and the buck does not just stop with oral medications.”

Dr. Newsome, president of the CMSC’s foundation, noted that pain syndromes affect most people who have spinal cord attacks. Research has suggested that the severity of initial attacks is a predictor of the severity of pain syndromes to come.

“There’s a number of triggers that can worsen these pain syndromes – not sleeping well the night before, anxiety, or when someone overheats,” he said. “A lot of our patients during the summertime, when they go out, they want to enjoy themselves and hang out with their family. If the ambient temperature is to a degree where they have increased symptoms, it really impacts their quality of life.”

Dr. Newsome urged colleagues to consider the three types of pain – primary, such as those related to spasticity or tonic spasms; secondary, which can be caused by weakness, reaction to weakness, and spasticity; and tertiary, which is the emotional response to pain.

Tertiary and secondary pain are often overlooked. On the latter front, “early on in my career, I was a big offender,” he said. “I would just focus how a person had a direct injury to the nervous system and not realize that their hip isn’t hurting because of it. It’s a compensatory mechanism after the direct injury, affecting the muscle skeletal system adversely, and having this wear-and-tear phenomenon – setting them up for advanced arthritis, or even a vascular necrosis.”

In regard to MS, he said, it’s helpful to understand pain syndromes. One type is neuropathic: pain that’s worse at night, doesn’t respond well to standard painkillers, and needs multiple therapies. Another type is paroxysmal cord phenomena, which include tonic spasms, Lhermitte’s sign (“an uncomfortable, shocking, vibrating, electrical pain that goes right down their spine” when the neck is flexed), and a condition known as MS hug. “Our patients will come in and say: ‘Oh, it feels like someone’s given me a bear hug or is strangling me.’”

What works as therapy for primary pain syndromes? “I personally don’t like opioids for any pain syndrome, for a lot of reasons,” he said, but a combination of other drugs can be helpful at low doses to start. “I’m a big believer in combining treatments that have different mechanism of actions” instead of, say, combining gabapentin with pregabalin, nerve drugs which work in similar ways.

Dr. Newsome recalled seeing a patient recently who said: “Oh, I tried that drug, I tried this drug, they didn’t help, and I couldn’t tolerate them.” Turns out the patient was taking maximum doses. “No wonder you didn’t tolerate it,” Dr. Newsome said.

Nonpharmaceutical interventions can play an important role, he said. “Believe it or not, we’ve had a lot of people get benefit from acupuncture and massage therapy. And we’ve had some people actually undergo spinal cord stimulation and get stimulators placed. It’s rare, but that’s a consideration for individuals who are refractory to everything you do.”

Medical marijuana, Botox, ketamine, and intrathecal baclofen are other options, he said.

Finally, he said, slowly taper a patient off pain medications if they’re pain free for 3 months. “If someone is doing nonpharmacological interventions, and they’re having a good deal of pain relief, then that’s definitely an opportunity to cut back on the pain medications.”

Pain is as individual as patients are, a multiple sclerosis (MS) specialist told colleagues, and one size does not fit all when it comes to treatment. Flexibility and multiple strategies are key, especially considering that pain can evolve over time because of changes in MS and related conditions.

“Pain syndromes are incredibly common. They can happen in monophasic, neurological attacks, or relapsing conditions,” neurologist Scott Newsome, DO, of Johns Hopkins University, Baltimore, said in a presentation about pain at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC). “The good news is there are a lot of things that we can do to help our patients, and the buck does not just stop with oral medications.”

Dr. Newsome, president of the CMSC’s foundation, noted that pain syndromes affect most people who have spinal cord attacks. Research has suggested that the severity of initial attacks is a predictor of the severity of pain syndromes to come.

“There’s a number of triggers that can worsen these pain syndromes – not sleeping well the night before, anxiety, or when someone overheats,” he said. “A lot of our patients during the summertime, when they go out, they want to enjoy themselves and hang out with their family. If the ambient temperature is to a degree where they have increased symptoms, it really impacts their quality of life.”

Dr. Newsome urged colleagues to consider the three types of pain – primary, such as those related to spasticity or tonic spasms; secondary, which can be caused by weakness, reaction to weakness, and spasticity; and tertiary, which is the emotional response to pain.

Tertiary and secondary pain are often overlooked. On the latter front, “early on in my career, I was a big offender,” he said. “I would just focus how a person had a direct injury to the nervous system and not realize that their hip isn’t hurting because of it. It’s a compensatory mechanism after the direct injury, affecting the muscle skeletal system adversely, and having this wear-and-tear phenomenon – setting them up for advanced arthritis, or even a vascular necrosis.”

In regard to MS, he said, it’s helpful to understand pain syndromes. One type is neuropathic: pain that’s worse at night, doesn’t respond well to standard painkillers, and needs multiple therapies. Another type is paroxysmal cord phenomena, which include tonic spasms, Lhermitte’s sign (“an uncomfortable, shocking, vibrating, electrical pain that goes right down their spine” when the neck is flexed), and a condition known as MS hug. “Our patients will come in and say: ‘Oh, it feels like someone’s given me a bear hug or is strangling me.’”

What works as therapy for primary pain syndromes? “I personally don’t like opioids for any pain syndrome, for a lot of reasons,” he said, but a combination of other drugs can be helpful at low doses to start. “I’m a big believer in combining treatments that have different mechanism of actions” instead of, say, combining gabapentin with pregabalin, nerve drugs which work in similar ways.

Dr. Newsome recalled seeing a patient recently who said: “Oh, I tried that drug, I tried this drug, they didn’t help, and I couldn’t tolerate them.” Turns out the patient was taking maximum doses. “No wonder you didn’t tolerate it,” Dr. Newsome said.

Nonpharmaceutical interventions can play an important role, he said. “Believe it or not, we’ve had a lot of people get benefit from acupuncture and massage therapy. And we’ve had some people actually undergo spinal cord stimulation and get stimulators placed. It’s rare, but that’s a consideration for individuals who are refractory to everything you do.”

Medical marijuana, Botox, ketamine, and intrathecal baclofen are other options, he said.

Finally, he said, slowly taper a patient off pain medications if they’re pain free for 3 months. “If someone is doing nonpharmacological interventions, and they’re having a good deal of pain relief, then that’s definitely an opportunity to cut back on the pain medications.”

Pain is as individual as patients are, a multiple sclerosis (MS) specialist told colleagues, and one size does not fit all when it comes to treatment. Flexibility and multiple strategies are key, especially considering that pain can evolve over time because of changes in MS and related conditions.

“Pain syndromes are incredibly common. They can happen in monophasic, neurological attacks, or relapsing conditions,” neurologist Scott Newsome, DO, of Johns Hopkins University, Baltimore, said in a presentation about pain at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC). “The good news is there are a lot of things that we can do to help our patients, and the buck does not just stop with oral medications.”

Dr. Newsome, president of the CMSC’s foundation, noted that pain syndromes affect most people who have spinal cord attacks. Research has suggested that the severity of initial attacks is a predictor of the severity of pain syndromes to come.

“There’s a number of triggers that can worsen these pain syndromes – not sleeping well the night before, anxiety, or when someone overheats,” he said. “A lot of our patients during the summertime, when they go out, they want to enjoy themselves and hang out with their family. If the ambient temperature is to a degree where they have increased symptoms, it really impacts their quality of life.”

Dr. Newsome urged colleagues to consider the three types of pain – primary, such as those related to spasticity or tonic spasms; secondary, which can be caused by weakness, reaction to weakness, and spasticity; and tertiary, which is the emotional response to pain.

Tertiary and secondary pain are often overlooked. On the latter front, “early on in my career, I was a big offender,” he said. “I would just focus how a person had a direct injury to the nervous system and not realize that their hip isn’t hurting because of it. It’s a compensatory mechanism after the direct injury, affecting the muscle skeletal system adversely, and having this wear-and-tear phenomenon – setting them up for advanced arthritis, or even a vascular necrosis.”

In regard to MS, he said, it’s helpful to understand pain syndromes. One type is neuropathic: pain that’s worse at night, doesn’t respond well to standard painkillers, and needs multiple therapies. Another type is paroxysmal cord phenomena, which include tonic spasms, Lhermitte’s sign (“an uncomfortable, shocking, vibrating, electrical pain that goes right down their spine” when the neck is flexed), and a condition known as MS hug. “Our patients will come in and say: ‘Oh, it feels like someone’s given me a bear hug or is strangling me.’”

What works as therapy for primary pain syndromes? “I personally don’t like opioids for any pain syndrome, for a lot of reasons,” he said, but a combination of other drugs can be helpful at low doses to start. “I’m a big believer in combining treatments that have different mechanism of actions” instead of, say, combining gabapentin with pregabalin, nerve drugs which work in similar ways.

Dr. Newsome recalled seeing a patient recently who said: “Oh, I tried that drug, I tried this drug, they didn’t help, and I couldn’t tolerate them.” Turns out the patient was taking maximum doses. “No wonder you didn’t tolerate it,” Dr. Newsome said.

Nonpharmaceutical interventions can play an important role, he said. “Believe it or not, we’ve had a lot of people get benefit from acupuncture and massage therapy. And we’ve had some people actually undergo spinal cord stimulation and get stimulators placed. It’s rare, but that’s a consideration for individuals who are refractory to everything you do.”

Medical marijuana, Botox, ketamine, and intrathecal baclofen are other options, he said.

Finally, he said, slowly taper a patient off pain medications if they’re pain free for 3 months. “If someone is doing nonpharmacological interventions, and they’re having a good deal of pain relief, then that’s definitely an opportunity to cut back on the pain medications.”

AGA President John Inadomi, MD, and former AGA President David Lieberman, MD, along with American Cancer Society Cancer Action Network and Fight CRC, met with Assistant Secretary of Labor, Ali Khawar, and representatives from the U.S. Department of Health & Human Services and U.S. Department of Treasury to request they direct private health plans to cover colonoscopy after a positive noninvasive colorectal cancer (CRC) screening test.

The meeting was in response to an appeal sent to the three agencies, which provided guidance to health plans to ensure that workers have the benefits that have been agreed upon by their employers. As part of the Affordable Care Act, plans are mandated to cover colorectal cancer screening without cost sharing.

In May 2021, when the United States Preventive Services Task Force (USPFTF) lowered the recommended CRC screening age to 45, it also stated that “positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.”

To ensure that privately insured Americans receive proper CRC screening, AGA, ACS, and Fight CRC are pushing the government to provide written guidance to private plans clarifying that follow-up colonoscopies conducted after a positive noninvasive screening test are part of the colorectal cancer screening process and, therefore, patients should not face out-of-pocket costs when completing colorectal cancer screening.

Colorectal cancer remains the second leading killer in cancer in the United States despite the availability of preventive screening options. In 2018, just 68.8% of those eligible were screened for colorectal cancer. The challenge of getting people screened was exacerbated in 2020 when it is estimated that colorectal cancer screening declined by 86% during the first few months of the COVID-19 pandemic.

AGA President John Inadomi, MD, and former AGA President David Lieberman, MD, along with American Cancer Society Cancer Action Network and Fight CRC, met with Assistant Secretary of Labor, Ali Khawar, and representatives from the U.S. Department of Health & Human Services and U.S. Department of Treasury to request they direct private health plans to cover colonoscopy after a positive noninvasive colorectal cancer (CRC) screening test.

The meeting was in response to an appeal sent to the three agencies, which provided guidance to health plans to ensure that workers have the benefits that have been agreed upon by their employers. As part of the Affordable Care Act, plans are mandated to cover colorectal cancer screening without cost sharing.

In May 2021, when the United States Preventive Services Task Force (USPFTF) lowered the recommended CRC screening age to 45, it also stated that “positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.”

To ensure that privately insured Americans receive proper CRC screening, AGA, ACS, and Fight CRC are pushing the government to provide written guidance to private plans clarifying that follow-up colonoscopies conducted after a positive noninvasive screening test are part of the colorectal cancer screening process and, therefore, patients should not face out-of-pocket costs when completing colorectal cancer screening.

Colorectal cancer remains the second leading killer in cancer in the United States despite the availability of preventive screening options. In 2018, just 68.8% of those eligible were screened for colorectal cancer. The challenge of getting people screened was exacerbated in 2020 when it is estimated that colorectal cancer screening declined by 86% during the first few months of the COVID-19 pandemic.

AGA President John Inadomi, MD, and former AGA President David Lieberman, MD, along with American Cancer Society Cancer Action Network and Fight CRC, met with Assistant Secretary of Labor, Ali Khawar, and representatives from the U.S. Department of Health & Human Services and U.S. Department of Treasury to request they direct private health plans to cover colonoscopy after a positive noninvasive colorectal cancer (CRC) screening test.

The meeting was in response to an appeal sent to the three agencies, which provided guidance to health plans to ensure that workers have the benefits that have been agreed upon by their employers. As part of the Affordable Care Act, plans are mandated to cover colorectal cancer screening without cost sharing.

In May 2021, when the United States Preventive Services Task Force (USPFTF) lowered the recommended CRC screening age to 45, it also stated that “positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.”

To ensure that privately insured Americans receive proper CRC screening, AGA, ACS, and Fight CRC are pushing the government to provide written guidance to private plans clarifying that follow-up colonoscopies conducted after a positive noninvasive screening test are part of the colorectal cancer screening process and, therefore, patients should not face out-of-pocket costs when completing colorectal cancer screening.

Colorectal cancer remains the second leading killer in cancer in the United States despite the availability of preventive screening options. In 2018, just 68.8% of those eligible were screened for colorectal cancer. The challenge of getting people screened was exacerbated in 2020 when it is estimated that colorectal cancer screening declined by 86% during the first few months of the COVID-19 pandemic.

An increasing number of people who are unvaccinated and pregnant are being hospitalized for COVID-19, report investigators who saw hospital admissions double in a single year.

“With the surge, we had expected to begin treating patients who developed severe or critical illness again in pregnancy,” says Emily Adhikari, MD, from the University of Texas Southwestern Medical Center in Dallas. “But we did not expect the level of respiratory illness that we began to see in our patients. That was a surprise and an alarming finding that we felt was really important to get out there.”

The researchers followed more than 1,500 pregnant women diagnosed with COVID-19 who received care from Parkland Health and Hospital System in Dallas County, one of the nation’s busiest for deliveries. After the emergence of the Delta variant, the number of pregnant women hospitalized with COVID-19 more than doubled over the previous year.

And 82 pregnant women went on to develop severe or critical COVID, they report in their study, published online in the American Journal of Obstetrics and Gynecology. All but 1 of these patients were unvaccinated, 10 needed a ventilator, and two died.

The proportion of cases that were critical was about 5% in 2020. However, in April 2021, even though the number of total cases remained low, the number of severe illnesses started to rise. After the Delta variant became dominant, both the number and severity of cases increased, and after August 2021, more than 25% of pregnant people diagnosed with COVID-19 required hospitalization.
 

Hospitalizations Double

“We need to focus and really act urgently to recommend vaccination in pregnancy because that is the primary prevention tool that we have,” says Dr. Adhikari. “We do not have a proven cure for this illness, and that is important to know.”

These findings, which focus on a vulnerable population, are especially important given the elevated prevalence of COVID-19 in pregnant people of lower economic status, said Lissette Tanner, MD, MPH, from Emory University in Atlanta, who was not involved with the study.

“There are higher rates of hospitalization and death among Black, Hispanic, and Native American communities,” she reported. “It is essential to know how the virus is affecting those most affected and often most disadvantaged to deal with the pandemic.”

Vaccination rates are low in this population; just 19.2% of pregnant women receive at least one dose during pregnancy, according to the CDC. But pregnancy confers a higher risk for severe COVID-19 illness and for adverse outcomes, such as preterm birth and stillbirth.

Of the 665 people in the study cohort who were pregnant or had given birth when the vaccines were available, only 21.4% received at least one dose of a COVID-19 vaccine.

Given the increased risk for COVID-19 during pregnancy, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the CDC recommend vaccination for people who are pregnant, breastfeeding, or trying to get pregnant.

According to ACOG, pregnant women who are fully vaccinated can follow the same guidelines as everyone else who is fully vaccinated; however, to prevent breakthrough infections, they might want to continue wearing a mask. ACOG also recommends that those not fully vaccinated follow physical-distancing guidelines and limit contact with people as much as possible to avoid infection.

A version of this article first appeared on WebMD.com.

An increasing number of people who are unvaccinated and pregnant are being hospitalized for COVID-19, report investigators who saw hospital admissions double in a single year.

“With the surge, we had expected to begin treating patients who developed severe or critical illness again in pregnancy,” says Emily Adhikari, MD, from the University of Texas Southwestern Medical Center in Dallas. “But we did not expect the level of respiratory illness that we began to see in our patients. That was a surprise and an alarming finding that we felt was really important to get out there.”

The researchers followed more than 1,500 pregnant women diagnosed with COVID-19 who received care from Parkland Health and Hospital System in Dallas County, one of the nation’s busiest for deliveries. After the emergence of the Delta variant, the number of pregnant women hospitalized with COVID-19 more than doubled over the previous year.

And 82 pregnant women went on to develop severe or critical COVID, they report in their study, published online in the American Journal of Obstetrics and Gynecology. All but 1 of these patients were unvaccinated, 10 needed a ventilator, and two died.

The proportion of cases that were critical was about 5% in 2020. However, in April 2021, even though the number of total cases remained low, the number of severe illnesses started to rise. After the Delta variant became dominant, both the number and severity of cases increased, and after August 2021, more than 25% of pregnant people diagnosed with COVID-19 required hospitalization.
 

Hospitalizations Double

“We need to focus and really act urgently to recommend vaccination in pregnancy because that is the primary prevention tool that we have,” says Dr. Adhikari. “We do not have a proven cure for this illness, and that is important to know.”

These findings, which focus on a vulnerable population, are especially important given the elevated prevalence of COVID-19 in pregnant people of lower economic status, said Lissette Tanner, MD, MPH, from Emory University in Atlanta, who was not involved with the study.

“There are higher rates of hospitalization and death among Black, Hispanic, and Native American communities,” she reported. “It is essential to know how the virus is affecting those most affected and often most disadvantaged to deal with the pandemic.”

Vaccination rates are low in this population; just 19.2% of pregnant women receive at least one dose during pregnancy, according to the CDC. But pregnancy confers a higher risk for severe COVID-19 illness and for adverse outcomes, such as preterm birth and stillbirth.

Of the 665 people in the study cohort who were pregnant or had given birth when the vaccines were available, only 21.4% received at least one dose of a COVID-19 vaccine.

Given the increased risk for COVID-19 during pregnancy, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the CDC recommend vaccination for people who are pregnant, breastfeeding, or trying to get pregnant.

According to ACOG, pregnant women who are fully vaccinated can follow the same guidelines as everyone else who is fully vaccinated; however, to prevent breakthrough infections, they might want to continue wearing a mask. ACOG also recommends that those not fully vaccinated follow physical-distancing guidelines and limit contact with people as much as possible to avoid infection.

A version of this article first appeared on WebMD.com.

An increasing number of people who are unvaccinated and pregnant are being hospitalized for COVID-19, report investigators who saw hospital admissions double in a single year.

“With the surge, we had expected to begin treating patients who developed severe or critical illness again in pregnancy,” says Emily Adhikari, MD, from the University of Texas Southwestern Medical Center in Dallas. “But we did not expect the level of respiratory illness that we began to see in our patients. That was a surprise and an alarming finding that we felt was really important to get out there.”

The researchers followed more than 1,500 pregnant women diagnosed with COVID-19 who received care from Parkland Health and Hospital System in Dallas County, one of the nation’s busiest for deliveries. After the emergence of the Delta variant, the number of pregnant women hospitalized with COVID-19 more than doubled over the previous year.

And 82 pregnant women went on to develop severe or critical COVID, they report in their study, published online in the American Journal of Obstetrics and Gynecology. All but 1 of these patients were unvaccinated, 10 needed a ventilator, and two died.

The proportion of cases that were critical was about 5% in 2020. However, in April 2021, even though the number of total cases remained low, the number of severe illnesses started to rise. After the Delta variant became dominant, both the number and severity of cases increased, and after August 2021, more than 25% of pregnant people diagnosed with COVID-19 required hospitalization.
 

Hospitalizations Double

“We need to focus and really act urgently to recommend vaccination in pregnancy because that is the primary prevention tool that we have,” says Dr. Adhikari. “We do not have a proven cure for this illness, and that is important to know.”

These findings, which focus on a vulnerable population, are especially important given the elevated prevalence of COVID-19 in pregnant people of lower economic status, said Lissette Tanner, MD, MPH, from Emory University in Atlanta, who was not involved with the study.

“There are higher rates of hospitalization and death among Black, Hispanic, and Native American communities,” she reported. “It is essential to know how the virus is affecting those most affected and often most disadvantaged to deal with the pandemic.”

Vaccination rates are low in this population; just 19.2% of pregnant women receive at least one dose during pregnancy, according to the CDC. But pregnancy confers a higher risk for severe COVID-19 illness and for adverse outcomes, such as preterm birth and stillbirth.

Of the 665 people in the study cohort who were pregnant or had given birth when the vaccines were available, only 21.4% received at least one dose of a COVID-19 vaccine.

Given the increased risk for COVID-19 during pregnancy, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the CDC recommend vaccination for people who are pregnant, breastfeeding, or trying to get pregnant.

According to ACOG, pregnant women who are fully vaccinated can follow the same guidelines as everyone else who is fully vaccinated; however, to prevent breakthrough infections, they might want to continue wearing a mask. ACOG also recommends that those not fully vaccinated follow physical-distancing guidelines and limit contact with people as much as possible to avoid infection.

A version of this article first appeared on WebMD.com.

Omar A. Ibrahimi, MD, PhD, hears some dermatology colleagues say they don’t bother to offer laser hair removal in their practices because they figure that the procedure is under the purview of medical spas, but he sees it differently.

“I offer laser hair removal in my practice as a way to protect my patients from being picked off by medical spas,” Dr. Ibrahimi, a dermatologist and medical director of the Connecticut Skin Institute, said during a virtual course on laser and aesthetic skin therapy. “These patients are going to want to get laser hair removal. If they’re not going to have the opportunity to get it at your practice, they’re going to seek it elsewhere. When they go elsewhere, they’re going to be picked off for other procedures as well.”

First developed in 1995 by R. Rox Anderson, MD, and colleagues at The Wellman Center for Photomedicine, laser hair removal has become the gold standard for permanent hair destruction, and ranks as the most common energy-based procedure performed in the world, Dr. Ibrahimi said. “Results are very long lasting and durable beyond 2 years after treatment,” he said. “These patients tend to be highly satisfied and have permanence with these treatments.”
 

Treatment goal, patient selection

While the target chromophore for the procedure is melanin, the goal is to destroy the stem cells located in the hair bulge and the hair bulb. “This is technically called the extended theory of selective photothermolysis, but it’s the same concept except that our target chromophore and our desired target for destruction are slightly spatially separated,” he said.

Proper patient selection is key, so a focused medical history and physical exam are essential prior to the procedure. If unwanted hair is located on the face, jawline, or chest of a female, consider and ask about potential endocrine-related dysfunctions such as polycystic ovary syndrome (PCOS). “Getting those addressed can often help the hypertrichosis as well,” he said. “Another condition is explosive hypertrichosis where hair growth starts very suddenly. It’s uncommon but it’s something to think about.”

Pregnancy is not an absolute contraindication for laser hair removal, Dr. Ibrahimi continued, but he elects not to perform the procedure on pregnant patients. He also asks patients about any history of photosensitivity, active infection at the intended treatment site, keloids, or hypertrophic scarring. Past methods of hair removal also matter. “What we’re targeting is the pigment in the hair shafts,” he said. “So, if your patient is waxing or plucking or epilating or removing the hair in some manner, they’re actually removing the target chromophore.”

Patients with darker Fitzpatrick skin types can be treated safely but tanned individuals face a risk of complications because of active melanocytes. “As we approach summer in New England, we slow down the amount of hair removal we do because it’s a riskier procedure,” he said. “I recommend that my patients not get any significant amount of sun exposure a month before or after treatment.”

The color and quality of hair also drive treatment success. Black and brown terminal hairs absorb the millisecond laser energy, but white, gray, red, and light blond hairs lack adequate melanin to make them suitable target chromophores.

Excessive and unwanted body hair ranges in severity and can usually be classified as either hypertrichosis or hirsutism.

The desired clinical endpoint is perifollicular edema and erythema. Treatment parameters that can be varied with Food and Drug Administration–cleared devices include wavelength, fluence, pulse duration, spot size, and skin cooling. The most popular devices are the Alexandrite 755 nm laser; the diode 800 nm laser; and the 1064 nm Nd:YAG laser, which is safe for all skin types. “Often you have to use higher relative fluences to treat patients with the 1064 nm Nd:YAG because on the absorption spectrum, the 1064-nm wavelength has a relatively lower absorption for melanin compared to the alexandrite. However, you can still get effective, long-term hair reduction with the Nd:YAG laser,” he said (Arch Dermatol. 2008 Oct;144[10]:1323-7).

More recently, Dr. Ibrahimi and colleagues found that a 1060-nm diode laser system with multiple handpieces for permanent hair reduction was safe for all skin types, in an open label prospective study.

Higher fluences have been correlated with greater rates of permanent hair removal, but they also are more likely to cause undesired side effects. Dr. Ibrahimi advises clinicians new to laser hair removal to conduct a few different test spots and look for the desired clinical endpoint of perifollicular erythema and edema. “The highest fluence that gives you that endpoint without any adverse reactions is going to the best fluence for treatment,” he said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “Do a few test spots, bring them back a week later and see which ones were tolerated well without any side effects and which weren’t. That gives you a good starting point for your treatment.”

Cooling down the epidermal melanin not only keeps the procedure safe, it’s a salve for pain. “There are a variety of methods of passive and active cooling,” said Dr. Ibrahimi, a member of the American Society for Dermatologic Surgery board of directors. “You can use something as simple as cold gel, but the active methods are better because once the method of passive application of cold gel warms up, you lose that cooling effect. You can use forced chilled air. Many commercial devices come with a cold tip which cools down the epidermal melanin. Others use dynamic cooling, which emit cryogen spray from a separate part of the handpiece. It hits right where the laser pulse is going to go, is absorbed by the skin, and it cools down the epidermal melanin.”


 

Treatment complications

Complications that can occur from treatment include pigmentary changes such as hyperpigmentation and hypopigmentation. “In lighter skinned individuals, sometimes excess fluence can lead to an erythematous appearance,” he said. “In darker-skinned individuals, this often manifests as hyperpigmentation and can be very long-lasting.” Dr. Ibrahimi ranks improper technique as a complication, “because ideally you want to lay your pulses down with 10%-15% overlap during treatment,” he explained. “If you don’t overlap, you’re going to have zones that don’t get any of the laser photons. If you do, then your patient is not going to be happy with you.”

Paradoxical hypertrichosis occurs in 1%-5% of patients, typically in women from Mediterranean, Middle Eastern, or South Asian ethnic backgrounds. This tends to develop on the lateral or jawline part of the face. “Often it occurs in the setting where they come in and want these vellus hairs treated,” he said. “Somehow the laser, instead of destroying the hair shaft, triggers it and stimulates it and can’t differentiate a vellus hair from a terminal hair. This is important to discuss during your informed consent, especially when you’re treating on the lateral jawline or the sideburn area. If this happens, you can treat through it.”

Transgender patients and future directions

Dr. Ibrahimi pointed out that increasing numbers of transgender patients are visiting dermatologists seeking laser hair removal. About 16 million Americans are estimated to have a gender identity that differs from the one assigned to them at birth, yet they face several barriers to care, “ranging from ignorance on our end to maybe our own biases being transposed onto these patients,” he said. “We really need to do a better job for them. We really have an obligation to provide good care for all of our patients.”

Transgender women typically seek hair removal on the face and neck as well as in the genital area to remove hairs in preparation for vaginoplasty. Transgender men typically seek hair reduction on the forearm or on the thigh, because those are graft sites in preparation for phalloplasty. As a resource for transgender care, he recommends the UCSF Transgender Care website.

As for future directions in the field, Dr. Ibrahimi predicted that hair removal devices for home use will continue to improve and become more widespread. “This raises a host of considerations, from the risk of eye damage to the risk for paradoxical hypertrichosis, and what happens when pigmented lesions get treated with these low-powered machines compared to the ones we have in our office,” he said. “I also think we’re going to see office-based devices with larger spot sizes, smarter devices that are capable of taking over more of the functions we do. I’m most excited about the potential for treating nonpigmented white hair or poorly pigmented blond or reddish hair in the future.”

Dr. Ibrahimi disclosed that he has received research funding and speaker honoraria from Lutronic, Lumenis, Cutera, and Syneron-Candela. He also holds stock in AVAVA Inc.

[email protected]

Omar A. Ibrahimi, MD, PhD, hears some dermatology colleagues say they don’t bother to offer laser hair removal in their practices because they figure that the procedure is under the purview of medical spas, but he sees it differently.

“I offer laser hair removal in my practice as a way to protect my patients from being picked off by medical spas,” Dr. Ibrahimi, a dermatologist and medical director of the Connecticut Skin Institute, said during a virtual course on laser and aesthetic skin therapy. “These patients are going to want to get laser hair removal. If they’re not going to have the opportunity to get it at your practice, they’re going to seek it elsewhere. When they go elsewhere, they’re going to be picked off for other procedures as well.”

First developed in 1995 by R. Rox Anderson, MD, and colleagues at The Wellman Center for Photomedicine, laser hair removal has become the gold standard for permanent hair destruction, and ranks as the most common energy-based procedure performed in the world, Dr. Ibrahimi said. “Results are very long lasting and durable beyond 2 years after treatment,” he said. “These patients tend to be highly satisfied and have permanence with these treatments.”
 

Treatment goal, patient selection

While the target chromophore for the procedure is melanin, the goal is to destroy the stem cells located in the hair bulge and the hair bulb. “This is technically called the extended theory of selective photothermolysis, but it’s the same concept except that our target chromophore and our desired target for destruction are slightly spatially separated,” he said.

Proper patient selection is key, so a focused medical history and physical exam are essential prior to the procedure. If unwanted hair is located on the face, jawline, or chest of a female, consider and ask about potential endocrine-related dysfunctions such as polycystic ovary syndrome (PCOS). “Getting those addressed can often help the hypertrichosis as well,” he said. “Another condition is explosive hypertrichosis where hair growth starts very suddenly. It’s uncommon but it’s something to think about.”

Pregnancy is not an absolute contraindication for laser hair removal, Dr. Ibrahimi continued, but he elects not to perform the procedure on pregnant patients. He also asks patients about any history of photosensitivity, active infection at the intended treatment site, keloids, or hypertrophic scarring. Past methods of hair removal also matter. “What we’re targeting is the pigment in the hair shafts,” he said. “So, if your patient is waxing or plucking or epilating or removing the hair in some manner, they’re actually removing the target chromophore.”

Patients with darker Fitzpatrick skin types can be treated safely but tanned individuals face a risk of complications because of active melanocytes. “As we approach summer in New England, we slow down the amount of hair removal we do because it’s a riskier procedure,” he said. “I recommend that my patients not get any significant amount of sun exposure a month before or after treatment.”

The color and quality of hair also drive treatment success. Black and brown terminal hairs absorb the millisecond laser energy, but white, gray, red, and light blond hairs lack adequate melanin to make them suitable target chromophores.

Excessive and unwanted body hair ranges in severity and can usually be classified as either hypertrichosis or hirsutism.

The desired clinical endpoint is perifollicular edema and erythema. Treatment parameters that can be varied with Food and Drug Administration–cleared devices include wavelength, fluence, pulse duration, spot size, and skin cooling. The most popular devices are the Alexandrite 755 nm laser; the diode 800 nm laser; and the 1064 nm Nd:YAG laser, which is safe for all skin types. “Often you have to use higher relative fluences to treat patients with the 1064 nm Nd:YAG because on the absorption spectrum, the 1064-nm wavelength has a relatively lower absorption for melanin compared to the alexandrite. However, you can still get effective, long-term hair reduction with the Nd:YAG laser,” he said (Arch Dermatol. 2008 Oct;144[10]:1323-7).

More recently, Dr. Ibrahimi and colleagues found that a 1060-nm diode laser system with multiple handpieces for permanent hair reduction was safe for all skin types, in an open label prospective study.

Higher fluences have been correlated with greater rates of permanent hair removal, but they also are more likely to cause undesired side effects. Dr. Ibrahimi advises clinicians new to laser hair removal to conduct a few different test spots and look for the desired clinical endpoint of perifollicular erythema and edema. “The highest fluence that gives you that endpoint without any adverse reactions is going to the best fluence for treatment,” he said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “Do a few test spots, bring them back a week later and see which ones were tolerated well without any side effects and which weren’t. That gives you a good starting point for your treatment.”

Cooling down the epidermal melanin not only keeps the procedure safe, it’s a salve for pain. “There are a variety of methods of passive and active cooling,” said Dr. Ibrahimi, a member of the American Society for Dermatologic Surgery board of directors. “You can use something as simple as cold gel, but the active methods are better because once the method of passive application of cold gel warms up, you lose that cooling effect. You can use forced chilled air. Many commercial devices come with a cold tip which cools down the epidermal melanin. Others use dynamic cooling, which emit cryogen spray from a separate part of the handpiece. It hits right where the laser pulse is going to go, is absorbed by the skin, and it cools down the epidermal melanin.”


 

Treatment complications

Complications that can occur from treatment include pigmentary changes such as hyperpigmentation and hypopigmentation. “In lighter skinned individuals, sometimes excess fluence can lead to an erythematous appearance,” he said. “In darker-skinned individuals, this often manifests as hyperpigmentation and can be very long-lasting.” Dr. Ibrahimi ranks improper technique as a complication, “because ideally you want to lay your pulses down with 10%-15% overlap during treatment,” he explained. “If you don’t overlap, you’re going to have zones that don’t get any of the laser photons. If you do, then your patient is not going to be happy with you.”

Paradoxical hypertrichosis occurs in 1%-5% of patients, typically in women from Mediterranean, Middle Eastern, or South Asian ethnic backgrounds. This tends to develop on the lateral or jawline part of the face. “Often it occurs in the setting where they come in and want these vellus hairs treated,” he said. “Somehow the laser, instead of destroying the hair shaft, triggers it and stimulates it and can’t differentiate a vellus hair from a terminal hair. This is important to discuss during your informed consent, especially when you’re treating on the lateral jawline or the sideburn area. If this happens, you can treat through it.”

Transgender patients and future directions

Dr. Ibrahimi pointed out that increasing numbers of transgender patients are visiting dermatologists seeking laser hair removal. About 16 million Americans are estimated to have a gender identity that differs from the one assigned to them at birth, yet they face several barriers to care, “ranging from ignorance on our end to maybe our own biases being transposed onto these patients,” he said. “We really need to do a better job for them. We really have an obligation to provide good care for all of our patients.”

Transgender women typically seek hair removal on the face and neck as well as in the genital area to remove hairs in preparation for vaginoplasty. Transgender men typically seek hair reduction on the forearm or on the thigh, because those are graft sites in preparation for phalloplasty. As a resource for transgender care, he recommends the UCSF Transgender Care website.

As for future directions in the field, Dr. Ibrahimi predicted that hair removal devices for home use will continue to improve and become more widespread. “This raises a host of considerations, from the risk of eye damage to the risk for paradoxical hypertrichosis, and what happens when pigmented lesions get treated with these low-powered machines compared to the ones we have in our office,” he said. “I also think we’re going to see office-based devices with larger spot sizes, smarter devices that are capable of taking over more of the functions we do. I’m most excited about the potential for treating nonpigmented white hair or poorly pigmented blond or reddish hair in the future.”

Dr. Ibrahimi disclosed that he has received research funding and speaker honoraria from Lutronic, Lumenis, Cutera, and Syneron-Candela. He also holds stock in AVAVA Inc.

[email protected]

Omar A. Ibrahimi, MD, PhD, hears some dermatology colleagues say they don’t bother to offer laser hair removal in their practices because they figure that the procedure is under the purview of medical spas, but he sees it differently.

“I offer laser hair removal in my practice as a way to protect my patients from being picked off by medical spas,” Dr. Ibrahimi, a dermatologist and medical director of the Connecticut Skin Institute, said during a virtual course on laser and aesthetic skin therapy. “These patients are going to want to get laser hair removal. If they’re not going to have the opportunity to get it at your practice, they’re going to seek it elsewhere. When they go elsewhere, they’re going to be picked off for other procedures as well.”

First developed in 1995 by R. Rox Anderson, MD, and colleagues at The Wellman Center for Photomedicine, laser hair removal has become the gold standard for permanent hair destruction, and ranks as the most common energy-based procedure performed in the world, Dr. Ibrahimi said. “Results are very long lasting and durable beyond 2 years after treatment,” he said. “These patients tend to be highly satisfied and have permanence with these treatments.”
 

Treatment goal, patient selection

While the target chromophore for the procedure is melanin, the goal is to destroy the stem cells located in the hair bulge and the hair bulb. “This is technically called the extended theory of selective photothermolysis, but it’s the same concept except that our target chromophore and our desired target for destruction are slightly spatially separated,” he said.

Proper patient selection is key, so a focused medical history and physical exam are essential prior to the procedure. If unwanted hair is located on the face, jawline, or chest of a female, consider and ask about potential endocrine-related dysfunctions such as polycystic ovary syndrome (PCOS). “Getting those addressed can often help the hypertrichosis as well,” he said. “Another condition is explosive hypertrichosis where hair growth starts very suddenly. It’s uncommon but it’s something to think about.”

Pregnancy is not an absolute contraindication for laser hair removal, Dr. Ibrahimi continued, but he elects not to perform the procedure on pregnant patients. He also asks patients about any history of photosensitivity, active infection at the intended treatment site, keloids, or hypertrophic scarring. Past methods of hair removal also matter. “What we’re targeting is the pigment in the hair shafts,” he said. “So, if your patient is waxing or plucking or epilating or removing the hair in some manner, they’re actually removing the target chromophore.”

Patients with darker Fitzpatrick skin types can be treated safely but tanned individuals face a risk of complications because of active melanocytes. “As we approach summer in New England, we slow down the amount of hair removal we do because it’s a riskier procedure,” he said. “I recommend that my patients not get any significant amount of sun exposure a month before or after treatment.”

The color and quality of hair also drive treatment success. Black and brown terminal hairs absorb the millisecond laser energy, but white, gray, red, and light blond hairs lack adequate melanin to make them suitable target chromophores.

Excessive and unwanted body hair ranges in severity and can usually be classified as either hypertrichosis or hirsutism.

The desired clinical endpoint is perifollicular edema and erythema. Treatment parameters that can be varied with Food and Drug Administration–cleared devices include wavelength, fluence, pulse duration, spot size, and skin cooling. The most popular devices are the Alexandrite 755 nm laser; the diode 800 nm laser; and the 1064 nm Nd:YAG laser, which is safe for all skin types. “Often you have to use higher relative fluences to treat patients with the 1064 nm Nd:YAG because on the absorption spectrum, the 1064-nm wavelength has a relatively lower absorption for melanin compared to the alexandrite. However, you can still get effective, long-term hair reduction with the Nd:YAG laser,” he said (Arch Dermatol. 2008 Oct;144[10]:1323-7).

More recently, Dr. Ibrahimi and colleagues found that a 1060-nm diode laser system with multiple handpieces for permanent hair reduction was safe for all skin types, in an open label prospective study.

Higher fluences have been correlated with greater rates of permanent hair removal, but they also are more likely to cause undesired side effects. Dr. Ibrahimi advises clinicians new to laser hair removal to conduct a few different test spots and look for the desired clinical endpoint of perifollicular erythema and edema. “The highest fluence that gives you that endpoint without any adverse reactions is going to the best fluence for treatment,” he said at the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. “Do a few test spots, bring them back a week later and see which ones were tolerated well without any side effects and which weren’t. That gives you a good starting point for your treatment.”

Cooling down the epidermal melanin not only keeps the procedure safe, it’s a salve for pain. “There are a variety of methods of passive and active cooling,” said Dr. Ibrahimi, a member of the American Society for Dermatologic Surgery board of directors. “You can use something as simple as cold gel, but the active methods are better because once the method of passive application of cold gel warms up, you lose that cooling effect. You can use forced chilled air. Many commercial devices come with a cold tip which cools down the epidermal melanin. Others use dynamic cooling, which emit cryogen spray from a separate part of the handpiece. It hits right where the laser pulse is going to go, is absorbed by the skin, and it cools down the epidermal melanin.”


 

Treatment complications

Complications that can occur from treatment include pigmentary changes such as hyperpigmentation and hypopigmentation. “In lighter skinned individuals, sometimes excess fluence can lead to an erythematous appearance,” he said. “In darker-skinned individuals, this often manifests as hyperpigmentation and can be very long-lasting.” Dr. Ibrahimi ranks improper technique as a complication, “because ideally you want to lay your pulses down with 10%-15% overlap during treatment,” he explained. “If you don’t overlap, you’re going to have zones that don’t get any of the laser photons. If you do, then your patient is not going to be happy with you.”

Paradoxical hypertrichosis occurs in 1%-5% of patients, typically in women from Mediterranean, Middle Eastern, or South Asian ethnic backgrounds. This tends to develop on the lateral or jawline part of the face. “Often it occurs in the setting where they come in and want these vellus hairs treated,” he said. “Somehow the laser, instead of destroying the hair shaft, triggers it and stimulates it and can’t differentiate a vellus hair from a terminal hair. This is important to discuss during your informed consent, especially when you’re treating on the lateral jawline or the sideburn area. If this happens, you can treat through it.”

Transgender patients and future directions

Dr. Ibrahimi pointed out that increasing numbers of transgender patients are visiting dermatologists seeking laser hair removal. About 16 million Americans are estimated to have a gender identity that differs from the one assigned to them at birth, yet they face several barriers to care, “ranging from ignorance on our end to maybe our own biases being transposed onto these patients,” he said. “We really need to do a better job for them. We really have an obligation to provide good care for all of our patients.”

Transgender women typically seek hair removal on the face and neck as well as in the genital area to remove hairs in preparation for vaginoplasty. Transgender men typically seek hair reduction on the forearm or on the thigh, because those are graft sites in preparation for phalloplasty. As a resource for transgender care, he recommends the UCSF Transgender Care website.

As for future directions in the field, Dr. Ibrahimi predicted that hair removal devices for home use will continue to improve and become more widespread. “This raises a host of considerations, from the risk of eye damage to the risk for paradoxical hypertrichosis, and what happens when pigmented lesions get treated with these low-powered machines compared to the ones we have in our office,” he said. “I also think we’re going to see office-based devices with larger spot sizes, smarter devices that are capable of taking over more of the functions we do. I’m most excited about the potential for treating nonpigmented white hair or poorly pigmented blond or reddish hair in the future.”

Dr. Ibrahimi disclosed that he has received research funding and speaker honoraria from Lutronic, Lumenis, Cutera, and Syneron-Candela. He also holds stock in AVAVA Inc.

[email protected]