Neil Osterweil

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

BOSTON – Sequential application of pulsed dye and Nd:YAG lasers is safe and effective for treating small basal cell carcinomas, based on data from a prospective study of patients with nodular and superficial BCC subtypes on the trunk and extremities.

The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery.

In a study of 10 patients with BCC, 7 of the 12 lesions treated with pulsed dye laser followed by Nd:YAG laser showed completed clinical and histologic clearance, said Dr. H. Ray Jalian of Massachusetts General Hospital in Boston.

"Targeting the microvasculature of BCC offers a promising new treatment approach. These tumors have large caliber feeding vessels; oftentimes these vessels are larger than the surrounding stroma," he said.

Data from a previous study (Lasers Surg. Med. 2009;41:417-42) showed a 92% regression rate of BCC lesions smaller than 1.5 cm treated with a 595 nm pulsed dye laser, Dr. Jalian noted.

The rationale for the sequential laser therapy is that pulsed dye laser energy is well absorbed by hemoglobin, which generates methemoglobin that in turn absorbs 1064 nm Nd:YAG energy, allowing the energy to penetrate to deep vessels.

"We hypothesized that targeting the vasculature of basal cells at two levels may be able to selectively destroy deeper vessels and perhaps achieve a higher cure rate," he said.

The investigators conducted a prospective study with 10 patients who had a total of 13 BCC of nodular and superficial subtypes on the trunk and extremities (1 patient with a single lesion was not available for follow-up).

The treated lesions were less than 2 cm with clearly visible margins that would be suitable for treatment with standard surgical excision. Patients with scars or infections in the area to be treated were excluded, as were those who were immunocompromised or pregnant.

The participants underwent four laser treatments 2-4 weeks apart with a 585-nm PDL set for a 7-mm spot size, 8-J/cm², 2-ms pulse duration, followed by a 1064-nm Nd:YAG laser set with a 7-mm spot, 40-J/cm², 15-ms pulse duration.

A total of 7 of the 12 lesions available for follow-up were completely cleared on both clinical and histologic evaluation. Of the eight tumors under 1 cm in size, six were completely cleared by sequential laser therapy,

Of the four patients with 5 lesions with residual disease after four laser sessions, three were on anticoagulation therapy with aspirin, and one with warfarin.

"We did see a clearance of the nodular component in most cases, but there was persistent residual superficial BCC in these patients," Dr. Jalian said.

Anticoagulation may hamper the laser effect by reducing laser-induced vascular injury, he noted.

Treatment-related side effects included erythema, scarring, and hyperpigmentation. Erythema and scarring decreased from the first treatment to the last follow-up visit, while hyperpigmentation increased slightly from the first to the third treatment, and then plateaued.

Biopsy scars improved with sequential treatments, Dr. Jalian noted.

Possible explanations for the lower success rate treating BCC compared to previous studies include the use of a slightly lower wavelength laser (585 vs. 595), and lower energy settings (8 J/cm² for 2 ms, vs. 15 J/cm² for 3 ms), and by mix of histologic subtypes, said Dr. Jalian.

"Superficial subtypes present in residual lesions suggest there may be a different vascular pattern in these lesions."

The findings also suggest that anticoagulation therapy may need to be suspended before treatment with pulsed dye, Nd:YAG, and other vascular-specific lasers, he added.

The study was internally supported. Dr. Jalian reported having no financial disclosures.

surgerynews@frontlinemedcom.com

NEW YORK – A traditional Mediterranean-style diet does not appear to be better at controlling glycemia, but its other healthy effects make it a worthwhile alternative to other diet plans for people with diabetes, according to nutritionist Jackie L. Boucher.

Definitions vary somewhat, but the Mediterranean dietary pattern – fruits and vegetables, whole grains, fish, olive oil, nuts and legumes, and red wine – is consistent with other nutritional plans for patients with diabetes, including Dietary Approaches to Stop Hypertension (DASH) and the American Diabetes Association (ADA) diet, she said at the annual advanced postgraduate course held by the American Diabetes Association.

©Dušan Zidar/Fotolia.com

"I think the Mediterranean-style diet can fit with recommendations for the prevention and treatment of diabetes," said Ms. Boucher, vice president for education and director of the Heart of New Ulm Project for the Minneapolis Heart Institute Foundation.

Both the ADA and Mediterranean eating plans encourage patients to be active and eat foods lower in saturated and trans fats, and combined with the dietary guidance provided by diabetes educators and nutritionists, can help to prevent some of the more dire complications associated with diabetes, she said.

Her presentation coincided with the online publication in the New England Journal of Medicine of a randomized clinical trial from Spain, showing that among persons at high risk for cardiovascular disease, including many with type 2 diabetes, a Mediterranean diet supplemented with extravirgin olive oil or nuts significantly reduced the incidence of major cardiovascular events. The study did not look at the effect of diet on glycemia, however.

Call it an ‘eating pattern’

A Mediterranean diet, as defined in 1993 in a European consensus conference, is rich in plant-based foods (vegetables, fruits, grains, nuts, and seeds); uses minimally processed and seasonal locally grown foods; and includes fruit as the typical daily dessert, supplemented with sweets based on nuts, olive oil, and honey or concentrated sugars on special occasions. Dairy products are eaten in low to moderate quantities, red meat is consumed infrequently, and meals are usually accompanied by wine in low to moderate amounts.

There are different regional flavors of the diet, with Greeks getting about 40% of total energy from fat, compared with about 30% from fat for Italians. Italians eat more pasta than the Greeks or Spaniards, and Spaniards typically eat more fish. Therefore, it makes sense to think of it more as an eating pattern than as a diet, Ms. Boucher said.

Evidence-based studies have hinted that such dietary patterns may protect against coronary heart disease, type 2 diabetes, hypertension, thromboembolic events, osteoporosis, and cancers of the breast, stomach, colorectal tract, and prostate, she said.

However, different study methodologies and definitions of a Mediterranean-style eating pattern have made it hard to tease out specific effects of following such a pattern. Additionally, some studies do not control for physical activity or for social engagement during meals, while others may exclude wine, which has been shown to offset lipid peroxidation from red meat consumption when the wine is taken with the meal.

Mixed results

A recently published systematic review of studies of macronutrients, food groups, and eating patterns in the management of diabetes noted that most studies leave out energy balance and healthy eating patterns, which are considered to be essential components of medical nutrition therapy.

Regarding the question of an optimal macronutrient ration for glycemic management and cardiovascular risk reduction in people with diabetes, the authors found that although "in many instances there were not statistically significant differences between dietary approaches, improvements were often seen from baseline to follow-up in both intervention groups, supporting the idea that several different macronutrient distributions may lead to improvements in glycemic and/or [cardiovascular disease] risk factors."

Although the Mediterranean diet pattern does not appear to have specific benefits on glycemic control when compared with other diet plans or healthy eating patterns, the general principles of eating whole foods, eating in moderation, and eating a variety of plant-based foods can be safely recommended to patients with diabetes, Ms. Boucher said.

She reported having no relevant financial disclosures.

NEW YORK – A traditional Mediterranean-style diet does not appear to be better at controlling glycemia, but its other healthy effects make it a worthwhile alternative to other diet plans for people with diabetes, according to nutritionist Jackie L. Boucher.

Definitions vary somewhat, but the Mediterranean dietary pattern – fruits and vegetables, whole grains, fish, olive oil, nuts and legumes, and red wine – is consistent with other nutritional plans for patients with diabetes, including Dietary Approaches to Stop Hypertension (DASH) and the American Diabetes Association (ADA) diet, she said at the annual advanced postgraduate course held by the American Diabetes Association.

©Dušan Zidar/Fotolia.com

"I think the Mediterranean-style diet can fit with recommendations for the prevention and treatment of diabetes," said Ms. Boucher, vice president for education and director of the Heart of New Ulm Project for the Minneapolis Heart Institute Foundation.

Both the ADA and Mediterranean eating plans encourage patients to be active and eat foods lower in saturated and trans fats, and combined with the dietary guidance provided by diabetes educators and nutritionists, can help to prevent some of the more dire complications associated with diabetes, she said.

Her presentation coincided with the online publication in the New England Journal of Medicine of a randomized clinical trial from Spain, showing that among persons at high risk for cardiovascular disease, including many with type 2 diabetes, a Mediterranean diet supplemented with extravirgin olive oil or nuts significantly reduced the incidence of major cardiovascular events. The study did not look at the effect of diet on glycemia, however.

Call it an ‘eating pattern’

A Mediterranean diet, as defined in 1993 in a European consensus conference, is rich in plant-based foods (vegetables, fruits, grains, nuts, and seeds); uses minimally processed and seasonal locally grown foods; and includes fruit as the typical daily dessert, supplemented with sweets based on nuts, olive oil, and honey or concentrated sugars on special occasions. Dairy products are eaten in low to moderate quantities, red meat is consumed infrequently, and meals are usually accompanied by wine in low to moderate amounts.

There are different regional flavors of the diet, with Greeks getting about 40% of total energy from fat, compared with about 30% from fat for Italians. Italians eat more pasta than the Greeks or Spaniards, and Spaniards typically eat more fish. Therefore, it makes sense to think of it more as an eating pattern than as a diet, Ms. Boucher said.

Evidence-based studies have hinted that such dietary patterns may protect against coronary heart disease, type 2 diabetes, hypertension, thromboembolic events, osteoporosis, and cancers of the breast, stomach, colorectal tract, and prostate, she said.

However, different study methodologies and definitions of a Mediterranean-style eating pattern have made it hard to tease out specific effects of following such a pattern. Additionally, some studies do not control for physical activity or for social engagement during meals, while others may exclude wine, which has been shown to offset lipid peroxidation from red meat consumption when the wine is taken with the meal.

Mixed results

A recently published systematic review of studies of macronutrients, food groups, and eating patterns in the management of diabetes noted that most studies leave out energy balance and healthy eating patterns, which are considered to be essential components of medical nutrition therapy.

Regarding the question of an optimal macronutrient ration for glycemic management and cardiovascular risk reduction in people with diabetes, the authors found that although "in many instances there were not statistically significant differences between dietary approaches, improvements were often seen from baseline to follow-up in both intervention groups, supporting the idea that several different macronutrient distributions may lead to improvements in glycemic and/or [cardiovascular disease] risk factors."

Although the Mediterranean diet pattern does not appear to have specific benefits on glycemic control when compared with other diet plans or healthy eating patterns, the general principles of eating whole foods, eating in moderation, and eating a variety of plant-based foods can be safely recommended to patients with diabetes, Ms. Boucher said.

She reported having no relevant financial disclosures.

NEW YORK – A traditional Mediterranean-style diet does not appear to be better at controlling glycemia, but its other healthy effects make it a worthwhile alternative to other diet plans for people with diabetes, according to nutritionist Jackie L. Boucher.

Definitions vary somewhat, but the Mediterranean dietary pattern – fruits and vegetables, whole grains, fish, olive oil, nuts and legumes, and red wine – is consistent with other nutritional plans for patients with diabetes, including Dietary Approaches to Stop Hypertension (DASH) and the American Diabetes Association (ADA) diet, she said at the annual advanced postgraduate course held by the American Diabetes Association.

©Dušan Zidar/Fotolia.com

"I think the Mediterranean-style diet can fit with recommendations for the prevention and treatment of diabetes," said Ms. Boucher, vice president for education and director of the Heart of New Ulm Project for the Minneapolis Heart Institute Foundation.

Both the ADA and Mediterranean eating plans encourage patients to be active and eat foods lower in saturated and trans fats, and combined with the dietary guidance provided by diabetes educators and nutritionists, can help to prevent some of the more dire complications associated with diabetes, she said.

Her presentation coincided with the online publication in the New England Journal of Medicine of a randomized clinical trial from Spain, showing that among persons at high risk for cardiovascular disease, including many with type 2 diabetes, a Mediterranean diet supplemented with extravirgin olive oil or nuts significantly reduced the incidence of major cardiovascular events. The study did not look at the effect of diet on glycemia, however.

Call it an ‘eating pattern’

A Mediterranean diet, as defined in 1993 in a European consensus conference, is rich in plant-based foods (vegetables, fruits, grains, nuts, and seeds); uses minimally processed and seasonal locally grown foods; and includes fruit as the typical daily dessert, supplemented with sweets based on nuts, olive oil, and honey or concentrated sugars on special occasions. Dairy products are eaten in low to moderate quantities, red meat is consumed infrequently, and meals are usually accompanied by wine in low to moderate amounts.

There are different regional flavors of the diet, with Greeks getting about 40% of total energy from fat, compared with about 30% from fat for Italians. Italians eat more pasta than the Greeks or Spaniards, and Spaniards typically eat more fish. Therefore, it makes sense to think of it more as an eating pattern than as a diet, Ms. Boucher said.

Evidence-based studies have hinted that such dietary patterns may protect against coronary heart disease, type 2 diabetes, hypertension, thromboembolic events, osteoporosis, and cancers of the breast, stomach, colorectal tract, and prostate, she said.

However, different study methodologies and definitions of a Mediterranean-style eating pattern have made it hard to tease out specific effects of following such a pattern. Additionally, some studies do not control for physical activity or for social engagement during meals, while others may exclude wine, which has been shown to offset lipid peroxidation from red meat consumption when the wine is taken with the meal.

Mixed results

A recently published systematic review of studies of macronutrients, food groups, and eating patterns in the management of diabetes noted that most studies leave out energy balance and healthy eating patterns, which are considered to be essential components of medical nutrition therapy.

Regarding the question of an optimal macronutrient ration for glycemic management and cardiovascular risk reduction in people with diabetes, the authors found that although "in many instances there were not statistically significant differences between dietary approaches, improvements were often seen from baseline to follow-up in both intervention groups, supporting the idea that several different macronutrient distributions may lead to improvements in glycemic and/or [cardiovascular disease] risk factors."

Although the Mediterranean diet pattern does not appear to have specific benefits on glycemic control when compared with other diet plans or healthy eating patterns, the general principles of eating whole foods, eating in moderation, and eating a variety of plant-based foods can be safely recommended to patients with diabetes, Ms. Boucher said.

She reported having no relevant financial disclosures.

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

sknews@frontlinemedcom.com

NEW YORK – More than 40% of Americans with type 2 diabetes never receive any formal education in self-management of their disease, a situation that is likely to only get worse as the population gets older and more obese, according to diabetes educator Dr. Sandra Drozdz Burke.

The Affordable Care Act is expected to bring millions more patients – many with diabetes – into the health care system through the expansion of Medicaid rolls. "When we have that much diabetes to deal with, we’re going to need to have lots of people who know how to take care of themselves," said Dr. Burke, director of the University of Illinois College of Nursing at Urbana-Champaign.

She noted that the number of Americans with diabetes is projected to grow from 23.7 million in 2008 to 44.1 million in 2034, and annual U.S. spending on diabetes is projected to triple – from $113 billion to $336 billion – over the same period (Diabetes Care 2009;32:2225-9).

In 2011, approximately 30,000 people were working as diabetes educators in the United States, which is 24,000 short of the estimated 54,000 projected to be needed by the year 2025, Dr. Burke said at the annual advanced postgraduate course held by the American Diabetes Association.

Most diabetes patients get their care from primary care practitioners, and many are typically referred to specialty care "only at the end of the road," when complications of diabetes are advanced and irreversible, she said. But in clinical practice – in the 8- to 12-minute encounter – there is little time to cram in everything a patient with diabetes needs to know about healthy eating, exercise and physical activity, medication, self-monitoring of blood glucose, risk reduction, and mental health.

"We know that diabetes educators, when they are embedded in primary care, work. We’ve seen research about that for the last several years," she said. "If we want to improve the care of patients with diabetes, we need to be in primary care," she said.

As the health care economy makes the transition from the fee-for-service model to accountable care organizations and patient-centered medical homes, diabetes educators will become even more important, Dr. Burke said. She proposed a patient-centered medical home model designed specifically for patients with diabetes, the metabolic syndrome, or people who are at risk for diabetes. Such a system could include diabetes educators, nutritionists, endocrinologists, physician assistants, pharmacists, and other clinicians who could help patients to manage their health and reduce the need for specialty care.

National standards revised

In a separate talk, Janice L. Koshinsky, diabetes program manager for the University of Pittsburgh’s Lions Diabetes Center in McKeesport, Pa., highlighted changes to recently published national standards for diabetes self-management education (DSME) and diabetes self-management support (DSMS) that may help to increase the ranks of diabetes educators.

The new standards include emphasis on ongoing self-management support and diabetes prevention (including treatment of gestational diabetes and prediabetes). Although most of the changes are minor, generally involving clarification of terms, one of the standards broadens the definition for instructional staff.

Previously, the standards held that at least one of the instructors in a diabetes self-management program should be a registered nurse, dietitian, or pharmacist.

The new standard, however, states that "one or more instructors will provide DSME, and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be an registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE [certified diabetes educator] or BC-ADM [board-certified advanced diabetes manager]. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes, and with supervision and support."

With the previous standards, "we were really excluding some other health care professionals who may be certified in diabetes education, especially if they were in a standalone program," Ms. Koshinsky said.

Dr. Burke reported being a consultant to Janssen Pharmaceuticals and Genentech. Ms. Koshinsky reported being a consultant to Healthy Interactions and Merck.

NEW YORK – More than 40% of Americans with type 2 diabetes never receive any formal education in self-management of their disease, a situation that is likely to only get worse as the population gets older and more obese, according to diabetes educator Dr. Sandra Drozdz Burke.

The Affordable Care Act is expected to bring millions more patients – many with diabetes – into the health care system through the expansion of Medicaid rolls. "When we have that much diabetes to deal with, we’re going to need to have lots of people who know how to take care of themselves," said Dr. Burke, director of the University of Illinois College of Nursing at Urbana-Champaign.

She noted that the number of Americans with diabetes is projected to grow from 23.7 million in 2008 to 44.1 million in 2034, and annual U.S. spending on diabetes is projected to triple – from $113 billion to $336 billion – over the same period (Diabetes Care 2009;32:2225-9).

In 2011, approximately 30,000 people were working as diabetes educators in the United States, which is 24,000 short of the estimated 54,000 projected to be needed by the year 2025, Dr. Burke said at the annual advanced postgraduate course held by the American Diabetes Association.

Most diabetes patients get their care from primary care practitioners, and many are typically referred to specialty care "only at the end of the road," when complications of diabetes are advanced and irreversible, she said. But in clinical practice – in the 8- to 12-minute encounter – there is little time to cram in everything a patient with diabetes needs to know about healthy eating, exercise and physical activity, medication, self-monitoring of blood glucose, risk reduction, and mental health.

"We know that diabetes educators, when they are embedded in primary care, work. We’ve seen research about that for the last several years," she said. "If we want to improve the care of patients with diabetes, we need to be in primary care," she said.

As the health care economy makes the transition from the fee-for-service model to accountable care organizations and patient-centered medical homes, diabetes educators will become even more important, Dr. Burke said. She proposed a patient-centered medical home model designed specifically for patients with diabetes, the metabolic syndrome, or people who are at risk for diabetes. Such a system could include diabetes educators, nutritionists, endocrinologists, physician assistants, pharmacists, and other clinicians who could help patients to manage their health and reduce the need for specialty care.

National standards revised

In a separate talk, Janice L. Koshinsky, diabetes program manager for the University of Pittsburgh’s Lions Diabetes Center in McKeesport, Pa., highlighted changes to recently published national standards for diabetes self-management education (DSME) and diabetes self-management support (DSMS) that may help to increase the ranks of diabetes educators.

The new standards include emphasis on ongoing self-management support and diabetes prevention (including treatment of gestational diabetes and prediabetes). Although most of the changes are minor, generally involving clarification of terms, one of the standards broadens the definition for instructional staff.

Previously, the standards held that at least one of the instructors in a diabetes self-management program should be a registered nurse, dietitian, or pharmacist.

The new standard, however, states that "one or more instructors will provide DSME, and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be an registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE [certified diabetes educator] or BC-ADM [board-certified advanced diabetes manager]. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes, and with supervision and support."

With the previous standards, "we were really excluding some other health care professionals who may be certified in diabetes education, especially if they were in a standalone program," Ms. Koshinsky said.

Dr. Burke reported being a consultant to Janssen Pharmaceuticals and Genentech. Ms. Koshinsky reported being a consultant to Healthy Interactions and Merck.

NEW YORK – More than 40% of Americans with type 2 diabetes never receive any formal education in self-management of their disease, a situation that is likely to only get worse as the population gets older and more obese, according to diabetes educator Dr. Sandra Drozdz Burke.

The Affordable Care Act is expected to bring millions more patients – many with diabetes – into the health care system through the expansion of Medicaid rolls. "When we have that much diabetes to deal with, we’re going to need to have lots of people who know how to take care of themselves," said Dr. Burke, director of the University of Illinois College of Nursing at Urbana-Champaign.

She noted that the number of Americans with diabetes is projected to grow from 23.7 million in 2008 to 44.1 million in 2034, and annual U.S. spending on diabetes is projected to triple – from $113 billion to $336 billion – over the same period (Diabetes Care 2009;32:2225-9).

In 2011, approximately 30,000 people were working as diabetes educators in the United States, which is 24,000 short of the estimated 54,000 projected to be needed by the year 2025, Dr. Burke said at the annual advanced postgraduate course held by the American Diabetes Association.

Most diabetes patients get their care from primary care practitioners, and many are typically referred to specialty care "only at the end of the road," when complications of diabetes are advanced and irreversible, she said. But in clinical practice – in the 8- to 12-minute encounter – there is little time to cram in everything a patient with diabetes needs to know about healthy eating, exercise and physical activity, medication, self-monitoring of blood glucose, risk reduction, and mental health.

"We know that diabetes educators, when they are embedded in primary care, work. We’ve seen research about that for the last several years," she said. "If we want to improve the care of patients with diabetes, we need to be in primary care," she said.

As the health care economy makes the transition from the fee-for-service model to accountable care organizations and patient-centered medical homes, diabetes educators will become even more important, Dr. Burke said. She proposed a patient-centered medical home model designed specifically for patients with diabetes, the metabolic syndrome, or people who are at risk for diabetes. Such a system could include diabetes educators, nutritionists, endocrinologists, physician assistants, pharmacists, and other clinicians who could help patients to manage their health and reduce the need for specialty care.

National standards revised

In a separate talk, Janice L. Koshinsky, diabetes program manager for the University of Pittsburgh’s Lions Diabetes Center in McKeesport, Pa., highlighted changes to recently published national standards for diabetes self-management education (DSME) and diabetes self-management support (DSMS) that may help to increase the ranks of diabetes educators.

The new standards include emphasis on ongoing self-management support and diabetes prevention (including treatment of gestational diabetes and prediabetes). Although most of the changes are minor, generally involving clarification of terms, one of the standards broadens the definition for instructional staff.

Previously, the standards held that at least one of the instructors in a diabetes self-management program should be a registered nurse, dietitian, or pharmacist.

The new standard, however, states that "one or more instructors will provide DSME, and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be an registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE [certified diabetes educator] or BC-ADM [board-certified advanced diabetes manager]. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes, and with supervision and support."

With the previous standards, "we were really excluding some other health care professionals who may be certified in diabetes education, especially if they were in a standalone program," Ms. Koshinsky said.

Dr. Burke reported being a consultant to Janssen Pharmaceuticals and Genentech. Ms. Koshinsky reported being a consultant to Healthy Interactions and Merck.

NEW YORK – Studies continue to examine approaches that might reduce the well-known increased risk for cognitive decline and dementia in people with type 2 diabetes.

A combination of hyperglycemia, insulin resistance, oxidative stress, and other diabetes-related factors appears to play a part in the cognitive impairment associated with type 2 diabetes, said Dr. Jeff D. Williamson, chief of gerontology and geriatric medicine and director of the Kulynych Brain Research Center at Wake Forest University in Winston-Salem, N.C.

But, to date, there hasn’t been much success in intervening in type 2 diabetes patients to affect cognitive outcomes.

"Brain disease is prevalent in type 2 diabetes, and the risk for progression to dementia is high. There’s really no evidence that intensive medication can change that rate, at least at this point, but there may be some evidence that behavioral interventions are effective," Dr. Williamson said at the annual advanced postgraduate course held by the American Diabetes Association.

He advised that "monitoring cognitive function should take its place alongside lipid monitoring, kidney function monitoring, and eye monitoring in your assessments of patients coming through. Diabetes education may be adapted in people who are showing cognitive frailty, and we really need more work to show what works best in this population, but we certainly know that they are going to need more backup strategies."

Pathways to dementia

Diabetes interacts with the brain through two primary pathways: neuronal factors, including advanced glycated end products (with the apt acronym AGES), altered metabolism of neurotransmitters, and hypoglycemia; and vascular factors, including hypertension, endothelial damage, infarction, white-matter lesions, and disruption of the blood-brain barrier.

Both pathways contribute to inflammation, oxidative stress, and altered energy metabolism, which in turn lead to small- and large-vessel disease in the case of vascular damage factors, and to cortical atrophy in the case of neuronal degeneration. The end result of these processes may be vascular or Alzheimer’s type cognitive impairment and dementia, Dr. Williamson said.

Imaging studies conducted as part of the ACCORD-Memory in Diabetes Study (ACCORD-MIND, a substudy of the ACCORD [Action to Control Cardiovascular Risk in Diabetes] Study), showed increased white-matter lesions and brain atrophy in some people with type 2 diabetes, he noted.

In addition, a 2011 study, which Dr. Williamson coauthored, found that postmenopausal women with type 2 diabetes had deficits in verbal knowledge and verbal memory relative to similar women with no diabetes. Deficits in fine motor speed, a marker of cognitive impairment, also were more common in women with longer diabetes duration. Insulin use, indicative of diabetes severity, was associated with greater cognitive deficits, whereas oral medications were associated with better relative cognitive function.

Similarly, a 2009 systematic review and meta-analysis detected significant relative risks (RRs) associated with all diabetes types and all dementia types (RR, 1.47), Alzheimer’s disease (RR, 1.39), and vascular dementia (RR, 2.38).

Disappointing results

As in the parent trial, the ACCORD-MIND trial investigators found that an intensive glucose control intervention did not affect patients’ scores on the Digital Symbol Substitution Test, the primary endpoint. Among the nearly 3,000 patients randomized in that study, those assigned to intensive glucose control had significantly greater total brain volume than did patients assigned to standard control, but no difference in cognitive outcomes.

"Combined with the unfavorable effects on other ACCORD outcomes, MIND findings do not support using intensive therapy to reduce the adverse effects of diabetes on the brain in patients similar to MIND participants," they wrote.

The fact that there was a reduction in the rate of brain volume loss in the intensive glucose control arm, however, gives hope to the investigators that there might be a "legacy" effect for a slower decline in cognitive function with better control over longer follow-up, Dr. Williamson said.

Researchers are now focusing on the Look AHEAD (Action for Health in Diabetes) study on the question of whether lifestyle interventions might be able to accomplish what drugs could not in ACCORD. Alternatively, it may be possible that the type of drug treatment is more important than a specific numeric target, he said.

Dr. Williamson reported having no financial disclosures.

NEW YORK – Studies continue to examine approaches that might reduce the well-known increased risk for cognitive decline and dementia in people with type 2 diabetes.

A combination of hyperglycemia, insulin resistance, oxidative stress, and other diabetes-related factors appears to play a part in the cognitive impairment associated with type 2 diabetes, said Dr. Jeff D. Williamson, chief of gerontology and geriatric medicine and director of the Kulynych Brain Research Center at Wake Forest University in Winston-Salem, N.C.

But, to date, there hasn’t been much success in intervening in type 2 diabetes patients to affect cognitive outcomes.

"Brain disease is prevalent in type 2 diabetes, and the risk for progression to dementia is high. There’s really no evidence that intensive medication can change that rate, at least at this point, but there may be some evidence that behavioral interventions are effective," Dr. Williamson said at the annual advanced postgraduate course held by the American Diabetes Association.

He advised that "monitoring cognitive function should take its place alongside lipid monitoring, kidney function monitoring, and eye monitoring in your assessments of patients coming through. Diabetes education may be adapted in people who are showing cognitive frailty, and we really need more work to show what works best in this population, but we certainly know that they are going to need more backup strategies."

Pathways to dementia

Diabetes interacts with the brain through two primary pathways: neuronal factors, including advanced glycated end products (with the apt acronym AGES), altered metabolism of neurotransmitters, and hypoglycemia; and vascular factors, including hypertension, endothelial damage, infarction, white-matter lesions, and disruption of the blood-brain barrier.

Both pathways contribute to inflammation, oxidative stress, and altered energy metabolism, which in turn lead to small- and large-vessel disease in the case of vascular damage factors, and to cortical atrophy in the case of neuronal degeneration. The end result of these processes may be vascular or Alzheimer’s type cognitive impairment and dementia, Dr. Williamson said.

Imaging studies conducted as part of the ACCORD-Memory in Diabetes Study (ACCORD-MIND, a substudy of the ACCORD [Action to Control Cardiovascular Risk in Diabetes] Study), showed increased white-matter lesions and brain atrophy in some people with type 2 diabetes, he noted.

In addition, a 2011 study, which Dr. Williamson coauthored, found that postmenopausal women with type 2 diabetes had deficits in verbal knowledge and verbal memory relative to similar women with no diabetes. Deficits in fine motor speed, a marker of cognitive impairment, also were more common in women with longer diabetes duration. Insulin use, indicative of diabetes severity, was associated with greater cognitive deficits, whereas oral medications were associated with better relative cognitive function.

Similarly, a 2009 systematic review and meta-analysis detected significant relative risks (RRs) associated with all diabetes types and all dementia types (RR, 1.47), Alzheimer’s disease (RR, 1.39), and vascular dementia (RR, 2.38).

Disappointing results

As in the parent trial, the ACCORD-MIND trial investigators found that an intensive glucose control intervention did not affect patients’ scores on the Digital Symbol Substitution Test, the primary endpoint. Among the nearly 3,000 patients randomized in that study, those assigned to intensive glucose control had significantly greater total brain volume than did patients assigned to standard control, but no difference in cognitive outcomes.

"Combined with the unfavorable effects on other ACCORD outcomes, MIND findings do not support using intensive therapy to reduce the adverse effects of diabetes on the brain in patients similar to MIND participants," they wrote.

The fact that there was a reduction in the rate of brain volume loss in the intensive glucose control arm, however, gives hope to the investigators that there might be a "legacy" effect for a slower decline in cognitive function with better control over longer follow-up, Dr. Williamson said.

Researchers are now focusing on the Look AHEAD (Action for Health in Diabetes) study on the question of whether lifestyle interventions might be able to accomplish what drugs could not in ACCORD. Alternatively, it may be possible that the type of drug treatment is more important than a specific numeric target, he said.

Dr. Williamson reported having no financial disclosures.

NEW YORK – Studies continue to examine approaches that might reduce the well-known increased risk for cognitive decline and dementia in people with type 2 diabetes.

A combination of hyperglycemia, insulin resistance, oxidative stress, and other diabetes-related factors appears to play a part in the cognitive impairment associated with type 2 diabetes, said Dr. Jeff D. Williamson, chief of gerontology and geriatric medicine and director of the Kulynych Brain Research Center at Wake Forest University in Winston-Salem, N.C.

But, to date, there hasn’t been much success in intervening in type 2 diabetes patients to affect cognitive outcomes.

"Brain disease is prevalent in type 2 diabetes, and the risk for progression to dementia is high. There’s really no evidence that intensive medication can change that rate, at least at this point, but there may be some evidence that behavioral interventions are effective," Dr. Williamson said at the annual advanced postgraduate course held by the American Diabetes Association.

He advised that "monitoring cognitive function should take its place alongside lipid monitoring, kidney function monitoring, and eye monitoring in your assessments of patients coming through. Diabetes education may be adapted in people who are showing cognitive frailty, and we really need more work to show what works best in this population, but we certainly know that they are going to need more backup strategies."

Pathways to dementia

Diabetes interacts with the brain through two primary pathways: neuronal factors, including advanced glycated end products (with the apt acronym AGES), altered metabolism of neurotransmitters, and hypoglycemia; and vascular factors, including hypertension, endothelial damage, infarction, white-matter lesions, and disruption of the blood-brain barrier.

Both pathways contribute to inflammation, oxidative stress, and altered energy metabolism, which in turn lead to small- and large-vessel disease in the case of vascular damage factors, and to cortical atrophy in the case of neuronal degeneration. The end result of these processes may be vascular or Alzheimer’s type cognitive impairment and dementia, Dr. Williamson said.

Imaging studies conducted as part of the ACCORD-Memory in Diabetes Study (ACCORD-MIND, a substudy of the ACCORD [Action to Control Cardiovascular Risk in Diabetes] Study), showed increased white-matter lesions and brain atrophy in some people with type 2 diabetes, he noted.

In addition, a 2011 study, which Dr. Williamson coauthored, found that postmenopausal women with type 2 diabetes had deficits in verbal knowledge and verbal memory relative to similar women with no diabetes. Deficits in fine motor speed, a marker of cognitive impairment, also were more common in women with longer diabetes duration. Insulin use, indicative of diabetes severity, was associated with greater cognitive deficits, whereas oral medications were associated with better relative cognitive function.

Similarly, a 2009 systematic review and meta-analysis detected significant relative risks (RRs) associated with all diabetes types and all dementia types (RR, 1.47), Alzheimer’s disease (RR, 1.39), and vascular dementia (RR, 2.38).

Disappointing results

As in the parent trial, the ACCORD-MIND trial investigators found that an intensive glucose control intervention did not affect patients’ scores on the Digital Symbol Substitution Test, the primary endpoint. Among the nearly 3,000 patients randomized in that study, those assigned to intensive glucose control had significantly greater total brain volume than did patients assigned to standard control, but no difference in cognitive outcomes.

"Combined with the unfavorable effects on other ACCORD outcomes, MIND findings do not support using intensive therapy to reduce the adverse effects of diabetes on the brain in patients similar to MIND participants," they wrote.

The fact that there was a reduction in the rate of brain volume loss in the intensive glucose control arm, however, gives hope to the investigators that there might be a "legacy" effect for a slower decline in cognitive function with better control over longer follow-up, Dr. Williamson said.

Researchers are now focusing on the Look AHEAD (Action for Health in Diabetes) study on the question of whether lifestyle interventions might be able to accomplish what drugs could not in ACCORD. Alternatively, it may be possible that the type of drug treatment is more important than a specific numeric target, he said.

Dr. Williamson reported having no financial disclosures.

NATIONAL HARBOR, MD. – Small surgical margins can mean big trouble for patients with breast cancer, said investigators at the annual Society of Surgical Oncology Cancer Symposium.

A retrospective study of outcomes for 2,377 women who underwent either breast-conserving therapy or mastectomy revealed that margins less than 2 mm resulted in a substantial risk of residual disease for all patients, reported Dr. Erin Garvey, a general surgery resident at Mayo Clinic Arizona in Phoenix.

"A policy of re-excision for margins less than 2 mm, coupled with a standardized multidisciplinary approach to breast cancer surgery, results in excellent re-excision and 5-year local recurrence rates. The local recurrence rate is higher, however, for those patients who complete breast-conserving therapy, thus warranting appropriate patient counseling regarding re-excision options and long-term outcome expectations," she said.

In a separate study, investigators from the University of Texas M.D. Anderson Cancer Center, Houston, reported 10-year follow-up data for women who opted for mastectomy to treat ductal carcinoma in situ (DCIS). They found that the incidence of local-regional recurrence (LRR) increased as the surgical margins shrank, and that close margins were the only independent predictor of LRR, reported Dr. Elizabeth FitzSullivan, a surgery fellow at M.D. Anderson.

"However, the local-regional recurrence rate in these patients is so low that routine postmastectomy radiation therapy is not warranted," she said.

No accord on margins

Despite multiple studies and meta-analyses, there is no standard for acceptable margin width in breast cancer, and surveys of both surgeons and radiation oncologists have shown wide variations in preferred margin widths, Dr. Garvey said.

Her group hypothesized that patients with invasive ductal carcinoma without an extensive in situ component who had surgical margins of at least 1 mm would have no evidence of residual disease on re-excision.

To test the idea, they took a retrospective look at records from a prospective database on 2,377 patients who underwent a total of 2,520 procedures from January 2000 through May 2012.

Of this group, 1,498 (63%) underwent lumpectomy, and 180 (12%) required re-excision surgery: 10% who had breast-conserving surgery alone, and 2% whose surgeries were converted to mastectomies. Of the 158 patients who had completed breast-conserving therapy following re-excision, 50 (32%) had residual disease, as did 20 of the 27 patients whose procedures were converted to mastectomies.

Of the 37% (879) who had up-front mastectomies, 2% (19) had re-excision, and of this group, 5 patients had residual disease.

In all, 40% of patients with positive margins had residual disease, compared with 38% of those with margins from 0.1 to 0.9 mm, and 33% for those with margins from 1.0 to 1.9 mm.

In univariate analysis, the presence of residual disease on re-excision did not show any significant association with age, race, menopausal status, width of the closest final margin, hormone receptor status, tumor histology, triple-negative disease, or the presence of angiolymphatic invasion. There was a trend, albeit nonsignificant, toward an association between residual disease and more than one margin narrower than 2 mm, Dr. Garvey noted.

At a median follow-up of 43 months (range, 0-140 months), 5-year local recurrence rates were 1.9% for patients who had breast-conserving therapy, and 1.1% for those who had mastectomy.

Patients who underwent breast-conserving therapy without re-excision had a 5-year local recurrence rate of 1.8%, compared with 4.3% for those who required re-excision, and 0% for those whose procedures were converted to mastectomy.

There was a nonsignificant trend toward higher local recurrence rates for breast-conserving therapy in patients who had re-excisions, which became significant when those patients who had conversion to mastectomy were excluded, with a hazard ratio compared with no re-excision of 2.56 (P = .04).

Narrower margins, larger risk

Dr. FitzSullivan and her M.D. Anderson colleagues reviewed the records of 810 women treated with mastectomy for DCIS from 1996 to 2009. They looked at the final width of histologic margins, defining disease-free margins as those of 3 mm or greater.

In all, 4 patients had positive margins, 59 had margins of 1 mm or smaller, and 35 had margins from 1.1 to 2.9 mm.

In multivariate analysis, independent predictors of close or positive margins were pathologic tumor size of 1.5 cm or greater (odds ratio, 5.11; P = .001), multicentric disease (OR, 5.44; P = .026), and the presence of necrosis (OR, 2.5; P = .003). Neither age, postmenopausal status, skin-sparing mastectomy, nor immediate breast reconstruction were significantly associated with close or positive margins, however.

None of seven patients who underwent postmastectomy radiotherapy had local-regional recurrences. Of the 803 patients who did not receive postsurgery radiation, 10-year LRR rates were 1%, consisting of 7 cases of invasive disease and 1 of DICS. Five patients had surgical management, and the remaining 3 had no further treatment.

When the researchers stratified the local recurrence rates by margin status, they saw that 5% of patients with margins of 1 mm or smaller had LRRs within 10 years, as did 3.6% of those with margins from 1.1 to 2.9 mm, compared with just 0.07% of those with disease-free margins (P less than .001). There was no difference in LRR between the two narrow-margin groups.

Among 546 patients with an intact contralateral breast, the 10-year rate of contralateral breast disease was 6.4%.

On univariate analysis, significant predictors of LRR included margin status (P = .002), multicentric disease (P = .005), and necrosis (P = .005). On multivariate analysis, however, only margin status remained significant, with an HR of 8.0 (P = .006).

Dr. FitzSullivan said that the low rate of LRR of DCIS treated with mastectomy and close surgical margins, compared with the rate of contralateral breast cancer, suggests that routine postmastectomy radiation therapy is not warranted, and should be reserved only for those patients with close or positive surgical margins that cannot be surgically excised.

Each study was internally funded. Dr. Garvey and Dr. FitzSullivan reported having no financial disclosures.

tor@frontlinemedcom.com

NATIONAL HARBOR, MD. – Small surgical margins can mean big trouble for patients with breast cancer, said investigators at the annual Society of Surgical Oncology Cancer Symposium.

A retrospective study of outcomes for 2,377 women who underwent either breast-conserving therapy or mastectomy revealed that margins less than 2 mm resulted in a substantial risk of residual disease for all patients, reported Dr. Erin Garvey, a general surgery resident at Mayo Clinic Arizona in Phoenix.

"A policy of re-excision for margins less than 2 mm, coupled with a standardized multidisciplinary approach to breast cancer surgery, results in excellent re-excision and 5-year local recurrence rates. The local recurrence rate is higher, however, for those patients who complete breast-conserving therapy, thus warranting appropriate patient counseling regarding re-excision options and long-term outcome expectations," she said.

In a separate study, investigators from the University of Texas M.D. Anderson Cancer Center, Houston, reported 10-year follow-up data for women who opted for mastectomy to treat ductal carcinoma in situ (DCIS). They found that the incidence of local-regional recurrence (LRR) increased as the surgical margins shrank, and that close margins were the only independent predictor of LRR, reported Dr. Elizabeth FitzSullivan, a surgery fellow at M.D. Anderson.

"However, the local-regional recurrence rate in these patients is so low that routine postmastectomy radiation therapy is not warranted," she said.

No accord on margins

Despite multiple studies and meta-analyses, there is no standard for acceptable margin width in breast cancer, and surveys of both surgeons and radiation oncologists have shown wide variations in preferred margin widths, Dr. Garvey said.

Her group hypothesized that patients with invasive ductal carcinoma without an extensive in situ component who had surgical margins of at least 1 mm would have no evidence of residual disease on re-excision.

To test the idea, they took a retrospective look at records from a prospective database on 2,377 patients who underwent a total of 2,520 procedures from January 2000 through May 2012.

Of this group, 1,498 (63%) underwent lumpectomy, and 180 (12%) required re-excision surgery: 10% who had breast-conserving surgery alone, and 2% whose surgeries were converted to mastectomies. Of the 158 patients who had completed breast-conserving therapy following re-excision, 50 (32%) had residual disease, as did 20 of the 27 patients whose procedures were converted to mastectomies.

Of the 37% (879) who had up-front mastectomies, 2% (19) had re-excision, and of this group, 5 patients had residual disease.

In all, 40% of patients with positive margins had residual disease, compared with 38% of those with margins from 0.1 to 0.9 mm, and 33% for those with margins from 1.0 to 1.9 mm.

In univariate analysis, the presence of residual disease on re-excision did not show any significant association with age, race, menopausal status, width of the closest final margin, hormone receptor status, tumor histology, triple-negative disease, or the presence of angiolymphatic invasion. There was a trend, albeit nonsignificant, toward an association between residual disease and more than one margin narrower than 2 mm, Dr. Garvey noted.

At a median follow-up of 43 months (range, 0-140 months), 5-year local recurrence rates were 1.9% for patients who had breast-conserving therapy, and 1.1% for those who had mastectomy.

Patients who underwent breast-conserving therapy without re-excision had a 5-year local recurrence rate of 1.8%, compared with 4.3% for those who required re-excision, and 0% for those whose procedures were converted to mastectomy.

There was a nonsignificant trend toward higher local recurrence rates for breast-conserving therapy in patients who had re-excisions, which became significant when those patients who had conversion to mastectomy were excluded, with a hazard ratio compared with no re-excision of 2.56 (P = .04).

Narrower margins, larger risk

Dr. FitzSullivan and her M.D. Anderson colleagues reviewed the records of 810 women treated with mastectomy for DCIS from 1996 to 2009. They looked at the final width of histologic margins, defining disease-free margins as those of 3 mm or greater.

In all, 4 patients had positive margins, 59 had margins of 1 mm or smaller, and 35 had margins from 1.1 to 2.9 mm.

In multivariate analysis, independent predictors of close or positive margins were pathologic tumor size of 1.5 cm or greater (odds ratio, 5.11; P = .001), multicentric disease (OR, 5.44; P = .026), and the presence of necrosis (OR, 2.5; P = .003). Neither age, postmenopausal status, skin-sparing mastectomy, nor immediate breast reconstruction were significantly associated with close or positive margins, however.

None of seven patients who underwent postmastectomy radiotherapy had local-regional recurrences. Of the 803 patients who did not receive postsurgery radiation, 10-year LRR rates were 1%, consisting of 7 cases of invasive disease and 1 of DICS. Five patients had surgical management, and the remaining 3 had no further treatment.

When the researchers stratified the local recurrence rates by margin status, they saw that 5% of patients with margins of 1 mm or smaller had LRRs within 10 years, as did 3.6% of those with margins from 1.1 to 2.9 mm, compared with just 0.07% of those with disease-free margins (P less than .001). There was no difference in LRR between the two narrow-margin groups.

Among 546 patients with an intact contralateral breast, the 10-year rate of contralateral breast disease was 6.4%.

On univariate analysis, significant predictors of LRR included margin status (P = .002), multicentric disease (P = .005), and necrosis (P = .005). On multivariate analysis, however, only margin status remained significant, with an HR of 8.0 (P = .006).

Dr. FitzSullivan said that the low rate of LRR of DCIS treated with mastectomy and close surgical margins, compared with the rate of contralateral breast cancer, suggests that routine postmastectomy radiation therapy is not warranted, and should be reserved only for those patients with close or positive surgical margins that cannot be surgically excised.

Each study was internally funded. Dr. Garvey and Dr. FitzSullivan reported having no financial disclosures.

tor@frontlinemedcom.com

NATIONAL HARBOR, MD. – Small surgical margins can mean big trouble for patients with breast cancer, said investigators at the annual Society of Surgical Oncology Cancer Symposium.

A retrospective study of outcomes for 2,377 women who underwent either breast-conserving therapy or mastectomy revealed that margins less than 2 mm resulted in a substantial risk of residual disease for all patients, reported Dr. Erin Garvey, a general surgery resident at Mayo Clinic Arizona in Phoenix.

"A policy of re-excision for margins less than 2 mm, coupled with a standardized multidisciplinary approach to breast cancer surgery, results in excellent re-excision and 5-year local recurrence rates. The local recurrence rate is higher, however, for those patients who complete breast-conserving therapy, thus warranting appropriate patient counseling regarding re-excision options and long-term outcome expectations," she said.

In a separate study, investigators from the University of Texas M.D. Anderson Cancer Center, Houston, reported 10-year follow-up data for women who opted for mastectomy to treat ductal carcinoma in situ (DCIS). They found that the incidence of local-regional recurrence (LRR) increased as the surgical margins shrank, and that close margins were the only independent predictor of LRR, reported Dr. Elizabeth FitzSullivan, a surgery fellow at M.D. Anderson.

"However, the local-regional recurrence rate in these patients is so low that routine postmastectomy radiation therapy is not warranted," she said.

No accord on margins

Despite multiple studies and meta-analyses, there is no standard for acceptable margin width in breast cancer, and surveys of both surgeons and radiation oncologists have shown wide variations in preferred margin widths, Dr. Garvey said.

Her group hypothesized that patients with invasive ductal carcinoma without an extensive in situ component who had surgical margins of at least 1 mm would have no evidence of residual disease on re-excision.

To test the idea, they took a retrospective look at records from a prospective database on 2,377 patients who underwent a total of 2,520 procedures from January 2000 through May 2012.

Of this group, 1,498 (63%) underwent lumpectomy, and 180 (12%) required re-excision surgery: 10% who had breast-conserving surgery alone, and 2% whose surgeries were converted to mastectomies. Of the 158 patients who had completed breast-conserving therapy following re-excision, 50 (32%) had residual disease, as did 20 of the 27 patients whose procedures were converted to mastectomies.

Of the 37% (879) who had up-front mastectomies, 2% (19) had re-excision, and of this group, 5 patients had residual disease.

In all, 40% of patients with positive margins had residual disease, compared with 38% of those with margins from 0.1 to 0.9 mm, and 33% for those with margins from 1.0 to 1.9 mm.

In univariate analysis, the presence of residual disease on re-excision did not show any significant association with age, race, menopausal status, width of the closest final margin, hormone receptor status, tumor histology, triple-negative disease, or the presence of angiolymphatic invasion. There was a trend, albeit nonsignificant, toward an association between residual disease and more than one margin narrower than 2 mm, Dr. Garvey noted.

At a median follow-up of 43 months (range, 0-140 months), 5-year local recurrence rates were 1.9% for patients who had breast-conserving therapy, and 1.1% for those who had mastectomy.

Patients who underwent breast-conserving therapy without re-excision had a 5-year local recurrence rate of 1.8%, compared with 4.3% for those who required re-excision, and 0% for those whose procedures were converted to mastectomy.

There was a nonsignificant trend toward higher local recurrence rates for breast-conserving therapy in patients who had re-excisions, which became significant when those patients who had conversion to mastectomy were excluded, with a hazard ratio compared with no re-excision of 2.56 (P = .04).

Narrower margins, larger risk

Dr. FitzSullivan and her M.D. Anderson colleagues reviewed the records of 810 women treated with mastectomy for DCIS from 1996 to 2009. They looked at the final width of histologic margins, defining disease-free margins as those of 3 mm or greater.

In all, 4 patients had positive margins, 59 had margins of 1 mm or smaller, and 35 had margins from 1.1 to 2.9 mm.

In multivariate analysis, independent predictors of close or positive margins were pathologic tumor size of 1.5 cm or greater (odds ratio, 5.11; P = .001), multicentric disease (OR, 5.44; P = .026), and the presence of necrosis (OR, 2.5; P = .003). Neither age, postmenopausal status, skin-sparing mastectomy, nor immediate breast reconstruction were significantly associated with close or positive margins, however.

None of seven patients who underwent postmastectomy radiotherapy had local-regional recurrences. Of the 803 patients who did not receive postsurgery radiation, 10-year LRR rates were 1%, consisting of 7 cases of invasive disease and 1 of DICS. Five patients had surgical management, and the remaining 3 had no further treatment.

When the researchers stratified the local recurrence rates by margin status, they saw that 5% of patients with margins of 1 mm or smaller had LRRs within 10 years, as did 3.6% of those with margins from 1.1 to 2.9 mm, compared with just 0.07% of those with disease-free margins (P less than .001). There was no difference in LRR between the two narrow-margin groups.

Among 546 patients with an intact contralateral breast, the 10-year rate of contralateral breast disease was 6.4%.

On univariate analysis, significant predictors of LRR included margin status (P = .002), multicentric disease (P = .005), and necrosis (P = .005). On multivariate analysis, however, only margin status remained significant, with an HR of 8.0 (P = .006).

Dr. FitzSullivan said that the low rate of LRR of DCIS treated with mastectomy and close surgical margins, compared with the rate of contralateral breast cancer, suggests that routine postmastectomy radiation therapy is not warranted, and should be reserved only for those patients with close or positive surgical margins that cannot be surgically excised.

Each study was internally funded. Dr. Garvey and Dr. FitzSullivan reported having no financial disclosures.

tor@frontlinemedcom.com

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.

BOSTON – The appearance of mature burn scars significantly improved after treatment with a nonablative fractional laser, based on data from a randomized controlled trial.

In a split-lesion study, laser-treated skin appeared smoother than did adjacent untreated control sites, and within 3 months both patients and clinicians rated laser-treated areas as significantly improved, said Dr. Merete Haedersdal of the University of Copenhagen, Denmark.

"We consider this as a safe treatment, we now have long-term clinical and histological efficacy, and we do have documentation that the efficacy improves over time. We are operating with an intact skin barrier, which may give us a good potential for when we are going to treat patients with large areas of burn scars," she said at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Haedersdal and her colleagues in Denmark, Germany, and Belgium examined long-term outcomes from the treatment of burn scars using a 1,540-nm fractional nonablative laser with compression handpieces to deliver energy to deep and superficial tissues.

Twenty patients (median age, 38 years) were enrolled, and 17 completed the study. The patients, all Fitzpatrick skin types II or III, had mature burn scars from fires (75%) or scalding (25%), and 75% had previously received skin grafts. The mature scars, with a median duration of 7 years, involved the trunk and/or extremities.

Side-by-side areas of each lesion were randomly assigned to receive three monthly deep and superficial treatments with Palomar Medical Technologies’ 1,540-nm nonablative fractional laser or to serve as untreated controls.

With the deep (XD) handpiece, the energy was applied with 15-ms pulses at 70 mJ per microbeam in three stacks for 10 passes. The compression tip of the handpiece squeezes moisture away from the applicator end, allowing delivery of energy into deep tissues.

The superficial (XF) handpiece was then used to deliver 50 mJ per microbeam in a 15-ms pulse for one stack with two passes.

"By ultrasound, we saw that we were able to deliver the energy into the deep layers of the skin," Dr. Haedersdal said. She cited the example of one patient whose scar was 1.08 mm thick before treatment, and immediately after treatment it was 3.52 mm thick from edema in the mid and deep dermal layers.

On-site clinical evaluations at 6 months performed by blinded observers rated 15 of 18 treated areas as improved, 3 as showing no response, and none as worsening. In contrast, all 18 control sites were rated as having no response.

The investigators also used the Patient and Observer Scar Assessment Scale (POSAS), which rates vascularity, pigmentation, thickness, relief, pliability, and surface area, as well as overall impression. The scale ranges from 1 for "normal skin" to 10 for "worst scar imaginable." The baseline median score was 7 (range, 3-8) for both groups.

At 1 month after treatment, there was no significant difference in POSAS score between the treated and untreated sides of the scars, but by 3 months the untreated sides were rated as a median of 7, compared with 5 for the treated sides (P = .0185). At 6 months the difference had increased slightly, with a median rating of 7 for the untreated sides and 4 for the treated sides (P = .0008).

The researchers also observed significant improvements in laser-treated (but not control) scars from baseline to 3 months (P = .0185), baseline to 6 months (P = .0008), and from 3 to 6 months (P = .0092), "which actually supports for the first time that when giving these nonablative fractional treatments, there is a continued improvement over time," Dr. Haedersdal said.

The researchers found that meshed (transplanted) skin tended to respond better than nontransplanted skin. Preliminary histology showed treatment-induced remodeling of the stratum corneum, frequently with a thicker epidermal compartment. In addition, post-treatment collagen deposition appeared closer to that found in normal skin, Dr. Haedersdal noted.

The immediate post-treatment responses included edema in 17 of 20 patients, erythema in 18, and purpura in 15, but there was no blistering of skin, and the skin barrier remained intact.

During the study period, 6 of 20 patients had hyperpigmentation, which resolved gradually over time.

"We also saw a grid pattern in three of the patients using these parameters, but we softened up the treatments afterward by giving following treatments with the XF handpiece," Dr. Haedersdal said.

The study was supported by an equipment loan and research grant to Dr. Haedersdal from Palomar Medical Technologies.