Mixed Topics

At the center of the emerging science on the unintended consequences of daily long-term use of marijuana lies a paradox.

For years, medical marijuana has been used to ease nausea from cancer chemotherapy and GI conditions. Now, with greater legalization comes growing awareness that chronic use of marijuana – also known as cannabis – can trigger a condition where, ironically, a person has hard-to-control vomiting and nausea.

Doug Menuez/thinkstock

Some people with the disorder, known as “cannabinoid hyperemesis syndrome,” also report crippling belly pain.

Linda can relate. The 33-year-old Oregon resident, who asked to remain anonymous to protect her privacy, refers to a medieval spiky metal ball on a chain when describing the pain.

“Picture a mace inside your stomach, pushing up inside your chest and, at the same time, exploding out,” she said.

To seek relief, she gets down on her knees, adopts a child’s yoga pose, and runs hot water in the bathroom for hours on end, a trick many with the disorder says has provided relief. She also occasionally goes outside and tries walking it off.

“I would just wander around my neighborhood, a lot of times at like 4 or 5 in the morning,” she said. “The fresh air helps a little bit. I just keep walking down the street, take about 10 steps, stop, vomit – walk a little bit more, stop, vomit.”

Her first experience with the disorder began in the middle of one night in 2017 while she was at a conference in Las Vegas.

“We went out to eat the night before, and I woke up about 4 in the morning with just the most intense pain I’ve ever had,” she said. “I found myself in a really hot shower in between throwing up everything and trying to say get some water down. I was sharing an Airbnb with my colleagues, so it was less than ideal.”

Many people with cannabinoid hyperemesis syndrome find relief from hot baths or showers. Researchers believe that hot water helps because temperature sensors in the skin send signals to the brain that can help ease the symptoms, at least for a while.

The problem is that people with this syndrome “can’t live in the water,” said emergency doctor and medical cannabis expert Leigh Vinocur, MD.

Fast-forward 6 months to another event in Boulder, Colo. Again, Linda woke up and could not stop vomiting.

“I was not feeling any better. Showering wasn’t helping. I ended up in the hospital,” she said.

She received opioids for her pain. But neither she nor the ED staff were quite sure what was happening. Her discharge paperwork read “cannabis allergy.”

Cannabinoid hyperemesis syndrome “shatters that image of cannabis only being a good thing. It’s a bold statement, but, you know, once you start to think about it, it’s like a little too much of anything isn’t good,” Linda said.

Experts suggest greater awareness is needed to identify this syndrome earlier, by both cannabinoid users and doctors. The bouts of vomiting, in particular, can get so severe that people can end up hospitalized with dehydration, electrolyte disorders, and weight loss.

The severe electrolyte imbalances “can really be life-threatening,” said David Johnson, MD, a professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk.

“By the time they come into emergency care, they’re in bad shape,” Dr. Vinocur agreed. “Many try to ignore it, but they continue to vomit.”
 

Genetic risk factors?

One mystery is why some regular marijuana users get this syndrome while others do not.

“I can say that not everybody gets this, thank goodness,” said Ethan Russo, MD. “But there has to be a reason that certain people are susceptible and others are not.”

Interestingly, a new study from Dr. Russo and colleagues suggests that genes play a role. They identified five genetic changes that could make a chronic marijuana user more likely to have cannabinoid hyperemesis syndrome in a study published July 5, 2021, in the journal Cannabis and Cannabinoid Research.

They compared 28 people with the disorder with 12 other high-frequency marijuana users without these symptoms.

The results are not final but could help guide future research, Dr. Russo said.

“What we’ve discovered – and it was far more than we expected – is that there’s a lot more to this than a hypersensitivity to cannabis,” said Dr. Russo, a neurologist and founder/CEO of CReDO Science, a firm that promotes cannabis research and develops commercial products.

Also, he said, those affected by cannabinoid hyperemesis syndrome could be at higher risk for other conditions, such as addiction to alcohol or other substances, dementia, diabetes, and heart disease.

“Most people with [cannabinoid hyperemesis syndrome] are going to be younger,” he said. “What we’ve demonstrated is there is a risk for more serious problems for decades to come. So someone who has these symptoms really deserves a look at this genetic screening.”
 

Battling disbelief

Getting back to the paradox, many users don’t believe marijuana can trigger serious vomiting and nausea because of its reputation for doing the opposite.

“Folks that have this are just uniquely resistant to the concept that cannabis is actually the problem and not the solution,” Dr. Russo said.

“It’s kind of counterintuitive because people think: ‘Oh, cannabis helps with nausea,’ so they use more of it,” said Dr. Vinocur, who is also a spokesperson for the American College of Emergency Physicians and runs a medical cannabis practice.

Most kinds of marijuana act in this way – doing opposite things at different doses. Once a certain threshold is passed, people with cannabinoid hyperemesis syndrome are “just uniquely susceptible and really can’t tolerate any significant amount of THC,” Dr. Russo said, referring to tetrahydrocannabinol, the substance that gets marijuana users high.

Once diagnosed, quitting is the most effective strategy. But it can be tough to persuade someone to stop using marijuana.

“You do have to try and convince them ... to try abstinence and to watch and see what happens,” Dr. Vinocur said.

People should “realize the root cause of this is its cannabinoid ingestion, and the treatment is really best directed at absolute avoidance,” Dr. Johnson said.

Unfortunately, evidence also shows that once a person stops using marijuana and gets relief, going back to marijuana or other forms of cannabinoids can cause the syndrome to start all over again.

“We’ve had people that quit for a month, a year, 2 years and upon resumption, almost invariably, they’re back into bouts of the hyperemesis along with all the other [symptoms],” Dr. Russo said.

Marijuana and cannabinoids can cause digestive problems, Dr. Johnson said, which may cause more problems.
 

What recent research reveals

Cannabinoid hyperemesis syndrome is a relatively young disorder – first described in 2004 – and early reports and case studies are giving way now to studies looking into potential treatments.

So far, the strongest evidence suggests a role for an over-the-counter cream called capsaicin to help manage symptoms, but more studies are needed.

Similar to hot showers, this ingredient from chili peppers can warm the skin and trigger the temperature-sensitive skin sensors to lessen the symptoms, Dr. Johnson said.

An October 2021 study in Spain looked at 54 ED visits among 29 people with cannabinoid hyperemesis syndrome. For the 75% treated with capsaicin, vomiting stopped after an average of 18 minutes.

Lead author Guillermo Burillo-Putze, MD, PhD, said he is most surprised by the growing number of new cases of the disorder.

“This should be of concern given the increase in cannabis use due to its legalization and permissiveness,” said Dr. Burillo-Putze, an emergency doctor at Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.

Cannabinoid hyperemesis syndrome appears not to discriminate across racial and ethic groups. Although most studies to date include White participants, a July 2021 study of 29 people, 90% of whom were Black, found repeat visits to the ED were common.

The study found that 16 people returned 42 times to the ED and accounted for 10 hospital admissions, for example.
 

Cannabis conspiracy theories

“Unfortunately, this condition has become the subject of great speculation hinging on conspiracy theories as its true cause,” Dr. Russo noted in a September 2021 letter to the editor in the American Journal of Emergency Medicine.

Some “myth busting” is in order, he said.

For example, cannabinoid hyperemesis syndrome does not happen because of exposure to products from a tree called neem or from pesticides applied to marijuana plants during cultivation, Dr. Russo said. It can also occur with high-dose synthetic cannabinoids.
 

The state of recreational and medical marijuana

Recreational marijuana is legal in 18 states, Washington, D.C., and Guam as of January 2022, according to a report in U.S. News. More states permit medical marijuana use – 37 in total, plus Washington, D.C., according to Britannica ProCon.

One of the states where only medicinal use is legal is Maryland, which is where Dr. Vinocur practices.

“We are seeing increasing numbers of cases” of cannabinoid hyperemesis syndrome, she said.

In addition to chronic use or higher doses, it’s likely that the higher potency levels of THC in the legal marijuana industry trigger the syndrome in some people as well.

Linda estimates she ended up in emergency rooms at least a half-dozen times in the last 5 years. In April 2021, she had a “pretty serious event.” She blames it on traveling a lot for work, not eating right, and not getting enough sleep. She broke her 2-year abstinence with alcohol.

“I basically didn’t listen to my body and paid a pretty significant price for it,” she said.

Linda did not stop altogether but said she “drastically changed the types and form of the cannabis I was using.”

“I can tell you on the record that I would be a hundred percent dead without this plant,” she said.

“The prospect of living without it was more detrimental to me than all of those things I just described to you, because addiction runs in my family and I had opiate problems myself that I overcame with cannabis.”

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

At the center of the emerging science on the unintended consequences of daily long-term use of marijuana lies a paradox.

For years, medical marijuana has been used to ease nausea from cancer chemotherapy and GI conditions. Now, with greater legalization comes growing awareness that chronic use of marijuana – also known as cannabis – can trigger a condition where, ironically, a person has hard-to-control vomiting and nausea.

Doug Menuez/thinkstock

Some people with the disorder, known as “cannabinoid hyperemesis syndrome,” also report crippling belly pain.

Linda can relate. The 33-year-old Oregon resident, who asked to remain anonymous to protect her privacy, refers to a medieval spiky metal ball on a chain when describing the pain.

“Picture a mace inside your stomach, pushing up inside your chest and, at the same time, exploding out,” she said.

To seek relief, she gets down on her knees, adopts a child’s yoga pose, and runs hot water in the bathroom for hours on end, a trick many with the disorder says has provided relief. She also occasionally goes outside and tries walking it off.

“I would just wander around my neighborhood, a lot of times at like 4 or 5 in the morning,” she said. “The fresh air helps a little bit. I just keep walking down the street, take about 10 steps, stop, vomit – walk a little bit more, stop, vomit.”

Her first experience with the disorder began in the middle of one night in 2017 while she was at a conference in Las Vegas.

“We went out to eat the night before, and I woke up about 4 in the morning with just the most intense pain I’ve ever had,” she said. “I found myself in a really hot shower in between throwing up everything and trying to say get some water down. I was sharing an Airbnb with my colleagues, so it was less than ideal.”

Many people with cannabinoid hyperemesis syndrome find relief from hot baths or showers. Researchers believe that hot water helps because temperature sensors in the skin send signals to the brain that can help ease the symptoms, at least for a while.

The problem is that people with this syndrome “can’t live in the water,” said emergency doctor and medical cannabis expert Leigh Vinocur, MD.

Fast-forward 6 months to another event in Boulder, Colo. Again, Linda woke up and could not stop vomiting.

“I was not feeling any better. Showering wasn’t helping. I ended up in the hospital,” she said.

She received opioids for her pain. But neither she nor the ED staff were quite sure what was happening. Her discharge paperwork read “cannabis allergy.”

Cannabinoid hyperemesis syndrome “shatters that image of cannabis only being a good thing. It’s a bold statement, but, you know, once you start to think about it, it’s like a little too much of anything isn’t good,” Linda said.

Experts suggest greater awareness is needed to identify this syndrome earlier, by both cannabinoid users and doctors. The bouts of vomiting, in particular, can get so severe that people can end up hospitalized with dehydration, electrolyte disorders, and weight loss.

The severe electrolyte imbalances “can really be life-threatening,” said David Johnson, MD, a professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk.

“By the time they come into emergency care, they’re in bad shape,” Dr. Vinocur agreed. “Many try to ignore it, but they continue to vomit.”
 

Genetic risk factors?

One mystery is why some regular marijuana users get this syndrome while others do not.

“I can say that not everybody gets this, thank goodness,” said Ethan Russo, MD. “But there has to be a reason that certain people are susceptible and others are not.”

Interestingly, a new study from Dr. Russo and colleagues suggests that genes play a role. They identified five genetic changes that could make a chronic marijuana user more likely to have cannabinoid hyperemesis syndrome in a study published July 5, 2021, in the journal Cannabis and Cannabinoid Research.

They compared 28 people with the disorder with 12 other high-frequency marijuana users without these symptoms.

The results are not final but could help guide future research, Dr. Russo said.

“What we’ve discovered – and it was far more than we expected – is that there’s a lot more to this than a hypersensitivity to cannabis,” said Dr. Russo, a neurologist and founder/CEO of CReDO Science, a firm that promotes cannabis research and develops commercial products.

Also, he said, those affected by cannabinoid hyperemesis syndrome could be at higher risk for other conditions, such as addiction to alcohol or other substances, dementia, diabetes, and heart disease.

“Most people with [cannabinoid hyperemesis syndrome] are going to be younger,” he said. “What we’ve demonstrated is there is a risk for more serious problems for decades to come. So someone who has these symptoms really deserves a look at this genetic screening.”
 

Battling disbelief

Getting back to the paradox, many users don’t believe marijuana can trigger serious vomiting and nausea because of its reputation for doing the opposite.

“Folks that have this are just uniquely resistant to the concept that cannabis is actually the problem and not the solution,” Dr. Russo said.

“It’s kind of counterintuitive because people think: ‘Oh, cannabis helps with nausea,’ so they use more of it,” said Dr. Vinocur, who is also a spokesperson for the American College of Emergency Physicians and runs a medical cannabis practice.

Most kinds of marijuana act in this way – doing opposite things at different doses. Once a certain threshold is passed, people with cannabinoid hyperemesis syndrome are “just uniquely susceptible and really can’t tolerate any significant amount of THC,” Dr. Russo said, referring to tetrahydrocannabinol, the substance that gets marijuana users high.

Once diagnosed, quitting is the most effective strategy. But it can be tough to persuade someone to stop using marijuana.

“You do have to try and convince them ... to try abstinence and to watch and see what happens,” Dr. Vinocur said.

People should “realize the root cause of this is its cannabinoid ingestion, and the treatment is really best directed at absolute avoidance,” Dr. Johnson said.

Unfortunately, evidence also shows that once a person stops using marijuana and gets relief, going back to marijuana or other forms of cannabinoids can cause the syndrome to start all over again.

“We’ve had people that quit for a month, a year, 2 years and upon resumption, almost invariably, they’re back into bouts of the hyperemesis along with all the other [symptoms],” Dr. Russo said.

Marijuana and cannabinoids can cause digestive problems, Dr. Johnson said, which may cause more problems.
 

What recent research reveals

Cannabinoid hyperemesis syndrome is a relatively young disorder – first described in 2004 – and early reports and case studies are giving way now to studies looking into potential treatments.

So far, the strongest evidence suggests a role for an over-the-counter cream called capsaicin to help manage symptoms, but more studies are needed.

Similar to hot showers, this ingredient from chili peppers can warm the skin and trigger the temperature-sensitive skin sensors to lessen the symptoms, Dr. Johnson said.

An October 2021 study in Spain looked at 54 ED visits among 29 people with cannabinoid hyperemesis syndrome. For the 75% treated with capsaicin, vomiting stopped after an average of 18 minutes.

Lead author Guillermo Burillo-Putze, MD, PhD, said he is most surprised by the growing number of new cases of the disorder.

“This should be of concern given the increase in cannabis use due to its legalization and permissiveness,” said Dr. Burillo-Putze, an emergency doctor at Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.

Cannabinoid hyperemesis syndrome appears not to discriminate across racial and ethic groups. Although most studies to date include White participants, a July 2021 study of 29 people, 90% of whom were Black, found repeat visits to the ED were common.

The study found that 16 people returned 42 times to the ED and accounted for 10 hospital admissions, for example.
 

Cannabis conspiracy theories

“Unfortunately, this condition has become the subject of great speculation hinging on conspiracy theories as its true cause,” Dr. Russo noted in a September 2021 letter to the editor in the American Journal of Emergency Medicine.

Some “myth busting” is in order, he said.

For example, cannabinoid hyperemesis syndrome does not happen because of exposure to products from a tree called neem or from pesticides applied to marijuana plants during cultivation, Dr. Russo said. It can also occur with high-dose synthetic cannabinoids.
 

The state of recreational and medical marijuana

Recreational marijuana is legal in 18 states, Washington, D.C., and Guam as of January 2022, according to a report in U.S. News. More states permit medical marijuana use – 37 in total, plus Washington, D.C., according to Britannica ProCon.

One of the states where only medicinal use is legal is Maryland, which is where Dr. Vinocur practices.

“We are seeing increasing numbers of cases” of cannabinoid hyperemesis syndrome, she said.

In addition to chronic use or higher doses, it’s likely that the higher potency levels of THC in the legal marijuana industry trigger the syndrome in some people as well.

Linda estimates she ended up in emergency rooms at least a half-dozen times in the last 5 years. In April 2021, she had a “pretty serious event.” She blames it on traveling a lot for work, not eating right, and not getting enough sleep. She broke her 2-year abstinence with alcohol.

“I basically didn’t listen to my body and paid a pretty significant price for it,” she said.

Linda did not stop altogether but said she “drastically changed the types and form of the cannabis I was using.”

“I can tell you on the record that I would be a hundred percent dead without this plant,” she said.

“The prospect of living without it was more detrimental to me than all of those things I just described to you, because addiction runs in my family and I had opiate problems myself that I overcame with cannabis.”

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

At the center of the emerging science on the unintended consequences of daily long-term use of marijuana lies a paradox.

For years, medical marijuana has been used to ease nausea from cancer chemotherapy and GI conditions. Now, with greater legalization comes growing awareness that chronic use of marijuana – also known as cannabis – can trigger a condition where, ironically, a person has hard-to-control vomiting and nausea.

Doug Menuez/thinkstock

Some people with the disorder, known as “cannabinoid hyperemesis syndrome,” also report crippling belly pain.

Linda can relate. The 33-year-old Oregon resident, who asked to remain anonymous to protect her privacy, refers to a medieval spiky metal ball on a chain when describing the pain.

“Picture a mace inside your stomach, pushing up inside your chest and, at the same time, exploding out,” she said.

To seek relief, she gets down on her knees, adopts a child’s yoga pose, and runs hot water in the bathroom for hours on end, a trick many with the disorder says has provided relief. She also occasionally goes outside and tries walking it off.

“I would just wander around my neighborhood, a lot of times at like 4 or 5 in the morning,” she said. “The fresh air helps a little bit. I just keep walking down the street, take about 10 steps, stop, vomit – walk a little bit more, stop, vomit.”

Her first experience with the disorder began in the middle of one night in 2017 while she was at a conference in Las Vegas.

“We went out to eat the night before, and I woke up about 4 in the morning with just the most intense pain I’ve ever had,” she said. “I found myself in a really hot shower in between throwing up everything and trying to say get some water down. I was sharing an Airbnb with my colleagues, so it was less than ideal.”

Many people with cannabinoid hyperemesis syndrome find relief from hot baths or showers. Researchers believe that hot water helps because temperature sensors in the skin send signals to the brain that can help ease the symptoms, at least for a while.

The problem is that people with this syndrome “can’t live in the water,” said emergency doctor and medical cannabis expert Leigh Vinocur, MD.

Fast-forward 6 months to another event in Boulder, Colo. Again, Linda woke up and could not stop vomiting.

“I was not feeling any better. Showering wasn’t helping. I ended up in the hospital,” she said.

She received opioids for her pain. But neither she nor the ED staff were quite sure what was happening. Her discharge paperwork read “cannabis allergy.”

Cannabinoid hyperemesis syndrome “shatters that image of cannabis only being a good thing. It’s a bold statement, but, you know, once you start to think about it, it’s like a little too much of anything isn’t good,” Linda said.

Experts suggest greater awareness is needed to identify this syndrome earlier, by both cannabinoid users and doctors. The bouts of vomiting, in particular, can get so severe that people can end up hospitalized with dehydration, electrolyte disorders, and weight loss.

The severe electrolyte imbalances “can really be life-threatening,” said David Johnson, MD, a professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk.

“By the time they come into emergency care, they’re in bad shape,” Dr. Vinocur agreed. “Many try to ignore it, but they continue to vomit.”
 

Genetic risk factors?

One mystery is why some regular marijuana users get this syndrome while others do not.

“I can say that not everybody gets this, thank goodness,” said Ethan Russo, MD. “But there has to be a reason that certain people are susceptible and others are not.”

Interestingly, a new study from Dr. Russo and colleagues suggests that genes play a role. They identified five genetic changes that could make a chronic marijuana user more likely to have cannabinoid hyperemesis syndrome in a study published July 5, 2021, in the journal Cannabis and Cannabinoid Research.

They compared 28 people with the disorder with 12 other high-frequency marijuana users without these symptoms.

The results are not final but could help guide future research, Dr. Russo said.

“What we’ve discovered – and it was far more than we expected – is that there’s a lot more to this than a hypersensitivity to cannabis,” said Dr. Russo, a neurologist and founder/CEO of CReDO Science, a firm that promotes cannabis research and develops commercial products.

Also, he said, those affected by cannabinoid hyperemesis syndrome could be at higher risk for other conditions, such as addiction to alcohol or other substances, dementia, diabetes, and heart disease.

“Most people with [cannabinoid hyperemesis syndrome] are going to be younger,” he said. “What we’ve demonstrated is there is a risk for more serious problems for decades to come. So someone who has these symptoms really deserves a look at this genetic screening.”
 

Battling disbelief

Getting back to the paradox, many users don’t believe marijuana can trigger serious vomiting and nausea because of its reputation for doing the opposite.

“Folks that have this are just uniquely resistant to the concept that cannabis is actually the problem and not the solution,” Dr. Russo said.

“It’s kind of counterintuitive because people think: ‘Oh, cannabis helps with nausea,’ so they use more of it,” said Dr. Vinocur, who is also a spokesperson for the American College of Emergency Physicians and runs a medical cannabis practice.

Most kinds of marijuana act in this way – doing opposite things at different doses. Once a certain threshold is passed, people with cannabinoid hyperemesis syndrome are “just uniquely susceptible and really can’t tolerate any significant amount of THC,” Dr. Russo said, referring to tetrahydrocannabinol, the substance that gets marijuana users high.

Once diagnosed, quitting is the most effective strategy. But it can be tough to persuade someone to stop using marijuana.

“You do have to try and convince them ... to try abstinence and to watch and see what happens,” Dr. Vinocur said.

People should “realize the root cause of this is its cannabinoid ingestion, and the treatment is really best directed at absolute avoidance,” Dr. Johnson said.

Unfortunately, evidence also shows that once a person stops using marijuana and gets relief, going back to marijuana or other forms of cannabinoids can cause the syndrome to start all over again.

“We’ve had people that quit for a month, a year, 2 years and upon resumption, almost invariably, they’re back into bouts of the hyperemesis along with all the other [symptoms],” Dr. Russo said.

Marijuana and cannabinoids can cause digestive problems, Dr. Johnson said, which may cause more problems.
 

What recent research reveals

Cannabinoid hyperemesis syndrome is a relatively young disorder – first described in 2004 – and early reports and case studies are giving way now to studies looking into potential treatments.

So far, the strongest evidence suggests a role for an over-the-counter cream called capsaicin to help manage symptoms, but more studies are needed.

Similar to hot showers, this ingredient from chili peppers can warm the skin and trigger the temperature-sensitive skin sensors to lessen the symptoms, Dr. Johnson said.

An October 2021 study in Spain looked at 54 ED visits among 29 people with cannabinoid hyperemesis syndrome. For the 75% treated with capsaicin, vomiting stopped after an average of 18 minutes.

Lead author Guillermo Burillo-Putze, MD, PhD, said he is most surprised by the growing number of new cases of the disorder.

“This should be of concern given the increase in cannabis use due to its legalization and permissiveness,” said Dr. Burillo-Putze, an emergency doctor at Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.

Cannabinoid hyperemesis syndrome appears not to discriminate across racial and ethic groups. Although most studies to date include White participants, a July 2021 study of 29 people, 90% of whom were Black, found repeat visits to the ED were common.

The study found that 16 people returned 42 times to the ED and accounted for 10 hospital admissions, for example.
 

Cannabis conspiracy theories

“Unfortunately, this condition has become the subject of great speculation hinging on conspiracy theories as its true cause,” Dr. Russo noted in a September 2021 letter to the editor in the American Journal of Emergency Medicine.

Some “myth busting” is in order, he said.

For example, cannabinoid hyperemesis syndrome does not happen because of exposure to products from a tree called neem or from pesticides applied to marijuana plants during cultivation, Dr. Russo said. It can also occur with high-dose synthetic cannabinoids.
 

The state of recreational and medical marijuana

Recreational marijuana is legal in 18 states, Washington, D.C., and Guam as of January 2022, according to a report in U.S. News. More states permit medical marijuana use – 37 in total, plus Washington, D.C., according to Britannica ProCon.

One of the states where only medicinal use is legal is Maryland, which is where Dr. Vinocur practices.

“We are seeing increasing numbers of cases” of cannabinoid hyperemesis syndrome, she said.

In addition to chronic use or higher doses, it’s likely that the higher potency levels of THC in the legal marijuana industry trigger the syndrome in some people as well.

Linda estimates she ended up in emergency rooms at least a half-dozen times in the last 5 years. In April 2021, she had a “pretty serious event.” She blames it on traveling a lot for work, not eating right, and not getting enough sleep. She broke her 2-year abstinence with alcohol.

“I basically didn’t listen to my body and paid a pretty significant price for it,” she said.

Linda did not stop altogether but said she “drastically changed the types and form of the cannabis I was using.”

“I can tell you on the record that I would be a hundred percent dead without this plant,” she said.

“The prospect of living without it was more detrimental to me than all of those things I just described to you, because addiction runs in my family and I had opiate problems myself that I overcame with cannabis.”

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

In a first, a middle-aged woman has been in remission from HIV for 14 months after being treated for leukemia with transplants of adult stem cells and umbilical cord blood. If she remains off treatment without any hint of HIV, she would be only the third person in the world – after the Berlin Patient and the London Patient – to be cured through a transplant.

“Her own virus could not infect her cells,” said Yvonne Bryson, MD, chief of pediatric infectious diseases at the University of California, Los Angeles, who presented the study at the Conference on Retroviruses and Opportunistic Infections, which both presenters and the audience attended remotely.

The middle-aged New York woman of mixed race, who has asked that her specific race and age not be shared to protect her privacy, was diagnosed with HIV in 2013 when she was still in the very early stages of infection. She started treatment immediately and quickly achieved an undetectable viral load. An undetectable viral load not only prevents someone from transmitting HIV to others but also reduces or eliminates HIV replication, which means fewer variants and less time for the virus to infiltrate cells where it can hide.

But in 2017, she was diagnosed with leukemia. As a last resort to cure her of the cancer, she received a combination of adult stem cells from a relative’s blood that closely matched her own and umbilical cord blood obtained from a cord blood bank. That particular sample of cord blood was selected for its genetic mutation against the CCR5 receptor on immune cells, CD4 T cells. That mutation makes the immune system resistant to HIV.

The two previous HIV cures, of Berlin Patient Timothy Ray Brown and London Patient Adam Castillejo, also used stem cell transplantation with a CCR5 mutation, but theirs were bone marrow transplants. Bone marrow transplants are more arduous than cord blood transplants, which are commonly used in pediatric cancer treatment.

In this case, the physicians treating her used both.

“This allows the adult cells to accelerate and grow up until the cord blood takes over,” said Dr. Bryson. During her presentation, Dr. Bryson pointed to two types of data: First, she presented data showing the level of HIV in the patient’s blood. Soon after HIV diagnosis and treatment, her viral load dropped to undetectable levels. She had a spike of virus when she received the transplant, but then it went back to undetectable and has stayed that way ever since.

Meanwhile, following the transplant, her immune system started rebuilding itself using the new, HIV-resistant cells provided in the transplant. As her care team watched, no graft-versus-host (GVH) disease, a common side effect of stem cell transplants, emerged. In fact, the transplant went so well that she was discharged early from the hospital.

One hundred days after the transplant, the immune system contained within the cord blood had taken over. Her CD4 immune cells returned to normal levels a little more than a year after the transplant. By 27 months, she decided to stop all HIV treatment to see if the transplant had worked.

This was the real test. But as Dr. Bryson and colleagues continued to watch her HIV viral load and her CD4 counts and search for infectious virus, they didn’t find any. She tested negative for HIV by antibody test. Dr. Bryson grew 75 million of her cells in a lab to look for any HIV. None. Aside from one blip in detectable HIV DNA at 14 weeks, researchers never found HIV in the patient again.

“Her cells are resistant to HIV now – both her own strains and laboratory strains,” Dr. Bryson told this news organization. “It’s been 14 months since then. She has no rebound and no detectable virus.”

The presentation drew as raucous as praise gets in a virtual environment. The comments began pouring in.

“Impressive results,” wrote Jim Hoxie, MD, professor emeritus at the University of Pennsylvania, Philadelphia.

“Exciting case,” wrote Allison Agwu, MD, a professor of pediatrics at Johns Hopkins University, Baltimore.

And Dennis Copertino, a research specialist at Weill Cornell Medicine, New York, wrote: “Thank you so much for translating this important cure strategy to people of color.”

Most donors with CCR5 mutations are White, Dr. Bryson said, suggesting that this approach, in a mixed-race woman, could expand the pool of people living with HIV and cancer who are good candidates for the approach.

But other observers had questions, ones that may require more research to answer. Some asked why this woman’s virus, after transplantation, wasn’t just immune to viruses with CCR5 but also another variant, called CXCR4, that one wouldn’t expect. Luis Montaner, DVM, director of the Immunopathogenesis Laboratory at the Wistar Institute in Philadelphia, wondered whether it was more than the blood that had cleared HIV. Did it get into the tissue, too? That question has not yet been answered.

For Carl Dieffenbach, PhD, director of the division of AIDS at the National Institute of Allergy and Infectious Diseases, the lack of GVH disease was a powerful and hopeful finding.

“There’s been this ongoing hypothesis that maybe graft-versus-host disease was needed at some level to help clear out every last single CD4+ T cell that may or may not have been harboring replication-competent virus,” Dr. Dieffenbach said in an interview. “But there was no GVH disease. That’s incredible. It’s a wonderful thing.”

Now the challenge is to move from a single case to making cure available to other people living with HIV.

The case also got cure researchers thinking.

Dr. Montaner called the case “an encouraging roadmap supporting anti-CCR5 strategies by CRISPR Cas9,” studies that are now underway.

Steven Deeks, MD, called the case “perhaps a model for how we might do this using a person’s own cells. Because we were never really going to be transplanting cells from another person as a scalable cure.”

For people living with HIV, particularly women of color, the results raise hopes and questions. Nina Martinez knows something about being a “first.” In 2019, she was the first American woman of color living with HIV to donate a kidney to another person living with the virus. To her, the excitement over the first woman of color being cured of HIV just shines a light on how very White and male HIV cure studies have been until now.

“For me, I’m not looking for a cure in which the successful step forward is me getting cancer,” she said in an interview. “I’m looking at, what’s going to be sustainable? I want to know what’s going to work for a group of people.”

Gina Marie Brown, a social worker living with HIV in New Orleans, is also thinking of groups of people.

“Every time we get a breakthrough, it’s like the sun is taken from behind the clouds a little more,” said Ms. Brown. “I think about people in the South, who bear a huge burden of HIV. I think about trans women. I think about Black women, and gay, bisexual, and same-gender-loving men. This could really impact HIV – in the same way that PrEP [pre-exposure prophylaxis] has, the same way that one pill once a day has.”

When Ms. Brown was diagnosed with HIV 22 years ago, she started to plan her funeral.

“That’s how much I thought HIV was a death sentence,” she told this news organization. “Oh my goodness! Glad you stuck around, Gina.”

The study was funded by the National Institutes of Health. Dr. Bryson, Dr. Dieffenbach, Dr. Deeks, and Dr. Montaner disclosed no relevant financial relationships.

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

In a first, a middle-aged woman has been in remission from HIV for 14 months after being treated for leukemia with transplants of adult stem cells and umbilical cord blood. If she remains off treatment without any hint of HIV, she would be only the third person in the world – after the Berlin Patient and the London Patient – to be cured through a transplant.

“Her own virus could not infect her cells,” said Yvonne Bryson, MD, chief of pediatric infectious diseases at the University of California, Los Angeles, who presented the study at the Conference on Retroviruses and Opportunistic Infections, which both presenters and the audience attended remotely.

The middle-aged New York woman of mixed race, who has asked that her specific race and age not be shared to protect her privacy, was diagnosed with HIV in 2013 when she was still in the very early stages of infection. She started treatment immediately and quickly achieved an undetectable viral load. An undetectable viral load not only prevents someone from transmitting HIV to others but also reduces or eliminates HIV replication, which means fewer variants and less time for the virus to infiltrate cells where it can hide.

But in 2017, she was diagnosed with leukemia. As a last resort to cure her of the cancer, she received a combination of adult stem cells from a relative’s blood that closely matched her own and umbilical cord blood obtained from a cord blood bank. That particular sample of cord blood was selected for its genetic mutation against the CCR5 receptor on immune cells, CD4 T cells. That mutation makes the immune system resistant to HIV.

The two previous HIV cures, of Berlin Patient Timothy Ray Brown and London Patient Adam Castillejo, also used stem cell transplantation with a CCR5 mutation, but theirs were bone marrow transplants. Bone marrow transplants are more arduous than cord blood transplants, which are commonly used in pediatric cancer treatment.

In this case, the physicians treating her used both.

“This allows the adult cells to accelerate and grow up until the cord blood takes over,” said Dr. Bryson. During her presentation, Dr. Bryson pointed to two types of data: First, she presented data showing the level of HIV in the patient’s blood. Soon after HIV diagnosis and treatment, her viral load dropped to undetectable levels. She had a spike of virus when she received the transplant, but then it went back to undetectable and has stayed that way ever since.

Meanwhile, following the transplant, her immune system started rebuilding itself using the new, HIV-resistant cells provided in the transplant. As her care team watched, no graft-versus-host (GVH) disease, a common side effect of stem cell transplants, emerged. In fact, the transplant went so well that she was discharged early from the hospital.

One hundred days after the transplant, the immune system contained within the cord blood had taken over. Her CD4 immune cells returned to normal levels a little more than a year after the transplant. By 27 months, she decided to stop all HIV treatment to see if the transplant had worked.

This was the real test. But as Dr. Bryson and colleagues continued to watch her HIV viral load and her CD4 counts and search for infectious virus, they didn’t find any. She tested negative for HIV by antibody test. Dr. Bryson grew 75 million of her cells in a lab to look for any HIV. None. Aside from one blip in detectable HIV DNA at 14 weeks, researchers never found HIV in the patient again.

“Her cells are resistant to HIV now – both her own strains and laboratory strains,” Dr. Bryson told this news organization. “It’s been 14 months since then. She has no rebound and no detectable virus.”

The presentation drew as raucous as praise gets in a virtual environment. The comments began pouring in.

“Impressive results,” wrote Jim Hoxie, MD, professor emeritus at the University of Pennsylvania, Philadelphia.

“Exciting case,” wrote Allison Agwu, MD, a professor of pediatrics at Johns Hopkins University, Baltimore.

And Dennis Copertino, a research specialist at Weill Cornell Medicine, New York, wrote: “Thank you so much for translating this important cure strategy to people of color.”

Most donors with CCR5 mutations are White, Dr. Bryson said, suggesting that this approach, in a mixed-race woman, could expand the pool of people living with HIV and cancer who are good candidates for the approach.

But other observers had questions, ones that may require more research to answer. Some asked why this woman’s virus, after transplantation, wasn’t just immune to viruses with CCR5 but also another variant, called CXCR4, that one wouldn’t expect. Luis Montaner, DVM, director of the Immunopathogenesis Laboratory at the Wistar Institute in Philadelphia, wondered whether it was more than the blood that had cleared HIV. Did it get into the tissue, too? That question has not yet been answered.

For Carl Dieffenbach, PhD, director of the division of AIDS at the National Institute of Allergy and Infectious Diseases, the lack of GVH disease was a powerful and hopeful finding.

“There’s been this ongoing hypothesis that maybe graft-versus-host disease was needed at some level to help clear out every last single CD4+ T cell that may or may not have been harboring replication-competent virus,” Dr. Dieffenbach said in an interview. “But there was no GVH disease. That’s incredible. It’s a wonderful thing.”

Now the challenge is to move from a single case to making cure available to other people living with HIV.

The case also got cure researchers thinking.

Dr. Montaner called the case “an encouraging roadmap supporting anti-CCR5 strategies by CRISPR Cas9,” studies that are now underway.

Steven Deeks, MD, called the case “perhaps a model for how we might do this using a person’s own cells. Because we were never really going to be transplanting cells from another person as a scalable cure.”

For people living with HIV, particularly women of color, the results raise hopes and questions. Nina Martinez knows something about being a “first.” In 2019, she was the first American woman of color living with HIV to donate a kidney to another person living with the virus. To her, the excitement over the first woman of color being cured of HIV just shines a light on how very White and male HIV cure studies have been until now.

“For me, I’m not looking for a cure in which the successful step forward is me getting cancer,” she said in an interview. “I’m looking at, what’s going to be sustainable? I want to know what’s going to work for a group of people.”

Gina Marie Brown, a social worker living with HIV in New Orleans, is also thinking of groups of people.

“Every time we get a breakthrough, it’s like the sun is taken from behind the clouds a little more,” said Ms. Brown. “I think about people in the South, who bear a huge burden of HIV. I think about trans women. I think about Black women, and gay, bisexual, and same-gender-loving men. This could really impact HIV – in the same way that PrEP [pre-exposure prophylaxis] has, the same way that one pill once a day has.”

When Ms. Brown was diagnosed with HIV 22 years ago, she started to plan her funeral.

“That’s how much I thought HIV was a death sentence,” she told this news organization. “Oh my goodness! Glad you stuck around, Gina.”

The study was funded by the National Institutes of Health. Dr. Bryson, Dr. Dieffenbach, Dr. Deeks, and Dr. Montaner disclosed no relevant financial relationships.

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

In a first, a middle-aged woman has been in remission from HIV for 14 months after being treated for leukemia with transplants of adult stem cells and umbilical cord blood. If she remains off treatment without any hint of HIV, she would be only the third person in the world – after the Berlin Patient and the London Patient – to be cured through a transplant.

“Her own virus could not infect her cells,” said Yvonne Bryson, MD, chief of pediatric infectious diseases at the University of California, Los Angeles, who presented the study at the Conference on Retroviruses and Opportunistic Infections, which both presenters and the audience attended remotely.

The middle-aged New York woman of mixed race, who has asked that her specific race and age not be shared to protect her privacy, was diagnosed with HIV in 2013 when she was still in the very early stages of infection. She started treatment immediately and quickly achieved an undetectable viral load. An undetectable viral load not only prevents someone from transmitting HIV to others but also reduces or eliminates HIV replication, which means fewer variants and less time for the virus to infiltrate cells where it can hide.

But in 2017, she was diagnosed with leukemia. As a last resort to cure her of the cancer, she received a combination of adult stem cells from a relative’s blood that closely matched her own and umbilical cord blood obtained from a cord blood bank. That particular sample of cord blood was selected for its genetic mutation against the CCR5 receptor on immune cells, CD4 T cells. That mutation makes the immune system resistant to HIV.

The two previous HIV cures, of Berlin Patient Timothy Ray Brown and London Patient Adam Castillejo, also used stem cell transplantation with a CCR5 mutation, but theirs were bone marrow transplants. Bone marrow transplants are more arduous than cord blood transplants, which are commonly used in pediatric cancer treatment.

In this case, the physicians treating her used both.

“This allows the adult cells to accelerate and grow up until the cord blood takes over,” said Dr. Bryson. During her presentation, Dr. Bryson pointed to two types of data: First, she presented data showing the level of HIV in the patient’s blood. Soon after HIV diagnosis and treatment, her viral load dropped to undetectable levels. She had a spike of virus when she received the transplant, but then it went back to undetectable and has stayed that way ever since.

Meanwhile, following the transplant, her immune system started rebuilding itself using the new, HIV-resistant cells provided in the transplant. As her care team watched, no graft-versus-host (GVH) disease, a common side effect of stem cell transplants, emerged. In fact, the transplant went so well that she was discharged early from the hospital.

One hundred days after the transplant, the immune system contained within the cord blood had taken over. Her CD4 immune cells returned to normal levels a little more than a year after the transplant. By 27 months, she decided to stop all HIV treatment to see if the transplant had worked.

This was the real test. But as Dr. Bryson and colleagues continued to watch her HIV viral load and her CD4 counts and search for infectious virus, they didn’t find any. She tested negative for HIV by antibody test. Dr. Bryson grew 75 million of her cells in a lab to look for any HIV. None. Aside from one blip in detectable HIV DNA at 14 weeks, researchers never found HIV in the patient again.

“Her cells are resistant to HIV now – both her own strains and laboratory strains,” Dr. Bryson told this news organization. “It’s been 14 months since then. She has no rebound and no detectable virus.”

The presentation drew as raucous as praise gets in a virtual environment. The comments began pouring in.

“Impressive results,” wrote Jim Hoxie, MD, professor emeritus at the University of Pennsylvania, Philadelphia.

“Exciting case,” wrote Allison Agwu, MD, a professor of pediatrics at Johns Hopkins University, Baltimore.

And Dennis Copertino, a research specialist at Weill Cornell Medicine, New York, wrote: “Thank you so much for translating this important cure strategy to people of color.”

Most donors with CCR5 mutations are White, Dr. Bryson said, suggesting that this approach, in a mixed-race woman, could expand the pool of people living with HIV and cancer who are good candidates for the approach.

But other observers had questions, ones that may require more research to answer. Some asked why this woman’s virus, after transplantation, wasn’t just immune to viruses with CCR5 but also another variant, called CXCR4, that one wouldn’t expect. Luis Montaner, DVM, director of the Immunopathogenesis Laboratory at the Wistar Institute in Philadelphia, wondered whether it was more than the blood that had cleared HIV. Did it get into the tissue, too? That question has not yet been answered.

For Carl Dieffenbach, PhD, director of the division of AIDS at the National Institute of Allergy and Infectious Diseases, the lack of GVH disease was a powerful and hopeful finding.

“There’s been this ongoing hypothesis that maybe graft-versus-host disease was needed at some level to help clear out every last single CD4+ T cell that may or may not have been harboring replication-competent virus,” Dr. Dieffenbach said in an interview. “But there was no GVH disease. That’s incredible. It’s a wonderful thing.”

Now the challenge is to move from a single case to making cure available to other people living with HIV.

The case also got cure researchers thinking.

Dr. Montaner called the case “an encouraging roadmap supporting anti-CCR5 strategies by CRISPR Cas9,” studies that are now underway.

Steven Deeks, MD, called the case “perhaps a model for how we might do this using a person’s own cells. Because we were never really going to be transplanting cells from another person as a scalable cure.”

For people living with HIV, particularly women of color, the results raise hopes and questions. Nina Martinez knows something about being a “first.” In 2019, she was the first American woman of color living with HIV to donate a kidney to another person living with the virus. To her, the excitement over the first woman of color being cured of HIV just shines a light on how very White and male HIV cure studies have been until now.

“For me, I’m not looking for a cure in which the successful step forward is me getting cancer,” she said in an interview. “I’m looking at, what’s going to be sustainable? I want to know what’s going to work for a group of people.”

Gina Marie Brown, a social worker living with HIV in New Orleans, is also thinking of groups of people.

“Every time we get a breakthrough, it’s like the sun is taken from behind the clouds a little more,” said Ms. Brown. “I think about people in the South, who bear a huge burden of HIV. I think about trans women. I think about Black women, and gay, bisexual, and same-gender-loving men. This could really impact HIV – in the same way that PrEP [pre-exposure prophylaxis] has, the same way that one pill once a day has.”

When Ms. Brown was diagnosed with HIV 22 years ago, she started to plan her funeral.

“That’s how much I thought HIV was a death sentence,” she told this news organization. “Oh my goodness! Glad you stuck around, Gina.”

The study was funded by the National Institutes of Health. Dr. Bryson, Dr. Dieffenbach, Dr. Deeks, and Dr. Montaner disclosed no relevant financial relationships.

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

In the age of COVID, what exactly does it mean to be optimistic? I get this question quite a bit from virtually everyone I meet in one form or another through my work with the George Washington Resiliency and Well-Being Center in Washington, D.C. Giving a lecture on resilience and staying positive can be a significant challenge. Especially when we wake up to the news that 1 of every 100 older Americans has died secondary to COVID. The mind doesn’t really know how to process this type of loss. It is hard to maintain any form of a positive attitude when you’re still struggling just to accept the magnitude of what humanity has experienced over the past 2 years.

In “Resilience: The Science of Mastering Life’s Greatest Challenges,” (Cambridge, England: Cambridge University Press, 2018), Steven M. Southwick, MD, and Dennis S. Charney, MD, identify 10 critical factors associated with very resilient individuals. The authors based their work on science, personal experience, and interviews of people who have literally been through hell and back. One of the critical factors they identified is optimism.
“Optimism ignites resilience, providing energy to power the other resilience factors. It facilitates an active and creative approach to coping with challenging situations.”

Dr. Southwick and Dr. Charney are a lot smarter than me and far more patient to weave all this data together into a coherent story about optimism. Sounds like a damn good factor to focus a lecture on in my book! Slight problem: In my experience, many health professionals are already expert optimists. They literally eat, sleep, and sincerely breathe this stuff. So if we are going to talk about optimism, then we need to discuss realistic optimism.

How does realistic optimism differ from, say, blind optimism? Dr. Southwick and Dr. Charney’s review of the literature points to three features worthy of highlighting.
 

Realistic vs. blind optimism: Take-home points

• In realistic optimism, we notice the negative but don’t stay engaged with it. Realistic optimists moved on from problems that were not solvable.
• Blind optimism can involve optimistic biases that affect self-deception or convincing oneself of desired beliefs without reality checks.
• Blind optimism can lead to underestimating risk, overestimating abilities, and inadequate preparation.

Growing up in northeast Ohio, I can absolutely embrace the concept of realistic optimism. It’s overcast in Cleveland 8 months out of the year. To hope for 3 sunny days in a row in April is genuinely a fools’ errand. So you learn over time, the sun will shine; you just have to at times wait 3-4 months for it to occur.

• “Once we get enough COVID-19 tests, things will improve.”
• “All we need to do is get vaccines, and then the new normal is right there.”
• “Once everyone gets the booster, then we got this thing beat.”

At this point, you could argue that I was engaged in blind optimism. I consider the above statements blind for a couple of reasons. They weren’t balanced (both positive and negative), didn’t have a clear definition of the outcome, and were more focused on external events I couldn’t control. These statements were the equivalent of wishes, and I don’t have a magic lamp with a genie, so I need to let go of my wishful thinking first. Let me rephrase that: I need to forcefully toss it into the sea of COVID variants and start figuring out how I’m going to tread water for another 6-12 months. So with this in mind, here are my initial thoughts on ways to navigate the next year of the pandemic:

• A multilayered form of protection gives me the best chance to survive the next 6 months of the pandemic.
• It will take time, but I’ll process the loss associated with a workplace that will never be the same.
• Until we have positivity test rates lower than 2% across the globe, COVID will remain a substantial disruption to humanity.
• I can’t bring back missed graduation or the first day of school, but I can share ways that I’ve countered and survived loneliness in my life with my children.

Okay, this is the starting point – hopefully not pessimistic, or blindly optimistic, just realistic. Now I can address other important topics, such as planning to rebuild my disappointing fantasy football team. I was No. 1 in our GW department of psychiatry fantasy football league until my star running back Derrick Henry went down. My residents will become attendings and still give me grief about this for many years to follow, and that is a very good thing.

Everyone be well and safe.

Dr. Norris is associate dean of student affairs; associate professor, department of psychiatry, George Washington University; chief wellness officer, GW Hospital, GW Medical Faculty Associates, and the GW School of Medicine and Health Sciences (GWU Medical Enterprise), Washington. He has disclosed having no relevant financial relationships. A version of this article first appeared on Medscape.com.

In the age of COVID, what exactly does it mean to be optimistic? I get this question quite a bit from virtually everyone I meet in one form or another through my work with the George Washington Resiliency and Well-Being Center in Washington, D.C. Giving a lecture on resilience and staying positive can be a significant challenge. Especially when we wake up to the news that 1 of every 100 older Americans has died secondary to COVID. The mind doesn’t really know how to process this type of loss. It is hard to maintain any form of a positive attitude when you’re still struggling just to accept the magnitude of what humanity has experienced over the past 2 years.

In “Resilience: The Science of Mastering Life’s Greatest Challenges,” (Cambridge, England: Cambridge University Press, 2018), Steven M. Southwick, MD, and Dennis S. Charney, MD, identify 10 critical factors associated with very resilient individuals. The authors based their work on science, personal experience, and interviews of people who have literally been through hell and back. One of the critical factors they identified is optimism.
“Optimism ignites resilience, providing energy to power the other resilience factors. It facilitates an active and creative approach to coping with challenging situations.”

Dr. Southwick and Dr. Charney are a lot smarter than me and far more patient to weave all this data together into a coherent story about optimism. Sounds like a damn good factor to focus a lecture on in my book! Slight problem: In my experience, many health professionals are already expert optimists. They literally eat, sleep, and sincerely breathe this stuff. So if we are going to talk about optimism, then we need to discuss realistic optimism.

How does realistic optimism differ from, say, blind optimism? Dr. Southwick and Dr. Charney’s review of the literature points to three features worthy of highlighting.
 

Realistic vs. blind optimism: Take-home points

• In realistic optimism, we notice the negative but don’t stay engaged with it. Realistic optimists moved on from problems that were not solvable.
• Blind optimism can involve optimistic biases that affect self-deception or convincing oneself of desired beliefs without reality checks.
• Blind optimism can lead to underestimating risk, overestimating abilities, and inadequate preparation.

Growing up in northeast Ohio, I can absolutely embrace the concept of realistic optimism. It’s overcast in Cleveland 8 months out of the year. To hope for 3 sunny days in a row in April is genuinely a fools’ errand. So you learn over time, the sun will shine; you just have to at times wait 3-4 months for it to occur.

• “Once we get enough COVID-19 tests, things will improve.”
• “All we need to do is get vaccines, and then the new normal is right there.”
• “Once everyone gets the booster, then we got this thing beat.”

At this point, you could argue that I was engaged in blind optimism. I consider the above statements blind for a couple of reasons. They weren’t balanced (both positive and negative), didn’t have a clear definition of the outcome, and were more focused on external events I couldn’t control. These statements were the equivalent of wishes, and I don’t have a magic lamp with a genie, so I need to let go of my wishful thinking first. Let me rephrase that: I need to forcefully toss it into the sea of COVID variants and start figuring out how I’m going to tread water for another 6-12 months. So with this in mind, here are my initial thoughts on ways to navigate the next year of the pandemic:

• A multilayered form of protection gives me the best chance to survive the next 6 months of the pandemic.
• It will take time, but I’ll process the loss associated with a workplace that will never be the same.
• Until we have positivity test rates lower than 2% across the globe, COVID will remain a substantial disruption to humanity.
• I can’t bring back missed graduation or the first day of school, but I can share ways that I’ve countered and survived loneliness in my life with my children.

Okay, this is the starting point – hopefully not pessimistic, or blindly optimistic, just realistic. Now I can address other important topics, such as planning to rebuild my disappointing fantasy football team. I was No. 1 in our GW department of psychiatry fantasy football league until my star running back Derrick Henry went down. My residents will become attendings and still give me grief about this for many years to follow, and that is a very good thing.

Everyone be well and safe.

Dr. Norris is associate dean of student affairs; associate professor, department of psychiatry, George Washington University; chief wellness officer, GW Hospital, GW Medical Faculty Associates, and the GW School of Medicine and Health Sciences (GWU Medical Enterprise), Washington. He has disclosed having no relevant financial relationships. A version of this article first appeared on Medscape.com.

In the age of COVID, what exactly does it mean to be optimistic? I get this question quite a bit from virtually everyone I meet in one form or another through my work with the George Washington Resiliency and Well-Being Center in Washington, D.C. Giving a lecture on resilience and staying positive can be a significant challenge. Especially when we wake up to the news that 1 of every 100 older Americans has died secondary to COVID. The mind doesn’t really know how to process this type of loss. It is hard to maintain any form of a positive attitude when you’re still struggling just to accept the magnitude of what humanity has experienced over the past 2 years.

In “Resilience: The Science of Mastering Life’s Greatest Challenges,” (Cambridge, England: Cambridge University Press, 2018), Steven M. Southwick, MD, and Dennis S. Charney, MD, identify 10 critical factors associated with very resilient individuals. The authors based their work on science, personal experience, and interviews of people who have literally been through hell and back. One of the critical factors they identified is optimism.
“Optimism ignites resilience, providing energy to power the other resilience factors. It facilitates an active and creative approach to coping with challenging situations.”

Dr. Southwick and Dr. Charney are a lot smarter than me and far more patient to weave all this data together into a coherent story about optimism. Sounds like a damn good factor to focus a lecture on in my book! Slight problem: In my experience, many health professionals are already expert optimists. They literally eat, sleep, and sincerely breathe this stuff. So if we are going to talk about optimism, then we need to discuss realistic optimism.

How does realistic optimism differ from, say, blind optimism? Dr. Southwick and Dr. Charney’s review of the literature points to three features worthy of highlighting.
 

Realistic vs. blind optimism: Take-home points

• In realistic optimism, we notice the negative but don’t stay engaged with it. Realistic optimists moved on from problems that were not solvable.
• Blind optimism can involve optimistic biases that affect self-deception or convincing oneself of desired beliefs without reality checks.
• Blind optimism can lead to underestimating risk, overestimating abilities, and inadequate preparation.

Growing up in northeast Ohio, I can absolutely embrace the concept of realistic optimism. It’s overcast in Cleveland 8 months out of the year. To hope for 3 sunny days in a row in April is genuinely a fools’ errand. So you learn over time, the sun will shine; you just have to at times wait 3-4 months for it to occur.

• “Once we get enough COVID-19 tests, things will improve.”
• “All we need to do is get vaccines, and then the new normal is right there.”
• “Once everyone gets the booster, then we got this thing beat.”

At this point, you could argue that I was engaged in blind optimism. I consider the above statements blind for a couple of reasons. They weren’t balanced (both positive and negative), didn’t have a clear definition of the outcome, and were more focused on external events I couldn’t control. These statements were the equivalent of wishes, and I don’t have a magic lamp with a genie, so I need to let go of my wishful thinking first. Let me rephrase that: I need to forcefully toss it into the sea of COVID variants and start figuring out how I’m going to tread water for another 6-12 months. So with this in mind, here are my initial thoughts on ways to navigate the next year of the pandemic:

• A multilayered form of protection gives me the best chance to survive the next 6 months of the pandemic.
• It will take time, but I’ll process the loss associated with a workplace that will never be the same.
• Until we have positivity test rates lower than 2% across the globe, COVID will remain a substantial disruption to humanity.
• I can’t bring back missed graduation or the first day of school, but I can share ways that I’ve countered and survived loneliness in my life with my children.

Okay, this is the starting point – hopefully not pessimistic, or blindly optimistic, just realistic. Now I can address other important topics, such as planning to rebuild my disappointing fantasy football team. I was No. 1 in our GW department of psychiatry fantasy football league until my star running back Derrick Henry went down. My residents will become attendings and still give me grief about this for many years to follow, and that is a very good thing.

Everyone be well and safe.

Dr. Norris is associate dean of student affairs; associate professor, department of psychiatry, George Washington University; chief wellness officer, GW Hospital, GW Medical Faculty Associates, and the GW School of Medicine and Health Sciences (GWU Medical Enterprise), Washington. He has disclosed having no relevant financial relationships. A version of this article first appeared on Medscape.com.

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

Global climate change is hitting home for dermatologists, according to a recent survey in which the majority of participants said their patients are already being impacted.

Almost 80% of the 148 participants who responded to an electronic survey reported this belief.

The survey was designed and distributed to the membership of various dermatological organizations by Misha Rosenbach, MD, and coauthors. The results were published in the British Journal of Dermatology.

Asked also about specific types of climate-driven phenomena with a current – or future – impact on their patients, 80.1% reported that they believed that increased exposure to ultraviolet radiation (UVR) is impactful, or will be. Changes in temporal or geographic patterns of vector-borne illnesses were affirmed by 78.7%, and an increase in social displacement caused by extreme weather or other events was affirmed by 67.1% as having an impact on their patients currently or in the future.

Other phenomena affirmed by respondents as already having an impact or impacting patients in the future were an increased incidence of heat exposure or heat-related illness (58.2%); an increase in rates of inflammatory skin disease flares (43.2%); increased incidence of waterborne infections (42.5%); and increased rates of allergic contact dermatitis (29.5%).

The survey was sent to the membership of the American Society of Dermatologic Surgery, the Society for Pediatric Dermatology, the Society for Investigative Dermatology, and the American Academy of Dermatology’s Climate Change Expert Resource Group (ERG), among other organizations.

The study design and membership overlap made it impossible to calculate a response rate, the authors said, but they estimated it to be about 10%.

Almost all respondents were from the United States, and most (86.3%) practiced in an academic setting. The findings are similar to those of an online survey of members of the International Society of Dermatology (ISD), published in 2020, which found that 89% of 158 respondents believed climate change will impact the incidence of skin diseases in their area.

“Physicians, including dermatologists, are starting to understand the impact of the climate crisis on both their patients and themselves ... both through lived experiences and [issues raised] more in the scientific literature and in meetings,” Dr. Rosenbach, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

A majority of participants in the U.S. survey agreed they have a responsibility to bring awareness of the health effects of climate change to patients (77.2%) and to policymakers (88.6%). (In the ISD survey, 88% said they believed that dermatologists should play an advocacy role in climate change-related issues).

Only a minority of respondents in the U.S. survey said that they would feel comfortable discussing climate change with their patients (37.2%). Almost one-third of the respondents said they would like to be better informed about climate change before doing so. And 81.8% said they would like to read more about the dermatological effects of climate change in scientific journals.

“There continues to be unfilled interest in education and advocacy regarding climate change, suggesting a ‘practice gap’ even among dermatologists,” Dr. Rosenbach and his colleagues wrote, noting opportunities for professional organizations and journals to provide more resources and “actionable items” regarding climate change.

Some dermatologists have been taking action, in the meantime, to reduce the carbon footprint of their practices and institutions. Reductions in facility energy consumption, and reductions in medical waste/optimization of recycling, were each reported by more than one-third of survey respondents.

And almost half indicated that their practice or institution had increased capacity for telemedicine or telecommuting in response to climate change. Only 8% said their practice or institution had divested from fossil fuel stocks and/or bonds.

“There are a lot of sustainability-in-medicine solutions that are actually cost-neutral or cost-saving for practices,” said Dr. Rosenbach, who is a founder and co-chair of the AAD’s ERG on Climate Change and Environmental Issues.

Research in dermatology is starting to quantify the environmental impact of some of these changes. In a research letter also published in the British Journal of Dermatology, researchers from Cardiff University and the department of dermatology at University Hospital of Wales, described how they determined that reusable surgical packs used for skin surgery are more sustainable than single-use packs because of their reduced cost and reduced greenhouse gas emissions.

Such single-site reports are “early feeders” into what will become a stream of larger studies quantifying the impact of measures taken in dermatology, Dr. Rosenbach said.

Across medicine, there is evidence that health care professionals are now seeing climate change as a threat to their patients. In a multinational survey published last year in The Lancet Planetary Health, 77% of 3,977 participants said that climate change will cause a moderate or great deal of harm for their patients.

Climate change will be discussed at the AAD’s annual meeting in late March in a session devoted to the topic, and as part of a broader session on controversies in dermatology.

Dr. Rosenbach and two of the five authors of the dermatology research letter are members of the AAD’s ERG on climate change, but in the publication they noted that they were not writing on behalf of the AAD. None of the authors reported any disclosures, and there was no funding source for the survey.

In a specialty clinic, dupilumab (Dupixent) injections significantly improved symptoms for patients with chronic rhinosinusitis with nasal polyps, based on provisional data from more than 100 adults.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant burden among working-age adults. Symptom control remains a challenge for many of these patients, and the cost in lost productivity and health care consumption can be substantial, write Rik J.L. van der Lans, MD, of the University of Amsterdam, and colleagues.

Dupilumab, a biologic that targets components of the type 2 inflammatory pathway, represents a new option that has shown effectiveness in clinical trials for regulatory approval, they said.

A new observational study tests dupilumab in patients who met criteria for biological treatment proposed in a recent major systematic review. The findings were published in the journal Allergy.

In the study, the researchers identified 131 adults older than 18 years (mean age 51.7) with CRSwNP treated at a single tertiary care center. Participants received 300 mg of dupilumab subcutaneous injection every 2 weeks for at least 12 weeks.

The primary outcomes were scores on several measures, including the SinoNasal Outcome Test-22 (SNOT-22, scale of 0-110), the bilateral Nasal Polyp Score (NPS, scale of 0-8), and the Sniffin’ Sticks-12 identification test (SSIT-12, scale of 0-6 anosmia, 7-10 hyposmia, 11-12 normosmia).

The mean scores on all three outcomes improved significantly from baseline to both 24 weeks and 48 weeks. Scores on the SNOT-22 improved from 52.4 at baseline to 18.5 and 16.8 at weeks 24 and 48, respectively. NPS improved from 5.4 at baseline to 1.6 and 1.0, respectively. SSIT-12 scores improved from 3.6 at baseline to 7.3 and 8.3, respectively.

At baseline, 95.8% of the patients had uncontrolled chronic rhinosinusitis, but at 24 and 48 weeks, respectively, 24.3% and 6.2% were uncontrolled.

Approximately half of the patients experienced treatment-emergent adverse events, but these were “mild and decreased in occurrence and intensity throughout treatment,” the researchers say.

For patients with a strong response, the researchers also tested an extension of the interval between doses to 4 weeks and 6 weeks, in a provisional indication of continued established control at these timepoints.

The study findings were limited by several factors, including the potential for selection bias, and data from only the first patient cohort, the researchers noted. However, the results were strengthened by the real-life context, standardized indications, and long-term follow up for almost a year, they said.

More research is needed on nonacademic patient cohorts, but the current data confirm the effectiveness of dupilumab as an add-on for difficult-to-treat CRSwNP, they concluded. The findings also validate the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) inclusion criteria for biologic treatment, they said.

The new study is important because of the need for verification of results from randomized controlled trials using real-world data, Dr. Van der Lans told this news organization.

“For example, differences in treatment efficacy might result from differing indication criteria, and the inclusion/exclusion criteria in the RCTs might have excluded patients one would encounter in daily practice,” he said. “With our prospective observational cohort, we are seeking to verify efficacy, monitor pharmacovigilance, and evaluate and advance the indication criteria and positioning of biologicals registered for CRSwNP, such as dupilumab.”

These cross-sectional results suggest dupilumab is more effective in preventing possibly harmful escape treatments, such as oral corticosteroids and/or surgery, than reported by the registration trials.

“Additionally, it appears possible to maintain established CRS-control during response-dependent, stepwise, interdose interval prolongation of up to 6 weeks, which is officially an off-label dosing interval,” he said. “This would greatly benefit patients’ treatment burden and direct costs,” he said. However, both findings require corroboration by anticipated longitudinal results in 2022, he noted.

The key message for clinicians in practice: “Biologicals like dupilumab are a potent and promising treatment for severe CRSwNP when conventional medical and surgical therapy fails,” he emphasized.

Looking ahead, important research objectives include head-on comparison studies of the diverse biological agents, establishing biomarkers to guide preferential therapy, and evaluating the economics of biologics compared with conventional therapy, Dr. Van der Lans added. Such research is vital not only for improving patient-centered care but to sustain the use of biologicals in a health-economic perspective.

One of the greatest criticisms of biologic therapy for CRSwNP is cost, particularly in a setting of ever-increasing health care costs. A recent review noted the average cost per year is greater than $30,000.
 

Real-life study verifies effectiveness

“As the authors pointed out, this is a real-life, prospective observational cohort with a decently large size, evaluating the therapeutic efficacy of add-on dupilumab,” said Seong H. Cho, MD, of the University of South Florida, Tampa, in an interview.

“Dupilumab is the first FDA-approved biologic to treat severe chronic rhinosinusitis with nasal polyps based on two phase 3 clinical trials,” said Dr. Cho, who was not involved with the study. “It has been more than 2 years since dupilumab was approved for severe CRSwNP by the FDA and EMA. This real-life, prospective, observational study with a decent size verified the efficacy of dupilumab as an add-on treatment when used with a proper indication such as EPOS2020 indication criteria.

“I am not surprised by the efficacy of dupilumab on severe CRSwNP, based on my clinical experience. My clinical observation is similar to the results of this study. This study verifies that dupilumab is highly efficacious in treating refractory and severe CRSwNP in a real-life setting by improving all subjective and objective clinical outcomes such as SNOT-22, NPS, and smell test score,” he said. The study also confirms that a stepwise, interdose interval prolongation from every 2-4 weeks for CRSwNP patients with good response should be a consideration for clinical practice, he added. 

The cost-effectiveness of dupilumab is the main barrier to more consistent use, Dr. Cho said. “There is no evidence that dupilumab can change the course of the disease, and we don’t know how long patients need to be on this drug. Therefore, nasal polyps need to be refractory and severe enough to use dupilumab and other biologics,” he explained.

Consequently, proper indication criteria, such as the EPOS2020 indication criteria for biologics, should be established before initiating dupilumab, Dr. Cho noted.

“Generally, endoscopic sinus surgery would be preferred in sinus-surgery naive CRSwNP patients, unless surgery is contraindicated or refused by patients because of cost-effectiveness rather than the superior efficacy,” he said. “If surgery fails, then dupilumab can be considered. In addition, proper evaluation of nasal polyp severity would be important.”

“One should establish an objective NPS by endoscopic exam before initiation of dupilumab. This baseline score would be an important marker to assess the efficacy of dupilumab in the course of treatment.”

Monitoring of the NPS together with the patient’s symptom improvement would be essential to implementing a stepwise, interdose interval prolongation to reduce the cost, he emphasized. 

“The most crucial additional research is establishing suitable biomarkers for the response of dupilumab and other biologics,” said Dr. Cho. “Overall, the performance of dupilumab seems to be good. But there are patients unresponsive to dupilumab, even more to other recently FDA-approved biologics for CRSwNP.”

Blood eosinophils and exhaled nitric oxide can be a good biomarker for type 2 asthma, Dr. Cho added. “Still, there is no evidence that these biomarkers are decent for CRSwNP, even though CRSwNP is mostly considered as type 2 disease. Therefore, it would be essential to find promising biomarkers for severe CRSwNP.”

Dr. Van der Lans disclosed serving as a consultant for GlaxoSmithKline, and several coauthors disclosed relationships with companies including Sanofi and Novartis. The patient registry from which the study population was drawn is cofunded by Sanofi and Novartis. Dr. Cho has disclosed no relevant financial relationships.

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

In a specialty clinic, dupilumab (Dupixent) injections significantly improved symptoms for patients with chronic rhinosinusitis with nasal polyps, based on provisional data from more than 100 adults.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant burden among working-age adults. Symptom control remains a challenge for many of these patients, and the cost in lost productivity and health care consumption can be substantial, write Rik J.L. van der Lans, MD, of the University of Amsterdam, and colleagues.

Dupilumab, a biologic that targets components of the type 2 inflammatory pathway, represents a new option that has shown effectiveness in clinical trials for regulatory approval, they said.

A new observational study tests dupilumab in patients who met criteria for biological treatment proposed in a recent major systematic review. The findings were published in the journal Allergy.

In the study, the researchers identified 131 adults older than 18 years (mean age 51.7) with CRSwNP treated at a single tertiary care center. Participants received 300 mg of dupilumab subcutaneous injection every 2 weeks for at least 12 weeks.

The primary outcomes were scores on several measures, including the SinoNasal Outcome Test-22 (SNOT-22, scale of 0-110), the bilateral Nasal Polyp Score (NPS, scale of 0-8), and the Sniffin’ Sticks-12 identification test (SSIT-12, scale of 0-6 anosmia, 7-10 hyposmia, 11-12 normosmia).

The mean scores on all three outcomes improved significantly from baseline to both 24 weeks and 48 weeks. Scores on the SNOT-22 improved from 52.4 at baseline to 18.5 and 16.8 at weeks 24 and 48, respectively. NPS improved from 5.4 at baseline to 1.6 and 1.0, respectively. SSIT-12 scores improved from 3.6 at baseline to 7.3 and 8.3, respectively.

At baseline, 95.8% of the patients had uncontrolled chronic rhinosinusitis, but at 24 and 48 weeks, respectively, 24.3% and 6.2% were uncontrolled.

Approximately half of the patients experienced treatment-emergent adverse events, but these were “mild and decreased in occurrence and intensity throughout treatment,” the researchers say.

For patients with a strong response, the researchers also tested an extension of the interval between doses to 4 weeks and 6 weeks, in a provisional indication of continued established control at these timepoints.

The study findings were limited by several factors, including the potential for selection bias, and data from only the first patient cohort, the researchers noted. However, the results were strengthened by the real-life context, standardized indications, and long-term follow up for almost a year, they said.

More research is needed on nonacademic patient cohorts, but the current data confirm the effectiveness of dupilumab as an add-on for difficult-to-treat CRSwNP, they concluded. The findings also validate the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) inclusion criteria for biologic treatment, they said.

The new study is important because of the need for verification of results from randomized controlled trials using real-world data, Dr. Van der Lans told this news organization.

“For example, differences in treatment efficacy might result from differing indication criteria, and the inclusion/exclusion criteria in the RCTs might have excluded patients one would encounter in daily practice,” he said. “With our prospective observational cohort, we are seeking to verify efficacy, monitor pharmacovigilance, and evaluate and advance the indication criteria and positioning of biologicals registered for CRSwNP, such as dupilumab.”

These cross-sectional results suggest dupilumab is more effective in preventing possibly harmful escape treatments, such as oral corticosteroids and/or surgery, than reported by the registration trials.

“Additionally, it appears possible to maintain established CRS-control during response-dependent, stepwise, interdose interval prolongation of up to 6 weeks, which is officially an off-label dosing interval,” he said. “This would greatly benefit patients’ treatment burden and direct costs,” he said. However, both findings require corroboration by anticipated longitudinal results in 2022, he noted.

The key message for clinicians in practice: “Biologicals like dupilumab are a potent and promising treatment for severe CRSwNP when conventional medical and surgical therapy fails,” he emphasized.

Looking ahead, important research objectives include head-on comparison studies of the diverse biological agents, establishing biomarkers to guide preferential therapy, and evaluating the economics of biologics compared with conventional therapy, Dr. Van der Lans added. Such research is vital not only for improving patient-centered care but to sustain the use of biologicals in a health-economic perspective.

One of the greatest criticisms of biologic therapy for CRSwNP is cost, particularly in a setting of ever-increasing health care costs. A recent review noted the average cost per year is greater than $30,000.
 

Real-life study verifies effectiveness

“As the authors pointed out, this is a real-life, prospective observational cohort with a decently large size, evaluating the therapeutic efficacy of add-on dupilumab,” said Seong H. Cho, MD, of the University of South Florida, Tampa, in an interview.

“Dupilumab is the first FDA-approved biologic to treat severe chronic rhinosinusitis with nasal polyps based on two phase 3 clinical trials,” said Dr. Cho, who was not involved with the study. “It has been more than 2 years since dupilumab was approved for severe CRSwNP by the FDA and EMA. This real-life, prospective, observational study with a decent size verified the efficacy of dupilumab as an add-on treatment when used with a proper indication such as EPOS2020 indication criteria.

“I am not surprised by the efficacy of dupilumab on severe CRSwNP, based on my clinical experience. My clinical observation is similar to the results of this study. This study verifies that dupilumab is highly efficacious in treating refractory and severe CRSwNP in a real-life setting by improving all subjective and objective clinical outcomes such as SNOT-22, NPS, and smell test score,” he said. The study also confirms that a stepwise, interdose interval prolongation from every 2-4 weeks for CRSwNP patients with good response should be a consideration for clinical practice, he added. 

The cost-effectiveness of dupilumab is the main barrier to more consistent use, Dr. Cho said. “There is no evidence that dupilumab can change the course of the disease, and we don’t know how long patients need to be on this drug. Therefore, nasal polyps need to be refractory and severe enough to use dupilumab and other biologics,” he explained.

Consequently, proper indication criteria, such as the EPOS2020 indication criteria for biologics, should be established before initiating dupilumab, Dr. Cho noted.

“Generally, endoscopic sinus surgery would be preferred in sinus-surgery naive CRSwNP patients, unless surgery is contraindicated or refused by patients because of cost-effectiveness rather than the superior efficacy,” he said. “If surgery fails, then dupilumab can be considered. In addition, proper evaluation of nasal polyp severity would be important.”

“One should establish an objective NPS by endoscopic exam before initiation of dupilumab. This baseline score would be an important marker to assess the efficacy of dupilumab in the course of treatment.”

Monitoring of the NPS together with the patient’s symptom improvement would be essential to implementing a stepwise, interdose interval prolongation to reduce the cost, he emphasized. 

“The most crucial additional research is establishing suitable biomarkers for the response of dupilumab and other biologics,” said Dr. Cho. “Overall, the performance of dupilumab seems to be good. But there are patients unresponsive to dupilumab, even more to other recently FDA-approved biologics for CRSwNP.”

Blood eosinophils and exhaled nitric oxide can be a good biomarker for type 2 asthma, Dr. Cho added. “Still, there is no evidence that these biomarkers are decent for CRSwNP, even though CRSwNP is mostly considered as type 2 disease. Therefore, it would be essential to find promising biomarkers for severe CRSwNP.”

Dr. Van der Lans disclosed serving as a consultant for GlaxoSmithKline, and several coauthors disclosed relationships with companies including Sanofi and Novartis. The patient registry from which the study population was drawn is cofunded by Sanofi and Novartis. Dr. Cho has disclosed no relevant financial relationships.

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

In a specialty clinic, dupilumab (Dupixent) injections significantly improved symptoms for patients with chronic rhinosinusitis with nasal polyps, based on provisional data from more than 100 adults.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a significant burden among working-age adults. Symptom control remains a challenge for many of these patients, and the cost in lost productivity and health care consumption can be substantial, write Rik J.L. van der Lans, MD, of the University of Amsterdam, and colleagues.

Dupilumab, a biologic that targets components of the type 2 inflammatory pathway, represents a new option that has shown effectiveness in clinical trials for regulatory approval, they said.

A new observational study tests dupilumab in patients who met criteria for biological treatment proposed in a recent major systematic review. The findings were published in the journal Allergy.

In the study, the researchers identified 131 adults older than 18 years (mean age 51.7) with CRSwNP treated at a single tertiary care center. Participants received 300 mg of dupilumab subcutaneous injection every 2 weeks for at least 12 weeks.

The primary outcomes were scores on several measures, including the SinoNasal Outcome Test-22 (SNOT-22, scale of 0-110), the bilateral Nasal Polyp Score (NPS, scale of 0-8), and the Sniffin’ Sticks-12 identification test (SSIT-12, scale of 0-6 anosmia, 7-10 hyposmia, 11-12 normosmia).

The mean scores on all three outcomes improved significantly from baseline to both 24 weeks and 48 weeks. Scores on the SNOT-22 improved from 52.4 at baseline to 18.5 and 16.8 at weeks 24 and 48, respectively. NPS improved from 5.4 at baseline to 1.6 and 1.0, respectively. SSIT-12 scores improved from 3.6 at baseline to 7.3 and 8.3, respectively.

At baseline, 95.8% of the patients had uncontrolled chronic rhinosinusitis, but at 24 and 48 weeks, respectively, 24.3% and 6.2% were uncontrolled.

Approximately half of the patients experienced treatment-emergent adverse events, but these were “mild and decreased in occurrence and intensity throughout treatment,” the researchers say.

For patients with a strong response, the researchers also tested an extension of the interval between doses to 4 weeks and 6 weeks, in a provisional indication of continued established control at these timepoints.

The study findings were limited by several factors, including the potential for selection bias, and data from only the first patient cohort, the researchers noted. However, the results were strengthened by the real-life context, standardized indications, and long-term follow up for almost a year, they said.

More research is needed on nonacademic patient cohorts, but the current data confirm the effectiveness of dupilumab as an add-on for difficult-to-treat CRSwNP, they concluded. The findings also validate the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) inclusion criteria for biologic treatment, they said.

The new study is important because of the need for verification of results from randomized controlled trials using real-world data, Dr. Van der Lans told this news organization.

“For example, differences in treatment efficacy might result from differing indication criteria, and the inclusion/exclusion criteria in the RCTs might have excluded patients one would encounter in daily practice,” he said. “With our prospective observational cohort, we are seeking to verify efficacy, monitor pharmacovigilance, and evaluate and advance the indication criteria and positioning of biologicals registered for CRSwNP, such as dupilumab.”

These cross-sectional results suggest dupilumab is more effective in preventing possibly harmful escape treatments, such as oral corticosteroids and/or surgery, than reported by the registration trials.

“Additionally, it appears possible to maintain established CRS-control during response-dependent, stepwise, interdose interval prolongation of up to 6 weeks, which is officially an off-label dosing interval,” he said. “This would greatly benefit patients’ treatment burden and direct costs,” he said. However, both findings require corroboration by anticipated longitudinal results in 2022, he noted.

The key message for clinicians in practice: “Biologicals like dupilumab are a potent and promising treatment for severe CRSwNP when conventional medical and surgical therapy fails,” he emphasized.

Looking ahead, important research objectives include head-on comparison studies of the diverse biological agents, establishing biomarkers to guide preferential therapy, and evaluating the economics of biologics compared with conventional therapy, Dr. Van der Lans added. Such research is vital not only for improving patient-centered care but to sustain the use of biologicals in a health-economic perspective.

One of the greatest criticisms of biologic therapy for CRSwNP is cost, particularly in a setting of ever-increasing health care costs. A recent review noted the average cost per year is greater than $30,000.
 

Real-life study verifies effectiveness

“As the authors pointed out, this is a real-life, prospective observational cohort with a decently large size, evaluating the therapeutic efficacy of add-on dupilumab,” said Seong H. Cho, MD, of the University of South Florida, Tampa, in an interview.

“Dupilumab is the first FDA-approved biologic to treat severe chronic rhinosinusitis with nasal polyps based on two phase 3 clinical trials,” said Dr. Cho, who was not involved with the study. “It has been more than 2 years since dupilumab was approved for severe CRSwNP by the FDA and EMA. This real-life, prospective, observational study with a decent size verified the efficacy of dupilumab as an add-on treatment when used with a proper indication such as EPOS2020 indication criteria.

“I am not surprised by the efficacy of dupilumab on severe CRSwNP, based on my clinical experience. My clinical observation is similar to the results of this study. This study verifies that dupilumab is highly efficacious in treating refractory and severe CRSwNP in a real-life setting by improving all subjective and objective clinical outcomes such as SNOT-22, NPS, and smell test score,” he said. The study also confirms that a stepwise, interdose interval prolongation from every 2-4 weeks for CRSwNP patients with good response should be a consideration for clinical practice, he added. 

The cost-effectiveness of dupilumab is the main barrier to more consistent use, Dr. Cho said. “There is no evidence that dupilumab can change the course of the disease, and we don’t know how long patients need to be on this drug. Therefore, nasal polyps need to be refractory and severe enough to use dupilumab and other biologics,” he explained.

Consequently, proper indication criteria, such as the EPOS2020 indication criteria for biologics, should be established before initiating dupilumab, Dr. Cho noted.

“Generally, endoscopic sinus surgery would be preferred in sinus-surgery naive CRSwNP patients, unless surgery is contraindicated or refused by patients because of cost-effectiveness rather than the superior efficacy,” he said. “If surgery fails, then dupilumab can be considered. In addition, proper evaluation of nasal polyp severity would be important.”

“One should establish an objective NPS by endoscopic exam before initiation of dupilumab. This baseline score would be an important marker to assess the efficacy of dupilumab in the course of treatment.”

Monitoring of the NPS together with the patient’s symptom improvement would be essential to implementing a stepwise, interdose interval prolongation to reduce the cost, he emphasized. 

“The most crucial additional research is establishing suitable biomarkers for the response of dupilumab and other biologics,” said Dr. Cho. “Overall, the performance of dupilumab seems to be good. But there are patients unresponsive to dupilumab, even more to other recently FDA-approved biologics for CRSwNP.”

Blood eosinophils and exhaled nitric oxide can be a good biomarker for type 2 asthma, Dr. Cho added. “Still, there is no evidence that these biomarkers are decent for CRSwNP, even though CRSwNP is mostly considered as type 2 disease. Therefore, it would be essential to find promising biomarkers for severe CRSwNP.”

Dr. Van der Lans disclosed serving as a consultant for GlaxoSmithKline, and several coauthors disclosed relationships with companies including Sanofi and Novartis. The patient registry from which the study population was drawn is cofunded by Sanofi and Novartis. Dr. Cho has disclosed no relevant financial relationships.

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

Sepsis is an alarmingly common cause behind ICU admissions in patients with multiple sclerosis (MS), a retrospective, population-based cohort study indicates.

Furthermore, it contributes to a disproportionately high percentage of the short-term mortality risk among patients with MS admitted to the ICU, findings also show. Short-term mortality risk was defined in the study as a combination of in-hospital death or discharge to hospice.

“We found that the risk of short-term mortality in critically ill patients with MS is four times higher among those with sepsis ... so sepsis appears to be comparatively more lethal among patients with MS than in the general population,” Lavi Oud, MD, professor of medicine, Texas Tech University HSC at the Permian Basin, Odessa, said in an email.

“[Although] the specific mechanisms underlying the markedly higher risk of sepsis among patients with MS compared to the general population remain to be fully elucidated ... it’s thought that the risk may stem from the dysfunction of the immune system in these patients related to MS itself and to the potentially adverse effect of the immunomodulating therapy we use in these patients,” he added.

The study was published online Jan. 11 in the Journal of Critical Care.
 

Sepsis rates

The Texas Inpatient Public Use Data File was used to identify adults with a diagnosis of MS admitted to the hospital between 2010 and 2017. Among the 19,837 patients with MS admitted to the ICU during the study interval, almost one-third (31.5%) had sepsis, investigators report. “The rate of sepsis among ICU admissions increased with age, ranging from 20.8% among those aged 18-44 to 39.4% among those aged 65 years or older,” investigators note.

The most common site of infection among MS patients admitted to the ICU were urinary in nature (65.2%), followed by respiratory (36.1%). A smaller proportion of infections (7.6%) involved the skin and soft tissues, researchers note. A full one-quarter of patients developed septic shock in response to their infection while the length of stay among patients with sepsis (mean of 10.9 days) was substantially longer than it was for those without sepsis (mean of 5.6 days), they observe.

At a mean total hospital cost of $121,797 for each ICU patient with sepsis, the cost of caring for each patient was nearly twofold higher than the mean total cost of taking care of ICU patients without sepsis (mean total cost, $65,179). On adjusted analysis, sepsis was associated with a 42.7% (95% confidence interval, 38.9-46.5; P < .0001) longer length of hospital stay and a 26.2% (95% CI, 23.1-29.1; P < .0001) higher total hospital cost compared with patients without sepsis, the authors point out.

Indeed, ICU admissions with sepsis accounted for 47.3% of all hospital days and for 46.1% of the aggregate hospital charges among all MS patients admitted to the ICU.

“The adjusted probability of short-term mortality was 13.4% (95% CI, 13.0-13.7) among ICU admissions with sepsis and 3.3% (95% CI, 3.2-3.4) among ICU admissions without sepsis,” the authors report.

This translated into a 44% higher risk of short-term mortality at an adjusted odds ratio of 1.44 (95% CI, 1.23-1.69; P < .0001) for those with sepsis, compared with those without, they add. Among all ICU admissions, sepsis was reported in over two-thirds of documented short-term mortality events. The risk of short-term mortality was also almost threefold higher among patients with sepsis who were age 65 years and older compared with patients aged 18-44. 

As Dr. Oud noted, there is no specific test for sepsis, and it can initially present in an atypical manner, especially in older, frailer, chronically ill patients as well as in patients with immune dysfunction. “Thus, considering sepsis as a possible cause of new deterioration in a patient’s condition is essential, along with the timely start of sepsis-related care,” Dr. Oud observed.

A limitation of the study was that the dataset did not include information on the type of MS a patient had, the duration of their illness, the treatment received, the level of disease activity, or the level of disability.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

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

Sepsis is an alarmingly common cause behind ICU admissions in patients with multiple sclerosis (MS), a retrospective, population-based cohort study indicates.

Furthermore, it contributes to a disproportionately high percentage of the short-term mortality risk among patients with MS admitted to the ICU, findings also show. Short-term mortality risk was defined in the study as a combination of in-hospital death or discharge to hospice.

“We found that the risk of short-term mortality in critically ill patients with MS is four times higher among those with sepsis ... so sepsis appears to be comparatively more lethal among patients with MS than in the general population,” Lavi Oud, MD, professor of medicine, Texas Tech University HSC at the Permian Basin, Odessa, said in an email.

“[Although] the specific mechanisms underlying the markedly higher risk of sepsis among patients with MS compared to the general population remain to be fully elucidated ... it’s thought that the risk may stem from the dysfunction of the immune system in these patients related to MS itself and to the potentially adverse effect of the immunomodulating therapy we use in these patients,” he added.

The study was published online Jan. 11 in the Journal of Critical Care.
 

Sepsis rates

The Texas Inpatient Public Use Data File was used to identify adults with a diagnosis of MS admitted to the hospital between 2010 and 2017. Among the 19,837 patients with MS admitted to the ICU during the study interval, almost one-third (31.5%) had sepsis, investigators report. “The rate of sepsis among ICU admissions increased with age, ranging from 20.8% among those aged 18-44 to 39.4% among those aged 65 years or older,” investigators note.

The most common site of infection among MS patients admitted to the ICU were urinary in nature (65.2%), followed by respiratory (36.1%). A smaller proportion of infections (7.6%) involved the skin and soft tissues, researchers note. A full one-quarter of patients developed septic shock in response to their infection while the length of stay among patients with sepsis (mean of 10.9 days) was substantially longer than it was for those without sepsis (mean of 5.6 days), they observe.

At a mean total hospital cost of $121,797 for each ICU patient with sepsis, the cost of caring for each patient was nearly twofold higher than the mean total cost of taking care of ICU patients without sepsis (mean total cost, $65,179). On adjusted analysis, sepsis was associated with a 42.7% (95% confidence interval, 38.9-46.5; P < .0001) longer length of hospital stay and a 26.2% (95% CI, 23.1-29.1; P < .0001) higher total hospital cost compared with patients without sepsis, the authors point out.

Indeed, ICU admissions with sepsis accounted for 47.3% of all hospital days and for 46.1% of the aggregate hospital charges among all MS patients admitted to the ICU.

“The adjusted probability of short-term mortality was 13.4% (95% CI, 13.0-13.7) among ICU admissions with sepsis and 3.3% (95% CI, 3.2-3.4) among ICU admissions without sepsis,” the authors report.

This translated into a 44% higher risk of short-term mortality at an adjusted odds ratio of 1.44 (95% CI, 1.23-1.69; P < .0001) for those with sepsis, compared with those without, they add. Among all ICU admissions, sepsis was reported in over two-thirds of documented short-term mortality events. The risk of short-term mortality was also almost threefold higher among patients with sepsis who were age 65 years and older compared with patients aged 18-44. 

As Dr. Oud noted, there is no specific test for sepsis, and it can initially present in an atypical manner, especially in older, frailer, chronically ill patients as well as in patients with immune dysfunction. “Thus, considering sepsis as a possible cause of new deterioration in a patient’s condition is essential, along with the timely start of sepsis-related care,” Dr. Oud observed.

A limitation of the study was that the dataset did not include information on the type of MS a patient had, the duration of their illness, the treatment received, the level of disease activity, or the level of disability.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

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

Sepsis is an alarmingly common cause behind ICU admissions in patients with multiple sclerosis (MS), a retrospective, population-based cohort study indicates.

Furthermore, it contributes to a disproportionately high percentage of the short-term mortality risk among patients with MS admitted to the ICU, findings also show. Short-term mortality risk was defined in the study as a combination of in-hospital death or discharge to hospice.

“We found that the risk of short-term mortality in critically ill patients with MS is four times higher among those with sepsis ... so sepsis appears to be comparatively more lethal among patients with MS than in the general population,” Lavi Oud, MD, professor of medicine, Texas Tech University HSC at the Permian Basin, Odessa, said in an email.

“[Although] the specific mechanisms underlying the markedly higher risk of sepsis among patients with MS compared to the general population remain to be fully elucidated ... it’s thought that the risk may stem from the dysfunction of the immune system in these patients related to MS itself and to the potentially adverse effect of the immunomodulating therapy we use in these patients,” he added.

The study was published online Jan. 11 in the Journal of Critical Care.
 

Sepsis rates

The Texas Inpatient Public Use Data File was used to identify adults with a diagnosis of MS admitted to the hospital between 2010 and 2017. Among the 19,837 patients with MS admitted to the ICU during the study interval, almost one-third (31.5%) had sepsis, investigators report. “The rate of sepsis among ICU admissions increased with age, ranging from 20.8% among those aged 18-44 to 39.4% among those aged 65 years or older,” investigators note.

The most common site of infection among MS patients admitted to the ICU were urinary in nature (65.2%), followed by respiratory (36.1%). A smaller proportion of infections (7.6%) involved the skin and soft tissues, researchers note. A full one-quarter of patients developed septic shock in response to their infection while the length of stay among patients with sepsis (mean of 10.9 days) was substantially longer than it was for those without sepsis (mean of 5.6 days), they observe.

At a mean total hospital cost of $121,797 for each ICU patient with sepsis, the cost of caring for each patient was nearly twofold higher than the mean total cost of taking care of ICU patients without sepsis (mean total cost, $65,179). On adjusted analysis, sepsis was associated with a 42.7% (95% confidence interval, 38.9-46.5; P < .0001) longer length of hospital stay and a 26.2% (95% CI, 23.1-29.1; P < .0001) higher total hospital cost compared with patients without sepsis, the authors point out.

Indeed, ICU admissions with sepsis accounted for 47.3% of all hospital days and for 46.1% of the aggregate hospital charges among all MS patients admitted to the ICU.

“The adjusted probability of short-term mortality was 13.4% (95% CI, 13.0-13.7) among ICU admissions with sepsis and 3.3% (95% CI, 3.2-3.4) among ICU admissions without sepsis,” the authors report.

This translated into a 44% higher risk of short-term mortality at an adjusted odds ratio of 1.44 (95% CI, 1.23-1.69; P < .0001) for those with sepsis, compared with those without, they add. Among all ICU admissions, sepsis was reported in over two-thirds of documented short-term mortality events. The risk of short-term mortality was also almost threefold higher among patients with sepsis who were age 65 years and older compared with patients aged 18-44. 

As Dr. Oud noted, there is no specific test for sepsis, and it can initially present in an atypical manner, especially in older, frailer, chronically ill patients as well as in patients with immune dysfunction. “Thus, considering sepsis as a possible cause of new deterioration in a patient’s condition is essential, along with the timely start of sepsis-related care,” Dr. Oud observed.

A limitation of the study was that the dataset did not include information on the type of MS a patient had, the duration of their illness, the treatment received, the level of disease activity, or the level of disability.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

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

To the Editor:

Sarcoidosis is a multisystem, noncaseating, granulomatous disorder thought to occur from a combination of immunologic, genetic, and environmental factors.¹ Often referred to as the “great imitator,” the cutaneous manifestations of sarcoidosis encompass many morphologies, including papules, plaques, nodules, and scars.¹ We report an unusual case of sarcoidosis presenting as telangiectatic macules on the lower extremities.

A woman in her early 30s presented with a burning, pruritic, erythematous, telangiectatic eruption on the lower extremities with concurrent ankle swelling of 4 weeks’ duration. The patient denied any fevers, chills, recent infections, or new medications. Evaluation by her primary care physician during the time of the eruption included unremarkable antinuclear antibodies, thyroid stimulating hormone level, complete blood cell count, comprehensive metabolic panel, urinalysis, chest radiography, and lower-extremity Doppler ultrasonography.

Physical examination at the current presentation revealed numerous scattered, faint, erythematous, blanchable macules on the lower extremities along with mild pitting edema (Figure 1). The patient’s current medications included cetirizine, which she had been taking for years, as well as an intrauterine device. A punch biopsy from the right lower leg revealed small, well-demarcated sarcoidal granulomatous inflammation surrounding vascular structures and skin appendages (Figure 2). No foreign bodies were observed with polarized light microscopy. Microscopic findings suggestive of an infection, including caseation necrosis and suppurative inflammation, also were absent. Angiotensin-converting enzyme levels were normal. Myeloperoxidase and proteinase 3 IgG antibody levels were evaluated due to potential vascular involvement but were negative. An infectious cause of the sarcoidal granulomas was unlikely given histopathologic findings and negative tuberculosis skin testing, which the patient underwent annually for her job, so a tissue culture was not performed. The patient was prescribed triamcinolone acetonide cream 0.1% for the itching and burning at the initial visit and was continued on this treatment after the diagnosis of sarcoidosis was made. At 2-month follow-up, the patient’s eruption had nearly resolved with topical therapy.

Cutaneous manifestation occurs in 20% to 35% of sarcoidosis cases and may develop in the presence or absence of systemic disease. Approximately 60% of individuals with cutaneous sarcoidosis are found to have systemic involvement; therefore, careful monitoring and diagnostic workup are important in the management of these patients.² While most cases of cutaneous sarcoidosis are papular, it is important for clinicians to maintain a level of suspicion for sarcoidosis in any uncertain dermatologic presentation.^1,2 Evidence of telangiectasias has been shown in rarer forms of sarcoidosis (eg, angiolupoid), but the lesions usually are confined to the face, ears, or neck.³ Granulomatous vasculitis has been reported in a small number of individuals with ulcerative sarcoidosis.⁴ In our case, no ulcerations were present, possibly indicating an early lesion or an entirely novel process. Lastly, although reticular dermal granulomas are found in drug-induced interstitial granulomatous dermatitis, these lesions often are dispersed interstitially amongst collagen bundles and are associated with necrobiosis of collagen and eosinophilic/neutrophilic infiltrates.⁵ The lack of these characteristic pathologic findings in our patient along with no known reported cases of cetirizine-induced granulomatous dermatitis led us to rule out reticular dermal granulomas as a diagnosis. We present our case as a reminder of the diversity of cutaneous sarcoidosis manifestations and the importance of early diagnosis of these lesions.

To the Editor:

Sarcoidosis is a multisystem, noncaseating, granulomatous disorder thought to occur from a combination of immunologic, genetic, and environmental factors.¹ Often referred to as the “great imitator,” the cutaneous manifestations of sarcoidosis encompass many morphologies, including papules, plaques, nodules, and scars.¹ We report an unusual case of sarcoidosis presenting as telangiectatic macules on the lower extremities.

A woman in her early 30s presented with a burning, pruritic, erythematous, telangiectatic eruption on the lower extremities with concurrent ankle swelling of 4 weeks’ duration. The patient denied any fevers, chills, recent infections, or new medications. Evaluation by her primary care physician during the time of the eruption included unremarkable antinuclear antibodies, thyroid stimulating hormone level, complete blood cell count, comprehensive metabolic panel, urinalysis, chest radiography, and lower-extremity Doppler ultrasonography.

Physical examination at the current presentation revealed numerous scattered, faint, erythematous, blanchable macules on the lower extremities along with mild pitting edema (Figure 1). The patient’s current medications included cetirizine, which she had been taking for years, as well as an intrauterine device. A punch biopsy from the right lower leg revealed small, well-demarcated sarcoidal granulomatous inflammation surrounding vascular structures and skin appendages (Figure 2). No foreign bodies were observed with polarized light microscopy. Microscopic findings suggestive of an infection, including caseation necrosis and suppurative inflammation, also were absent. Angiotensin-converting enzyme levels were normal. Myeloperoxidase and proteinase 3 IgG antibody levels were evaluated due to potential vascular involvement but were negative. An infectious cause of the sarcoidal granulomas was unlikely given histopathologic findings and negative tuberculosis skin testing, which the patient underwent annually for her job, so a tissue culture was not performed. The patient was prescribed triamcinolone acetonide cream 0.1% for the itching and burning at the initial visit and was continued on this treatment after the diagnosis of sarcoidosis was made. At 2-month follow-up, the patient’s eruption had nearly resolved with topical therapy.

Cutaneous manifestation occurs in 20% to 35% of sarcoidosis cases and may develop in the presence or absence of systemic disease. Approximately 60% of individuals with cutaneous sarcoidosis are found to have systemic involvement; therefore, careful monitoring and diagnostic workup are important in the management of these patients.² While most cases of cutaneous sarcoidosis are papular, it is important for clinicians to maintain a level of suspicion for sarcoidosis in any uncertain dermatologic presentation.^1,2 Evidence of telangiectasias has been shown in rarer forms of sarcoidosis (eg, angiolupoid), but the lesions usually are confined to the face, ears, or neck.³ Granulomatous vasculitis has been reported in a small number of individuals with ulcerative sarcoidosis.⁴ In our case, no ulcerations were present, possibly indicating an early lesion or an entirely novel process. Lastly, although reticular dermal granulomas are found in drug-induced interstitial granulomatous dermatitis, these lesions often are dispersed interstitially amongst collagen bundles and are associated with necrobiosis of collagen and eosinophilic/neutrophilic infiltrates.⁵ The lack of these characteristic pathologic findings in our patient along with no known reported cases of cetirizine-induced granulomatous dermatitis led us to rule out reticular dermal granulomas as a diagnosis. We present our case as a reminder of the diversity of cutaneous sarcoidosis manifestations and the importance of early diagnosis of these lesions.

To the Editor:

Sarcoidosis is a multisystem, noncaseating, granulomatous disorder thought to occur from a combination of immunologic, genetic, and environmental factors.¹ Often referred to as the “great imitator,” the cutaneous manifestations of sarcoidosis encompass many morphologies, including papules, plaques, nodules, and scars.¹ We report an unusual case of sarcoidosis presenting as telangiectatic macules on the lower extremities.

A woman in her early 30s presented with a burning, pruritic, erythematous, telangiectatic eruption on the lower extremities with concurrent ankle swelling of 4 weeks’ duration. The patient denied any fevers, chills, recent infections, or new medications. Evaluation by her primary care physician during the time of the eruption included unremarkable antinuclear antibodies, thyroid stimulating hormone level, complete blood cell count, comprehensive metabolic panel, urinalysis, chest radiography, and lower-extremity Doppler ultrasonography.

Physical examination at the current presentation revealed numerous scattered, faint, erythematous, blanchable macules on the lower extremities along with mild pitting edema (Figure 1). The patient’s current medications included cetirizine, which she had been taking for years, as well as an intrauterine device. A punch biopsy from the right lower leg revealed small, well-demarcated sarcoidal granulomatous inflammation surrounding vascular structures and skin appendages (Figure 2). No foreign bodies were observed with polarized light microscopy. Microscopic findings suggestive of an infection, including caseation necrosis and suppurative inflammation, also were absent. Angiotensin-converting enzyme levels were normal. Myeloperoxidase and proteinase 3 IgG antibody levels were evaluated due to potential vascular involvement but were negative. An infectious cause of the sarcoidal granulomas was unlikely given histopathologic findings and negative tuberculosis skin testing, which the patient underwent annually for her job, so a tissue culture was not performed. The patient was prescribed triamcinolone acetonide cream 0.1% for the itching and burning at the initial visit and was continued on this treatment after the diagnosis of sarcoidosis was made. At 2-month follow-up, the patient’s eruption had nearly resolved with topical therapy.

Cutaneous manifestation occurs in 20% to 35% of sarcoidosis cases and may develop in the presence or absence of systemic disease. Approximately 60% of individuals with cutaneous sarcoidosis are found to have systemic involvement; therefore, careful monitoring and diagnostic workup are important in the management of these patients.² While most cases of cutaneous sarcoidosis are papular, it is important for clinicians to maintain a level of suspicion for sarcoidosis in any uncertain dermatologic presentation.^1,2 Evidence of telangiectasias has been shown in rarer forms of sarcoidosis (eg, angiolupoid), but the lesions usually are confined to the face, ears, or neck.³ Granulomatous vasculitis has been reported in a small number of individuals with ulcerative sarcoidosis.⁴ In our case, no ulcerations were present, possibly indicating an early lesion or an entirely novel process. Lastly, although reticular dermal granulomas are found in drug-induced interstitial granulomatous dermatitis, these lesions often are dispersed interstitially amongst collagen bundles and are associated with necrobiosis of collagen and eosinophilic/neutrophilic infiltrates.⁵ The lack of these characteristic pathologic findings in our patient along with no known reported cases of cetirizine-induced granulomatous dermatitis led us to rule out reticular dermal granulomas as a diagnosis. We present our case as a reminder of the diversity of cutaneous sarcoidosis manifestations and the importance of early diagnosis of these lesions.

Two new studies suggest the expansion of Medicaid under the Patient Protection and Affordable Care Act in 2010 may be leading to more frequent diagnosis of colorectal cancer (CRC) among Hispanics.

The studies, presented at the 2022 Gastrointestinal Cancers Symposium, suggest that Medicaid expansion may have a diverse impact on various ethnic groups.

“The take-home message for both physicians and policy makers is that health policy has the capacity to shift health care delivery, yet we need to consider the effects of health policy might influence subgroups of patients differently. This is useful information for providers caring for a diverse group of patients. For policy makers, this study emphasizes the importance of evaluating the impact of health policy among different racial and ethnic subgroups to fully understand the impact of [policy] change,” said study lead author James D. Murphy, MD, MS, assistant vice chair of radiation medicine at the University of California San Diego.

Dr. Murphy and associates cautioned that other factors, not just Medicaid expansion, could be responsible for the uptick in colon cancer diagnoses.

“Our observations could potentially be influenced by other risk factors. Medicaid expansion was not a ‘randomized experiment,’ and states which opted to expand Medicaid might have fundamental differences which could impact colorectal cancer incidence,” he said.

His group’s analysis of the Surveillance, Epidemiology, and End Results database included 21 states where Medicaid was expanded and 16 states where expansion did not occur. Between 2010-2013 and 2014-2018, among patients under 65, overall colorectal cancer incidence rates did not differ by Medicaid expansion status. In nonexpansion states, there was a greater increase in CRC rates among Hispanics (5.4 vs. 1.6 increase per 100,000; P = .002) and Asian/Pacific Islanders (4.3 vs. 0.4 per 100,000; P = .02), but there was no difference among Black or non-Hispanic White individuals.
 

Early-onset colorectal cancer diagnoses increase under Medicaid expansion

In another study presented at the meeting, researchers examined early-onset CRC data from the National Cancer Database. Among Hispanics, the rate of change of incidence of newly diagnosed cases among patients age 40-49 in Medicaid expansion states increased from 4.3% per year between 2010 and 2014 and 9.8% between 2014 and 2017. That compares with the general background increase in incidence of about 2%. In nonexpansion states, the rate of change decreased from 6.4% to 1% (P = .03). There were no statistically significant differences in the change of incidence among Blacks or Whites between expansion and nonexpansion states.

The reduced rate of change among Hispanics in nonexpansion states was a surprise, and the researchers haven’t determined the reason, according to Sanjay Goel, MD, an oncologist with Montefiore Medical Center, New York, and lead author on the National Cancer Database study. Dr. Goel speculated that some people may have migrated from nonexpansion states to states that expanded Medicaid in order to gain health care coverage.

The apparent benefit seen in Hispanics, but not Black patients, may be caused by greater susceptibility to early-onset CRC among Hispanics, leading to a stronger effect on that population when Medicaid was expanded, Dr. Goel said.

“At this point, with our available data, we do not have the ability to understand the underlying sources of these disparities, though these are questions which deserve additional research,” Dr. Murphy said.

Regardless of the reason, the message is clear, Dr. Goel said. “The bottom we want to state is that politics aside, providing health care coverage to as many people as possible, ideally to everyone, is the right way of going forward.”

The implications of the findings extend beyond policy. “The general advice I give is that, especially if you treat a Hispanic person, regardless of age, with any symptom or sign that could be suggestive of a malignancy, do not take it lightly. Follow the patient closely. I’m not advocating that you refer everybody with lower abdominal pain or bleeding for a colonoscopy, but do factor it in mind. Call them back in a week or 2, or have them make a follow-up appointment in a month so that they don’t get neglected by the system.”

Dr. Murphy and Dr. Goel have no relevant financial disclosures. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Two new studies suggest the expansion of Medicaid under the Patient Protection and Affordable Care Act in 2010 may be leading to more frequent diagnosis of colorectal cancer (CRC) among Hispanics.

The studies, presented at the 2022 Gastrointestinal Cancers Symposium, suggest that Medicaid expansion may have a diverse impact on various ethnic groups.

“The take-home message for both physicians and policy makers is that health policy has the capacity to shift health care delivery, yet we need to consider the effects of health policy might influence subgroups of patients differently. This is useful information for providers caring for a diverse group of patients. For policy makers, this study emphasizes the importance of evaluating the impact of health policy among different racial and ethnic subgroups to fully understand the impact of [policy] change,” said study lead author James D. Murphy, MD, MS, assistant vice chair of radiation medicine at the University of California San Diego.

Dr. Murphy and associates cautioned that other factors, not just Medicaid expansion, could be responsible for the uptick in colon cancer diagnoses.

“Our observations could potentially be influenced by other risk factors. Medicaid expansion was not a ‘randomized experiment,’ and states which opted to expand Medicaid might have fundamental differences which could impact colorectal cancer incidence,” he said.

His group’s analysis of the Surveillance, Epidemiology, and End Results database included 21 states where Medicaid was expanded and 16 states where expansion did not occur. Between 2010-2013 and 2014-2018, among patients under 65, overall colorectal cancer incidence rates did not differ by Medicaid expansion status. In nonexpansion states, there was a greater increase in CRC rates among Hispanics (5.4 vs. 1.6 increase per 100,000; P = .002) and Asian/Pacific Islanders (4.3 vs. 0.4 per 100,000; P = .02), but there was no difference among Black or non-Hispanic White individuals.
 

Early-onset colorectal cancer diagnoses increase under Medicaid expansion

In another study presented at the meeting, researchers examined early-onset CRC data from the National Cancer Database. Among Hispanics, the rate of change of incidence of newly diagnosed cases among patients age 40-49 in Medicaid expansion states increased from 4.3% per year between 2010 and 2014 and 9.8% between 2014 and 2017. That compares with the general background increase in incidence of about 2%. In nonexpansion states, the rate of change decreased from 6.4% to 1% (P = .03). There were no statistically significant differences in the change of incidence among Blacks or Whites between expansion and nonexpansion states.

The reduced rate of change among Hispanics in nonexpansion states was a surprise, and the researchers haven’t determined the reason, according to Sanjay Goel, MD, an oncologist with Montefiore Medical Center, New York, and lead author on the National Cancer Database study. Dr. Goel speculated that some people may have migrated from nonexpansion states to states that expanded Medicaid in order to gain health care coverage.

The apparent benefit seen in Hispanics, but not Black patients, may be caused by greater susceptibility to early-onset CRC among Hispanics, leading to a stronger effect on that population when Medicaid was expanded, Dr. Goel said.

“At this point, with our available data, we do not have the ability to understand the underlying sources of these disparities, though these are questions which deserve additional research,” Dr. Murphy said.

Regardless of the reason, the message is clear, Dr. Goel said. “The bottom we want to state is that politics aside, providing health care coverage to as many people as possible, ideally to everyone, is the right way of going forward.”

The implications of the findings extend beyond policy. “The general advice I give is that, especially if you treat a Hispanic person, regardless of age, with any symptom or sign that could be suggestive of a malignancy, do not take it lightly. Follow the patient closely. I’m not advocating that you refer everybody with lower abdominal pain or bleeding for a colonoscopy, but do factor it in mind. Call them back in a week or 2, or have them make a follow-up appointment in a month so that they don’t get neglected by the system.”

Dr. Murphy and Dr. Goel have no relevant financial disclosures. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Two new studies suggest the expansion of Medicaid under the Patient Protection and Affordable Care Act in 2010 may be leading to more frequent diagnosis of colorectal cancer (CRC) among Hispanics.

The studies, presented at the 2022 Gastrointestinal Cancers Symposium, suggest that Medicaid expansion may have a diverse impact on various ethnic groups.

“The take-home message for both physicians and policy makers is that health policy has the capacity to shift health care delivery, yet we need to consider the effects of health policy might influence subgroups of patients differently. This is useful information for providers caring for a diverse group of patients. For policy makers, this study emphasizes the importance of evaluating the impact of health policy among different racial and ethnic subgroups to fully understand the impact of [policy] change,” said study lead author James D. Murphy, MD, MS, assistant vice chair of radiation medicine at the University of California San Diego.

Dr. Murphy and associates cautioned that other factors, not just Medicaid expansion, could be responsible for the uptick in colon cancer diagnoses.

“Our observations could potentially be influenced by other risk factors. Medicaid expansion was not a ‘randomized experiment,’ and states which opted to expand Medicaid might have fundamental differences which could impact colorectal cancer incidence,” he said.

His group’s analysis of the Surveillance, Epidemiology, and End Results database included 21 states where Medicaid was expanded and 16 states where expansion did not occur. Between 2010-2013 and 2014-2018, among patients under 65, overall colorectal cancer incidence rates did not differ by Medicaid expansion status. In nonexpansion states, there was a greater increase in CRC rates among Hispanics (5.4 vs. 1.6 increase per 100,000; P = .002) and Asian/Pacific Islanders (4.3 vs. 0.4 per 100,000; P = .02), but there was no difference among Black or non-Hispanic White individuals.
 

Early-onset colorectal cancer diagnoses increase under Medicaid expansion

In another study presented at the meeting, researchers examined early-onset CRC data from the National Cancer Database. Among Hispanics, the rate of change of incidence of newly diagnosed cases among patients age 40-49 in Medicaid expansion states increased from 4.3% per year between 2010 and 2014 and 9.8% between 2014 and 2017. That compares with the general background increase in incidence of about 2%. In nonexpansion states, the rate of change decreased from 6.4% to 1% (P = .03). There were no statistically significant differences in the change of incidence among Blacks or Whites between expansion and nonexpansion states.

The reduced rate of change among Hispanics in nonexpansion states was a surprise, and the researchers haven’t determined the reason, according to Sanjay Goel, MD, an oncologist with Montefiore Medical Center, New York, and lead author on the National Cancer Database study. Dr. Goel speculated that some people may have migrated from nonexpansion states to states that expanded Medicaid in order to gain health care coverage.

The apparent benefit seen in Hispanics, but not Black patients, may be caused by greater susceptibility to early-onset CRC among Hispanics, leading to a stronger effect on that population when Medicaid was expanded, Dr. Goel said.

“At this point, with our available data, we do not have the ability to understand the underlying sources of these disparities, though these are questions which deserve additional research,” Dr. Murphy said.

Regardless of the reason, the message is clear, Dr. Goel said. “The bottom we want to state is that politics aside, providing health care coverage to as many people as possible, ideally to everyone, is the right way of going forward.”

The implications of the findings extend beyond policy. “The general advice I give is that, especially if you treat a Hispanic person, regardless of age, with any symptom or sign that could be suggestive of a malignancy, do not take it lightly. Follow the patient closely. I’m not advocating that you refer everybody with lower abdominal pain or bleeding for a colonoscopy, but do factor it in mind. Call them back in a week or 2, or have them make a follow-up appointment in a month so that they don’t get neglected by the system.”

Dr. Murphy and Dr. Goel have no relevant financial disclosures. The Gastrointestinal Cancers Symposium is sponsored by the American Gastroenterological Association, the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

In the treatment of male androgenetic alopecia (AGA), low-dose dutasteride (0.5 mg/day), used off label in the United States, tops a ranking of the most commonly used oral and topical agents in a new meta-analysis.

While up to 90% of men experience AGA in their lifetime, only three therapies are currently approved for treatment of the condition by the Food and Drug Administration – topical minoxidil, oral finasteride 1 mg, and low-level light therapy.

However, with common use of off-label oral minoxidil, as well as oral dutasteride and higher doses of oral finasteride, the latter two being 5-alpha reductase inhibitors, Aditya K. Gupta, MD, PhD, of Mediprobe Research, in London, Ont., and colleagues sought to compare the data on the three agents. Their results were published in JAMA Dermatology.

They note that, while there have been recent comparisons between oral and topical minoxidil, “to our knowledge no study has determined the comparative effectiveness of these 2 [formulations] with that of local and systemic dutasteride and finasteride.”

For the meta-analysis, the authors identified 23 studies meeting their criteria, involving patients with mean ages ranging from 22.8 to 41.8 years.

For the primary endpoint of the greatest increases in total hair count at 24 weeks, the analysis showed the 0.5-mg/day dose of dutasteride topped the list, with significantly greater efficacy, compared with 1 mg/day of finasteride (mean difference, 7.1 hairs per cm²).

The 0.5-mg/d dutasteride dose also showed higher efficacy than oral minoxidil at 0.25 mg/day (mean difference, 23.7 hairs per cm²) and 5 mg/day (mean difference, 15.0 hairs per cm²) and topical minoxidil at 2% (mean difference, 8.5 hairs per cm²).

For the secondary endpoint of the greatest increase in terminal hair count at 24 weeks, the 5-mg/day dose of minoxidil had significantly greater efficacy compared with the 0.25-mg/day dose of the drug, as well as with minoxidil’s 2% and 5% topical formulations.

The minoxidil 5-mg/day dose was also significantly more effective than 1 mg/day of finasteride for terminal hair count at 24 weeks.

In longer-term outcomes at 48 weeks, the greatest increase in total hair count at 48 weeks was observed with 5 mg/day of finasteride, which was significantly more effective, compared with 2% topical minoxidil.

And the greatest increase in terminal hair count at 48 weeks was observed with 1 mg/day of oral finasteride, which was significantly more effective than 2% as well as 5% topical minoxidil.

Based on the results, the authors ranked the agents in a decreasing order of efficacy: 0.5 mg/day of oral dutasteride, 5 mg/day of oral finasteride, 5 mg/day of oral minoxidil, 1 mg/day of oral finasteride, 5% topical minoxidil, 2% topical minoxidil, and 0.25 mg/day of oral minoxidil.

Commenting on the analysis in an accompanying editorial, Kathie P. Huang, MD, of the department of dermatology, Brigham and Women’s Hospital, Boston, and Maryanne M. Senna, MD, of the department of dermatology, Massachusetts General Hospital, Boston, said the results, in general, are consistent with their experiences, noting that 2% minoxidil is typically not used in men.

They noted that, “although topical minoxidil ranked higher than the very-low-dose 0.25 mg oral minoxidil, our personal experience is that oral minoxidil at doses of 1.25 mg to 5 mg are far superior to topical minoxidil for treating AGA.”

Adverse event considerations important

Importantly, however, strong consideration needs to be given to adverse-event profiles, as well as patient comorbidities in selecting agents, the editorial authors asserted.

With 1 mg finasteride, for instance, potential adverse events include decreased libido, erectile dysfunction, decreased ejaculatory volume, reduction in sperm count, testicular pain, depression, and gynecomastia, they noted.

And while finasteride appears to be associated with a decreased risk of prostate cancer, those receiving the drug who do develop prostate cancer may be diagnosed with higher-grade prostate cancer; however, that “might be related to tissue sampling artifact,” the editorial authors said.

Less has been published on dutasteride’s adverse-event profile, and that, in itself, is a concern.

Dr. Antonella Tosti

Overall, “as more direct-to-consumer companies treating male AGA emerge, it is especially important that the potential risks of these medications be made clear to patients,” they added.

Further commenting on the analysis to this news organization, Antonella Tosti, MD, the Fredric Brandt Endowed Professor of Dermatology and Cutaneous Surgery at the University of Miami, said the study offers some important insights – and caveats.

“I think this is a very interesting study, but you have to consider what works for your patients,” she said.

Dr. Tosti noted that the 5-mg dose of minoxidil is a concern in terms of side effects. “That dose is pretty high and could feasibly cause some hypertrichosis, which can be a concern to men as well as women.”

She agrees that the lack of data on side effects with dutasteride is also a concern, especially in light of some of the known side effects with other agents.

“That’s why I don’t use it very much in younger patients – because I’m afraid it could potentially affect their fertility,” Dr. Tosti said.

In general, Dr. Tosti said she finds a combination of agents provides the best results, as many clinicians use.

“I find dutasteride (0.5 mg/day) plus oral minoxidil (1-2.5 mg/day) plus topical 5% minoxidil is the best combination,” she said.

The authors and Dr. Tosti disclosed no relevant financial relationships.

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

In the treatment of male androgenetic alopecia (AGA), low-dose dutasteride (0.5 mg/day), used off label in the United States, tops a ranking of the most commonly used oral and topical agents in a new meta-analysis.

While up to 90% of men experience AGA in their lifetime, only three therapies are currently approved for treatment of the condition by the Food and Drug Administration – topical minoxidil, oral finasteride 1 mg, and low-level light therapy.

However, with common use of off-label oral minoxidil, as well as oral dutasteride and higher doses of oral finasteride, the latter two being 5-alpha reductase inhibitors, Aditya K. Gupta, MD, PhD, of Mediprobe Research, in London, Ont., and colleagues sought to compare the data on the three agents. Their results were published in JAMA Dermatology.

They note that, while there have been recent comparisons between oral and topical minoxidil, “to our knowledge no study has determined the comparative effectiveness of these 2 [formulations] with that of local and systemic dutasteride and finasteride.”

For the meta-analysis, the authors identified 23 studies meeting their criteria, involving patients with mean ages ranging from 22.8 to 41.8 years.

For the primary endpoint of the greatest increases in total hair count at 24 weeks, the analysis showed the 0.5-mg/day dose of dutasteride topped the list, with significantly greater efficacy, compared with 1 mg/day of finasteride (mean difference, 7.1 hairs per cm²).

The 0.5-mg/d dutasteride dose also showed higher efficacy than oral minoxidil at 0.25 mg/day (mean difference, 23.7 hairs per cm²) and 5 mg/day (mean difference, 15.0 hairs per cm²) and topical minoxidil at 2% (mean difference, 8.5 hairs per cm²).

For the secondary endpoint of the greatest increase in terminal hair count at 24 weeks, the 5-mg/day dose of minoxidil had significantly greater efficacy compared with the 0.25-mg/day dose of the drug, as well as with minoxidil’s 2% and 5% topical formulations.

The minoxidil 5-mg/day dose was also significantly more effective than 1 mg/day of finasteride for terminal hair count at 24 weeks.

In longer-term outcomes at 48 weeks, the greatest increase in total hair count at 48 weeks was observed with 5 mg/day of finasteride, which was significantly more effective, compared with 2% topical minoxidil.

And the greatest increase in terminal hair count at 48 weeks was observed with 1 mg/day of oral finasteride, which was significantly more effective than 2% as well as 5% topical minoxidil.

Based on the results, the authors ranked the agents in a decreasing order of efficacy: 0.5 mg/day of oral dutasteride, 5 mg/day of oral finasteride, 5 mg/day of oral minoxidil, 1 mg/day of oral finasteride, 5% topical minoxidil, 2% topical minoxidil, and 0.25 mg/day of oral minoxidil.

Commenting on the analysis in an accompanying editorial, Kathie P. Huang, MD, of the department of dermatology, Brigham and Women’s Hospital, Boston, and Maryanne M. Senna, MD, of the department of dermatology, Massachusetts General Hospital, Boston, said the results, in general, are consistent with their experiences, noting that 2% minoxidil is typically not used in men.

They noted that, “although topical minoxidil ranked higher than the very-low-dose 0.25 mg oral minoxidil, our personal experience is that oral minoxidil at doses of 1.25 mg to 5 mg are far superior to topical minoxidil for treating AGA.”

Adverse event considerations important

Importantly, however, strong consideration needs to be given to adverse-event profiles, as well as patient comorbidities in selecting agents, the editorial authors asserted.

With 1 mg finasteride, for instance, potential adverse events include decreased libido, erectile dysfunction, decreased ejaculatory volume, reduction in sperm count, testicular pain, depression, and gynecomastia, they noted.

And while finasteride appears to be associated with a decreased risk of prostate cancer, those receiving the drug who do develop prostate cancer may be diagnosed with higher-grade prostate cancer; however, that “might be related to tissue sampling artifact,” the editorial authors said.

Less has been published on dutasteride’s adverse-event profile, and that, in itself, is a concern.

Dr. Antonella Tosti

Overall, “as more direct-to-consumer companies treating male AGA emerge, it is especially important that the potential risks of these medications be made clear to patients,” they added.

Further commenting on the analysis to this news organization, Antonella Tosti, MD, the Fredric Brandt Endowed Professor of Dermatology and Cutaneous Surgery at the University of Miami, said the study offers some important insights – and caveats.

“I think this is a very interesting study, but you have to consider what works for your patients,” she said.

Dr. Tosti noted that the 5-mg dose of minoxidil is a concern in terms of side effects. “That dose is pretty high and could feasibly cause some hypertrichosis, which can be a concern to men as well as women.”

She agrees that the lack of data on side effects with dutasteride is also a concern, especially in light of some of the known side effects with other agents.

“That’s why I don’t use it very much in younger patients – because I’m afraid it could potentially affect their fertility,” Dr. Tosti said.

In general, Dr. Tosti said she finds a combination of agents provides the best results, as many clinicians use.

“I find dutasteride (0.5 mg/day) plus oral minoxidil (1-2.5 mg/day) plus topical 5% minoxidil is the best combination,” she said.

The authors and Dr. Tosti disclosed no relevant financial relationships.

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

In the treatment of male androgenetic alopecia (AGA), low-dose dutasteride (0.5 mg/day), used off label in the United States, tops a ranking of the most commonly used oral and topical agents in a new meta-analysis.

While up to 90% of men experience AGA in their lifetime, only three therapies are currently approved for treatment of the condition by the Food and Drug Administration – topical minoxidil, oral finasteride 1 mg, and low-level light therapy.

However, with common use of off-label oral minoxidil, as well as oral dutasteride and higher doses of oral finasteride, the latter two being 5-alpha reductase inhibitors, Aditya K. Gupta, MD, PhD, of Mediprobe Research, in London, Ont., and colleagues sought to compare the data on the three agents. Their results were published in JAMA Dermatology.

They note that, while there have been recent comparisons between oral and topical minoxidil, “to our knowledge no study has determined the comparative effectiveness of these 2 [formulations] with that of local and systemic dutasteride and finasteride.”

For the meta-analysis, the authors identified 23 studies meeting their criteria, involving patients with mean ages ranging from 22.8 to 41.8 years.

For the primary endpoint of the greatest increases in total hair count at 24 weeks, the analysis showed the 0.5-mg/day dose of dutasteride topped the list, with significantly greater efficacy, compared with 1 mg/day of finasteride (mean difference, 7.1 hairs per cm²).

The 0.5-mg/d dutasteride dose also showed higher efficacy than oral minoxidil at 0.25 mg/day (mean difference, 23.7 hairs per cm²) and 5 mg/day (mean difference, 15.0 hairs per cm²) and topical minoxidil at 2% (mean difference, 8.5 hairs per cm²).

For the secondary endpoint of the greatest increase in terminal hair count at 24 weeks, the 5-mg/day dose of minoxidil had significantly greater efficacy compared with the 0.25-mg/day dose of the drug, as well as with minoxidil’s 2% and 5% topical formulations.

The minoxidil 5-mg/day dose was also significantly more effective than 1 mg/day of finasteride for terminal hair count at 24 weeks.

In longer-term outcomes at 48 weeks, the greatest increase in total hair count at 48 weeks was observed with 5 mg/day of finasteride, which was significantly more effective, compared with 2% topical minoxidil.

And the greatest increase in terminal hair count at 48 weeks was observed with 1 mg/day of oral finasteride, which was significantly more effective than 2% as well as 5% topical minoxidil.

Based on the results, the authors ranked the agents in a decreasing order of efficacy: 0.5 mg/day of oral dutasteride, 5 mg/day of oral finasteride, 5 mg/day of oral minoxidil, 1 mg/day of oral finasteride, 5% topical minoxidil, 2% topical minoxidil, and 0.25 mg/day of oral minoxidil.

Commenting on the analysis in an accompanying editorial, Kathie P. Huang, MD, of the department of dermatology, Brigham and Women’s Hospital, Boston, and Maryanne M. Senna, MD, of the department of dermatology, Massachusetts General Hospital, Boston, said the results, in general, are consistent with their experiences, noting that 2% minoxidil is typically not used in men.

They noted that, “although topical minoxidil ranked higher than the very-low-dose 0.25 mg oral minoxidil, our personal experience is that oral minoxidil at doses of 1.25 mg to 5 mg are far superior to topical minoxidil for treating AGA.”

Adverse event considerations important

Importantly, however, strong consideration needs to be given to adverse-event profiles, as well as patient comorbidities in selecting agents, the editorial authors asserted.

With 1 mg finasteride, for instance, potential adverse events include decreased libido, erectile dysfunction, decreased ejaculatory volume, reduction in sperm count, testicular pain, depression, and gynecomastia, they noted.

And while finasteride appears to be associated with a decreased risk of prostate cancer, those receiving the drug who do develop prostate cancer may be diagnosed with higher-grade prostate cancer; however, that “might be related to tissue sampling artifact,” the editorial authors said.

Less has been published on dutasteride’s adverse-event profile, and that, in itself, is a concern.

Dr. Antonella Tosti

Overall, “as more direct-to-consumer companies treating male AGA emerge, it is especially important that the potential risks of these medications be made clear to patients,” they added.

Further commenting on the analysis to this news organization, Antonella Tosti, MD, the Fredric Brandt Endowed Professor of Dermatology and Cutaneous Surgery at the University of Miami, said the study offers some important insights – and caveats.

“I think this is a very interesting study, but you have to consider what works for your patients,” she said.

Dr. Tosti noted that the 5-mg dose of minoxidil is a concern in terms of side effects. “That dose is pretty high and could feasibly cause some hypertrichosis, which can be a concern to men as well as women.”

She agrees that the lack of data on side effects with dutasteride is also a concern, especially in light of some of the known side effects with other agents.

“That’s why I don’t use it very much in younger patients – because I’m afraid it could potentially affect their fertility,” Dr. Tosti said.

In general, Dr. Tosti said she finds a combination of agents provides the best results, as many clinicians use.

“I find dutasteride (0.5 mg/day) plus oral minoxidil (1-2.5 mg/day) plus topical 5% minoxidil is the best combination,” she said.

The authors and Dr. Tosti disclosed no relevant financial relationships.

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

The “Cancer Moonshot” is about to be relaunched.

In a White House briefing, President Joe Biden announced that he is “reigniting” the initiative he spearheaded when he was vice president during the Obama administration.

During the livestreamed event, the president discussed his plans to bring a “fierce sense of urgency” to the fight against cancer and better support patients with cancer and their families.

He emphasized that cancer is one of the truly bipartisan issues. There is strong support from both “sides of the aisle,” he said, and he sees it as an issue that can bring the country together.

“We can do this. I promise you, we can do this. For all those we lost, for all those we miss. We can end cancer as we know it,” he said. “This is a presidential White House priority.”

The aim is to reduce the death rate from cancer by at least 50% over the next 25 years.

One of the efforts will be directed to get people back to routine cancer screenings, such as mammograms and colonoscopies, with a special focus on ensuring equitable access.

There is also a proposal to create the Advanced Research Projects Agency for Health, which would focus on driving cutting-edge innovation in health research.

Part of the plan is to assemble a “cancer cabinet” that includes 18 federal departments, agencies, and offices, including leaders from the departments of Health & Human Services, Veterans Affairs, Defense, Energy, and Agriculture.

At present, there are few details about the new program or how it will be funded.

Presumably more will be revealed at the Cancer Moonshot Summit being planned, as well as on a planned new website where people can track its progress.
 

President priority

Cancer Moonshot began back in 2016, when during his last State of the Union Address, former President Barack Obama announced the ambitious initiative. A few days later, Obama asked Congress for $1 billion to send cancer to the moon, and he put Biden, then vice president, in charge of “mission control” in the remaining months of the administration.

The new initiative will be headed by Danielle Carnival, PhD, who serves in the White House Office of Science and Technology Policy and has been appointed as White House Cancer Moonshot coordinator.

At the briefing, Mr. Biden and Vice President Kamala Harris spoke about losing family members to cancer. The president spoke about his eldest son, Beau, who died from brain cancer when he was 46 years old, while Ms. Harris spoke about her mother, Shyamala Gopalan, a breast cancer researcher who died of colon cancer in 2009.
 

Accolades but a bit of caution

The president’s speech was applauded by many cancer groups, both professional organizations and patient advocacy groups.

Karen E. Knudsen, PhD, chief executive officer of the American Cancer Society and its advocacy affiliate, the American Cancer Society Cancer Action Network, commended Mr. Biden for reigniting Cancer Moonshot.

“In 2022 alone, there will be an estimated 1.9 million people diagnosed with cancer and more than 600,000 people in the U.S. will die. Marshaling the resources of the federal government will be critical in our ability to reduce death and suffering from this disease,” she said.

The American Society for Radiation Oncology issued a press release, saying: “On behalf of radiation oncologists who treat people with cancer every day, we support the Biden-Harris administration’s move to drastically reduce the number of cancer deaths in the United States and improve the lives of people diagnosed with this disease.

“We believe the administration’s commitment to expand cancer prevention efforts and to increase equitable access to screenings and treatments will help mitigate some of the negative impact of the COVID-19 pandemic,” the society added.

At the American Association for Cancer Research, Chief Executive Officer Margaret Foti, MD, PhD, said she was thrilled to hear the announcement after the devastating interruptions in cancer research and patient care over the past 2 years.

“The reignited Cancer Moonshot will provide an important framework to help improve cancer prevention strategies, increase cancer screenings and early detection, reduce cancer disparities, and propel new lifesaving cures for patients with cancer,” she said.

However, increased funding from Congress will be needed for these goals to be achieved, she emphasized.

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

The “Cancer Moonshot” is about to be relaunched.

In a White House briefing, President Joe Biden announced that he is “reigniting” the initiative he spearheaded when he was vice president during the Obama administration.

During the livestreamed event, the president discussed his plans to bring a “fierce sense of urgency” to the fight against cancer and better support patients with cancer and their families.

He emphasized that cancer is one of the truly bipartisan issues. There is strong support from both “sides of the aisle,” he said, and he sees it as an issue that can bring the country together.

“We can do this. I promise you, we can do this. For all those we lost, for all those we miss. We can end cancer as we know it,” he said. “This is a presidential White House priority.”

The aim is to reduce the death rate from cancer by at least 50% over the next 25 years.

One of the efforts will be directed to get people back to routine cancer screenings, such as mammograms and colonoscopies, with a special focus on ensuring equitable access.

There is also a proposal to create the Advanced Research Projects Agency for Health, which would focus on driving cutting-edge innovation in health research.

Part of the plan is to assemble a “cancer cabinet” that includes 18 federal departments, agencies, and offices, including leaders from the departments of Health & Human Services, Veterans Affairs, Defense, Energy, and Agriculture.

At present, there are few details about the new program or how it will be funded.

Presumably more will be revealed at the Cancer Moonshot Summit being planned, as well as on a planned new website where people can track its progress.
 

President priority

Cancer Moonshot began back in 2016, when during his last State of the Union Address, former President Barack Obama announced the ambitious initiative. A few days later, Obama asked Congress for $1 billion to send cancer to the moon, and he put Biden, then vice president, in charge of “mission control” in the remaining months of the administration.

The new initiative will be headed by Danielle Carnival, PhD, who serves in the White House Office of Science and Technology Policy and has been appointed as White House Cancer Moonshot coordinator.

At the briefing, Mr. Biden and Vice President Kamala Harris spoke about losing family members to cancer. The president spoke about his eldest son, Beau, who died from brain cancer when he was 46 years old, while Ms. Harris spoke about her mother, Shyamala Gopalan, a breast cancer researcher who died of colon cancer in 2009.
 

Accolades but a bit of caution

The president’s speech was applauded by many cancer groups, both professional organizations and patient advocacy groups.

Karen E. Knudsen, PhD, chief executive officer of the American Cancer Society and its advocacy affiliate, the American Cancer Society Cancer Action Network, commended Mr. Biden for reigniting Cancer Moonshot.

“In 2022 alone, there will be an estimated 1.9 million people diagnosed with cancer and more than 600,000 people in the U.S. will die. Marshaling the resources of the federal government will be critical in our ability to reduce death and suffering from this disease,” she said.

The American Society for Radiation Oncology issued a press release, saying: “On behalf of radiation oncologists who treat people with cancer every day, we support the Biden-Harris administration’s move to drastically reduce the number of cancer deaths in the United States and improve the lives of people diagnosed with this disease.

“We believe the administration’s commitment to expand cancer prevention efforts and to increase equitable access to screenings and treatments will help mitigate some of the negative impact of the COVID-19 pandemic,” the society added.

At the American Association for Cancer Research, Chief Executive Officer Margaret Foti, MD, PhD, said she was thrilled to hear the announcement after the devastating interruptions in cancer research and patient care over the past 2 years.

“The reignited Cancer Moonshot will provide an important framework to help improve cancer prevention strategies, increase cancer screenings and early detection, reduce cancer disparities, and propel new lifesaving cures for patients with cancer,” she said.

However, increased funding from Congress will be needed for these goals to be achieved, she emphasized.

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

The “Cancer Moonshot” is about to be relaunched.

In a White House briefing, President Joe Biden announced that he is “reigniting” the initiative he spearheaded when he was vice president during the Obama administration.

During the livestreamed event, the president discussed his plans to bring a “fierce sense of urgency” to the fight against cancer and better support patients with cancer and their families.

He emphasized that cancer is one of the truly bipartisan issues. There is strong support from both “sides of the aisle,” he said, and he sees it as an issue that can bring the country together.

“We can do this. I promise you, we can do this. For all those we lost, for all those we miss. We can end cancer as we know it,” he said. “This is a presidential White House priority.”

The aim is to reduce the death rate from cancer by at least 50% over the next 25 years.

One of the efforts will be directed to get people back to routine cancer screenings, such as mammograms and colonoscopies, with a special focus on ensuring equitable access.

There is also a proposal to create the Advanced Research Projects Agency for Health, which would focus on driving cutting-edge innovation in health research.

Part of the plan is to assemble a “cancer cabinet” that includes 18 federal departments, agencies, and offices, including leaders from the departments of Health & Human Services, Veterans Affairs, Defense, Energy, and Agriculture.

At present, there are few details about the new program or how it will be funded.

Presumably more will be revealed at the Cancer Moonshot Summit being planned, as well as on a planned new website where people can track its progress.
 

President priority

Cancer Moonshot began back in 2016, when during his last State of the Union Address, former President Barack Obama announced the ambitious initiative. A few days later, Obama asked Congress for $1 billion to send cancer to the moon, and he put Biden, then vice president, in charge of “mission control” in the remaining months of the administration.

The new initiative will be headed by Danielle Carnival, PhD, who serves in the White House Office of Science and Technology Policy and has been appointed as White House Cancer Moonshot coordinator.

At the briefing, Mr. Biden and Vice President Kamala Harris spoke about losing family members to cancer. The president spoke about his eldest son, Beau, who died from brain cancer when he was 46 years old, while Ms. Harris spoke about her mother, Shyamala Gopalan, a breast cancer researcher who died of colon cancer in 2009.
 

Accolades but a bit of caution

The president’s speech was applauded by many cancer groups, both professional organizations and patient advocacy groups.

Karen E. Knudsen, PhD, chief executive officer of the American Cancer Society and its advocacy affiliate, the American Cancer Society Cancer Action Network, commended Mr. Biden for reigniting Cancer Moonshot.

“In 2022 alone, there will be an estimated 1.9 million people diagnosed with cancer and more than 600,000 people in the U.S. will die. Marshaling the resources of the federal government will be critical in our ability to reduce death and suffering from this disease,” she said.

The American Society for Radiation Oncology issued a press release, saying: “On behalf of radiation oncologists who treat people with cancer every day, we support the Biden-Harris administration’s move to drastically reduce the number of cancer deaths in the United States and improve the lives of people diagnosed with this disease.

“We believe the administration’s commitment to expand cancer prevention efforts and to increase equitable access to screenings and treatments will help mitigate some of the negative impact of the COVID-19 pandemic,” the society added.

At the American Association for Cancer Research, Chief Executive Officer Margaret Foti, MD, PhD, said she was thrilled to hear the announcement after the devastating interruptions in cancer research and patient care over the past 2 years.

“The reignited Cancer Moonshot will provide an important framework to help improve cancer prevention strategies, increase cancer screenings and early detection, reduce cancer disparities, and propel new lifesaving cures for patients with cancer,” she said.

However, increased funding from Congress will be needed for these goals to be achieved, she emphasized.

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