United States

Background
Right heart failure (RHF) is a complex syndrome commonly associated with serious cardiac and/or pulmonary disease and carries a high burden of morbidity and mortality. The burden of RHF versus left heart failure (LHF) and biventricular heart failure is not well-quantified and there is a lack of a direct comparison between these types of heart failure in patients’ data from a large clinical database. This study examines the prevalence of all-cause mortality and common comorbidities such as end-stage renal disease (ESRD) and cirrhosis in patients diagnosed with RHF versus LHF and other HF diagnoses.

Methods
Using the Epic COSMOS database, which integrates ICD-10 health information across over 200 health systems in the United States, we evaluated the proportion of death, cirrhosis, ESRD, and average length of hospitalization associated with RHF diagnoses versus other HF diagnoses, including LHF, from 1/1/2010-12/31/2023.

Results
From 577392 patients diagnosed with either RHF or LHF, we found 294233 diagnosed with RHF and 302222 diagnosed with LHF. 7027 were diagnosed with both.
RHF was associated with an average 38.7±0.2% death compared to 26.6±0.03% (p&lt;0.0001) for that of other HF diagnoses and 31.1±0.2% (p&lt;0.0001) for that of LHF diagnoses. The mean length of hospital stay was 7.5±0.03 days for RHF versus 6.7±0.01 days for other HF diagnoses. Furthermore, RHF patients were more likely to develop cirrhosis (p&lt;0.0001) and ESRD (p&lt;0.0001) than LHF patients after diagnosis.

Conclusion
Mortality associated with RHF is 12.3% greater than that of other HF diagnoses and 7.6% greater than that of LHF diagnoses. RHF seems to associate more with serious comorbidities such as ESRD and cirrhosis. Despite the increased mortality and morbidities associated with RHF, the length of hospitalization was not clinically different between the two groups. Since our data shows that RHF indicates a poor prognosis, greater emphasis should be placed on early diagnosis and management of RHF. Further studies are required to explore the pathophysiology of RHF and improve therapeutic approaches.

AMA Research Challenge 2024 

Right Heart Failure Linked to Worse Outcomes Than Left Heart Failure and Other Heart Failure

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background
Right heart failure (RHF) is a complex syndrome commonly associated with serious cardiac and/or pulmonary disease and carries a high burden of morbidity and mortality. The burden of RHF versus left heart failure (LHF) and biventricular heart failure is not well-quantified and there is a lack of a direct comparison between these types of heart failure in patients’ data from a large clinical database. This study examines the prevalence of all-cause mortality and common comorbidities such as end-stage renal disease (ESRD) and cirrhosis in patients diagnosed with RHF versus LHF and other HF diagnoses.

Methods
Using the Epic COSMOS database, which integrates ICD-10 health information across over 200 health systems in the United States, we evaluated the proportion of death, cirrhosis, ESRD, and average length of hospitalization associated with RHF diagnoses versus other HF diagnoses, including LHF, from 1/1/2010-12/31/2023.

Results
From 577392 patients diagnosed with either RHF or LHF, we found 294233 diagnosed with RHF and 302222 diagnosed with LHF. 7027 were diagnosed with both.
RHF was associated with an average 38.7±0.2% death compared to 26.6±0.03% (p<0.0001) for that of other HF diagnoses and 31.1±0.2% (p<0.0001) for that of LHF diagnoses. The mean length of hospital stay was 7.5±0.03 days for RHF versus 6.7±0.01 days for other HF diagnoses. Furthermore, RHF patients were more likely to develop cirrhosis (p<0.0001) and ESRD (p<0.0001) than LHF patients after diagnosis.

Conclusion
Mortality associated with RHF is 12.3% greater than that of other HF diagnoses and 7.6% greater than that of LHF diagnoses. RHF seems to associate more with serious comorbidities such as ESRD and cirrhosis. Despite the increased mortality and morbidities associated with RHF, the length of hospitalization was not clinically different between the two groups. Since our data shows that RHF indicates a poor prognosis, greater emphasis should be placed on early diagnosis and management of RHF. Further studies are required to explore the pathophysiology of RHF and improve therapeutic approaches.

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### Grand Prize Sponsor

AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in winner selection process. The winner will be announced on February 20, 2025 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

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Background
Atrial fibrillation (AF) affects 38 million individuals worldwide and is responsible for $26 billion in healthcare costs in the U.S. alone, with 75% of costs attributed to hospitalizations. Early rhythm control improves cardiovascular outcomes in AF and is a cornerstone of treatment. Class III antiarrhythmic drugs (AADs) (e.g., dofetilide, sotalol) typically require inpatient initiation due to the risk of QT prolongation and torsades de pointes (TdP). This limits access and increases healthcare costs, with a single 3-day hospitalization for AAD initiation costing approximately $13,400. This burden disproportionately affects underserved populations, including minorities and rural populations, who may have limited access to appropriate healthcare facilities. We hypothesized that a novel machine learning (ML) algorithm paired with the SafeBeat Rx technology could enable safe outpatient AAD initiation, potentially improving access to care and reducing costs.
Methods
We developed CNN-BiLSTN based ML-model to automate ECG analysis and QTc measurement to drive AAD dosing recommendations. The model was trained on approximately 9M hand-annotated ECG heartbeats, utilizing data augmentation (e.g. noise) and k-fold cross validation (k=5). We then conducted a prospective study of patients admitted for in-patient dofetilide or sotalol initiation. Parallel to standard-of-care drug dosing, based on physician measured QTc on 12-lead ECG at baseline and 2 hours after each dose, patients were instructed to simultaneously record a mECG device (KardiaMobile 6L; AliveCor) which was transmitted to the software application. Software performance was evaluated by comparing software-annotated, physician adjudicated mECG QTc to blinded physician-measured 12-lead ECG QTc.
Results
A total of 50 patients (mean age 67 + 11 years, 64% male, 64% caucasian, 22% Asian/Pacific Islander, 8% Hispanic, mean baseline creatinine clearance 85.5 + 33.0mL/min, mean baseline QTc 417.7 + 30.1ms) underwent AAD initiation (44 dofetilide, 6 sotalol). The ML-based QTc measurement algorithm was used to analyze 314 mECGs that were used to guide 264 AAD doses. The ML- and physician-prescribed AAD dosing were congruent or more conservative in 245/264 (92.8%).
Conclusion
Overall, the software-recommended AAD drug dosing utilizing the ML QTc measurement was in high agreement with cardiologist-determined AAD drug dosing. These data demonstrate this software platform's potential to match clinician decisions for AAD dosing, offering the ability to support streamlined AAD titration regardless of patient setting. This approach shows promise for enabling safe outpatient initiation of AADs, potentially improving access to antiarrhythmic treatment and reducing healthcare costs.

SafeBeat Rx: A Novel Machine Learning Algorithm for Safe Initiation of Antiarrhythmic Drugs

Background: Sex disparities in cardiovascular disorders are well documented, but data on in-hospital outcomes for Complete Heart Block (CHB) remain scarce. Using a national readmissions database, we assessed the association of sex with the outcomes of CHB cases.
Methods: We examined the 2016-2020 Nationwide Readmission Database (NRD) to identify patients with a principal diagnosis of CHB. Men were used as our control group, while women comprised our cohort. The primary outcome was mortality. Secondary outcomes included odds of mechanical ventilation use, all cause 30-day readmission, length of stay (LOS) and total hospitalization charges (THC). Multivariate linear and logistic regression models were used to adjust for confounders.
Results: Among the patients with CHB (N = 175,257), 45% were Female. A Female sex was associated with higher odds of mortality (adjusted OR [aOR] 1.42, 95% CI 1.3 – 1.55, p<0.001) compared to male patients with CHB. Additionally, female sex was associated with a higher likelihood of mechanical ventilation use (aOR 1.1, 95% CI 1.03 – 1.2, p=0.004), all cause 30-day readmission (aOR 1.08, 95% CI 1.03 – 1.13, p=0.004), longer LOS (4.13 days vs 3.86 days, p<0.001) and lower THC ($89,908 vs. $94,590, p=0.002) compared to male patients with CHB. 
Conclusions: Among patients with CHB, female sex was associated with higher odds of mortality and non-fatal adverse events compared to male patients.

Sex-Based Differences in Hospitalization Outcomes for Complete Heart Block: A Population-Based Study 


Background
Methamphetamine use is associated with a range of cardiovascular conditions including hypertension and heart failure. Beta blocker use is commonly avoided when treating patients intoxicated with methamphetamines due to a fear of inducing unopposed alpha stimulation and worsening hypertension.
Methods
We performed a retrospective review of medical records in a county hospital in California with a high prevalence of methamphetamine users. We included adults who tested positive for methamphetamine use on urine toxicology and were admitted to the hospital or stayed in the ER for over 24 hours. Subjects who tested positive for methamphetamines and received beta blockers within 48 hours of their arrival to the ER were assigned to cases, subjects who tested positive for methamphetamines and received a non-beta blocker antihypertensive or no antihypertensive were assigned to the control group. We compared length of stay (LOS), readmission rate within 30 days and systolic (SBP) and diastolic blood pressures (DBP) between the groups at admission and 24 hours.
Results
130 cases and 117 controls were analyzed for LOS, 30 day readmission rate and SBP and DBP. Subjects were predominately male (60-70%) in both groups, with an average age of 52 for cases and 45 for controls. There was no significant difference between LOS and 30 day readmission rates between subjects who received beta blockers and subjects who did not. Subjects who received carvedilol were compared to subjects in the control group who received another antihypertensive, there was no significant difference in LOS between these groups. SBP at admission and 24 hours was significantly higher in the case group, however the effect size diminished over 24 hours. When comparing subjects who received carvedilol to those who received another antihypertensive, SBP was significantly higher at admission, but showed no significant difference after 24 hours.
Conclusion
Our results indicate that beta-blockers, particularly carvedilol, are an effective and safe treatment modality in methamphetamine users. Treatment with beta-blockers in the case group did not increase length of stay or re-admission rates compared to the control group, and treatment with carvedilol effectively reduced systolic blood pressure in patients with hypertension and cardiomyopathy. However it may be prudent to treat patients acutely intoxicated with methamphetamines with a combination of antihypertensives, including beta blockers, particularly in patients with cardiac comorbidities.

The Role of Beta Blockers in Methamphetamine Users with Cardiac Conditions- a Case Control Study

Background:
Mixed aortic valve disease (MAVD) is defined as aortic stenosis (AS) occurring simultaneously with aortic regurgitation (AR), and is the most frequent concomitant valvular disease worldwide. Transcatheter aortic valve replacement (TAVR) is indicated based on guidelines for the primary lesion while considering the concomitant disease. TAVR seems to be associated with similar mortality rates in patients with MAVD compared to AS, while complications have conflicting data in literature. The aim of this study is to systematically synthesize the latest evidence to compare clinical outcomes of TAVR in MAVD compared to AS.

Methods:
Systematic literature review was conducted on PubMed and Embase for studies on outcomes of TAVR in MAVD from inception until April 2024. Data extracted from the articles included baseline characteristics and several outcomes. Primary outcomes were short- (<30 days) and long-term (>30 days) mortality. Secondary outcomes were complications in accordance with the Valve Academic Research Consortium-2 (VARC-2) consensus, including paravalvular regurgitation, vascular and bleeding complications, pacemaker implantation, and cerebrovascular events. A random-effects model was used to pool risk ratios (RR) and 95% confidence intervals (CI) for clinical endpoints, and was conducted using RStudio.

Results:
11 observational studies including 133,558 patients were included in the analysis. There were no significant differences in primary endpoints (p>0.05). MAVD was associated with lower risk of cerebrovascular complications (RR: 0.65, 95% CI: 0.53-0.97) and higher risk of paravalvular regurgitation (RR: 1.29, 95% CI: 1.07-1.55). No significant differences were noted in other secondary outcomes (p>0.05).

Conclusions:
The similar mortality risk of TAVR in MAVD compared to AS as well as higher risk of paravalvular regurgitation in MAVD is in accordance with most recent studies. However, this meta-analysis is the first to show a significantly lower risk of cerebrovascular events in MAVD patients. This study highlights the importance of future research to further delineate differences in procedural outcomes in this population.

Transcatheter Aortic Valve Replacement for Mixed Aortic Valve Disease: An Updated Meta-analysis

Background: 
Psoriasis is a chronic, relapsing inflammatory condition that mostly affects the skin and joints. Recent data indicate that psoriasis is an independent risk factor for myocardial infarction (MI) and contributes to several cardiovascular (CV) risk factors, including metabolic syndrome, smoking, obesity, hypertension, insulin resistance, and dyslipidemia. Our study quantifies cardiovascular-related deaths among psoriasis patients, examines trends over time, and highlights demographic and geographic disparities to better understand the impact of these coexisting conditions. 

Methods: Data from the CDC WONDER database was analyzed to identify cardiovascular- related deaths among adults aged 25 and older with psoriasis in the United States from 1999 to 2020. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent change (APC) were calculated and stratified by year, sex, and age group. 

Results: Between 1999 and 2020, cardiovascular-related deaths in individuals with psoriasis accounted for 2,353 deaths among adults aged 25 and older in the US. The overall AAMR for cardiovascular-related deaths in psoriasis decreased from 0.87 in 1999 to 0.7 in 2020, with an Average Annual Percent Change (AAPC) of -0.9324 (95% CI: -1.5179 to -0.3276, p < 0.05). A significant decline occurred from 1999 to 2011 (APC: -5.0752; 95% CI: -6.6070 to -3.8388), followed by a notable increase from 2011 to 2020 (APC: 4.8738; 95% CI: 2.9977 to 7.5961). Men exhibited higher AAMRs compared to women. The AAMR for both men and women decreased, with a steeper decline for women from 1999 to 2011 (APC: -5.05) compared to men in the same period (APC: -4.97). Individuals aged 65 and older demonstrated a decline in AAMR from 1999 to 2011 (APC: -5.66), followed by an increase from 2011 to 2020 (APC: 4.69). Individuals aged 35 to 64 did not demonstrate a similar trend, with an APC of 0.48 from 1999 to 2020. 

Conclusion: This analysis reveals significant differences in cardiovascular-related mortality rates among individuals with psoriasis. Men had higher mortality rates than women, with a notable decline from 1999 to 2011 followed by an increase from 2011 to 2020. People aged 65 and older showed a similar pattern, while those aged 35 to 64 exhibited stable rates. These findings emphasize the need for targeted interventions to address the increasing mortality rates, particularly in older adults and men, to improve health outcomes for patients with psoriasis.

Trends and Disparities in Cardiovascular-Related Mortality Among 
Individuals with Psoriasis in the United States (1999-2020)

Background:
Heart failure and Diabetes are interrelated conditions, whereby the presence of one condition heightens the likelihood of developing the other. Given the poor prognosis of heart failure in diabetic patients, this study aims to quantify mortality rates among heart failure patients with and without diabetes. It examines trends over time and highlights demographic and geographic disparities to better understand the impact of these coexisting conditions.

Methods: Data from the CDC WONDER database was analyzed to identify heart failure- related deaths with and without diabetes mellitus among all age groups in the United States from 1999 to 2020. Age-adjusted mortality rates (AAMR) per 100,000 persons and annual percent change (APC) were calculated and stratified by year, sex, race/ethnicity, region, and urbanization.

Results: Between 1999 and 2020, heart failure-related deaths with diabetes mellitus accounted for 1,028,703 deaths, while heart failure-related deaths without diabetes accounted for 3,912,345 deaths. The overall AAMR for heart failure-related deaths with diabetes increased from 22 in 1999 to 27.3 in 2020, with an Average Annual Percent Change (AAPC) of 0.4646 (95% CI: 0.0134 to 0.8398, p = 0.0455). A significant decline occurred from 1999 to 2016 (APC: -1.2046; 95% CI: -1.8079 to -0.7404), followed by a notable increase from 2016 to 2020 (APC: 7.8768; 95% CI: 4.3018 to 16.9504). Men exhibited a higher AAMR than women (25.9 vs. 18.5). The American Indian or Alaska Native group had the highest AAMR, followed by Black or African American, with comparable levels for Hispanics or Latinos and Whites. Asian or Pacific Islanders had the lowest AAMR. Geographically, the Midwest, West, and South showed comparable mortality rates, while the Northeast had the lowest AAMR. Non-metropolitan areas had higher AAMRs than metropolitan areas (28.5 vs. 20.1), with a significant decrease in non-metropolitan areas (AAPC: 0.9306, p = 0.0016) and a non-significant decrease in metropolitan areas (AAPC: 0.4025, p = 0.0571).

Conclusion: This analysis reveals significant differences in mortality rates between heart failure with and without diabetes mellitus, based on demographic and geographic factors. While heart failure-related mortality rates initially declined from 1999 to 2016, a recent rise has been observed from 2016 to 2020. Men, American Indian or Alaska Natives, and those in non-metropolitan areas exhibited the highest mortality rates. These findings signify the need for targeted public health interventions to address these disparities and improve health outcomes for high-risk groups.

Trends and Disparities in Heart Failure Mortality With and Without Diabetes Mellitus in the US

Background 

The Arc of Riolan (AoR) is known to provide collateral vascularization between the Superior Mesenteric Artery (SMA) and the Inferior Mesenteric Artery (IMA), yet inconsistent definitions regarding the artery’s course exist. The AoR is a highly contested and confusing collateral artery among existing gastrointestinal arteries. The identification and preservation of the AoR is crucial to reducing the risk of acute colonic ischemia following splenic procedures. However, more details about the AoR 
prevalence and pattern are needed to corroborate the likelihood of finding this collateral artery in a patient. This study aimed to explore the prevalence and pattern of the AoR as defined by a connectionbetween the Middle Colic Artery (MCA) and Ascending Left Colic Artery (ALCA). 

Methods 
A total of fifty-two cadaveric colons were dissected at Tilman J. Fertitta Family College of Medicine and Baylor College of Medicine. Specific dissection techniques were employed to expose the ascending, transverse, and descending colon, and associated vasculature. AoR patterns were observed and photographed in all the donors. Photographic analysis followed dissection to determine whether a connection between the MCA and ALCA was present. 

Results 
The AoR was identified in six bodies (11.5%) as a smaller artery forming collateral circulation between the Ascending Left Colic Artery off the IMA and the Middle Colic Artery off the SMA. The AoR was thin in nature when compared with SMA and IMA arterial branches. The authors of this study hypothesize that corroborating previous Arc studies with additional prevalence data regarding the AoR connection will encourage and assist with the identification and preservation of the Arc during colonic procedures. 

Conclusion 
The AoR was identified in 11.5% of the colons examined and the artery’s course was noted. The frequency of the connection identified in this study matches existing AoR prevalence studies. Additional samples will be collected to determine the statistical significance of this pilot study. Vasculature and anastomotic connections among the transverse and descending colon are highly variable from patient to patient; however, surgeons must be aware of a collateral artery that connects the MCA with the ALCA, given that its frequency is about 11% among patients. Proper identification and preservation of the AoR could prevent post-operative ischemia following bowel resection. 



Exploring the Prevalence of the Arc of Riolan Artery in the Large Intestine - A Cadaveric Pilot Study

Background: The risk of developing cutaneous T-cell lymphoma (CTCL) in patients with psoriatic disease using tumor necrosis factor inhibitors (TNFi) has not been well characterized. This study aims to review the incidence of CTCL in clinical trials of TNFi and TNF inhibitor biosimilars used to treat patients
with psoriasis and other psoriatic diseases.
Methods: The US National Library of Medicine clinical trials database (clinicaltrials.gov) was queried to identify all phase 3 and 4 clinical trials of the 5 FDA-approved TNFi and TNFi biosimilar biologic therapies. The search was limited to clinical trials involving psoriatic diseases treated with TNFi and biosimilars. Trials involving the following psoriatic diseases were identified and included: psoriasis, psoriatic arthritis, generalized pustular psoriasis, and palmoplantar pustulosis. The incidence of CTCL in these trials was examined and summarized. Fisher’s exact test was performed to determine differences in the rate of CTCL between patients who received biologic therapy and those who received placebo treatments. A p-value less than 0.05 was considered statistically significant.
Results: Data from 98 phase 3 and 4 trials of TNFi and TNFi biosimilars were analyzed. No cases of CTCL were reported in 17,906 patients with psoriatic diseases who received TNFi in phase 3 trials. No cases of CTCL were reported in 4,066 patients with psoriatic diseases who received TNFi in phase 4 trials. No cases of CTCL were reported in 1,621 patients with psoriatic diseases who received TNFi biosimilar in phase 3 trials. There were no TNFi biosimilar phase 4 trials. Of the 3,283 patients who received placebo in phase 3 trials and 248 patients who received placebo in phase 4 trials, no cases of CTCL were reported. No difference was found between the incidence of CTCL in patients treated with TNFi and those treated with placebo in both phase 3 and 4 trials using the Fisher’s exact test (p > 0.05).
Lastly, no difference was found between the incidence of CTCL in patients treated with TNFi biosimilars and those treated with placebo using the Fisher’s exact test (p > 0.05).
Conclusion: Our findings indicate that the use of TNFi and TNFi biosimilars in the treatment of psoriatic diseases is rarely associated with the development of CTCL.

Assessing the Risk of Cutaneous T-Cell Lymphoma Associated with Tumor Necrosis
Factor Inhibitors and Biosimilars

Objective/Background 
Livedoid vasculopathy (LV) is a rare vasculopathy that affects the lower extremities, causing painful recurrent ulcerations, livedo reticularis and atrophie blanche.1 It might be idiopathic or present in association with hypercoagulable states or vascular disorders in 50-70%.2 Despite increased treatment options, patients often face suboptimal treatment outcomes.3 Data based on systematic review for treatment outcomes of LV are initially needed to identify gaps of knowledge and inform next steps in clinical trial design. 

Methods 
We searched major databases from January 2017 to October 2023 using key terms related to Livedoid Vasculopathy and its treatment outcomes. We included case reports, series, cross-sectional and retrospective studies (excluding reviews and articles without defined treatment outcomes). Analysis followed PRISMA guidelines with two reviewers independently assessing studies. Conflicts were resolved by a third party. 

Results 
Out of 614 articles identified, 44 were included in the final review, most of which were case reports or series. In total, there were 216 participants (155 female, 61 male) with median age 44 years (14-73). 

Rivaroxaban was the most reported treatment (n=58), showing complete (n=18, 31%) or partial (n=40, 68%) ulcer healing and complete pain resolution in the 19% reported. Other factor Xa inhibitors (n=4) led to complete wound healing and pain relief in our review. IVIG (n=36) showed promising results in wound and pain resolution, though some patients did not achieve adequate healing (n=4, 11%). Less common treatments like hyperbaric oxygen therapy (n=3), anti-TNF (n=1), and others also achieved complete healing and pain improvement. 

Conclusion 
A variety of therapeutic strategies for LV have shown promise, but data to support any specific regimen remains lacking. In recent literature, Rivaroxaban was the most used therapy with 82.2% (60/73) of patients achieving rapid healing and pain relief.4 IVIG disrupts inflammatory cytokines, modulates lymphocytes, and neutralizes autoantibodies, making it a potential treatment for LV due to the presence of these markers in LV patients.5 Future directions consist of determining which patients (with primary or secondary LV) might benefit from single or combined therapies and establishing standard of care for this condition that can also be used as a comparator arm in clinical trials.

Clinical and patient reported treatment outcomes of livedoid vasculopathy: A systematic review​

Delayed but Long-term Resolution of Nevus of Ota 
After Cessation of Picosecond 755-nm Alexandrite Laser Treatment 
Moore, Angela, MD1,2,3,4; Nguyen, An, B.S4; Nguyen, Ly4, Michael Thornton, D.O.5
1Arlington Center for Dermatology, Arlington, TX; 2Arlington Research Center, Arlington, TX; 3Baylor University Medical Center, Dallas, TX;4Texas Christian University Anne Burnett Marion School of Medicine, Fort Worth, TX; 5Mansfield Cosmetic Surgery Center, Mansfield, TX

Key words: Nevus of Ota, hyperpigmentation, picosecond, alexandrite
Corresponding author:
Angela Yen Moore, MD
Arlington Center for Dermatology
711 East Lamar Blvd., Suite 200, Arlington, Texas 76011
817-795-7546 phone
817-385-7568 fax
acderm@acderm.com
Word Count: 399
References: 9
Figure/Tables: 2
Funding: None
Conflicts of interest: None

Consent: Consent for the publication of all patient photographs and medical information was provided by the authors at the time of article submission to the journal stating that all patients gave consent for their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available. 

Introduction
Nevus of Ota presents as unilateral benign melanosis in the distribution of the trigeminal nerve, with increased risk of uveal melanoma and glaucoma¹.
Since the advent of selective photothermolysis, Q-switched nanosecond lasers have been reported for treatment of dermal pigmented lesions⁷. Two prospective, randomized, split-lesion, controlled studies have concluded that picosecond lasers were more effective³. In these cases, treatment until clinical clearance was performed. We would like to report a case of nevus of Ota that was treated with a picosecond 755 nm Alexandrite laser displaying continued marked resolution after cessation of treatment, without recurrence for 5 years.
Case Report
A thirty-five-year-old Asian woman with a bluish-gray confluent pigmentation along the right V1 distribution presented for diagnosis and treatment. Six treatments with a 750-picosecond pulse duration 755-nm alexandrite laser were performed, with one session every 2 weeks over 10 weeks. Patient was instructed to use topical sunscreen with zinc oxide >11% and topical healing creams. The patient experienced 8/10 pain with the first treatment session that decreased to 2/10 with pre-application of topical anesthetic cream (benzocaine 20%/ lidocaine 4%/ tetracaine 1%) 30 minutes prior to each session. Local skin reactions included temporary erythema and mild transient hyperpigmentation but no hypopigmentation. 
The hyperpigmentation decreased progressively but with persistent central blue-black pigmentation.Treatment was terminated when the patient moved away. When the patient was seen 1 year later, the nevus of Ota had resolved completely and the patient reported continued improvement for the 6 months after the last laser session until full clearance. The only continued maintenance treatment was usage of topical sunscreen with 11% zinc oxide. 
Bibliography
Picosecond lasers rely on photomechanical effects rather than photothermal. In contrast to nanosecond-domain Q-switched lasers, picosecond-domain lasers have a pulse width shorter than the stress relaxation time of dermal dendritic melanocytes and melanophages⁵. 
Mechanical stress generated within a very short period of time results in stress lock-in causing rise in pressure and fracture of the target particle and photoacoustic destruction of the particle, with a minimal photothermal component. The bursts of energy have been speculated to break down the melanin granules and melanophages, with clinical resolution occurring as macrophages carry away the fractured particles even after cessation of laser sessions⁴. 
This case report of delayed but persistent clinical resolution of a nevus of Ota validates theories on how picosecond lasers achieve clinical response through photomechanical effects followed by immunologic response.














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