The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Any of four variants of genes associated with immunity can significantly increase a carrier’s risk for developing progressive multifocal leukoencephalopathy (PML) after exposure to immunosuppressing drugs, a team of European and U.S. investigators reported.

The four-gene signature could be used to screen patients who are currently taking or are candidates for drugs know to increase risk for PML, a rare but frequently lethal demyelinating disorder of the central nervous system, according to Eli Hatchwell, MD, PhD, from Population BIO UK in Oxfordshire, England, and colleagues.

“Due to the seriousness of a PML diagnosis – particularly because it often leads to life-threatening outcomes and the lack of treatment options once it develops – it would seem unethical not to test individuals considering immunosuppressive therapies with PML risk for our top four variants, and advising those with a positive result to consider an alternative therapy or treatment strategy,” they wrote in a study published in Frontiers in Neurology.
 

Benign virus, bad disease

PML is caused by reactivation of the otherwise benign JC virus (JCV), also known as human polyomavirus 2. (The “J” and “C” in the virus’ common name stand for John Cunningham, a man with Hodgkin lymphoma from whose brain the virus was first isolated, in 1971.)

The estimated prevalence of JCV infection ranges from 40% to 70% of the population worldwide, although PML itself is rare, with an incidence of approximately 1 in 200,000.

PML is a complication of treatment with targeted monoclonal antibodies, such as natalizumab (Tysabri), rituximab (Rituxan), alemtuzumab (Campath; Lemtrada), and other agents with immunosuppressive properties, such as dimethyl fumarate and mycophenolate mofetil.

In addition, PML can occur among patients with diseases that disrupt or inhibit natural immunity, such as HIV/AIDS, hematologic cancers, and autoimmune diseases.
 

Predisposing variants suspected

Dr. Hatchwell and colleagues hypothesized that some patients may have rare genetic variants in immune-system genes that predispose them to increased risk for PML. The researchers had previously shown an association between PML and 19 genetic risk variants among 184 patients with PML.

In the current study, they looked at variants in an additional 152 patients with PML who served as a validation sample. Of the 19 risk variants they had previously identified, the investigators narrowed the field down to 4 variants in both population controls and in a matched control set consisting of patients with multiple sclerosis (MS) who were positive for JCV and who were on therapy with a PML-linked drug for at least 2 years.

The four variants they identified, all linked to immune viral defense, were C8B, 1-57409459-C-A, rs139498867; LY9 (a checkpoint regulator also known as SLAMF3), 1-160769595-AG-A, rs763811636; FCN2, 9-137779251-G-A, rs76267164; and STXBP2, 19-7712287-G-C, rs35490401.

In all, 10.9% of patients with PML carried at least one of the variants.

The investigators reported that carriers of any one of the variants has a nearly ninefold risk for developing PML after exposure to a PML-linked drug compared with non-carriers with similar drug exposures (odds ratio, 8.7; P < .001).

“Measures of clinical validity and utility compare favorably to other genetic risk tests, such as BRCA1 and BRCA2 screening for breast cancer risk and HLA-B_15:02 pharmacogenetic screening for pharmacovigilance of carbamazepine to prevent Stevens-Johnson syndrome and toxic epidermal necrolysis,” the authors noted.
 

Screening? Maybe

In a press release, Lawrence Steinman, MD, from Stanford (Calif.) University, who was not involved in the study, stated that “preventative screening for these variants should become part of the standard of care. I wish we had more powerful tools like this for other therapies.”

But another neurologist who was not involved in the study commented that the finding, while “exciting” as a confirmation study, is not as yet practice changing.

“It does give us very good confidence that these four genes are indeed risk factors that increase the risk of this brain infection by quite a bit, so that makes it very exciting,” said Robert Fox, MD, from the Neurological Institute at the Cleveland Clinic.

“Indeed, we are trying to risk-stratify patients to try to reduce the risk of PML in the patients treated with our MS drugs. So for natalizumab we risk stratify by testing them for JC virus serology. Half of people don’t have it and we say ‘OK, you’re good to go.’ With other drugs like Tecfidera – dimethyl fumarate – we follow their lymphocyte counts, so when their lymphocyte counts drop too low we say ‘OK, you need to come off the drug because of the risk of PML,’ ” he said in an interview.

The four-gene signature, however, only identifies about 11% of patients with PML, which is not a sufficiently large enough effect to be clinically useful. For example, the risk for PML in patients treated with natalizumab is about 1%, and if the test can only detect enhanced risk in about 11% of those patients, the risk would drop from 1% to 0.9%, which “doesn’t really the move needle much,” he pointed out.

Dr. Fox also noted that neurologists now have a large formulary of drugs to offer their patients, including agents (such as interferon-beta and corticosteroids that are not associated with increased risk for PML).

The study was funded by Emerald Lake Safety and Population Bio. Dr. Hatchwell and several coauthors are employees of the respective companies, and several are inventors of genetic screening methods for PML. Dr. Steiman has disclosed consulting for TG Therapeutics. Dr. Fox reported consulting for manufacturers of MS therapies.

Any of four variants of genes associated with immunity can significantly increase a carrier’s risk for developing progressive multifocal leukoencephalopathy (PML) after exposure to immunosuppressing drugs, a team of European and U.S. investigators reported.

The four-gene signature could be used to screen patients who are currently taking or are candidates for drugs know to increase risk for PML, a rare but frequently lethal demyelinating disorder of the central nervous system, according to Eli Hatchwell, MD, PhD, from Population BIO UK in Oxfordshire, England, and colleagues.

“Due to the seriousness of a PML diagnosis – particularly because it often leads to life-threatening outcomes and the lack of treatment options once it develops – it would seem unethical not to test individuals considering immunosuppressive therapies with PML risk for our top four variants, and advising those with a positive result to consider an alternative therapy or treatment strategy,” they wrote in a study published in Frontiers in Neurology.
 

Benign virus, bad disease

PML is caused by reactivation of the otherwise benign JC virus (JCV), also known as human polyomavirus 2. (The “J” and “C” in the virus’ common name stand for John Cunningham, a man with Hodgkin lymphoma from whose brain the virus was first isolated, in 1971.)

The estimated prevalence of JCV infection ranges from 40% to 70% of the population worldwide, although PML itself is rare, with an incidence of approximately 1 in 200,000.

PML is a complication of treatment with targeted monoclonal antibodies, such as natalizumab (Tysabri), rituximab (Rituxan), alemtuzumab (Campath; Lemtrada), and other agents with immunosuppressive properties, such as dimethyl fumarate and mycophenolate mofetil.

In addition, PML can occur among patients with diseases that disrupt or inhibit natural immunity, such as HIV/AIDS, hematologic cancers, and autoimmune diseases.
 

Predisposing variants suspected

Dr. Hatchwell and colleagues hypothesized that some patients may have rare genetic variants in immune-system genes that predispose them to increased risk for PML. The researchers had previously shown an association between PML and 19 genetic risk variants among 184 patients with PML.

In the current study, they looked at variants in an additional 152 patients with PML who served as a validation sample. Of the 19 risk variants they had previously identified, the investigators narrowed the field down to 4 variants in both population controls and in a matched control set consisting of patients with multiple sclerosis (MS) who were positive for JCV and who were on therapy with a PML-linked drug for at least 2 years.

The four variants they identified, all linked to immune viral defense, were C8B, 1-57409459-C-A, rs139498867; LY9 (a checkpoint regulator also known as SLAMF3), 1-160769595-AG-A, rs763811636; FCN2, 9-137779251-G-A, rs76267164; and STXBP2, 19-7712287-G-C, rs35490401.

In all, 10.9% of patients with PML carried at least one of the variants.

The investigators reported that carriers of any one of the variants has a nearly ninefold risk for developing PML after exposure to a PML-linked drug compared with non-carriers with similar drug exposures (odds ratio, 8.7; P < .001).

“Measures of clinical validity and utility compare favorably to other genetic risk tests, such as BRCA1 and BRCA2 screening for breast cancer risk and HLA-B_15:02 pharmacogenetic screening for pharmacovigilance of carbamazepine to prevent Stevens-Johnson syndrome and toxic epidermal necrolysis,” the authors noted.
 

Screening? Maybe

In a press release, Lawrence Steinman, MD, from Stanford (Calif.) University, who was not involved in the study, stated that “preventative screening for these variants should become part of the standard of care. I wish we had more powerful tools like this for other therapies.”

But another neurologist who was not involved in the study commented that the finding, while “exciting” as a confirmation study, is not as yet practice changing.

“It does give us very good confidence that these four genes are indeed risk factors that increase the risk of this brain infection by quite a bit, so that makes it very exciting,” said Robert Fox, MD, from the Neurological Institute at the Cleveland Clinic.

“Indeed, we are trying to risk-stratify patients to try to reduce the risk of PML in the patients treated with our MS drugs. So for natalizumab we risk stratify by testing them for JC virus serology. Half of people don’t have it and we say ‘OK, you’re good to go.’ With other drugs like Tecfidera – dimethyl fumarate – we follow their lymphocyte counts, so when their lymphocyte counts drop too low we say ‘OK, you need to come off the drug because of the risk of PML,’ ” he said in an interview.

The four-gene signature, however, only identifies about 11% of patients with PML, which is not a sufficiently large enough effect to be clinically useful. For example, the risk for PML in patients treated with natalizumab is about 1%, and if the test can only detect enhanced risk in about 11% of those patients, the risk would drop from 1% to 0.9%, which “doesn’t really the move needle much,” he pointed out.

Dr. Fox also noted that neurologists now have a large formulary of drugs to offer their patients, including agents (such as interferon-beta and corticosteroids that are not associated with increased risk for PML).

The study was funded by Emerald Lake Safety and Population Bio. Dr. Hatchwell and several coauthors are employees of the respective companies, and several are inventors of genetic screening methods for PML. Dr. Steiman has disclosed consulting for TG Therapeutics. Dr. Fox reported consulting for manufacturers of MS therapies.

Any of four variants of genes associated with immunity can significantly increase a carrier’s risk for developing progressive multifocal leukoencephalopathy (PML) after exposure to immunosuppressing drugs, a team of European and U.S. investigators reported.

The four-gene signature could be used to screen patients who are currently taking or are candidates for drugs know to increase risk for PML, a rare but frequently lethal demyelinating disorder of the central nervous system, according to Eli Hatchwell, MD, PhD, from Population BIO UK in Oxfordshire, England, and colleagues.

“Due to the seriousness of a PML diagnosis – particularly because it often leads to life-threatening outcomes and the lack of treatment options once it develops – it would seem unethical not to test individuals considering immunosuppressive therapies with PML risk for our top four variants, and advising those with a positive result to consider an alternative therapy or treatment strategy,” they wrote in a study published in Frontiers in Neurology.
 

Benign virus, bad disease

PML is caused by reactivation of the otherwise benign JC virus (JCV), also known as human polyomavirus 2. (The “J” and “C” in the virus’ common name stand for John Cunningham, a man with Hodgkin lymphoma from whose brain the virus was first isolated, in 1971.)

The estimated prevalence of JCV infection ranges from 40% to 70% of the population worldwide, although PML itself is rare, with an incidence of approximately 1 in 200,000.

PML is a complication of treatment with targeted monoclonal antibodies, such as natalizumab (Tysabri), rituximab (Rituxan), alemtuzumab (Campath; Lemtrada), and other agents with immunosuppressive properties, such as dimethyl fumarate and mycophenolate mofetil.

In addition, PML can occur among patients with diseases that disrupt or inhibit natural immunity, such as HIV/AIDS, hematologic cancers, and autoimmune diseases.
 

Predisposing variants suspected

Dr. Hatchwell and colleagues hypothesized that some patients may have rare genetic variants in immune-system genes that predispose them to increased risk for PML. The researchers had previously shown an association between PML and 19 genetic risk variants among 184 patients with PML.

In the current study, they looked at variants in an additional 152 patients with PML who served as a validation sample. Of the 19 risk variants they had previously identified, the investigators narrowed the field down to 4 variants in both population controls and in a matched control set consisting of patients with multiple sclerosis (MS) who were positive for JCV and who were on therapy with a PML-linked drug for at least 2 years.

The four variants they identified, all linked to immune viral defense, were C8B, 1-57409459-C-A, rs139498867; LY9 (a checkpoint regulator also known as SLAMF3), 1-160769595-AG-A, rs763811636; FCN2, 9-137779251-G-A, rs76267164; and STXBP2, 19-7712287-G-C, rs35490401.

In all, 10.9% of patients with PML carried at least one of the variants.

The investigators reported that carriers of any one of the variants has a nearly ninefold risk for developing PML after exposure to a PML-linked drug compared with non-carriers with similar drug exposures (odds ratio, 8.7; P < .001).

“Measures of clinical validity and utility compare favorably to other genetic risk tests, such as BRCA1 and BRCA2 screening for breast cancer risk and HLA-B_15:02 pharmacogenetic screening for pharmacovigilance of carbamazepine to prevent Stevens-Johnson syndrome and toxic epidermal necrolysis,” the authors noted.
 

Screening? Maybe

In a press release, Lawrence Steinman, MD, from Stanford (Calif.) University, who was not involved in the study, stated that “preventative screening for these variants should become part of the standard of care. I wish we had more powerful tools like this for other therapies.”

But another neurologist who was not involved in the study commented that the finding, while “exciting” as a confirmation study, is not as yet practice changing.

“It does give us very good confidence that these four genes are indeed risk factors that increase the risk of this brain infection by quite a bit, so that makes it very exciting,” said Robert Fox, MD, from the Neurological Institute at the Cleveland Clinic.

“Indeed, we are trying to risk-stratify patients to try to reduce the risk of PML in the patients treated with our MS drugs. So for natalizumab we risk stratify by testing them for JC virus serology. Half of people don’t have it and we say ‘OK, you’re good to go.’ With other drugs like Tecfidera – dimethyl fumarate – we follow their lymphocyte counts, so when their lymphocyte counts drop too low we say ‘OK, you need to come off the drug because of the risk of PML,’ ” he said in an interview.

The four-gene signature, however, only identifies about 11% of patients with PML, which is not a sufficiently large enough effect to be clinically useful. For example, the risk for PML in patients treated with natalizumab is about 1%, and if the test can only detect enhanced risk in about 11% of those patients, the risk would drop from 1% to 0.9%, which “doesn’t really the move needle much,” he pointed out.

Dr. Fox also noted that neurologists now have a large formulary of drugs to offer their patients, including agents (such as interferon-beta and corticosteroids that are not associated with increased risk for PML).

The study was funded by Emerald Lake Safety and Population Bio. Dr. Hatchwell and several coauthors are employees of the respective companies, and several are inventors of genetic screening methods for PML. Dr. Steiman has disclosed consulting for TG Therapeutics. Dr. Fox reported consulting for manufacturers of MS therapies.

SAN DIEGO – Proper patient selection and setting realistic expectations are the keys to enhancing results with fractional radiofrequency (RF) microneedling devices, according to Catherine M. DiGiorgio, MD.

Most core fractional RF microneedling indications – acne scars, rhytides, skin tightening – require multiple treatments, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. “That’s an important expectation to set for your patients,” she said. “You also want to select depth and density parameters based on pathophysiology of the condition being treated, and combination treatments always provide the best results. So, whether you’re treating someone for acne scars or rhytides, you want to treat them for their erythema or their dermatoheliosis. The same goes for skin tightening procedures.”

Many nonpolar and bipolar devices are available for use, most of which feature adjustable depths and energies. Tips can be insulated or noninsulated. Generally, the insulated tips are safer for darker skin types because the energy is not delivered to the epidermis. However, the Sylfirm X device from Benev has a noninsulated tip but is safe for all skin types because the energy is delivered from the tip of a conically shaped needle and moves proximally but never reaches the epidermis, said Dr. DiGiorgio. Continuous wave mode is used for tightening and wrinkles while pulsed mode is used for pigment and vascular lesions.

Treatment with most fractional RF microneedling devices is painful so topical anesthesia is required. Dr. DiGiorgio typically uses topical 23% lidocaine and 7% tetracaine. The downtime varies depending on which device is being used. For anesthesia prior to aggressive fractional microneedle RF treatments such as with the Profound RF for skin tightening, Dr. DiGiorgio typically uses a Mesoram needle with a cocktail of 30 ccs of 2% lidocaine with epinephrine, 15 ccs of bicarbonate, and 5 ccs of saline. “More aggressive RF procedures can result in bruising for 7 to 8 days,” she said. “It can be covered with makeup. Wearing masks during the COVID-19 pandemic have also helped patients cover the bruising.”

In her clinical experience, the ideal patient for skin tightening with fractional RF microneedling has mild to moderate skin laxity that does not require surgical intervention. “Nonsurgical treatments provide nonsurgical results,” she said. “If a patient comes in holding their skin back and there is a lot of laxity, this is not going to be the right treatment for that person.”

Dr. DiGiorgio offers fractional RF microneedling in the context of a full-face rejuvenation. She begins by addressing volume loss and dynamic rhytides with injectables prior to skin tightening devices such as fractional RF microneedling or ultrasound-based tightening devices such as Sofwave or Ulthera (also referred to as Ultherapy). “You can add an ablative fractional to target deeper rhytides or pigment-targeting laser to address their dermatoheliosis, which will enhance their results,” she said. “Finally, you can follow up with a thread lift two weeks after the microneedle RF to achieve greater skin tightening. If the thread lift is performed before the microneedle RF, you want to wait about 2 months because the microneedle RF can damage the thread.”

Despite the limited efficacy for tissue tightening with fractional RF microneedling, “it’s a good alternative to lasers, especially for darker skin types,” she said. “Combination treatments will always enhance your results.”

Dr. DiGiorgio disclosed that she is a member of the advisory board for Quthero. She is also a consultant for Revelle and has received equipment from Acclaro.

SAN DIEGO – Proper patient selection and setting realistic expectations are the keys to enhancing results with fractional radiofrequency (RF) microneedling devices, according to Catherine M. DiGiorgio, MD.

Most core fractional RF microneedling indications – acne scars, rhytides, skin tightening – require multiple treatments, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. “That’s an important expectation to set for your patients,” she said. “You also want to select depth and density parameters based on pathophysiology of the condition being treated, and combination treatments always provide the best results. So, whether you’re treating someone for acne scars or rhytides, you want to treat them for their erythema or their dermatoheliosis. The same goes for skin tightening procedures.”

Many nonpolar and bipolar devices are available for use, most of which feature adjustable depths and energies. Tips can be insulated or noninsulated. Generally, the insulated tips are safer for darker skin types because the energy is not delivered to the epidermis. However, the Sylfirm X device from Benev has a noninsulated tip but is safe for all skin types because the energy is delivered from the tip of a conically shaped needle and moves proximally but never reaches the epidermis, said Dr. DiGiorgio. Continuous wave mode is used for tightening and wrinkles while pulsed mode is used for pigment and vascular lesions.

Treatment with most fractional RF microneedling devices is painful so topical anesthesia is required. Dr. DiGiorgio typically uses topical 23% lidocaine and 7% tetracaine. The downtime varies depending on which device is being used. For anesthesia prior to aggressive fractional microneedle RF treatments such as with the Profound RF for skin tightening, Dr. DiGiorgio typically uses a Mesoram needle with a cocktail of 30 ccs of 2% lidocaine with epinephrine, 15 ccs of bicarbonate, and 5 ccs of saline. “More aggressive RF procedures can result in bruising for 7 to 8 days,” she said. “It can be covered with makeup. Wearing masks during the COVID-19 pandemic have also helped patients cover the bruising.”

In her clinical experience, the ideal patient for skin tightening with fractional RF microneedling has mild to moderate skin laxity that does not require surgical intervention. “Nonsurgical treatments provide nonsurgical results,” she said. “If a patient comes in holding their skin back and there is a lot of laxity, this is not going to be the right treatment for that person.”

Dr. DiGiorgio offers fractional RF microneedling in the context of a full-face rejuvenation. She begins by addressing volume loss and dynamic rhytides with injectables prior to skin tightening devices such as fractional RF microneedling or ultrasound-based tightening devices such as Sofwave or Ulthera (also referred to as Ultherapy). “You can add an ablative fractional to target deeper rhytides or pigment-targeting laser to address their dermatoheliosis, which will enhance their results,” she said. “Finally, you can follow up with a thread lift two weeks after the microneedle RF to achieve greater skin tightening. If the thread lift is performed before the microneedle RF, you want to wait about 2 months because the microneedle RF can damage the thread.”

Despite the limited efficacy for tissue tightening with fractional RF microneedling, “it’s a good alternative to lasers, especially for darker skin types,” she said. “Combination treatments will always enhance your results.”

Dr. DiGiorgio disclosed that she is a member of the advisory board for Quthero. She is also a consultant for Revelle and has received equipment from Acclaro.

SAN DIEGO – Proper patient selection and setting realistic expectations are the keys to enhancing results with fractional radiofrequency (RF) microneedling devices, according to Catherine M. DiGiorgio, MD.

Most core fractional RF microneedling indications – acne scars, rhytides, skin tightening – require multiple treatments, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. “That’s an important expectation to set for your patients,” she said. “You also want to select depth and density parameters based on pathophysiology of the condition being treated, and combination treatments always provide the best results. So, whether you’re treating someone for acne scars or rhytides, you want to treat them for their erythema or their dermatoheliosis. The same goes for skin tightening procedures.”

Many nonpolar and bipolar devices are available for use, most of which feature adjustable depths and energies. Tips can be insulated or noninsulated. Generally, the insulated tips are safer for darker skin types because the energy is not delivered to the epidermis. However, the Sylfirm X device from Benev has a noninsulated tip but is safe for all skin types because the energy is delivered from the tip of a conically shaped needle and moves proximally but never reaches the epidermis, said Dr. DiGiorgio. Continuous wave mode is used for tightening and wrinkles while pulsed mode is used for pigment and vascular lesions.

Treatment with most fractional RF microneedling devices is painful so topical anesthesia is required. Dr. DiGiorgio typically uses topical 23% lidocaine and 7% tetracaine. The downtime varies depending on which device is being used. For anesthesia prior to aggressive fractional microneedle RF treatments such as with the Profound RF for skin tightening, Dr. DiGiorgio typically uses a Mesoram needle with a cocktail of 30 ccs of 2% lidocaine with epinephrine, 15 ccs of bicarbonate, and 5 ccs of saline. “More aggressive RF procedures can result in bruising for 7 to 8 days,” she said. “It can be covered with makeup. Wearing masks during the COVID-19 pandemic have also helped patients cover the bruising.”

In her clinical experience, the ideal patient for skin tightening with fractional RF microneedling has mild to moderate skin laxity that does not require surgical intervention. “Nonsurgical treatments provide nonsurgical results,” she said. “If a patient comes in holding their skin back and there is a lot of laxity, this is not going to be the right treatment for that person.”

Dr. DiGiorgio offers fractional RF microneedling in the context of a full-face rejuvenation. She begins by addressing volume loss and dynamic rhytides with injectables prior to skin tightening devices such as fractional RF microneedling or ultrasound-based tightening devices such as Sofwave or Ulthera (also referred to as Ultherapy). “You can add an ablative fractional to target deeper rhytides or pigment-targeting laser to address their dermatoheliosis, which will enhance their results,” she said. “Finally, you can follow up with a thread lift two weeks after the microneedle RF to achieve greater skin tightening. If the thread lift is performed before the microneedle RF, you want to wait about 2 months because the microneedle RF can damage the thread.”

Despite the limited efficacy for tissue tightening with fractional RF microneedling, “it’s a good alternative to lasers, especially for darker skin types,” she said. “Combination treatments will always enhance your results.”

Dr. DiGiorgio disclosed that she is a member of the advisory board for Quthero. She is also a consultant for Revelle and has received equipment from Acclaro.