Zika – What You Need To Know

July 25, 2016
By Maureen S Hamel MD, Brenna L Hughes MD MSc – Modern Medicine Network

60980924 - doctor hand touching zika virus sign on virtual screen. medical concept

Zika virus was first identified from the Rhesus monkey in 1947 in the Zika Forest, Uganda. The virus was subsequently isolated from humans 5 years later. Since the 1950s 3 major outbreaks have been reported: 2007 in the Yap islands of Micronesia; 2013 in French Polynesia; and most recently in 2014–2015 in Brazil. Because the symptoms of Zika are similar to several other viruses such as chikungunya and dengue fever, it is likely that cases in other regions have occurred but have not been identified.

Prior to 2007, Zika was not reported outside of Africa and Asia, and since it was first reported in Brazil in May 2015, the virus has swiftly spread across South and Central America and into the Caribbean. During this time, Brazil has seen a concomitant increase in the frequency of neonatal microcephaly. These parallel findings suggested a link between Zika and birth defects—a relationship not previously identified. With the outbreak of Zika infection and its probable link to teratogenicity has come vast media attention. Zika was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) in February 2016 and it is predicted that transmission to new countries and territories will continue during the upcoming months to years. In fact, in June 2016, the WHO took the momentous step of recommending that women living in Zika-endemic areas delay child-bearing.


Zika is transmitted to humans via the Aedes species of mosquitoes. These mosquitoes are also responsible for the transmission of dengue fever and chikungunya viruses. The Aedes mosquitoes are unique; unlike other species of mosquitoes, they are aggressive daytime biters. The primary species transmitting Zika to humans is the Aedes aegypti and the secondary species is the Aedes albopictus. The virus is transmitted during a blood meal. Both Aedes aegypti and Aedes albopictus have been found in the United States, primarily in the southeastern region. Aedes albopictus is the vastly more prevalent species (Figure 1).


Disease features

Zika is a flavivirus, a single-stranded RNA virus. Zika virus is challenging to identify and therefore challenging to study for several reasons.

  1. First, only 1 in 5 people infected with the virus will become ill.
  2. Not only are disease symptoms usually mild, they can be identical to many other common mosquito-transmitted viruses. Because mild viral illnesses are ubiquitous in many of the regions affected with Zika, people may never realize they have been infected. In patients who do experience symptoms, these symptoms will occur between 3 and 12 days after being bitten by an infected mosquito and will last between 2 and 7 days. Symptoms include mild fever, maculopapular rash, headache, arthralgias, and myalgias. One distinctive feature of Zika is non-purulent conjunctivitis; while this complaint is also found among patients with dengue fever and chikungunya, its presentation seems to be much more common and severe in Zika cases. Zika has not been shown to cause hemorrhagic fever, and disease requiring hospitalization and/or resulting in death is rare. As in the case of other viral illnesses, once infected, individuals are protected from future infection.

Infection prevention

The most effective methods of disease prevention are to protect against mosquito bites and to reduce opportunities for vector proliferation. The Centers for Disease Control (CDC) has recommended long-sleeved shirts and long pants in Zika-infected regions both in the daytime and at dusk. Mosquito bed nets are essential if air conditioning or screens are unavailable. The CDC also recommends the application of Environmental Protection Agency (EPA)-approved repellents to skin and clothing. These products include DEET (N,N-Diethyl-meta-toluamide) and premethrin. DEET-containing products are recommended for skin application and provide the longest-lasting skin protection. Premethrin should be used on clothing and netting. Products approved by the EPA are not expected to cause adverse health effects and are safe in pregnancy. In fact, reports have suggested it may soon be possible in some states to receive Medicare/Medicaid for DEET products. Finally, vector reduction is essential for disease pre vention. The CDC has advised state and local governments to urge residents to reduce standing water by eliminating old tires, old barrels, and other vessels for standing water. An initiative has begun to treat standing water and wetlands with larvicides such as the bacterial insecticide Bti (Bacillus thurengiensis israeliensis).


Although Zika was discovered more than 60 years ago, because adverse pregnancy or birth outcomes have never been previously reported, research into perinatal infection and perinatal transmission is limited and ongoing. Two theories of perinatal transmission exist. The first is transplacental transmission. This theory proposes that virus is transferred directly from the mother to the fetus via the placenta. Once infected, the fetus suffers neural damage as a direct result of the virus. The other theory is one of placental inflammation, which proposes that maternal viral infection creates a placental inflammatory response. This response in turn results in fetal neural damage. The former theory is similar to other documented models of viral transmission and poor outcomes and is the more widely accepted view.

Zika can be sexually transmitted from men to their sexual partners and the possibility of male-to-female sexual transmission with subsequent fetal transmission raises concern. The first documented case of sexual transmission occurred in 2008; this was male-to-female with the sexual contact occurring a few days before the onset of symptoms in the man. With regard to the current outbreak, the first report of sexual transmission was in February 2016. However, as of March 2016, 6 cases of sexual transmission of Zika from men to their sexual partners had been confirmed in the United States. All cases of sexual transmission have been from a man to his sexual partner via vaginal, anal, or oral sex and the sexual contact has occurred before, during, or soon after resolution of symptoms consistent with Zika infection. One recent report out of New York City suggests the first case of female-to-male transmission, however it remains under investigation and it is currently unknown whether asymptomatic men can transmit virus to their sexual partners.

The duration of Zika within the male genitourinary tract is unclear and the process of viral shedding within the genitourinary system is not well understood. As such, Zika testing for the sole purpose of assessing the risk of sexual transmission is not recommended. Because of the risks of transmission from men to women and particularly the risk to the fetus during pregnancy, the CDC has set forth guidelines regarding sexual activity (see bellow)


Two cases of peripartum transmission (ie, transmission at delivery or in the immediate postpartum period) from mother to infant have been reported; both cases resulted in mild disease for the mothers and neonates and no long-term morbidity. While viral particles have been detected in breast milk, breastfeeding has yet to be documented as a mode of transmission. Likewise, infection status after blood transfusion has yet to be reported; however, it is expected, as Zika was found in 2.8% of donors during the 2013 French Polynesian outbreak.

In June 2016, the NEJM published the first report of an affected fetus in the United States. Driggers et al. describe the case of a 33-year-old woman who traveled to Guatemala, Mexico, and Belize during her 11th week of pregnancy. A day after her return to the United States she developed symptoms of a viral infection including rash, mild fever, myalgia, and ocular pain. Her partner had similar symptoms. Serologic testing was positive for both IgM and IgG antibodies against Zika, consistent with Zika infection. Fetal ultrasounds after symptom resolution were negative for intracranial pathology. At 19 weeks, a detailed ultrasound demonstrated brain abnormalities such as bilateral frontal horn enlargement, upward displacement of the third ventricle, absence of the cavum septum pellucidum, and a decrease in head circumference from the 47th to the 24th percentile for gestational age. Fetal MRI confirmed abnormalities of the lateral ventricles, the third ventricle, and the corpus collosum. The patient elected for termination at 21 weeks’ gestation. Postmortem examination of the fetus confirmed the presence of Zika in the amniotic fluid, placenta, fetal brain, muscle, liver, lung, and spleen.

The research regarding perinatal Zika infection, while at times compelling, is limited. And many questions remain. The challenge for patients as well as practitioners is facing the unknown. The true incidence of Zika among pregnant women is unclear, as is the rate of vertical transmission. In turn, among fetuses to whom the virus is transmitted, the rate and range of clinical manifestations cannot be predicted. Indeed it seems there is a delay between maternal exposure, fetal transmission, and ultrasonographically detectable abnormalities, but this time course is not well understood. The case by Driggers et al. demonstrates that fetal abnormalities may not be seen for up to 9 weeks after maternal exposure.

Finally, and perhaps most distressing to expectant mothers, is the unknown prognosis for infants born with Zika infection. Using data from the current outbreak in Bahia as well the previous outbreaks in Micronesia and French Polynesia as models, Johansson and others estimate the risk of microcephaly among infants of mothers infected by Zika to be between 0.9% and 13%. While this estimate is concerning, it must be considered with caution as it is based on modeling and limited retrospective data. Likewise, microcephaly is only one of several potentially adverse outcomes. It is well established that infants with severe microcephaly from other causes will experience a range of neurologic sequelae, but it is unclear if this is true for all cases of Zika-related microcephaly. Neurologic problems can range from intellectual disability to sensory deficits to seizures; they can be mild, severe, or life-threatening. Long-term outcomes are not at all clear and will not be for years to come.

Countries where pregnant women are advised not to travel:

  • American Samoa
  • Argentina
  • Aruba
  • Bahamas
  • Barbados
  • Belize
  • Bolivia
  • Bonaire
  • Brazil
  • Cape Verde
  • Caribbean
  • Chile
  • Colombia
  • Costa Rica
  • Curacao
  • Dominican Republic
  • Ecuador
  • El Salvador
  • French Guiana
  • Guadeloupe
  • Guatemala
  • Haiti
  • Honduras
  • Jamaica
  • Martinique
  • Mexico
  • Nicaragua
  • Panama
  • Paraguay
  • Peru
  • Puerto Rico
  • Samoa
  • Saint Martin
  • Suriname
  • Tonga
  • U.S. Virgin Islands
  • Uruguay
  • Venezuela

Common pediatric disorders in skin of color


August 10, 2016
By Lisette Hilton / Dermatology Times

While pediatric atopic dermatitis and acne have some similarities among skin of color and lighter-skin children, there are important differences when these common skin conditions affect darker skin types, according to Nanette Silverberg, M.D., clinical professor of dermatology and pediatrics, Icahn School of Medicine at Mount Sinai and chief, pediatric dermatology, Mount Sinai Health System.

Starting with eczema

Atopic dermatitis is the most common skin condition of childhood and affects about 25 percent of children in the U.S., according to Dr. Silverberg, who presented on the topic at The Skin of Color Seminar Series, held earlier this year in New York City.

“In particular, there have been studies that have shown atopic dermatitis is more common in children of African American descent or of Afro-Caribbean descent,” she says. “It certainly represents a very concerning issue in children of color.”

Differences in atopic dermatitis can occur in the presentation and severity among children of color.

“In somebody who is very light skinned, eczema is going to be red. But in children of color, we see much less erythema. We see much more in the way of lichenification, or thickening of the skin, and more follicular prominence. These are particularly vexing types of eczema, in that the lichenification, or lichenoid, type of dermatitis is often very thick and very itchy. And the follicular type can be quite deceptive. You don’t see redness. You don’t necessarily see thick or oozing skin, but it is incredibly itchy and it significantly affects children psychologically,” Dr. Silverberg says.

One of the major issues with treating children of color is that there are differences biologically, in terms of the basis of atopic dermatitis, according to the dermatologist.

In African American children, it has been demonstrated that there are reductions in ceramide content, and that could be the reason the skin barrier is not working as effectively as it should be. In children who are Caucasian of European descent, eczema is more associated with a filaggrin defect, she says.

“Filaggrin defects, particularly in Asian children, are somewhat different than those noted in Caucasian children, so we know there are some reasons biologically that the kids may be a little different,” Dr. Silverberg says.

As a result, dermatologists treating children of color who have eczema often need to use thicker emollients, including emollients that might have extra ceramide content or extra balanced fat content to enhance the skin barrier.

“We’re still moving forward to see whether the biologic basis of eczema affects how children respond to treatment. In atopic dermatitis, many of the kids with atopic dermatitis will manifest in early childhood with a lot of hypopigmentation or lightness of the skin. So, pigmentary alterations, which we see in kids of color, are temporary but are sometimes very noticeable and can concern parents,” Dr. Silverberg says. “But this generally resolves, and that’s something we can reassure parents about.”


Acne is common and comes with different concerns in children with skin of color.

“Whereas many of our Caucasian patients talk about the actual pimple lesions, most of our African American patients and many of our Hispanic and Asian patients will obsess over post-inflammatory pigmentary alterations after their acne clears,” Dr. Silverberg says. “So, there’s a focus in the skin of color acne patients, even in the teenagers, on specifically pigmentation issues.”

Hispanic pediatric patients tend to have the most severe acne types among children of skin of color, Dr. Silverberg says.

“We don’t see as much in the way of cystic acne in African American patients, historically and in the literature,” she says. “So, the population that we tend to focus on for more severe treatment or treatment, like isotretinoin, are usually Hispanic teenagers. It’s an important consideration because they have some tendency to have the cystic component, although you can see it in everybody, it seems to be the most concerning amongst that population in the teenage years.”

Dermatologists treating these children need to pay special attention to communicating the need for using good sun protection to enhance pigmentation returning properly. It’s also important to work with patients to develop a skincare regimen that’s effective both at clearing current lesions and preventing new lesions, so the pigmentation improves over time, according to Dr. Silverberg.

“There are some wonderful new acne guidelines that have come out recently from the American Academy of Dermatology … saying it’s clear that most patients of color will respond quite nicely to the products we have available, including topical retinoids … as well as azelaic acid, which has been demonstrated to be beneficial in improving both tone and skin lesions,” she says.

Study shows poor skin cancer survival in patients with skin of color

Dermatologist urges everyone to be aware of their risk and take steps toward prevention, detection
SCHAUMBURG, Ill. – July 28, 2016


 Because Caucasians have a higher skin cancer risk than the general population, people with skin of color may believe that they don’t need to be concerned about this disease — but new research reveals this to be a dangerous misconception.

According to a study published online in the Journal of the American Academy of Dermatology on July 28, although melanoma incidence is higher in Caucasians, patients with skin of color are less likely to survive the disease.

“Everyone is at risk for skin cancer, regardless of race,” says board-certified dermatologist Jeremy S. Bordeaux, MD, MPH, FAAD, one of the study authors. “Patients with skin of color may believe they aren’t at risk, but that is not the case — and when they do get skin cancer, it may be especially deadly.”

Researchers at Case Western Reserve University in Cleveland utilized the National Cancer Institute’s Surveillance, Epidemiology and End Results database to study nearly 97,000 patients diagnosed with melanoma, the deadliest form of skin cancer, from 1992 to 2009. Although Caucasian patients had the highest melanoma incidence rate, they also had the best overall survival rate, followed by Hispanic patients and patients in the Asian American/Native American/Pacific Islander group.

African-American patients had the worst overall survival rate, and they were also the group most likely to be diagnosed with melanoma in its later stages, when the disease is more difficult to treat. According to the study, however, the timing of the diagnosis is not the only factor that affects this group’s survival rates, as African-American patients had the worst prognosis for every stage of melanoma.

Dr. Bordeaux says these differences in survival rates may be due to disparities in the timeliness of melanoma detection and treatment among different races; for example, patients with skin of color may not seek medical attention for irregular spots on their skin because they don’t believe these lesions pose a risk. Additionally, he says, there may be biologic differences in melanoma among patients with skin of color, resulting in more aggressive disease in these patients. More research is necessary to determine why survival rates differ among different ethnic groups, he says, but in the meantime, patients of with skin of color should be aware of their skin cancer risk.

“Because skin cancer can affect anyone, everyone should be proactive about skin cancer prevention and detection,” Dr. Bordeaux says. “Don’t let this potentially deadly disease sneak up on you because you don’t think it can happen to you.”

Ultraviolet radiation exposure is the most preventable skin cancer risk factor, Dr. Bordeaux says, so everyone, regardless of skin color, should take steps to protect themselves from the sun’s harmful UV rays. The American Academy of Dermatology recommends seeking shade, wearing protective clothing, and using a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

Although sun protection is important for everyone, Dr. Bordeaux says, people with skin of color are prone to skin cancer in areas that aren’t commonly exposed to the sun, including the palms of the hands and the soles of the feet. He says these individuals should be especially careful to examine hard-to-see areas when monitoring their skin for signs of skin cancer, asking a partner to help if necessary.

“Skin cancer is most treatable when detected early, so everyone should regularly examine their skin for new or suspicious spots,” Dr. Bordeaux says. “If you notice any spots that are different from the others, or anything changing, itching or bleeding on your skin, make an appointment to see a board-certified dermatologist.”

Cellulite: An Illness of Modernity

By Liondale | May 24, 2016

Today, cellulite plagues 90% of American women – but there are tribes with women completely free of cellulite, even at age 60 with multiple children. What is cellulite, and why do some cultures have more or less of it? Is it a modern problem? Learn the history, causes, and cures for cellulite in this article:

The History of Cellulite

To this day, no historians, anthropologists, or physicians are certain of the origins of cellulite. However, there is scant evidence for it existing much before the past 150 years in a majority of the female population. Ancient medical texts, literature, and artwork all depict women with smooth skin and no blemishes.

Before the 20th-century cellulite only appeared sparsely in art depicting thick goddesses or women of high social status. Overall, the majority of women in art and photography, until recently, were cellulite free. In the 1920s, American Photographer Arthur Albert took 4,000 photographs of women of varying body types, and those images also reveal that the women of that time period had little to no cellulite.


This may incline one to believe that simply diet and exercise are the main culprits, which is candidly not the case. Overweight women of the past often were without cellulite, as seen in Arthur Albert’s photographs. Respectively, today many women of healthy weight and even athletic women often have cellulite.

What is Cellulite?

This may incline one to believe that simply diet and exercise are the main culprits, which is candidly not the case. Overweight women of the past often were without cellulite, as seen in Arthur Albert’s photographs. Respectively, today many women of healthy weight and even athletic women often have cellulite.


It is also a myth that cellulite is merely fat: we now know that cellulite is the abnormal appearance of fat cells caused by poor circulation and lymph drainage, resulting in the degeneration of connective tissues that hold fat and skin cells in the normal position.

Tribes Without Cellulite in the Modern World

There are populations that exist today with virtually no cellulite. One example is the indigenous Shipibo women of Peru, who exhibit no cellulite even past age 60 or after childbirth.

Some important differences in the lifestyles of the Shipibo and western women include lifestyle and diet. These women do not lead a sedentary lifestyle: they are active most of the day, and they eat nearly all-organic diets high in yam and yucca. Plants in the yam and yucca family contain plenty of phytoestrogens, which mimic the effects of naturally occurring estrogen in the body. Decreasing estrogen levels are known to damage the integrity of the skin, and this is how cellulite is formed; this is also why many American women experience an increase in cellulite after menopause.


Vitamins and Deficiencies

In addition, with their diverse diets, they get on average more vitamin A, C, and magnesium, which are crucial in maintaining skin health4. These vitamins have been studied extensively for their role in wrinkle reduction and for their anti-aging properties but are rarely studied in their effect on cellulite. This is likely due to the general lack of understanding surrounding cellulite: that cellulite is actually a result of the degeneration of connective skin tissues.1

Additionally, these indigenous tribes’ diets are higher in vitamins due to their agriculture practices. Pesticides, monocultures, and other poor land practices used by the majority of America’s agriculture cause a decrease in the nutrients in crops and soil. Americans are deficient in many of the essential nutrients that prevent and reduce cellulite.

In fact, vitamin deficiencies in America are staggering. According to the United States Department of Agriculture:

  • only 46% of the population consumes adequate levels of vitamin A
  • only 51% have sufficient vitamin C intake
  • Only 43% of all Americans ingest adequate levels of magnesium,which is a mineral vital to over 300 bodily functions including the collagen synthesis process7

Why do American women have more cellulite?

Causes of Cellulite

It is possible that the increase in meat and processed food consumption lead to diets with fewer vegetables, therefore leading to critical deficiencies as discussed above. Since 1961, meat consumption has been on the rise in Americans who consume twice as much meat as Europeans.

Worse, meat in the United States comes from animals commonly fed with hormones. Consuming this meat can cause hormone imbalances  which is another cause of cellulite. This is also why, as mentioned above, it can help to increase consumption of phytoestrogen-rich foods such as yam and yucca.

Another cause of cellulite could be due to the fact that modern agricultural practices in the United States: with the increase in pesticide use and the depletion of nutrients in the soil from poor land practices, it takes more of a particular vegetable to get the same nutritional benefits that previous generations received.

Also, nearly all food consumed by South American tribes who exhibit no cellulite is organic. Studies have proven that organic food has significantly higher levels of vitamins, particularly vitamin C and magnesium.

In conclusion, these tribes not only have a high vitamin diet due to the different organic foods they consume but also the vegetables they are consuming are of higher quality than their western counterparts through their farming practices.


Sedentary lives

Finally, Americans’ lives are far more sedentary than these indigenous tribes. The Shipibo women are physically active all day working in fields, caring for children, walking, and maintaining their households. Technology and modern appliances that help with workloads are non-existent and therefore the Shipibo women are much more active that their American counterparts.

So, proper diet and exercise are known to help prevent cellulite (though, it cannot reduce or eliminate cellulite after it has occured).

Yes: Cellulite is a Modern Problem, But One that We Can Cure

Cellulite is relatively modern medical condition, but because of this, we understand better than ever how to prevent and treat cellulite.

A few ways to start reducing cellulite on your own include:

  • Increasing your vitamin A and C intake, as well as your magnesium consumption. Sweet Potatoes, red peppers, and spinach have the highest levels of vitamins A, C, and magnesium respectively
  • When buying vegetables, keep in mind organic options will have significantly higher levels of beneficial vitamins
  • Exercising, like diet, is always a beneficial activity. Strength training in particular that targets the legs and glutes are ideal for combating cellulite (a few exercise ideas can be found here)
  • Consume more foods with phytoestrogens, such as yucca or yams
  • Another important factor to check is your hormone levels. Hormone imbalances can certainly cause cellulite, but also a host of other serious symptoms including hypothyroidism, fatigue, and fibrocystic breast. Schedule a visit with your doctor to be sure your estrogen levels are where they should be

To discuss your Cellulite Chicago treatment with a Board Certified Dermatologist or a Licensed Healthcare Professional please make an online appointment or call 773-281-9200 today.

To view the source article on LIONDALE click here.

MiraDry: No more excessive sweat with new procedure

Posted: Apr 28 2016 10:59PM EDT   Updated: Apr 28 2016 10:59PM EDT

We all do it. Some of us more than others.

Sweating’s a natural thing, but excessive sweating can be embarrassing and even stop you from living your life to its fullest.

Now, there’s a way to ditch your deodorants and your antiperspirants, for good.

Sweating is just part of being human, regulating your body’s temperature and keeping you cool. But, for some people it gets in the way of everyday life.

“I’ve tried everything from Drysol which is a prescription antiperspirant which really irritates the skin. It’s not so fun. It works. I’ve also tried Botox which is great and works but is temporary,” Christine Sharkey explained.

Christine has pulled out all the stops to just stop sweating.
“Once I hit puberty I felt like I always sweat a little too much,” Christine added.
“For the longest time, Botox was our only real good treatment for excessive sweating. But that was needles in the underarms. Some people would get needles in their hands if they were sweating,” plastic surgeon Dr. Louis Bucky said, “And you had to do it over and over again.” “And you had to do it over all over again.”

Enter MiraDry. One and done technology.

Dr. Louis Bucky says 80% of people can trash their deodorants and antiperspirants after just one treatment.
“We’re selectively microwaving the sweat glands—heating them up to a point where they’re not functional anymore,” Dr. Bucky explained.

Lidocaine injections numb the area while a template maps it out so the energy targets each spot precisely, with no overlap, and nothing missed. It takes about 30 minutes a side, and for women especially, this comes with one big extra. No more hair. It’s a two-fer.

Dr. Jonas Nelson is a University of Pennsylvania plastic surgery resident who just underwent the procedure. He’s one of the 20% that might have to do it twice to completely eradicate his underarm sweat.

“Just targeting those glands that tend to sweat a little bit more than others when you’re not working out or your just doing your normal everyday activities just really makes sense,” Dr. Nelson said, “You’re just going to sweat normally everywhere else and not sweat in those under arm areas.”

“We get responses back like ‘You’ve changed my life. Game changer, you know? And it’s very rewarding,” Dr. Bucky explained.

“To not worry about ‘Oh do I have deodorant with me?’ Or, you know, kind of always checking. It’s great,” added Christine.

Source: FOX 29

Is There A Replacement Skin In Our Future? (2)

By Lisette Hilton – Dermatology Times

Smart skin that acts like the real thing

Using household items, engineers in Saudi Arabia have created a recyclable paper-based smart skin, capable of detecting temperature, humidity, pH, pressure, touch, flow, motion and proximity at 13 cm, according to a new study in Advanced Materials Technologies.

The study’s senior and corresponding author Muhammad Mustafa Hussain, Ph.D., says this is the first time a singular platform shows multi-sensory functionalities close to that of natural skin.

A model of a paper skin with an array of 6 x 6 sensors which can sense pressure, proximity, temperature, strain, pH, flow and humidity. This sensor array is made with recyclable household materials. Photo: Muhammad Mustafa Hussain, Ph.D.

A model of a paper skin with an array of 6 x 6 sensors which can sense pressure, proximity, temperature, strain, pH, flow and humidity. This sensor array is made with recyclable household materials.
Photo: Muhammad Mustafa Hussain, Ph.D.

Dr. Hussain, associate professor of the electrical engineering, King Abdullah University of Science and Technology (KAUST) in Thuwal, Saudi Arabia, tells Dermatology Times that the development of artificial skin is an important goal in skin care, especially for wounded war, vehicle injury and acid victims. Since skin is mesoporous and covers a larger surface area, the artificial technology needs not only necessary sensory capabilities, but also should be made from affordable materials and by appropriate electronic device engineering to integrate sensory functionalities.

“In that sense, our demonstration shows the proper integration strategy for multi-sensory skin type platform creation, which can sense simultaneously and in an affordable manner,” Dr. Hussain says. “I believe that there will be more advent in this area based on our work and, soon enough, artificial skin mimicking natural skin will be developed, which can be connected to our neural system. Dermatologists can guide us (engineers) to innovate and to develop right ‘skin.’”

They made the smart skin from recyclable materials, including aluminum foil, carbon paper, sponge and more—materials manufactured cheaply and at high volumes, according to Dr. Hussain.

“The integrated strategy we have developed can make an absolutely manufactureable version [of the smart skin] in two years,” Dr. Hussain says. “A major challenge would be neural connectivity …. We also envision and have been working on adding capabilities like drug delivery in this ‘skin’ which can personalize medication.”

Is There A New Skin In Our Future? (1)

Anne Trafton | MIT News Office


Scientists at MIT, Massachusetts General Hospital, Living Proof, and Olivo Labs have developed a new material that can temporarily protect and tighten skin, and smooth wrinkles. With further development, it could also be used to deliver drugs to help treat skin conditions such as eczema and other types of dermatitis.

The material, a silicone-based polymer that could be applied on the skin as a thin, imperceptible coating, mimics the mechanical and elastic properties of healthy, youthful skin. In tests with human subjects, the researchers found that the material was able to reshape “eye bags” under the lower eyelids and also enhance skin hydration. This type of “second skin” could also be adapted to provide long-lasting ultraviolet protection, the researchers say.

“It’s an invisible layer that can provide a barrier, provide cosmetic improvement, and potentially deliver a drug locally to the area that’s being treated. Those three things together could really make it ideal for use in humans,” says Daniel Anderson, an associate professor in MIT’s Department of Chemical Engineering and a member of MIT’s Koch Institute for Integrative Cancer Research and Institute for Medical Engineering and Science (IMES).

Anderson is one of the authors of a paper describing the polymer in the May 9 online issue of Nature Materials. Robert Langer, the David H. Koch Institute Professor at MIT and a member of the Koch Institute, is the paper’s senior author, and the paper’s lead author is Betty Yu SM ’98, ScD ’02, former vice president at Living Proof. Langer and Anderson are co-founders of Living Proof and Olivo Labs, and Yu earned her master’s and doctorate at MIT.

Scientists at MIT and elsewhere have developed a new material that can temporarily protect 
and tighten skin, and smooth wrinkles. With further development, it could also be used 
to deliver drugs to help treat various skin conditions.

Video: Melanie Gonick/MIT

Mimicking skin

As skin ages, it becomes less firm and less elastic — problems that can be exacerbated by sun exposure. This impairs skin’s ability to protect against extreme temperatures, toxins, microorganisms, radiation, and injury. About 10 years ago, the research team set out to develop a protective coating that could restore the properties of healthy skin, for both medical and cosmetic applications.

“We started thinking about how we might be able to control the properties of skin by coating it with polymers that would impart beneficial effects,” Anderson says. “We also wanted it to be invisible and comfortable.”

The researchers created a library of more than 100 possible polymers, all of which contained a chemical structure known as siloxane — a chain of alternating atoms of silicon and oxygen. These polymers can be assembled into a network arrangement known as a cross-linked polymer layer (XPL). The researchers then tested the materials in search of one that would best mimic the appearance, strength, and elasticity of healthy skin.

“It has to have the right optical properties, otherwise it won’t look good, and it has to have the right mechanical properties, otherwise it won’t have the right strength and it won’t perform correctly,” Langer says.

The best-performing material has elastic properties very similar to those of skin. In laboratory tests, it easily returned to its original state after being stretched more than 250 percent (natural skin can be elongated about 180 percent). In laboratory tests, the novel XPL’s elasticity was much better than that of two other types of wound dressings now used on skin — silicone gel sheets and polyurethane films.

“Creating a material that behaves like skin is very difficult,” says Barbara Gilchrest, a dermatologist at MGH and an author of the paper. “Many people have tried to do this, and the materials that have been available up until this have not had the properties of being flexible, comfortable, nonirritating, and able to conform to the movement of the skin and return to its original shape.”

The XPL is currently delivered in a two-step process. First, polysiloxane components are applied to the skin, followed by a platinum catalyst that induces the polymer to form a strong cross-linked film that remains on the skin for up to 24 hours. This catalyst has to be added after the polymer is applied because after this step the material becomes too stiff to spread. Both layers are applied as creams or ointments, and once spread onto the skin, XPL becomes essentially invisible.

High performance

The researchers performed several studies in humans to test the material’s safety and effectiveness. In one study, the XPL was applied to the under-eye area where “eye bags” often form as skin ages. These eye bags are caused by protrusion of the fat pad underlying the skin of the lower lid. When the material was applied, it applied a steady compressive force that tightened the skin, an effect that lasted for about 24 hours.

In another study, the XPL was applied to forearm skin to test its elasticity. When the XPL-treated skin was distended with a suction cup, it returned to its original position faster than untreated skin.

The researchers also tested the material’s ability to prevent water loss from dry skin. Two hours after application, skin treated with the novel XPL suffered much less water loss than skin treated with a high-end commercial moisturizer. Skin coated with petrolatum was as effective as XPL in tests done two hours after treatment, but after 24 hours, skin treated with XPL had retained much more water. None of the study participants reported any irritation from wearing XPL.

“I think it has great potential for both cosmetic and noncosmetic applications, especially if you could incorporate antimicrobial agents or medications,” says Thahn Nga Tran, a dermatologist and instructor at Harvard Medical School, who was not involved in the research.

Living Proof has spun out the XPL technology to Olivo Laboratories, LLC, a new startup formed to focus on the further development of the XPL technology. Initially, Olivo’s team will focus on medical applications of the technology for treating skin conditions such as dermatitis.

Israeli breakthrough helped cure Jimmy Carter’s cancer

Researched and tested at Tel Hashomer Sheba Medical Center, Keytruda fights tumors using the body’s natural immune system


Former President Jimmy Carter discusses his cancer diagnosis during a press conference at the Carter Center on August 20, 2015 in Atlanta, Georgia. (Jessica McGowan/Getty Images/AFP)

Researched in Israel by Professor Jacob Schachter of the Ella Institute for melanoma treatment and research at the Sheba Medical Center in Tel Hashomer, Keytruda is part of a promising new class of drugs called immunotherapies, which harness the body’s immune system to help fight cancer. The US-based Merck pharmaceutical company’s injectable biotech drug works by blocking a protein found in certain tumors called PD-1, which inhibits the body’s natural response to cancer cells.

Carter, 91, announced Sunday that doctors found no evidence of the four lesions discovered on his brain last summer and no signs of new cancer growth. He revealed in August, 2015 that he had been diagnosed with melanoma and had begun treatment, including surgery to remove part of his liver, targeted radiation therapy and doses of a recently approved drug to help his immune system seek out any new cancer cells.

“I will continue to receive regular 3-week immunotherapy treatments of pembrolizumab,” he said. That drug goes by the name Keytruda commercially.

This undated product image provided by Merck & Co., Inc. shows packaging for its Keytruda cancer drug. The Food and Drug Administration on Thursday, Sept. 4, 2014 said it has granted accelerated approval to Keytruda, for treating melanoma that's spread or can't be surgically removed, in patients previously treated with another drug. (AP Photo/Merck & Co., Inc.)

This undated product image provided by Merck & Co., Inc. shows packaging for its Keytruda cancer drug. The Food and Drug Administration on Thursday, Sept. 4, 2014 said it has granted accelerated approval to Keytruda, for treating melanoma that’s spread or can’t be surgically removed, in patients previously treated with another drug. (AP Photo/Merck & Co., Inc.)

“For today, the news cannot be better,” said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society. “Circumstances may change over time or he may be in a situation where it does not recur for many years or at all.”

Carter said he will continue to receive Keytruda every three weeks in order to prevent the growth of further tumors.


Melanoma specialists credit the drug for improving treatment of the disease without the side effects of traditional chemotherapy drugs that can cause hair loss and other symptoms, said Dr. Douglas Johnson, a melanoma specialist at Vanderbilt-Ingram Cancer Center who is not involved with Carter’s treatment.

The drugs also have shown promise as a “long-lasting” treatment, but doctors continue to learn more as the drugs are used outside of clinical trials, he said.

“So many cancer treatments can be effective in the short-term, causing tumors to shrink,” he said. “Immune therapy, in at least a subset of patients, has truly long-lasting responses.”

Carter has said he experienced no side effects during treatment, a positive sign for his doctors, said Dr. Keith Flaherty, a melanoma specialist at Massachusetts General Hospital’s Termeer Center for Targeted Therapies who is not involved in Carter’s treatment.

“If a patient breaks the right way, the likelihood that he will do well in the short term is extremely high,” Flaherty said. “There have been instances of relapse two to three years in while using immunotherapy treatment, but you’d say there is a good reason to be quite optimistic. At President Carter’s age, it’s very likely he’s going to enjoy an excellent quality of life.”

But doctors caution that they are still learning about the long-term effect of Keytruda and similar drugs, which have only received approval for wide patient use in the last five years.

“President Carter’s doctors certainly will continue close surveillance as they would for any patient in this situation,” Lichtenfeld said. “One hopes that by using immunotherapy the body can respond to whatever happens but cancer cells are clever and can develop workarounds for the various treatments.”

Doctors will continue to scan Carter’s brain and the rest of his body to ensure the disease hasn’t spread, Johnson said. The scans typically are done every three months, for a year or two after tests show no signs of cancer growth, he said.

Carter’s unexpected comments Sunday came first at the small church where he frequently teaches Sunday school lessons in his hometown of Plains, Georgia.

“And when I went this week, they didn’t find any cancer at all,” Carter told the congregation, prompting gasps and applause as he smiled slightly. “So I have good news.”

As word spread from Maranatha Baptist Church, Carter issued a brief statement confirming the scan showed no signs of the four lesions that doctors discovered this summer on his brain or new cancer growth.

Carter has remained active during treatment, including a home-building project with Habitat for Humanity and work at The Carter Center, the human rights organization he founded after leaving the White House.


From rebellious to routine: A path to tattoo regret

By Randy Dotinga – Dermatology Times


A modern tattoo sensibility

In the beginning, there were bodies and there was art. Early humans mixed the two and declared them to be a fine match. Now, tattoos are finally gaining widespread respectability.

In just a matter of decades, body art has shed much — but not all — of its tawdry reputation as an emblem of sailors, outcasts and criminals. In 2014, an NBC/Wall Street Journal poll found that 40% of respondents live with someone with a tattoo, almost twice the number as 15 years earlier. And in 2010, a Pew Research Center study found that almost 40% of millennials — adults born after 1980 — had tattoos. About 7% reported having six or more.

The new prime minister of Canada has a “badass tattoo,” as the magazine GQ puts it, on his upper arm. Across the pond, the wife of the U.K. prime minister has one on her foot.

According to news reports, Carolyn Kennedy, the presidential daughter and ambassador to Japan, got a tattoo in the 1980s. Helen Mirren, Jennifer Anniston, Ben Affleck and Brad Pitt are all tattooed. Even the Barbie doll — briefly — sported a butterfly tattoo of her own.

Along with the dramatic rise in acceptability of tattoos has come a dramatic rise in tattoo regrets. But thanks to dermatologists and technological advances, people have more power to remove unwanted tattoos.

But before we get to tattoos (and tattoo removal) in the present day, let’s start with an unfortunate prehistoric body-art enthusiast known as Ötzi the Iceman.

Dawn of the tattoo

Tattoos and related body modifications like intentional scars “have been documented in almost all known cultures and on all inhabited continents,” says Matt Lodder, Ph.D., a tattoo researcher, very tattooed person and lecturer in contemporary art and visual culture at the University of Essex in the U.K. According to him, some evidence suggests that tattoos date back to at least the Upper Paleolithic era, also known as the Stone Age, some 10,000-50,000 years ago before humans figured out how to farm.

The earliest firm evidence of human tattoos dates back more recently, to about 5,000 years ago. That’s when Ötzi the Iceman — as he’s known — lived in the mountains that now split Austria and Italy.

Hikers discovered Ötzi’s mummified body in 1991. Preserved in snow and ice after his apparent murder, he survived for millennia along with his clothes, his tools and a stunning 61 tattoos.

Italy’s South Tyrol Museum of Archaeology, which displays the mummy, says the tattoos look like lines and crosses and were created by rubbing charcoal into fine incisions. The museum thinks the tattoos may have been designed to relieve pain, perhaps as part of an early form of acupuncture, although there’s debate about this.

When the upper crust embraced the tat

Ötzi the Iceman’s tattoos are unusual because they appear to be health-related. It’s more common in Western culture for people to use tattoos to stand apart. Like fashion, “they distinguish our identities and create distinctive bodies,” says Dave C. Lane, Ph.D., an assistant professor of sociology at the University of South Dakota who studies tattoos and is heavily tattooed himself.

Aaron Deter-Wolf, a tattoo researcher and Tennessee archaeologist, and colleagues put it this way in a 2016 report in the Journal of Archaeological Science: “Depending on the culture and time period, indigenous tattoo traditions have functioned to signal entry into adulthood, reflect social status, document martial achievement, demonstrate lineage and group affiliation, and to channel and direct preternatural forces.” And, of course, some tattoos simply serve as decoration.

For a while, just over a century ago, tattoos were actually a craze among the British upper crust.

“Elites and military officers would travel to Japan to get tattoos as marks of their aristocratic status,” Dr. Lane says. “For some reason, we have constructed the idea that tattoos were the property of sailors and criminals and outlaws. Tattoo researchers are just beginning to challenge and explore that narrative. One of the arguments is that elites moved away from tattooing around the time the tattoo machine appeared and made tattooing cheap and accessible at all.”

A modern tattoo sensibility

In the 20th century, tattoos dipped in public acceptance as they became emblems of the rough and rebellious even as they began to be used in new ways.

“Since at least the First World War, there’s also been some uptake of tattooing by cosmetic surgeons and dermatologists to re-pigment skin affected by conditions which leave skin patches, to simulate hair in bald patients or those with alopecia, to simulate nipples on women with mastectomies, and to reduce the appearance of scars and marks,” the U.K.’s Dr. Lodder says.

Over the past 50 years, a “tattoo renaissance” has resulted in massive growth in tattoos. “You had a number of people who entered the world of tattooing with an art school background,” the University of South Dakota’s Dr. Lane says. “They also were able to incorporate the aesthetics of the art world, and they were key in terms of changing attitudes regarding sterility.”

Improved safety arrived along with streamlined tattoo inks. “I’m sure plenty of dermatologists today would be horrified by some of the ingredients of early tattoo inks, particularly as tattooers experimented with color,” Dr. Lodder says. “Many early red inks were made from mercury-derived vermillion. And sailors in the 18th century would often use gunpowder mixed with urine as their ink.”

Tattoo regret

No one knows when a first human regretted a tattoo and tried to do something about it, but Dr. Lodder thinks it happened early. “I do not doubt that removing permanent tattoo marks has been attempted, by abrasion and excision, for millennia,” Dr. Lodder says.

Indeed, tattoo artists have offered “home remedies” for tattoo removal since at least the late 19th century, he says. Up until the 1980s, some artists used chemicals like tannin to diminish tattoos by tattooing over the original artwork. “Reports suggest that these were moderately successful,” he says, “particularly when the goal was to lighten the tattoo so that it could be covered with new work rather than removed entirely.”

Why get rid of tattoos? “People often regret bad decisions, like offensive tattoos, jail house tattoos, gang tattoos, and just plain ugly tattoos. Or they get the name of a boyfriend, girlfriend, husband, or wife and, after the love affair is over, they may seek removal,” says Melbourne, Fla., dermatologist Terrence A. Cronin Jr., M.D. As a result, “professional tattoo artists are resistant to tattooing names other than your mother’s or your children’s.”

The tattooed may also worry about stigma and their ability to find work.

“I have an example of a waiter seeking removal of a tattoo on his hand in the 1880s due to it affecting his career choices,” Dr. Lodder says.

A 2008 study in Archives of Dermatology of 196 patients seeking tattoo removal found that more than half were embarrassed by their tattoos. The research turned up a startling statistic: More than two-thirds of those seeking tattoo removal were women.

“Society hasn’t caught up with women having all these tattoos,” says study author Myrna L. Armstrong, Ed.D., RN, who’s now a professor emerita at Texas Tech University Health Sciences Center. “Women are the ones who show up at tattoo removal clinics and tend to go through with it. Men may not like their tattoos either, but a lot of them don’t follow through with the decision-making to have it done.”

As Americans’ taste for tattoos has grown, experts say, so have many tattoo wearers’ regrets.

Nationally, says Eric F. Bernstein, M.D., M.S.E., “There’s a total epidemic of people wanting their tattoos removed.” He is clinical professor, Department of Dermatology, University of Pennsylvania School of Medicine.

George Hruza, M.D., M.B.A., says he commonly sees parents who want tattoos removed from children – who got them without permission – as young as 16. He is a Chesterfield, Missouri-based dermatologist in private practice. Dr. Bernstein adds that he’s removed recent tattoos from patients from 14 years old to senior citizens.

Regarding tattoo locations, Dr. Hruza says that as tattoos have grown more mainstream, he increasingly zaps them from highly visible areas such as the neck, once the wearers rethink their ink.

Roy Geronemus, M.D., adds that as people become more aware that lasers can safely and effectively remove tattoos, he sees growing numbers of patients with lip and eyeliner tattoos they want removed.

Treating tattooed-on cosmetics can be tricky, however. Frequently, explains Dr. Hruza, they contain iron oxide (for tan and rust tones) or titanium dioxide (for pastels and flesh tones). Immediately after Q-switched or picosecond laser treatment, he says, both materials often irreversibly darken to gray or pitch-black tones as refractory as genuine black ink. Dr. Bernstein says the darkened pigment can take double or triple the usual number of Q-switched laser treatments.

At Lakeview Dermatology tattoo removal with the Q switch laser can be done in the Palos Heights office for black inked tattoo.  Tattoo removal with the Q switch laser may require multiple treatments; usually about 8-12 are recommended.

To discuss your tattoos removal treatment with a Board Certified Dermatologist or a Licensed Healthcare Professional please make an online appointment or call 773-281-9200 today.

Challenges in treating pediatric skin conditions

By Randy Dotinga – Dermatology Times


Uniquely tailored strategies improve diagnosis and treatment

Beware of the rare, ask questions of the littlest patients, and make sure to treat children as individuals with unique needs. These are the messages from dermatologists who spoke to colleagues about the special challenges of treating skin conditions in children, especially those who are far from their teen years.

“Most dermatologists are very cautious with kids and probably not as familiar with treating them,” says Leslie Castelo-Soccio, M.D., Ph.D., an assistant professor of pediatrics and dermatology at The Children’s Hospital of Philadelphia, who spoke during a session about children and skin disease at the 73rd annual meeting of the American Academy of Dermatology (San Francisco, 2015).

For example, phototherapy is often a beneficial treatment for kids with conditions like eczema, psoriasis and vitiligo. It’s typically used for inflammatory conditions when patients have failed topical and systemic therapy, Dr. Castelo-Soccio says. But many dermatologists won’t try the treatment on children under 18 even if they have the equipment, she says, despite studies that suggest early treatment is crucial for vitiligo in particular.

In fact, “children tolerate it beautifully,” she says. “We’ve treated kids as young as 16 months up to teenagers and early adults.”

She cautions dermatologists to consider the ages of children undergoing the treatment. Older children over 4 or 5 years old can handle going into the closet-like space of a light box on their own for a matter of seconds or minutes, she says.

But younger children won’t tolerate being alone in a light box, so Dr. Castelo-Soccio will open the device and let the light emanate into the room. A parent stays with the child but is covered for protection from the light.

“You partner with parents to get the child through the treatment, and you learn strategies of distraction like talking, singing and visualization that you don’t need with adults,” she says.

Important cautions

“You want to be very careful with the energy and the amount of the time that a patient is in the light box,” she says. Side effects include pink skin and burning. Cold sores, which are especially common in the summer, can be activated by light, she says.

An increased risk of skin cancer is also a concern. While the light rays in phototherapy are different from sun rays, they are potentially damaging and do pose an unknown long-term risk.

“We think it’s safe,” she says, “but there are no long-term studies for kids who have had therapy when they’re 40, 50, 60 years old.”

Insurance typically covers the treatments, which are often time-consuming and repetitive. According to Dr. Castelo-Soccio, two to three treatments a week may be required for four to five months.

“Distance and interference with school or other activities is one reason compliance isn’t great,” she says. “If you carefully select the patients and parents, that’s not as much of an issue. You tell them what we’re expecting, and that this is the time commitment,” she says.

The good news, she says, is that re-pigmentation is possible for vitiligo, and eczema and psoriasis may improve or go into remission.

“Not every patient responds. We’d stop the therapy if we’re not seeing any response after 40 treatments. But overall we’ve been very pleased with the response in the children we’re treating,” she says.

Drug reactions

Jim Treat, M.D., an associate professor of pediatrics and dermatology and fellowship director of pediatric dermatology at Children’s Hospital of Philadelphia, told the audience at the American Academy of Dermatology about the challenges of treating life-threatening cutaneous drug reactions and infections. These conditions are rare, he says.

Many patients get rashes from medications, he says, but it’s especially dangerous when they develop with fever.

“If you don’t suspect a systemic reaction, it can brew for a while and hurt the patient,” Dr. Treat says.

Indeed, dermatologists may miss the wider picture when they don’t ask rash patients about other symptoms, and the patients don’t bring it up.

“It’s not up to the patient to know what to tell you,” he says. “You need to ask, and the most important question is: Is there a fever? Systemic drug reactions almost always come with a fever, and it can be a sign of systemic inflammation from the drug rash.”

A wide variety of drugs can lead to skin-related reactions. Antibiotics can cause acute generalized exanthematous pustulosis (AGEP). Sulfa medications, antibiotics (including minocycline), HIV medications, anticonvulsants and others can cause DRESS (drug reaction with eosinophilia and systemic symptoms), which is also known as drug hypersensitivity syndrome (DHS) and drug-induced hypersensitivity syndrome (DIHS).

Minocycline causes severe drug reactions so Dr. Treat doesn’t use it as a first-line acne treatment (“that’s certainly controversial,” he says). When he does prescribe it, he tells patients to stop using the drug to let him know immediately if they have a fever or rash within the first couple months of treatment.

When diagnosing children, Dr. Treat says it’s important to ask them how they feel instead of just relying on their parents because Mom and Dad may not know a child has a fever or is feeling ill, especially teenagers. It’s also crucial to check labs if you suspect a systemic reaction, he says.

According to him, patients should be considered for hospital admission if they suffer from serious complications like abnormal vital signs or labs, high fever, hypotension and tachycardia.

However, if caught early, dermatologists may be able to handle DRESS or AGEP without a hospital admission. Stevens Johnson Syndrome, a rare reaction, always requires admission due to the need for multispecialty care and wound care, he says. Dr. Treat adds that standard care for DRESS includes withdrawal of the drug in question and treatment with systemic steroids for a few weeks if not a couple months.

Vascular anomalies require multidisciplinary care

Erin Mathes, M.D., an assistant clinical professor of dermatology and pediatrics at the University of California at San Francisco, spoke about treatment of vascular malformations and tumors in children.

“For complex vascular tumors and malformations, the most important overarching message is to refer these patients to centers with multi-disciplinary teams that have experience with them,” she says. “At UCSF’s Birthmark & Vascular Anomalies Center, we work with neurologists, dermatologist surgeons, plastic surgeons, general surgeons, hematologists, otolaryngologists and radiologists to manage these patients.”

Fortunately, many other parts of the country are also home to vascular anomaly clinics, she says. If there is no nearby vascular anomalies center, patients can travel to a regional center, or dermatologists can reach out to other specialists in their area to figure out who has the most experience with vascular anomalies. Diagnostic imaging and tissue biopsy can help make the diagnosis.

The prognosis for these patients will vary, she says. Smaller vascular tumors and malformations may simply require surgical excision, but some cases can be much more serious, requiring multiple procedures and systemic medication.

“It depends on the specific site that’s affected and how severely affected it is and what other co-morbidities the patient has,” she says.

As for the future, “there are a lot of new medicines coming down the pipeline for these conditions,” she says. “We’re discovering more about the genetic causes, and we can apply targeted therapies that already exist and develop new targeted therapies. That’s particularly exciting and another reason to seek treatment in a center that has experience.”