Explaining Jeuveau: The New Injectable Aiming to Make You Look Younger

On February 1, 2019, the U.S. Food and Drug Administration (FDA) approved Jeuveau™ (prabotulinumtoxinA-xvfs) for the treatment of glabellar lines. Known as frown lines or the “11,” these lines can be found between the eyebrows and are a common complaint of many patients. Jeuveau™ is the first aesthetic neurotoxin to be approved by the FDA in almost 10 years, joining commonly used injectables like Botox®, Dysport®, and Xeomin®. Joshua Rosenberg, MD, Chief of the Division of Facial Plastic and Reconstructive Surgery at Mount Sinai’s Department of Otolaryngology – Head and Neck Surgery, explains the new drug, how it works, and compares the drug to its popular competitors.

What exactly is Jeuveau?

Very similar to the ubiquitous Botox, Jeuveau is a purified botulinum toxin type A complex. It is an aesthetic neurotoxin which produces results by paralyzing the muscle. Although the effect sounds scary, these injectable medications are completely safe when administered professionally.

How do neurotoxins reduce lines and wrinkles?

Repetitive movements are responsible for many of the lines and wrinkles that form as we age, especially horizontal forehead lines and crow’s feet. Cosmetically speaking, all neurotoxins do the same thing: relax muscles involved in facial expression. Through their ability to relax our underlying facial muscles, Botox, Dysport, Xeomin, and now Jeuveau are great tools to prevent these lines from forming or soften lines that are already there to give you a younger, more refreshed look.

What is the difference between the available injectables?

Although they are distinct formulations of botulinum toxin type A, there are few practical differences between Botox, Dysport, and Xeomin for the average patient. They all produce temporary results that last between three and six months, require similar injection techniques, and have similar prices. For many patients, the product decision is made by a dermatologist or facial plastic surgeon.

So, why is the industry so excited by this new drug?

The excitement centers not only on its “new kid” status but also its potentially lower price. Unlike Botox, which can also be used to treat non-aesthetic conditions, Jeuveau has only been approved for cosmetic use. Due to this, the drug is expected to be 25-30 percent cheaper than its competitors. I have yet to meet a patient, especially a New York patient, who was not excited by getting a similar product for a better price.

When will patients be able to try this drug?

Jeuveau is available in offices. If you are interested in trying this new injectable, make an appointment with a Mount Sinai facial plastic surgeon.

Joshua Rosenberg, MD, is an Assistant Professor, Otolaryngology at the Icahn School of Medicine at Mount Sinai and Co-Chief of the Division of Facial Plastic and Reconstructive Surgery at Mount Sinai’s Department of Otolaryngology – Head and Neck Surgery. A diplomate of the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology, Dr. Rosenberg is an expert in facial plastic and reconstructive surgery and microvascular reconstruction.

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New Pathway to Treating Rheumatoid Arthritis Identified

Pércio S. Gulko, MD, center, with team members Teresina Laragione, PhD, Assistant Professor of Medicine (Rheumatology), left, and Carolyn Harris, Senior Associate Researcher.

A new gene associated with disease severity in rheumatoid arthritis (RA) has been identified by researchers at the Icahn School of Medicine at Mount Sinai. This finding could provide a new pathway for treatment and a way to measure the prognosis of patients diagnosed with this autoimmune condition.

Through a series of experiments, Pércio S. Gulko, MD, Chief of the Division of Rheumatology, and the Lillian and Henry M. Stratton Professor of Medicine (Rheumatology), and his colleagues showed that Huntingtin-interacting protein 1 (HIP1) is a driver in inflammatory arthritis severity. The findings were published in July 2018 in the Annals of the Rheumatic Diseases. “It is known that this gene is expressed in some cancers, but precisely how it contributed to cancer was not known, and it has never been implicated in inflammation or arthritis. So this new discovery, that it regulates cell invasion, is completely novel,” says Dr. Gulko, senior author of the paper.

Rheumatoid arthritis is a chronic disease affecting more than 1.3 million Americans. The disease causes pain, swelling, and sometimes deformation of joints and affects about 1 percent of the world’s population. In the last 20 years, there have been major advances in the treatment of RA, but the existing treatments immunosuppress patients, increasing the risk for infections.

Dr. Gulko with images of synovial fibroblasts, cells in the joints that are central to his team’s study of rheumatoid arthritis.

“At my laboratory, we have been looking for alternative strategies,” Dr. Gulko says. “We have focused on understanding the regulation of disease severity and joint damage, and this led us to the synovial tissue and the fibroblasts.” These cells are present in all joints and produce the fluid that lubricates and nourishes the cartilage, but in patients with RA, they grow out of control, invading and destroying cartilage and bone.

Dr. Gulko’s team started with rodent models of arthritis, studying animals that were highly susceptible to RA and those that were resistant. Using a technique called positional cloning, the researchers identified gene variants that control arthritis severity and the behavior of the synovial fibroblasts, finding that HIP1 made the cells highly invasive. Next, the team studied synovial fibroblasts from patients with RA and found that HIP1 was strongly expressed in those cells.  To test the finding further, the team used a molecular biology technique to “knock down,” or remove, HIP1 from the cells of RA patients, and found that this significantly reduced the cells’ ability to invade.

The team unexpectedly found further evidence implicating HIP1 while  collaborating in a study of RA and epigenetics, the environmental influence on genetics. The study, which was published in May 2018 in Nature Communications, compared the synovial fibroblasts of patients with RA with those from patients with osteoarthritis, which is not considered an inflammatory disease. The researchers were looking for dysregulated genes and pathways that differentiated the two groups of patients.

“One key pathway found to be epigenomically dysregulated was the Huntington protein pathway, including HIP1,” Dr. Gulko says.

Going forward, Dr. Gulko has several goals: improving the understanding of how HIP1 regulates disease; finding a way to quantify HIP1 levels in the blood or synovial fluid cells with the aim of creating a predictor of disease prognosis; and developing a drug that would target the HIP1 gene. The ultimate goal is to achieve remission for RA patients.

“I treat many patients with rheumatoid arthritis,” Dr. Gulko says, “and all the work that we have done throughout my career has been centered on trying to bring a benefit to these patients.”

 

A New Waiting Room that Supports Men’s Health

The idea that men often take better care of their cars than their own health led to the recent opening of a sports-themed waiting room at the Milton and Carroll Petrie Department of Urology’s midtown office at 625 Madison Avenue. The special space was designed to serve as a refuge for male patients waiting for a doctor’s appointment or looking for
educational resources on prostate health or men’s health.

Amid the mounted football jerseys belonging to former Super Bowl winners and other framed sports memorabilia featured in the room, male patients can find information on medical services, holistic treatments, or emotional support when dealing with a critical prostate diagnosis.

Ash Tewari, MBBS, MCh, left, and Tom Milana Jr. celebrated the opening of the waiting room with a ribbon-cutting.

The new space was donated by Man Cave Health, Inc., a nonprofit led by philanthropist and Mount Sinai Health System patient Tom Milana Jr., a prostate cancer survivor who recognized the need to raise awareness about the disease and men’s health as he was recovering from his 2016 diagnosis.

At the official ribbon-cutting ceremony in January, Mr. Milana said, “This is a place where men can get educated, screened, and treated for prostate cancer in a welcoming environment. Our goal is to get more men to go to the doctor for their annual screening, which will lead to fewer prostate cancer deaths in this country.”

Mr. Milana’s physician at Mount Sinai, Ash Tewari, MBBS, MCh, the Kyung Hyun Kim, MD Chair in Urology, said, “Men avoid going to the doctor. I think this room makes a difference. They can come here and relax.”

The inspirational message, he added, is about winning at sports and winning the fight against cancer.

Teledermatology: Expanding Care Where Access is Limited

Shira Wieder, MD, logs in to our secure teledermatology website fora visit with a patient in Cooperstown, New York.

Diagnosing and treating patients from hundreds of miles away using online platforms is the basis of telemedicine, a new and fastgrowing trend. In dermatology, there are already numerous studies highlighting the value of teledermatology in delivering quality care to communities where dermatologists are scarce.

Herbert Goodheart, MD, oversaw the first teledermatology initiative at Elmhurst Hospital Center, a Mount Sinai Health System affiliate. This year, the Kimberly and Eric J. Waldman Department of Dermatology launched a formal teledermatology program directed by George Han, MD, PhD, at Mount Sinai Beth Israel. Under the supervision of Dr. Han, residents see patients remotely in real time at Bassett Medical Center in Cooperstown, New York.

Our doctors conduct online interviews and examinations, order tests, and prescribe medications, all from over a hundred miles away.

“Teledermatology allows us to help people in a way that other patients experience in Manhattan, where dermatologists are abundant,” says Shira Wieder, MD, a dermatology resident at Mount Sinai. “We have had the opportunity to help patients suffering from untreated psoriasis or atopic dermatitis their entire lives and have never been able to see a dermatologist. Patients are so appreciative of our help and seem to love the service, despite only getting to meet us over the computer.” Dr. Wieder said that some clinic nurses were initially skeptical about the teledermatology concept but now think it is a wonderful addition to their clinic. Ellen de Moll, MD, a dermatology resident, said she has also enjoyed her time on the rotation. “It has allowed me to help many patients with limited access and provide truly life-changing treatments for everything from acne to severe psoriasis to rare diseases, she says.” Dr. de Moll also noted some of the challenges of teledermatology, including the difficulty of obtaining clear images and the inability to touch and apply pressure to skin lesions.

Patient feedback has been very positive, with testimonials such as, “Less wait time to be seen by specialists” and “Getting care from physicians at a premier hospital.” Patients also appreciate the chance to see changes in their clinical photos and receive opinions from several physicians over the course of their care. Prior to teledermatology, the average wait time for a dermatology appointment for these patients in upstate New York was close to a year. Now they can consult with a Mount Sinai dermatologist within a couple of weeks, and sooner for urgent problems.

“Dermatology lends itself to telemedicine, given the uneven distribution of dermatologists in the U.S. and the visual nature of our field,” says Dr. de Moll.

Post authored by Mohammad-Ali Yazdani, MD, Dermatology Resident at the Icahn School of Medicine at Mount Sinai.

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How to Manage Skin Rashes During Pregnancy

Pregnancy can be associated with skin conditions that require medical evaluation because of possible health risks to the mother or her baby. The first manifestation may be itching, which affects up to 20 percent of pregnant women. Itching can be mild but in some instances is severe enough to affect sleep and quality of life. Most often, itching is caused by flare-ups of pre-existing skin conditions like eczema or atopic dermatitis. In such cases, the response to topical corticosteroids and good skin care is usually excellent, and there are no significant effects on fetal or maternal health.

One of the most common rashes specific to pregnancy is called polymorphic eruption of pregnancy (PEP), also known as pruritic  urticarial papules and plaques of pregnancy (PUPPP). PEP is linked to rapid weight gain and multiple pregnancies. It usually begins with itchy, hive-like lesions on the abdomen, especially within stretch marks, and may spread to involve the buttocks or thighs. It generally appears during late pregnancy and resolves within four to six weeks after delivery. A diagnosis of PEP is based on the classic appearance. PEP is not associated with increased maternal or fetal risks, and it usually does not recur during subsequent pregnancies.

A more serious condition is pemphigoid gestationis (PG), a rare autoimmune disorder that usually occurs during late pregnancy with an abrupt onset of itchy blisters. These are typically on the abdomen in the umbilical area and can spread to the whole body. An office-based procedure called a skin biopsy, in which a small piece of skin is removed and sent in a special medium to detect immunofluorescence, can clinch the diagnosis. Severe cases usually require oral corticosteroid treatment. PG is associated with an increased risk of prematurity, and the newborn may be small for its age. After delivery, the rash usually resolves within weeks to a few months. Skin manifestations may appear in the infant due to transfer of antibodies across the placenta. It is possible for PG to recur in the mother during subsequent pregnancies.

There are numerous other causes of itching and skin eruptions during pregnancy. The timing of onset, appearance, and distribution of the rash are important diagnostic signs. The dermatologist plays a key role in diagnosis and prompt treatment, which are crucial to protect the mother and her baby.

Photo of Rina AnvekarPost authored by Rina A. Anvekar, MD, a board certified dermatologist, clinical researcher, and clinical educator who practices at both The Mount Sinai Hospital and Mount Sinai Queens. Her clinical interests include acne, eczema, psoriasis, total body skin checks, and skin cancer. Her goal is to enable patients to maintain healthy skin by providing preventative counseling and cutting edge treatment options. She is committed to compassionate, community-oriented patient care and has a passion for resident education.

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What Causes Speech Delay in Children?

Pediatric otolaryngologists (ear, nose, and throat doctors) play a vital role in the evaluation and management of children with speech delay, a communication disorder characterized by late speech and language development. These specialists, working with audiologists, speech therapists, and teachers, are an important part of the team that many children with speech delay rely on to reach their potential. Aldo Londino, MD, a pediatric otolaryngologist at The Mount Sinai Hospital, explains speech delay, what parents should expect during a physician visit, and how the condition is treated.

How do I know if my child has a speech delay?

While common causes of the condition include oral-motor problems (difficulty controlling speech muscles), significant ear wax buildup, chronic ear infections, or fluid behind the ear drums, signs of speech delay are varied.

Contact your child’s physician if your child:

  • By four months is not babbling with expression and copying sounds he or she hears
  • By six months is not responding to his or her name and/or cannot string vowels together (“ah,” “eh,” “oh”)
  • By 12 months is not able to say “Mama” and “Dada” and/or is not expressing gestures, such as pointing or shaking head “no”
  • By 18 months has difficulties imitating sounds
  • By two years cannot follow simple directions or use verbal language to communicate more than immediate needs

Early detection can be critical. There are various steps both parents and doctors can take to help at-risk children.  If you need additional help deciding when to ask your pediatrician or ear, nose, and throat specialist about possible speech delay, consult the well-organized and thorough reference of milestones during childhood compiled by the U.S. Centers for Disease Control and Prevention.

Keep in mind that many children are late bloomers. Not every child with a late start will go on to have a speech delay.  Albert Einstein, for instance, was initially considered delayed because he developed speech late in childhood.

What tests are important for evaluating speech delay in children?

All children with a suspected speech delay receive a formal hearing test in the office.  Though sometimes difficult to perform in a young child, this test is a complete evaluation of how your child hears and provides valuable information about the health and function of their ears.  We always review hearing test results with the parent in the office.  Additionally, as part of the evaluation for delayed speech, we always perform a thorough physical examination of your child, focused particularly on the ears and the oral cavity.  We also evaluate the tongue for a tongue-tie and ensure that the tongue has good mobility.

What should I expect during a visit for speech delay?

Your pediatric ear, nose, and throat doctor will ask several questions about you and your child. Records from birth and from your child’s pediatrician can inform the best diagnosis and treatment.  Be prepared to answer the following questions, among many others:

  • Were there any hurdles or challenges during the pregnancy or delivery of your child?
  • A hearing test is generally done while your baby is in the nursery soon after birth. Did your child pass this screening?
  • Has your child suffered from recurrent ear infections? If so, how frequent and how severe?
  • Has your child ever had ear surgery?
  • Is there a history of hearing loss in your family? Please note younger family members with hearing aids or any possible hereditary hearing loss.
  • Does your child respond to sounds/noises/conversation in his or her environment?
  • When was the last time your child had a hearing test?
  • How is your child doing in school or day care?

How is speech delay treated?

The effective treatment of speech delay very much relies on the underlying cause. Treating recurrent ear infections, for example, can help a child hear normally, and thereby enhance their ability to interact and learn from the words and sounds in their environment. Repairing a tongue-tie can help increase the mobility of the tongue and, with practice and help, have a big impact on pronunciation.

Regardless of the underlying cause, it is important that your child has a team dedicated to helping them reach their full potential.  Pediatricians, pediatric otolaryngologists, audiologists, speech therapists, and teachers all play a critical role in helping you and your child reach your goals. As a parent, always communicate with your child.  Your positive reinforcement of their expressive habits is a valuable tool. And, most importantly, if you have concerns about your child, ask your pediatrician about consultation with a pediatric ear, nose, and throat specialist.

Photo of Aldo Londino IIIAldo Londino, MD, is a pediatric otolaryngologist at the Division of Pediatric ENT, who treats patients at Mount Sinai Doctors East 85 Street (234 East 85th Street, Fourth Floor) and 2025 Richmond Road on Staten Island. Dr. Londino specializes in the diagnosis and treatment of the full gamut of ear, nose, and throat conditions in children and adolescents, including the most complex cases.

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