Quest Diagnostics’ Cleveland HeartLab acquisition reflects personalized medicine trend

Quest Diagnostics has clicked up Cleveland Clinic spinoff Cleveland HeartLab within an equity deal and created a proper collaboration using the health system. The purchase provides the national clinical lab testing business accessibility HeartLab’s proprietary tests identifying biomarkers connected with coronary disease which go well past the traditional screening tests for cholesterol.

Quest stated inside a news release it plans to help make the Cleveland HeartLab a middle of excellence for cardiometabolic disorders.

The HeartLab’s relationship with MDVIP — a principal care network with nearly 1,000 doctors — can also be of great interest as both Quest and Cleveland HeartLab provide specialized services for primary care.

The offer may also mean more patients can get access to Cleveland HeartLab’s tests, given Quest’s relationships with insurers, a Crain’s Cleveland Business report noted. 

Quest and Cleveland Clinic will generate a steering committee from both institutions to judge biomarkers for a number of illnesses discovered through the Lerner Research Institute along with other areas of Cleveland Clinic. Quest may develop tests for many of individuals biomarkers. The institutions would collaborate on numerous studies to evaluate the value of those biomarkers, this news release stated.

Included in the personalized medicine trend, there’s been lots of curiosity about identifying biomarkers connected with cardiovascular disease to produce modern-day screening tools to aid earlier intervention, which can lead to reduced medical costs within the longterm.

An increasing body of studies suggest that cardiovascular risk might be affected by certain kinds of inflammation, genetics, endocrine and metabolic disorders, fat particle composition and intestinal microbes, based on the release.

“Despite a mountain of research showing traditional cholesterol testing can miss cardiovascular disease, many people are still at nighttime regarding their true risk,” said Mike Orville, Cleveland HeartLab Chief executive officer, stated inside a statement. “With investment and concentrate from the leader like Quest, and accessibility science of Cleveland Clinic, Cleveland HeartLab is going to be well positioned to accelerate diagnostic innovations that reveal chance of cardiovascular disease for that individual patient.”

Photo: maxsattana, Getty Images 

Automatic-Aided Surgery – Current Challenges and Future Directions: Interview with Dr. Mona Orady

Over the past decade . 5, automatic-aided surgery has brought to smaller sized scars, less discomfort, and faster recoveries for patients. Concurrently, surgeons by using this technology have taken advantage of having the ability to perform surgeries inside a much more comfortable position, whilst experiencing greater visualization that has been enhanced precision. Wonderful these benefits, automatic-aided surgeries have become more and more common worldwide, especially in the U . s . States, where greater than 67 percent famous Intuitive Surgical‘s da Vinci robots are set up. Furthermore, just yesterday we covered the Food and drug administration clearance from the Senhance surgical automatic system from TransEnterix, the very first true competitor towards the da Vinci.  (Note: The photos from the automatic system in the following paragraphs have the Senhance, and therefore are thanks to TransEnterix.)

However, just like any disruptive technology, it faces some skepticism and challenges. We at Medgadget were in the MIS WEEK in Bay Area earlier this year and sitting lower with Dr. Mona Orady, Non-invasive Gynecologic Surgeon, Director of Automatic Surgery Services, St. Francis Memorial Hospital, Dignity Health Medical Group, to speak much more about the obstacles facing automatic-aided surgery and it is future.

Medgadget, Kenan Raddawi, M.D: Prior to getting began, inform us more details on your job in automatic-aided surgery and the reason why you made the decision to enter seo.

Dr. Mona Orady: I’ve been doing automatic surgery because the finish of 2007, just 2 yrs following the Food and drug administration approved using automatic aided surgery in gynecological surgery.

I recall the very first patient I’d after i was beginning to include automatic-aided surgery into my non-invasive surgery tool package. She would be a single mom of six children, with three jobs, along with a huge uterus because of fibroids. My first question to her was why have you wait such a long time to find treatment? Why didn’t you will find the surgery earlier? She responded, “Nobody explained which i might have the surgery refrained from taking six or even more days off work. Basically take six days off work, I will lose my job after which the house, and my children is going to be in the pub.Inches That patient is among individuals who helped me be a automatic surgeon, because I saw that automatic surgery could push the boundaries of laparoscopy and non-invasive surgery to incorporate patients who otherwise will not have a non-invasive option.

In automatic surgery, you’ve elevated vision, more precision, and elevated skill. Therefore, I saw the possibility to complete more difficult surgeries utilizing a robot. In those days, I did not be aware of degree that individuals limits might be pressed, however, greater than a 1000 complex surgeries later, I’ve discovered that the majority patients, regardless of how complex, will have a non-invasive surgical option.

Medgadget: What is your opinion would be the primary obstacles and challenges facing the adoption of automatic-aided surgery?

Dr. Orady: The greatest obstacles towards the adoption of automatic-aided surgery happen to be a couple of things: first, the price, and 2nd, working out. You’re speaking to somebody who has been very associated with residency training and education. I helped get the curriculum for residents training in the Cleveland Clinic. I implemented it, and that i helped train the residents within the enter in non-invasive surgery using a mix of didactic teaching, laboratory simulation, and on the job training.

The problem with automatic-aided surgery training is the fact that there’s a real dichotomy. You do not just learn ways to use the instrument, however, you should also learn to carry out the surgery. Whenever we train during residency, and almost in any schools, everyone concentrates on manual skill and becoming to understand the tool. However, just like important, and much more important, may be the knowledge of surgery being an art. If you’re teaching someone how you can paint, you do not provide him a brush and simply tell him ways to use the paint and just what colors to dip in. You need to educate him the idea of 3D depth perception, what lies beneath the surface, the sunlight, shadows, etcetera. It’s the same manner with surgery. We ought to educate the concepts of hemostasis, dissection techniques, and the way to avoid traumatizing tissue, etc. It’s an unfortunate reality that in many Obstetrics and Gynecology residencies, there’s a lot to understand in 4 years – obstetrics, gynecology, primary care, office procedures, automatic surgery – and frequently, one thing that will get neglected is surgical techniques. Because of this , the advent and interest in Non-invasive Surgical Fellowships is growing, and the requirement for the niche to separate as numerous others did, has become more apparent.

Medgadget: What are the technical/logistic factors that restrict the performance of automatic-aided surgery?

Dr. Orady: Let’s first discuss what many people working in the area of automatic surgery usually explain as missing or restricting factors, after which, discuss things i personally want after i execute a automatic-aided surgery. Lots of surgeons explain the truth that in automatic aided surgery, it’s not necessary haptic feedback. You lose a feeling of touch. In my experience, that has not been a large issue because after you have done this most cases, it become super easy to get the capability to feel with an alternate feeling of vision, so known as “visual hepatics”, and so i don’t take into account that being an issue. The publication of the size the robot and seeking to pier it’s been improved with newer models. A few of the newer surgical robots which are being developed are smaller sized, slimmer, and outfitted with longer arms to achieve the surgery site while allowing employees to gain access to the individual within an simpler way. When it comes to energy, In my opinion all automatic companies need to pay attention to their energy application. I helped write articles about the way forward for energy, and for me, while sticking with just traditional monopolar and bipolar energy is ok. But, automatic companies really should enter into the advanced bipolar energy, I’m not speaking concerning the sealing, cutting techniques, however i am speaking about advanced impedance recognition, having a pulsed waveform, and modifying the kind and creation of energy towards the tissue reaction. We view that Intuitive Surgical had the PK energy within their Si system and required them back their new Xi system. I have faith that is really a mistake, once we should not go backwards and really should always attempt to move towards using more complex energy for the patients.

Medgadget: What’s the one factor you want you’d any time you sit lower at the da Vinci console?

Dr. Orady: Undoubtedly If only for smaller sized instruments. Eight millimeters continues to be pretty big, especially since i have perform Microlaparoscopical and Minilaparoscopical surgery. I personally use 3 millimeters instruments in traditional laparoscopic procedures. Jumping from three millimeters – almost a scarless cut – to eight millimeters cut is exactly what sometimes steers me more lower the laparoscopy route as opposed to the automatic-aided route. The 2nd factor that If only I’d is really a dedicated and trained team. A passionate automatic team is among the most significant things for efficiency inside a automatic-aided procedure. The robot differs from other traditional surgical treatments. It’s a pc-based product, there’s lots of troubleshooting happening, and you need to be capable of working through and connect error messages efficiently. Therefore, to optimize the part from the robot, you’ll need somebody that is actually savvy in modifying things perfectly and rapidly.

Medgadget: Intuitive Surgical has already established without any competitors during the last decade. Do you consider this can change in the near future?

Dr. Orady: It certainly can change. It can’t stay like this forever. The da Vinci robot has been available since 1999, so almost twenty years. New automatic companies happen to be focusing on their robots for maybe ten years or even more although, not one of them happen to be Food and drug administration approved yet however, many are extremely close. [Note: this interview was conducted before the Food and drug administration clearance of Senhance from TransEnterix] Actually, another product is presently getting used in Europe and could be Food and drug administration approved over the following couple of days to several weeks. Now you ask ,, can they get caught up? Maybe, and many likely, most likely. Intuitive Surgical hasn’t really innovated much within the last ten years. They almost stored everything exactly the same, as well as when i pointed out before, go backwards sometimes, like removing advanced bipolar energy using their new Xi system. Also, Intuitive Surgical is focusing more about moving towards single port surgery rather of concentrating on smaller sized instruments. For me, this might not always be to right direction, owing to single port surgery, you finish track of a larger, more painful cut, and research has proven that. In my opinion future automatic firms that will concentrate on smaller sized incisions, while keeping the truth and vision, are the type which will succeed later on.

Medgadget: What is the way forward for automatic surgery? Do you consider Artificial Intelligence (AI) can lead to automatic-aided surgery? Shall we be moving towards more automation during these kinds of surgeries?

Dr. Orady: In my opinion tissue is extremely dynamic. You will find a lot of variables – the effectiveness of the tissue, the feel, and just how it stretches and reacts to tension and is very variable person to person. It’s an excessive amount of data to input right now to think that AI can completely dominate. Artificial intelligence will certainly help guide to our hands and eyes when we’re performing the process using overlapped imaging or any other recognition methods.

I have faith that in very specific procedures, like placing stents or perhaps in valvuloplasty, where it’s a fairly straightforward procedure with minimal steps, we may see more automation utilizing artificial intelligence. However, when it comes to intra-abdominal pelvic surgery, the variability and dynamic variation in anatomy make these kinds of surgical treatments really complicated so that you can automate. It is not easy enough to educate human brains how to sit in variables in anatomy and also the dynamic facets of tissue reaction and also to adjust and vary technique for everybody situation because the situation progresses. Thus, outdoors of utilizing AI to assist locate anatomy or educate people how to sit in the dynamic movement from the tissue, it might be hard to depend onto it to really carry out the procedures. I’m not going to say never, however i believe the quantity of investment you need to place in will far exceed the price of purchasing training good surgeons and teaching them ways to use the information which we are able to obtain using advanced imaging and advanced energy to merely perform better, better, and fewer invasive surgery.

Also, In my opinion what’s going to happen later on in surgical treatment is consolidation. We can’t educate 100 1000 physicians to do countless procedures. I believe everyone will probably be great in a couple of things and merely repeat individuals procedures. Repetition is essential. For surgeons making them repeat exactly the same surgery again and again, they will improve. Should you perform a hysterectomy monthly versus ten per month, the advance rate is going to be exponential. It’s just like a pianist who practices a bit of music daily versus monthly.

Yes, robots will end up more automated in performing some things, like real-time imaging. But, will a surgical procedure be practiced completely by AI with no surgeon? I believe at this time we’re too much from this.

Flashback: The Possible Future of Surgical Robotics: Interview with Chief executive officer of TransEnterix… TransEnterix Will get Food and drug administration Clearance for Senhance Surgical Robot…

Guilty plea from former Cleveland Clinic Innovations professional Gary Fingerhut

Gary Fingerhut, the former executive director of Cleveland Clinic’s commercialization arm, Cleveland Clinic Innovations, pleaded guilty in a U.S. District Court now to charges he helped swindle the institution more than $2.seven million.

He’s likely to be sentenced in The month of january the coming year by U.S. District Judge Christopher Boyko. Cleveland.com noted that federal prosecutors and Fingerhut have agreed to inquire about a sentence that will probably be between 41 and 51 several weeks in federal prison, included in the plea. He may also be expected to repay the entire amount, although it’s possible he might simply be needed to repay the $469,000 he received in illegal payments, allegedly to keep quiet concerning the plan.

Charges include one count of conspiracy to commit wire fraud and honest services wire fraud and something count of creating false statements towards the FBI.

Fingerhut was fired in the Cleveland Clinic in 2015 amongst a federal analysis. He’d labored for Cleveland Clinic Innovations since 2010 as gm of information technologies before becoming executive director in 2013.

Fingerhut generate a subsidiary business called Interactive Visual Health Records, or IVHR, to make a visual medical charting concept from certain Clinic physicians, based on information reported through the attorney’s office. An individual he hired like a chief technology officer for that business referred to as “W.R.” generate a covering company referred to as iStarFZE LLC to create software for IVHR.

Recently Fingerhut offered an announcement through his lawyer J. Timothy Bender by which he expressed remorse for his actions and apologized for that “bad decisions” he’d made.

Photo: Chris Ryan, Getty Images

Groupon cofounder’s healthcare startup Tempus closes $70 million Series C round

Chicago-based Tempus, a biotechnology company that’s creating a database of clinical data and which makes it accessible, has closed a $70 million Series C round co-brought by New Enterprise Associates (NEA) and Revolution Growth.

Tempus uses the funds to develop its database and get greater scale, a business spokesperson stated.

The cash brings the startup’s total funding to $130 million.

Two-year-old Tempus was cofounded by Groupon cofounder and chairman Eric Lefkofsky. Though he never likely to dive into healthcare, things altered when his wife was identified as having cancer of the breast around three years back.

“I only agreed to be surprised about how little technology had permeated her care and that i grew to become infatuated with attempting to realise why,Inches he stated within an interview captured.

He began to go to top NCI cancer centers to higher comprehend the problems, and therefore, Tempus was created. Lefkofsky presently can serve as Chief executive officer.

The organization has stayed creating data pipelines to gather and evaluate considerable amounts of information. Stated pipelines power computer programs that really help with clinical decision support and academic research. The startup also features its own CLIA-certified lab, with a current capacity in excess of 50,000 patients yearly.

It’s collaborations with community hospitals in addition to systems like Cleveland Clinic, Mayo Clinic and College of Chicago Medicine.

“It’s been an incredible few years,Inches Lefkofsky stated. “We had wished maybe a couple of top medical facilities may wish to use us and we’ve been overwhelmed with the number of top NCI cancer centers are adopting our technology.”

Inside a statement, NEA Managing General Partner Peter Barris commented around the purchase of Tempus.

“Given NEA’s lengthy and effective history purchasing the intersection of technology and existence science, we felt such as the perfect proper partner given Tempus’ pursuit to help doctors personalize care by collecting and analyzing bulk of information,Inches he stated.

NEA has additionally committed to Groupon. Barris themself sits around the board of Groupon, along with Ted Leonsis, a founder and partner of Revolution Growth.

Photo: TAW4, Getty Images

Ex-Cleveland Clinic Innovations director Gary Fingerhut billed in $2.7M fraud against health system

The previous executive director of Cleveland Clinic’s technology transfer office, Cleveland Clinic Innovations, was billed with bilking the system out in excess of $2.seven million following an analysis through the FBI, based on a news release in the U.S. Attorney’s office for that Northern District of Ohio.

Cleveland Clinic ignored Gary Fingerhut in June 2015 following the institution was notified “by a government agency” about financial transactions involving certainly one of its spin-off companies and Fingerhut was discovered to possess violated Cleveland Clinic policy. Fingerhut had labored for Cleveland Clinic Innovations since 2010 as gm of information technologies before becoming executive director in 2013.

The attorney’s office billed Fingerhut with one count of conspiracy to commit wire fraud and honest services wire fraud and something count of creating false statements. An analysis is ongoing, based on the release.

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A Cleveland Clinic spokeswoman emailed an announcement as a result of a request for a remark around the charges against Fingerhut:

“Cleveland Clinic first discovered this problem with the Federal Bureau of Investigations (FBI). We fully cooperated using their efforts along with the U.S. Attorney’s Office in going after this trouble. We commend both offices on their own great work.”

The U.S. Attorneys Office highlighted information from court papers that brought towards the charges against Fingerhut in news reports release:

  • More than a two-year period, Fingerhut, an individual known in the court filings as W.R., yet others allegedly diverted greater than $2.seven million in the Clinic.
  • Fingerhut generate a subsidiary business called Interactive Visual Health Records to make a visual medical charting concept from certain Clinic physicians, based on information reported through the attorney’s office. He allegedly hired a person, known in the court documents as “W.R.”, to operate like a consultant after which chief technology officer at IVHR to build up the merchandise.
  • W.R. yet others allegedly generate a covering company referred to as iStarFZE LLC (ISTAR) having a website and emails along with a mailing address in New You are able to City. W.R. had ISTAR submit an offer to create and convey software for IVHR and elevated the cost the Clinic compensated for individuals services, but didn’t reveal W.R.’s financial curiosity about ISTAR, the attorney’s office alleged. Fingerhut’s and W.R.’s employment agreement avoided them from receiving any financial benefit or getting any personal or familial financial interests in companies the Clinic did business with.
  • Fingerhut allegedly recognized $469,000 from W.R. between November 2012 and August 2014 in “commission” or “referral” charges to keep quiet concerning the plan.

Fingerhut’s attorney J. Timothy Bender released an announcement Thursday on his client’s account, reported by Cleveland.com.

“I apologize for that bad decisions which i made these were wrong and i’m deeply remorseful,” Fingerhut stated through his attorney “I hurt my loved ones, my former employer and my community and that i take complete responsibility in my actions.”

Founded in 2000, Cleveland Clinic Innovations has launched greater than 40 spin-off companies, that have attracted nearly $1 billion in equity investment.

In May, Cleveland Clinic President and Chief executive officer Candice Cosgrove announced he’d retire  this year after 13 years in the helm. Tomislav Mihaljevic, Cleveland Clinic Abu Dhabi Chief executive officer, is anticipated to consider over Cosgrove’s role in 2018.

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PQ Bypass’ trial shows DETOUR system effectiveness to deal with lengthy blockages in femoropopliteal artery

Printed 13 September 2017

PQ Bypass’ DETOUR I medical trial has demonstrated safety and effectiveness from the DETOUR system in treating lengthy-segment (>25 cm) blockages within the femoropopliteal artery

The information were presented like a late breaking medical trial session today at Vascular InterVentional Advances (VIVA 17) by Dr. Sean Lyden, chairman from the department of Vascular Surgery at Cleveland Clinic.

In complex peripheral artery disease (PAD), arterial blood vessels within the leg may become blocked by lengthy segments of plaque that restrict bloodstream flow towards the calf and feet. This may lead to discomfort, lack of mobility and amputation.

Very lengthy blockages, for example individuals more than 20 centimeters, are very difficult to treat. In the past, physicians have treated these blockages with open bypass surgery, that has the advantage of durability however, it’s connected by having an elevated chance of complications, longer hospital stays and prolonged rehabilitation.

Non-invasive methods to PAD, including angioplasty and stenting, work perfectly on shorter blockages however, they haven’t yet been as effective on longer ones.

“Patients with lengthy segment femoropopliteal blockages require advanced therapeutic options to existing treatments. While endovascular revascularization works well in shorter lesions, its durability in longer segment blockages hasn’t matched those of open surgery. Fully percutaneous bypass is made to combine the sturdiness benefits of surgical bypass using the non-invasive benefits of a percutaneous procedure,” stated Dr. Lyden.

“The outcomes there has been within the DETOUR I trial indicate that the fully percutaneous bypass procedure has possibility to fill this gap in treatments.Inches

Case study of the subset from the DETOUR I study presented today at VIVA 17 is among the largest prospective series ever to judge the percutaneous management of femoropopliteal blockages with lengths of 25 cm to 45 cm (mean of 33.8 cm).

 The six-month outcomes from 50 patients shown the DETOUR System’s capability to effectively treat these lengthy blockages without significant effect on venous health insurance and reduced rates of major adverse occasions (MAEs). The outcomes incorporated:

Primary safety endpoint: 2 percent MAEs – understood to be dying, target vessel revascularization (TVR) or amputation at thirty days. There have been no deaths or amputations and something TVR.1

Primary patency of 88.9 % at six several weeks with optimal placement overall primary patency of 76.9 %

Effective delivery of devices towards the identified area and elimination of the delivery system in 100 % of lesions (53/53)

Improvement in Rutherford Class with a minimum of 2 grades in 92 percent of patients (45/49)2

Significant improvement in ankle brachial index from .64 ± .17 to .92 ± .14 (p<0.0001)

No effect on venous function no device-related deep vein thrombosis in treated vessels

Percutaneous femoropopliteal bypass (the DETOUR procedure) is really a recently developed method that utilizes PQ Bypass’ proprietary DETOUR System technologies – TORUS Stent Graft, DETOUR Crossing Tool and DETOUR Snare – to supply fully percutaneous bypass of lengthy-segment blockages within the femoropopliteal artery.

The DETOUR procedure results in a path around a lesion by putting stent grafts that mix in the superficial femoral artery (SFA) in to the femoral vein and into the artery. The brand new path with the stent grafts re-directs oxygen-wealthy bloodstream round the blockage and restores bloodstream flow towards the calf and feet from the patient.

“PQ Bypass has lengthy been dedicated to addressing the requirement for value-based, patient-centered advancements in PAD which help minimize trauma, reduce period of stay and improve recovery occasions, whilst supplying a effective and safe clinical solution of these patients who’re in need of assistance,Inches stated Richard Ferrari, PQ Bypass’ chairman from the board.

“These data demonstrate the potential for the DETOUR procedure in very lengthy SFA lesions. We expect to ongoing our path toward regulatory approval with DETOUR II, a pivotal trial that people anticipate initiating through the finish of the year.”

In March 2017, PQ Bypass received CE (Conformité Européenne) Mark approval for those three devices which are incorporated within the DETOUR System.

VIVA 17 may be the premier global, multidisciplinary course for vascular intervention and medicine, supplying excellence in professional education for those specialties and stakeholders who treat the vascular patient.

Source: Company Pr Release

Cleveland Clinic appoints new Chief executive officer

In May, Cleveland Clinic President and Chief executive officer Dr. Candice Cosgrove announced his intention to step lower.

Now, four several weeks later, the system has named his successor: Dr. Tomislav “Tom” Mihaljevic, the present Chief executive officer of Cleveland Clinic Abu Dhabi. He’ll go ahead and take helm The month of january 1, 2018.

Mihaljevic is really a cardiothoracic surgeon, meaning his specialization is comparable to those of Cosgrove, who’s a cardiac surgeon.

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But unlike his predecessor, Mihaljevic is initially from Croatia and earned his medical degree in the College of Zagreb. He gone to live in America in 1995 and became a member of the employees of Brigham and Women’s Hospital.

By 2004, he found Cleveland Clinic, where he focused on non-invasive and robotically aided cardiac surgeries.

Mihaljevic’s work continues to be rather notable. In 2005, he earned a patent for any cardioscopy system for non-invasive cardiac surgery. A couple of years back, he spoken with HeartValveSurgery.com, a web-based patient community and academic resource, about the advantages of automatic mitral valve repair.

Furthermore, he won the Cleveland Clinic Innovation Award in the year 2006 and 2007.

More lately, he offered as chief of staff and also the chairman from the Heart & Vascular Institute of Cleveland Clinic Abu Dhabi. He held that position until 2015, as he was hired Chief executive officer of Cleveland Clinic Abu Dhabi.

Based on a news release, a nomination committee unanimously recommended Mihaljevic as Cosgrove’s successor, and also the board of governors and board of company directors unanimously selected him.

Inside a statement, Mihaljevic didn’t discuss his new role, but instead on the way forward for healthcare at Cleveland Clinic:

Though healthcare is in the middle of a significant transformation, Cleveland Clinic is extremely well positioned for future years. Our ongoing success will hinge on the capability to maintain high-quality outcomes, while reducing healthcare costs, encouraging innovation and improving access and affordabilty for patients.

For Cosgrove, he’ll use Mihaljevic on the transition process before the finish of 2017. On The month of january 1, he’ll undertake an advisory role that’ll be determined by Mihaljevic and also the board of company directors.

“While I might be walking aside as president and Chief executive officer, I won’t be departing Cleveland Clinic behind,” Cosgrove stated.

It will likely be interesting to look at whether Mihaljevic will mirror Cosgrove’s style or take their own route. For instance, Cosgrove was a part of President Trump’s Proper and Policy Forum, that has been disbanded. And under his leadership, Cleveland Clinic announced its 2018 annual fundraising event won’t occur at Trump’s Marly-a-Lago club in Florida.

How will Mihaljevic lead the business? We’ll have to hang about until the coming year to discover.

Photo: cnythzl, Getty Images