Smilow Shares with Primary Care: Benign Hematology and Elevated Blood Counts

Transcript

• 00:00I'll go ahead and get
• 00:01us started. So good evening.
• 00:03This is Smilo shares with
• 00:05primary care,
• 00:07which is a monthly
• 00:09series
• 00:11with primary care here at
• 00:13Northeast Medical Group and Yale
• 00:15New Haven Health System
• 00:16and our oncology
• 00:18Yale Cancer colleagues
• 00:20at SMILO.
• 00:22We like to discuss topics
• 00:24where they may present in
• 00:26primary care. Primary care may
• 00:28have some testing to do,
• 00:30evaluation,
• 00:31have to decide on referral
• 00:33criteria,
• 00:35and get a good sense
• 00:37of what's going to happen.
• 00:40We will
• 00:42today be focusing on hematologic
• 00:45issues,
• 00:46with a special focus on
• 00:48when things are too high,
• 00:50and we'll get started there
• 00:51in just a second.
• 00:53But first, I wanna make
• 00:55sure I introduce,
• 00:57myself and,
• 00:59pass it over to, Anne
• 01:01Chang
• 01:02who is,
• 01:03in the Smilow Cancer Center
• 01:05and will introduce
• 01:07her colleagues as well.
• 01:09So, I'm Karen Brown. I'm
• 01:11the medical director of primary
• 01:12care at Northeast Medical Group
• 01:14at Yale New Haven Health
• 01:15System.
• 01:16And Frank Ciminielo
• 01:18is my colleague,
• 01:20also a primary care physician
• 01:22with a background
• 01:24of a chemistry degree at
• 01:26Georgetown University,
• 01:28working as an HIV case
• 01:30manager
• 01:31back in what we would
• 01:32call the day when there
• 01:33was,
• 01:34uncontrolled
• 01:35HIV.
• 01:36And then, went to medical
• 01:38school at NYU and did
• 01:39his residency at University of
• 01:40Pennsylvania.
• 01:42He did a clinician educator
• 01:44fellowship and was on faculty
• 01:46there for four years before
• 01:47moving to Connecticut and joining,
• 01:50PrimeMed, which is a medical
• 01:52group which is now part
• 01:53of,
• 01:54larger Northeast Medical Group.
• 01:56He's received an MBA from
• 01:57the Yale School of Management
• 01:59and is now both the
• 02:00regional medical director for the
• 02:03Bridgeport region,
• 02:04as well as the president
• 02:06of the Prime Med Physicians
• 02:07PSA.
• 02:09He's on the board of
• 02:09trustees and the CIN board
• 02:11of directors.
• 02:13And, he lives in Easton
• 02:14with his wife who's an
• 02:16OB GYN, so he always
• 02:18has extra perspective to add
• 02:20and, tells me that he's
• 02:22feeling miserable
• 02:23miserably at learning tennis in
• 02:25a world of pickleball players.
• 02:28Anne, I will pass it
• 02:29over to you to introduce,
• 02:30the rest of our speakers.
• 02:33Okay. Thank you. Frank that
• 02:34picture is a little old.
• 02:37I think that's all right.
• 02:38Doesn't do you justice.
• 02:40Thank you, Karen. This is
• 02:42such a
• 02:43pleasure to be here tonight.
• 02:44I'm a medical oncologist and
• 02:46also associate cancer center director
• 02:49for clinical initiatives. And tonight
• 02:51we have two SMILO
• 02:53colleagues of mine.
• 02:55Doctor. Kelsey Martin, who's an
• 02:57assistant professor of medicine in
• 02:59hematology.
• 03:00She received her medical degree
• 03:02from the Royal College of
• 03:03Surgeons in Dublin, Ireland and
• 03:05completed her residency
• 03:06in Internal Medicine at the
• 03:08Jacobi Medical Center, Albert Einstein
• 03:10College of Medicine in New
• 03:11York.
• 03:12She subsequently completed her subspecialty
• 03:15training in hematology
• 03:16and medical oncology at Lenox
• 03:18Hill Hospital in New York
• 03:19City,
• 03:20and has been here at
• 03:21Smilo since that time.
• 03:23It's such a joy to
• 03:24have you.
• 03:25And also,
• 03:27Doctor. Martin's clinical interests include,
• 03:30patient communication,
• 03:31hematology,
• 03:32hematologic
• 03:33disorders
• 03:34in women, cancer prevention, including
• 03:36the role of nutrition, obesity
• 03:38and the environment in cancer.
• 03:40She's actively involved in the
• 03:42Yale community as a member
• 03:43of status of women in
• 03:44medicine and the women faculty
• 03:46forum.
• 03:47And she's an highly engaged
• 03:48member of the American society
• 03:50of hematology
• 03:51as a member of the
• 03:52committee and practice and representative
• 03:54for the AMA
• 03:55House of Delegates.
• 03:57Doctor. Martin's interested in how
• 03:59sex and gender influence health
• 04:01and collaborates with the women's
• 04:03health research at Yale. So
• 04:04thank you, Kelsey.
• 04:06And then I'd like to
• 04:07also introduce Doctor. Anish Sharda
• 04:10who's an assistant
• 04:11professor of medicine in hematology.
• 04:13And he cares for patients
• 04:14as part of the SMILO
• 04:16Classic Hematology Program,
• 04:18previously known as benign hematology.
• 04:20Now we call it classic.
• 04:22His clinical and research interests
• 04:23are in bleeding, clotting and
• 04:25plateless platelet disorders. His research,
• 04:31in vascular biology is, is
• 04:33funded by the NIH.
• 04:34He received his medical degree
• 04:36from the BP Koala
• 04:38Institute of Health Scientists in,
• 04:40Dharan, Nepal and completed his
• 04:42residency at the University of
• 04:44Minnesota Medical Center,
• 04:46followed by clinical and research
• 04:47fellowship and the Hemang fellowship
• 04:50at BI Deaconess Medical Center
• 04:52and Harvard Medical School in
• 04:53Boston. So
• 04:54welcome to both of you.
• 04:58And
• 04:59I'm gonna turn it over
• 05:00to doctor oops, sorry.
• 05:02Oh, I was just gonna
• 05:03say, we're gonna turn it
• 05:04over to doctor Chimenola to
• 05:06get us started with the
• 05:07cases.
• 05:08If you have questions as
• 05:09we go, please feel free
• 05:10to enter them in the
• 05:12q and a section and
• 05:13we will, break at the
• 05:15appropriate point to answer them.
• 05:17It's it's part of what
• 05:18makes this series great is
• 05:19the ability to really answer
• 05:21questions real time throughout.
• 05:24And I see some of
• 05:25our regulars,
• 05:26and you guys are always
• 05:28very engaged. So thank you
• 05:29again. I know it's a
• 05:30busy time. Happy New Year,
• 05:32and we'll we'll get started.
• 05:33Thank you for attending.
• 05:36Yeah. Well, yeah. Yeah. Thank
• 05:37you for attending.
• 05:38Thank you for
• 05:40having me. So,
• 05:41these are two cases from
• 05:44my panel.
• 05:45The data is
• 05:47a hundred percent like just
• 05:49transferred over and you'll and
• 05:50then you'll
• 05:53you'll see where maybe I
• 05:54could have done a little
• 05:55more before referral,
• 05:57as well. So these are
• 05:58just, real cases I thought
• 06:00would make the most sense
• 06:01to to you all, the
• 06:02audience, and and, hopefully,
• 06:05you agree. So,
• 06:07we're gonna talk about two
• 06:08cases where the blood counts
• 06:09are high. Right? We think
• 06:10about referring for a lot
• 06:12of lows, a lot of
• 06:13penis, but there's a lot
• 06:14of elevated
• 06:16and abnormal blood counts, when
• 06:18you start, looking. And there's
• 06:20a substantial amount of prework,
• 06:22that can be done prior
• 06:23to referral,
• 06:24which may actually eliminate the
• 06:26need for a referral,
• 06:28in some cases, but also
• 06:29sort of identify people who
• 06:30need more urgent referrals,
• 06:32as well. And so we'll
• 06:33go through, these cases. If
• 06:35I get the next slide,
• 06:36please. So the first case
• 06:38was, is a gentleman
• 06:40who, about eight years ago,
• 06:42we saw,
• 06:44for fatigue
• 06:46and
• 06:47not a significant medical problem.
• 06:50History, just really high blood
• 06:51pressure was his only active
• 06:52problem. He was at the
• 06:54time on lisinopril and hydrochlorothiazide,
• 06:57married, no real, significant social
• 06:59history,
• 07:00works as a social worker
• 07:02and,
• 07:03licensed clinical social worker.
• 07:06BMI was was
• 07:07technically over, overweight, but but
• 07:09but pretty good.
• 07:11And you can see his
• 07:12family history, which did sort
• 07:13of,
• 07:14include some
• 07:16some potential hematolite,
• 07:18heme or hemonc,
• 07:20diseases. So he came in
• 07:22for fatigue.
• 07:23We ran simple perfect. We
• 07:24ran some blood work and
• 07:25found that, initially his hemoglobin
• 07:27was,
• 07:28elevated,
• 07:30slightly. The rest of his
• 07:31CBC was, generally unremarkable.
• 07:35We actually stopped his hydrochlorothiazide,
• 07:38and, rechecked, but the CBC
• 07:41was relatively unchanged. The hemoglobin
• 07:43had stayed in the seventeen
• 07:45to seventeen point five range.
• 07:47So
• 07:48mildly elevated. And other than
• 07:50the fatigue, really no other
• 07:52symptoms.
• 07:53We, we started the workup,
• 07:54which showed the normal iron
• 07:56studies,
• 07:58that you saw before.
• 07:59And, and then sort of
• 08:01kind of what and we
• 08:02were at and those were
• 08:03unrevealing.
• 08:04And then sort of the
• 08:05plan was sort of, you
• 08:06know, what, what next? And
• 08:08so,
• 08:09before we go back to,
• 08:10to him, just sort of
• 08:11a little bit of a,
• 08:13a reintroduction
• 08:15to people on the care
• 08:16signature pathways.
• 08:18And you can see that
• 08:19in the last
• 08:20few months, they've really,
• 08:23increased
• 08:24especially in some of the
• 08:26basic hematologic
• 08:27diseases. And you can you
• 08:28can see some some here.
• 08:32As most of you know,
• 08:33the the care signature pathways
• 08:36are pathways that are designed
• 08:37by,
• 08:38of a group of our
• 08:40local,
• 08:41clinicians and experts,
• 08:43to provide sort of best
• 08:44practices for a certain condition,
• 08:46a certain, problem. We probably
• 08:48all know it started or
• 08:50or, really gained some some
• 08:52fame with the COVID.
• 08:55But now is,
• 08:58the number,
• 09:00and then the depth of
• 09:01some of the information you
• 09:02get from there is, is
• 09:04incredible. And, and it's a
• 09:05live,
• 09:07a live document, so to
• 09:08speak, where it it's continuing
• 09:10to change.
• 09:12And so
• 09:14just, so these are some
• 09:15of the new ones,
• 09:17or some of them, including
• 09:18some that are really relatively
• 09:21brand new. Another reason we
• 09:22pick some of these cases
• 09:23was to highlight some of
• 09:24the new care signature pathways.
• 09:27If I can get to
• 09:28the next slide, please. So,
• 09:30as you can see here,
• 09:32there's a pretty substantial care
• 09:34signature pathway,
• 09:35for an elevated,
• 09:37hemoglobin.
• 09:38Should have mentioned
• 09:40in in the history part
• 09:41that his pulse ox had
• 09:43been consistently
• 09:45normal.
• 09:46We saw, I'm on the
• 09:48right side actually now some
• 09:49of the basic stuff. You
• 09:50know, he wasn't on testosterone,
• 09:53as well. But if you
• 09:55start looking and you can
• 09:56see some of the things
• 09:57that we had done now
• 09:58this was twenty in my
• 09:59defense, it was twenty fifteen,
• 10:01so there wasn't a cancerous
• 10:02pathway, but there was an
• 10:03up to date. So we
• 10:04did some of the workup.
• 10:05As you can see, there's
• 10:06probably a little bit more
• 10:07that we should have done.
• 10:08He certainly didn't need an
• 10:09urgent referral,
• 10:12but the care synergy pathway
• 10:14really does sort of,
• 10:16I find to be incredibly
• 10:17helpful,
• 10:18for some, for a lot
• 10:19of the hematologic
• 10:21diseases
• 10:22in particular.
• 10:25I'm I'm gonna, we'll go
• 10:27to the next
• 10:28slide,
• 10:30and, I'm gonna pass this,
• 10:33forward,
• 10:35but, I'm gonna stick around
• 10:36if there's any questions from,
• 10:39for me.
• 10:42Great.
• 10:43Thank you, Frank. So,
• 10:45I'm gonna go through,
• 10:47initially, some definitions
• 10:49of erythrocytosis,
• 10:50just because I actually think
• 10:51that's where the referral starts.
• 10:53Sometimes different labs might have
• 10:55different normal ranges,
• 10:57which could flag something as
• 10:59potentially being high when maybe
• 11:00we don't consider it as
• 11:02such.
• 11:03But,
• 11:04there are sex differences,
• 11:06in how we define arthrocytosis
• 11:08and for sixteen point five
• 11:10grams per deciliter for males
• 11:11and sixteen grams per deciliter
• 11:13for females with the corresponding
• 11:14hematocrit, in parentheses following that.
• 11:17The main our main goal,
• 11:19for these cases is trying
• 11:20to distinguish primary arthrocytosis,
• 11:23which is really an autonomous
• 11:25production. And and for the
• 11:27sake of this discussion, that
• 11:28that really means, polycythemia
• 11:30vera, which is a a
• 11:31malignant disorder.
• 11:33Everything else which is more
• 11:34common would fall into secondary
• 11:36erythrocytosis.
• 11:37And these are,
• 11:38situations in which it's it's
• 11:40not autonomous or rather an
• 11:41external factor, which is leading
• 11:43to the booster red cell
• 11:44red blood cell production. And
• 11:46mainly, this is driven by,
• 11:48erythropoietin
• 11:49or EPO, and this can
• 11:50happen for a variety of
• 11:51reasons.
• 11:53Both of these can be
• 11:55classified in another way, either
• 11:57congenital or acquired. But in
• 11:58our adult,
• 12:01primary care practices, we're mostly
• 12:03gonna be discussing acquired
• 12:05causes.
• 12:07I'll just briefly mention,
• 12:09the idea of relative erythrocytosis,
• 12:11which I think is what,
• 12:14doctor Chimneyel was, like, discussing
• 12:16in his case,
• 12:18where they
• 12:19discontinued the,
• 12:21hydrochlorothiazide.
• 12:26The,
• 12:28you know, most of the
• 12:29time, when we're thinking about
• 12:30a relative of retrocytosis, right,
• 12:32where the there's
• 12:34a change in the plasma
• 12:35volume creating this,
• 12:37increase,
• 12:38or apparent increase,
• 12:40in the hemoglobin or hematocrit.
• 12:42We might often be talking
• 12:43about something transient such as
• 12:45diuretics,
• 12:47or
• 12:47GI losses through, you know,
• 12:49either vomiting or diarrhea, but
• 12:50I just did wanna make
• 12:51a brief mention that there
• 12:52is a,
• 12:54condition,
• 12:55called case box polycythemia, which
• 12:57can really be thought of
• 12:57as almost a chronic form
• 12:59of of relative polycythemia.
• 13:01We we might tend to
• 13:01see that in,
• 13:03males with hypertension
• 13:04who are obese. So sometimes,
• 13:07I personally find it's almost
• 13:09like a diagnosis exclusion, but
• 13:11something that we do keep
• 13:11in in mind. Go to
• 13:13the next slide.
• 13:16So, you know, one brief
• 13:17slide here on polycythemia
• 13:18vera because I think that's
• 13:19often,
• 13:21as a malignant condition, something,
• 13:22of course, we don't wanna
• 13:24miss.
• 13:25And this is a,
• 13:27cancer, a myeloproliferative
• 13:29neoplasm that's really characterized by
• 13:30an increase in erythrocyte mass.
• 13:32Patients often have thrombotic,
• 13:34but sometimes bleeding complications and
• 13:36can have vasomotor
• 13:38symptoms.
• 13:40For simplicity's sake for this
• 13:42discussion,
• 13:43essentially, all patients with polycythemia
• 13:46there will have a JAK
• 13:47two mutation. So
• 13:49most of those are this
• 13:50JAK two v six one
• 13:51seven f mutation, and then
• 13:53a smaller percentage
• 13:54are kinda what we call
• 13:55other other JAK mutations.
• 13:57And so if somebody is
• 13:59has a JAK mutation
• 14:01negative,
• 14:02it's extremely unlikely that they
• 14:04would have polycythemia
• 14:05vera.
• 14:09So this is a,
• 14:10one proposed
• 14:12approach, but,
• 14:15you know, starting at the
• 14:16top left, again, that has
• 14:17just our definitions. This is,
• 14:19taken from a,
• 14:21European journal, so you can
• 14:22notice the change in decimal
• 14:23places. But,
• 14:25you know, following the definitions
• 14:26we outlined earlier for erythrocytosis,
• 14:28again, first excluding that relative,
• 14:31erythrocytosis,
• 14:32which is really things like
• 14:33dehydration,
• 14:35you know, then we get
• 14:36to this next main fork
• 14:37in the road. And of
• 14:38the next kind of very
• 14:40useful test that can be
• 14:41done is the erythropoietin level.
• 14:44And whether that turns out
• 14:46to be high, low, or
• 14:47normal, that helps,
• 14:49bring us into the next,
• 14:52most likely,
• 14:54leading us down the diagnostic
• 14:55pathway. And so if the
• 14:56erythropoietin level is high, we're
• 14:58really looking at these secondary
• 15:00acquired causes. So not polycythemia
• 15:03vera, not the can not
• 15:04a cancerous condition, but something
• 15:05else driving EPO levels to
• 15:07be high.
• 15:08And often the main the
• 15:09main,
• 15:10reasons here are hypoxia and
• 15:12medical conditions that cause such
• 15:14and medications.
• 15:15We're rarely gonna see congenital,
• 15:18associated causes in practice.
• 15:20If the,
• 15:22erythropoietin level is low or
• 15:23very low, then that's where
• 15:25we often will next check
• 15:26the JAK two,
• 15:28mutation testing. Again, if it's
• 15:29positive, that confirms that someone
• 15:31has polycythemia
• 15:32vera.
• 15:33If it's negative, we we,
• 15:36we'll we'll look for those
• 15:38other JAK mutations.
• 15:40And,
• 15:41again, if these are all
• 15:42negative,
• 15:43it makes it very unlikely
• 15:45the patient has polycythemia vera.
• 15:47Okay. Next slide.
• 15:49Okay. So, again, our in
• 15:50terms of our diagnostic approach,
• 15:52the first most important, lab
• 15:54to check would be an
• 15:54erythropoietin
• 15:55level.
• 15:57And, again, if it's low,
• 15:58that really points us in
• 15:59the direction of placentia vera.
• 16:01And if it's normal or
• 16:02elevated, then we're going down
• 16:03the more common
• 16:05likelihood of secondary etiologies.
• 16:09So this is just a
• 16:10list of diseases that as
• 16:12primary care,
• 16:14providers,
• 16:15you might commonly see in
• 16:17your practice,
• 16:19that can
• 16:20that can, again, have a
• 16:22erythrocytosis
• 16:23and with either a normal
• 16:24or increased erythropoietin
• 16:25level.
• 16:28So cardiopulmonary
• 16:29disease and obstructive sleep apnea,
• 16:31I think, are are quite
• 16:32common in our patient population,
• 16:35given that we don't live
• 16:36in a high altitude.
• 16:38Cigarette smoking,
• 16:40often, I think,
• 16:42we might see either separate
• 16:44but often together with cardiopulmonary
• 16:46diseases.
• 16:47And then I just wanted
• 16:48to bring attention to carbon
• 16:50monoxide poisoning as, of course,
• 16:51something we wouldn't wanna miss,
• 16:52and that can be identified
• 16:53on lab work. And then
• 16:55also a list of,
• 16:56medications here,
• 17:00Pointing out that SGLT
• 17:02SGLT
• 17:03two,
• 17:04inhibitors,
• 17:05the drugs that end in
• 17:06neflozins,
• 17:07we're seeing an increased number
• 17:09of these prescribed as,
• 17:12in our patient population, and
• 17:13we do see erythrocytosis from
• 17:15these. So just keep that
• 17:16in mind, kind of doing
• 17:17a quick medication check when
• 17:18you
• 17:19notice a higher hemoglobin in
• 17:21your with your patients.
• 17:23In addition to things like
• 17:24testosterone,
• 17:25I'd say that's
• 17:27also
• 17:28often prevalent in our patient
• 17:29population.
• 17:31I personally don't see that
• 17:33many patients,
• 17:35using,
• 17:37you know, EPO doping, but,
• 17:38of course, it it, I
• 17:39think, intuitively makes sense to
• 17:41think about that.
• 17:44If we talked about the
• 17:45relative,
• 17:46erythrocytosis,
• 17:47and then if we see
• 17:48a high EPO,
• 17:49level,
• 17:51tumors, both malignant and benign,
• 17:53including, like, uterine fibroids, which
• 17:55is something I've seen in
• 17:56practice, can actually sudd secrete
• 17:58EPO.
• 18:01And then also renal conditions,
• 18:03so renal artery stenosis, renal
• 18:05cysts, and,
• 18:07and patients who have also
• 18:08had a, kidney transplant as
• 18:10well.
• 18:13So in terms of other
• 18:14labs to to check, in
• 18:15addition to those,
• 18:17iron studies, a lot of
• 18:18our patients with polycythemia
• 18:20vera will have kinda low
• 18:21iron at baseline,
• 18:24which was checked in your
• 18:25case.
• 18:26And, also, a blood smear,
• 18:28is useful,
• 18:30really to look for some
• 18:31of those kind of more
• 18:32ominous markers,
• 18:34sort of,
• 18:35blasts, which could be seen.
• 18:37It could highlight a potential
• 18:38malignant condition
• 18:40or
• 18:41what we call leukoerythroblastosis,
• 18:43just sort of these younger
• 18:45precursor cells, so nucleated red
• 18:46blood cells, for example.
• 18:49Again, just, this was, I
• 18:50guess, kinda outlined on the
• 18:51prior slide, but just in
• 18:52a different format.
• 18:55I think some of these
• 18:56are relatively common conditions in
• 18:58the primary care population.
• 19:01Just as you,
• 19:03after you've checked in erythropoietin
• 19:05and you see that it's
• 19:06either normal or high, and
• 19:08kinda try to go through
• 19:09this list of different possibility.
• 19:15And, again, we just wanted
• 19:17to highlight,
• 19:18particularly this last bullet point
• 19:19here as we're seeing more
• 19:20of these prescribed in practice.
• 19:25When we're taking a history,
• 19:28you know, I think,
• 19:29it largely is going to,
• 19:32the medication list, obviously, we
• 19:34might have in front of
• 19:34us. We're we're gonna take
• 19:35a smoking history, of course.
• 19:37You know, do you have
• 19:38a carbon monoxide monitor in
• 19:39your home? And symptoms of,
• 19:41I think, sleep apnea are
• 19:42are quite,
• 19:43useful.
• 19:46And on our physical exam,
• 19:48you know, hypertension,
• 19:50plethora,
• 19:51signs of,
• 19:52scratching, itching from pruritus patients
• 19:54might experience.
• 19:56Certainly, if someone has splenomegaly,
• 19:58I think we're really gonna
• 19:59wanna
• 19:59wanna make sure we're ruling
• 20:01out any malignant etiology.
• 20:03So these are helpful things
• 20:04to look for.
• 20:08So who should be referred
• 20:09to hematology? So I I
• 20:10would say my my my
• 20:12recommendations would be anybody who
• 20:13has a low erythropoietin level,
• 20:17someone who has really long
• 20:19standing erythrocytosis
• 20:21or a clear family history
• 20:22patient's younger because while they're
• 20:24quite rare, there are,
• 20:26we do have a handful
• 20:27of patients with hereditary forms
• 20:29of erythrocytosis,
• 20:32certainly somebody who has a
• 20:33JAK2 mutation.
• 20:35And then I think that
• 20:36there are patients who,
• 20:39we might feel have symptoms
• 20:41related to erythrocytosis,
• 20:42which can be challenging to
• 20:44to
• 20:45manage.
• 20:46So
• 20:46headaches, for example, I'd say
• 20:48would be a very common
• 20:49symptom,
• 20:51kind of mental fogginess,
• 20:55would probably be a second
• 20:56thing I would think about.
• 20:58And so, certainly,
• 20:59if there's concerns that symptoms
• 21:01patients have are related to
• 21:02erythrocytosis, I think we should
• 21:03see those patients, in my
• 21:04opinion.
• 21:07I have one brief thing
• 21:09on how we manage polycythemia
• 21:10vera only because it often
• 21:13in the past, how we
• 21:14manage polycythemia vera sort of
• 21:16trickled into how one
• 21:19Sometimes we might think we
• 21:20should manage other causes of
• 21:22arthrocytosis.
• 21:23But very briefly, these patients
• 21:24get,
• 21:25have phlebotomy to reduce their
• 21:27hematocrit often to a level
• 21:28of less than forty five.
• 21:30Most of these patients are
• 21:31on aspirin, and sometimes they,
• 21:33receive,
• 21:34like,
• 21:36phytoreductive pills like hydroxyurea
• 21:40or others.
• 21:42So, but for secondary erythrocytosis,
• 21:46we we really should not
• 21:47be doing phlebotomy. It's really
• 21:49the, like, take home point
• 21:50of this.
• 21:51And the treatment is really
• 21:53directed at the underlying cause
• 21:55if we think it's even
• 21:56necessary,
• 21:59You know, especially when it
• 22:00comes to hypoxic pulmonary disease,
• 22:03right, we might see this
• 22:04in more advanced forms of
• 22:05COPD or OSA, and
• 22:07prognostic significance is not exactly
• 22:09clear. There's sort of mixed
• 22:11data in this space.
• 22:13And there's really no clear
• 22:14evidence that phlebotomy is necessary,
• 22:17or even effective at reducing
• 22:19thrombotic risk and could actually
• 22:20increase thrombotic risk.
• 22:24And, certainly,
• 22:25to try to assess someone's
• 22:27thrombotic risk, you know, we
• 22:28need to think about other
• 22:29other risk other risk factors
• 22:31patients might have.
• 22:33We do know that when
• 22:34patients with OSA are on
• 22:36CPAP, it can reduce their
• 22:37withrocytosis.
• 22:39But, otherwise, in terms
• 22:41of directed management to lower,
• 22:43the erythrocyt count, its data
• 22:45is less clear.
• 22:48One brief slide on testosterone
• 22:49because I we see a
• 22:50lot of these patients as
• 22:51referrals.
• 22:53We know testosterone can cause
• 22:55arthrocytosis,
• 22:57for a few reasons, but
• 22:58probably initially due to a
• 22:59rise in arthropoietin levels.
• 23:04Often, patients have been referred
• 23:06to sort of decide if
• 23:08they should if they would
• 23:09benefit from phlebotomy, and,
• 23:12there's not really a clear
• 23:14data to say we should
• 23:15do that, and it may
• 23:16actually make things worse.
• 23:21So going back to the
• 23:22our case,
• 23:24I think that,
• 23:26you know, we the JAK
• 23:27two mutation was negative from
• 23:29what I recall, so we're
• 23:30now kinda going down this
• 23:31path of what we call
• 23:32secondary causes.
• 23:35For this patient, I would
• 23:36say it's really crucial to
• 23:37rule out medication related causes.
• 23:39Certainly check for carbon dioxide
• 23:41poisoning. And I think checking
• 23:42the erythropoietin
• 23:43level,
• 23:44will help kinda guide us
• 23:45on next steps.
• 23:49Commonly, we might have a
• 23:50patient who has signs or
• 23:52symptoms suggestive of sleep apnea
• 23:53and a referral to pulmonary
• 23:54or sleep medicine sometimes can
• 23:56be useful.
• 23:58And I do not think
• 23:59there's any role for therapeutic
• 24:00phlebotomy in this type of
• 24:02case.
• 24:06Great. Thanks. Before we do
• 24:07case two, since this was
• 24:08eight years ago, I can
• 24:09give you, like, the the
• 24:10final. So he did have
• 24:12a an epogen level before
• 24:14seeing hematology. It was negative.
• 24:17And then,
• 24:19he saw, Doctor. Persico,
• 24:21who did do the,
• 24:23the carboxyhemoglobin
• 24:25study that was normal.
• 24:27And he did the CalR
• 24:28exon analysis
• 24:30as well, which was negative.
• 24:32The workup eventually found that
• 24:34he had some, you know,
• 24:35mild to moderate sleep apnea,
• 24:37and he's been on,
• 24:39CPAP,
• 24:40since. And his,
• 24:42hemoglobin has been generally,
• 24:44staying in, like, the sixteen
• 24:45range. So, upper normal and
• 24:47remained off because he didn't,
• 24:49you know, we switched his
• 24:50blood pressure around blood pressure
• 24:52medicines around off the hydrochlorothiazide.
• 24:54So,
• 24:54and he may still have
• 24:55a little bit of fatigue,
• 24:56but, who who does?
• 24:59So, thank you. The the
• 25:00second case is,
• 25:02this one, is actually sort
• 25:04of in the workup,
• 25:06now. It's a,
• 25:08seventy four year old woman.
• 25:09So recently
• 25:11just for a routine follow-up.
• 25:13She has, some chronic medical
• 25:15problems including obesity,
• 25:17AFib, hypertension, hyperlipidemia,
• 25:20remote history of adrenal insufficiency.
• 25:23You can see her medications.
• 25:24Most of them are old.
• 25:25The Gemteza,
• 25:27is, you know, maybe more
• 25:28new.
• 25:30She,
• 25:31was a former smoker, a
• 25:33fair amount, as you can
• 25:34see, ten to fifteen,
• 25:36pack year.
• 25:37And her family history also
• 25:38interestingly enough has
• 25:40a possible,
• 25:41hematologic,
• 25:43positive finding with the,
• 25:45what she says is her,
• 25:47her,
• 25:51father had, you know, elevated
• 25:53blood counts,
• 25:54but didn't necessarily do
• 25:57she didn't know the diagnosis
• 25:59per se. So,
• 26:00so this is her.
• 26:03We did some, some blood
• 26:05work and, you can see
• 26:06her white count upper normal,
• 26:08hemoglobin
• 26:09normal,
• 26:10and platelets were elevated,
• 26:12repeated
• 26:13and were,
• 26:15pretty similar in the four
• 26:17fifty to five twenty five
• 26:19range.
• 26:20No evidence of kidney disease,
• 26:23liver disease,
• 26:24did do an
• 26:26ultrasound,
• 26:27as part of the workup
• 26:28as well, which showed evidence
• 26:29of fatty liver, not surprising
• 26:30given her her medical history,
• 26:33and, no evidence of any,
• 26:35splenomegaly
• 26:36or,
• 26:37or any,
• 26:39any abnormalities in the spleen.
• 26:43So,
• 26:44this one's on ongoing.
• 26:46So she,
• 26:48were next to order the,
• 26:50blood smear, but thought, unlike
• 26:52the other case, we can
• 26:52do sort of a a
• 26:54a fresh case.
• 26:55And you can see again,
• 26:58a a care signature pathway,
• 27:00showing no,
• 27:01real
• 27:02alarm symptoms,
• 27:04which is good, but a
• 27:05peripheral,
• 27:06blood smear that sort of,
• 27:08you know, ordered not done.
• 27:09So you can see on
• 27:09the bottom, you know, some
• 27:11more worrisome,
• 27:13findings,
• 27:14that we haven't gotten to.
• 27:15Hopefully, won't get to, but
• 27:17haven't ruled out yet.
• 27:21So I'll pass,
• 27:22this,
• 27:23onto our expert and
• 27:26and, obviously, I'm around for
• 27:28questions.
• 27:32Thank you.
• 27:34So I think unlike
• 27:36erythrocytosis or polycythemia,
• 27:39the workup of thrombocytosis
• 27:41is and I misspelled it
• 27:43here,
• 27:46the expert. But,
• 27:49it's it's
• 27:51I think clinically in both
• 27:53the laboratory evaluation and,
• 27:55you know, different causes, it's
• 27:57just a lot more
• 27:58simple or simpler,
• 28:00and
• 28:01perhaps reflects
• 28:02the physiology
• 28:05because you know the platelet
• 28:06production and its regulation is
• 28:07so much
• 28:08simpler
• 28:10than red cells, you know
• 28:11there's no kidney involved, there's
• 28:13no liver involved, and you
• 28:14know there isn't
• 28:15a you know feedback mechanism
• 28:17that's
• 28:18related to kind of oxygen
• 28:21levels or hypoxia or hyperoxia.
• 28:23And,
• 28:24so thrombocytosis
• 28:25is, especially
• 28:29isolated thrombocytosis,
• 28:30and and this is what
• 28:31our our our
• 28:33patient here has is,
• 28:35is mostly
• 28:37incidental.
• 28:38And,
• 28:41with that, what I mean
• 28:42is, you know, most of
• 28:43the time,
• 28:44patients are not very symptomatic,
• 28:46and these are picked up,
• 28:48either, you know, routine labs.
• 28:50They they could be peri
• 28:51up. They could be just
• 28:52their handles, physicals,
• 28:54or otherwise.
• 28:56And and
• 28:57and to sum it up,
• 28:59most of the times when
• 29:00we're
• 29:02when when we're dealing with,
• 29:03with thrombocytosis
• 29:05or
• 29:06especially a persistent, you know,
• 29:08thrombocytosis
• 29:08or elevated platelet counts, we
• 29:10we wanna
• 29:12perhaps,
• 29:13you know, figure out whether
• 29:14it's reactive or or, essential.
• 29:18Next slide, please.
• 29:22So when I'm,
• 29:24seeing
• 29:26a referral,
• 29:28of course, you know, I
• 29:29go through history and,
• 29:31and and and that and
• 29:33just trying to see whether
• 29:34there are any symptoms, which,
• 29:36most of these patients typically
• 29:37don't.
• 29:38I I I feel
• 29:40patients with polycythemia
• 29:41or, other myeloprolifer neoplasms typically,
• 29:45tend tend to have,
• 29:46some more symptoms especially on,
• 29:48you know, when we get
• 29:49down to more direct questions.
• 29:52But
• 29:53but but you know thrombocytosis
• 29:55can also produce some vasomotor
• 29:57symptoms and I've certainly had
• 29:59people with with migraines or
• 30:02with other
• 30:03vasomotor symptoms that get better
• 30:04with with treatment especially with
• 30:06essential
• 30:07thrombocytosis.
• 30:10But in history, other than
• 30:11that, I'm I'm just trying
• 30:12to, figure out,
• 30:15you know, whether the the
• 30:16person is asplenic,
• 30:18and and and happens less
• 30:19so, but but certainly, you
• 30:21know, we we see people
• 30:23from, you know,
• 30:24from,
• 30:26time to time getting,
• 30:29either traumatic or, you know,
• 30:30other,
• 30:31re for for other reasons,
• 30:33getting splenectomy or and and
• 30:34our ACE clinic on that,
• 30:36and that will always,
• 30:38you know, cause kind of
• 30:40mild to moderate thrombocytosis.
• 30:42And then the trend is,
• 30:44really important because, you know,
• 30:47if if it's
• 30:49really,
• 30:52you know, you look back
• 30:52and,
• 30:54someone
• 30:55lives lives around hundred, hundred
• 30:56and fifty or, you know,
• 30:57two hundred and,
• 30:59and, you know, and slowly,
• 31:00the numbers have been creeping
• 31:02up, and they've just recently
• 31:03have come up to maybe
• 31:04four fifty or five hundred
• 31:06range. You know, it kind
• 31:07of gives a sort of
• 31:08sense that maybe this is
• 31:10an essential thrombocytosis
• 31:11and usually takes years to
• 31:13kind of, double,
• 31:16or, you know, the doubling
• 31:17time is typically very, very
• 31:18slow. The trend is important.
• 31:21And then if I see
• 31:21some there's someone who perhaps
• 31:23goes up to six hundred,
• 31:24seven hundred and then goes
• 31:25back to normal and then,
• 31:26you know, goes back again,
• 31:28I,
• 31:29I,
• 31:30typically, like, you know,
• 31:32after finishing the workup,
• 31:34you know,
• 31:35realize that, you know, these
• 31:36are mostly kind of reactive,
• 31:39thrombocytosis.
• 31:41And
• 31:42and then, you know, with
• 31:43recent history of, you know,
• 31:45surgery, sometimes, like, you know,
• 31:47patients can have very extensive
• 31:48surgery, especially orthopedic surgery is
• 31:50very well described,
• 31:53hip surgery for example hip
• 31:54fracture surgery you know patients
• 31:55can have
• 31:56first thrombocytopenia and then you
• 31:58know reactive thrombocytosis that can
• 32:00last for months,
• 32:02and and the same is
• 32:03with chronic infections it could
• 32:04be also myelitis or you
• 32:05know other chronic infections
• 32:07Even acute infection, viral infection,
• 32:09you would see only, you
• 32:10know, ITP or, you know,
• 32:12thrombocytopenia
• 32:13kind of syndrome, but a
• 32:14thrombocytosis
• 32:15that could last for weeks,
• 32:16weeks to months and and
• 32:17then other, chronic inflammatory states,
• 32:20especially rheumatologic diseases. But but
• 32:22even
• 32:24milder,
• 32:26general sort of
• 32:27or, you know, in in
• 32:29inflammatory
• 32:29kind of conditions, even diabetes
• 32:31or,
• 32:32or a poorly controlled diabetes
• 32:34or or others.
• 32:36And then, some medications as
• 32:37well. I mean, I've certainly
• 32:39seen,
• 32:40patients getting steroids.
• 32:43The last one I saw
• 32:44was, you know,
• 32:45a person getting,
• 32:47you know, I think
• 32:48epidurals and and every time,
• 32:50you know, it go up
• 32:51and then come down. And
• 32:52then six months later, you
• 32:53know, it'll go up and
• 32:54come down. So, definitely, you
• 32:55know, steroids can do that.
• 32:57Stimulants also I've seen,
• 32:59especially with methylphenidate.
• 33:02It's not being reported, but,
• 33:03you know, I think I've
• 33:05seen a bunch of patients
• 33:06who really go on it.
• 33:07The patients go high,
• 33:09and then, you know, and
• 33:10then they're off of it
• 33:11and and it comes down.
• 33:12So,
• 33:13and then,
• 33:15and then there are other,
• 33:16you know, chemotherapeutic agents. And
• 33:17gemcitabine is a big one
• 33:18where, you know, you could
• 33:19have really extreme thrombocytosis,
• 33:21but those those would be
• 33:23rare.
• 33:25And then, then coming to
• 33:26the laboratory workup and so,
• 33:27you know,
• 33:29you know, they've had at
• 33:31least a few CBC, but,
• 33:32you know, that's what, we
• 33:34end up getting in smear.
• 33:35And smear becomes very important
• 33:37because,
• 33:40many times,
• 33:41you know, thrombocytosis
• 33:43also causes,
• 33:45how do I put this,
• 33:47some degree of pseudothrombocytopenia.
• 33:51And what I mean by
• 33:52that is, like, you know,
• 33:53you'd see a platelet count
• 33:54of five hundred or six
• 33:55hundred reported platelet count of
• 33:56five, six hundred, and then
• 33:57you look under the smear
• 33:58and there are many, many,
• 33:58many clumps. And so especially
• 34:00with the central thrombocytosis. And
• 34:02so
• 34:03so the, you know, the
• 34:03platelet count the actual platelet
• 34:05count is is way much
• 34:07higher. And,
• 34:09and I
• 34:10sort of, like,
• 34:11you know, see that a
• 34:12lot more with with,
• 34:14with, inflammatory,
• 34:17states.
• 34:18But, anyway, smear is pretty
• 34:19useful,
• 34:20especially you're also looking for
• 34:22other atypical, you know, cells
• 34:23or, you know, sometimes they're
• 34:24not reported or they're within
• 34:26the normal range and and,
• 34:28and you appreciate, you know,
• 34:29they maybe,
• 34:31or question this poise or
• 34:32or,
• 34:33so smear becomes very important.
• 34:34And then and then ferritin,
• 34:36and with with that, what
• 34:37I mean is iron iron
• 34:38studies, I personally just, you
• 34:40know, get ferritin, and that's
• 34:42my iron panel. But,
• 34:44but, you know, in in
• 34:46outpatients,
• 34:47the most common cause of,
• 34:49of thrombocytosis
• 34:50is is,
• 34:51is iron deficiency and, you
• 34:53know, now the the biology
• 34:54and the mechanism behind it
• 34:56is also,
• 34:57very well known.
• 34:59In fact, you can kind
• 35:00of divide the humanity into
• 35:01two, those who would, you
• 35:02know, really have thrombocytosis
• 35:04and those who wouldn't with
• 35:05iron deficiency. And so, so
• 35:06this is, you know, you
• 35:07know, perhaps the most common,
• 35:09cause
• 35:10with, iron deficiency being,
• 35:12for for thrombocytosis.
• 35:13And then once, you know,
• 35:15you've really,
• 35:17really ruled out all of
• 35:19this, which is, you know,
• 35:20normal inflammation, infection, surgery even,
• 35:23you know, three months ago.
• 35:25They're up to date with
• 35:26cancer screening and and everything.
• 35:28And,
• 35:29then, you know, the the
• 35:31likelihood
• 35:32of a persistent
• 35:33thrombocytosis
• 35:37being
• 35:37essential thrombocytosis
• 35:39or thrombocythemia,
• 35:42is, you
• 35:43know, is more.
• 35:45So,
• 35:46and and then, you know,
• 35:47that's really,
• 35:49really,
• 35:50diagnosed
• 35:51by,
• 35:52by mutation testing. So fifty
• 35:54percent of them those will
• 35:55have JAK two v six
• 35:56one seven f mutation,
• 35:58and then about, you know,
• 35:59thirty percent will have CALR.
• 36:01And then, you know, five
• 36:01to ten percent will have
• 36:03the MIPL or MPL mutation.
• 36:05So, you know, that makes
• 36:05it eighty, eighty five percent,
• 36:07and the remaining,
• 36:08would, you know, require a
• 36:09bone or biopsy,
• 36:10for diagnosis.
• 36:12And and, you know, and
• 36:13these days, we are we
• 36:14are with sending a bigger
• 36:16myeloid, you know, panels. We
• 36:18are, we are finding,
• 36:20other rare mutations that are
• 36:21associated with essential thrombocytosis.
• 36:23And so
• 36:24so that's,
• 36:25that's really the laboratory workup.
• 36:29Next slide, please.
• 36:32And so just summarizing,
• 36:33you know, what I just
• 36:34said, you know, most common
• 36:36etiology is iron deficiency, and
• 36:38so your iron panel,
• 36:40is is, you know it
• 36:42probably will rule out,
• 36:44you know, good, you know,
• 36:46twenty, thirty, thirty percent of
• 36:47the cases,
• 36:49and then followed by by
• 36:50reactive or secondary cases such
• 36:52as, you know, post up
• 36:53status or, you know, in
• 36:54in chronic inflammatory conditions.
• 36:57Many times,
• 36:58we'd finish on the whole
• 36:59workup including bone marrow biopsy
• 37:01in a younger person and
• 37:02and,
• 37:03and not, you know, not
• 37:05really get a diagnosis. And
• 37:07and and that's
• 37:08that's, you know, that's perhaps
• 37:10because of, you know,
• 37:12I have, you know, kind
• 37:13of, you know, seen people
• 37:15developing diabetes or, you know,
• 37:16very general
• 37:17kind of mild chronic inflammatory
• 37:19sort of,
• 37:21states. And then once, these
• 37:23have been ruled out, then,
• 37:24you know, a
• 37:26workup for
• 37:28for,
• 37:29myeloproliferative
• 37:31neoplasm,
• 37:32is is justified. And, you
• 37:34know, that can just,
• 37:35be started off with JAK2
• 37:37mutation,
• 37:38and then reflects to other
• 37:39mutations followed by a pulmonary
• 37:40biopsy.
• 37:45Alright. No. Thank you. So
• 37:46this like I said, this
• 37:47case is sort of ongoing.
• 37:48I'm suspecting we won't find
• 37:50the cause, but we have
• 37:51the smear,
• 37:52still coming on. And and
• 37:53then just,
• 37:55one
• 37:56final plug on on the
• 37:57pathway. So,
• 37:59you know, when you're putting
• 38:00at least for me, when
• 38:01I'm putting in the smear
• 38:03order, if I if you
• 38:04type in peripheral smear, it
• 38:06it doesn't always show,
• 38:08on the order what you
• 38:09want.
• 38:10But if you click on
• 38:12it from the pathway,
• 38:14it pops up. And so
• 38:15for those of you taking
• 38:16notes at home, it's peripheral
• 38:18smear for pathology.
• 38:20If you type in
• 38:21peripheral,
• 38:23blood or peripheral blood smear,
• 38:25you actually doesn't always show
• 38:27up in EPIC.
• 38:28So another,
• 38:30plug on on on the
• 38:31pathway for,
• 38:34in some ways, it may
• 38:35be sometimes worth the time
• 38:36to go in just to
• 38:37make the ordering,
• 38:39easier.
• 38:40And so,
• 38:42but, like I said, her
• 38:43case is ongoing. I'm suspecting,
• 38:46since she's been relatively stable
• 38:47in the four fifty to
• 38:49five twenty five range that
• 38:50we will probably not find
• 38:52anything,
• 38:53pathologic.
• 38:55But I'm happy to when
• 38:57I'm back, if people want,
• 38:59give a another update.
• 39:02I don't I have been
• 39:04following the chat. I don't
• 39:05know if there's any questions.
• 39:07Otherwise, I'm gonna pass them
• 39:08back back over.
• 39:11Yeah. No. We have not
• 39:12gotten any questions,
• 39:14although we had a a
• 39:16couple of other things that
• 39:17we didn't know if we
• 39:18were gonna have time to
• 39:19discuss, and and so maybe
• 39:20we can,
• 39:22pull those in. And if
• 39:23you do have questions, please
• 39:25enter them in the q
• 39:27and a.
• 39:28Well, I have one. If
• 39:29that's something too. Yeah. Thanks
• 39:31for going. Yeah. Okay. Good.
• 39:33Yeah. No. You mine mine
• 39:35is a question, so it's
• 39:36a complete change. So you
• 39:37do
• 39:38Okay. I I was actually
• 39:39gonna ask, because I probably
• 39:41missed it in your case
• 39:42and maybe to doctor Sharda
• 39:43as well,
• 39:47about if your patient's body
• 39:48mass index and if they're
• 39:50obese. You might have said
• 39:51that, and I missed it.
• 39:52But I think
• 39:53yeah. Good question. I think
• 39:55I see that a lot
• 39:56in practice as part of
• 39:57this
• 39:59inflammatory
• 40:01state. Right.
• 40:02Yeah. Yeah. And I I,
• 40:04no. I I complete her
• 40:05BMI is thirty seven,
• 40:08and that's why I think
• 40:09we're not gonna find a
• 40:10pathological cause.
• 40:11This wasn't a a question,
• 40:13but it makes me think
• 40:14of something like,
• 40:16we didn't talk about, leukocytosis,
• 40:18but
• 40:19I I sort of feel
• 40:20and I and I haven't
• 40:21looked this up. So I
• 40:22I this is obvious to
• 40:23everyone else. I I apologize
• 40:25that that a fair amount
• 40:26of people with, you know,
• 40:27higher levels of obesity
• 40:29seem to have like a
• 40:31white counts of ten to
• 40:33twelve, you know, nothing that's
• 40:35sort of triggering a workup,
• 40:36but seems to have. And
• 40:38so I wonder, like you
• 40:39said, if there's another sort
• 40:40of, like, and you said,
• 40:41like maybe there's a little
• 40:42bit of non pathologic
• 40:44chronic inflammation
• 40:46that's driving some of these,
• 40:48thrombocytosis
• 40:49that may be causing a
• 40:49little bit of leukocytosis
• 40:51because I do see that
• 40:52a lot. So good question
• 40:53about the the the BMI.
• 40:55Yeah. Hers was is thirty
• 40:56seven.
• 40:59Yeah. And yes, I think
• 41:00we see a lot of
• 41:01patients with leukocytosis
• 41:03who are,
• 41:04with an elevated BMI,
• 41:06and there's increasing,
• 41:08I think, literature on that,
• 41:11that I've looked at that
• 41:12I think is,
• 41:13really fascinating. So yeah.
• 41:18We have a a comment
• 41:19from Mary Anne Davies.
• 41:22Thank you for a fabulous
• 41:23presentation and thrilled that you
• 41:25highlight the care signature pathways
• 41:26and the value for primary
• 41:28care. Mary Anne, thanks for
• 41:29the work that you and
• 41:30your team do
• 41:31on the signature care pathway,
• 41:33and thank you for sharing
• 41:34the slides that we some
• 41:36of the slides that we
• 41:37used. So thank you. Yeah.
• 41:40No. And they're they're well
• 41:41done. I agree with Frank.
• 41:43Yeah. Yeah. And and the
• 41:44fact that they're living and
• 41:45get,
• 41:46updated.
• 41:47So right. We we highlighted
• 41:49these topics because there was
• 41:50a couple of new ones,
• 41:51but they they'll change as
• 41:53as need be, which is
• 41:54which is great.
• 41:58But I don't know if
• 41:59there's no other questions at
• 42:00a time. I did have
• 42:01one question. We see a
• 42:02lot of elevated fair, you
• 42:04know, through all these, all
• 42:06both of these cases, right?
• 42:07The workup was let's get
• 42:09some iron studies.
• 42:10And
• 42:11I will say,
• 42:12in primary care,
• 42:14I do see a lot
• 42:15of iron studies that show
• 42:17an elevated ferritin
• 42:19and, and
• 42:21often
• 42:22my mind goes to, could,
• 42:24is this
• 42:25hemochromatosis
• 42:26and do I need to
• 42:27worry about hemochromatosis?
• 42:29And so, I had a
• 42:30question of, of, you know,
• 42:32you know what would be
• 42:34maybe the best marker
• 42:36or trigger that you would
• 42:37wanna share, with your primary
• 42:40care
• 42:40colleagues of
• 42:42when is it worth the
• 42:43the the testing for hemochromatosis?
• 42:49I
• 42:50I think by an iron
• 42:51saturation of more than forty
• 42:53five percent is usually a,
• 42:57a better test to kinda
• 42:59screen for hemochromatosis.
• 43:01So I think,
• 43:02but certainly other ways that
• 43:03someone might come to us
• 43:04too. I mean, sometimes patients
• 43:06have had,
• 43:07you know, an MRI. And
• 43:08if there's sort of iron
• 43:09deposition of on, like, a
• 43:10liver MRI, I think that's
• 43:11certainly
• 43:12like, we think about that
• 43:13as well. But the ferritin,
• 43:15you know,
• 43:16in a similar
• 43:17thing and has a lot
• 43:18of sort of reactive you
• 43:19know, as an acute phase
• 43:20reactant, we might see a
• 43:21high ferritin or from liver
• 43:23diseases and
• 43:25and other spaces, alcohol.
• 43:27I don't know, doctor Sharda,
• 43:28your thoughts.
• 43:31No. I agree. And and
• 43:32and then it becomes tough
• 43:34because, you know,
• 43:36because,
• 43:38the the you know, many
• 43:39times we end up seeing,
• 43:41seeing,
• 43:43people who've already had, mutation
• 43:45testing and then, you know,
• 43:46they have either the h
• 43:48sixty three d or just,
• 43:49you know, they're heterozygous and
• 43:50then, you know, you're just
• 43:51stuck with someone with a
• 43:52ferritin of seven eight hundred
• 43:54who perhaps is, you know,
• 43:56if you follow the, you
• 43:57know, if you're a tourist
• 43:58and follow the textbook,
• 44:00you, you know, you shouldn't
• 44:01be phlebotomizing
• 44:03and but, you know, you
• 44:05end up do you know,
• 44:06you're just stuck there in
• 44:07the middle. But, yeah, ferritin
• 44:08becomes
• 44:09really tough too. And it's
• 44:11got very half longer, much
• 44:13longer half life, I feel.
• 44:15I guess, you know, not
• 44:16half life in terms of
• 44:17the protein, but, like, you
• 44:18know, just physiologically
• 44:20because
• 44:21after acute infections, I I
• 44:23think, you know, in surgeries,
• 44:25ferritin is gonna be high
• 44:26for a very long time.
• 44:27And so then it becomes
• 44:29hard to, you know, obese
• 44:30peep you know, individuals,
• 44:32diabetes,
• 44:33having surgery, or, you know,
• 44:34foot infection. You know? It
• 44:36just becomes very difficult,
• 44:38at some point. Yeah.
• 44:42Yeah. That that so that
• 44:43that was another good pearl.
• 44:45That in the SGLT
• 44:46two inhibitors,
• 44:48those are some good pearls,
• 44:50to lymph by.
• 44:52Yeah. I'm I'm curious.
• 44:54Now I know that this
• 44:56could be an entire presentation
• 44:58in and of itself,
• 45:00but, you know, we talked
• 45:01about high platelets. And,
• 45:03you know, now that patients
• 45:05can see their own results
• 45:08in my chart,
• 45:09we get a lot of
• 45:10very pointed questions.
• 45:12You know, the ferritin would
• 45:14be an example
• 45:15on platelets. And, you know,
• 45:17are you sure there's nothing
• 45:18wrong? And I wanna see
• 45:20a a specialist. I mean,
• 45:21it it's a kind of
• 45:22interesting situation where we you
• 45:24know, things that we never
• 45:26had to completely
• 45:27explain, we we now have
• 45:28to explain.
• 45:30And, you know, there's always
• 45:31a a kind of fear
• 45:32of, like, are we dismissing
• 45:33something when it gets called
• 45:35up that way.
• 45:36And and the other thing
• 45:37that comes up a lot
• 45:38is, you know, these kind
• 45:39of intermittent,
• 45:40very mildly low platelet counts,
• 45:44where, you know, if you
• 45:45can actually do a smear
• 45:46and see clumping, you're like,
• 45:48amen. Hallelujah. Nothing to do.
• 45:51But but otherwise,
• 45:53again, I I don't think
• 45:54people bleed until they go
• 45:56significantly
• 45:57lower, but what should be
• 45:58our threshold for doing a
• 46:00workup?
• 46:01And and what should we
• 46:02tell patients when it's just
• 46:04really not a problem? They're
• 46:05only very mildly lower.
• 46:12Anish, I think it's your
• 46:13turn. Okay. Yeah. You're up.
• 46:14No. I agree. And I
• 46:16think I think,
• 46:18I I don't I I
• 46:19don't think there's even a
• 46:20term called minimal thrombocytopenia,
• 46:22but I tend to use
• 46:23it even in my description
• 46:25and
• 46:26because, you know, if you
• 46:27again, if you're a purist
• 46:28like I am,
• 46:30you know, definition of thrombocytopenia
• 46:31is less than hundred actually
• 46:32because, you know, people have
• 46:33gotten together and actually the
• 46:35world thrombocytopenia
• 46:36whatever, so, you know, is
• 46:38less than one hundred. But
• 46:39if you see the
• 46:41CBC and what you know,
• 46:42any lab, they would Yeah.
• 46:44Still report normal as one
• 46:46forty, one fifty, one to
• 46:47sixty, whatever their, you know,
• 46:48lower ranges.
• 46:50And so
• 46:51I and it's a lot
• 46:52you know, it's more common
• 46:54than
• 46:55than thrombocytosis
• 46:57or I would say, at
• 46:58least in my experience. And
• 47:00and and I agree. I
• 47:02mean, it becomes I I
• 47:03think they just need reassurance.
• 47:06I, you know, I I
• 47:07we see plenty of it.
• 47:08I I see plenty of
• 47:09it for referrals.
• 47:11But,
• 47:13but they, you know, it
• 47:14just needs they just need
• 47:15reassurance because I agree with
• 47:17you that
• 47:18that, you know,
• 47:20usually,
• 47:21there's no bleeding even at
• 47:23fifty. Or, you know, fifty
• 47:24is a you know, you
• 47:25can get a hip hip
• 47:26replacement. I mean, you know,
• 47:28so,
• 47:29you know, it's usually been
• 47:31the most the risk of
• 47:33major bleeding is five percent
• 47:34with less than twenty. So
• 47:36so, you know, the the
• 47:37you you don't there's a
• 47:38lot of redundancy and, you
• 47:40know, there's
• 47:40so usually,
• 47:42hundred you know, if they're
• 47:43great really greater than hundred
• 47:45and you have repeated it,
• 47:47you know, and it's still
• 47:48greater than hundred and or
• 47:49it bounces around, it really,
• 47:51I think, is very reassuring.
• 47:54And, you know, and and
• 47:55that you know, one one
• 47:56could just be clear that,
• 47:57actually,
• 47:58the real, you know, we
• 48:00call low platelets, you know,
• 48:02on the medicine you know,
• 48:03from the real definition is
• 48:05less than one hundred.
• 48:08So
• 48:10That is another great pearl.
• 48:12We have, like, just pearls
• 48:14flowing. These are really wonderful
• 48:16because, you know,
• 48:18I don't know about you,
• 48:19Frank. I see, you know,
• 48:20CBCs. I, you know, I
• 48:22probably look at,
• 48:23I don't know, twenty, thirty
• 48:25a day. You know, it's
• 48:26a lot, and and they
• 48:27all have things just outside
• 48:28of normal.
• 48:30And so, this is very
• 48:32helpful,
• 48:33to not kind of over
• 48:34refer things that are, you
• 48:35know, pretty clearly fine.
• 48:37Yeah. I think that I
• 48:38I agree with everything doctor
• 48:40Shutter just said. And I
• 48:40think that,
• 48:42like, the
• 48:44sometimes, like, just in terms
• 48:45of what to say to
• 48:46patients, you know, and, you
• 48:48know, just
• 48:49some some patients, I think,
• 48:51accept that idea of, like,
• 48:52you could have a surgery
• 48:53at this level. You know?
• 48:54And then that's, I think,
• 48:55just, like, clinically, people could
• 48:57that somehow resonates with people.
• 48:58I think, you know, if
• 48:59there's assuming it's just isolated
• 49:01thrombocytopenia
• 49:02and not there's no other
• 49:04kind of cell lines. I
• 49:06think the age of the
• 49:07patient. Right? Like and then
• 49:08I guess just as I'm
• 49:10sure we do, you know,
• 49:11even if it was mildly
• 49:12low, I guess I would
• 49:13just add that if it
• 49:14was recently much higher than,
• 49:15like, maybe I would maybe
• 49:17I personally would monitor it.
• 49:18And then
• 49:19I don't know. I look
• 49:20at the mean platelet volume,
• 49:21which, you know, might be
• 49:22one of the things that
• 49:23the other gets disregarded. But
• 49:24if it's a little bit
• 49:26high, I mean, sometimes I
• 49:27think that's kind of these
• 49:28autoimmune ish people. Not that
• 49:30anything needs to be done,
• 49:31but
• 49:34I think that that's something
• 49:35we see a lot in
• 49:36practice. But I think it's,
• 49:39yeah, I think just sort
• 49:41of how we reassure patients
• 49:43in general is hard. I
• 49:44think that
• 49:46it's a difficult
• 49:48there's a lot of things
• 49:49on a CBC that we
• 49:51don't really probably look at
• 49:52in such great detail, but
• 49:53to patients that MCHC
• 49:55is crucial to their,
• 49:57you
• 49:58know, well-being. And that's hard,
• 49:59I think, too. It's just
• 50:00like the number of data
• 50:02points. You know? I think
• 50:03if I may, like, I
• 50:04think,
• 50:09but just wanted to bring
• 50:10it up. But that, like,
• 50:11you know, for for someone
• 50:12we're dealing with who's really
• 50:14not being reassured and would
• 50:15really like, you know,
• 50:17like, even one sentence from,
• 50:19you know, for from a
• 50:21specialist.
• 50:22I think,
• 50:24for cases like that where,
• 50:25you know, it's very borderline
• 50:27thrombocytosis
• 50:28or a very borderline, you
• 50:29know, thrombocytopenia.
• 50:31I think eConsult is a
• 50:32very nice
• 50:34pathway too, and,
• 50:36and I'm not sure, you
• 50:37know, if it's, you know,
• 50:39to what
• 50:40extent kind of, you know,
• 50:41it's it it goes
• 50:43out into this, you know,
• 50:44world, like, in the the
• 50:45whole system, outer system. But
• 50:47I certainly do it, you
• 50:48know, a few weeks, a
• 50:50year, and,
• 50:51and those are you know,
• 50:52they take two, three minutes.
• 50:53I mean and,
• 50:54and, you know, someone signs
• 50:56their life that, you know,
• 50:57this is fine. You know?
• 50:58And so I I I
• 50:59think that that could, you
• 51:00know, be reassuring to everyone
• 51:02and save everyone's time,
• 51:04including patients and, you know,
• 51:05because, you know, you know,
• 51:06it could take a long
• 51:07time to get a referral
• 51:08for something like that.
• 51:10That is another very helpful
• 51:12suggestion.
• 51:14So we have, a a
• 51:15question from an anonymous attendee,
• 51:19and, it says, what pathways
• 51:21are available?
• 51:22I only saw iron deficiency.
• 51:24So all of the ones
• 51:26that we showed are in
• 51:27there.
• 51:29Actually,
• 51:30we can to that?
• 51:32Yeah.
• 51:33Oh, yeah. The give us
• 51:34a table of contents of
• 51:35that. It was, like, seven
• 51:37slide seventeen or something.
• 51:40Renee,
• 51:41are you able to
• 51:45She might have stepped away.
• 51:51I'll try to share it,
• 51:52but let's see. Yeah. Okay.
• 51:54Here it comes. Good. Always.
• 51:57Yeah. And if you can
• 51:58make that bigger.
• 52:03So we have
• 52:06thrombocytosis,
• 52:07lymphocytosis,
• 52:09ferritin evaluation,
• 52:11and erythrocytosis
• 52:13are what I'm reading
• 52:14with my face right up
• 52:15to the computer
• 52:17and bleeding
• 52:18concern for bleeding disorder.
• 52:22And and these were launched,
• 52:24they're they're a little simpler
• 52:25than some of the other
• 52:26pathways,
• 52:27and and so they were
• 52:28kind of launched. There there's
• 52:29actually some more ready to
• 52:31go in hematology,
• 52:32if, people,
• 52:34find these helpful, which I
• 52:35I think we've had a
• 52:36resounding,
• 52:37endorsement.
• 52:38Frank, you looked at that.
• 52:39You're like, these are great.
• 52:41So and, of course, there's,
• 52:42a ton of pathways in
• 52:43other things, diabetes, hypertension,
• 52:46you know, but not other
• 52:48things aside from heme as
• 52:49well.
• 52:53And whoever it is that
• 52:54asks
• 52:56can always send me a
• 52:57quick note, and I will
• 52:58make sure you have somebody
• 52:59help you find the additional
• 53:01pathways.
• 53:03Great. And, Frank, I'm gonna
• 53:05be going back.
• 53:06I was oh, and if
• 53:07you can't find it, maybe
• 53:09that's a reason to, you
• 53:11know, put it on the
• 53:12list. Maybe it's being added
• 53:13as we speak, but maybe
• 53:15it's on the list. If
• 53:16not, we could put it
• 53:17on the list.
• 53:19Exactly.
• 53:20Okay. Well, it looks like
• 53:22we
• 53:24are ending nearing the end
• 53:25of our hour where Kelsey's
• 53:27daughter has announced it's time
• 53:29to come have dinner or
• 53:30something. Right?
• 53:33I was gonna ask go
• 53:34back to, Frank, your your
• 53:36background slide introducing this whole
• 53:38thing, which was sort of
• 53:39elevated blood counts and that,
• 53:42you know, there's
• 53:44it's so common.
• 53:45Every day you're looking at
• 53:46so many CBCs,
• 53:49trying to figure out what
• 53:50to do beforehand
• 53:52versus who really needs urgent
• 53:54care,
• 53:55or urgent referral or, you
• 53:58know, accessing the e referral.
• 54:00Do you do you and
• 54:02Karen feel like you have
• 54:03a good handle on that?
• 54:05Are there other instances
• 54:07where
• 54:09where
• 54:11you're you're thinking that that
• 54:12you need a little extra
• 54:14help or or that you're
• 54:15not quite sure where to
• 54:16go from there?
• 54:20Right?
• 54:21I think,
• 54:22I mean, I think, you
• 54:23know, like what Karen said,
• 54:24sometimes managing, like, sort of
• 54:26the patient expectation is sort
• 54:27of the our other job,
• 54:29right, besides just handling the
• 54:30medical stuff. And so sometimes
• 54:32there is no no amount
• 54:34of reassurance
• 54:35I can give someone.
• 54:37And so there there is
• 54:38unfortunately some
• 54:39it is what it is
• 54:40patient driven,
• 54:42referrals. I mean, I think
• 54:44the I would say the
• 54:45other ones that come up.
• 54:47So the, the gammopathy or
• 54:48the MGUS pathway, I think
• 54:50I use a fair amount,
• 54:52or or can't see myself
• 54:53using a fair amount, which
• 54:54is which is great.
• 54:56And then,
• 54:58the I think I think
• 54:59someone alluded to the you
• 55:01you see a pre op,
• 55:02someone at had asked for
• 55:05the,
• 55:06the PT and PTT and
• 55:07it's mildly elevated.
• 55:09And then you're like, well,
• 55:10now what I now what
• 55:11do we do? Right? And
• 55:12so
• 55:13so,
• 55:14you know, that's a that's
• 55:15another, I think, really, like,
• 55:17if,
• 55:17you know, you bookmark things,
• 55:19like, you know, is this
• 55:20a bookmarkable one? So those
• 55:21I think are are are
• 55:23good. I've not used, the
• 55:25eConsult as much, but I
• 55:26feel like there's just a
• 55:28a a a hidden or
• 55:30not so hidden, like, potential
• 55:32to really,
• 55:34improve the through the throughput
• 55:36between, primary care and and
• 55:38heme,
• 55:39with that. And so I
• 55:41think I feel like that's
• 55:42something that we should take
• 55:43back,
• 55:44and figure out how do
• 55:45we make this,
• 55:48more user
• 55:49used more.
• 55:51Mhmm. Yeah. It's pretty user
• 55:52friendly.
• 55:53And it it's nice, because
• 55:55so many of us kind
• 55:56of do curbsides. Right?
• 55:58We call we phone a
• 55:59friend.
• 56:00But that that's not in
• 56:01the chart,
• 56:03and it, you know, it
• 56:03it doesn't have any credit.
• 56:04The the there's actually billing
• 56:06credit for the specialist through
• 56:07the econsult. So,
• 56:09they they kind of get
• 56:10productivity credit and and and
• 56:12we get a a very
• 56:13clear answer.
• 56:15And, again, if we want
• 56:16to, we can have a
• 56:17whole another encounter to discuss
• 56:18the answer if it's complicated,
• 56:20or or we can just
• 56:21simply send the patient a
• 56:22note or or call the
• 56:23patient if it's kind of
• 56:24what we were expecting
• 56:26to say anyway.
• 56:28So
• 56:29alright. Well, I have to
• 56:31thank our speakers
• 56:32very much for all of
• 56:33the preparation
• 56:34and wisdom and pearls that
• 56:36came through,
• 56:38and, and and, Frank, for
• 56:40keeping us on