February 10, 2022: We are Here for You: A Smilow Patient and Family Forum

February 11, 2022

Information

Hosted by Dr. Eric Winer. Presentations by: Drs. Kevin Billingsley and Scott Huntington, and Osama Abdelghany, PharmD, MHA, BCOP, Kim Slusser, RN, Dana Brewer and Lisa Barbarotta, MSN, APRN-BC, AOCNS

ID7441

To CiteDCA Citation Guide

00:00Welcome everyone,
00:02I'm Eric Weiner and I have actually.
00:06Been the Yale Cancer Center
00:09director and the physician in chief
00:12at Smilow for all of eight days.
00:15I, I suppose you could say that I've
00:18been around a little bit longer because.
00:21Since since being offered the
00:24position and accepting it,
00:25I've been very involved by zoom
00:27and a little bit in person for
00:30the past two to three months,
00:31and I I dare say that's given me a
00:34running start and has been very helpful.
00:36I just want to start off with about
00:405 minutes both about who I am and why
00:45I came and my vision and I'll I'll
00:48do my best to be relatively brief.
00:51So I have the distinction of having only
00:53lived in three cities in my entire life.
00:56I grew up in Boston at age 17,
00:59I came to Yale as an undergraduate,
01:02managed to extract myself from
01:04New Haven 13 years later,
01:06after completing college and
01:08going to medical school and doing
01:11my internal medicine residency.
01:13I spent 10 years down at Duke in
01:15North Carolina and then moved to Dana
01:18Farber Cancer Institute in Boston,
01:19where I was for.
01:22A little more than two decades,
01:24and at Dana Farber,
01:26I directed our breast cancer program
01:29and and had a variety of other.
01:33Leadership jobs.
01:34Over the past few years,
01:36and I suppose if I have any claim to
01:38fame that claim to fame is that I'm a
01:41breast cancer doctor and researcher.
01:45Over the past few years,
01:46I've wondered whether it was time
01:47to do something a little different,
01:49and I looked at a number of
01:53different positions.
01:54And ultimately decided that this
01:57was really the right fit for me.
02:00And it was the right fit for me,
02:02because Yale has great science.
02:06Yale has great clinical care and
02:10very strong clinical research,
02:14and it has huge potential because by
02:17bringing all of those elements together,
02:20I fully believe that we can have
02:23a a world renowned Cancer Center
02:26and and and program in oncology.
02:30And what that means is that we will
02:33provide truly unsurpassed care to
02:36patients unsurpassed in all ways,
02:38both in terms of the technical
02:41aspects and some of the.
02:44Perhaps?
02:46Warmer and fuzzier parts of cancer care
02:49for lack of a better way of saying it,
02:53meaning that we take care of patients,
02:56and we take care of their families
02:58and when they come see us from the
03:01minute they make that call until
03:03they no longer need our care.
03:05They feel like we're giving
03:07them a big warm hug,
03:08and I think that that's really important.
03:11I often say that one of the.
03:15Remarkable things about being a
03:17Doctor Who takes care of patients
03:19with cancer is that there are
03:22relatively few opportunities when,
03:23as a doctor,
03:24you are suddenly given a
03:26door into people's lives.
03:27And this isn't true just for doctors.
03:31It's true for nurses and social
03:33workers and and everyone else
03:35who who works with us clinically.
03:37But if in fact you choose
03:39to go through that door,
03:40it's a pretty rich experience,
03:41and I think that we can do quite remarkable
03:44things for people and at the same time,
03:46while we're doing those things,
03:48they're important lessons for us.
03:51So my vision is that.
03:55Over the course of the next five years,
03:5910 years, there's no real specific
04:03point in time when I think that
04:06we can say that we will have
04:08accomplished what we're striving to do.
04:10But then we will be truly
04:13a world renowned program.
04:14For in all the ways that I described to you,
04:17both clinical and both in terms
04:20of clinical care, but also very,
04:22very importantly in terms
04:24of research because.
04:25We all know that while we have been
04:29much more successful in treating cancer
04:31over the course of the past ten years,
04:33there's still a long way to go.
04:35There are many people,
04:37both in the United States and
04:39even more so around the world,
04:40but still very much so in our own country.
04:44Who suffer far more than they should,
04:46who lose their lives prematurely and who
04:50have to go through and experience that.
04:52Of course, we don't wish on anyone.
04:56So when we get to the point where all
04:59cancers can be treated with the equivalent
05:02of penicillin for the strep throat,
05:04then I think maybe our job is is is not done,
05:09but we will have really
05:11accomplished something,
05:12and I think that's actually
05:13a place where we can be.
05:15And when I say we, I'm for this.
05:17I mean,
05:17we very broadly those of us at Yale and
05:19those of us who we work with around
05:21the country and around the world.
05:25So I think that's enough about where
05:29I think we're going and and who I am.
05:32And let's move on with the program.
05:35We have really a great program.
05:37We have three sets of speakers and
05:40we're going to start with clinical
05:43updates from Kevin Billingsley,
05:46our our Chief Medical Officer,
05:48and Kim Slusser,
05:50who is Vice President for Patient
05:52Services and Chief Nursing Officer.
05:55Of smiler so Kevin and Kim.
06:01Well, Doctor Weiner, thank you. I know
06:03I speak for all of us in our community.
06:07In saying that we are absolutely
06:09thrilled that you are here and it is
06:11great to have you with our patient and
06:14family forum audience this evening.
06:15So it's it's an exciting time.
06:19And Kim and I are both pleased
06:21to to give this clinical update.
06:24Next slide. You know,
06:27I don't think it is any secret to our
06:31audience this evening that we continue.
06:34To work our way through a pandemic of.
06:41Really unprecedented proportions,
06:44and you know these.
06:46These data demonstrate what we've
06:48been through in the past six
06:50weeks here in Connecticut,
06:52fueled by the Omicron surge in early January,
06:56we reached an all time high of
06:59daily case rates in Connecticut,
07:02and nearly an all time high
07:06in hospitalizations.
07:08And I will share that Yale New
07:11Haven Health System was on the very
07:14forefront of caring for this group
07:16of of patients and families, and.
07:20Although we are a Cancer Center
07:22and caring for our cancer patients
07:24is job number one,
07:26we also feel that we are important
07:28citizens within a larger health
07:30care system and all of our teams
07:33have made contributions to caring
07:36for COVID patients in various ways,
07:38shapes and forms not only within
07:41COVID within our particular patients
07:43but also contributions to the care of
07:46COVID patients across our health care system.
07:49I'm not going to share specific data,
07:52but I do want to comment that that
07:55that this health system cared for
07:58the vast significant majority of
08:00COVID patients in the state over
08:03the past six weeks.
08:04And our outcomes were absolutely
08:08spectacular that the success
08:11rates driven by our protocolized
08:14treatments were the best in the state.
08:17So again,
08:17I just want to take a minute to say
08:19thank you to all of our teams who've
08:22contributed to this next slide.
08:25The overall story is in recent weeks.
08:30Good news, as you can see from these graphs.
08:35Across our health system,
08:37we went up to over 700 patients.
08:41You can see in the blue line and
08:43as of this morning we're down to
08:46144 COVID patients in our hospital
08:49system and here in New Haven at
08:52Yale New Haven Hospital.
08:53After going up to about 450
08:55patients in the hospital.
08:57Fortunately, we're down to 88 in patients,
09:00and fortunately the trend continues and
09:04a positive direction. So good news.
09:07All around next slide please.
09:10You know one of the things that I
09:12am most proud of for the work that
09:15our teams have done in recent weeks.
09:17Is that what we have learned is?
09:20Although the pandemic certainly creates
09:22a stress on our on our health care system,
09:27it is absolutely the critical
09:29that we continue to provide health
09:31care to all of our patients,
09:33particularly our cancer patients.
09:36And this is a graphical display
09:39of our ambulatory.
09:41Visit volumes across the Smilow
09:44system during the the weeks
09:47of December into January,
09:49really at it at a time when
09:53the the rates of Omak,
09:56Ron driven COVID infection were soaring
09:59and you can see we took a dip in our visit
10:02volume right around the week of Christmas.
10:04As you would anticipate and then as the
10:08height of the surge hit, we did transition.
10:12Many of our visits to video and phone
10:16keeping a number of potentially
10:18vulnerable patients and families out
10:20of our physical facilities.
10:22Yet we maintained our overall visit
10:25volume and our care visits virtually
10:28without interruption through this surge.
10:31Next slide.
10:34The other thing that we learned was
10:36a was really challenging during the
10:38first wave of the COVID-19 pandemic.
10:40Was that at that time in 2020 we
10:43really shut down and many of our
10:47surgical procedural areas. And.
10:52During this most recent surge,
10:54we were absolutely committed as a
10:56health care system and a cancer care
10:59enterprise to continuing to provide
11:01surgical care to cancer patients.
11:03And again,
11:04you can see that in late December
11:06we had a drop,
11:07but really continued to provide
11:10surgical oncology care and a very
11:12uninterrupted and ongoing way.
11:15Next slide, please.
11:18Similarly,
11:18our patients who are on radiation
11:21on radiation receiving radiation
11:23therapy continued to receive
11:25their daily treatments at all of
11:28our locations across the system,
11:30virtually without interruption.
11:34Next slide, please.
11:37So it has been a really, I think,
11:40challenging yet successful period of time,
11:43and I again want to thank all of our
11:45teams and I'm really pleased to that
11:47we've been able to care for our patients
11:50through this difficult period, Kim.
11:52Over to you. Get Kevin
11:56as Kevin mentioned, we just had we're
11:59just coming off the heels of another
12:01surge and we constantly want to make
12:04sure that we're doing everything
12:06that we can to keep our patients
12:09their loved ones and our staff safe.
12:11So one of the new requirements every
12:14got guidance around booster vaccination.
12:16Is that all of our faculty and help
12:19systems staff are now required to
12:21get their booster vaccinations.
12:23This is a way to.
12:24Again, increased safety within the
12:26walls of the care that we provide to
12:30we know that the COVID-19 vaccine
12:32boosters have a substantial impact
12:34on reducing COVID-19 infections.
12:36Severity of illness.
12:38If you were to still get COVID-19
12:41hospitalization and death.
12:44So we are very proud to know that all
12:47of our faculty and help us and stuff
12:50are getting very close to vaccinations.
12:54I wanted to take this time also to
12:56update our visitation of what's
12:58going on with visitation at across
13:00the health system and within smile.
13:03Oh, I know that this can be very
13:05confusing for our patients and their
13:07loved ones and sometimes even for our
13:10staff because we do change visitation
13:13guidelines based on what's happening
13:15across our state and within our
13:18health system right now for inpatient
13:21for patients that are hospitalized.
13:23They can have one visitor accompany them.
13:27And also one visitor canal company
13:30patients as of last week to outpatient
13:35appointments for the inpatient guidelines.
13:37It is just one visitor per day,
13:39though we do not allow more than
13:42one patient in one visitor.
13:44I'm sorry to visit even if it's
13:48at a different time,
13:49so we only allow one visitor that
13:51day and then the next day if
13:53there's another visitor that would
13:54like to visit that patient.
13:56If they can be the one to.
13:58With that,
13:59but we do try to still have try to
14:03limit the amount of traffic that we have
14:05coming in and out of our hospital doors.
14:08Our visitors that are visiting our
14:10inpatients have to have proof of
14:13being fully vaccinated and there
14:15is no booster requirement right now
14:17for our visitors if they cannot,
14:19if they're not vaccinated,
14:20they have to show proof of a
14:23negative PCR tests within 72 hours
14:25and visitation is not permitted.
14:284 hours to get positive and patience.
14:31And for outpatient guidelines,
14:32like I said, we are, as of last week,
14:35allowing 1 visitor per patient.
14:38But there are still social distancing
14:41guidelines that we are trying to
14:43maintain and there are times where some
14:46of our sites just really challenge us
14:48to keep that safe social distancing.
14:51So there may be times where we talk
14:54to our patients and their loved ones
14:56about not having a visitor come with
14:59them because of space constraints.
15:01But the the pretty much the the guideline
15:05is if you're coming for your clinic visit.
15:08You can have somebody accompany
15:10you if it's your infusion visit
15:13or radiation treatment visit.
15:15There may be times where you are asked
15:19not to have a visitor happy New Year,
15:21but that will be discussed with you and
15:24depending on the site, but we are very.
15:28We want our our patients to have
15:30their loved ones with them and we
15:32know this has been very challenging
15:34so we are glad to see that we
15:37are able to have some visitation.
15:39And again both this may change
15:41as time goes on.
15:42Over the next few weeks and we will
15:44continue to keep you informed on
15:47our website and our social media.
15:52Stop sharing. And I will turn
15:56it back over to doctor on this,
15:58but thank you again to everyone on this
16:01call for trusting us with your care.
16:04It's really a privilege and we
16:06take it very seriously and we do
16:08everything we can to keep everyone
16:10safe during this time. Thank you.
16:13And I I don't know whether the
16:14audience can see this or not,
16:16but they're actually 260
16:19participants on this call,
16:21and I can imagine that at some
16:24computers or iPads that there's
16:27more than one person there.
16:29So really, thanks for for being part of this.
16:32So our our next item is pharmacy
16:36and clinical practice updates,
16:38and I'm going to turn it
16:41over to Osama abdelghany.
16:44Who is the executive director of the
16:47oncology pharmacy and Lisa Barbara,
16:50who's the program director for Oncology
16:52Education and clinical practice and
16:55finally Doctor Scott Huntington,
16:57Associate Professor of Medicine
16:59and Medical Director,
17:01director of the Hematology
17:03Outpatient clinic so.
17:04I turn it over to the three of you.
17:08Thanks
17:08Doctor Weiner and thanks to
17:10everybody for joining tonight.
17:11It's exciting to see so many people join.
17:14I'm just going to take a
17:16minute to open up my slides.
17:25Can the other panelists see the slides OK?
17:28Ken, you're not.
17:29You're not in presentation mode,
17:32but I don't actually see the typical.
17:36Screen that allows you to
17:38go into presentation mode.
17:43Let me try again.
17:48If not, it's OK. I mean how's that?
17:51It's it's not just slide mode.
17:53Here we go there. You go perfect perfect.
17:55Oh sorry, there must be a delay.
17:56Sorry about that everyone.
17:58OK, so we're going to be discussing some
18:01complex topics this evening and some are
18:04still actively evolving even as we speak.
18:06And I'll, I'll give some
18:08additional explanation to that
18:09as we go through the slides.
18:11We're really going to do our best to give
18:13you specific answers to all your questions,
18:15so we expect that some of the guidance
18:17we're going to be providing tonight,
18:19maybe a bit more general until
18:21we learn more information.
18:23Over the course of the next week or so,
18:25we thought it was important to start
18:28with a definition for immunocompromise.
18:30This is a frequently asked question
18:32that we get on our town halls and
18:34and that we all get, you know,
18:37contacted for via various routes.
18:40This definition is our VAC COVID
18:43vaccine guideline working definition
18:45for immuno compromised and you'll
18:46see that this is a very broad
18:50definition for immunocompromise.
18:51The Immunocompromise population is large.
18:55And includes our range of those who
18:58may not be at significantly increased
19:00risk all the way to patients who are
19:04the most severely immunocompromised.
19:06However,
19:06in regards to our vaccine recommendations,
19:09we opted to take a very cautious
19:13approach and really recommend a 3
19:16dose vaccine series for patients that
19:19meet the definitions outlined here.
19:22So that includes any patient
19:24with an active blood cancer,
19:26even if you're not actively
19:28receiving treatment for that cancer.
19:30Patients with solid tumors like
19:32breast cancer, lung cancer,
19:33colon cancer, and others who are
19:35being treated with chemotherapy,
19:37hormonal therapy,
19:38immunotherapy,
19:39or even patients who have had surgery
19:42for cancer in the last year and as well
19:46as patients receiving radiation therapy.
19:48Of course,
19:49we include our patients who have
19:51undergone stem cell transplant.
19:53Within the last two years,
19:54or those who are still on
19:57immunosuppressive medications,
19:57as well as some other populations,
19:59you'll see outline,
20:01including solid organ transplant recipients,
20:03patients with primary immunodeficiency
20:06syndromes,
20:07patients with advanced HIV,
20:08and then you'll see a long list
20:10of medications at the bottom.
20:12And those medications are not
20:13just used to treat cancers,
20:15but may be used to treat other
20:17types of non cancerous conditions,
20:20but those patients are still
20:22considered immunocompromised.
20:23And needing additional protection,
20:25and I'll just call out rituximab
20:28is on that list,
20:29and that's a medication that's
20:31used very frequently both in
20:33cancer and non cancer indications,
20:35and we recommend a 3 dose vaccine
20:38series for those patients and
20:40I'll I'll talk about the vaccine
20:42definitions on the next slide,
20:44the other frequently asked question that
20:46comes up that I'll just call out here.
20:48We get a lot of questions from
20:50our CLL population about whether
20:52they meet the criteria.
20:54Or immuno compromised even if
20:56they're not on treatment and
20:58according to this definition,
20:59any patient with CLL would
21:01fall into this category.
21:07So then I wanted to just clarify
21:10our vaccine terminology,
21:11because this can be very confusing,
21:13but I want us to get into the habit of
21:16thinking about the terminology primary
21:19series and then boost our vaccination.
21:23So for a person with a healthy immune system,
21:26so people who don't meet one of
21:29the criteria on the previous slide
21:31would get a 2 dose M RNA vaccine,
21:34so two doses of Pfizer,
21:35or two doses of Moderna or
21:37one dose of a J&J vaccine.
21:40Patients that meet one of those
21:42criteria from the previous slide in
21:45are considered immunocompromised.
21:46Their primary series is defined as
21:50three doses of an M RNA vaccine.
21:54And so that is a frequently asked question.
21:56I'll give some examples on the next slide,
21:59but I want us to start thinking
22:01about the primary series for
22:02immunocompromised patients as three dose.
22:05A booster is a shot that's given at
22:08least five months after completion
22:10of the primary series,
22:12and again I'll give a couple of
22:14examples in the next slide and
22:16immuno compromised patients who have
22:18completed that primary 3 dose series
22:20are eligible for a booster or a fourth
22:22shot which were really trying to move
22:25away from that terminology after they
22:28complete their three dose series.
22:31Now some of you may have heard in
22:33the press and via social media.
22:35That the booster timeframe may be
22:38changing to three months and I just
22:40want to take a minute to explain.
22:42That the CDC has an advisory committee
22:45called the Advisory Committee on
22:48Immunization Practices or ACIP.
22:50The ACIP advises the CDC on vaccine
22:52related items and so the ACIP met
22:55on Friday and they made some
22:57recommendations about vaccination
22:59for immunocompromised patients and
23:01one of those recommendations is
23:04that we decrease the time frame for
23:07the booster shot from five months
23:10to three months.
23:11However,
23:11Yale New Haven Health system is
23:14not changing their policy or their
23:17guideline until the CDC formally
23:19issues their recommendations,
23:22and we know that based on you
23:24know past history with COVID that
23:26the CDC takes some time to review
23:29the ACIP recommendations,
23:30but we expect the CDC to be
23:32coming out with more information
23:34in the next week to two weeks.
23:37So as of today, Thursday,
23:39February 10th,
23:40the timeframe for boosters for immuno
23:42compromised patients remains 5 months.
23:45But I'll just ask everybody to
23:47stay tuned in our health system.
23:50Vaccine website should really be what
23:52we call the primary source of truth
23:54or the one place that you all go to
23:57to get the most updated information.
23:59Because the health system will be updating
24:03that website as information changes.
24:05And as the CDC makes.
24:07Their final recommendations.
24:11So we wanted to just include pictoral of
24:15the the vaccine series as I just find it.
24:19So if you meet the criteria for
24:22immunocompromise as previously described
24:23in the first slide, your primary
24:26vaccine series is those three doses.
24:29Followed by a booster dose.
24:32At this point, five months
24:34after the third dose.
24:36And I'll just give a couple of examples
24:38because I think that would be helpful.
24:39So I'm a person with a healthy immune system,
24:42so I received 2 doses of the Moderna vaccine.
24:47Five months after my second Moderna
24:49vaccine I got my Moderna booster shot.
24:53I have a patient who is a 36 year old who
24:56meets the criteria for immunocompromise.
24:59She received her three primary dose series.
25:04With Pfizer and five months later,
25:07she received her booster dose
25:09or her 4th dose,
25:10which were really again trying to move
25:13away from because we know that inevitably
25:15there will be additional doses so that
25:18everything after the primary dose.
25:20We will really start to refer
25:22to as a booster shot.
25:26Now we haven't really talked about the
25:29the Johnson and Johnson vaccination much.
25:31We know that we recommended for the majority
25:34of our patients that they received Pfizer
25:36or Moderna one of the M RNA vaccines.
25:38But we know that some of you all were very
25:41good and quick to get vaccinated so some
25:44have may have received the day and day.
25:46So again at this point today their
25:49recommendation for those who receive J&J
25:52should have had a primary dose followed by 1.
25:55Booster dose.
25:56Again, we suspect this may change with
26:00the acip's recommendations on Friday,
26:02so this is another area I'll
26:04just ask you to stay tuned to.
26:09And I think the other FAQ.
26:11As it relates to boosters is, well, OK.
26:14I completed my primary 3 dose series
26:17and I'm getting my booster now.
26:20When should I get another shot and
26:22we don't have an answer to that yet.
26:25We know that every year we get a flu shot
26:27and that the flu shot doesn't last forever.
26:29We don't have an answer yet on the
26:31frequency with which we're going to have
26:33to continue to get COVID vaccination,
26:35so that's another stage 2.
26:38If you have not,
26:40if you meet the immuno compromised
26:42definition and you have not yet
26:44received a third dose or you have not
26:47yet completed your primary series.
26:49The recommendation is that you complete
26:52your your primary series and get a
26:55third dose and then five months after
26:57you complete your third dose you will
26:59be eligible for a booster and again
27:01if that time frame changes to three
27:03months then you would follow that.
27:06I'm just want to reference
27:07our vaccine scheduling site.
27:09As I mentioned that this is this is
27:11updated and actually contains all
27:13the information I just reviewed.
27:15It includes the definition of
27:17immuno compromised.
27:18It outlines the difference between
27:19the third dose and the booster dose
27:22and you can see here if you walk
27:24through it to schedule yourself.
27:26If you look at the third bullet down,
27:29I'm scheduling my third dose
27:31because I am an immuno compromised.
27:33Patient and I have completed my
27:35second dose at least 28 days ago,
27:38so if that's you and you haven't
27:40received a third dose and you completed
27:42your second dose at least 28 days ago,
27:44that's what you would select.
27:46If you completed your third dose
27:49as an immunocompromised person
27:51and five months have passed,
27:52you would select the 4th button
27:54and then you would be able to
27:57schedule your booster dose.
27:59I know that that's very confusing and
28:01continues to evolve as mentioned,
28:04so please stay tuned and I am going
28:06to hand over to my friend Sam who's
28:08going to talk about a visual,
28:10which is one of their very popular topic.
28:13Thank you Lisa and good evening everyone.
28:16While the vaccine remained the main and
28:18the best defense we have against COVID,
28:21we want to share some information with you
28:23about new drug that just became available
28:25as of December to prevent COVID infection.
28:29The drug is ever shield is actually
28:31made of two different drugs formulated
28:33together and both of these drugs
28:36bind his different part of the virus
28:38and by binding with the virus they
28:41neutralize it and prevent infection.
28:43The FDA images.
28:44Be available in August under
28:46emergency use authorization,
28:48and I'm sure most of you
28:49heard that term already.
28:50It's a mechanism for the FDA to
28:52make an experimental drug available
28:54before full approval when there's
28:57public health emergency.
28:59And obviously we are in the middle
29:01of 1 so that FDA approved this drug
29:06specifically to prevent COVID-19 infection
29:08in patients with weakened immune system.
29:12The definition here,
29:13patient with moderate to severe.
29:15Immune compromise,
29:16which encompasses most
29:17of not all our patients,
29:20and the idea here that this drug can be
29:22used in this patients because they have
29:25inadequate response to vaccinations.
29:28The study the drug would study
29:30in one clinical trial where
29:32it was compared to a patient,
29:34got the active drug and the other
29:36half did not and there was a big
29:38reduction in the number of patients
29:41who had COVID infection with symptoms.
29:44About 77%.
29:46Reduction.
29:47In terms of side effects,
29:48it would generally safe and well
29:50tolerated in clinical trials,
29:52so there's no safety concerns
29:53in terms of side effects,
29:55and you can see here the most
29:57side effects were headache,
29:58fatigue, and cough,
29:59and as you expect from age
30:02and intramuscular injection,
30:03there was some bleeding at
30:04the at the injection site.
30:06The way we administered the drug
30:08is 2 intramuscular injection.
30:10Given back to back in the same
30:13visit in the buttocks area.
30:16And after the injection,
30:17we asked that patient be monitored
30:20in the clinic for about an hour.
30:22Next slide, please.
30:29I don't know if you can
30:30able to forward or delay.
30:40OK, well there's the slide moves.
30:44I think it's moving slowly.
30:46I want to highlight some of the
30:48important factors that we want
30:50to mention about this drug.
30:51While it's effective in preventing infection,
30:55at least in this one clinical trial,
30:57it was really never studied in in
30:59patient who got in the vaccine.
31:01The study that was conducted with.
31:03Before any of the vaccines were available,
31:05so we don't know how effective this
31:07drug and in today's environment where
31:09most of our patients are already got
31:12in more than one dose of vaccination,
31:15it's not approved to treat patients who
31:18really have COVID infection and it's
31:20not approved for for patients who got
31:23exposed to somebody with their infection.
31:25So it's really truly a preventive
31:28method in eligible patients.
31:31And like I mentioned in the beginning,
31:33this is not it.
31:34To substitute vaccination because
31:35it is the best,
31:36vaccination is the best option we have today.
31:40And only other caveat in terms of safety,
31:43because it's an an injection
31:44in the muscles we need.
31:46It needs to be given in caution with patients
31:49with low platelets or bleeding disorders.
31:52So that's something we monitor
31:54for and make sure that their
31:57selection criteria is accurate.
32:00Next slide please.
32:03So where are we today?
32:04Because we before the meeting and
32:06throughout the last few weeks,
32:07we've gotten a lot of questions about
32:09every shield where it's available
32:11is available to meet for me today.
32:14So we we have some of the.
32:18The patient population that are
32:21eligible for this treatment today.
32:24The reason we had this specific patient
32:27population to start with is that the
32:30amount of violence or number of doses
32:31that we got when this program started.
32:34The government bought 300,000
32:35doses for the entire country.
32:37Early on, they distribute that
32:39throughout the country, state by state,
32:41and we had an allocation.
32:43So because of the limited supply and
32:45the potential for the large number
32:48of immunocompromise that we needed,
32:50at least I mentioned that.
32:52This patient population is quite
32:54large in the health system in
32:56cancer and also had cancer.
32:57We came up with this criteria
32:59identify who would likely benefit the
33:01most and you can see here all the
33:03indication and this is the first step,
33:05so we identify.
33:07Some population based on disease
33:09or treatment.
33:10Acute leukemia chronic leukemia
33:13transplant and others.
33:16But then we do a test to to make
33:18sure or to determine if this patient
33:20responded or did not respond to
33:22vaccine and based on that we make
33:24the decision who would likely
33:25benefit from this dose next.
33:27Next slide please.
33:29Our current recommendation today,
33:32vaccination should be first with
33:34the completion of the primary
33:36series or a booster dose.
33:40Two weeks after the the vaccine,
33:42we gonna measure response to that vaccine.
33:44But a blood test and the results
33:46of this test will guide weather.
33:48Ever shield can be beneficial or
33:51not patient who have low responsive
33:53vaccination as determined by these
33:55steps will can receive the medication.
33:58We have the drug available in all
34:00our clinics and and site so in terms
34:04of availability locally without
34:05having to travel to different
34:07location that is not an issue now.
34:10Our patients who are not eligible
34:12to receive the vaccine because
34:14of the treatment like bone marrow
34:17transplantation or we know based on
34:20response to previous vaccine doses
34:22that have not responded and those
34:25also can be eligible for every shield now.
34:28Without that additional test.
34:32I just have one slide about treatment.
34:35We talked about vaccination every
34:36shield as another way to prevent COVID,
34:39but unfortunately many of our patients and
34:43family and relatives do this positive.
34:47And when should we use some information
34:49about the drugs that we have today
34:51to treat COVID an ambulatory side?
34:53We also have different drugs in
34:55in the hospital there are two
34:57oral medication available today,
34:58back Slavic and maneuver.
35:00And there is one app, Ivy medication.
35:04So travel map.
35:06Those all this medication are
35:08available today.
35:09Luckily, because of the number of
35:11infection are are down in the state.
35:13You heard that early from Doctor Billingsley
35:15and a number of hospitalized patients.
35:17So because of the numbers of infection
35:20is down and the supply are now
35:23becoming steady to the health system,
35:25we opened our criteria where any of our
35:29patients if they need any of these drugs,
35:31will be available to them,
35:33the choice of which drug with our Ivy or P.
35:35Oh it depends a lot of factors.
35:37Some of the oral medication have a lot of.
35:40Actually both of them have side effects,
35:42one more than other.
35:43Without going a lot of details.
35:45So the right drug will depend for the.
35:48For the most part on.
35:51Medication history side effect
35:53profile and what we think will work.
35:55We are updating our guidelines at
35:58as as we speak and and then newest
36:01version will will guide clinician to
36:04the best option again for for every
36:07patient but drug driving traction
36:09is 1 factor but there are others.
36:11I think this is my last slide.
36:14Thank you so much and happy to
36:15answer any questions.
36:19Scott, are you speaking as well?
36:22Or are you here for questions primarily?
36:24I'm here for questions, right?
36:27So if I can make 2 quick comments one,
36:32although we don't know,
36:34many of us are very hopeful that
36:37we're really reaching the point
36:39where COVID is going to be endemic,
36:42not pandemic, and that life will very
36:46slowly become a little bit more normal.
36:49Maybe with some peaks and valleys of
36:52of having to step up our precautions.
36:55The one other thing I want to say which is
36:59for the 3.8 million breast cancer survivors,
37:03is that and I'm not contradicting
37:05Lisa because I I don't think that
37:08Lisa actually wrote some of the
37:10all of those guidelines herself,
37:12but I know of no evidence that
37:15a woman who's had breast cancer
37:17and is on hormonal therapy.
37:20With tamoxifen or an AROMATIZE
37:22inhibitor is immuno compromised?
37:24So I have no doubt that in this audience
37:27there are at least some number of women
37:30with breast cancer who are taking to
37:32marksman or in aroma taste inhibitor.
37:34And I'm talking about women with early
37:35stage breast cancer and I don't think
37:37you have to panic that you have to
37:39suddenly do something different in
37:40terms of your vaccination because I
37:42don't think that you're you should be
37:45vaccinated and you should be boosted but
37:47you don't have to worry excessively.
37:50Get your immunocompromised.
37:51Of course many,
37:52many of our other patients do need
37:55to worry about that.
37:56Lisa,
37:56you OK with that comment.
37:59Yes, I think in the early in the
38:02pandemic when we were formulating
38:04the third dose recommendations
38:05that thought was to air on the
38:08side of being cautious and liberal
38:10and that may be worth revisiting.
38:14But I I just don't want everyone
38:16to to to worry too much about that.
38:20So our last speaker and I think that
38:23the last two presentations have
38:25been pretty dense and I think that
38:29this presentation may be a little
38:31bit less dense and a nice break
38:34before we get to the the questions.
38:37So Dana Brewer is the creative expression
38:41coordinator in Smilow as part of
38:44the Integrative medicine program,
38:46and she is going to speak to us about
38:49creative expression and integrative medicine.
38:51In it thanks so much.
38:52And of course, let me just say that
38:55our integrative medicine program is
38:57a very important part of what we do,
38:59something that many patients look
39:02look to for help getting through
39:05their whole experience.
39:06And Dan is going to touch on this
39:09right? Thank you.
39:13Just gonna try to share a screen.
39:21OK, I'm Dana Brewer.
39:23I've been in the integrative
39:25medicine field for 20 years
39:27at Yale New Haven Hospital.
39:29I developed and coordinated the Creative
39:31expression program within SMILOW,
39:33so I've been doing that
39:34for the last 11 years.
39:38Integrative medicine offers care for
39:39the mind, the body and the spirit.
39:41The goal of our program is to empower our
39:44patients with knowledge and support needed.
39:46We help improve and maintain quality
39:49of life through treatment and beyond.
39:51We offer additional avenues for
39:52Wellness that we can help reduce some
39:55of the side effects of treatment.
39:59This is a sample of our virtual calendar
40:03for both patients and caregivers,
40:05'cause we recognize that being a.
40:19And caregiver is equally as
40:20important for these services,
40:21and high Cheech and we also have pregnant
40:23so you can watch them at your time.
40:26We offer outpatient massage and Reiki
40:28for people that don't know exactly
40:30what we do with integrative medicine.
40:32We have inpatient visits as well as at
40:35Smilow Cancer Hospital in New Haven.
40:37You can schedule by calling
40:38our department directly.
40:39You can get more information
40:41from us if you're inpatient,
40:43you could request a visit as an
40:45impatient through your care team.
40:47You could also schedule clinical
40:49consultations with Doctor Gary
40:51software that can provide guidance
40:53on nutritional interventions and
40:55mind body modalities and all of
40:58this information is on the calendar.
41:00And can be found at the Yale Cancer
41:03Center and Smilow Cancer Hospital at YN each.
41:06Each webpage under integrative medicine.
41:10And if you're on our email list,
41:11we send this out weekly to you
41:14so you'll know what's happening.
41:16But today I get to also share one
41:18of our ongoing latest projects,
41:21and it's called the Origami Crane project.
41:24The story of Sadako and the thousand
41:27paper Greens inspired Jean Parkin to
41:29begin creating origami cranes with our
41:31Fairfield Woods Middle School students,
41:34their families,
41:35friends and fellow teachers.
41:37Some of these beautiful cranes are
41:39hanging in the healing garden vestibule
41:41and became the start of this project.
41:43Since December,
41:44over 260 participants have created
41:491651 origami cranes.
41:50That number continues to grow as
41:53we keep adding to the display.
41:55It was really important
41:57during this challenging time,
41:59it became a tangible symbol of peace,
42:01hope, love and healing.
42:04And it provided connection for
42:06patients and our and our staff as well.
42:10The cranes that have been coming
42:11in are made from origami paper,
42:13wrapping paper, magazine and book pages,
42:16and as more cranes arrived.
42:18I sort them by color,
42:19thread them and I put them
42:21into the installation.
42:25The second part happened organically
42:27and we titled It Woven Together.
42:30I had left one personal message
42:32of encouragement and placed extra
42:34strips of paper alongside the nest
42:36that was on display with the cranes.
42:39I left a single marker and
42:41of course hand sanitizer.
42:43But no directions.
42:44And then the magic started to
42:46happen as usually does with
42:49these collaborative projects,
42:50and a dialogue ensued with
42:52messages for encouragement,
42:53gratitude, healing,
42:54and personal wishes from the end for us,
42:57Milo community, our youngest patients
42:59that visited the Healing Garden,
43:02left messages and I was there to
43:04witness one day, one of them writing,
43:06and he wrote, be brave,
43:07and he wrote,
43:08I love you and weaves them into
43:10the the nest display.
43:14I want to thank everyone for
43:16supporting creative expression
43:17in our collaborative projects
43:19within the hospital because I
43:21believe they're so important.
43:23And I invite you to visit our
43:25Yale Cancer Center integrative
43:26page For more information on
43:27our services and how to.
43:29And if you choose to,
43:30and I hope you do participate
43:32by emailing me your messages
43:35which will be added to our nest.
43:38The messages eventually with time
43:40and volume becoming the nest itself,
43:42so that'll be the second
43:43part of the project.
43:46And you can also contribute this
43:49product contribute to this project
43:51by still creating origami cranes.
43:53I'd like to share a quick 6050 second
43:57video that popped up as a memory
43:59on my phone and it will give you
44:01a glimpse into this installation.
45:05I want to thank you to everyone
45:07that participated thus far,
45:08and those that are intending to do so,
45:10and all of our guest artists,
45:12past and present, that have made our
45:14collaborative projects so successful.
45:15We'll be sharing more about this project
45:17and others on our social media platform.
45:22Yeah, thanks very much.
45:24There is actually a very lovely
45:27children's book about a young girl
45:30who lived through Hiroshima and
45:34who made cranes, origami cranes
45:37that was actually the
45:39catalyst for this project.
45:42I used to love to read it to my
45:44kids so it was really great.
45:46Before we get to some of the
45:49questions that relate to.
45:51Relate to vaccination.
45:52I just wanted to ask you to give us
45:56a sense of what percentage of the
46:00patients in smilow use the integrative
46:03medicine services and you know how
46:05we might encourage more of that.
46:09I think that with our virtual platform
46:12we were able to reach many more
46:14patients and their family members.
46:16Currently we see in patients we
46:18have people that are actively going
46:20upstairs and I know with the creative
46:22expression program our numbers have
46:24been really high because it's been
46:26very easy to participate virtually.
46:29And you know, I, I think it's a good lesson
46:32that we've learned from COVID and from how,
46:35in terms of how we practice medicine
46:37and how we care for people during COVID.
46:39And there are some lessons that we're going
46:42to want to take into life post pandemic.
46:45Alright, I'm going to move on and and
46:48there are a number of questions that
46:51that were submitted and I'm gonna
46:54turn to our our panelists for these.
46:57So here's the first of them.
46:58I'm being monitored for CLL.
47:00My accounts are slowly going up.
47:02I received a full dose of the
47:05Moderna vaccine as a booster a few
47:08weeks and by booster this this would
47:12presume presumably be the 3rd of
47:15this persons doses a few weeks before
47:18the guidelines were published,
47:20recommending a half dose.
47:22Should I now receive a fourth dose or what?
47:26We would now call the booster
47:27for this patient.
47:31I'm not going to call in people,
47:32I'm gonna just let you chime in.
47:36You want to take it,
47:36yeah? So you know I I specialize in
47:39CLL and this is a common question
47:41that I that I address daily with
47:43patients and so patients with CLL,
47:45even without treatment may not respond to the
47:48antibodies or not respond to the vaccines.
47:51And so when we only had two vaccines,
47:55we told patients to take good precautions
47:58to call us immediately if they had
48:00illness so they could be treated with
48:03antibody therapy and then a booster came
48:04and we were really excited about it and.
48:06Looking at those patients that
48:08didn't respond could respond.
48:09Many of those patients still don't respond,
48:12and so now we actually have other things,
48:14like a fourth dose or primary
48:17series in your booster.
48:19Or have you shelled?
48:20And so I think what we've developed
48:22here is if you've tolerated your three
48:25series well without side effects,
48:27get a fourth dose and that would
48:29be your first booster now within
48:31revised CDC guidance in two weeks,
48:34after three weeks after having antibody test.
48:36Benefits undetectable or less than 200,
48:39which is based off subsidy CDC guidance,
48:42as you shelled would likely
48:44be what we'd be recommending,
48:45and I think that is a general
48:48approach and whether you had the
48:51booster Moderna or full dose Moderna
48:53that is still being considered of
48:55how we would kind of address that.
48:57But in general,
48:58if we're using antibody levels
49:00now to kind of identify who might
49:02benefit the most from every shelled,
49:04I find that a more kind of rational.
49:06Thinking about how to identify
49:08those that are in greatest need
49:11for antibody prophylaxis,
49:13would that be filled?
49:14Thanks, Scott. The next question also?
49:18Or touches on antibody tests and is
49:24a fairly straightforward question.
49:26What does the antibody test
49:29mean in a 63 year old?
49:32Who is immuno compromised?
49:36Through a level of 63,
49:38so I think that so so the levels that
49:41we do obtain is semi quantitative.
49:43We don't exactly know what the level
49:45means in terms of reduction to the next
49:48variant or current circulating variance,
49:50but it tells us the antibody response.
49:52How robust antibody production
49:54was after the vaccination,
49:55and so based off of CDC guidance
49:58of using convalescent plasma
50:00which used about 210 cut off.
50:03That is currently what we're thinking.
50:05Are those folks that are most.
50:06I am in need or most likely
50:09to benefit from heavy shelled.
50:11These numbers can change,
50:12but that is generally what we're
50:14aiming for after a full series
50:17series three and a booster.
50:20If your levels over 210 generally,
50:23we'd be talking about delaying
50:25heavy shelled or additional
50:26strategies in the future.
50:29Can I just add one?
50:30Can I just add one quick caveat to that
50:32so the 210 applies to the Roach platform,
50:35which is what we use at why NHH?
50:38However, Quest Greenwich in Lab 4
50:40use different platforms and so that
50:42number cutoff may vary depending
50:44on where people get the lab.
50:46That's that's correct.
50:47For the Roach it's 210.
50:49So the answer depends on where
50:51the lab was obtained.
50:55OK, next.
50:59I'm eligible for my fourth shot this month,
51:02but it hasn't been a year yet since
51:04I stopped RTX and there's there's
51:06a theme here in terms of treatment.
51:09My understanding is that it can take
51:11a year for my B cells to come back.
51:13Would it be better for people like
51:15me to wait for my fourth shot
51:18until I'm a year off for Texan?
51:22I could take that.
51:23I mean this is a good question
51:25and the answer is we don't know.
51:26There's a lot of uncertainty here.
51:27I I think by adding this test based strategy,
51:30the antibody based strategy we at
51:32least have some understanding about
51:34how robust the immune responses in
51:35terms of the antibody production.
51:37So I think following what we're
51:40recommending and and and having a booster,
51:43a fourth dose in this situation,
51:45and checking a level is informative
51:48and things could change.
51:49We made you know,
51:51recommend additional levels in the fall.
51:53But at least right now this is a I
51:56think a good approach to you know,
51:59trying to understand timing away
52:01from rituximab and the antibody
52:02production after vaccine.
52:05Alright, so Sam I'm gonna.
52:09Give you this one, it's I think
52:12also pretty straightforward.
52:14The question is, can I go to the
52:16local pharmacy that gives COVID
52:18vaccine for the 4th vaccine?
52:21Yes, but they follow the
52:24CDC guidelines closely.
52:26So right now it says five months after
52:29your primary series and until that
52:32change any other duration you would
52:34be blocked so they are consistent
52:37with our recommendation today.
52:39CBS has exactly the same.
52:43Alright. I had Pfizer.
52:50The first Pfizer dose in January of 2021.
52:53The second Pfizer dose in February 21,
52:57then a Pfizer booster September 30th.
53:01I'm 80 and in good health.
53:03When should I get a second booster? Lisa
53:10so if I understand what you said
53:11correctly, they got 3 Pfizer shots.
53:16Correct it and its immuno compromised
53:18person and asking the question.
53:21Well the person says that he or
53:23she is 80 and in good health.
53:26OK so I'll answer it both ways.
53:28If they do not meet the criteria for
53:31being immuno compromised then they had
53:34their primary series of two doses and
53:37then they also completed their booster.
53:40So at this time there's no
53:42additional action needed.
53:44If the the person asking the question meets.
53:46Any of the criteria for immuno
53:49compromised and they completed 3
53:51doses of Pfizer then they completed
53:53their primary series after immuno
53:55compromised patients and they would
53:57be eligible for their first booster
53:59five months after the first job.
54:03Right? So the next question is a
54:07little different and and certainly
54:09demonstrates that sometimes our
54:11patients try to take care of us.
54:16And the question is when I come in
54:18for treatment, staff are very busy,
54:20many indicating that they're
54:22working double shifts.
54:23There are reports that doctors and
54:26nurses and other clinical staff working
54:29around are working around the clock.
54:32Our staff getting the time
54:34to rest and reflect.
54:38Doctor Weiner, I think both Kim
54:40and I can speak to this. And I.
54:44So appreciate the thoughtfulness of
54:46this question because our teams have
54:50been working very hard and we have
54:53been challenged over the past six
54:55weeks by both staff illness as well
54:57as some of the staffing challenges
55:00that health care organizations
55:02across the country have been facing.
55:05That being said, our frontline
55:07nurses in particularly in particular,
55:10have worked heroically.
55:12We have been able to retain.
55:15Many of our nursing staff members and
55:19I'm pleased to say that the rates of
55:22staff illness have dropped precipitously,
55:24and we're back on a very stable
55:27footing in terms of our staffing,
55:29both for frontline clinicians physicians,
55:33aips and nurses, and Kim early,
55:37so you probably have additional
55:39to add to that.
55:43Thanks, Kevin. I think the only thing
55:45I would add is we wish that our staff
55:49and our providers had more time.
55:51We are trying to provide them lots of
55:55resources that and avenues to provide,
55:58you know, to give themselves
56:00self care and take that time.
56:02But we have been leaning on every
56:04single team member and and there are
56:06times where they are working extra
56:08shifts and our teams across all
56:10smiles and helping each other out
56:13across sites and across inpatient and
56:15outpatient settings to make sure that
56:17we're taking care of our patients.
56:19And so again I can't extend my
56:21gratitude enough to the teens.
56:23And again I want to say exactly
56:26what Kevin said.
56:26It's very thoughtful and caring that you
56:29care about us as much as we care about you.
56:33But this is a very disruptive
56:35time across the country,
56:36in particular with nurse staffing,
56:39and we are really doing everything we
56:42can across the health system to be
56:45innovative and stabilizing our workforce.
56:48But it has been a difficult 2 1/2
56:50years for health care providers.
56:53I can just add a comment.
56:57We're really dealing with
57:00two separate issues.
57:01One is that for a number of years, there
57:06has been concern about physician burnout,
57:09and for that matter, nurse burnout.
57:12And you know, this is been a.
57:17Commonly discussed problem,
57:19and then we're also dealing with the
57:23so-called great resignation that has
57:25occurred associated with with the pandemic.
57:28I think that what we try very hard
57:32to do is to support all of the staff.
57:36The doctors, the nurses,
57:38the pharmacists, the social workers,
57:40everyone who is there. And.
57:44I don't think that we can overstate
57:47the importance of doing that,
57:49because the truth is.
57:51And this is,
57:52I think what is partially implied
57:54by the question is that when people
57:57are not feeling up to themselves and
57:59when they're not functioning at 100%,
58:02it's hard for us to do our jobs.
58:04So as you know,
58:06as a group of of leaders we are trying.
58:10Incredibly hard to make sure that
58:12during all of this that we're taking
58:15care of the people who work at smilow.
58:20And that we're setting them up for
58:22success in in in patient care and counters,
58:24because that's what we need to
58:27do for for all of you.
58:29I think we probably have time
58:32for one last question.
58:38And I'll I'll I'll.
58:41Pick the last question that
58:43was submitted on my sheet.
58:45If one continues with no immunity.
58:48What is the recommendation for a
58:51second booster for spouses or other
58:53family members living with the patient?
58:56Is there something unique or special
58:59that should be done for for those family
59:03members to give them extra protection?
59:06Scott, do you wanna take this?
59:08Yeah, at this point the general consensus
59:11is if you've are not immunosuppressed
59:14and you have a primary series of two
59:18vaccines and a third shot for booster,
59:20you are fairly well protected
59:23at severe illness.
59:25As a virus that will become endemic,
59:28it will occasionally circulate and
59:30in in many or most of us will be
59:33exposed and I do worry about our
59:35patients long term that that those
59:37that are on immunosuppressive agents
59:39may not have a response and so.
59:43A vaccination policies are important
59:46percautions when when the pandemic
59:49or endemic is raging is important,
59:52but also having treatments
59:53are incredibly important,
59:54so Sam had a nice slide at the last.
59:58You know, basically showing them
60:00the treatment options and for
01:00:02our patients that will be very
01:00:04important going in the future
01:00:05whether you've had vaccinations and
01:00:07then are treated with rituximab.
01:00:08Other important therapies,
01:00:09you may lose the response and
01:00:11having a backup having treatments.
01:00:13Is really critical and knowing that
01:00:15the current variant is sensitive to
01:00:18the current treatment is also very,
01:00:20very important,
01:00:21so the Omicron pandemic was was quite
01:00:24difficult for us because we lost some
01:00:27important therapies early with Omak, Ron.
01:00:29We now have new therapies that are effective,
01:00:31and so having you know your oncologist
01:00:34on speed dial and if you have concerns
01:00:37about COVID calling and asking about,
01:00:40are there treatments if you are exposed,
01:00:42that is a really critical importantly thing.
01:00:44To now going forward,
01:00:45because this is something that
01:00:47we'll be dealing with really for
01:00:48the months and years to come,
01:00:50and Sam is the one person who has made a
01:00:53comment in this question and answer period.
01:00:56I'm gonna give him a chance to make a
01:00:59a comment, but first let me just say
01:01:03that in my mind that the hidden heroes
01:01:06from patients are the pharmacists,
01:01:09the radiologists and the pathologist.
01:01:14You don't necessarily always
01:01:15see the pharmacists who are.
01:01:17Back mixing chemotherapy.
01:01:20Checking to make sure that you that you are
01:01:24patients get exactly the right drug dose,
01:01:27making sure that there isn't
01:01:30anything that needs one more check.
01:01:32One more question, so Sam.
01:01:34Any final comments.
01:01:38Nothing really other than glad to be here.
01:01:41Happy to do whatever we
01:01:43can to help our patients.
01:01:46I think this is a great team and we
01:01:49approach everything as a team so don't
01:01:52always wear my pharmacist at all.
01:01:54Just one team and do whatever is needed. So
01:01:57so I want to thank all of our
01:02:01speakers and and and panelists.
01:02:04I want to thank Renee Gaudet who.
01:02:07Is really the hidden person here who
01:02:09has put all of this together and
01:02:12organized us all and does this so
01:02:16seamlessly time after time and I want
01:02:20to thank all of you who attended.
01:02:23It was really great having you.
01:02:25I hope. I hope this was helpful to
01:02:27you and if you have suggestions
01:02:28for topics that you want us to
01:02:31cover in in future sessions,
01:02:32please reach out and and and let us know.
01:02:35And with that, goodnight.
01:02:37Have a have a good upcoming
01:02:39weekend bye bye right?