WEBVTT

NOTE duration: "00:56:40.343"


NOTE Confidence: 0.93632483

00:00:00.000 --> 00:00:01.120
I'll go ahead and get

NOTE Confidence: 0.93632483

00:00:01.120 --> 00:00:02.879
us started. So good evening.

NOTE Confidence: 0.93632483

00:00:02.879 --> 00:00:04.880
This is Smilo shares with

NOTE Confidence: 0.93632483

00:00:04.880 --> 00:00:06.019
primary care,

NOTE Confidence: 0.99932766

00:00:06.799 --> 00:00:08.420
which is a monthly

NOTE Confidence: 0.9998053

00:00:08.960 --> 00:00:09.460
series

NOTE Confidence: 0.95823085

00:00:10.639 --> 00:00:13.045
with primary care here at

NOTE Confidence: 0.95823085

00:00:13.045 --> 00:00:14.644
Northeast Medical Group and Yale

NOTE Confidence: 0.95823085

00:00:14.644 --> 00:00:15.865
New Haven Health System

NOTE Confidence: 0.8833659

00:00:16.404 --> 00:00:17.864
and our oncology

NOTE Confidence: 0.82112724

00:00:18.404 --> 00:00:19.945
Yale Cancer colleagues

NOTE Confidence: 0.74619365

00:00:20.324 --> 00:00:21.064
at SMILO.

NOTE Confidence: 0.996029

00:00:22.085 --> 00:00:23.785
We like to discuss topics

NOTE Confidence: 0.9823504

00:00:24.164 --> 00:00:26.000
where they may present in

NOTE Confidence: 0.9823504

00:00:26.000 --> 00:00:28.320
primary care. Primary care may

NOTE Confidence: 0.9823504

00:00:28.320 --> 00:00:30.000
have some testing to do,

NOTE Confidence: 0.9823504

00:00:30.000 --> 00:00:30.500
evaluation,

NOTE Confidence: 0.9974182

00:00:31.279 --> 00:00:33.059
have to decide on referral

NOTE Confidence: 0.9974182

00:00:33.120 --> 00:00:33.620
criteria,

NOTE Confidence: 0.9522354

00:00:34.800 --> 00:00:36.879
and get a good sense

NOTE Confidence: 0.9522354

00:00:36.879 --> 00:00:38.340
of what's going to happen.

NOTE Confidence: 0.86867857

00:00:40.254 --> 00:00:41.074
We will

NOTE Confidence: 0.9084905

00:00:41.774 --> 00:00:44.034
today be focusing on hematologic

NOTE Confidence: 0.7501181

00:00:44.815 --> 00:00:45.315
issues,

NOTE Confidence: 0.97184026

00:00:46.175 --> 00:00:47.534
with a special focus on

NOTE Confidence: 0.97184026

00:00:47.534 --> 00:00:48.915
when things are too high,

NOTE Confidence: 0.9937282

00:00:49.614 --> 00:00:51.214
and we'll get started there

NOTE Confidence: 0.9937282

00:00:51.214 --> 00:00:52.434
in just a second.

NOTE Confidence: 0.9243219

00:00:53.489 --> 00:00:55.010
But first, I wanna make

NOTE Confidence: 0.9243219

00:00:55.010 --> 00:00:56.390
sure I introduce,

NOTE Confidence: 0.86550415

00:00:57.250 --> 00:00:58.449
myself and,

NOTE Confidence: 0.8982895

00:00:59.010 --> 00:01:00.769
pass it over to, Anne

NOTE Confidence: 0.8982895

00:01:00.769 --> 00:01:01.269
Chang

NOTE Confidence: 0.73073024

00:01:01.649 --> 00:01:02.370
who is,

NOTE Confidence: 0.9644532

00:01:03.170 --> 00:01:05.170
in the Smilow Cancer Center

NOTE Confidence: 0.9644532

00:01:05.170 --> 00:01:06.310
and will introduce

NOTE Confidence: 0.998747

00:01:06.690 --> 00:01:08.229
her colleagues as well.

NOTE Confidence: 0.9757371

00:01:08.875 --> 00:01:10.555
So, I'm Karen Brown. I'm

NOTE Confidence: 0.9757371

00:01:10.555 --> 00:01:12.075
the medical director of primary

NOTE Confidence: 0.9757371

00:01:12.075 --> 00:01:13.675
care at Northeast Medical Group

NOTE Confidence: 0.9757371

00:01:13.675 --> 00:01:14.875
at Yale New Haven Health

NOTE Confidence: 0.9757371

00:01:14.875 --> 00:01:15.375
System.

NOTE Confidence: 0.886161

00:01:15.834 --> 00:01:17.135
And Frank Ciminielo

NOTE Confidence: 0.980918

00:01:17.755 --> 00:01:19.055
is my colleague,

NOTE Confidence: 0.99810255

00:01:19.755 --> 00:01:21.855
also a primary care physician

NOTE Confidence: 0.97214013

00:01:22.475 --> 00:01:23.375
with a background

NOTE Confidence: 0.96608216

00:01:23.950 --> 00:01:25.630
of a chemistry degree at

NOTE Confidence: 0.96608216

00:01:25.630 --> 00:01:26.690
Georgetown University,

NOTE Confidence: 0.9993963

00:01:27.790 --> 00:01:29.630
working as an HIV case

NOTE Confidence: 0.9993963

00:01:29.630 --> 00:01:30.130
manager

NOTE Confidence: 0.99108756

00:01:30.670 --> 00:01:31.709
back in what we would

NOTE Confidence: 0.99108756

00:01:31.709 --> 00:01:33.310
call the day when there

NOTE Confidence: 0.99108756

00:01:33.310 --> 00:01:33.709
was,

NOTE Confidence: 0.99904555

00:01:34.110 --> 00:01:34.610
uncontrolled

NOTE Confidence: 0.76463974

00:01:34.910 --> 00:01:35.410
HIV.

NOTE Confidence: 0.9874777

00:01:36.215 --> 00:01:37.655
And then, went to medical

NOTE Confidence: 0.9874777

00:01:37.655 --> 00:01:39.015
school at NYU and did

NOTE Confidence: 0.9874777

00:01:39.015 --> 00:01:40.455
his residency at University of

NOTE Confidence: 0.9874777

00:01:40.455 --> 00:01:40.955
Pennsylvania.

NOTE Confidence: 0.86768854

00:01:41.735 --> 00:01:43.355
He did a clinician educator

NOTE Confidence: 0.9618855

00:01:43.895 --> 00:01:45.515
fellowship and was on faculty

NOTE Confidence: 0.9618855

00:01:45.575 --> 00:01:47.415
there for four years before

NOTE Confidence: 0.9618855

00:01:47.415 --> 00:01:49.435
moving to Connecticut and joining,

NOTE Confidence: 0.91937727

00:01:50.040 --> 00:01:51.560
PrimeMed, which is a medical

NOTE Confidence: 0.91937727

00:01:51.560 --> 00:01:52.759
group which is now part

NOTE Confidence: 0.91937727

00:01:52.759 --> 00:01:53.159
of,

NOTE Confidence: 0.94259953

00:01:53.560 --> 00:01:55.420
larger Northeast Medical Group.

NOTE Confidence: 0.9958021

00:01:55.799 --> 00:01:57.320
He's received an MBA from

NOTE Confidence: 0.9958021

00:01:57.320 --> 00:01:58.700
the Yale School of Management

NOTE Confidence: 0.976458

00:01:59.079 --> 00:02:00.280
and is now both the

NOTE Confidence: 0.976458

00:02:00.280 --> 00:02:02.325
regional medical director for the

NOTE Confidence: 0.976458

00:02:02.564 --> 00:02:03.704
Bridgeport region,

NOTE Confidence: 0.8892187

00:02:04.325 --> 00:02:05.685
as well as the president

NOTE Confidence: 0.8892187

00:02:05.685 --> 00:02:07.225
of the Prime Med Physicians

NOTE Confidence: 0.8892187

00:02:07.365 --> 00:02:07.865
PSA.

NOTE Confidence: 0.97248846

00:02:08.565 --> 00:02:09.444
He's on the board of

NOTE Confidence: 0.97248846

00:02:09.444 --> 00:02:11.285
trustees and the CIN board

NOTE Confidence: 0.97248846

00:02:11.285 --> 00:02:11.944
of directors.

NOTE Confidence: 0.96833026

00:02:12.644 --> 00:02:14.245
And, he lives in Easton

NOTE Confidence: 0.96833026

00:02:14.245 --> 00:02:15.750
with his wife who's an

NOTE Confidence: 0.96833026

00:02:15.990 --> 00:02:17.669
OB GYN, so he always

NOTE Confidence: 0.96833026

00:02:17.669 --> 00:02:19.530
has extra perspective to add

NOTE Confidence: 0.9670574

00:02:19.830 --> 00:02:21.590
and, tells me that he's

NOTE Confidence: 0.9670574

00:02:21.590 --> 00:02:22.490
feeling miserable

NOTE Confidence: 0.99815243

00:02:22.870 --> 00:02:24.550
miserably at learning tennis in

NOTE Confidence: 0.99815243

00:02:24.550 --> 00:02:26.250
a world of pickleball players.

NOTE Confidence: 0.9824748

00:02:27.669 --> 00:02:28.790
Anne, I will pass it

NOTE Confidence: 0.9824748

00:02:28.790 --> 00:02:30.090
over to you to introduce,

NOTE Confidence: 0.9985512

00:02:30.470 --> 00:02:31.610
the rest of our speakers.

NOTE Confidence: 0.82211125

00:02:32.625 --> 00:02:33.985
Okay. Thank you. Frank that

NOTE Confidence: 0.82211125

00:02:33.985 --> 00:02:35.364
picture is a little old.

NOTE Confidence: 0.78600156

00:02:36.944 --> 00:02:37.905
I think that's all right.

NOTE Confidence: 0.78600156

00:02:37.905 --> 00:02:39.044
Doesn't do you justice.

NOTE Confidence: 0.9439913

00:02:39.984 --> 00:02:41.584
Thank you, Karen. This is

NOTE Confidence: 0.9439913

00:02:41.584 --> 00:02:42.325
such a

NOTE Confidence: 0.9356517

00:02:42.944 --> 00:02:44.385
pleasure to be here tonight.

NOTE Confidence: 0.9356517

00:02:44.385 --> 00:02:46.064
I'm a medical oncologist and

NOTE Confidence: 0.9356517

00:02:46.064 --> 00:02:48.620
also associate cancer center director

NOTE Confidence: 0.94020057

00:02:49.160 --> 00:02:51.240
for clinical initiatives. And tonight

NOTE Confidence: 0.94020057

00:02:51.240 --> 00:02:52.380
we have two SMILO

NOTE Confidence: 0.8657263

00:02:53.000 --> 00:02:54.220
colleagues of mine.

NOTE Confidence: 0.8628307

00:02:55.000 --> 00:02:56.940
Doctor. Kelsey Martin, who's an

NOTE Confidence: 0.8628307

00:02:57.080 --> 00:02:59.000
assistant professor of medicine in

NOTE Confidence: 0.8628307

00:02:59.000 --> 00:02:59.500
hematology.

NOTE Confidence: 0.97700906

00:03:00.255 --> 00:03:01.855
She received her medical degree

NOTE Confidence: 0.97700906

00:03:01.855 --> 00:03:03.055
from the Royal College of

NOTE Confidence: 0.97700906

00:03:03.055 --> 00:03:04.735
Surgeons in Dublin, Ireland and

NOTE Confidence: 0.97700906

00:03:04.735 --> 00:03:05.875
completed her residency

NOTE Confidence: 0.94456303

00:03:06.255 --> 00:03:07.615
in Internal Medicine at the

NOTE Confidence: 0.94456303

00:03:07.615 --> 00:03:10.014
Jacobi Medical Center, Albert Einstein

NOTE Confidence: 0.94456303

00:03:10.014 --> 00:03:11.294
College of Medicine in New

NOTE Confidence: 0.94456303

00:03:11.294 --> 00:03:11.794
York.

NOTE Confidence: 0.99016476

00:03:12.220 --> 00:03:14.239
She subsequently completed her subspecialty

NOTE Confidence: 0.95615244

00:03:14.540 --> 00:03:15.680
training in hematology

NOTE Confidence: 0.97643775

00:03:15.980 --> 00:03:17.739
and medical oncology at Lenox

NOTE Confidence: 0.97643775

00:03:17.739 --> 00:03:19.180
Hill Hospital in New York

NOTE Confidence: 0.97643775

00:03:19.180 --> 00:03:19.680
City,

NOTE Confidence: 0.9637319

00:03:20.139 --> 00:03:21.340
and has been here at

NOTE Confidence: 0.9637319

00:03:21.340 --> 00:03:22.720
Smilo since that time.

NOTE Confidence: 0.9941236

00:03:23.099 --> 00:03:24.060
It's such a joy to

NOTE Confidence: 0.9941236

00:03:24.060 --> 00:03:24.705
have you.

NOTE Confidence: 0.95999265

00:03:25.185 --> 00:03:26.085
And also,

NOTE Confidence: 0.9318754

00:03:27.105 --> 00:03:29.205
Doctor. Martin's clinical interests include,

NOTE Confidence: 0.98024

00:03:30.065 --> 00:03:30.965
patient communication,

NOTE Confidence: 0.9865458

00:03:31.264 --> 00:03:31.764
hematology,

NOTE Confidence: 0.98033816

00:03:32.385 --> 00:03:32.885
hematologic

NOTE Confidence: 0.99922705

00:03:33.264 --> 00:03:33.764
disorders

NOTE Confidence: 0.9498963

00:03:34.065 --> 00:03:36.225
in women, cancer prevention, including

NOTE Confidence: 0.9498963

00:03:36.225 --> 00:03:38.085
the role of nutrition, obesity

NOTE Confidence: 0.9498963

00:03:38.225 --> 00:03:39.765
and the environment in cancer.

NOTE Confidence: 0.9608591

00:03:40.140 --> 00:03:41.579
She's actively involved in the

NOTE Confidence: 0.9608591

00:03:41.579 --> 00:03:42.860
Yale community as a member

NOTE Confidence: 0.9608591

00:03:42.860 --> 00:03:44.060
of status of women in

NOTE Confidence: 0.9608591

00:03:44.060 --> 00:03:45.980
medicine and the women faculty

NOTE Confidence: 0.9608591

00:03:45.980 --> 00:03:46.480
forum.

NOTE Confidence: 0.9333849

00:03:46.939 --> 00:03:48.379
And she's an highly engaged

NOTE Confidence: 0.9333849

00:03:48.379 --> 00:03:49.900
member of the American society

NOTE Confidence: 0.9333849

00:03:49.900 --> 00:03:50.560
of hematology

NOTE Confidence: 0.9656308

00:03:51.099 --> 00:03:51.900
as a member of the

NOTE Confidence: 0.9656308

00:03:51.900 --> 00:03:53.680
committee and practice and representative

NOTE Confidence: 0.9656308

00:03:53.900 --> 00:03:54.720
for the AMA

NOTE Confidence: 0.94258314

00:03:55.185 --> 00:03:56.165
House of Delegates.

NOTE Confidence: 0.97219664

00:03:57.185 --> 00:03:58.944
Doctor. Martin's interested in how

NOTE Confidence: 0.97219664

00:03:58.944 --> 00:04:00.805
sex and gender influence health

NOTE Confidence: 0.97219664

00:04:00.944 --> 00:04:02.545
and collaborates with the women's

NOTE Confidence: 0.97219664

00:04:02.545 --> 00:04:04.065
health research at Yale. So

NOTE Confidence: 0.97219664

00:04:04.065 --> 00:04:04.965
thank you, Kelsey.

NOTE Confidence: 0.95006084

00:04:05.584 --> 00:04:06.625
And then I'd like to

NOTE Confidence: 0.95006084

00:04:06.625 --> 00:04:09.285
also introduce Doctor. Anish Sharda

NOTE Confidence: 0.95006084

00:04:09.530 --> 00:04:10.430
who's an assistant

NOTE Confidence: 0.8476922

00:04:10.730 --> 00:04:12.349
professor of medicine in hematology.

NOTE Confidence: 0.9195467

00:04:12.890 --> 00:04:14.250
And he cares for patients

NOTE Confidence: 0.9195467

00:04:14.250 --> 00:04:15.310
as part of the SMILO

NOTE Confidence: 0.9195467

00:04:15.530 --> 00:04:17.150
Classic Hematology Program,

NOTE Confidence: 0.93821543

00:04:17.690 --> 00:04:19.550
previously known as benign hematology.

NOTE Confidence: 0.93821543

00:04:19.610 --> 00:04:20.910
Now we call it classic.

NOTE Confidence: 0.94309103

00:04:21.610 --> 00:04:23.370
His clinical and research interests

NOTE Confidence: 0.94309103

00:04:23.370 --> 00:04:24.889
are in bleeding, clotting and

NOTE Confidence: 0.94309103

00:04:24.889 --> 00:04:27.764
plateless platelet disorders. His research,

NOTE Confidence: 0.96787465

00:04:30.544 --> 00:04:32.544
in vascular biology is, is

NOTE Confidence: 0.96787465

00:04:32.544 --> 00:04:33.685
funded by the NIH.

NOTE Confidence: 0.9637815

00:04:34.065 --> 00:04:35.745
He received his medical degree

NOTE Confidence: 0.9637815

00:04:35.745 --> 00:04:37.365
from the BP Koala

NOTE Confidence: 0.8133405

00:04:37.760 --> 00:04:39.779
Institute of Health Scientists in,

NOTE Confidence: 0.9216178

00:04:40.080 --> 00:04:42.080
Dharan, Nepal and completed his

NOTE Confidence: 0.9216178

00:04:42.080 --> 00:04:43.520
residency at the University of

NOTE Confidence: 0.9216178

00:04:43.520 --> 00:04:44.980
Minnesota Medical Center,

NOTE Confidence: 0.8823976

00:04:45.600 --> 00:04:47.200
followed by clinical and research

NOTE Confidence: 0.8823976

00:04:47.200 --> 00:04:49.779
fellowship and the Hemang fellowship

NOTE Confidence: 0.8823976

00:04:49.839 --> 00:04:51.760
at BI Deaconess Medical Center

NOTE Confidence: 0.8823976

00:04:51.760 --> 00:04:53.035
and Harvard Medical School in

NOTE Confidence: 0.8823976

00:04:53.035 --> 00:04:54.095
Boston. So

NOTE Confidence: 0.9883506

00:04:54.395 --> 00:04:56.335
welcome to both of you.

NOTE Confidence: 0.38876128

00:04:57.755 --> 00:04:58.255
And

NOTE Confidence: 0.94827896

00:04:58.635 --> 00:04:59.675
I'm gonna turn it over

NOTE Confidence: 0.94827896

00:04:59.675 --> 00:05:01.375
to doctor oops, sorry.

NOTE Confidence: 0.9508931

00:05:01.995 --> 00:05:03.035
Oh, I was just gonna

NOTE Confidence: 0.9508931

00:05:03.035 --> 00:05:04.154
say, we're gonna turn it

NOTE Confidence: 0.9508931

00:05:04.154 --> 00:05:05.675
over to doctor Chimenola to

NOTE Confidence: 0.9508931

00:05:05.675 --> 00:05:06.635
get us started with the

NOTE Confidence: 0.9508931

00:05:06.635 --> 00:05:07.135
cases.

NOTE Confidence: 0.9659155

00:05:07.630 --> 00:05:08.990
If you have questions as

NOTE Confidence: 0.9659155

00:05:08.990 --> 00:05:10.430
we go, please feel free

NOTE Confidence: 0.9659155

00:05:10.430 --> 00:05:11.630
to enter them in the

NOTE Confidence: 0.9659155

00:05:11.630 --> 00:05:13.150
q and a section and

NOTE Confidence: 0.9659155

00:05:13.150 --> 00:05:14.589
we will, break at the

NOTE Confidence: 0.9659155

00:05:14.589 --> 00:05:16.589
appropriate point to answer them.

NOTE Confidence: 0.9659155

00:05:16.910 --> 00:05:18.029
It's it's part of what

NOTE Confidence: 0.9659155

00:05:18.029 --> 00:05:19.390
makes this series great is

NOTE Confidence: 0.9659155

00:05:19.390 --> 00:05:21.230
the ability to really answer

NOTE Confidence: 0.9659155

00:05:21.230 --> 00:05:23.089
questions real time throughout.

NOTE Confidence: 0.94069326

00:05:23.845 --> 00:05:24.884
And I see some of

NOTE Confidence: 0.94069326

00:05:24.884 --> 00:05:25.625
our regulars,

NOTE Confidence: 0.95317143

00:05:26.324 --> 00:05:27.525
and you guys are always

NOTE Confidence: 0.95317143

00:05:27.525 --> 00:05:28.645
very engaged. So thank you

NOTE Confidence: 0.95317143

00:05:28.645 --> 00:05:29.525
again. I know it's a

NOTE Confidence: 0.95317143

00:05:29.525 --> 00:05:31.224
busy time. Happy New Year,

NOTE Confidence: 0.99540126

00:05:31.844 --> 00:05:33.365
and we'll we'll get started.

NOTE Confidence: 0.99540126

00:05:33.365 --> 00:05:34.504
Thank you for attending.

NOTE Confidence: 0.93652797

00:05:35.620 --> 00:05:36.900
Yeah. Well, yeah. Yeah. Thank

NOTE Confidence: 0.93652797

00:05:36.900 --> 00:05:37.720
you for attending.

NOTE Confidence: 0.9954555

00:05:38.180 --> 00:05:39.160
Thank you for

NOTE Confidence: 0.8372368

00:05:39.539 --> 00:05:40.600
having me. So,

NOTE Confidence: 0.9123501

00:05:41.380 --> 00:05:43.539
these are two cases from

NOTE Confidence: 0.9123501

00:05:43.539 --> 00:05:44.440
my panel.

NOTE Confidence: 0.9991432

00:05:44.979 --> 00:05:46.199
The data is

NOTE Confidence: 0.8098436

00:05:47.380 --> 00:05:48.979
a hundred percent like just

NOTE Confidence: 0.8098436

00:05:48.979 --> 00:05:50.339
transferred over and you'll and

NOTE Confidence: 0.8098436

00:05:50.339 --> 00:05:51.080
then you'll

NOTE Confidence: 0.9771627

00:05:52.545 --> 00:05:54.065
you'll see where maybe I

NOTE Confidence: 0.9771627

00:05:54.065 --> 00:05:54.945
could have done a little

NOTE Confidence: 0.9771627

00:05:54.945 --> 00:05:56.085
more before referral,

NOTE Confidence: 0.9781444

00:05:56.785 --> 00:05:57.745
as well. So these are

NOTE Confidence: 0.9781444

00:05:57.745 --> 00:05:59.665
just, real cases I thought

NOTE Confidence: 0.9781444

00:05:59.665 --> 00:06:01.345
would make the most sense

NOTE Confidence: 0.9781444

00:06:01.345 --> 00:06:02.464
to to you all, the

NOTE Confidence: 0.9781444

00:06:02.464 --> 00:06:04.480
audience, and and, hopefully,

NOTE Confidence: 0.9960365

00:06:05.020 --> 00:06:06.160
you agree. So,

NOTE Confidence: 0.95165586

00:06:06.700 --> 00:06:07.820
we're gonna talk about two

NOTE Confidence: 0.95165586

00:06:07.820 --> 00:06:09.420
cases where the blood counts

NOTE Confidence: 0.95165586

00:06:09.420 --> 00:06:10.460
are high. Right? We think

NOTE Confidence: 0.95165586

00:06:10.460 --> 00:06:12.140
about referring for a lot

NOTE Confidence: 0.95165586

00:06:12.140 --> 00:06:13.100
of lows, a lot of

NOTE Confidence: 0.95165586

00:06:13.100 --> 00:06:14.460
penis, but there's a lot

NOTE Confidence: 0.95165586

00:06:14.460 --> 00:06:15.200
of elevated

NOTE Confidence: 0.9751708

00:06:15.714 --> 00:06:17.875
and abnormal blood counts, when

NOTE Confidence: 0.9751708

00:06:17.875 --> 00:06:19.634
you start, looking. And there's

NOTE Confidence: 0.9751708

00:06:19.634 --> 00:06:21.175
a substantial amount of prework,

NOTE Confidence: 0.99891883

00:06:21.955 --> 00:06:23.154
that can be done prior

NOTE Confidence: 0.99891883

00:06:23.154 --> 00:06:23.815
to referral,

NOTE Confidence: 0.9795475

00:06:24.354 --> 00:06:25.955
which may actually eliminate the

NOTE Confidence: 0.9795475

00:06:25.955 --> 00:06:27.014
need for a referral,

NOTE Confidence: 0.9766687

00:06:27.555 --> 00:06:28.755
in some cases, but also

NOTE Confidence: 0.9766687

00:06:28.755 --> 00:06:30.035
sort of identify people who

NOTE Confidence: 0.9766687

00:06:30.035 --> 00:06:31.495
need more urgent referrals,

NOTE Confidence: 0.91468734

00:06:31.850 --> 00:06:33.370
as well. And so we'll

NOTE Confidence: 0.91468734

00:06:33.370 --> 00:06:34.810
go through, these cases. If

NOTE Confidence: 0.91468734

00:06:34.810 --> 00:06:36.270
I get the next slide,

NOTE Confidence: 0.91468734

00:06:36.410 --> 00:06:38.089
please. So the first case

NOTE Confidence: 0.91468734

00:06:38.089 --> 00:06:39.630
was, is a gentleman

NOTE Confidence: 0.96351385

00:06:40.490 --> 00:06:42.330
who, about eight years ago,

NOTE Confidence: 0.96351385

00:06:42.330 --> 00:06:42.990
we saw,

NOTE Confidence: 0.99573326

00:06:43.529 --> 00:06:44.589
for fatigue

NOTE Confidence: 0.94465506

00:06:46.025 --> 00:06:46.525
and

NOTE Confidence: 0.90360796

00:06:47.064 --> 00:06:49.164
not a significant medical problem.

NOTE Confidence: 0.9502303

00:06:49.544 --> 00:06:50.904
History, just really high blood

NOTE Confidence: 0.9502303

00:06:50.904 --> 00:06:52.264
pressure was his only active

NOTE Confidence: 0.9502303

00:06:52.264 --> 00:06:53.625
problem. He was at the

NOTE Confidence: 0.9502303

00:06:53.625 --> 00:06:55.404
time on lisinopril and hydrochlorothiazide,

NOTE Confidence: 0.9256368

00:06:56.824 --> 00:06:59.305
married, no real, significant social

NOTE Confidence: 0.9256368

00:06:59.305 --> 00:06:59.805
history,

NOTE Confidence: 0.93959785

00:07:00.389 --> 00:07:01.710
works as a social worker

NOTE Confidence: 0.93959785

00:07:01.710 --> 00:07:01.910
and,

NOTE Confidence: 0.88970315

00:07:03.110 --> 00:07:04.810
licensed clinical social worker.

NOTE Confidence: 0.8832819

00:07:05.589 --> 00:07:06.729
BMI was was

NOTE Confidence: 0.9237931

00:07:07.029 --> 00:07:09.430
technically over, overweight, but but

NOTE Confidence: 0.9237931

00:07:09.430 --> 00:07:10.490
but pretty good.

NOTE Confidence: 0.9666483

00:07:11.270 --> 00:07:12.150
And you can see his

NOTE Confidence: 0.9666483

00:07:12.150 --> 00:07:13.270
family history, which did sort

NOTE Confidence: 0.9666483

00:07:13.270 --> 00:07:13.590
of,

NOTE Confidence: 0.9111615

00:07:14.150 --> 00:07:15.210
include some

NOTE Confidence: 0.84775454

00:07:15.525 --> 00:07:16.985
some potential hematolite,

NOTE Confidence: 0.8428981

00:07:18.005 --> 00:07:19.065
heme or hemonc,

NOTE Confidence: 0.9822407

00:07:19.845 --> 00:07:21.525
diseases. So he came in

NOTE Confidence: 0.9822407

00:07:21.525 --> 00:07:22.345
for fatigue.

NOTE Confidence: 0.94698465

00:07:22.885 --> 00:07:24.165
We ran simple perfect. We

NOTE Confidence: 0.94698465

00:07:24.165 --> 00:07:25.125
ran some blood work and

NOTE Confidence: 0.94698465

00:07:25.125 --> 00:07:26.985
found that, initially his hemoglobin

NOTE Confidence: 0.94698465

00:07:27.285 --> 00:07:27.785
was,

NOTE Confidence: 0.7510143

00:07:28.485 --> 00:07:28.985
elevated,

NOTE Confidence: 0.99094176

00:07:30.050 --> 00:07:31.410
slightly. The rest of his

NOTE Confidence: 0.99094176

00:07:31.410 --> 00:07:33.430
CBC was, generally unremarkable.

NOTE Confidence: 0.93517816

00:07:34.770 --> 00:07:36.229
We actually stopped his hydrochlorothiazide,

NOTE Confidence: 0.9867686

00:07:38.130 --> 00:07:40.770
and, rechecked, but the CBC

NOTE Confidence: 0.9867686

00:07:40.770 --> 00:07:42.789
was relatively unchanged. The hemoglobin

NOTE Confidence: 0.977074

00:07:43.354 --> 00:07:44.815
had stayed in the seventeen

NOTE Confidence: 0.977074

00:07:45.035 --> 00:07:46.555
to seventeen point five range.

NOTE Confidence: 0.977074

00:07:46.555 --> 00:07:47.055
So

NOTE Confidence: 0.95495707

00:07:47.995 --> 00:07:50.074
mildly elevated. And other than

NOTE Confidence: 0.95495707

00:07:50.074 --> 00:07:51.835
the fatigue, really no other

NOTE Confidence: 0.95495707

00:07:51.835 --> 00:07:52.335
symptoms.

NOTE Confidence: 0.928549

00:07:53.115 --> 00:07:54.395
We, we started the workup,

NOTE Confidence: 0.928549

00:07:54.395 --> 00:07:55.595
which showed the normal iron

NOTE Confidence: 0.928549

00:07:55.595 --> 00:07:56.095
studies,

NOTE Confidence: 0.86368823

00:07:57.514 --> 00:07:58.655
that you saw before.

NOTE Confidence: 0.92203414

00:07:59.220 --> 00:08:00.660
And, and then sort of

NOTE Confidence: 0.92203414

00:08:00.660 --> 00:08:01.780
kind of what and we

NOTE Confidence: 0.92203414

00:08:01.780 --> 00:08:03.060
were at and those were

NOTE Confidence: 0.92203414

00:08:03.060 --> 00:08:03.560
unrevealing.

NOTE Confidence: 0.9699258

00:08:04.260 --> 00:08:05.140
And then sort of the

NOTE Confidence: 0.9699258

00:08:05.140 --> 00:08:06.100
plan was sort of, you

NOTE Confidence: 0.9699258

00:08:06.100 --> 00:08:07.620
know, what, what next? And

NOTE Confidence: 0.9699258

00:08:07.620 --> 00:08:08.120
so,

NOTE Confidence: 0.94349617

00:08:08.660 --> 00:08:10.020
before we go back to,

NOTE Confidence: 0.94349617

00:08:10.020 --> 00:08:11.460
to him, just sort of

NOTE Confidence: 0.94349617

00:08:11.460 --> 00:08:12.760
a little bit of a,

NOTE Confidence: 0.8543508

00:08:13.384 --> 00:08:14.125
a reintroduction

NOTE Confidence: 0.95798963

00:08:14.664 --> 00:08:15.945
to people on the care

NOTE Confidence: 0.95798963

00:08:15.945 --> 00:08:17.005
signature pathways.

NOTE Confidence: 0.9970139

00:08:17.625 --> 00:08:18.585
And you can see that

NOTE Confidence: 0.9970139

00:08:18.585 --> 00:08:19.405
in the last

NOTE Confidence: 0.9664081

00:08:19.945 --> 00:08:21.805
few months, they've really,

NOTE Confidence: 0.7088167

00:08:22.905 --> 00:08:23.405
increased

NOTE Confidence: 0.94867116

00:08:23.945 --> 00:08:25.405
especially in some of the

NOTE Confidence: 0.9967053

00:08:25.960 --> 00:08:26.780
basic hematologic

NOTE Confidence: 0.9586462

00:08:27.160 --> 00:08:28.200
diseases. And you can you

NOTE Confidence: 0.9586462

00:08:28.200 --> 00:08:30.060
can see some some here.

NOTE Confidence: 0.8887714

00:08:31.800 --> 00:08:33.260
As most of you know,

NOTE Confidence: 0.8887714

00:08:33.320 --> 00:08:35.260
the the care signature pathways

NOTE Confidence: 0.8805368

00:08:35.880 --> 00:08:37.320
are pathways that are designed

NOTE Confidence: 0.8805368

00:08:37.320 --> 00:08:37.820
by,

NOTE Confidence: 0.88520163

00:08:38.342 --> 00:08:39.925
of a group of our

NOTE Confidence: 0.88520163

00:08:39.925 --> 00:08:40.425
local,

NOTE Confidence: 0.98651856

00:08:41.125 --> 00:08:42.345
clinicians and experts,

NOTE Confidence: 0.97097313

00:08:42.804 --> 00:08:44.005
to provide sort of best

NOTE Confidence: 0.97097313

00:08:44.005 --> 00:08:46.245
practices for a certain condition,

NOTE Confidence: 0.97097313

00:08:46.245 --> 00:08:48.405
a certain, problem. We probably

NOTE Confidence: 0.97097313

00:08:48.405 --> 00:08:50.085
all know it started or

NOTE Confidence: 0.97097313

00:08:50.085 --> 00:08:52.485
or, really gained some some

NOTE Confidence: 0.97097313

00:08:52.485 --> 00:08:54.184
fame with the COVID.

NOTE Confidence: 0.9192319

00:08:54.720 --> 00:08:56.100
But now is,

NOTE Confidence: 0.7858081

00:08:57.839 --> 00:08:58.660
the number,

NOTE Confidence: 0.9494369

00:08:59.519 --> 00:09:00.800
and then the depth of

NOTE Confidence: 0.9494369

00:09:00.800 --> 00:09:02.079
some of the information you

NOTE Confidence: 0.9494369

00:09:02.079 --> 00:09:03.519
get from there is, is

NOTE Confidence: 0.9494369

00:09:03.519 --> 00:09:05.199
incredible. And, and it's a

NOTE Confidence: 0.9494369

00:09:05.199 --> 00:09:05.699
live,

NOTE Confidence: 0.95538336

00:09:06.959 --> 00:09:08.079
a live document, so to

NOTE Confidence: 0.95538336

00:09:08.079 --> 00:09:10.095
speak, where it it's continuing

NOTE Confidence: 0.95538336

00:09:10.315 --> 00:09:11.135
to change.

NOTE Confidence: 0.9909595

00:09:11.995 --> 00:09:12.815
And so

NOTE Confidence: 0.9779561

00:09:13.515 --> 00:09:15.275
just, so these are some

NOTE Confidence: 0.9779561

00:09:15.275 --> 00:09:16.175
of the new ones,

NOTE Confidence: 0.96494776

00:09:16.635 --> 00:09:17.934
or some of them, including

NOTE Confidence: 0.96494776

00:09:18.075 --> 00:09:20.415
some that are really relatively

NOTE Confidence: 0.96494776

00:09:20.554 --> 00:09:21.835
brand new. Another reason we

NOTE Confidence: 0.96494776

00:09:21.835 --> 00:09:23.035
pick some of these cases

NOTE Confidence: 0.96494776

00:09:23.035 --> 00:09:23.995
was to highlight some of

NOTE Confidence: 0.96494776

00:09:23.995 --> 00:09:26.010
the new care signature pathways.

NOTE Confidence: 0.99153775

00:09:26.870 --> 00:09:27.670
If I can get to

NOTE Confidence: 0.99153775

00:09:27.670 --> 00:09:29.530
the next slide, please. So,

NOTE Confidence: 0.98300236

00:09:30.150 --> 00:09:31.530
as you can see here,

NOTE Confidence: 0.98300236

00:09:31.830 --> 00:09:33.510
there's a pretty substantial care

NOTE Confidence: 0.98300236

00:09:33.510 --> 00:09:34.410
signature pathway,

NOTE Confidence: 0.98404235

00:09:35.190 --> 00:09:36.090
for an elevated,

NOTE Confidence: 0.92816

00:09:36.550 --> 00:09:37.050
hemoglobin.

NOTE Confidence: 0.9600396

00:09:38.465 --> 00:09:39.285
Should have mentioned

NOTE Confidence: 0.9206803

00:09:39.745 --> 00:09:41.345
in in the history part

NOTE Confidence: 0.9206803

00:09:41.345 --> 00:09:43.125
that his pulse ox had

NOTE Confidence: 0.9206803

00:09:43.184 --> 00:09:44.085
been consistently

NOTE Confidence: 0.99781096

00:09:44.545 --> 00:09:45.045
normal.

NOTE Confidence: 0.9338819

00:09:45.585 --> 00:09:47.285
We saw, I'm on the

NOTE Confidence: 0.9338819

00:09:47.505 --> 00:09:49.025
right side actually now some

NOTE Confidence: 0.9338819

00:09:49.025 --> 00:09:50.465
of the basic stuff. You

NOTE Confidence: 0.9338819

00:09:50.465 --> 00:09:51.845
know, he wasn't on testosterone,

NOTE Confidence: 0.9543383

00:09:53.360 --> 00:09:55.120
as well. But if you

NOTE Confidence: 0.9543383

00:09:55.120 --> 00:09:56.240
start looking and you can

NOTE Confidence: 0.9543383

00:09:56.240 --> 00:09:57.200
see some of the things

NOTE Confidence: 0.9543383

00:09:57.200 --> 00:09:58.000
that we had done now

NOTE Confidence: 0.9543383

00:09:58.000 --> 00:09:59.200
this was twenty in my

NOTE Confidence: 0.9543383

00:09:59.200 --> 00:10:00.720
defense, it was twenty fifteen,

NOTE Confidence: 0.9543383

00:10:00.720 --> 00:10:01.840
so there wasn't a cancerous

NOTE Confidence: 0.9543383

00:10:01.840 --> 00:10:02.880
pathway, but there was an

NOTE Confidence: 0.9543383

00:10:02.880 --> 00:10:04.320
up to date. So we

NOTE Confidence: 0.9543383

00:10:04.320 --> 00:10:05.360
did some of the workup.

NOTE Confidence: 0.9543383

00:10:05.360 --> 00:10:06.160
As you can see, there's

NOTE Confidence: 0.9543383

00:10:06.160 --> 00:10:07.120
probably a little bit more

NOTE Confidence: 0.9543383

00:10:07.120 --> 00:10:08.175
that we should have done.

NOTE Confidence: 0.9543383

00:10:08.255 --> 00:10:09.375
He certainly didn't need an

NOTE Confidence: 0.9543383

00:10:09.375 --> 00:10:10.355
urgent referral,

NOTE Confidence: 0.8410642

00:10:12.095 --> 00:10:13.535
but the care synergy pathway

NOTE Confidence: 0.8410642

00:10:13.535 --> 00:10:14.755
really does sort of,

NOTE Confidence: 0.9806145

00:10:15.855 --> 00:10:16.995
I find to be incredibly

NOTE Confidence: 0.9806145

00:10:17.054 --> 00:10:17.554
helpful,

NOTE Confidence: 0.98356074

00:10:18.015 --> 00:10:19.455
for some, for a lot

NOTE Confidence: 0.98356074

00:10:19.455 --> 00:10:20.274
of the hematologic

NOTE Confidence: 0.6092245

00:10:20.894 --> 00:10:21.394
diseases

NOTE Confidence: 0.9929857

00:10:21.855 --> 00:10:22.595
in particular.

NOTE Confidence: 0.944028

00:10:25.440 --> 00:10:27.040
I'm I'm gonna, we'll go

NOTE Confidence: 0.944028

00:10:27.040 --> 00:10:27.860
to the next

NOTE Confidence: 0.84552956

00:10:28.399 --> 00:10:28.899
slide,

NOTE Confidence: 0.9386131

00:10:29.920 --> 00:10:32.100
and, I'm gonna pass this,

NOTE Confidence: 0.7687911

00:10:32.959 --> 00:10:33.459
forward,

NOTE Confidence: 0.9824729

00:10:34.959 --> 00:10:36.480
but, I'm gonna stick around

NOTE Confidence: 0.9824729

00:10:36.480 --> 00:10:38.019
if there's any questions from,

NOTE Confidence: 0.9873227

00:10:38.645 --> 00:10:39.304
for me.

NOTE Confidence: 0.99561745

00:10:41.765 --> 00:10:42.265
Great.

NOTE Confidence: 0.9696146

00:10:43.205 --> 00:10:44.405
Thank you, Frank. So,

NOTE Confidence: 0.9736035

00:10:45.285 --> 00:10:46.425
I'm gonna go through,

NOTE Confidence: 0.92720515

00:10:46.804 --> 00:10:48.184
initially, some definitions

NOTE Confidence: 0.9927879

00:10:48.725 --> 00:10:49.385
of erythrocytosis,

NOTE Confidence: 0.96245086

00:10:50.405 --> 00:10:51.445
just because I actually think

NOTE Confidence: 0.96245086

00:10:51.445 --> 00:10:52.965
that's where the referral starts.

NOTE Confidence: 0.96245086

00:10:52.965 --> 00:10:54.890
Sometimes different labs might have

NOTE Confidence: 0.96245086

00:10:54.890 --> 00:10:56.110
different normal ranges,

NOTE Confidence: 0.98538804

00:10:56.890 --> 00:10:58.730
which could flag something as

NOTE Confidence: 0.98538804

00:10:58.730 --> 00:11:00.329
potentially being high when maybe

NOTE Confidence: 0.98538804

00:11:00.329 --> 00:11:01.529
we don't consider it as

NOTE Confidence: 0.98538804

00:11:01.529 --> 00:11:02.029
such.

NOTE Confidence: 0.9481716

00:11:02.970 --> 00:11:03.450
But,

NOTE Confidence: 0.98788285

00:11:04.010 --> 00:11:05.550
there are sex differences,

NOTE Confidence: 0.982975

00:11:06.250 --> 00:11:07.709
in how we define arthrocytosis

NOTE Confidence: 0.96160966

00:11:08.170 --> 00:11:09.595
and for sixteen point five

NOTE Confidence: 0.96160966

00:11:09.595 --> 00:11:10.795
grams per deciliter for males

NOTE Confidence: 0.96160966

00:11:10.795 --> 00:11:12.554
and sixteen grams per deciliter

NOTE Confidence: 0.96160966

00:11:12.554 --> 00:11:14.255
for females with the corresponding

NOTE Confidence: 0.96160966

00:11:14.394 --> 00:11:16.975
hematocrit, in parentheses following that.

NOTE Confidence: 0.9925354

00:11:17.355 --> 00:11:18.634
The main our main goal,

NOTE Confidence: 0.9925354

00:11:19.035 --> 00:11:20.394
for these cases is trying

NOTE Confidence: 0.9925354

00:11:20.394 --> 00:11:22.255
to distinguish primary arthrocytosis,

NOTE Confidence: 0.9841196

00:11:22.714 --> 00:11:24.660
which is really an autonomous

NOTE Confidence: 0.9841196

00:11:24.720 --> 00:11:26.640
production. And and for the

NOTE Confidence: 0.9841196

00:11:26.640 --> 00:11:28.000
sake of this discussion, that

NOTE Confidence: 0.9841196

00:11:28.000 --> 00:11:29.620
that really means, polycythemia

NOTE Confidence: 0.94070613

00:11:30.240 --> 00:11:31.200
vera, which is a a

NOTE Confidence: 0.94070613

00:11:31.200 --> 00:11:32.340
malignant disorder.

NOTE Confidence: 0.96738344

00:11:33.040 --> 00:11:34.320
Everything else which is more

NOTE Confidence: 0.96738344

00:11:34.320 --> 00:11:36.020
common would fall into secondary

NOTE Confidence: 0.96738344

00:11:36.080 --> 00:11:36.580
erythrocytosis.

NOTE Confidence: 0.968684

00:11:36.960 --> 00:11:37.755
And these are,

NOTE Confidence: 0.95943564

00:11:38.395 --> 00:11:39.755
situations in which it's it's

NOTE Confidence: 0.95943564

00:11:39.755 --> 00:11:41.035
not autonomous or rather an

NOTE Confidence: 0.95943564

00:11:41.035 --> 00:11:43.035
external factor, which is leading

NOTE Confidence: 0.95943564

00:11:43.035 --> 00:11:44.395
to the booster red cell

NOTE Confidence: 0.95943564

00:11:44.395 --> 00:11:45.515
red blood cell production. And

NOTE Confidence: 0.95943564

00:11:45.515 --> 00:11:47.135
mainly, this is driven by,

NOTE Confidence: 0.9996629

00:11:47.675 --> 00:11:48.175
erythropoietin

NOTE Confidence: 0.9852262

00:11:48.715 --> 00:11:49.915
or EPO, and this can

NOTE Confidence: 0.9852262

00:11:49.915 --> 00:11:51.115
happen for a variety of

NOTE Confidence: 0.9852262

00:11:51.115 --> 00:11:51.615
reasons.

NOTE Confidence: 0.9755343

00:11:52.970 --> 00:11:54.350
Both of these can be

NOTE Confidence: 0.97896695

00:11:55.130 --> 00:11:56.570
classified in another way, either

NOTE Confidence: 0.97896695

00:11:56.570 --> 00:11:58.490
congenital or acquired. But in

NOTE Confidence: 0.97896695

00:11:58.490 --> 00:11:59.550
our adult,

NOTE Confidence: 0.9990809

00:12:00.809 --> 00:12:02.570
primary care practices, we're mostly

NOTE Confidence: 0.9990809

00:12:02.570 --> 00:12:04.429
gonna be discussing acquired

NOTE Confidence: 0.9153285

00:12:05.065 --> 00:12:05.565
causes.

NOTE Confidence: 0.9307235

00:12:07.225 --> 00:12:08.605
I'll just briefly mention,

NOTE Confidence: 0.9915613

00:12:09.225 --> 00:12:10.925
the idea of relative erythrocytosis,

NOTE Confidence: 0.9915613

00:12:11.225 --> 00:12:12.765
which I think is what,

NOTE Confidence: 0.8787774

00:12:14.025 --> 00:12:15.785
doctor Chimneyel was, like, discussing

NOTE Confidence: 0.8787774

00:12:15.785 --> 00:12:16.605
in his case,

NOTE Confidence: 0.9937452

00:12:17.625 --> 00:12:18.285
where they

NOTE Confidence: 0.9905009

00:12:18.720 --> 00:12:19.779
discontinued the,

NOTE Confidence: 0.92420363

00:12:20.880 --> 00:12:21.380
hydrochlorothiazide.

NOTE Confidence: 0.8557842

00:12:26.480 --> 00:12:26.980
The,

NOTE Confidence: 0.8790788

00:12:28.160 --> 00:12:29.199
you know, most of the

NOTE Confidence: 0.8790788

00:12:29.199 --> 00:12:30.320
time, when we're thinking about

NOTE Confidence: 0.8790788

00:12:30.320 --> 00:12:31.920
a relative of retrocytosis, right,

NOTE Confidence: 0.8790788

00:12:31.920 --> 00:12:33.565
where the there's

NOTE Confidence: 0.92205864

00:12:34.024 --> 00:12:35.144
a change in the plasma

NOTE Confidence: 0.92205864

00:12:35.144 --> 00:12:36.605
volume creating this,

NOTE Confidence: 0.9599186

00:12:37.225 --> 00:12:37.725
increase,

NOTE Confidence: 0.90502363

00:12:38.265 --> 00:12:39.325
or apparent increase,

NOTE Confidence: 0.97982424

00:12:40.105 --> 00:12:41.725
in the hemoglobin or hematocrit.

NOTE Confidence: 0.9620136

00:12:42.184 --> 00:12:43.464
We might often be talking

NOTE Confidence: 0.9620136

00:12:43.464 --> 00:12:45.304
about something transient such as

NOTE Confidence: 0.9620136

00:12:45.304 --> 00:12:45.804
diuretics,

NOTE Confidence: 0.9989033

00:12:46.505 --> 00:12:47.005
or

NOTE Confidence: 0.9848222

00:12:47.459 --> 00:12:48.899
GI losses through, you know,

NOTE Confidence: 0.9848222

00:12:48.899 --> 00:12:50.259
either vomiting or diarrhea, but

NOTE Confidence: 0.9848222

00:12:50.259 --> 00:12:51.139
I just did wanna make

NOTE Confidence: 0.9848222

00:12:51.139 --> 00:12:52.100
a brief mention that there

NOTE Confidence: 0.9848222

00:12:52.100 --> 00:12:52.759
is a,

NOTE Confidence: 0.9856453

00:12:53.620 --> 00:12:54.120
condition,

NOTE Confidence: 0.9784883

00:12:54.660 --> 00:12:56.500
called case box polycythemia, which

NOTE Confidence: 0.9784883

00:12:56.500 --> 00:12:57.220
can really be thought of

NOTE Confidence: 0.9784883

00:12:57.220 --> 00:12:58.500
as almost a chronic form

NOTE Confidence: 0.9784883

00:12:58.500 --> 00:13:00.199
of of relative polycythemia.

NOTE Confidence: 0.9290268

00:13:00.500 --> 00:13:01.379
We we might tend to

NOTE Confidence: 0.9290268

00:13:01.379 --> 00:13:02.355
see that in,

NOTE Confidence: 0.9995733

00:13:02.834 --> 00:13:04.054
males with hypertension

NOTE Confidence: 0.9804183

00:13:04.434 --> 00:13:06.375
who are obese. So sometimes,

NOTE Confidence: 0.94842976

00:13:07.475 --> 00:13:08.675
I personally find it's almost

NOTE Confidence: 0.94842976

00:13:08.675 --> 00:13:10.514
like a diagnosis exclusion, but

NOTE Confidence: 0.94842976

00:13:10.514 --> 00:13:11.475
something that we do keep

NOTE Confidence: 0.94842976

00:13:11.475 --> 00:13:12.915
in in mind. Go to

NOTE Confidence: 0.94842976

00:13:12.915 --> 00:13:13.815
the next slide.

NOTE Confidence: 0.99731797

00:13:15.510 --> 00:13:16.950
So, you know, one brief

NOTE Confidence: 0.99731797

00:13:16.950 --> 00:13:18.010
slide here on polycythemia

NOTE Confidence: 0.96928763

00:13:18.310 --> 00:13:19.350
vera because I think that's

NOTE Confidence: 0.96928763

00:13:19.350 --> 00:13:19.850
often,

NOTE Confidence: 0.97349435

00:13:20.710 --> 00:13:22.310
as a malignant condition, something,

NOTE Confidence: 0.97349435

00:13:22.310 --> 00:13:23.750
of course, we don't wanna

NOTE Confidence: 0.97349435

00:13:23.750 --> 00:13:24.250
miss.

NOTE Confidence: 0.99458706

00:13:24.950 --> 00:13:26.330
And this is a,

NOTE Confidence: 0.9908933

00:13:27.030 --> 00:13:28.170
cancer, a myeloproliferative

NOTE Confidence: 0.98997915

00:13:28.630 --> 00:13:30.485
neoplasm that's really characterized by

NOTE Confidence: 0.98997915

00:13:30.485 --> 00:13:32.184
an increase in erythrocyte mass.

NOTE Confidence: 0.98997915

00:13:32.325 --> 00:13:33.785
Patients often have thrombotic,

NOTE Confidence: 0.973397

00:13:34.245 --> 00:13:36.005
but sometimes bleeding complications and

NOTE Confidence: 0.973397

00:13:36.005 --> 00:13:36.985
can have vasomotor

NOTE Confidence: 0.99926305

00:13:37.684 --> 00:13:38.184
symptoms.

NOTE Confidence: 0.8745522

00:13:40.245 --> 00:13:42.085
For simplicity's sake for this

NOTE Confidence: 0.8745522

00:13:42.085 --> 00:13:42.585
discussion,

NOTE Confidence: 0.98010826

00:13:43.410 --> 00:13:45.269
essentially, all patients with polycythemia

NOTE Confidence: 0.92975676

00:13:45.809 --> 00:13:46.850
there will have a JAK

NOTE Confidence: 0.92975676

00:13:46.850 --> 00:13:48.389
two mutation. So

NOTE Confidence: 0.97821236

00:13:49.089 --> 00:13:50.209
most of those are this

NOTE Confidence: 0.97821236

00:13:50.209 --> 00:13:51.329
JAK two v six one

NOTE Confidence: 0.97821236

00:13:51.329 --> 00:13:52.529
seven f mutation, and then

NOTE Confidence: 0.97821236

00:13:52.529 --> 00:13:53.589
a smaller percentage

NOTE Confidence: 0.9437024

00:13:54.050 --> 00:13:55.089
are kinda what we call

NOTE Confidence: 0.9437024

00:13:55.089 --> 00:13:56.630
other other JAK mutations.

NOTE Confidence: 0.95516163

00:13:57.345 --> 00:13:58.545
And so if somebody is

NOTE Confidence: 0.95516163

00:13:58.704 --> 00:14:00.165
has a JAK mutation

NOTE Confidence: 0.99594086

00:14:00.545 --> 00:14:01.045
negative,

NOTE Confidence: 0.96772575

00:14:02.144 --> 00:14:04.065
it's extremely unlikely that they

NOTE Confidence: 0.96772575

00:14:04.065 --> 00:14:04.964
would have polycythemia

NOTE Confidence: 0.9992502

00:14:05.345 --> 00:14:05.845
vera.

NOTE Confidence: 0.9837497

00:14:08.704 --> 00:14:09.824
So this is a,

NOTE Confidence: 0.99972284

00:14:10.385 --> 00:14:11.204
one proposed

NOTE Confidence: 0.9217806

00:14:11.580 --> 00:14:12.540
approach, but,

NOTE Confidence: 0.9243212

00:14:14.780 --> 00:14:15.980
you know, starting at the

NOTE Confidence: 0.9243212

00:14:15.980 --> 00:14:17.340
top left, again, that has

NOTE Confidence: 0.9243212

00:14:17.340 --> 00:14:18.860
just our definitions. This is,

NOTE Confidence: 0.9243212

00:14:19.180 --> 00:14:20.240
taken from a,

NOTE Confidence: 0.94164735

00:14:20.700 --> 00:14:22.060
European journal, so you can

NOTE Confidence: 0.94164735

00:14:22.060 --> 00:14:23.260
notice the change in decimal

NOTE Confidence: 0.94164735

00:14:23.260 --> 00:14:23.835
places. But,

NOTE Confidence: 0.9960408

00:14:24.795 --> 00:14:26.075
you know, following the definitions

NOTE Confidence: 0.9960408

00:14:26.075 --> 00:14:27.695
we outlined earlier for erythrocytosis,

NOTE Confidence: 0.94976103

00:14:28.235 --> 00:14:30.095
again, first excluding that relative,

NOTE Confidence: 0.99270463

00:14:30.955 --> 00:14:31.455
erythrocytosis,

NOTE Confidence: 0.97480124

00:14:31.835 --> 00:14:32.875
which is really things like

NOTE Confidence: 0.97480124

00:14:32.875 --> 00:14:33.375
dehydration,

NOTE Confidence: 0.9717315

00:14:34.875 --> 00:14:35.675
you know, then we get

NOTE Confidence: 0.9717315

00:14:35.675 --> 00:14:36.795
to this next main fork

NOTE Confidence: 0.9717315

00:14:36.795 --> 00:14:38.250
in the road. And of

NOTE Confidence: 0.9717315

00:14:38.250 --> 00:14:39.690
the next kind of very

NOTE Confidence: 0.9717315

00:14:39.690 --> 00:14:40.890
useful test that can be

NOTE Confidence: 0.9717315

00:14:40.890 --> 00:14:43.870
done is the erythropoietin level.

NOTE Confidence: 0.99294

00:14:44.410 --> 00:14:45.690
And whether that turns out

NOTE Confidence: 0.99294

00:14:45.690 --> 00:14:47.370
to be high, low, or

NOTE Confidence: 0.99294

00:14:47.370 --> 00:14:48.430
normal, that helps,

NOTE Confidence: 0.9963527

00:14:48.970 --> 00:14:50.430
bring us into the next,

NOTE Confidence: 0.98264384

00:14:52.395 --> 00:14:53.195
most likely,

NOTE Confidence: 0.9483717

00:14:53.755 --> 00:14:55.115
leading us down the diagnostic

NOTE Confidence: 0.9483717

00:14:55.115 --> 00:14:56.315
pathway. And so if the

NOTE Confidence: 0.9483717

00:14:56.315 --> 00:14:57.995
erythropoietin level is high, we're

NOTE Confidence: 0.9483717

00:14:57.995 --> 00:14:59.935
really looking at these secondary

NOTE Confidence: 0.9703277

00:15:00.475 --> 00:15:02.255
acquired causes. So not polycythemia

NOTE Confidence: 0.95924973

00:15:02.635 --> 00:15:03.675
vera, not the can not

NOTE Confidence: 0.95924973

00:15:03.675 --> 00:15:05.035
a cancerous condition, but something

NOTE Confidence: 0.95924973

00:15:05.035 --> 00:15:06.795
else driving EPO levels to

NOTE Confidence: 0.95924973

00:15:06.795 --> 00:15:07.410
be high.

NOTE Confidence: 0.8886964

00:15:07.810 --> 00:15:09.490
And often the main the

NOTE Confidence: 0.8886964

00:15:09.490 --> 00:15:09.970
main,

NOTE Confidence: 0.98166305

00:15:10.370 --> 00:15:12.050
reasons here are hypoxia and

NOTE Confidence: 0.98166305

00:15:12.050 --> 00:15:13.829
medical conditions that cause such

NOTE Confidence: 0.98166305

00:15:13.889 --> 00:15:14.629
and medications.

NOTE Confidence: 0.9874741

00:15:15.410 --> 00:15:17.110
We're rarely gonna see congenital,

NOTE Confidence: 0.9976945

00:15:17.649 --> 00:15:19.190
associated causes in practice.

NOTE Confidence: 0.9054123

00:15:20.264 --> 00:15:21.084
If the,

NOTE Confidence: 0.9589318

00:15:21.625 --> 00:15:23.385
erythropoietin level is low or

NOTE Confidence: 0.9589318

00:15:23.385 --> 00:15:24.584
very low, then that's where

NOTE Confidence: 0.9589318

00:15:24.584 --> 00:15:26.105
we often will next check

NOTE Confidence: 0.9589318

00:15:26.105 --> 00:15:27.144
the JAK two,

NOTE Confidence: 0.9943852

00:15:27.865 --> 00:15:29.225
mutation testing. Again, if it's

NOTE Confidence: 0.9943852

00:15:29.225 --> 00:15:30.745
positive, that confirms that someone

NOTE Confidence: 0.9943852

00:15:30.745 --> 00:15:31.404
has polycythemia

NOTE Confidence: 0.9987032

00:15:31.865 --> 00:15:32.365
vera.

NOTE Confidence: 0.9682441

00:15:33.050 --> 00:15:34.830
If it's negative, we we,

NOTE Confidence: 0.9800927

00:15:36.170 --> 00:15:37.610
we'll we'll look for those

NOTE Confidence: 0.9800927

00:15:37.610 --> 00:15:38.589
other JAK mutations.

NOTE Confidence: 0.9919288

00:15:39.930 --> 00:15:40.430
And,

NOTE Confidence: 0.99857956

00:15:40.970 --> 00:15:42.330
again, if these are all

NOTE Confidence: 0.99857956

00:15:42.330 --> 00:15:42.830
negative,

NOTE Confidence: 0.97134566

00:15:43.290 --> 00:15:44.649
it makes it very unlikely

NOTE Confidence: 0.97134566

00:15:44.649 --> 00:15:46.430
the patient has polycythemia vera.

NOTE Confidence: 0.97134566

00:15:46.730 --> 00:15:47.870
Okay. Next slide.

NOTE Confidence: 0.9606091

00:15:49.285 --> 00:15:50.405
Okay. So, again, our in

NOTE Confidence: 0.9606091

00:15:50.405 --> 00:15:51.765
terms of our diagnostic approach,

NOTE Confidence: 0.9606091

00:15:51.765 --> 00:15:53.525
the first most important, lab

NOTE Confidence: 0.9606091

00:15:53.525 --> 00:15:54.485
to check would be an

NOTE Confidence: 0.9606091

00:15:54.485 --> 00:15:54.985
erythropoietin

NOTE Confidence: 0.9902204

00:15:55.365 --> 00:15:55.865
level.

NOTE Confidence: 0.97699517

00:15:56.645 --> 00:15:58.005
And, again, if it's low,

NOTE Confidence: 0.97699517

00:15:58.005 --> 00:15:59.045
that really points us in

NOTE Confidence: 0.97699517

00:15:59.045 --> 00:16:00.805
the direction of placentia vera.

NOTE Confidence: 0.97699517

00:16:00.805 --> 00:16:02.085
And if it's normal or

NOTE Confidence: 0.97699517

00:16:02.085 --> 00:16:03.445
elevated, then we're going down

NOTE Confidence: 0.97699517

00:16:03.445 --> 00:16:04.345
the more common

NOTE Confidence: 0.99921113

00:16:04.780 --> 00:16:06.560
likelihood of secondary etiologies.

NOTE Confidence: 0.9531681

00:16:08.620 --> 00:16:09.500
So this is just a

NOTE Confidence: 0.9531681

00:16:09.500 --> 00:16:11.980
list of diseases that as

NOTE Confidence: 0.9531681

00:16:11.980 --> 00:16:12.960
primary care,

NOTE Confidence: 0.9967663

00:16:13.660 --> 00:16:14.160
providers,

NOTE Confidence: 0.99654216

00:16:15.340 --> 00:16:16.780
you might commonly see in

NOTE Confidence: 0.99654216

00:16:16.780 --> 00:16:17.520
your practice,

NOTE Confidence: 0.99342704

00:16:18.620 --> 00:16:19.200
that can

NOTE Confidence: 0.934058

00:16:19.835 --> 00:16:21.755
that can, again, have a

NOTE Confidence: 0.934058

00:16:21.755 --> 00:16:22.255
erythrocytosis

NOTE Confidence: 0.920996

00:16:22.635 --> 00:16:23.995
and with either a normal

NOTE Confidence: 0.920996

00:16:23.995 --> 00:16:25.055
or increased erythropoietin

NOTE Confidence: 0.955305

00:16:25.435 --> 00:16:25.935
level.

NOTE Confidence: 0.75976354

00:16:28.155 --> 00:16:28.975
So cardiopulmonary

NOTE Confidence: 0.9806707

00:16:29.435 --> 00:16:31.115
disease and obstructive sleep apnea,

NOTE Confidence: 0.9806707

00:16:31.115 --> 00:16:32.235
I think, are are quite

NOTE Confidence: 0.9806707

00:16:32.235 --> 00:16:33.680
common in our patient population,

NOTE Confidence: 0.94769454

00:16:34.540 --> 00:16:35.580
given that we don't live

NOTE Confidence: 0.94769454

00:16:35.580 --> 00:16:36.480
in a high altitude.

NOTE Confidence: 0.8279263

00:16:37.980 --> 00:16:39.120
Cigarette smoking,

NOTE Confidence: 0.9667382

00:16:39.900 --> 00:16:40.960
often, I think,

NOTE Confidence: 0.92394257

00:16:42.380 --> 00:16:44.220
we might see either separate

NOTE Confidence: 0.92394257

00:16:44.220 --> 00:16:45.680
but often together with cardiopulmonary

NOTE Confidence: 0.996021

00:16:46.140 --> 00:16:46.640
diseases.

NOTE Confidence: 0.95507926

00:16:47.015 --> 00:16:47.895
And then I just wanted

NOTE Confidence: 0.95507926

00:16:47.895 --> 00:16:49.654
to bring attention to carbon

NOTE Confidence: 0.95507926

00:16:49.654 --> 00:16:51.175
monoxide poisoning as, of course,

NOTE Confidence: 0.95507926

00:16:51.175 --> 00:16:52.375
something we wouldn't wanna miss,

NOTE Confidence: 0.95507926

00:16:52.375 --> 00:16:53.495
and that can be identified

NOTE Confidence: 0.95507926

00:16:53.495 --> 00:16:54.775
on lab work. And then

NOTE Confidence: 0.95507926

00:16:54.775 --> 00:16:55.895
also a list of,

NOTE Confidence: 0.9029821

00:16:56.455 --> 00:16:57.495
medications here,

NOTE Confidence: 0.8898392

00:17:00.360 --> 00:17:01.660
Pointing out that SGLT

NOTE Confidence: 0.8315924

00:17:02.280 --> 00:17:02.780
SGLT

NOTE Confidence: 0.90415055

00:17:03.240 --> 00:17:03.740
two,

NOTE Confidence: 0.9969063

00:17:04.119 --> 00:17:04.619
inhibitors,

NOTE Confidence: 0.9616509

00:17:04.920 --> 00:17:05.960
the drugs that end in

NOTE Confidence: 0.9616509

00:17:05.960 --> 00:17:06.460
neflozins,

NOTE Confidence: 0.92236924

00:17:07.480 --> 00:17:09.480
we're seeing an increased number

NOTE Confidence: 0.92236924

00:17:09.480 --> 00:17:11.020
of these prescribed as,

NOTE Confidence: 0.98768765

00:17:11.720 --> 00:17:12.984
in our patient population, and

NOTE Confidence: 0.98768765

00:17:12.984 --> 00:17:14.984
we do see erythrocytosis from

NOTE Confidence: 0.98768765

00:17:14.984 --> 00:17:15.945
these. So just keep that

NOTE Confidence: 0.98768765

00:17:15.945 --> 00:17:16.905
in mind, kind of doing

NOTE Confidence: 0.98768765

00:17:16.905 --> 00:17:18.184
a quick medication check when

NOTE Confidence: 0.98768765

00:17:18.184 --> 00:17:18.684
you

NOTE Confidence: 0.90507615

00:17:18.984 --> 00:17:20.825
notice a higher hemoglobin in

NOTE Confidence: 0.90507615

00:17:20.825 --> 00:17:22.205
your with your patients.

NOTE Confidence: 0.996689

00:17:23.065 --> 00:17:24.345
In addition to things like

NOTE Confidence: 0.996689

00:17:24.345 --> 00:17:24.845
testosterone,

NOTE Confidence: 0.99739885

00:17:25.145 --> 00:17:26.045
I'd say that's

NOTE Confidence: 0.99968874

00:17:26.570 --> 00:17:27.070
also

NOTE Confidence: 0.9200067

00:17:27.530 --> 00:17:29.130
often prevalent in our patient

NOTE Confidence: 0.9200067

00:17:29.130 --> 00:17:29.630
population.

NOTE Confidence: 0.915491

00:17:31.290 --> 00:17:32.970
I personally don't see that

NOTE Confidence: 0.915491

00:17:32.970 --> 00:17:33.710
many patients,

NOTE Confidence: 0.99669564

00:17:35.210 --> 00:17:35.710
using,

NOTE Confidence: 0.9490137

00:17:36.970 --> 00:17:38.410
you know, EPO doping, but,

NOTE Confidence: 0.9490137

00:17:38.410 --> 00:17:39.450
of course, it it, I

NOTE Confidence: 0.9490137

00:17:39.450 --> 00:17:40.890
think, intuitively makes sense to

NOTE Confidence: 0.9490137

00:17:40.890 --> 00:17:41.950
think about that.

NOTE Confidence: 0.9677413

00:17:43.565 --> 00:17:44.765
If we talked about the

NOTE Confidence: 0.9677413

00:17:44.765 --> 00:17:45.265
relative,

NOTE Confidence: 0.880446

00:17:45.965 --> 00:17:46.465
erythrocytosis,

NOTE Confidence: 0.9869564

00:17:47.005 --> 00:17:47.805
and then if we see

NOTE Confidence: 0.9869564

00:17:47.805 --> 00:17:48.625
a high EPO,

NOTE Confidence: 0.7785151

00:17:49.325 --> 00:17:49.825
level,

NOTE Confidence: 0.9312222

00:17:51.085 --> 00:17:53.265
tumors, both malignant and benign,

NOTE Confidence: 0.9312222

00:17:53.405 --> 00:17:55.165
including, like, uterine fibroids, which

NOTE Confidence: 0.9312222

00:17:55.165 --> 00:17:56.205
is something I've seen in

NOTE Confidence: 0.9312222

00:17:56.205 --> 00:17:57.919
practice, can actually sudd secrete

NOTE Confidence: 0.9312222

00:17:57.919 --> 00:17:58.119
EPO.

NOTE Confidence: 0.8999782

00:18:00.760 --> 00:18:02.840
And then also renal conditions,

NOTE Confidence: 0.8999782

00:18:02.840 --> 00:18:04.840
so renal artery stenosis, renal

NOTE Confidence: 0.8999782

00:18:04.840 --> 00:18:06.040
cysts, and,

NOTE Confidence: 0.9879542

00:18:06.520 --> 00:18:07.800
and patients who have also

NOTE Confidence: 0.9879542

00:18:07.800 --> 00:18:09.800
had a, kidney transplant as

NOTE Confidence: 0.9879542

00:18:09.800 --> 00:18:10.300
well.

NOTE Confidence: 0.9961371

00:18:12.945 --> 00:18:13.905
So in terms of other

NOTE Confidence: 0.9961371

00:18:13.905 --> 00:18:15.424
labs to to check, in

NOTE Confidence: 0.9961371

00:18:15.424 --> 00:18:16.385
addition to those,

NOTE Confidence: 0.99878323

00:18:16.945 --> 00:18:17.984
iron studies, a lot of

NOTE Confidence: 0.99878323

00:18:17.984 --> 00:18:19.205
our patients with polycythemia

NOTE Confidence: 0.93630934

00:18:19.744 --> 00:18:21.365
vera will have kinda low

NOTE Confidence: 0.93630934

00:18:21.424 --> 00:18:22.484
iron at baseline,

NOTE Confidence: 0.967433

00:18:23.984 --> 00:18:25.105
which was checked in your

NOTE Confidence: 0.967433

00:18:25.105 --> 00:18:25.605
case.

NOTE Confidence: 0.9032192

00:18:25.930 --> 00:18:27.470
And, also, a blood smear,

NOTE Confidence: 0.98944396

00:18:28.090 --> 00:18:28.830
is useful,

NOTE Confidence: 0.9901748

00:18:29.770 --> 00:18:30.730
really to look for some

NOTE Confidence: 0.9901748

00:18:30.730 --> 00:18:31.850
of those kind of more

NOTE Confidence: 0.9901748

00:18:31.850 --> 00:18:32.670
ominous markers,

NOTE Confidence: 0.98669547

00:18:33.609 --> 00:18:34.270
sort of,

NOTE Confidence: 0.9271629

00:18:35.450 --> 00:18:37.050
blasts, which could be seen.

NOTE Confidence: 0.9271629

00:18:37.050 --> 00:18:38.330
It could highlight a potential

NOTE Confidence: 0.9271629

00:18:38.330 --> 00:18:39.390
malignant condition

NOTE Confidence: 0.941426

00:18:39.850 --> 00:18:40.350
or

NOTE Confidence: 0.9497781

00:18:41.284 --> 00:18:42.184
what we call leukoerythroblastosis,

NOTE Confidence: 0.930518

00:18:43.445 --> 00:18:44.565
just sort of these younger

NOTE Confidence: 0.930518

00:18:44.565 --> 00:18:46.244
precursor cells, so nucleated red

NOTE Confidence: 0.930518

00:18:46.244 --> 00:18:47.544
blood cells, for example.

NOTE Confidence: 0.97895026

00:18:48.725 --> 00:18:50.005
Again, just, this was, I

NOTE Confidence: 0.97895026

00:18:50.005 --> 00:18:51.044
guess, kinda outlined on the

NOTE Confidence: 0.97895026

00:18:51.044 --> 00:18:52.164
prior slide, but just in

NOTE Confidence: 0.97895026

00:18:52.164 --> 00:18:53.144
a different format.

NOTE Confidence: 0.9701085

00:18:55.000 --> 00:18:55.880
I think some of these

NOTE Confidence: 0.9701085

00:18:55.880 --> 00:18:57.799
are relatively common conditions in

NOTE Confidence: 0.9701085

00:18:57.799 --> 00:18:59.260
the primary care population.

NOTE Confidence: 0.9758385

00:19:01.159 --> 00:19:02.140
Just as you,

NOTE Confidence: 0.97426116

00:19:03.400 --> 00:19:04.940
after you've checked in erythropoietin

NOTE Confidence: 0.95866185

00:19:05.240 --> 00:19:06.119
and you see that it's

NOTE Confidence: 0.95866185

00:19:06.119 --> 00:19:07.785
either normal or high, and

NOTE Confidence: 0.95866185

00:19:07.785 --> 00:19:08.744
kinda try to go through

NOTE Confidence: 0.95866185

00:19:08.744 --> 00:19:10.525
this list of different possibility.

NOTE Confidence: 0.9224344

00:19:15.145 --> 00:19:16.685
And, again, we just wanted

NOTE Confidence: 0.9224344

00:19:16.744 --> 00:19:17.405
to highlight,

NOTE Confidence: 0.98727196

00:19:17.785 --> 00:19:19.305
particularly this last bullet point

NOTE Confidence: 0.98727196

00:19:19.305 --> 00:19:20.425
here as we're seeing more

NOTE Confidence: 0.98727196

00:19:20.425 --> 00:19:21.965
of these prescribed in practice.

NOTE Confidence: 0.9976737

00:19:25.369 --> 00:19:26.590
When we're taking a history,

NOTE Confidence: 0.9980181

00:19:27.690 --> 00:19:28.590
you know, I think,

NOTE Confidence: 0.981146

00:19:29.050 --> 00:19:30.910
it largely is going to,

NOTE Confidence: 0.93875664

00:19:32.170 --> 00:19:33.530
the medication list, obviously, we

NOTE Confidence: 0.93875664

00:19:33.530 --> 00:19:34.250
might have in front of

NOTE Confidence: 0.93875664

00:19:34.250 --> 00:19:35.369
us. We're we're gonna take

NOTE Confidence: 0.93875664

00:19:35.369 --> 00:19:37.050
a smoking history, of course.

NOTE Confidence: 0.93875664

00:19:37.050 --> 00:19:37.695
You know, do you have

NOTE Confidence: 0.93875664

00:19:37.695 --> 00:19:39.135
a carbon monoxide monitor in

NOTE Confidence: 0.93875664

00:19:39.135 --> 00:19:41.054
your home? And symptoms of,

NOTE Confidence: 0.93875664

00:19:41.054 --> 00:19:42.215
I think, sleep apnea are

NOTE Confidence: 0.93875664

00:19:42.215 --> 00:19:42.815
are quite,

NOTE Confidence: 0.9996029

00:19:43.215 --> 00:19:43.715
useful.

NOTE Confidence: 0.99916726

00:19:45.775 --> 00:19:47.395
And on our physical exam,

NOTE Confidence: 0.9983938

00:19:48.255 --> 00:19:49.154
you know, hypertension,

NOTE Confidence: 0.9787526

00:19:49.855 --> 00:19:50.355
plethora,

NOTE Confidence: 0.91523415

00:19:51.215 --> 00:19:51.855
signs of,

NOTE Confidence: 0.9556031

00:19:52.429 --> 00:19:54.030
scratching, itching from pruritus patients

NOTE Confidence: 0.9556031

00:19:54.030 --> 00:19:54.850
might experience.

NOTE Confidence: 0.9907906

00:19:56.190 --> 00:19:57.490
Certainly, if someone has splenomegaly,

NOTE Confidence: 0.9907906

00:19:57.710 --> 00:19:58.669
I think we're really gonna

NOTE Confidence: 0.9907906

00:19:58.669 --> 00:19:59.169
wanna

NOTE Confidence: 0.9684305

00:19:59.470 --> 00:20:00.590
wanna make sure we're ruling

NOTE Confidence: 0.9684305

00:20:00.590 --> 00:20:02.049
out any malignant etiology.

NOTE Confidence: 0.9974916

00:20:02.990 --> 00:20:04.429
So these are helpful things

NOTE Confidence: 0.9974916

00:20:04.429 --> 00:20:05.330
to look for.

NOTE Confidence: 0.94405526

00:20:08.025 --> 00:20:09.145
So who should be referred

NOTE Confidence: 0.94405526

00:20:09.145 --> 00:20:10.265
to hematology? So I I

NOTE Confidence: 0.94405526

00:20:10.265 --> 00:20:11.544
would say my my my

NOTE Confidence: 0.94405526

00:20:11.544 --> 00:20:12.905
recommendations would be anybody who

NOTE Confidence: 0.94405526

00:20:12.905 --> 00:20:14.765
has a low erythropoietin level,

NOTE Confidence: 0.9632174

00:20:17.465 --> 00:20:18.905
someone who has really long

NOTE Confidence: 0.9632174

00:20:18.905 --> 00:20:20.125
standing erythrocytosis

NOTE Confidence: 0.8647949

00:20:20.585 --> 00:20:21.690
or a clear family history

NOTE Confidence: 0.8647949

00:20:22.090 --> 00:20:24.029
patient's younger because while they're

NOTE Confidence: 0.8647949

00:20:24.250 --> 00:20:25.450
quite rare, there are,

NOTE Confidence: 0.99176884

00:20:25.929 --> 00:20:26.970
we do have a handful

NOTE Confidence: 0.99176884

00:20:26.970 --> 00:20:28.570
of patients with hereditary forms

NOTE Confidence: 0.99176884

00:20:28.570 --> 00:20:29.309
of erythrocytosis,

NOTE Confidence: 0.9418495

00:20:31.850 --> 00:20:33.210
certainly somebody who has a

NOTE Confidence: 0.9418495

00:20:33.210 --> 00:20:34.269
JAK2 mutation.

NOTE Confidence: 0.99556977

00:20:34.915 --> 00:20:36.195
And then I think that

NOTE Confidence: 0.99556977

00:20:36.195 --> 00:20:37.575
there are patients who,

NOTE Confidence: 0.98437995

00:20:38.835 --> 00:20:40.535
we might feel have symptoms

NOTE Confidence: 0.98437995

00:20:40.595 --> 00:20:41.734
related to erythrocytosis,

NOTE Confidence: 0.95727396

00:20:42.035 --> 00:20:43.635
which can be challenging to

NOTE Confidence: 0.95727396

00:20:43.635 --> 00:20:44.135
to

NOTE Confidence: 0.98615074

00:20:44.515 --> 00:20:45.015
manage.

NOTE Confidence: 0.9941117

00:20:45.555 --> 00:20:46.055
So

NOTE Confidence: 0.9561772

00:20:46.435 --> 00:20:48.035
headaches, for example, I'd say

NOTE Confidence: 0.9561772

00:20:48.035 --> 00:20:49.255
would be a very common

NOTE Confidence: 0.9561772

00:20:49.315 --> 00:20:49.815
symptom,

NOTE Confidence: 0.9577518

00:20:50.659 --> 00:20:52.039
kind of mental fogginess,

NOTE Confidence: 0.9963414

00:20:55.220 --> 00:20:56.179
would probably be a second

NOTE Confidence: 0.9963414

00:20:56.179 --> 00:20:57.380
thing I would think about.

NOTE Confidence: 0.9433082

00:20:57.779 --> 00:20:58.679
And so, certainly,

NOTE Confidence: 0.9526133

00:20:59.220 --> 00:21:00.659
if there's concerns that symptoms

NOTE Confidence: 0.9526133

00:21:00.659 --> 00:21:01.859
patients have are related to

NOTE Confidence: 0.9526133

00:21:01.859 --> 00:21:03.140
erythrocytosis, I think we should

NOTE Confidence: 0.9526133

00:21:03.140 --> 00:21:04.260
see those patients, in my

NOTE Confidence: 0.9526133

00:21:04.260 --> 00:21:04.760
opinion.

NOTE Confidence: 0.9571164

00:21:07.445 --> 00:21:08.804
I have one brief thing

NOTE Confidence: 0.9571164

00:21:08.804 --> 00:21:10.025
on how we manage polycythemia

NOTE Confidence: 0.9571164

00:21:10.325 --> 00:21:11.784
vera only because it often

NOTE Confidence: 0.97728914

00:21:13.205 --> 00:21:14.325
in the past, how we

NOTE Confidence: 0.97728914

00:21:14.325 --> 00:21:16.404
manage polycythemia vera sort of

NOTE Confidence: 0.97728914

00:21:16.404 --> 00:21:17.684
trickled into how one

NOTE Confidence: 0.9615427

00:21:18.850 --> 00:21:20.210
Sometimes we might think we

NOTE Confidence: 0.9615427

00:21:20.210 --> 00:21:21.970
should manage other causes of

NOTE Confidence: 0.9615427

00:21:21.970 --> 00:21:22.470
arthrocytosis.

NOTE Confidence: 0.99271274

00:21:22.850 --> 00:21:24.450
But very briefly, these patients

NOTE Confidence: 0.99271274

00:21:24.450 --> 00:21:24.690
get,

NOTE Confidence: 0.94145864

00:21:25.330 --> 00:21:26.850
have phlebotomy to reduce their

NOTE Confidence: 0.94145864

00:21:26.850 --> 00:21:28.450
hematocrit often to a level

NOTE Confidence: 0.94145864

00:21:28.450 --> 00:21:29.750
of less than forty five.

NOTE Confidence: 0.94145864

00:21:29.809 --> 00:21:30.784
Most of these patients are

NOTE Confidence: 0.94145864

00:21:30.784 --> 00:21:32.544
on aspirin, and sometimes they,

NOTE Confidence: 0.94145864

00:21:32.945 --> 00:21:33.445
receive,

NOTE Confidence: 0.9962071

00:21:34.145 --> 00:21:34.645
like,

NOTE Confidence: 0.88737184

00:21:36.225 --> 00:21:38.005
phytoreductive pills like hydroxyurea

NOTE Confidence: 0.9841652

00:21:39.744 --> 00:21:40.325
or others.

NOTE Confidence: 0.9859298

00:21:42.385 --> 00:21:44.645
So, but for secondary erythrocytosis,

NOTE Confidence: 0.97399646

00:21:45.585 --> 00:21:47.190
we we really should not

NOTE Confidence: 0.97399646

00:21:47.190 --> 00:21:49.030
be doing phlebotomy. It's really

NOTE Confidence: 0.97399646

00:21:49.030 --> 00:21:49.990
the, like, take home point

NOTE Confidence: 0.97399646

00:21:49.990 --> 00:21:50.470
of this.

NOTE Confidence: 0.9791629

00:21:51.429 --> 00:21:52.869
And the treatment is really

NOTE Confidence: 0.9791629

00:21:52.869 --> 00:21:54.630
directed at the underlying cause

NOTE Confidence: 0.9791629

00:21:54.630 --> 00:21:55.669
if we think it's even

NOTE Confidence: 0.9791629

00:21:55.669 --> 00:21:56.169
necessary,

NOTE Confidence: 0.9426502

00:21:59.325 --> 00:22:00.365
You know, especially when it

NOTE Confidence: 0.9426502

00:22:00.365 --> 00:22:02.625
comes to hypoxic pulmonary disease,

NOTE Confidence: 0.9716889

00:22:03.005 --> 00:22:03.885
right, we might see this

NOTE Confidence: 0.9716889

00:22:03.885 --> 00:22:05.005
in more advanced forms of

NOTE Confidence: 0.9716889

00:22:05.005 --> 00:22:06.465
COPD or OSA, and

NOTE Confidence: 0.97089386

00:22:06.845 --> 00:22:09.105
prognostic significance is not exactly

NOTE Confidence: 0.97089386

00:22:09.165 --> 00:22:10.605
clear. There's sort of mixed

NOTE Confidence: 0.97089386

00:22:10.605 --> 00:22:11.825
data in this space.

NOTE Confidence: 0.9784323

00:22:12.710 --> 00:22:13.830
And there's really no clear

NOTE Confidence: 0.9784323

00:22:13.830 --> 00:22:15.850
evidence that phlebotomy is necessary,

NOTE Confidence: 0.99103236

00:22:16.950 --> 00:22:18.630
or even effective at reducing

NOTE Confidence: 0.99103236

00:22:18.630 --> 00:22:20.310
thrombotic risk and could actually

NOTE Confidence: 0.99103236

00:22:20.310 --> 00:22:21.850
increase thrombotic risk.

NOTE Confidence: 0.83603066

00:22:23.670 --> 00:22:24.410
And, certainly,

NOTE Confidence: 0.92278886

00:22:25.325 --> 00:22:26.525
to try to assess someone's

NOTE Confidence: 0.92278886

00:22:26.525 --> 00:22:27.725
thrombotic risk, you know, we

NOTE Confidence: 0.92278886

00:22:27.725 --> 00:22:29.005
need to think about other

NOTE Confidence: 0.92278886

00:22:29.005 --> 00:22:30.525
other risk other risk factors

NOTE Confidence: 0.92278886

00:22:30.525 --> 00:22:31.665
patients might have.

NOTE Confidence: 0.97835946

00:22:33.005 --> 00:22:34.205
We do know that when

NOTE Confidence: 0.97835946

00:22:34.205 --> 00:22:35.725
patients with OSA are on

NOTE Confidence: 0.97835946

00:22:35.725 --> 00:22:37.005
CPAP, it can reduce their

NOTE Confidence: 0.97835946

00:22:37.005 --> 00:22:37.505
withrocytosis.

NOTE Confidence: 0.941954

00:22:39.250 --> 00:22:40.789
But, otherwise, in terms

NOTE Confidence: 0.91396356

00:22:41.090 --> 00:22:43.010
of directed management to lower,

NOTE Confidence: 0.91396356

00:22:43.330 --> 00:22:44.690
the erythrocyt count, its data

NOTE Confidence: 0.91396356

00:22:44.690 --> 00:22:45.590
is less clear.

NOTE Confidence: 0.94235706

00:22:47.809 --> 00:22:49.169
One brief slide on testosterone

NOTE Confidence: 0.94235706

00:22:49.169 --> 00:22:50.049
because I we see a

NOTE Confidence: 0.94235706

00:22:50.049 --> 00:22:51.250
lot of these patients as

NOTE Confidence: 0.94235706

00:22:51.250 --> 00:22:51.750
referrals.

NOTE Confidence: 0.9740381

00:22:53.395 --> 00:22:54.994
We know testosterone can cause

NOTE Confidence: 0.9740381

00:22:54.994 --> 00:22:55.494
arthrocytosis,

NOTE Confidence: 0.96447045

00:22:57.155 --> 00:22:58.355
for a few reasons, but

NOTE Confidence: 0.96447045

00:22:58.355 --> 00:22:59.315
probably initially due to a

NOTE Confidence: 0.96447045

00:22:59.315 --> 00:23:00.934
rise in arthropoietin levels.

NOTE Confidence: 0.9662818

00:23:04.115 --> 00:23:06.035
Often, patients have been referred

NOTE Confidence: 0.9662818

00:23:06.035 --> 00:23:07.530
to sort of decide if

NOTE Confidence: 0.9662818

00:23:07.530 --> 00:23:08.650
they should if they would

NOTE Confidence: 0.9662818

00:23:08.650 --> 00:23:10.670
benefit from phlebotomy, and,

NOTE Confidence: 0.9808407

00:23:12.490 --> 00:23:13.850
there's not really a clear

NOTE Confidence: 0.9808407

00:23:13.850 --> 00:23:14.890
data to say we should

NOTE Confidence: 0.9808407

00:23:14.890 --> 00:23:16.010
do that, and it may

NOTE Confidence: 0.9808407

00:23:16.010 --> 00:23:17.390
actually make things worse.

NOTE Confidence: 0.93023175

00:23:20.684 --> 00:23:22.125
So going back to the

NOTE Confidence: 0.93023175

00:23:22.285 --> 00:23:22.945
our case,

NOTE Confidence: 0.99929446

00:23:23.965 --> 00:23:25.005
I think that,

NOTE Confidence: 0.9683259

00:23:25.885 --> 00:23:27.405
you know, we the JAK

NOTE Confidence: 0.9683259

00:23:27.405 --> 00:23:29.164
two mutation was negative from

NOTE Confidence: 0.9683259

00:23:29.164 --> 00:23:30.285
what I recall, so we're

NOTE Confidence: 0.9683259

00:23:30.285 --> 00:23:31.484
now kinda going down this

NOTE Confidence: 0.9683259

00:23:31.484 --> 00:23:32.445
path of what we call

NOTE Confidence: 0.9683259

00:23:32.445 --> 00:23:33.505
secondary causes.

NOTE Confidence: 0.96985286

00:23:34.880 --> 00:23:36.000
For this patient, I would

NOTE Confidence: 0.96985286

00:23:36.000 --> 00:23:37.040
say it's really crucial to

NOTE Confidence: 0.96985286

00:23:37.040 --> 00:23:38.900
rule out medication related causes.

NOTE Confidence: 0.92582494

00:23:39.280 --> 00:23:40.720
Certainly check for carbon dioxide

NOTE Confidence: 0.92582494

00:23:40.720 --> 00:23:42.000
poisoning. And I think checking

NOTE Confidence: 0.92582494

00:23:42.000 --> 00:23:42.740
the erythropoietin

NOTE Confidence: 0.99184316

00:23:43.040 --> 00:23:43.540
level,

NOTE Confidence: 0.9925945

00:23:44.000 --> 00:23:45.200
will help kinda guide us

NOTE Confidence: 0.9925945

00:23:45.200 --> 00:23:46.100
on next steps.

NOTE Confidence: 0.94159406

00:23:48.505 --> 00:23:49.945
Commonly, we might have a

NOTE Confidence: 0.94159406

00:23:49.945 --> 00:23:51.545
patient who has signs or

NOTE Confidence: 0.94159406

00:23:51.545 --> 00:23:53.225
symptoms suggestive of sleep apnea

NOTE Confidence: 0.94159406

00:23:53.225 --> 00:23:54.425
and a referral to pulmonary

NOTE Confidence: 0.94159406

00:23:54.425 --> 00:23:55.785
or sleep medicine sometimes can

NOTE Confidence: 0.94159406

00:23:55.785 --> 00:23:56.365
be useful.

NOTE Confidence: 0.9755587

00:23:57.625 --> 00:23:58.585
And I do not think

NOTE Confidence: 0.9755587

00:23:58.585 --> 00:24:00.045
there's any role for therapeutic

NOTE Confidence: 0.9755587

00:24:00.185 --> 00:24:01.625
phlebotomy in this type of

NOTE Confidence: 0.9755587

00:24:01.625 --> 00:24:02.125
case.

NOTE Confidence: 0.9536772

00:24:05.859 --> 00:24:07.059
Great. Thanks. Before we do

NOTE Confidence: 0.9536772

00:24:07.059 --> 00:24:08.100
case two, since this was

NOTE Confidence: 0.9536772

00:24:08.100 --> 00:24:08.980
eight years ago, I can

NOTE Confidence: 0.9536772

00:24:08.980 --> 00:24:10.260
give you, like, the the

NOTE Confidence: 0.9536772

00:24:10.260 --> 00:24:12.100
final. So he did have

NOTE Confidence: 0.9536772

00:24:12.100 --> 00:24:13.940
a an epogen level before

NOTE Confidence: 0.9536772

00:24:13.940 --> 00:24:15.799
seeing hematology. It was negative.

NOTE Confidence: 0.9358852

00:24:17.059 --> 00:24:17.700
And then,

NOTE Confidence: 0.95180243

00:24:18.544 --> 00:24:20.404
he saw, Doctor. Persico,

NOTE Confidence: 0.99151874

00:24:21.265 --> 00:24:22.565
who did do the,

NOTE Confidence: 0.948748

00:24:23.105 --> 00:24:23.765
the carboxyhemoglobin

NOTE Confidence: 0.96820104

00:24:24.625 --> 00:24:25.924
study that was normal.

NOTE Confidence: 0.89120966

00:24:26.705 --> 00:24:28.005
And he did the CalR

NOTE Confidence: 0.89120966

00:24:28.225 --> 00:24:29.284
exon analysis

NOTE Confidence: 0.960588

00:24:29.664 --> 00:24:31.205
as well, which was negative.

NOTE Confidence: 0.98772824

00:24:32.090 --> 00:24:33.770
The workup eventually found that

NOTE Confidence: 0.98772824

00:24:33.770 --> 00:24:35.150
he had some, you know,

NOTE Confidence: 0.9711155

00:24:35.450 --> 00:24:37.050
mild to moderate sleep apnea,

NOTE Confidence: 0.9711155

00:24:37.050 --> 00:24:38.109
and he's been on,

NOTE Confidence: 0.8642767

00:24:38.970 --> 00:24:39.470
CPAP,

NOTE Confidence: 0.8700054

00:24:39.850 --> 00:24:40.670
since. And his,

NOTE Confidence: 0.98239464

00:24:41.530 --> 00:24:43.230
hemoglobin has been generally,

NOTE Confidence: 0.9101066

00:24:43.930 --> 00:24:45.130
staying in, like, the sixteen

NOTE Confidence: 0.9101066

00:24:45.130 --> 00:24:47.175
range. So, upper normal and

NOTE Confidence: 0.9101066

00:24:47.255 --> 00:24:48.775
remained off because he didn't,

NOTE Confidence: 0.9101066

00:24:48.775 --> 00:24:49.735
you know, we switched his

NOTE Confidence: 0.9101066

00:24:49.735 --> 00:24:51.575
blood pressure around blood pressure

NOTE Confidence: 0.9101066

00:24:51.575 --> 00:24:52.955
medicines around off the hydrochlorothiazide.

NOTE Confidence: 0.99349856

00:24:53.575 --> 00:24:54.075
So,

NOTE Confidence: 0.9642011

00:24:54.455 --> 00:24:55.335
and he may still have

NOTE Confidence: 0.9642011

00:24:55.335 --> 00:24:56.295
a little bit of fatigue,

NOTE Confidence: 0.9642011

00:24:56.295 --> 00:24:57.835
but, who who does?

NOTE Confidence: 0.9110043

00:24:58.855 --> 00:25:00.455
So, thank you. The the

NOTE Confidence: 0.9110043

00:25:00.455 --> 00:25:01.175
second case is,

NOTE Confidence: 0.9634057

00:25:01.920 --> 00:25:03.920
this one, is actually sort

NOTE Confidence: 0.9634057

00:25:03.920 --> 00:25:04.900
of in the workup,

NOTE Confidence: 0.84993935

00:25:06.240 --> 00:25:07.220
now. It's a,

NOTE Confidence: 0.90196574

00:25:07.760 --> 00:25:08.880
seventy four year old woman.

NOTE Confidence: 0.90196574

00:25:08.880 --> 00:25:09.540
So recently

NOTE Confidence: 0.91295254

00:25:10.960 --> 00:25:12.660
just for a routine follow-up.

NOTE Confidence: 0.91295254

00:25:12.720 --> 00:25:14.720
She has, some chronic medical

NOTE Confidence: 0.91295254

00:25:14.720 --> 00:25:16.100
problems including obesity,

NOTE Confidence: 0.9411072

00:25:16.785 --> 00:25:18.565
AFib, hypertension, hyperlipidemia,

NOTE Confidence: 0.99696285

00:25:19.905 --> 00:25:21.845
remote history of adrenal insufficiency.

NOTE Confidence: 0.9342513

00:25:22.705 --> 00:25:23.925
You can see her medications.

NOTE Confidence: 0.9342513

00:25:24.145 --> 00:25:25.105
Most of them are old.

NOTE Confidence: 0.9342513

00:25:25.105 --> 00:25:25.845
The Gemteza,

NOTE Confidence: 0.8716335

00:25:26.545 --> 00:25:27.984
is, you know, maybe more

NOTE Confidence: 0.8716335

00:25:27.984 --> 00:25:28.484
new.

NOTE Confidence: 0.93365943

00:25:29.585 --> 00:25:30.065
She,

NOTE Confidence: 0.917304

00:25:30.625 --> 00:25:32.520
was a former smoker, a

NOTE Confidence: 0.917304

00:25:32.600 --> 00:25:33.560
fair amount, as you can

NOTE Confidence: 0.917304

00:25:33.560 --> 00:25:34.700
see, ten to fifteen,

NOTE Confidence: 0.87620664

00:25:35.560 --> 00:25:36.380
pack year.

NOTE Confidence: 0.9290324

00:25:36.680 --> 00:25:38.300
And her family history also

NOTE Confidence: 0.9290324

00:25:38.359 --> 00:25:39.500
interestingly enough has

NOTE Confidence: 0.94067883

00:25:39.880 --> 00:25:40.460
a possible,

NOTE Confidence: 0.9554987

00:25:41.240 --> 00:25:41.740
hematologic,

NOTE Confidence: 0.9480469

00:25:43.000 --> 00:25:44.700
positive finding with the,

NOTE Confidence: 0.8607256

00:25:45.320 --> 00:25:47.020
what she says is her,

NOTE Confidence: 0.8607256

00:25:47.240 --> 00:25:47.740
her,

NOTE Confidence: 0.94592136

00:25:51.205 --> 00:25:52.905
father had, you know, elevated

NOTE Confidence: 0.94592136

00:25:53.045 --> 00:25:53.785
blood counts,

NOTE Confidence: 0.860061

00:25:54.244 --> 00:25:55.845
but didn't necessarily do

NOTE Confidence: 0.9210445

00:25:56.645 --> 00:25:58.025
she didn't know the diagnosis

NOTE Confidence: 0.957985

00:25:58.725 --> 00:26:00.005
per se. So,

NOTE Confidence: 0.9958976

00:26:00.484 --> 00:26:01.465
so this is her.

NOTE Confidence: 0.9423406

00:26:03.109 --> 00:26:04.550
We did some, some blood

NOTE Confidence: 0.9423406

00:26:04.550 --> 00:26:06.230
work and, you can see

NOTE Confidence: 0.9423406

00:26:06.230 --> 00:26:07.830
her white count upper normal,

NOTE Confidence: 0.9423406

00:26:07.830 --> 00:26:08.330
hemoglobin

NOTE Confidence: 0.8940203

00:26:08.869 --> 00:26:09.369
normal,

NOTE Confidence: 0.99632245

00:26:10.070 --> 00:26:11.530
and platelets were elevated,

NOTE Confidence: 0.9997824

00:26:12.150 --> 00:26:12.650
repeated

NOTE Confidence: 0.84418213

00:26:13.270 --> 00:26:14.070
and were,

NOTE Confidence: 0.9988748

00:26:14.630 --> 00:26:16.410
pretty similar in the four

NOTE Confidence: 0.99367374

00:26:16.845 --> 00:26:18.684
fifty to five twenty five

NOTE Confidence: 0.99367374

00:26:18.684 --> 00:26:19.184
range.

NOTE Confidence: 0.99348944

00:26:20.125 --> 00:26:21.665
No evidence of kidney disease,

NOTE Confidence: 0.8656547

00:26:22.845 --> 00:26:23.744
liver disease,

NOTE Confidence: 0.99855155

00:26:24.445 --> 00:26:25.345
did do an

NOTE Confidence: 0.80284965

00:26:25.645 --> 00:26:26.145
ultrasound,

NOTE Confidence: 0.97956055

00:26:26.765 --> 00:26:27.725
as part of the workup

NOTE Confidence: 0.97956055

00:26:27.725 --> 00:26:29.005
as well, which showed evidence

NOTE Confidence: 0.97956055

00:26:29.005 --> 00:26:30.365
of fatty liver, not surprising

NOTE Confidence: 0.97956055

00:26:30.365 --> 00:26:32.230
given her her medical history,

NOTE Confidence: 0.97559404

00:26:32.850 --> 00:26:34.530
and, no evidence of any,

NOTE Confidence: 0.97559404

00:26:35.010 --> 00:26:35.510
splenomegaly

NOTE Confidence: 0.95412064

00:26:35.970 --> 00:26:36.470
or,

NOTE Confidence: 0.839105

00:26:37.010 --> 00:26:37.670
or any,

NOTE Confidence: 0.99831486

00:26:38.850 --> 00:26:40.950
any abnormalities in the spleen.

NOTE Confidence: 0.9444338

00:26:43.250 --> 00:26:43.750
So,

NOTE Confidence: 0.9555517

00:26:44.475 --> 00:26:46.015
this one's on ongoing.

NOTE Confidence: 0.9828774

00:26:46.315 --> 00:26:47.215
So she,

NOTE Confidence: 0.9059272

00:26:48.075 --> 00:26:49.595
were next to order the,

NOTE Confidence: 0.9059272

00:26:49.835 --> 00:26:51.515
blood smear, but thought, unlike

NOTE Confidence: 0.9059272

00:26:51.515 --> 00:26:52.395
the other case, we can

NOTE Confidence: 0.9059272

00:26:52.395 --> 00:26:53.755
do sort of a a

NOTE Confidence: 0.9059272

00:26:53.755 --> 00:26:54.734
a fresh case.

NOTE Confidence: 0.93908674

00:26:55.435 --> 00:26:56.895
And you can see again,

NOTE Confidence: 0.8126709

00:26:57.595 --> 00:26:59.215
a a care signature pathway,

NOTE Confidence: 0.97581744

00:27:00.040 --> 00:27:01.000
showing no,

NOTE Confidence: 0.9993611

00:27:01.480 --> 00:27:01.980
real

NOTE Confidence: 0.9903834

00:27:02.440 --> 00:27:03.420
alarm symptoms,

NOTE Confidence: 0.96589565

00:27:03.880 --> 00:27:04.920
which is good, but a

NOTE Confidence: 0.96589565

00:27:04.920 --> 00:27:05.420
peripheral,

NOTE Confidence: 0.949256

00:27:05.880 --> 00:27:07.240
blood smear that sort of,

NOTE Confidence: 0.949256

00:27:07.560 --> 00:27:08.760
you know, ordered not done.

NOTE Confidence: 0.949256

00:27:08.760 --> 00:27:09.400
So you can see on

NOTE Confidence: 0.949256

00:27:09.400 --> 00:27:10.760
the bottom, you know, some

NOTE Confidence: 0.949256

00:27:10.760 --> 00:27:11.500
more worrisome,

NOTE Confidence: 0.9562943

00:27:12.945 --> 00:27:13.445
findings,

NOTE Confidence: 0.9596957

00:27:14.145 --> 00:27:15.424
that we haven't gotten to.

NOTE Confidence: 0.9596957

00:27:15.424 --> 00:27:16.545
Hopefully, won't get to, but

NOTE Confidence: 0.9596957

00:27:16.545 --> 00:27:18.005
haven't ruled out yet.

NOTE Confidence: 0.9144208

00:27:20.865 --> 00:27:22.005
So I'll pass,

NOTE Confidence: 0.81979966

00:27:22.465 --> 00:27:22.965
this,

NOTE Confidence: 0.81197315

00:27:23.265 --> 00:27:24.980
onto our expert and

NOTE Confidence: 0.9665192

00:27:26.000 --> 00:27:27.760
and, obviously, I'm around for

NOTE Confidence: 0.9665192

00:27:27.760 --> 00:27:28.260
questions.

NOTE Confidence: 0.74971354

00:27:31.520 --> 00:27:32.420
Thank you.

NOTE Confidence: 0.97699606

00:27:33.840 --> 00:27:35.140
So I think unlike

NOTE Confidence: 0.99107057

00:27:36.475 --> 00:27:37.855
erythrocytosis or polycythemia,

NOTE Confidence: 0.908761

00:27:38.715 --> 00:27:40.494
the workup of thrombocytosis

NOTE Confidence: 0.77447015

00:27:41.034 --> 00:27:43.034
is and I misspelled it

NOTE Confidence: 0.77447015

00:27:43.034 --> 00:27:43.534
here,

NOTE Confidence: 0.8341453

00:27:45.595 --> 00:27:46.635
the expert. But,

NOTE Confidence: 0.8968192

00:27:48.875 --> 00:27:49.595
it's it's

NOTE Confidence: 0.89703494

00:27:50.850 --> 00:27:52.630
I think clinically in both

NOTE Confidence: 0.89703494

00:27:52.690 --> 00:27:54.450
the laboratory evaluation and,

NOTE Confidence: 0.9398525

00:27:55.010 --> 00:27:56.609
you know, different causes, it's

NOTE Confidence: 0.9398525

00:27:56.609 --> 00:27:57.669
just a lot more

NOTE Confidence: 0.8810647

00:27:58.049 --> 00:27:59.190
simple or simpler,

NOTE Confidence: 0.9904963

00:27:59.730 --> 00:28:00.230
and

NOTE Confidence: 0.63593274

00:28:00.530 --> 00:28:01.510
perhaps reflects

NOTE Confidence: 0.77340686

00:28:02.130 --> 00:28:02.789
the physiology

NOTE Confidence: 0.90240926

00:28:04.544 --> 00:28:05.585
because you know the platelet

NOTE Confidence: 0.90240926

00:28:05.585 --> 00:28:07.184
production and its regulation is

NOTE Confidence: 0.90240926

00:28:07.184 --> 00:28:07.845
so much

NOTE Confidence: 0.97986513

00:28:08.465 --> 00:28:08.965
simpler

NOTE Confidence: 0.91632164

00:28:09.744 --> 00:28:10.865
than red cells, you know

NOTE Confidence: 0.91632164

00:28:10.865 --> 00:28:12.544
there's no kidney involved, there's

NOTE Confidence: 0.91632164

00:28:12.544 --> 00:28:13.744
no liver involved, and you

NOTE Confidence: 0.91632164

00:28:13.744 --> 00:28:14.565
know there isn't

NOTE Confidence: 0.88465947

00:28:14.865 --> 00:28:16.484
a you know feedback mechanism

NOTE Confidence: 0.96182483

00:28:17.024 --> 00:28:17.524
that's

NOTE Confidence: 0.93573534

00:28:18.304 --> 00:28:20.970
related to kind of oxygen

NOTE Confidence: 0.93573534

00:28:20.970 --> 00:28:22.830
levels or hypoxia or hyperoxia.

NOTE Confidence: 0.93573534

00:28:22.970 --> 00:28:23.470
And,

NOTE Confidence: 0.9754739

00:28:23.930 --> 00:28:24.670
so thrombocytosis

NOTE Confidence: 0.89931214

00:28:24.970 --> 00:28:26.030
is, especially

NOTE Confidence: 0.92382157

00:28:28.570 --> 00:28:29.630
isolated thrombocytosis,

NOTE Confidence: 0.9526966

00:28:30.090 --> 00:28:31.050
and and this is what

NOTE Confidence: 0.9526966

00:28:31.050 --> 00:28:32.590
our our our

NOTE Confidence: 0.9192524

00:28:32.905 --> 00:28:34.205
patient here has is,

NOTE Confidence: 0.79799455

00:28:35.065 --> 00:28:36.045
is mostly

NOTE Confidence: 0.9483092

00:28:36.505 --> 00:28:37.005
incidental.

NOTE Confidence: 0.64306974

00:28:38.345 --> 00:28:38.845
And,

NOTE Confidence: 0.97414

00:28:41.065 --> 00:28:42.025
with that, what I mean

NOTE Confidence: 0.97414

00:28:42.025 --> 00:28:43.225
is, you know, most of

NOTE Confidence: 0.97414

00:28:43.225 --> 00:28:43.885
the time,

NOTE Confidence: 0.9233688

00:28:44.265 --> 00:28:45.645
patients are not very symptomatic,

NOTE Confidence: 0.9233688

00:28:45.705 --> 00:28:47.245
and these are picked up,

NOTE Confidence: 0.90702313

00:28:47.810 --> 00:28:49.570
either, you know, routine labs.

NOTE Confidence: 0.90702313

00:28:49.570 --> 00:28:50.530
They they could be peri

NOTE Confidence: 0.90702313

00:28:50.530 --> 00:28:51.650
up. They could be just

NOTE Confidence: 0.90702313

00:28:51.650 --> 00:28:52.710
their handles, physicals,

NOTE Confidence: 0.9661348

00:28:54.130 --> 00:28:54.870
or otherwise.

NOTE Confidence: 0.9504588

00:28:55.810 --> 00:28:56.630
And and

NOTE Confidence: 0.99547845

00:28:56.930 --> 00:28:58.790
and to sum it up,

NOTE Confidence: 0.9431283

00:28:59.410 --> 00:29:00.450
most of the times when

NOTE Confidence: 0.9431283

00:29:00.450 --> 00:29:00.950
we're

NOTE Confidence: 0.9923752

00:29:01.835 --> 00:29:03.035
when when we're dealing with,

NOTE Confidence: 0.9923752

00:29:03.275 --> 00:29:04.095
with thrombocytosis

NOTE Confidence: 0.91396415

00:29:05.035 --> 00:29:05.535
or

NOTE Confidence: 0.8324205

00:29:05.915 --> 00:29:07.595
especially a persistent, you know,

NOTE Confidence: 0.8324205

00:29:07.595 --> 00:29:08.095
thrombocytosis

NOTE Confidence: 0.9636649

00:29:08.475 --> 00:29:10.395
or elevated platelet counts, we

NOTE Confidence: 0.9636649

00:29:10.395 --> 00:29:11.055
we wanna

NOTE Confidence: 0.81179047

00:29:11.995 --> 00:29:12.495
perhaps,

NOTE Confidence: 0.9869682

00:29:13.130 --> 00:29:14.410
you know, figure out whether

NOTE Confidence: 0.9869682

00:29:14.410 --> 00:29:17.390
it's reactive or or, essential.

NOTE Confidence: 0.98661727

00:29:18.490 --> 00:29:19.470
Next slide, please.

NOTE Confidence: 0.96666354

00:29:21.770 --> 00:29:23.070
So when I'm,

NOTE Confidence: 0.99819237

00:29:24.090 --> 00:29:24.590
seeing

NOTE Confidence: 0.99233186

00:29:25.815 --> 00:29:26.475
a referral,

NOTE Confidence: 0.9156189

00:29:27.815 --> 00:29:28.934
of course, you know, I

NOTE Confidence: 0.9156189

00:29:28.934 --> 00:29:30.635
go through history and,

NOTE Confidence: 0.92967975

00:29:31.335 --> 00:29:32.695
and and and that and

NOTE Confidence: 0.92967975

00:29:32.695 --> 00:29:33.735
just trying to see whether

NOTE Confidence: 0.92967975

00:29:33.735 --> 00:29:35.414
there are any symptoms, which,

NOTE Confidence: 0.92967975

00:29:35.654 --> 00:29:37.174
most of these patients typically

NOTE Confidence: 0.92967975

00:29:37.174 --> 00:29:37.674
don't.

NOTE Confidence: 0.98629713

00:29:37.975 --> 00:29:39.195
I I I feel

NOTE Confidence: 0.96475583

00:29:39.610 --> 00:29:40.990
patients with polycythemia

NOTE Confidence: 0.9202901

00:29:41.370 --> 00:29:44.090
or, other myeloprolifer neoplasms typically,

NOTE Confidence: 0.9246631

00:29:44.730 --> 00:29:45.870
tend tend to have,

NOTE Confidence: 0.9484636

00:29:46.490 --> 00:29:47.929
some more symptoms especially on,

NOTE Confidence: 0.9484636

00:29:47.929 --> 00:29:49.130
you know, when we get

NOTE Confidence: 0.9484636

00:29:49.130 --> 00:29:51.149
down to more direct questions.

NOTE Confidence: 0.9586236

00:29:52.325 --> 00:29:52.825
But

NOTE Confidence: 0.85855377

00:29:53.365 --> 00:29:54.905
but but you know thrombocytosis

NOTE Confidence: 0.9771355

00:29:55.365 --> 00:29:56.985
can also produce some vasomotor

NOTE Confidence: 0.94092155

00:29:57.285 --> 00:29:59.045
symptoms and I've certainly had

NOTE Confidence: 0.94092155

00:29:59.045 --> 00:30:01.305
people with with migraines or

NOTE Confidence: 0.94092155

00:30:01.605 --> 00:30:02.265
with other

NOTE Confidence: 0.9139916

00:30:02.565 --> 00:30:04.345
vasomotor symptoms that get better

NOTE Confidence: 0.9139916

00:30:04.405 --> 00:30:06.485
with with treatment especially with

NOTE Confidence: 0.9139916

00:30:06.485 --> 00:30:06.985
essential

NOTE Confidence: 0.9850853

00:30:07.490 --> 00:30:07.990
thrombocytosis.

NOTE Confidence: 0.9734914

00:30:09.570 --> 00:30:10.770
But in history, other than

NOTE Confidence: 0.9734914

00:30:10.770 --> 00:30:11.890
that, I'm I'm just trying

NOTE Confidence: 0.9734914

00:30:11.890 --> 00:30:13.190
to, figure out,

NOTE Confidence: 0.92386127

00:30:14.930 --> 00:30:16.130
you know, whether the the

NOTE Confidence: 0.92386127

00:30:16.130 --> 00:30:17.350
person is asplenic,

NOTE Confidence: 0.93230313

00:30:17.730 --> 00:30:19.330
and and and happens less

NOTE Confidence: 0.93230313

00:30:19.330 --> 00:30:21.250
so, but but certainly, you

NOTE Confidence: 0.93230313

00:30:21.250 --> 00:30:22.610
know, we we see people

NOTE Confidence: 0.93230313

00:30:22.610 --> 00:30:23.865
from, you know,

NOTE Confidence: 0.8536245

00:30:24.345 --> 00:30:24.845
from,

NOTE Confidence: 0.92021704

00:30:25.785 --> 00:30:26.925
time to time getting,

NOTE Confidence: 0.9576209

00:30:28.905 --> 00:30:30.185
either traumatic or, you know,

NOTE Confidence: 0.9576209

00:30:30.185 --> 00:30:30.685
other,

NOTE Confidence: 0.9221064

00:30:31.305 --> 00:30:32.825
re for for other reasons,

NOTE Confidence: 0.9221064

00:30:32.825 --> 00:30:34.425
getting splenectomy or and and

NOTE Confidence: 0.9221064

00:30:34.425 --> 00:30:35.760
our ACE clinic on that,

NOTE Confidence: 0.9221064

00:30:35.760 --> 00:30:36.980
and that will always,

NOTE Confidence: 0.9351534

00:30:38.240 --> 00:30:39.680
you know, cause kind of

NOTE Confidence: 0.9351534

00:30:39.680 --> 00:30:40.980
mild to moderate thrombocytosis.

NOTE Confidence: 0.9720168

00:30:42.080 --> 00:30:43.440
And then the trend is,

NOTE Confidence: 0.9720168

00:30:43.680 --> 00:30:45.460
really important because, you know,

NOTE Confidence: 0.8425031

00:30:47.280 --> 00:30:48.340
if if it's

NOTE Confidence: 0.98192096

00:30:48.720 --> 00:30:49.220
really,

NOTE Confidence: 0.9743922

00:30:51.655 --> 00:30:52.455
you know, you look back

NOTE Confidence: 0.9743922

00:30:52.455 --> 00:30:52.955
and,

NOTE Confidence: 0.9793489

00:30:53.575 --> 00:30:54.075
someone

NOTE Confidence: 0.952685

00:30:54.615 --> 00:30:56.295
lives lives around hundred, hundred

NOTE Confidence: 0.952685

00:30:56.295 --> 00:30:57.335
and fifty or, you know,

NOTE Confidence: 0.952685

00:30:57.335 --> 00:30:58.315
two hundred and,

NOTE Confidence: 0.971148

00:30:58.935 --> 00:31:00.455
and, you know, and slowly,

NOTE Confidence: 0.971148

00:31:00.455 --> 00:31:01.575
the numbers have been creeping

NOTE Confidence: 0.971148

00:31:01.575 --> 00:31:03.335
up, and they've just recently

NOTE Confidence: 0.971148

00:31:03.335 --> 00:31:04.455
have come up to maybe

NOTE Confidence: 0.971148

00:31:04.455 --> 00:31:05.735
four fifty or five hundred

NOTE Confidence: 0.971148

00:31:05.735 --> 00:31:07.010
range. You know, it kind

NOTE Confidence: 0.971148

00:31:07.010 --> 00:31:08.289
of gives a sort of

NOTE Confidence: 0.971148

00:31:08.289 --> 00:31:09.649
sense that maybe this is

NOTE Confidence: 0.971148

00:31:09.649 --> 00:31:10.630
an essential thrombocytosis

NOTE Confidence: 0.8735603

00:31:11.490 --> 00:31:13.169
and usually takes years to

NOTE Confidence: 0.8735603

00:31:13.169 --> 00:31:14.470
kind of, double,

NOTE Confidence: 0.96781135

00:31:15.649 --> 00:31:16.610
or, you know, the doubling

NOTE Confidence: 0.96781135

00:31:16.610 --> 00:31:18.450
time is typically very, very

NOTE Confidence: 0.96781135

00:31:18.450 --> 00:31:19.975
slow. The trend is important.

NOTE Confidence: 0.9536549

00:31:20.515 --> 00:31:21.475
And then if I see

NOTE Confidence: 0.9536549

00:31:21.475 --> 00:31:23.315
some there's someone who perhaps

NOTE Confidence: 0.9536549

00:31:23.315 --> 00:31:24.355
goes up to six hundred,

NOTE Confidence: 0.9536549

00:31:24.355 --> 00:31:25.395
seven hundred and then goes

NOTE Confidence: 0.9536549

00:31:25.395 --> 00:31:26.435
back to normal and then,

NOTE Confidence: 0.9536549

00:31:26.435 --> 00:31:27.735
you know, goes back again,

NOTE Confidence: 0.9536549

00:31:27.875 --> 00:31:28.195
I,

NOTE Confidence: 0.96155995

00:31:28.755 --> 00:31:29.235
I,

NOTE Confidence: 0.9378726

00:31:29.555 --> 00:31:31.095
typically, like, you know,

NOTE Confidence: 0.9832322

00:31:31.715 --> 00:31:33.335
after finishing the workup,

NOTE Confidence: 0.9893218

00:31:33.715 --> 00:31:34.375
you know,

NOTE Confidence: 0.9313566

00:31:35.240 --> 00:31:36.280
realize that, you know, these

NOTE Confidence: 0.9313566

00:31:36.280 --> 00:31:38.060
are mostly kind of reactive,

NOTE Confidence: 0.99822086

00:31:38.680 --> 00:31:39.180
thrombocytosis.

NOTE Confidence: 0.56037474

00:31:41.160 --> 00:31:41.660
And

NOTE Confidence: 0.9508942

00:31:41.960 --> 00:31:43.480
and then, you know, with

NOTE Confidence: 0.9508942

00:31:43.480 --> 00:31:44.680
recent history of, you know,

NOTE Confidence: 0.9508942

00:31:44.680 --> 00:31:46.540
surgery, sometimes, like, you know,

NOTE Confidence: 0.9508942

00:31:46.760 --> 00:31:48.200
patients can have very extensive

NOTE Confidence: 0.9508942

00:31:48.200 --> 00:31:49.960
surgery, especially orthopedic surgery is

NOTE Confidence: 0.9508942

00:31:49.960 --> 00:31:51.315
very well described,

NOTE Confidence: 0.92068577

00:31:52.655 --> 00:31:53.855
hip surgery for example hip

NOTE Confidence: 0.92068577

00:31:53.855 --> 00:31:55.455
fracture surgery you know patients

NOTE Confidence: 0.92068577

00:31:55.455 --> 00:31:56.115
can have

NOTE Confidence: 0.93970215

00:31:56.415 --> 00:31:58.015
first thrombocytopenia and then you

NOTE Confidence: 0.93970215

00:31:58.015 --> 00:31:59.695
know reactive thrombocytosis that can

NOTE Confidence: 0.93970215

00:31:59.695 --> 00:32:00.675
last for months,

NOTE Confidence: 0.92398524

00:32:01.775 --> 00:32:02.735
and and the same is

NOTE Confidence: 0.92398524

00:32:02.735 --> 00:32:04.015
with chronic infections it could

NOTE Confidence: 0.92398524

00:32:04.015 --> 00:32:05.135
be also myelitis or you

NOTE Confidence: 0.92398524

00:32:05.135 --> 00:32:06.435
know other chronic infections

NOTE Confidence: 0.93970835

00:32:07.110 --> 00:32:08.870
Even acute infection, viral infection,

NOTE Confidence: 0.93970835

00:32:08.870 --> 00:32:10.470
you would see only, you

NOTE Confidence: 0.93970835

00:32:10.470 --> 00:32:11.670
know, ITP or, you know,

NOTE Confidence: 0.93970835

00:32:11.670 --> 00:32:12.170
thrombocytopenia

NOTE Confidence: 0.90314835

00:32:12.710 --> 00:32:13.750
kind of syndrome, but a

NOTE Confidence: 0.90314835

00:32:13.750 --> 00:32:14.250
thrombocytosis

NOTE Confidence: 0.9027762

00:32:14.630 --> 00:32:15.930
that could last for weeks,

NOTE Confidence: 0.9027762

00:32:16.230 --> 00:32:17.430
weeks to months and and

NOTE Confidence: 0.9027762

00:32:17.430 --> 00:32:19.770
then other, chronic inflammatory states,

NOTE Confidence: 0.95465994

00:32:20.150 --> 00:32:22.465
especially rheumatologic diseases. But but

NOTE Confidence: 0.95465994

00:32:22.465 --> 00:32:22.965
even

NOTE Confidence: 0.94208384

00:32:23.664 --> 00:32:24.164
milder,

NOTE Confidence: 0.9790897

00:32:25.504 --> 00:32:26.804
general sort of

NOTE Confidence: 0.8984043

00:32:27.184 --> 00:32:28.544
or, you know, in in

NOTE Confidence: 0.8984043

00:32:28.544 --> 00:32:29.044
inflammatory

NOTE Confidence: 0.9465534

00:32:29.424 --> 00:32:31.205
kind of conditions, even diabetes

NOTE Confidence: 0.9465534

00:32:31.264 --> 00:32:31.764
or,

NOTE Confidence: 0.90120614

00:32:32.225 --> 00:32:33.745
or a poorly controlled diabetes

NOTE Confidence: 0.90120614

00:32:33.745 --> 00:32:34.804
or or others.

NOTE Confidence: 0.95464283

00:32:35.850 --> 00:32:37.450
And then, some medications as

NOTE Confidence: 0.95464283

00:32:37.450 --> 00:32:38.650
well. I mean, I've certainly

NOTE Confidence: 0.95464283

00:32:38.650 --> 00:32:39.150
seen,

NOTE Confidence: 0.97000533

00:32:40.490 --> 00:32:41.710
patients getting steroids.

NOTE Confidence: 0.9961434

00:32:42.890 --> 00:32:43.770
The last one I saw

NOTE Confidence: 0.9961434

00:32:43.770 --> 00:32:44.670
was, you know,

NOTE Confidence: 0.78436214

00:32:45.050 --> 00:32:45.950
a person getting,

NOTE Confidence: 0.997572

00:32:46.985 --> 00:32:47.805
you know, I think

NOTE Confidence: 0.93525404

00:32:48.425 --> 00:32:50.185
epidurals and and every time,

NOTE Confidence: 0.93525404

00:32:50.185 --> 00:32:51.225
you know, it go up

NOTE Confidence: 0.93525404

00:32:51.225 --> 00:32:52.105
and then come down. And

NOTE Confidence: 0.93525404

00:32:52.105 --> 00:32:53.305
then six months later, you

NOTE Confidence: 0.93525404

00:32:53.305 --> 00:32:54.185
know, it'll go up and

NOTE Confidence: 0.93525404

00:32:54.185 --> 00:32:55.385
come down. So, definitely, you

NOTE Confidence: 0.93525404

00:32:55.385 --> 00:32:56.765
know, steroids can do that.

NOTE Confidence: 0.93525404

00:32:56.905 --> 00:32:58.365
Stimulants also I've seen,

NOTE Confidence: 0.9502632

00:32:59.450 --> 00:33:00.750
especially with methylphenidate.

NOTE Confidence: 0.9678008

00:33:01.930 --> 00:33:03.290
It's not being reported, but,

NOTE Confidence: 0.9678008

00:33:03.290 --> 00:33:04.570
you know, I think I've

NOTE Confidence: 0.9678008

00:33:04.570 --> 00:33:05.690
seen a bunch of patients

NOTE Confidence: 0.9678008

00:33:05.690 --> 00:33:06.970
who really go on it.

NOTE Confidence: 0.9678008

00:33:06.970 --> 00:33:08.270
The patients go high,

NOTE Confidence: 0.94497997

00:33:08.970 --> 00:33:10.410
and then, you know, and

NOTE Confidence: 0.94497997

00:33:10.410 --> 00:33:11.290
then they're off of it

NOTE Confidence: 0.94497997

00:33:11.290 --> 00:33:12.250
and and it comes down.

NOTE Confidence: 0.94497997

00:33:12.250 --> 00:33:12.705
So,

NOTE Confidence: 0.97014797

00:33:13.345 --> 00:33:14.085
and then,

NOTE Confidence: 0.9518502

00:33:14.544 --> 00:33:15.505
and then there are other,

NOTE Confidence: 0.9518502

00:33:15.505 --> 00:33:16.865
you know, chemotherapeutic agents. And

NOTE Confidence: 0.9518502

00:33:16.865 --> 00:33:18.065
gemcitabine is a big one

NOTE Confidence: 0.9518502

00:33:18.065 --> 00:33:18.865
where, you know, you could

NOTE Confidence: 0.9518502

00:33:18.865 --> 00:33:20.005
have really extreme thrombocytosis,

NOTE Confidence: 0.97290534

00:33:20.945 --> 00:33:22.404
but those those would be

NOTE Confidence: 0.97290534

00:33:22.544 --> 00:33:23.044
rare.

NOTE Confidence: 0.8535692

00:33:24.544 --> 00:33:25.745
And then, then coming to

NOTE Confidence: 0.8535692

00:33:25.745 --> 00:33:27.424
the laboratory workup and so,

NOTE Confidence: 0.8535692

00:33:27.424 --> 00:33:28.005
you know,

NOTE Confidence: 0.9408829

00:33:29.490 --> 00:33:30.850
you know, they've had at

NOTE Confidence: 0.9408829

00:33:30.850 --> 00:33:32.130
least a few CBC, but,

NOTE Confidence: 0.9408829

00:33:32.130 --> 00:33:33.810
you know, that's what, we

NOTE Confidence: 0.9408829

00:33:33.810 --> 00:33:34.770
end up getting in smear.

NOTE Confidence: 0.9408829

00:33:34.770 --> 00:33:36.770
And smear becomes very important

NOTE Confidence: 0.9408829

00:33:36.770 --> 00:33:37.270
because,

NOTE Confidence: 0.9954866

00:33:39.730 --> 00:33:40.470
many times,

NOTE Confidence: 0.9037695

00:33:41.145 --> 00:33:42.445
you know, thrombocytosis

NOTE Confidence: 0.9306202

00:33:42.905 --> 00:33:43.885
also causes,

NOTE Confidence: 0.9536624

00:33:45.225 --> 00:33:46.365
how do I put this,

NOTE Confidence: 0.99099004

00:33:46.665 --> 00:33:48.205
some degree of pseudothrombocytopenia.

NOTE Confidence: 0.94385654

00:33:50.825 --> 00:33:51.865
And what I mean by

NOTE Confidence: 0.94385654

00:33:51.865 --> 00:33:52.665
that is, like, you know,

NOTE Confidence: 0.94385654

00:33:52.665 --> 00:33:53.785
you'd see a platelet count

NOTE Confidence: 0.94385654

00:33:53.785 --> 00:33:54.600
of five hundred or six

NOTE Confidence: 0.94385654

00:33:54.679 --> 00:33:55.960
hundred reported platelet count of

NOTE Confidence: 0.94385654

00:33:55.960 --> 00:33:56.679
five, six hundred, and then

NOTE Confidence: 0.94385654

00:33:56.679 --> 00:33:57.640
you look under the smear

NOTE Confidence: 0.94385654

00:33:57.640 --> 00:33:58.440
and there are many, many,

NOTE Confidence: 0.94385654

00:33:58.440 --> 00:34:00.200
many clumps. And so especially

NOTE Confidence: 0.94385654

00:34:00.200 --> 00:34:01.799
with the central thrombocytosis. And

NOTE Confidence: 0.94385654

00:34:01.799 --> 00:34:02.299
so

NOTE Confidence: 0.9694464

00:34:02.600 --> 00:34:03.480
so the, you know, the

NOTE Confidence: 0.9694464

00:34:03.480 --> 00:34:05.080
platelet count the actual platelet

NOTE Confidence: 0.9694464

00:34:05.080 --> 00:34:07.240
count is is way much

NOTE Confidence: 0.9694464

00:34:07.240 --> 00:34:08.140
higher. And,

NOTE Confidence: 0.99652433

00:34:08.600 --> 00:34:09.420
and I

NOTE Confidence: 0.96291804

00:34:10.025 --> 00:34:10.844
sort of, like,

NOTE Confidence: 0.9879109

00:34:11.145 --> 00:34:12.265
you know, see that a

NOTE Confidence: 0.9879109

00:34:12.265 --> 00:34:13.565
lot more with with,

NOTE Confidence: 0.9022719

00:34:14.025 --> 00:34:15.245
with, inflammatory,

NOTE Confidence: 0.99109554

00:34:16.985 --> 00:34:17.485
states.

NOTE Confidence: 0.90172416

00:34:18.105 --> 00:34:19.385
But, anyway, smear is pretty

NOTE Confidence: 0.90172416

00:34:19.385 --> 00:34:19.885
useful,

NOTE Confidence: 0.92333764

00:34:20.344 --> 00:34:21.625
especially you're also looking for

NOTE Confidence: 0.92333764

00:34:21.625 --> 00:34:23.225
other atypical, you know, cells

NOTE Confidence: 0.92333764

00:34:23.225 --> 00:34:24.480
or, you know, sometimes they're

NOTE Confidence: 0.92333764

00:34:24.480 --> 00:34:25.600
not reported or they're within

NOTE Confidence: 0.92333764

00:34:25.600 --> 00:34:27.360
the normal range and and,

NOTE Confidence: 0.92333764

00:34:27.600 --> 00:34:29.200
and you appreciate, you know,

NOTE Confidence: 0.92333764

00:34:29.200 --> 00:34:30.020
they maybe,

NOTE Confidence: 0.64667237

00:34:30.560 --> 00:34:31.760
or question this poise or

NOTE Confidence: 0.64667237

00:34:31.760 --> 00:34:32.260
or,

NOTE Confidence: 0.95636356

00:34:33.200 --> 00:34:34.400
so smear becomes very important.

NOTE Confidence: 0.95636356

00:34:34.400 --> 00:34:36.020
And then and then ferritin,

NOTE Confidence: 0.9327403

00:34:36.400 --> 00:34:37.440
and with with that, what

NOTE Confidence: 0.9327403

00:34:37.440 --> 00:34:38.400
I mean is iron iron

NOTE Confidence: 0.9327403

00:34:38.400 --> 00:34:39.705
studies, I personally just, you

NOTE Confidence: 0.9327403

00:34:39.705 --> 00:34:41.625
know, get ferritin, and that's

NOTE Confidence: 0.9327403

00:34:41.625 --> 00:34:43.005
my iron panel. But,

NOTE Confidence: 0.99254274

00:34:43.625 --> 00:34:45.885
but, you know, in in

NOTE Confidence: 0.99254274

00:34:46.025 --> 00:34:46.525
outpatients,

NOTE Confidence: 0.9918328

00:34:46.825 --> 00:34:48.185
the most common cause of,

NOTE Confidence: 0.9918328

00:34:48.505 --> 00:34:49.165
of thrombocytosis

NOTE Confidence: 0.5759155

00:34:50.025 --> 00:34:50.685
is is,

NOTE Confidence: 0.9597764

00:34:51.305 --> 00:34:52.665
is iron deficiency and, you

NOTE Confidence: 0.9597764

00:34:52.665 --> 00:34:54.260
know, now the the biology

NOTE Confidence: 0.9597764

00:34:54.260 --> 00:34:55.540
and the mechanism behind it

NOTE Confidence: 0.9597764

00:34:55.540 --> 00:34:56.099
is also,

NOTE Confidence: 0.9939809

00:34:56.500 --> 00:34:57.480
very well known.

NOTE Confidence: 0.9725072

00:34:58.500 --> 00:34:59.619
In fact, you can kind

NOTE Confidence: 0.9725072

00:34:59.619 --> 00:35:01.060
of divide the humanity into

NOTE Confidence: 0.9725072

00:35:01.060 --> 00:35:01.940
two, those who would, you

NOTE Confidence: 0.9725072

00:35:01.940 --> 00:35:03.320
know, really have thrombocytosis

NOTE Confidence: 0.94364893

00:35:03.700 --> 00:35:04.660
and those who wouldn't with

NOTE Confidence: 0.94364893

00:35:04.660 --> 00:35:06.494
iron deficiency. And so, so

NOTE Confidence: 0.94364893

00:35:06.494 --> 00:35:07.214
this is, you know, you

NOTE Confidence: 0.94364893

00:35:07.214 --> 00:35:08.594
know, perhaps the most common,

NOTE Confidence: 0.99775934

00:35:08.974 --> 00:35:09.474
cause

NOTE Confidence: 0.8362523

00:35:10.015 --> 00:35:11.315
with, iron deficiency being,

NOTE Confidence: 0.9982224

00:35:11.614 --> 00:35:13.154
for for thrombocytosis.

NOTE Confidence: 0.9900446

00:35:13.454 --> 00:35:14.974
And then once, you know,

NOTE Confidence: 0.9900446

00:35:14.974 --> 00:35:15.954
you've really,

NOTE Confidence: 0.92708826

00:35:17.454 --> 00:35:19.295
really ruled out all of

NOTE Confidence: 0.92708826

00:35:19.295 --> 00:35:20.160
this, which is, you know,

NOTE Confidence: 0.92708826

00:35:20.160 --> 00:35:22.559
normal inflammation, infection, surgery even,

NOTE Confidence: 0.92708826

00:35:22.559 --> 00:35:23.780
you know, three months ago.

NOTE Confidence: 0.9661469

00:35:25.440 --> 00:35:26.319
They're up to date with

NOTE Confidence: 0.9661469

00:35:26.319 --> 00:35:28.180
cancer screening and and everything.

NOTE Confidence: 0.9661469

00:35:28.239 --> 00:35:28.739
And,

NOTE Confidence: 0.9958296

00:35:29.040 --> 00:35:30.719
then, you know, the the

NOTE Confidence: 0.9958296

00:35:30.719 --> 00:35:31.219
likelihood

NOTE Confidence: 0.90029

00:35:31.599 --> 00:35:32.660
of a persistent

NOTE Confidence: 0.99017674

00:35:33.040 --> 00:35:33.540
thrombocytosis

NOTE Confidence: 0.9982742

00:35:36.614 --> 00:35:37.114
being

NOTE Confidence: 0.839481

00:35:37.495 --> 00:35:38.795
essential thrombocytosis

NOTE Confidence: 0.9482966

00:35:39.094 --> 00:35:39.755
or thrombocythemia,

NOTE Confidence: 0.9067595

00:35:41.895 --> 00:35:42.635
is, you

NOTE Confidence: 0.91822857

00:35:43.094 --> 00:35:44.315
know, is more.

NOTE Confidence: 0.8158523

00:35:45.015 --> 00:35:45.515
So,

NOTE Confidence: 0.98667717

00:35:45.975 --> 00:35:47.015
and and then, you know,

NOTE Confidence: 0.98667717

00:35:47.015 --> 00:35:47.915
that's really,

NOTE Confidence: 0.9930123

00:35:49.255 --> 00:35:49.755
really,

NOTE Confidence: 0.97800374

00:35:50.375 --> 00:35:50.875
diagnosed

NOTE Confidence: 0.9341669

00:35:51.430 --> 00:35:51.930
by,

NOTE Confidence: 0.957993

00:35:52.390 --> 00:35:53.830
by mutation testing. So fifty

NOTE Confidence: 0.957993

00:35:53.830 --> 00:35:55.110
percent of them those will

NOTE Confidence: 0.957993

00:35:55.110 --> 00:35:56.070
have JAK two v six

NOTE Confidence: 0.957993

00:35:56.070 --> 00:35:57.290
one seven f mutation,

NOTE Confidence: 0.9540304

00:35:57.590 --> 00:35:58.550
and then about, you know,

NOTE Confidence: 0.9540304

00:35:58.550 --> 00:36:00.010
thirty percent will have CALR.

NOTE Confidence: 0.94598716

00:36:00.630 --> 00:36:01.430
And then, you know, five

NOTE Confidence: 0.94598716

00:36:01.430 --> 00:36:02.630
to ten percent will have

NOTE Confidence: 0.94598716

00:36:02.630 --> 00:36:04.489
the MIPL or MPL mutation.

NOTE Confidence: 0.94598716

00:36:04.630 --> 00:36:05.475
So, you know, that makes

NOTE Confidence: 0.94598716

00:36:05.475 --> 00:36:06.515
it eighty, eighty five percent,

NOTE Confidence: 0.94598716

00:36:06.515 --> 00:36:07.335
and the remaining,

NOTE Confidence: 0.9207023

00:36:07.955 --> 00:36:09.075
would, you know, require a

NOTE Confidence: 0.9207023

00:36:09.075 --> 00:36:10.035
bone or biopsy,

NOTE Confidence: 0.9713268

00:36:10.355 --> 00:36:11.095
for diagnosis.

NOTE Confidence: 0.94337803

00:36:11.635 --> 00:36:12.995
And and, you know, and

NOTE Confidence: 0.94337803

00:36:12.995 --> 00:36:14.195
these days, we are we

NOTE Confidence: 0.94337803

00:36:14.195 --> 00:36:16.195
are with sending a bigger

NOTE Confidence: 0.94337803

00:36:16.195 --> 00:36:17.795
myeloid, you know, panels. We

NOTE Confidence: 0.94337803

00:36:17.795 --> 00:36:19.095
are, we are finding,

NOTE Confidence: 0.9835953

00:36:19.739 --> 00:36:21.020
other rare mutations that are

NOTE Confidence: 0.9835953

00:36:21.020 --> 00:36:22.480
associated with essential thrombocytosis.

NOTE Confidence: 0.99301445

00:36:22.860 --> 00:36:23.520
And so

NOTE Confidence: 0.98798704

00:36:23.820 --> 00:36:24.560
so that's,

NOTE Confidence: 0.983071

00:36:25.420 --> 00:36:27.440
that's really the laboratory workup.

NOTE Confidence: 0.9616135

00:36:29.180 --> 00:36:30.160
Next slide, please.

NOTE Confidence: 0.966143

00:36:31.605 --> 00:36:33.145
And so just summarizing,

NOTE Confidence: 0.9405675

00:36:33.445 --> 00:36:34.325
you know, what I just

NOTE Confidence: 0.9405675

00:36:34.325 --> 00:36:35.545
said, you know, most common

NOTE Confidence: 0.9405675

00:36:35.765 --> 00:36:37.605
etiology is iron deficiency, and

NOTE Confidence: 0.9405675

00:36:37.605 --> 00:36:38.985
so your iron panel,

NOTE Confidence: 0.90306866

00:36:40.485 --> 00:36:42.085
is is, you know it

NOTE Confidence: 0.90306866

00:36:42.085 --> 00:36:43.545
probably will rule out,

NOTE Confidence: 0.96850127

00:36:43.844 --> 00:36:45.890
you know, good, you know,

NOTE Confidence: 0.96850127

00:36:45.950 --> 00:36:47.309
twenty, thirty, thirty percent of

NOTE Confidence: 0.96850127

00:36:47.309 --> 00:36:47.969
the cases,

NOTE Confidence: 0.9214129

00:36:48.589 --> 00:36:50.190
and then followed by by

NOTE Confidence: 0.9214129

00:36:50.190 --> 00:36:52.109
reactive or secondary cases such

NOTE Confidence: 0.9214129

00:36:52.109 --> 00:36:53.069
as, you know, post up

NOTE Confidence: 0.9214129

00:36:53.069 --> 00:36:54.430
status or, you know, in

NOTE Confidence: 0.9214129

00:36:54.430 --> 00:36:56.289
in chronic inflammatory conditions.

NOTE Confidence: 0.99733233

00:36:56.910 --> 00:36:57.650
Many times,

NOTE Confidence: 0.9079612

00:36:58.029 --> 00:36:59.325
we'd finish on the whole

NOTE Confidence: 0.9079612

00:36:59.325 --> 00:37:00.844
workup including bone marrow biopsy

NOTE Confidence: 0.9079612

00:37:00.844 --> 00:37:02.285
in a younger person and

NOTE Confidence: 0.9079612

00:37:02.285 --> 00:37:02.685
and,

NOTE Confidence: 0.9966448

00:37:03.085 --> 00:37:04.625
and not, you know, not

NOTE Confidence: 0.9562602

00:37:04.925 --> 00:37:06.525
really get a diagnosis. And

NOTE Confidence: 0.9562602

00:37:06.525 --> 00:37:07.425
and and that's

NOTE Confidence: 0.9713511

00:37:07.805 --> 00:37:10.125
that's, you know, that's perhaps

NOTE Confidence: 0.9713511

00:37:10.125 --> 00:37:11.425
because of, you know,

NOTE Confidence: 0.9726739

00:37:12.150 --> 00:37:12.950
I have, you know, kind

NOTE Confidence: 0.9726739

00:37:12.950 --> 00:37:14.630
of, you know, seen people

NOTE Confidence: 0.9726739

00:37:14.630 --> 00:37:16.069
developing diabetes or, you know,

NOTE Confidence: 0.9726739

00:37:16.069 --> 00:37:16.890
very general

NOTE Confidence: 0.8713304

00:37:17.190 --> 00:37:18.969
kind of mild chronic inflammatory

NOTE Confidence: 0.93622935

00:37:19.430 --> 00:37:20.089
sort of,

NOTE Confidence: 0.9591881

00:37:20.869 --> 00:37:23.109
states. And then once, these

NOTE Confidence: 0.9591881

00:37:23.109 --> 00:37:24.069
have been ruled out, then,

NOTE Confidence: 0.9591881

00:37:24.069 --> 00:37:25.450
you know, a

NOTE Confidence: 0.88547933

00:37:25.910 --> 00:37:27.130
workup for

NOTE Confidence: 0.9760504

00:37:27.805 --> 00:37:28.305
for,

NOTE Confidence: 0.797839

00:37:29.005 --> 00:37:29.505
myeloproliferative

NOTE Confidence: 0.95628226

00:37:30.844 --> 00:37:31.344
neoplasm,

NOTE Confidence: 0.95728236

00:37:31.965 --> 00:37:33.725
is is justified. And, you

NOTE Confidence: 0.95728236

00:37:33.725 --> 00:37:34.785
know, that can just,

NOTE Confidence: 0.94897383

00:37:35.325 --> 00:37:36.844
be started off with JAK2

NOTE Confidence: 0.94897383

00:37:36.844 --> 00:37:37.344
mutation,

NOTE Confidence: 0.9320204

00:37:37.965 --> 00:37:39.085
and then reflects to other

NOTE Confidence: 0.9320204

00:37:39.085 --> 00:37:40.445
mutations followed by a pulmonary

NOTE Confidence: 0.9320204

00:37:40.445 --> 00:37:40.945
biopsy.

NOTE Confidence: 0.9557816

00:37:44.660 --> 00:37:45.940
Alright. No. Thank you. So

NOTE Confidence: 0.9557816

00:37:45.940 --> 00:37:46.900
this like I said, this

NOTE Confidence: 0.9557816

00:37:46.900 --> 00:37:48.339
case is sort of ongoing.

NOTE Confidence: 0.9557816

00:37:48.339 --> 00:37:49.780
I'm suspecting we won't find

NOTE Confidence: 0.9557816

00:37:49.780 --> 00:37:50.579
the cause, but we have

NOTE Confidence: 0.9557816

00:37:50.579 --> 00:37:51.320
the smear,

NOTE Confidence: 0.98768437

00:37:52.180 --> 00:37:53.380
still coming on. And and

NOTE Confidence: 0.98768437

00:37:53.380 --> 00:37:54.265
then just,

NOTE Confidence: 0.999851

00:37:54.825 --> 00:37:55.325
one

NOTE Confidence: 0.9935044

00:37:55.705 --> 00:37:57.465
final plug on on the

NOTE Confidence: 0.9935044

00:37:57.465 --> 00:37:58.765
pathway. So,

NOTE Confidence: 0.9901169

00:37:59.225 --> 00:38:00.105
you know, when you're putting

NOTE Confidence: 0.9901169

00:38:00.185 --> 00:38:01.145
at least for me, when

NOTE Confidence: 0.9901169

00:38:01.145 --> 00:38:03.005
I'm putting in the smear

NOTE Confidence: 0.9901169

00:38:03.065 --> 00:38:04.344
order, if I if you

NOTE Confidence: 0.9901169

00:38:04.344 --> 00:38:06.205
type in peripheral smear, it

NOTE Confidence: 0.9901169

00:38:06.265 --> 00:38:07.645
it doesn't always show,

NOTE Confidence: 0.9843865

00:38:08.025 --> 00:38:09.225
on the order what you

NOTE Confidence: 0.9843865

00:38:09.225 --> 00:38:09.725
want.

NOTE Confidence: 0.9888935

00:38:10.370 --> 00:38:11.890
But if you click on

NOTE Confidence: 0.9888935

00:38:11.890 --> 00:38:13.510
it from the pathway,

NOTE Confidence: 0.9750306

00:38:14.130 --> 00:38:15.410
it pops up. And so

NOTE Confidence: 0.9750306

00:38:15.410 --> 00:38:16.210
for those of you taking

NOTE Confidence: 0.9750306

00:38:16.210 --> 00:38:18.070
notes at home, it's peripheral

NOTE Confidence: 0.9750306

00:38:18.130 --> 00:38:19.350
smear for pathology.

NOTE Confidence: 0.9994404

00:38:19.969 --> 00:38:21.030
If you type in

NOTE Confidence: 0.89779985

00:38:21.410 --> 00:38:21.910
peripheral,

NOTE Confidence: 0.9427882

00:38:22.930 --> 00:38:24.790
blood or peripheral blood smear,

NOTE Confidence: 0.9427882

00:38:25.035 --> 00:38:26.875
you actually doesn't always show

NOTE Confidence: 0.9427882

00:38:26.875 --> 00:38:27.855
up in EPIC.

NOTE Confidence: 0.9616073

00:38:28.395 --> 00:38:29.135
So another,

NOTE Confidence: 0.9870066

00:38:29.914 --> 00:38:31.194
plug on on on the

NOTE Confidence: 0.9870066

00:38:31.194 --> 00:38:32.335
pathway for,

NOTE Confidence: 0.94717526

00:38:33.994 --> 00:38:34.875
in some ways, it may

NOTE Confidence: 0.94717526

00:38:34.875 --> 00:38:36.075
be sometimes worth the time

NOTE Confidence: 0.94717526

00:38:36.075 --> 00:38:37.355
to go in just to

NOTE Confidence: 0.94717526

00:38:37.355 --> 00:38:38.255
make the ordering,

NOTE Confidence: 0.998514

00:38:38.954 --> 00:38:39.420
easier.

NOTE Confidence: 0.9709958

00:38:39.980 --> 00:38:40.719
And so,

NOTE Confidence: 0.9934971

00:38:41.819 --> 00:38:43.260
but, like I said, her

NOTE Confidence: 0.9934971

00:38:43.260 --> 00:38:44.960
case is ongoing. I'm suspecting,

NOTE Confidence: 0.98344266

00:38:45.819 --> 00:38:47.420
since she's been relatively stable

NOTE Confidence: 0.98344266

00:38:47.420 --> 00:38:48.540
in the four fifty to

NOTE Confidence: 0.98344266

00:38:48.540 --> 00:38:49.739
five twenty five range that

NOTE Confidence: 0.98344266

00:38:49.739 --> 00:38:51.599
we will probably not find

NOTE Confidence: 0.98344266

00:38:51.739 --> 00:38:52.239
anything,

NOTE Confidence: 0.8982029

00:38:53.020 --> 00:38:53.520
pathologic.

NOTE Confidence: 0.8986207

00:38:54.755 --> 00:38:56.755
But I'm happy to when

NOTE Confidence: 0.8986207

00:38:56.755 --> 00:38:58.275
I'm back, if people want,

NOTE Confidence: 0.8986207

00:38:58.515 --> 00:39:00.215
give a another update.

NOTE Confidence: 0.97246355

00:39:02.195 --> 00:39:03.555
I don't I have been

NOTE Confidence: 0.97246355

00:39:03.555 --> 00:39:04.835
following the chat. I don't

NOTE Confidence: 0.97246355

00:39:04.835 --> 00:39:06.295
know if there's any questions.

NOTE Confidence: 0.93616766

00:39:06.915 --> 00:39:08.114
Otherwise, I'm gonna pass them

NOTE Confidence: 0.93616766

00:39:08.114 --> 00:39:09.415
back back over.

NOTE Confidence: 0.96670383

00:39:10.779 --> 00:39:12.219
Yeah. No. We have not

NOTE Confidence: 0.96670383

00:39:12.219 --> 00:39:13.440
gotten any questions,

NOTE Confidence: 0.9584539

00:39:14.140 --> 00:39:15.579
although we had a a

NOTE Confidence: 0.9584539

00:39:15.579 --> 00:39:17.099
couple of other things that

NOTE Confidence: 0.9584539

00:39:17.099 --> 00:39:18.059
we didn't know if we

NOTE Confidence: 0.9584539

00:39:18.059 --> 00:39:19.099
were gonna have time to

NOTE Confidence: 0.9584539

00:39:19.099 --> 00:39:20.460
discuss, and and so maybe

NOTE Confidence: 0.9584539

00:39:20.460 --> 00:39:21.119
we can,

NOTE Confidence: 0.9966239

00:39:21.579 --> 00:39:23.099
pull those in. And if

NOTE Confidence: 0.9966239

00:39:23.099 --> 00:39:24.859
you do have questions, please

NOTE Confidence: 0.9966239

00:39:24.859 --> 00:39:26.685
enter them in the q

NOTE Confidence: 0.9966239

00:39:26.685 --> 00:39:27.265
and a.

NOTE Confidence: 0.74906117

00:39:28.205 --> 00:39:29.245
Well, I have one. If

NOTE Confidence: 0.74906117

00:39:29.245 --> 00:39:31.085
that's something too. Yeah. Thanks

NOTE Confidence: 0.74906117

00:39:31.085 --> 00:39:32.465
for going. Yeah. Okay. Good.

NOTE Confidence: 0.8733034

00:39:33.245 --> 00:39:34.685
Yeah. No. You mine mine

NOTE Confidence: 0.8733034

00:39:34.685 --> 00:39:35.645
is a question, so it's

NOTE Confidence: 0.8733034

00:39:35.645 --> 00:39:36.685
a complete change. So you

NOTE Confidence: 0.8733034

00:39:36.685 --> 00:39:36.765
do

NOTE Confidence: 0.9567528

00:39:37.725 --> 00:39:39.005
Okay. I I was actually

NOTE Confidence: 0.9567528

00:39:39.005 --> 00:39:40.500
gonna ask, because I probably

NOTE Confidence: 0.9567528

00:39:40.500 --> 00:39:41.540
missed it in your case

NOTE Confidence: 0.9567528

00:39:41.540 --> 00:39:42.980
and maybe to doctor Sharda

NOTE Confidence: 0.9567528

00:39:42.980 --> 00:39:43.640
as well,

NOTE Confidence: 0.9085981

00:39:46.739 --> 00:39:48.180
about if your patient's body

NOTE Confidence: 0.9085981

00:39:48.180 --> 00:39:49.780
mass index and if they're

NOTE Confidence: 0.9085981

00:39:49.780 --> 00:39:51.060
obese. You might have said

NOTE Confidence: 0.9085981

00:39:51.060 --> 00:39:52.020
that, and I missed it.

NOTE Confidence: 0.9085981

00:39:52.020 --> 00:39:52.760
But I think

NOTE Confidence: 0.939854

00:39:53.300 --> 00:39:54.894
yeah. Good question. I think

NOTE Confidence: 0.939854

00:39:54.894 --> 00:39:55.855
I see that a lot

NOTE Confidence: 0.939854

00:39:55.855 --> 00:39:57.214
in practice as part of

NOTE Confidence: 0.939854

00:39:57.214 --> 00:39:57.714
this

NOTE Confidence: 0.69244534

00:39:59.214 --> 00:39:59.714
inflammatory

NOTE Confidence: 0.85728574

00:40:00.575 --> 00:40:01.394
state. Right.

NOTE Confidence: 0.9423076

00:40:02.015 --> 00:40:03.454
Yeah. Yeah. And I I,

NOTE Confidence: 0.9423076

00:40:03.775 --> 00:40:04.815
no. I I complete her

NOTE Confidence: 0.9423076

00:40:04.815 --> 00:40:06.355
BMI is thirty seven,

NOTE Confidence: 0.9884467

00:40:07.509 --> 00:40:08.549
and that's why I think

NOTE Confidence: 0.9884467

00:40:08.549 --> 00:40:09.589
we're not gonna find a

NOTE Confidence: 0.9884467

00:40:09.589 --> 00:40:10.730
pathological cause.

NOTE Confidence: 0.94134533

00:40:11.190 --> 00:40:12.549
This wasn't a a question,

NOTE Confidence: 0.94134533

00:40:12.549 --> 00:40:13.509
but it makes me think

NOTE Confidence: 0.94134533

00:40:13.509 --> 00:40:14.650
of something like,

NOTE Confidence: 0.85751486

00:40:15.589 --> 00:40:17.289
we didn't talk about, leukocytosis,

NOTE Confidence: 0.9984712

00:40:17.989 --> 00:40:18.489
but

NOTE Confidence: 0.9355345

00:40:18.805 --> 00:40:19.844
I I sort of feel

NOTE Confidence: 0.9355345

00:40:19.844 --> 00:40:20.725
and I and I haven't

NOTE Confidence: 0.9355345

00:40:20.725 --> 00:40:21.844
looked this up. So I

NOTE Confidence: 0.9355345

00:40:21.844 --> 00:40:22.965
I this is obvious to

NOTE Confidence: 0.9355345

00:40:22.965 --> 00:40:24.505
everyone else. I I apologize

NOTE Confidence: 0.9355345

00:40:24.645 --> 00:40:26.085
that that a fair amount

NOTE Confidence: 0.9355345

00:40:26.085 --> 00:40:27.364
of people with, you know,

NOTE Confidence: 0.9355345

00:40:27.364 --> 00:40:28.825
higher levels of obesity

NOTE Confidence: 0.9227397

00:40:29.445 --> 00:40:31.205
seem to have like a

NOTE Confidence: 0.9227397

00:40:31.205 --> 00:40:32.825
white counts of ten to

NOTE Confidence: 0.91531605

00:40:33.480 --> 00:40:35.160
twelve, you know, nothing that's

NOTE Confidence: 0.91531605

00:40:35.160 --> 00:40:36.440
sort of triggering a workup,

NOTE Confidence: 0.91531605

00:40:36.440 --> 00:40:37.880
but seems to have. And

NOTE Confidence: 0.91531605

00:40:37.880 --> 00:40:39.000
so I wonder, like you

NOTE Confidence: 0.91531605

00:40:39.000 --> 00:40:40.119
said, if there's another sort

NOTE Confidence: 0.91531605

00:40:40.119 --> 00:40:41.400
of, like, and you said,

NOTE Confidence: 0.91531605

00:40:41.400 --> 00:40:42.440
like maybe there's a little

NOTE Confidence: 0.91531605

00:40:42.440 --> 00:40:43.660
bit of non pathologic

NOTE Confidence: 0.96304023

00:40:44.280 --> 00:40:45.180
chronic inflammation

NOTE Confidence: 0.9366716

00:40:45.560 --> 00:40:47.000
that's driving some of these,

NOTE Confidence: 0.9967583

00:40:47.735 --> 00:40:48.235
thrombocytosis

NOTE Confidence: 0.98170257

00:40:48.614 --> 00:40:49.495
that may be causing a

NOTE Confidence: 0.98170257

00:40:49.495 --> 00:40:50.395
little bit of leukocytosis

NOTE Confidence: 0.9594556

00:40:50.695 --> 00:40:51.655
because I do see that

NOTE Confidence: 0.9594556

00:40:51.655 --> 00:40:53.094
a lot. So good question

NOTE Confidence: 0.9594556

00:40:53.094 --> 00:40:54.715
about the the the BMI.

NOTE Confidence: 0.9594556

00:40:54.935 --> 00:40:56.455
Yeah. Hers was is thirty

NOTE Confidence: 0.9594556

00:40:56.455 --> 00:40:56.955
seven.

NOTE Confidence: 0.9390021

00:40:59.495 --> 00:41:00.375
Yeah. And yes, I think

NOTE Confidence: 0.9390021

00:41:00.375 --> 00:41:01.094
we see a lot of

NOTE Confidence: 0.9390021

00:41:01.094 --> 00:41:02.395
patients with leukocytosis

NOTE Confidence: 0.997337

00:41:03.080 --> 00:41:03.640
who are,

NOTE Confidence: 0.95941186

00:41:04.120 --> 00:41:05.500
with an elevated BMI,

NOTE Confidence: 0.99174744

00:41:05.800 --> 00:41:07.180
and there's increasing,

NOTE Confidence: 0.99260414

00:41:07.719 --> 00:41:09.500
I think, literature on that,

NOTE Confidence: 0.9147542

00:41:11.000 --> 00:41:11.880
that I've looked at that

NOTE Confidence: 0.9147542

00:41:11.880 --> 00:41:12.440
I think is,

NOTE Confidence: 0.9975978

00:41:13.160 --> 00:41:14.950
really fascinating. So yeah.

NOTE Confidence: 0.86032116

00:41:17.605 --> 00:41:19.285
We have a a comment

NOTE Confidence: 0.86032116

00:41:19.285 --> 00:41:20.505
from Mary Anne Davies.

NOTE Confidence: 0.9675707

00:41:21.844 --> 00:41:22.985
Thank you for a fabulous

NOTE Confidence: 0.9675707

00:41:23.125 --> 00:41:24.565
presentation and thrilled that you

NOTE Confidence: 0.9675707

00:41:24.565 --> 00:41:26.344
highlight the care signature pathways

NOTE Confidence: 0.9675707

00:41:26.485 --> 00:41:27.685
and the value for primary

NOTE Confidence: 0.9675707

00:41:27.685 --> 00:41:28.805
care. Mary Anne, thanks for

NOTE Confidence: 0.9675707

00:41:28.805 --> 00:41:29.685
the work that you and

NOTE Confidence: 0.9675707

00:41:29.685 --> 00:41:30.665
your team do

NOTE Confidence: 0.95424944

00:41:30.989 --> 00:41:32.510
on the signature care pathway,

NOTE Confidence: 0.95424944

00:41:32.510 --> 00:41:33.870
and thank you for sharing

NOTE Confidence: 0.95424944

00:41:33.870 --> 00:41:35.950
the slides that we some

NOTE Confidence: 0.95424944

00:41:35.950 --> 00:41:36.989
of the slides that we

NOTE Confidence: 0.95424944

00:41:36.989 --> 00:41:39.090
used. So thank you. Yeah.

NOTE Confidence: 0.9727694

00:41:39.630 --> 00:41:40.670
No. And they're they're well

NOTE Confidence: 0.9727694

00:41:40.670 --> 00:41:42.050
done. I agree with Frank.

NOTE Confidence: 0.93788755

00:41:42.905 --> 00:41:44.185
Yeah. Yeah. And and the

NOTE Confidence: 0.93788755

00:41:44.185 --> 00:41:45.385
fact that they're living and

NOTE Confidence: 0.93788755

00:41:45.385 --> 00:41:45.704
get,

NOTE Confidence: 0.7050968

00:41:46.265 --> 00:41:46.765
updated.

NOTE Confidence: 0.9706316

00:41:47.464 --> 00:41:48.825
So right. We we highlighted

NOTE Confidence: 0.9706316

00:41:48.825 --> 00:41:49.785
these topics because there was

NOTE Confidence: 0.9706316

00:41:49.785 --> 00:41:50.744
a couple of new ones,

NOTE Confidence: 0.9706316

00:41:50.744 --> 00:41:52.905
but they they'll change as

NOTE Confidence: 0.9706316

00:41:52.905 --> 00:41:54.025
as need be, which is

NOTE Confidence: 0.9706316

00:41:54.025 --> 00:41:54.844
which is great.

NOTE Confidence: 0.9392949

00:41:58.180 --> 00:41:58.820
But I don't know if

NOTE Confidence: 0.9392949

00:41:58.820 --> 00:42:00.100
there's no other questions at

NOTE Confidence: 0.9392949

00:42:00.100 --> 00:42:00.980
a time. I did have

NOTE Confidence: 0.9392949

00:42:00.980 --> 00:42:02.340
one question. We see a

NOTE Confidence: 0.9392949

00:42:02.340 --> 00:42:04.020
lot of elevated fair, you

NOTE Confidence: 0.9392949

00:42:04.020 --> 00:42:06.020
know, through all these, all

NOTE Confidence: 0.9392949

00:42:06.020 --> 00:42:07.460
both of these cases, right?

NOTE Confidence: 0.9392949

00:42:07.460 --> 00:42:08.580
The workup was let's get

NOTE Confidence: 0.9392949

00:42:08.580 --> 00:42:09.640
some iron studies.

NOTE Confidence: 0.9941981

00:42:10.100 --> 00:42:10.600
And

NOTE Confidence: 0.8394037

00:42:10.900 --> 00:42:11.780
I will say,

NOTE Confidence: 0.9840463

00:42:12.100 --> 00:42:13.480
in primary care,

NOTE Confidence: 0.9611543

00:42:14.035 --> 00:42:15.315
I do see a lot

NOTE Confidence: 0.9611543

00:42:15.315 --> 00:42:16.935
of iron studies that show

NOTE Confidence: 0.9611543

00:42:16.995 --> 00:42:18.455
an elevated ferritin

NOTE Confidence: 0.8937598

00:42:19.315 --> 00:42:20.375
and, and

NOTE Confidence: 0.7399415

00:42:20.675 --> 00:42:21.175
often

NOTE Confidence: 0.9228538

00:42:21.795 --> 00:42:23.635
my mind goes to, could,

NOTE Confidence: 0.9228538

00:42:23.635 --> 00:42:24.295
is this

NOTE Confidence: 0.92290384

00:42:24.915 --> 00:42:25.415
hemochromatosis

NOTE Confidence: 0.948854

00:42:26.435 --> 00:42:27.155
and do I need to

NOTE Confidence: 0.948854

00:42:27.155 --> 00:42:28.135
worry about hemochromatosis?

NOTE Confidence: 0.93123835

00:42:28.675 --> 00:42:30.490
And so, I had a

NOTE Confidence: 0.93123835

00:42:30.490 --> 00:42:32.430
question of, of, you know,

NOTE Confidence: 0.93123835

00:42:32.490 --> 00:42:33.930
you know what would be

NOTE Confidence: 0.93123835

00:42:33.930 --> 00:42:35.550
maybe the best marker

NOTE Confidence: 0.9591293

00:42:35.850 --> 00:42:37.130
or trigger that you would

NOTE Confidence: 0.9591293

00:42:37.130 --> 00:42:39.610
wanna share, with your primary

NOTE Confidence: 0.9591293

00:42:39.610 --> 00:42:40.110
care

NOTE Confidence: 0.9911236

00:42:40.410 --> 00:42:41.385
colleagues of

NOTE Confidence: 0.98937976

00:42:41.705 --> 00:42:43.225
when is it worth the

NOTE Confidence: 0.98937976

00:42:43.225 --> 00:42:44.844
the the testing for hemochromatosis?

NOTE Confidence: 0.7833681

00:42:49.225 --> 00:42:49.725
I

NOTE Confidence: 0.93697304

00:42:50.105 --> 00:42:51.145
I think by an iron

NOTE Confidence: 0.93697304

00:42:51.145 --> 00:42:52.825
saturation of more than forty

NOTE Confidence: 0.93697304

00:42:52.825 --> 00:42:54.605
five percent is usually a,

NOTE Confidence: 0.9587893

00:42:56.750 --> 00:42:58.750
a better test to kinda

NOTE Confidence: 0.9587893

00:42:58.750 --> 00:42:59.969
screen for hemochromatosis.

NOTE Confidence: 0.9674308

00:43:00.590 --> 00:43:01.330
So I think,

NOTE Confidence: 0.96253675

00:43:02.030 --> 00:43:03.469
but certainly other ways that

NOTE Confidence: 0.96253675

00:43:03.469 --> 00:43:04.430
someone might come to us

NOTE Confidence: 0.96253675

00:43:04.430 --> 00:43:05.710
too. I mean, sometimes patients

NOTE Confidence: 0.96253675

00:43:05.710 --> 00:43:06.270
have had,

NOTE Confidence: 0.9393526

00:43:06.910 --> 00:43:07.950
you know, an MRI. And

NOTE Confidence: 0.9393526

00:43:07.950 --> 00:43:08.989
if there's sort of iron

NOTE Confidence: 0.9393526

00:43:08.989 --> 00:43:10.109
deposition of on, like, a

NOTE Confidence: 0.9393526

00:43:10.109 --> 00:43:11.154
liver MRI, I think that's

NOTE Confidence: 0.9393526

00:43:11.154 --> 00:43:11.654
certainly

NOTE Confidence: 0.9710727

00:43:12.035 --> 00:43:13.075
like, we think about that

NOTE Confidence: 0.9710727

00:43:13.075 --> 00:43:14.454
as well. But the ferritin,

NOTE Confidence: 0.9710727

00:43:14.515 --> 00:43:15.094
you know,

NOTE Confidence: 0.99622726

00:43:15.714 --> 00:43:16.535
in a similar

NOTE Confidence: 0.9601907

00:43:17.234 --> 00:43:18.194
thing and has a lot

NOTE Confidence: 0.9601907

00:43:18.194 --> 00:43:19.315
of sort of reactive you

NOTE Confidence: 0.9601907

00:43:19.315 --> 00:43:20.355
know, as an acute phase

NOTE Confidence: 0.9601907

00:43:20.355 --> 00:43:21.234
reactant, we might see a

NOTE Confidence: 0.9601907

00:43:21.234 --> 00:43:22.994
high ferritin or from liver

NOTE Confidence: 0.9601907

00:43:22.994 --> 00:43:24.055
diseases and

NOTE Confidence: 0.88788

00:43:24.500 --> 00:43:25.319
and other spaces, alcohol.

NOTE Confidence: 0.86596924

00:43:27.140 --> 00:43:28.260
I don't know, doctor Sharda,

NOTE Confidence: 0.86596924

00:43:28.260 --> 00:43:29.079
your thoughts.

NOTE Confidence: 0.98589027

00:43:30.980 --> 00:43:32.420
No. I agree. And and

NOTE Confidence: 0.98589027

00:43:32.420 --> 00:43:33.780
and then it becomes tough

NOTE Confidence: 0.98589027

00:43:33.780 --> 00:43:34.920
because, you know,

NOTE Confidence: 0.95273495

00:43:36.420 --> 00:43:36.920
because,

NOTE Confidence: 0.93854254

00:43:37.700 --> 00:43:39.105
the the you know, many

NOTE Confidence: 0.93854254

00:43:39.105 --> 00:43:40.725
times we end up seeing,

NOTE Confidence: 0.9477544

00:43:41.344 --> 00:43:41.825
seeing,

NOTE Confidence: 0.917021

00:43:43.185 --> 00:43:45.344
people who've already had, mutation

NOTE Confidence: 0.917021

00:43:45.344 --> 00:43:46.225
testing and then, you know,

NOTE Confidence: 0.917021

00:43:46.225 --> 00:43:47.745
they have either the h

NOTE Confidence: 0.917021

00:43:47.745 --> 00:43:48.864
sixty three d or just,

NOTE Confidence: 0.917021

00:43:48.864 --> 00:43:50.305
you know, they're heterozygous and

NOTE Confidence: 0.917021

00:43:50.305 --> 00:43:51.265
then, you know, you're just

NOTE Confidence: 0.917021

00:43:51.265 --> 00:43:52.465
stuck with someone with a

NOTE Confidence: 0.917021

00:43:52.465 --> 00:43:54.005
ferritin of seven eight hundred

NOTE Confidence: 0.8561363

00:43:54.380 --> 00:43:56.000
who perhaps is, you know,

NOTE Confidence: 0.8818578

00:43:56.300 --> 00:43:57.420
if you follow the, you

NOTE Confidence: 0.8818578

00:43:57.420 --> 00:43:58.380
know, if you're a tourist

NOTE Confidence: 0.8818578

00:43:58.380 --> 00:43:59.520
and follow the textbook,

NOTE Confidence: 0.95324177

00:44:00.219 --> 00:44:01.260
you, you know, you shouldn't

NOTE Confidence: 0.95324177

00:44:01.260 --> 00:44:02.480
be phlebotomizing

NOTE Confidence: 0.9560171

00:44:03.420 --> 00:44:04.780
and but, you know, you

NOTE Confidence: 0.9560171

00:44:04.780 --> 00:44:05.739
end up do you know,

NOTE Confidence: 0.9560171

00:44:05.739 --> 00:44:07.005
you're just stuck there in

NOTE Confidence: 0.9560171

00:44:07.005 --> 00:44:08.125
the middle. But, yeah, ferritin

NOTE Confidence: 0.9560171

00:44:08.125 --> 00:44:08.625
becomes

NOTE Confidence: 0.94622505

00:44:09.085 --> 00:44:10.684
really tough too. And it's

NOTE Confidence: 0.94622505

00:44:10.684 --> 00:44:12.605
got very half longer, much

NOTE Confidence: 0.94622505

00:44:12.605 --> 00:44:14.464
longer half life, I feel.

NOTE Confidence: 0.99141204

00:44:15.244 --> 00:44:16.364
I guess, you know, not

NOTE Confidence: 0.99141204

00:44:16.364 --> 00:44:17.325
half life in terms of

NOTE Confidence: 0.99141204

00:44:17.325 --> 00:44:18.444
the protein, but, like, you

NOTE Confidence: 0.99141204

00:44:18.444 --> 00:44:19.760
know, just physiologically

NOTE Confidence: 0.5446054

00:44:20.300 --> 00:44:20.800
because

NOTE Confidence: 0.91748863

00:44:21.420 --> 00:44:23.180
after acute infections, I I

NOTE Confidence: 0.91748863

00:44:23.180 --> 00:44:24.800
think, you know, in surgeries,

NOTE Confidence: 0.91748863

00:44:24.860 --> 00:44:26.140
ferritin is gonna be high

NOTE Confidence: 0.91748863

00:44:26.140 --> 00:44:27.340
for a very long time.

NOTE Confidence: 0.91748863

00:44:27.340 --> 00:44:28.540
And so then it becomes

NOTE Confidence: 0.91748863

00:44:28.540 --> 00:44:30.060
hard to, you know, obese

NOTE Confidence: 0.91748863

00:44:30.060 --> 00:44:31.360
peep you know, individuals,

NOTE Confidence: 0.99404997

00:44:31.739 --> 00:44:32.239
diabetes,

NOTE Confidence: 0.92872494

00:44:33.055 --> 00:44:34.415
having surgery, or, you know,

NOTE Confidence: 0.92872494

00:44:34.415 --> 00:44:35.855
foot infection. You know? It

NOTE Confidence: 0.92872494

00:44:35.855 --> 00:44:37.635
just becomes very difficult,

NOTE Confidence: 0.9152445

00:44:38.015 --> 00:44:39.235
at some point. Yeah.

NOTE Confidence: 0.98804396

00:44:41.614 --> 00:44:43.055
Yeah. That that so that

NOTE Confidence: 0.98804396

00:44:43.055 --> 00:44:44.594
that was another good pearl.

NOTE Confidence: 0.7129718

00:44:44.910 --> 00:44:46.130
That in the SGLT

NOTE Confidence: 0.9632914

00:44:46.430 --> 00:44:47.170
two inhibitors,

NOTE Confidence: 0.8303625

00:44:48.109 --> 00:44:49.549
those are some good pearls,

NOTE Confidence: 0.8303625

00:44:49.710 --> 00:44:50.849
to lymph by.

NOTE Confidence: 0.9474859

00:44:51.950 --> 00:44:53.329
Yeah. I'm I'm curious.

NOTE Confidence: 0.96480006

00:44:54.030 --> 00:44:55.630
Now I know that this

NOTE Confidence: 0.96480006

00:44:55.630 --> 00:44:57.410
could be an entire presentation

NOTE Confidence: 0.9364316

00:44:57.869 --> 00:44:58.849
in and of itself,

NOTE Confidence: 0.9747569

00:44:59.904 --> 00:45:00.704
but, you know, we talked

NOTE Confidence: 0.9747569

00:45:00.704 --> 00:45:02.484
about high platelets. And,

NOTE Confidence: 0.9988187

00:45:03.105 --> 00:45:04.724
you know, now that patients

NOTE Confidence: 0.9988187

00:45:04.785 --> 00:45:06.805
can see their own results

NOTE Confidence: 0.909908

00:45:07.505 --> 00:45:08.645
in my chart,

NOTE Confidence: 0.9946121

00:45:09.424 --> 00:45:10.464
we get a lot of

NOTE Confidence: 0.9946121

00:45:10.464 --> 00:45:12.085
very pointed questions.

NOTE Confidence: 0.9817005

00:45:12.469 --> 00:45:13.589
You know, the ferritin would

NOTE Confidence: 0.9817005

00:45:13.589 --> 00:45:14.410
be an example

NOTE Confidence: 0.98049957

00:45:14.950 --> 00:45:16.630
on platelets. And, you know,

NOTE Confidence: 0.98049957

00:45:16.630 --> 00:45:18.309
are you sure there's nothing

NOTE Confidence: 0.98049957

00:45:18.309 --> 00:45:19.750
wrong? And I wanna see

NOTE Confidence: 0.98049957

00:45:19.750 --> 00:45:21.029
a a specialist. I mean,

NOTE Confidence: 0.98049957

00:45:21.029 --> 00:45:21.989
it it's a kind of

NOTE Confidence: 0.98049957

00:45:21.989 --> 00:45:24.309
interesting situation where we you

NOTE Confidence: 0.98049957

00:45:24.309 --> 00:45:25.589
know, things that we never

NOTE Confidence: 0.98049957

00:45:25.589 --> 00:45:26.650
had to completely

NOTE Confidence: 0.9700828

00:45:27.085 --> 00:45:28.445
explain, we we now have

NOTE Confidence: 0.9700828

00:45:28.445 --> 00:45:29.105
to explain.

NOTE Confidence: 0.9669073

00:45:29.805 --> 00:45:31.005
And, you know, there's always

NOTE Confidence: 0.9669073

00:45:31.005 --> 00:45:32.125
a a kind of fear

NOTE Confidence: 0.9669073

00:45:32.125 --> 00:45:33.405
of, like, are we dismissing

NOTE Confidence: 0.9669073

00:45:33.405 --> 00:45:35.005
something when it gets called

NOTE Confidence: 0.9669073

00:45:35.005 --> 00:45:35.825
up that way.

NOTE Confidence: 0.97442436

00:45:36.364 --> 00:45:37.245
And and the other thing

NOTE Confidence: 0.97442436

00:45:37.245 --> 00:45:38.045
that comes up a lot

NOTE Confidence: 0.97442436

00:45:38.045 --> 00:45:39.085
is, you know, these kind

NOTE Confidence: 0.97442436

00:45:39.085 --> 00:45:39.745
of intermittent,

NOTE Confidence: 0.9750339

00:45:40.045 --> 00:45:42.760
very mildly low platelet counts,

NOTE Confidence: 0.9893006

00:45:43.540 --> 00:45:44.819
where, you know, if you

NOTE Confidence: 0.9893006

00:45:44.819 --> 00:45:46.020
can actually do a smear

NOTE Confidence: 0.9893006

00:45:46.020 --> 00:45:47.619
and see clumping, you're like,

NOTE Confidence: 0.9893006

00:45:47.619 --> 00:45:49.960
amen. Hallelujah. Nothing to do.

NOTE Confidence: 0.9215093

00:45:51.140 --> 00:45:52.200
But but otherwise,

NOTE Confidence: 0.977142

00:45:52.819 --> 00:45:54.020
again, I I don't think

NOTE Confidence: 0.977142

00:45:54.020 --> 00:45:56.020
people bleed until they go

NOTE Confidence: 0.977142

00:45:56.020 --> 00:45:56.520
significantly

NOTE Confidence: 0.9640318

00:45:56.980 --> 00:45:58.114
lower, but what should be

NOTE Confidence: 0.9640318

00:45:58.114 --> 00:46:00.194
our threshold for doing a

NOTE Confidence: 0.9640318

00:46:00.194 --> 00:46:00.694
workup?

NOTE Confidence: 0.9814164

00:46:01.315 --> 00:46:02.275
And and what should we

NOTE Confidence: 0.9814164

00:46:02.275 --> 00:46:04.035
tell patients when it's just

NOTE Confidence: 0.9814164

00:46:04.035 --> 00:46:05.234
really not a problem? They're

NOTE Confidence: 0.9814164

00:46:05.234 --> 00:46:06.855
only very mildly lower.

NOTE Confidence: 0.9349343

00:46:11.500 --> 00:46:12.619
Anish, I think it's your

NOTE Confidence: 0.9349343

00:46:12.619 --> 00:46:14.460
turn. Okay. Yeah. You're up.

NOTE Confidence: 0.9349343

00:46:14.460 --> 00:46:15.579
No. I agree. And I

NOTE Confidence: 0.9349343

00:46:15.579 --> 00:46:17.039
think I think,

NOTE Confidence: 0.99636084

00:46:17.980 --> 00:46:19.180
I I don't I I

NOTE Confidence: 0.99636084

00:46:19.180 --> 00:46:20.299
don't think there's even a

NOTE Confidence: 0.99636084

00:46:20.299 --> 00:46:21.680
term called minimal thrombocytopenia,

NOTE Confidence: 0.94928604

00:46:22.140 --> 00:46:23.260
but I tend to use

NOTE Confidence: 0.94928604

00:46:23.260 --> 00:46:24.559
it even in my description

NOTE Confidence: 0.94928604

00:46:24.619 --> 00:46:25.119
and

NOTE Confidence: 0.9535878

00:46:25.635 --> 00:46:26.435
because, you know, if you

NOTE Confidence: 0.9535878

00:46:26.515 --> 00:46:27.715
again, if you're a purist

NOTE Confidence: 0.9535878

00:46:27.715 --> 00:46:29.015
like I am,

NOTE Confidence: 0.91453403

00:46:29.635 --> 00:46:31.015
you know, definition of thrombocytopenia

NOTE Confidence: 0.91453403

00:46:31.235 --> 00:46:32.435
is less than hundred actually

NOTE Confidence: 0.91453403

00:46:32.435 --> 00:46:33.315
because, you know, people have

NOTE Confidence: 0.91453403

00:46:33.315 --> 00:46:34.915
gotten together and actually the

NOTE Confidence: 0.91453403

00:46:34.915 --> 00:46:35.735
world thrombocytopenia

NOTE Confidence: 0.9286958

00:46:36.195 --> 00:46:37.635
whatever, so, you know, is

NOTE Confidence: 0.9286958

00:46:37.635 --> 00:46:38.915
less than one hundred. But

NOTE Confidence: 0.9286958

00:46:38.915 --> 00:46:40.295
if you see the

NOTE Confidence: 0.95478094

00:46:40.800 --> 00:46:42.239
CBC and what you know,

NOTE Confidence: 0.95478094

00:46:42.239 --> 00:46:43.880
any lab, they would Yeah.

NOTE Confidence: 0.95478094

00:46:44.080 --> 00:46:45.680
Still report normal as one

NOTE Confidence: 0.95478094

00:46:45.680 --> 00:46:46.719
forty, one fifty, one to

NOTE Confidence: 0.95478094

00:46:46.719 --> 00:46:48.160
sixty, whatever their, you know,

NOTE Confidence: 0.95478094

00:46:48.160 --> 00:46:48.980
lower ranges.

NOTE Confidence: 0.99647796

00:46:49.600 --> 00:46:50.420
And so

NOTE Confidence: 0.99390656

00:46:50.880 --> 00:46:52.080
I and it's a lot

NOTE Confidence: 0.99390656

00:46:52.239 --> 00:46:53.600
you know, it's more common

NOTE Confidence: 0.99390656

00:46:53.600 --> 00:46:54.100
than

NOTE Confidence: 0.9968778

00:46:54.735 --> 00:46:55.875
than thrombocytosis

NOTE Confidence: 0.9185541

00:46:56.575 --> 00:46:58.495
or I would say, at

NOTE Confidence: 0.9185541

00:46:58.495 --> 00:47:00.195
least in my experience. And

NOTE Confidence: 0.9890146

00:47:00.495 --> 00:47:01.615
and and I agree. I

NOTE Confidence: 0.9890146

00:47:01.615 --> 00:47:02.815
mean, it becomes I I

NOTE Confidence: 0.9890146

00:47:02.815 --> 00:47:04.195
think they just need reassurance.

NOTE Confidence: 0.96481735

00:47:05.855 --> 00:47:07.215
I, you know, I I

NOTE Confidence: 0.96481735

00:47:07.375 --> 00:47:08.415
we see plenty of it.

NOTE Confidence: 0.96481735

00:47:08.415 --> 00:47:09.295
I I see plenty of

NOTE Confidence: 0.96481735

00:47:09.295 --> 00:47:10.195
it for referrals.

NOTE Confidence: 0.7864604

00:47:11.430 --> 00:47:11.930
But,

NOTE Confidence: 0.9583617

00:47:12.630 --> 00:47:13.750
but they, you know, it

NOTE Confidence: 0.9583617

00:47:13.750 --> 00:47:15.430
just needs they just need

NOTE Confidence: 0.9583617

00:47:15.430 --> 00:47:17.190
reassurance because I agree with

NOTE Confidence: 0.9583617

00:47:17.190 --> 00:47:18.010
you that

NOTE Confidence: 0.9522347

00:47:18.390 --> 00:47:19.530
that, you know,

NOTE Confidence: 0.88771737

00:47:20.469 --> 00:47:20.969
usually,

NOTE Confidence: 0.9415475

00:47:21.270 --> 00:47:22.710
there's no bleeding even at

NOTE Confidence: 0.9415475

00:47:22.710 --> 00:47:24.070
fifty. Or, you know, fifty

NOTE Confidence: 0.9415475

00:47:24.070 --> 00:47:25.055
is a you know, you

NOTE Confidence: 0.9415475

00:47:25.055 --> 00:47:26.255
can get a hip hip

NOTE Confidence: 0.9415475

00:47:26.255 --> 00:47:27.614
replacement. I mean, you know,

NOTE Confidence: 0.9415475

00:47:27.614 --> 00:47:28.114
so,

NOTE Confidence: 0.94941396

00:47:29.295 --> 00:47:31.135
you know, it's usually been

NOTE Confidence: 0.94941396

00:47:31.135 --> 00:47:32.575
the most the risk of

NOTE Confidence: 0.94941396

00:47:32.575 --> 00:47:33.935
major bleeding is five percent

NOTE Confidence: 0.94941396

00:47:33.935 --> 00:47:35.715
with less than twenty. So

NOTE Confidence: 0.94035846

00:47:36.015 --> 00:47:36.975
so, you know, the the

NOTE Confidence: 0.94035846

00:47:37.055 --> 00:47:38.255
you you don't there's a

NOTE Confidence: 0.94035846

00:47:38.255 --> 00:47:39.530
lot of redundancy and, you

NOTE Confidence: 0.94035846

00:47:39.530 --> 00:47:40.190
know, there's

NOTE Confidence: 0.8144647

00:47:40.489 --> 00:47:41.310
so usually,

NOTE Confidence: 0.9365341

00:47:42.010 --> 00:47:43.450
hundred you know, if they're

NOTE Confidence: 0.9365341

00:47:43.450 --> 00:47:44.989
great really greater than hundred

NOTE Confidence: 0.94272774

00:47:45.369 --> 00:47:47.210
and you have repeated it,

NOTE Confidence: 0.94272774

00:47:47.210 --> 00:47:48.329
you know, and it's still

NOTE Confidence: 0.94272774

00:47:48.329 --> 00:47:49.450
greater than hundred and or

NOTE Confidence: 0.94272774

00:47:49.450 --> 00:47:51.450
it bounces around, it really,

NOTE Confidence: 0.94272774

00:47:51.450 --> 00:47:52.750
I think, is very reassuring.

NOTE Confidence: 0.9732696

00:47:53.805 --> 00:47:55.085
And, you know, and and

NOTE Confidence: 0.9732696

00:47:55.085 --> 00:47:56.045
that you know, one one

NOTE Confidence: 0.9732696

00:47:56.045 --> 00:47:57.165
could just be clear that,

NOTE Confidence: 0.9732696

00:47:57.165 --> 00:47:57.665
actually,

NOTE Confidence: 0.94982964

00:47:58.285 --> 00:47:59.885
the real, you know, we

NOTE Confidence: 0.94982964

00:47:59.885 --> 00:48:01.805
call low platelets, you know,

NOTE Confidence: 0.94982964

00:48:01.964 --> 00:48:03.085
on the medicine you know,

NOTE Confidence: 0.94982964

00:48:03.085 --> 00:48:04.605
from the real definition is

NOTE Confidence: 0.94982964

00:48:04.605 --> 00:48:05.665
less than one hundred.

NOTE Confidence: 0.6333549

00:48:07.645 --> 00:48:08.145
So

NOTE Confidence: 0.9061628

00:48:10.180 --> 00:48:12.239
That is another great pearl.

NOTE Confidence: 0.9061628

00:48:12.300 --> 00:48:13.920
We have, like, just pearls

NOTE Confidence: 0.9061628

00:48:14.140 --> 00:48:16.000
flowing. These are really wonderful

NOTE Confidence: 0.9061628

00:48:16.060 --> 00:48:17.339
because, you know,

NOTE Confidence: 0.94646144

00:48:17.660 --> 00:48:18.540
I don't know about you,

NOTE Confidence: 0.94646144

00:48:18.540 --> 00:48:20.219
Frank. I see, you know,

NOTE Confidence: 0.94646144

00:48:20.219 --> 00:48:21.660
CBCs. I, you know, I

NOTE Confidence: 0.94646144

00:48:21.660 --> 00:48:22.719
probably look at,

NOTE Confidence: 0.9871738

00:48:23.020 --> 00:48:24.705
I don't know, twenty, thirty

NOTE Confidence: 0.9871738

00:48:24.705 --> 00:48:25.985
a day. You know, it's

NOTE Confidence: 0.9871738

00:48:25.985 --> 00:48:27.025
a lot, and and they

NOTE Confidence: 0.9871738

00:48:27.025 --> 00:48:28.385
all have things just outside

NOTE Confidence: 0.9871738

00:48:28.385 --> 00:48:29.045
of normal.

NOTE Confidence: 0.93549204

00:48:30.305 --> 00:48:31.585
And so, this is very

NOTE Confidence: 0.93549204

00:48:31.585 --> 00:48:32.085
helpful,

NOTE Confidence: 0.9704903

00:48:32.625 --> 00:48:33.665
to not kind of over

NOTE Confidence: 0.9704903

00:48:33.665 --> 00:48:35.025
refer things that are, you

NOTE Confidence: 0.9704903

00:48:35.025 --> 00:48:36.565
know, pretty clearly fine.

NOTE Confidence: 0.8322561

00:48:37.250 --> 00:48:38.450
Yeah. I think that I

NOTE Confidence: 0.8322561

00:48:38.450 --> 00:48:39.650
I agree with everything doctor

NOTE Confidence: 0.8322561

00:48:39.650 --> 00:48:40.369
Shutter just said. And I

NOTE Confidence: 0.8322561

00:48:40.369 --> 00:48:41.190
think that,

NOTE Confidence: 0.98690176

00:48:42.369 --> 00:48:43.170
like, the

NOTE Confidence: 0.87965864

00:48:43.809 --> 00:48:45.410
sometimes, like, just in terms

NOTE Confidence: 0.87965864

00:48:45.410 --> 00:48:46.210
of what to say to

NOTE Confidence: 0.87965864

00:48:46.210 --> 00:48:47.650
patients, you know, and, you

NOTE Confidence: 0.87965864

00:48:47.650 --> 00:48:48.550
know, just

NOTE Confidence: 0.9351932

00:48:48.930 --> 00:48:50.450
some some patients, I think,

NOTE Confidence: 0.9472119

00:48:51.405 --> 00:48:52.445
accept that idea of, like,

NOTE Confidence: 0.9472119

00:48:52.445 --> 00:48:53.405
you could have a surgery

NOTE Confidence: 0.9472119

00:48:53.405 --> 00:48:54.445
at this level. You know?

NOTE Confidence: 0.9472119

00:48:54.445 --> 00:48:55.405
And then that's, I think,

NOTE Confidence: 0.9472119

00:48:55.405 --> 00:48:56.685
just, like, clinically, people could

NOTE Confidence: 0.9472119

00:48:56.765 --> 00:48:58.125
that somehow resonates with people.

NOTE Confidence: 0.9472119

00:48:58.125 --> 00:48:58.765
I think, you know, if

NOTE Confidence: 0.9472119

00:48:58.765 --> 00:49:00.945
there's assuming it's just isolated

NOTE Confidence: 0.9472119

00:49:01.005 --> 00:49:01.505
thrombocytopenia

NOTE Confidence: 0.937825

00:49:02.125 --> 00:49:03.905
and not there's no other

NOTE Confidence: 0.9622801

00:49:04.410 --> 00:49:05.690
kind of cell lines. I

NOTE Confidence: 0.9622801

00:49:05.690 --> 00:49:06.569
think the age of the

NOTE Confidence: 0.9622801

00:49:06.569 --> 00:49:08.410
patient. Right? Like and then

NOTE Confidence: 0.9622801

00:49:08.410 --> 00:49:09.690
I guess just as I'm

NOTE Confidence: 0.9622801

00:49:09.690 --> 00:49:11.150
sure we do, you know,

NOTE Confidence: 0.9622801

00:49:11.210 --> 00:49:12.489
even if it was mildly

NOTE Confidence: 0.9622801

00:49:12.489 --> 00:49:13.130
low, I guess I would

NOTE Confidence: 0.9622801

00:49:13.130 --> 00:49:13.930
just add that if it

NOTE Confidence: 0.9622801

00:49:13.930 --> 00:49:15.369
was recently much higher than,

NOTE Confidence: 0.9622801

00:49:15.369 --> 00:49:16.730
like, maybe I would maybe

NOTE Confidence: 0.9622801

00:49:16.730 --> 00:49:18.170
I personally would monitor it.

NOTE Confidence: 0.9622801

00:49:18.170 --> 00:49:18.829
And then

NOTE Confidence: 0.9329569

00:49:19.245 --> 00:49:19.885
I don't know. I look

NOTE Confidence: 0.9329569

00:49:19.885 --> 00:49:21.425
at the mean platelet volume,

NOTE Confidence: 0.9329569

00:49:21.485 --> 00:49:22.445
which, you know, might be

NOTE Confidence: 0.9329569

00:49:22.445 --> 00:49:23.085
one of the things that

NOTE Confidence: 0.9329569

00:49:23.085 --> 00:49:24.445
the other gets disregarded. But

NOTE Confidence: 0.9329569

00:49:24.445 --> 00:49:25.585
if it's a little bit

NOTE Confidence: 0.9329569

00:49:25.725 --> 00:49:26.765
high, I mean, sometimes I

NOTE Confidence: 0.9329569

00:49:26.765 --> 00:49:28.045
think that's kind of these

NOTE Confidence: 0.9329569

00:49:28.045 --> 00:49:29.885
autoimmune ish people. Not that

NOTE Confidence: 0.9329569

00:49:29.885 --> 00:49:31.165
anything needs to be done,

NOTE Confidence: 0.9329569

00:49:31.165 --> 00:49:31.665
but

NOTE Confidence: 0.9905072

00:49:33.590 --> 00:49:35.110
I think that that's something

NOTE Confidence: 0.9905072

00:49:35.110 --> 00:49:35.830
we see a lot in

NOTE Confidence: 0.9905072

00:49:35.830 --> 00:49:36.950
practice. But I think it's,

NOTE Confidence: 0.9175348

00:49:39.430 --> 00:49:41.050
yeah, I think just sort

NOTE Confidence: 0.97004867

00:49:41.430 --> 00:49:43.030
of how we reassure patients

NOTE Confidence: 0.97004867

00:49:43.030 --> 00:49:44.150
in general is hard. I

NOTE Confidence: 0.97004867

00:49:44.150 --> 00:49:44.969
think that

NOTE Confidence: 0.8598128

00:49:45.765 --> 00:49:46.885
it's a difficult

NOTE Confidence: 0.94368124

00:49:48.404 --> 00:49:49.204
there's a lot of things

NOTE Confidence: 0.94368124

00:49:49.204 --> 00:49:50.805
on a CBC that we

NOTE Confidence: 0.94368124

00:49:50.805 --> 00:49:52.005
don't really probably look at

NOTE Confidence: 0.94368124

00:49:52.005 --> 00:49:53.204
in such great detail, but

NOTE Confidence: 0.94368124

00:49:53.204 --> 00:49:54.984
to patients that MCHC

NOTE Confidence: 0.9982994

00:49:55.364 --> 00:49:56.585
is crucial to their,

NOTE Confidence: 0.99947506

00:49:56.885 --> 00:49:57.385
you

NOTE Confidence: 0.88523537

00:49:57.924 --> 00:49:59.364
know, well-being. And that's hard,

NOTE Confidence: 0.88523537

00:49:59.364 --> 00:50:00.244
I think, too. It's just

NOTE Confidence: 0.88523537

00:50:00.244 --> 00:50:01.500
like the number of data

NOTE Confidence: 0.88523537

00:50:01.500 --> 00:50:03.420
points. You know? I think

NOTE Confidence: 0.88523537

00:50:03.420 --> 00:50:04.460
if I may, like, I

NOTE Confidence: 0.88523537

00:50:04.460 --> 00:50:04.960
think,

NOTE Confidence: 0.9621549

00:50:08.620 --> 00:50:09.580
but just wanted to bring

NOTE Confidence: 0.9621549

00:50:09.580 --> 00:50:10.780
it up. But that, like,

NOTE Confidence: 0.9621549

00:50:10.780 --> 00:50:12.060
you know, for for someone

NOTE Confidence: 0.9621549

00:50:12.060 --> 00:50:13.580
we're dealing with who's really

NOTE Confidence: 0.9621549

00:50:13.580 --> 00:50:14.940
not being reassured and would

NOTE Confidence: 0.9621549

00:50:14.940 --> 00:50:16.320
really like, you know,

NOTE Confidence: 0.83827764

00:50:16.665 --> 00:50:19.005
like, even one sentence from,

NOTE Confidence: 0.83827764

00:50:19.065 --> 00:50:20.665
you know, for from a

NOTE Confidence: 0.83827764

00:50:20.665 --> 00:50:21.165
specialist.

NOTE Confidence: 0.9536239

00:50:21.785 --> 00:50:22.445
I think,

NOTE Confidence: 0.98717344

00:50:23.625 --> 00:50:24.985
for cases like that where,

NOTE Confidence: 0.98717344

00:50:24.985 --> 00:50:26.364
you know, it's very borderline

NOTE Confidence: 0.98717344

00:50:26.505 --> 00:50:27.005
thrombocytosis

NOTE Confidence: 0.9754203

00:50:27.545 --> 00:50:28.905
or a very borderline, you

NOTE Confidence: 0.9754203

00:50:28.905 --> 00:50:30.010
know, thrombocytopenia.

NOTE Confidence: 0.97587883

00:50:30.950 --> 00:50:32.469
I think eConsult is a

NOTE Confidence: 0.97587883

00:50:32.469 --> 00:50:33.369
very nice

NOTE Confidence: 0.9473497

00:50:33.910 --> 00:50:35.270
pathway too, and,

NOTE Confidence: 0.98724204

00:50:35.750 --> 00:50:36.550
and I'm not sure, you

NOTE Confidence: 0.98724204

00:50:36.550 --> 00:50:37.690
know, if it's, you know,

NOTE Confidence: 0.9984213

00:50:38.710 --> 00:50:39.450
to what

NOTE Confidence: 0.96379304

00:50:39.910 --> 00:50:41.109
extent kind of, you know,

NOTE Confidence: 0.96379304

00:50:41.109 --> 00:50:42.489
it's it it goes

NOTE Confidence: 0.9490204

00:50:42.945 --> 00:50:44.065
out into this, you know,

NOTE Confidence: 0.9490204

00:50:44.065 --> 00:50:45.344
world, like, in the the

NOTE Confidence: 0.9490204

00:50:45.344 --> 00:50:47.265
whole system, outer system. But

NOTE Confidence: 0.9490204

00:50:47.265 --> 00:50:48.465
I certainly do it, you

NOTE Confidence: 0.9490204

00:50:48.465 --> 00:50:49.505
know, a few weeks, a

NOTE Confidence: 0.9490204

00:50:49.505 --> 00:50:50.325
year, and,

NOTE Confidence: 0.9794973

00:50:51.025 --> 00:50:51.985
and those are you know,

NOTE Confidence: 0.9794973

00:50:51.985 --> 00:50:53.025
they take two, three minutes.

NOTE Confidence: 0.9794973

00:50:53.025 --> 00:50:53.844
I mean and,

NOTE Confidence: 0.9872879

00:50:54.385 --> 00:50:55.745
and, you know, someone signs

NOTE Confidence: 0.9872879

00:50:55.745 --> 00:50:56.864
their life that, you know,

NOTE Confidence: 0.9872879

00:50:56.864 --> 00:50:57.969
this is fine. You know?

NOTE Confidence: 0.9872879

00:50:57.969 --> 00:50:58.930
And so I I I

NOTE Confidence: 0.9872879

00:50:58.930 --> 00:51:00.370
think that that could, you

NOTE Confidence: 0.9872879

00:51:00.370 --> 00:51:01.810
know, be reassuring to everyone

NOTE Confidence: 0.9872879

00:51:01.810 --> 00:51:03.350
and save everyone's time,

NOTE Confidence: 0.9705915

00:51:03.730 --> 00:51:05.170
including patients and, you know,

NOTE Confidence: 0.9705915

00:51:05.170 --> 00:51:06.130
because, you know, you know,

NOTE Confidence: 0.9705915

00:51:06.130 --> 00:51:06.850
it could take a long

NOTE Confidence: 0.9705915

00:51:06.850 --> 00:51:07.810
time to get a referral

NOTE Confidence: 0.9705915

00:51:07.810 --> 00:51:08.950
for something like that.

NOTE Confidence: 0.9986404

00:51:09.810 --> 00:51:11.750
That is another very helpful

NOTE Confidence: 0.9997556

00:51:12.050 --> 00:51:12.550
suggestion.

NOTE Confidence: 0.93397725

00:51:13.775 --> 00:51:15.315
So we have, a a

NOTE Confidence: 0.93397725

00:51:15.455 --> 00:51:17.795
question from an anonymous attendee,

NOTE Confidence: 0.9619132

00:51:18.735 --> 00:51:20.595
and, it says, what pathways

NOTE Confidence: 0.9619132

00:51:20.655 --> 00:51:21.395
are available?

NOTE Confidence: 0.9788517

00:51:22.015 --> 00:51:23.955
I only saw iron deficiency.

NOTE Confidence: 0.991301

00:51:24.255 --> 00:51:25.614
So all of the ones

NOTE Confidence: 0.991301

00:51:25.614 --> 00:51:26.815
that we showed are in

NOTE Confidence: 0.991301

00:51:26.815 --> 00:51:27.315
there.

NOTE Confidence: 0.8110366

00:51:28.700 --> 00:51:28.859
Actually,

NOTE Confidence: 0.5098155

00:51:29.500 --> 00:51:31.039
we can to that?

NOTE Confidence: 0.997337

00:51:31.739 --> 00:51:32.239
Yeah.

NOTE Confidence: 0.9111601

00:51:32.700 --> 00:51:33.819
Oh, yeah. The give us

NOTE Confidence: 0.9111601

00:51:33.819 --> 00:51:35.180
a table of contents of

NOTE Confidence: 0.9111601

00:51:35.180 --> 00:51:36.619
that. It was, like, seven

NOTE Confidence: 0.9111601

00:51:36.700 --> 00:51:38.160
slide seventeen or something.

NOTE Confidence: 0.92970324

00:51:39.900 --> 00:51:40.400
Renee,

NOTE Confidence: 0.95845705

00:51:40.859 --> 00:51:41.920
are you able to

NOTE Confidence: 0.7762842

00:51:44.825 --> 00:51:46.444
She might have stepped away.

NOTE Confidence: 0.8996194

00:51:51.065 --> 00:51:52.025
I'll try to share it,

NOTE Confidence: 0.8996194

00:51:52.025 --> 00:51:54.045
but let's see. Yeah. Okay.

NOTE Confidence: 0.8996194

00:51:54.105 --> 00:51:55.885
Here it comes. Good. Always.

NOTE Confidence: 0.9623297

00:51:57.110 --> 00:51:58.469
Yeah. And if you can

NOTE Confidence: 0.9623297

00:51:58.469 --> 00:51:59.450
make that bigger.

NOTE Confidence: 0.9965258

00:52:03.350 --> 00:52:04.330
So we have

NOTE Confidence: 0.9992337

00:52:05.590 --> 00:52:06.090
thrombocytosis,

NOTE Confidence: 0.99970865

00:52:06.950 --> 00:52:07.450
lymphocytosis,

NOTE Confidence: 0.99049854

00:52:09.204 --> 00:52:10.265
ferritin evaluation,

NOTE Confidence: 0.99647003

00:52:10.805 --> 00:52:11.704
and erythrocytosis

NOTE Confidence: 0.9580866

00:52:12.565 --> 00:52:13.625
are what I'm reading

NOTE Confidence: 0.98949444

00:52:14.005 --> 00:52:15.204
with my face right up

NOTE Confidence: 0.98949444

00:52:15.204 --> 00:52:16.025
to the computer

NOTE Confidence: 0.7723934

00:52:17.364 --> 00:52:17.924
and bleeding

NOTE Confidence: 0.88567907

00:52:18.405 --> 00:52:19.944
concern for bleeding disorder.

NOTE Confidence: 0.9108159

00:52:22.290 --> 00:52:23.590
And and these were launched,

NOTE Confidence: 0.98470074

00:52:23.890 --> 00:52:25.330
they're they're a little simpler

NOTE Confidence: 0.98470074

00:52:25.330 --> 00:52:26.130
than some of the other

NOTE Confidence: 0.98470074

00:52:26.130 --> 00:52:26.630
pathways,

NOTE Confidence: 0.9824171

00:52:27.410 --> 00:52:28.450
and and so they were

NOTE Confidence: 0.9824171

00:52:28.450 --> 00:52:29.489
kind of launched. There there's

NOTE Confidence: 0.9824171

00:52:29.489 --> 00:52:30.530
actually some more ready to

NOTE Confidence: 0.9824171

00:52:30.530 --> 00:52:31.510
go in hematology,

NOTE Confidence: 0.85045063

00:52:32.210 --> 00:52:33.315
if, people,

NOTE Confidence: 0.9520633

00:52:33.954 --> 00:52:35.155
find these helpful, which I

NOTE Confidence: 0.9520633

00:52:35.155 --> 00:52:35.954
I think we've had a

NOTE Confidence: 0.9520633

00:52:35.954 --> 00:52:36.454
resounding,

NOTE Confidence: 0.9866704

00:52:37.075 --> 00:52:37.575
endorsement.

NOTE Confidence: 0.9489173

00:52:38.114 --> 00:52:39.075
Frank, you looked at that.

NOTE Confidence: 0.9489173

00:52:39.075 --> 00:52:40.375
You're like, these are great.

NOTE Confidence: 0.9489173

00:52:40.515 --> 00:52:41.635
So and, of course, there's,

NOTE Confidence: 0.9489173

00:52:41.875 --> 00:52:43.075
a ton of pathways in

NOTE Confidence: 0.9489173

00:52:43.075 --> 00:52:44.694
other things, diabetes, hypertension,

NOTE Confidence: 0.91452444

00:52:46.160 --> 00:52:47.680
you know, but not other

NOTE Confidence: 0.91452444

00:52:47.680 --> 00:52:49.200
things aside from heme as

NOTE Confidence: 0.91452444

00:52:49.200 --> 00:52:49.700
well.

NOTE Confidence: 0.91520935

00:52:52.960 --> 00:52:54.239
And whoever it is that

NOTE Confidence: 0.91520935

00:52:54.239 --> 00:52:54.739
asks

NOTE Confidence: 0.995009

00:52:55.520 --> 00:52:56.960
can always send me a

NOTE Confidence: 0.995009

00:52:56.960 --> 00:52:58.080
quick note, and I will

NOTE Confidence: 0.995009

00:52:58.080 --> 00:52:59.300
make sure you have somebody

NOTE Confidence: 0.995009

00:52:59.360 --> 00:53:00.880
help you find the additional

NOTE Confidence: 0.995009

00:53:00.880 --> 00:53:01.380
pathways.

NOTE Confidence: 0.715229

00:53:03.305 --> 00:53:04.585
Great. And, Frank, I'm gonna

NOTE Confidence: 0.715229

00:53:04.585 --> 00:53:05.484
be going back.

NOTE Confidence: 0.96782917

00:53:06.105 --> 00:53:06.905
I was oh, and if

NOTE Confidence: 0.96782917

00:53:06.905 --> 00:53:08.585
you can't find it, maybe

NOTE Confidence: 0.96782917

00:53:08.585 --> 00:53:10.984
that's a reason to, you

NOTE Confidence: 0.96782917

00:53:10.984 --> 00:53:11.864
know, put it on the

NOTE Confidence: 0.96782917

00:53:11.864 --> 00:53:13.464
list. Maybe it's being added

NOTE Confidence: 0.96782917

00:53:13.464 --> 00:53:14.664
as we speak, but maybe

NOTE Confidence: 0.96782917

00:53:14.664 --> 00:53:15.785
it's on the list. If

NOTE Confidence: 0.96782917

00:53:15.785 --> 00:53:16.585
not, we could put it

NOTE Confidence: 0.96782917

00:53:16.585 --> 00:53:17.565
on the list.

NOTE Confidence: 0.9973422

00:53:18.800 --> 00:53:19.300
Exactly.

NOTE Confidence: 0.8934162

00:53:20.320 --> 00:53:22.480
Okay. Well, it looks like

NOTE Confidence: 0.8934162

00:53:22.480 --> 00:53:22.980
we

NOTE Confidence: 0.9816767

00:53:24.080 --> 00:53:25.120
are ending nearing the end

NOTE Confidence: 0.9816767

00:53:25.120 --> 00:53:26.900
of our hour where Kelsey's

NOTE Confidence: 0.9816767

00:53:26.960 --> 00:53:28.880
daughter has announced it's time

NOTE Confidence: 0.9816767

00:53:28.880 --> 00:53:30.320
to come have dinner or

NOTE Confidence: 0.9816767

00:53:30.320 --> 00:53:31.300
something. Right?

NOTE Confidence: 0.9729091

00:53:32.994 --> 00:53:34.435
I was gonna ask go

NOTE Confidence: 0.9729091

00:53:34.435 --> 00:53:35.715
back to, Frank, your your

NOTE Confidence: 0.9729091

00:53:35.715 --> 00:53:37.795
background slide introducing this whole

NOTE Confidence: 0.9729091

00:53:37.795 --> 00:53:39.315
thing, which was sort of

NOTE Confidence: 0.9729091

00:53:39.315 --> 00:53:41.575
elevated blood counts and that,

NOTE Confidence: 0.9993966

00:53:41.955 --> 00:53:43.075
you know, there's

NOTE Confidence: 0.94977474

00:53:43.635 --> 00:53:44.855
it's so common.

NOTE Confidence: 0.9511358

00:53:45.309 --> 00:53:46.349
Every day you're looking at

NOTE Confidence: 0.9511358

00:53:46.349 --> 00:53:47.329
so many CBCs,

NOTE Confidence: 0.98294955

00:53:48.989 --> 00:53:50.430
trying to figure out what

NOTE Confidence: 0.98294955

00:53:50.430 --> 00:53:51.410
to do beforehand

NOTE Confidence: 0.95925736

00:53:51.789 --> 00:53:54.349
versus who really needs urgent

NOTE Confidence: 0.95925736

00:53:54.349 --> 00:53:54.849
care,

NOTE Confidence: 0.8965012

00:53:55.469 --> 00:53:57.710
or urgent referral or, you

NOTE Confidence: 0.8965012

00:53:57.710 --> 00:53:59.650
know, accessing the e referral.

NOTE Confidence: 0.963155

00:54:00.005 --> 00:54:01.685
Do you do you and

NOTE Confidence: 0.963155

00:54:01.685 --> 00:54:02.965
Karen feel like you have

NOTE Confidence: 0.963155

00:54:02.965 --> 00:54:04.265
a good handle on that?

NOTE Confidence: 0.9948271

00:54:05.364 --> 00:54:06.585
Are there other instances

NOTE Confidence: 0.9971846

00:54:06.885 --> 00:54:07.385
where

NOTE Confidence: 0.9915245

00:54:09.205 --> 00:54:09.705
where

NOTE Confidence: 0.98809576

00:54:10.805 --> 00:54:12.405
you're you're thinking that that

NOTE Confidence: 0.98809576

00:54:12.405 --> 00:54:13.525
you need a little extra

NOTE Confidence: 0.98809576

00:54:13.525 --> 00:54:14.645
help or or that you're

NOTE Confidence: 0.98809576

00:54:14.645 --> 00:54:15.650
not quite sure where to

NOTE Confidence: 0.98809576

00:54:15.650 --> 00:54:16.550
go from there?

NOTE Confidence: 0.48823148

00:54:19.890 --> 00:54:20.390
Right?

NOTE Confidence: 0.9924346

00:54:21.010 --> 00:54:21.670
I think,

NOTE Confidence: 0.97443265

00:54:22.130 --> 00:54:23.090
I mean, I think, you

NOTE Confidence: 0.97443265

00:54:23.090 --> 00:54:24.130
know, like what Karen said,

NOTE Confidence: 0.97443265

00:54:24.130 --> 00:54:25.730
sometimes managing, like, sort of

NOTE Confidence: 0.97443265

00:54:25.730 --> 00:54:27.330
the patient expectation is sort

NOTE Confidence: 0.97443265

00:54:27.330 --> 00:54:28.770
of the our other job,

NOTE Confidence: 0.97443265

00:54:28.770 --> 00:54:30.195
right, besides just handling the

NOTE Confidence: 0.97443265

00:54:30.195 --> 00:54:32.195
medical stuff. And so sometimes

NOTE Confidence: 0.97443265

00:54:32.195 --> 00:54:33.795
there is no no amount

NOTE Confidence: 0.97443265

00:54:33.795 --> 00:54:34.455
of reassurance

NOTE Confidence: 0.9931617

00:54:34.755 --> 00:54:35.735
I can give someone.

NOTE Confidence: 0.95866525

00:54:36.594 --> 00:54:37.715
And so there there is

NOTE Confidence: 0.95866525

00:54:37.715 --> 00:54:38.935
unfortunately some

NOTE Confidence: 0.90476525

00:54:39.315 --> 00:54:40.114
it is what it is

NOTE Confidence: 0.90476525

00:54:40.114 --> 00:54:40.935
patient driven,

NOTE Confidence: 0.99927914

00:54:41.795 --> 00:54:43.255
referrals. I mean, I think

NOTE Confidence: 0.97002256

00:54:43.910 --> 00:54:45.270
the I would say the

NOTE Confidence: 0.97002256

00:54:45.270 --> 00:54:46.630
other ones that come up.

NOTE Confidence: 0.97002256

00:54:46.630 --> 00:54:48.469
So the, the gammopathy or

NOTE Confidence: 0.97002256

00:54:48.469 --> 00:54:49.910
the MGUS pathway, I think

NOTE Confidence: 0.97002256

00:54:49.910 --> 00:54:51.130
I use a fair amount,

NOTE Confidence: 0.9845862

00:54:51.830 --> 00:54:53.270
or or can't see myself

NOTE Confidence: 0.9845862

00:54:53.270 --> 00:54:54.469
using a fair amount, which

NOTE Confidence: 0.9845862

00:54:54.469 --> 00:54:55.610
is which is great.

NOTE Confidence: 0.89735514

00:54:56.469 --> 00:54:57.030
And then,

NOTE Confidence: 0.9488437

00:54:58.485 --> 00:54:59.445
the I think I think

NOTE Confidence: 0.9488437

00:54:59.445 --> 00:55:01.225
someone alluded to the you

NOTE Confidence: 0.9488437

00:55:01.445 --> 00:55:02.485
you see a pre op,

NOTE Confidence: 0.9488437

00:55:02.485 --> 00:55:04.725
someone at had asked for

NOTE Confidence: 0.9488437

00:55:04.725 --> 00:55:05.225
the,

NOTE Confidence: 0.92407423

00:55:05.525 --> 00:55:07.045
the PT and PTT and

NOTE Confidence: 0.92407423

00:55:07.045 --> 00:55:08.425
it's mildly elevated.

NOTE Confidence: 0.9781652

00:55:08.805 --> 00:55:09.765
And then you're like, well,

NOTE Confidence: 0.9781652

00:55:09.765 --> 00:55:10.885
now what I now what

NOTE Confidence: 0.9781652

00:55:10.885 --> 00:55:11.845
do we do? Right? And

NOTE Confidence: 0.9781652

00:55:11.845 --> 00:55:12.345
so

NOTE Confidence: 0.998163

00:55:12.690 --> 00:55:13.190
so,

NOTE Confidence: 0.9233217

00:55:13.570 --> 00:55:14.609
you know, that's a that's

NOTE Confidence: 0.9233217

00:55:14.609 --> 00:55:16.530
another, I think, really, like,

NOTE Confidence: 0.9233217

00:55:16.530 --> 00:55:17.030
if,

NOTE Confidence: 0.9264686

00:55:17.489 --> 00:55:18.849
you know, you bookmark things,

NOTE Confidence: 0.9264686

00:55:18.849 --> 00:55:19.730
like, you know, is this

NOTE Confidence: 0.9264686

00:55:19.730 --> 00:55:21.410
a bookmarkable one? So those

NOTE Confidence: 0.9264686

00:55:21.410 --> 00:55:22.530
I think are are are

NOTE Confidence: 0.9264686

00:55:22.530 --> 00:55:24.609
good. I've not used, the

NOTE Confidence: 0.9264686

00:55:24.609 --> 00:55:25.890
eConsult as much, but I

NOTE Confidence: 0.9264686

00:55:25.890 --> 00:55:27.989
feel like there's just a

NOTE Confidence: 0.9264686

00:55:28.033 --> 00:55:30.145
a a a hidden or

NOTE Confidence: 0.9264686

00:55:30.145 --> 00:55:32.085
not so hidden, like, potential

NOTE Confidence: 0.9264686

00:55:32.145 --> 00:55:32.885
to really,

NOTE Confidence: 0.928289

00:55:33.905 --> 00:55:35.765
improve the through the throughput

NOTE Confidence: 0.928289

00:55:35.985 --> 00:55:37.985
between, primary care and and

NOTE Confidence: 0.928289

00:55:37.985 --> 00:55:38.485
heme,

NOTE Confidence: 0.96129036

00:55:39.230 --> 00:55:40.750
with that. And so I

NOTE Confidence: 0.96129036

00:55:40.750 --> 00:55:41.869
think I feel like that's

NOTE Confidence: 0.96129036

00:55:41.869 --> 00:55:42.989
something that we should take

NOTE Confidence: 0.96129036

00:55:42.989 --> 00:55:43.489
back,

NOTE Confidence: 0.96626747

00:55:43.950 --> 00:55:44.989
and figure out how do

NOTE Confidence: 0.96626747

00:55:44.989 --> 00:55:46.130
we make this,

NOTE Confidence: 0.99572504

00:55:47.549 --> 00:55:48.349
more user

NOTE Confidence: 0.9337691

00:55:48.989 --> 00:55:49.809
used more.

NOTE Confidence: 0.9688559

00:55:50.589 --> 00:55:52.190
Mhmm. Yeah. It's pretty user

NOTE Confidence: 0.9688559

00:55:52.190 --> 00:55:52.690
friendly.

NOTE Confidence: 0.98178375

00:55:53.265 --> 00:55:54.864
And it it's nice, because

NOTE Confidence: 0.98178375

00:55:54.864 --> 00:55:55.825
so many of us kind

NOTE Confidence: 0.98178375

00:55:55.825 --> 00:55:57.204
of do curbsides. Right?

NOTE Confidence: 0.8535652

00:55:57.905 --> 00:55:58.864
We call we phone a

NOTE Confidence: 0.8535652

00:55:58.864 --> 00:55:59.364
friend.

NOTE Confidence: 0.9593945

00:56:00.145 --> 00:56:01.265
But that that's not in

NOTE Confidence: 0.9593945

00:56:01.265 --> 00:56:01.924
the chart,

NOTE Confidence: 0.9197286

00:56:02.545 --> 00:56:03.344
and it, you know, it

NOTE Confidence: 0.9197286

00:56:03.344 --> 00:56:04.464
it doesn't have any credit.

NOTE Confidence: 0.9197286

00:56:04.464 --> 00:56:05.910
The the there's actually billing

NOTE Confidence: 0.9197286

00:56:05.910 --> 00:56:07.349
credit for the specialist through

NOTE Confidence: 0.9197286

00:56:07.349 --> 00:56:08.650
the econsult. So,

NOTE Confidence: 0.9482699

00:56:09.270 --> 00:56:10.230
they they kind of get

NOTE Confidence: 0.9482699

00:56:10.230 --> 00:56:11.989
productivity credit and and and

NOTE Confidence: 0.9482699

00:56:11.989 --> 00:56:13.030
we get a a very

NOTE Confidence: 0.9482699

00:56:13.030 --> 00:56:13.849
clear answer.

NOTE Confidence: 0.97764677

00:56:14.630 --> 00:56:15.829
And, again, if we want

NOTE Confidence: 0.97764677

00:56:15.829 --> 00:56:16.869
to, we can have a

NOTE Confidence: 0.97764677

00:56:16.869 --> 00:56:18.390
whole another encounter to discuss

NOTE Confidence: 0.97764677

00:56:18.390 --> 00:56:20.010
the answer if it's complicated,

NOTE Confidence: 0.97764677

00:56:20.069 --> 00:56:21.045
or or we can just

NOTE Confidence: 0.97764677

00:56:21.204 --> 00:56:22.244
simply send the patient a

NOTE Confidence: 0.97764677

00:56:22.244 --> 00:56:23.204
note or or call the

NOTE Confidence: 0.97764677

00:56:23.204 --> 00:56:24.325
patient if it's kind of

NOTE Confidence: 0.97764677

00:56:24.325 --> 00:56:25.305
what we were expecting

NOTE Confidence: 0.98047906

00:56:25.605 --> 00:56:26.424
to say anyway.

NOTE Confidence: 0.9842136

00:56:27.684 --> 00:56:28.184
So

NOTE Confidence: 0.9993308

00:56:28.898 --> 00:56:30.658
alright. Well, I have to

NOTE Confidence: 0.9993308

00:56:30.658 --> 00:56:31.878
thank our speakers

NOTE Confidence: 0.99957734

00:56:32.178 --> 00:56:33.378
very much for all of

NOTE Confidence: 0.99957734

00:56:33.378 --> 00:56:33.958
the preparation

NOTE Confidence: 0.96082836

00:56:34.258 --> 00:56:36.098
and wisdom and pearls that

NOTE Confidence: 0.96082836

00:56:36.098 --> 00:56:36.838
came through,

NOTE Confidence: 0.9558716

00:56:37.938 --> 00:56:39.698
and, and and, Frank, for

NOTE Confidence: 0.9558716

00:56:39.698 --> 00:56:40.343
keeping us on