{"version":"1.0.0","segments":[{"startTime":7.995,"endTime":9.745,"body":"Welcome back to the Ninja Nerd Podcast."},{"startTime":9.765,"endTime":13.515,"body":"Today we have a new episode on"},{"startTime":9.765,"endTime":13.515,"body":"Myelodysplastic syndrome, or we're just"},{"startTime":13.515,"endTime":16.365,"body":"gonna go ahead and abbreviate that,"},{"startTime":13.515,"endTime":16.365,"body":"MDS keep it quick and simple, right?"},{"startTime":16.425,"endTime":16.935,"body":"I like it."},{"startTime":16.935,"endTime":20.025,"body":"Any way you can abbreviate something"},{"startTime":16.935,"endTime":20.025,"body":"always makes my life, and I think a"},{"startTime":20.025,"endTime":21.645,"body":"lot of people's life easier, but yeah."},{"startTime":21.705,"endTime":23.205,"body":"All right, so we'll keep"},{"startTime":21.705,"endTime":23.205,"body":"it quick with that one."},{"startTime":23.475,"endTime":25.034,"body":"MDS, I don't know what that is."},{"startTime":26.805,"endTime":29.534,"body":"I think a lot of people probably"},{"startTime":26.805,"endTime":29.534,"body":"haven't always heard of this one."},{"startTime":29.534,"endTime":32.895,"body":"It's kind of one of those insidious ones,"},{"startTime":29.534,"endTime":32.895,"body":"something in older individuals, but."},{"startTime":33.555,"endTime":37.095,"body":"Oftentimes, it's kind of a common"},{"startTime":33.555,"endTime":37.095,"body":"thing that may come up in the workup"},{"startTime":37.095,"endTime":39.795,"body":"of anemia or sometimes pancytopenia."},{"startTime":39.795,"endTime":42.555,"body":"And so I think that's the big thing"},{"startTime":39.795,"endTime":42.555,"body":"to take away from this is when a"},{"startTime":42.555,"endTime":46.755,"body":"patient who's a little bit older comes"},{"startTime":42.555,"endTime":46.755,"body":"in, they got either one or a couple"},{"startTime":46.755,"endTime":48.645,"body":"different cell lines being affected."},{"startTime":49.005,"endTime":50.325,"body":"It could be a part of that differential."},{"startTime":50.415,"endTime":53.145,"body":"So I think we'll talk about that"},{"startTime":50.415,"endTime":53.145,"body":"and kind of get a really good"},{"startTime":53.145,"endTime":54.675,"body":"understanding at the end of this case."},{"startTime":55.05,"endTime":56.58,"body":"About how to really think about MDS."},{"startTime":56.73,"endTime":59.88,"body":"Alright, well as always, let's"},{"startTime":56.73,"endTime":59.88,"body":"get right into it with a case."},{"startTime":59.88,"endTime":64.0,"body":"We'll go through some a patient case,"},{"startTime":59.88,"endTime":64.0,"body":"some findings, and hopefully we can"},{"startTime":64.21,"endTime":65.349,"body":"really learn a lot from this one."},{"startTime":65.379,"endTime":66.16,"body":"Yeah, I think we will."},{"startTime":66.28,"endTime":67.66,"body":"Alright, let's begin."},{"startTime":67.69,"endTime":72.31,"body":"We have a 70-year-old female presents"},{"startTime":67.69,"endTime":72.31,"body":"with progressive fatigue, increased"},{"startTime":72.31,"endTime":75.13,"body":"bruising, and mild exertional"},{"startTime":72.31,"endTime":75.13,"body":"dyspnea for the past four months."},{"startTime":75.82,"endTime":79.42,"body":"The patient describes a gradual decline"},{"startTime":75.82,"endTime":79.42,"body":"in her energy levels, forcing her to limit"},{"startTime":79.42,"endTime":81.07,"body":"her usual walks around the neighborhood."},{"startTime":81.66,"endTime":84.84,"body":"Over the last two months, she has"},{"startTime":81.66,"endTime":84.84,"body":"noticed easy bruising on her arms"},{"startTime":84.84,"endTime":86.64,"body":"and legs without significant trauma."},{"startTime":87.27,"endTime":91.56,"body":"She denies chest pain, fevers, night"},{"startTime":87.27,"endTime":91.56,"body":"sweats, or significant weight changes."},{"startTime":92.19,"endTime":95.37,"body":"She's experienced occasional headaches"},{"startTime":92.19,"endTime":95.37,"body":"but attributes them to stress."},{"startTime":95.85,"endTime":98.88,"body":"There is no known family"},{"startTime":95.85,"endTime":98.88,"body":"history of hematologic disease."},{"startTime":99.27,"endTime":103.95,"body":"She also notes that she has felt more"},{"startTime":99.27,"endTime":103.95,"body":"prone to infections recently having"},{"startTime":103.95,"endTime":107.61,"body":"had two sinus infections over the last"},{"startTime":103.95,"endTime":107.61,"body":"three months, which is unusual for her."},{"startTime":107.66,"endTime":110.57,"body":"Her past medical history is"},{"startTime":107.66,"endTime":110.57,"body":"pertinent for hypertension,"},{"startTime":110.93,"endTime":113.15,"body":"osteoarthritis to the bilateral knees."},{"startTime":113.57,"endTime":117.08,"body":"No known malignancies, no prior"},{"startTime":113.57,"endTime":117.08,"body":"radiation therapy or chemotherapy."},{"startTime":118.535,"endTime":121.265,"body":"She's currently taking"},{"startTime":118.535,"endTime":121.265,"body":"amlodipine, acetaminophen as"},{"startTime":121.265,"endTime":122.375,"body":"needed for her joint pain."},{"startTime":122.795,"endTime":124.205,"body":"Vitamin D supplementation."},{"startTime":124.865,"endTime":128.675,"body":"For her Review of systems,"},{"startTime":124.865,"endTime":128.675,"body":"general fatigue, mild malaise."},{"startTime":128.825,"endTime":131.256,"body":"Cardiovascular, mild exertional dyspnea."},{"startTime":131.555,"endTime":132.455,"body":"No chest pain."},{"startTime":132.965,"endTime":135.485,"body":"Respiratory, no cough,"},{"startTime":132.965,"endTime":135.485,"body":"no sputum production."},{"startTime":135.95,"endTime":140.06,"body":"Neurologic, occasional headaches,"},{"startTime":135.95,"endTime":140.06,"body":"again, attributed possibly to stress."},{"startTime":140.3,"endTime":141.47,"body":"No paresthesias."},{"startTime":141.8,"endTime":146.33,"body":"Hematologic, easy bruising, possible"},{"startTime":141.8,"endTime":146.33,"body":"increased infection frequency."},{"startTime":146.96,"endTime":150.11,"body":"Gastrointestinal, regular bowel"},{"startTime":146.96,"endTime":150.11,"body":"movements, no abdominal pain."},{"startTime":150.56,"endTime":153.63,"body":"And then for her derm, no new rashes."},{"startTime":153.84,"endTime":156.09,"body":"Vitals, BP is 120/70."},{"startTime":156.21,"endTime":162.055,"body":"Heart rate is 90, temp 36.8 Celsius,"},{"startTime":156.21,"endTime":162.055,"body":"and her O2 SAT is 98% on room air."},{"startTime":162.535,"endTime":166.585,"body":"Skin we note pale conjunctiva,"},{"startTime":162.535,"endTime":166.585,"body":"scattered ecchymosis on her arms."},{"startTime":167.095,"endTime":169.285,"body":"Cardio she has a regular rate and rhythm."},{"startTime":169.315,"endTime":172.315,"body":"No murmurs, no significant"},{"startTime":169.315,"endTime":172.315,"body":"jugular venous distension."},{"startTime":173.01,"endTime":174.78,"body":"Pulmonary is clear to auscultation."},{"startTime":174.78,"endTime":176.34,"body":"No crackles or wheezes."},{"startTime":176.61,"endTime":178.64,"body":"Abdomen is soft non-tender."},{"startTime":178.82,"endTime":180.01,"body":"No hepatosplenomegaly."},{"startTime":180.59,"endTime":182.81,"body":"Neuro- there are no focal deficits."},{"startTime":183.02,"endTime":184.52,"body":"Extremities, no edema."},{"startTime":184.61,"endTime":185.81,"body":"Full range of motion."},{"startTime":186.14,"endTime":187.31,"body":"Except for them knees, though."},{"startTime":187.34,"endTime":188.51,"body":"They Yeah, they'd be hurting."},{"startTime":188.66,"endTime":188.81,"body":"Yeah."},{"startTime":188.81,"endTime":191.36,"body":"Rice Krispies down there, but like"},{"startTime":188.81,"endTime":191.36,"body":"potato chips, when you get out of"},{"startTime":191.36,"endTime":194.685,"body":"bed, ka kaka based upon all this,"},{"startTime":191.36,"endTime":194.685,"body":"we go back and say, all right,"},{"startTime":194.685,"endTime":196.575,"body":"let's get a nice lab panel for her."},{"startTime":196.605,"endTime":196.875,"body":"Yeah."},{"startTime":196.875,"endTime":197.79,"body":"We order the following."},{"startTime":197.88,"endTime":203.97,"body":"We have a hemoglobin of 9.2,"},{"startTime":197.88,"endTime":203.97,"body":"MCV of 105, white blood cell"},{"startTime":203.97,"endTime":207.36,"body":"of 3,500, platelets 85,000."},{"startTime":208.29,"endTime":211.05,"body":"Reticulocyte count is 0.6%."},{"startTime":211.44,"endTime":213.09,"body":"B12 is 450."},{"startTime":213.405,"endTime":215.535,"body":"Folate is 9.0."},{"startTime":216.465,"endTime":221.985,"body":"We do an LDH, which comes back at"},{"startTime":216.465,"endTime":221.985,"body":"200 and a peripheral blood smear that"},{"startTime":221.985,"endTime":225.045,"body":"we note for dysplastic neutrophils."},{"startTime":225.735,"endTime":227.985,"body":"I gave you a shat ton of information."},{"startTime":228.915,"endTime":228.975,"body":"Yeah."},{"startTime":228.975,"endTime":230.475,"body":"Are you able to process all of that?"},{"startTime":230.505,"endTime":231.285,"body":"Yeah."},{"startTime":231.375,"endTime":234.465,"body":"I think the biggest thing is this patient."},{"startTime":234.485,"endTime":240.155,"body":"When you look at this, it screams"},{"startTime":234.485,"endTime":240.155,"body":"pancytopenia just right off the chief"},{"startTime":240.155,"endTime":244.565,"body":"complaint when you hear progressive"},{"startTime":240.155,"endTime":244.565,"body":"fatigue, maybe even some palor, things"},{"startTime":244.565,"endTime":246.125,"body":"like that, some exertional dyspnea."},{"startTime":246.125,"endTime":251.195,"body":"I. It's all signs of anemia,"},{"startTime":246.125,"endTime":251.195,"body":"at least subjectively."},{"startTime":251.505,"endTime":255.045,"body":"I was able to confirm that"},{"startTime":251.505,"endTime":255.045,"body":"based upon the CBC results, that"},{"startTime":255.045,"endTime":257.115,"body":"gave me a hemoglobin of 9.2."},{"startTime":257.565,"endTime":263.135,"body":"So for this patient, hemoglobin boom,"},{"startTime":257.565,"endTime":263.135,"body":"if it's less than, usually we say if"},{"startTime":263.135,"endTime":266.645,"body":"it's less than 12 and a female, that's"},{"startTime":263.135,"endTime":266.645,"body":"enough to say that it's likely anemia."},{"startTime":266.915,"endTime":269.825,"body":"This is 9.2, so I know"},{"startTime":266.915,"endTime":269.825,"body":"that there's anemia."},{"startTime":270.065,"endTime":271.835,"body":"The next thing is I hear the bruising."},{"startTime":272.115,"endTime":277.575,"body":"A lot of bruising going on ecchymosis"},{"startTime":272.115,"endTime":277.575,"body":"that's present on her physical exam."},{"startTime":278.055,"endTime":280.795,"body":"And then you get the platelet"},{"startTime":278.055,"endTime":280.795,"body":"count and it's 85,000."},{"startTime":280.795,"endTime":281.785,"body":"So that's also low."},{"startTime":281.785,"endTime":281.845,"body":"Yeah."},{"startTime":281.875,"endTime":283.765,"body":"So there's another cell"},{"startTime":281.875,"endTime":283.765,"body":"line that's affected."},{"startTime":284.095,"endTime":288.475,"body":"Remember I told you this is an old"},{"startTime":284.095,"endTime":288.475,"body":"person disease, 70-year-old with"},{"startTime":288.565,"endTime":290.755,"body":"potentially one or multiple cell lines."},{"startTime":290.755,"endTime":294.835,"body":"Anemia is the most common, but so"},{"startTime":290.755,"endTime":294.835,"body":"far we got red cells and platelets."},{"startTime":295.465,"endTime":298.885,"body":"The third thing I heard is"},{"startTime":295.465,"endTime":298.885,"body":"recurrent infections, cyop."},{"startTime":298.885,"endTime":300.895,"body":"Pulmonary infections are"},{"startTime":298.885,"endTime":300.895,"body":"usually the common way."},{"startTime":300.895,"endTime":304.475,"body":"Sinus infections, pneumonia, bronchitis,"},{"startTime":300.895,"endTime":304.475,"body":"things like that are pretty common."},{"startTime":305.105,"endTime":307.865,"body":"This is two of them over"},{"startTime":305.105,"endTime":307.865,"body":"the past three months."},{"startTime":308.135,"endTime":310.445,"body":"So there's a recurrent"},{"startTime":308.135,"endTime":310.445,"body":"infections that are coming about."},{"startTime":310.835,"endTime":313.625,"body":"Makes me concerned is there's something"},{"startTime":310.835,"endTime":313.625,"body":"wrong with the white cell line."},{"startTime":313.625,"endTime":315.795,"body":"I. However, her white cell is low."},{"startTime":315.915,"endTime":316.425,"body":"Yeah."},{"startTime":316.425,"endTime":318.885,"body":"So wouldn't you expect it"},{"startTime":316.425,"endTime":318.885,"body":"to be high with infections?"},{"startTime":318.885,"endTime":321.285,"body":"It would as a response to an infection."},{"startTime":321.285,"endTime":325.245,"body":"But in this case, she's not developing a"},{"startTime":321.285,"endTime":325.245,"body":"bone marrow that's capable of producing"},{"startTime":325.245,"endTime":329.235,"body":"these white cells, and that's probably"},{"startTime":325.245,"endTime":329.235,"body":"what's causing these recurrent infections."},{"startTime":329.235,"endTime":333.855,"body":"And so when I see that white cell"},{"startTime":329.235,"endTime":333.855,"body":"count that is 3,500, is it on"},{"startTime":333.855,"endTime":336.145,"body":"the, it's below the lower limit."},{"startTime":336.535,"endTime":339.295,"body":"So there is a mild leukopenia here too."},{"startTime":339.775,"endTime":342.445,"body":"I'd say the most significant"},{"startTime":339.775,"endTime":342.445,"body":"ones are gonna be the red"},{"startTime":342.445,"endTime":343.675,"body":"cells and then the platelets."},{"startTime":343.675,"endTime":345.925,"body":"So we do have a pancytopenia."},{"startTime":346.285,"endTime":351.485,"body":"Now, when you have pancytopenia, you"},{"startTime":346.285,"endTime":351.485,"body":"always think what's going on with"},{"startTime":351.485,"endTime":354.065,"body":"the bone marrow because it's always"},{"startTime":351.485,"endTime":354.065,"body":"almost kinda tells you something's"},{"startTime":354.065,"endTime":355.205,"body":"going on with the bone marrow."},{"startTime":355.715,"endTime":359.255,"body":"And so you probably remember back"},{"startTime":355.715,"endTime":359.255,"body":"from like our normocytic anemia"},{"startTime":359.255,"endTime":363.785,"body":"talk that we talked about, aplastic"},{"startTime":359.255,"endTime":363.785,"body":"anemia where the bone marrow fails,"},{"startTime":363.785,"endTime":366.215,"body":"like there's destruction of the"},{"startTime":363.785,"endTime":366.215,"body":"hematopoietic stem cells and they"},{"startTime":366.215,"endTime":368.075,"body":"just stop producing all cell lines."},{"startTime":368.885,"endTime":373.835,"body":"Well, MDS is kind of like that, but"},{"startTime":368.885,"endTime":373.835,"body":"it's, you make this weird cell who"},{"startTime":373.835,"endTime":378.995,"body":"then is not able to capably like-"},{"startTime":373.835,"endTime":378.995,"body":"effectively produce all the other cells."},{"startTime":379.235,"endTime":383.465,"body":"So it's like this weird dysplastic"},{"startTime":379.235,"endTime":383.465,"body":"cell and this dysplastic cell is"},{"startTime":383.465,"endTime":387.605,"body":"not capable of making normal red"},{"startTime":383.465,"endTime":387.605,"body":"cells, normal white cells and normal"},{"startTime":387.605,"endTime":389.525,"body":"platelets, and it's very ineffective."},{"startTime":389.915,"endTime":391.385,"body":"So it's kind of like that."},{"startTime":391.595,"endTime":393.095,"body":"And so that's definitely concerning."},{"startTime":393.095,"endTime":398.375,"body":"So when I have this evidence of anemia,"},{"startTime":393.095,"endTime":398.375,"body":"leukopenia, thrombocytopenia, and then"},{"startTime":398.375,"endTime":401.975,"body":"the symptoms that suggest, that makes"},{"startTime":398.375,"endTime":401.975,"body":"me definitely concerned for that."},{"startTime":402.275,"endTime":402.335,"body":"Now."},{"startTime":403.385,"endTime":406.445,"body":"There's a couple other things when we"},{"startTime":403.385,"endTime":406.445,"body":"think about anemia for this patient."},{"startTime":407.675,"endTime":411.875,"body":"We see the MCV is high, so"},{"startTime":407.675,"endTime":411.875,"body":"it's greater than a hundred."},{"startTime":411.875,"endTime":413.905,"body":"So that tells me it's macrocytic anemia."},{"startTime":414.235,"endTime":418.105,"body":"It's almost always, at least for your"},{"startTime":414.235,"endTime":418.105,"body":"board's, B12 or folate deficiency, right?"},{"startTime":418.645,"endTime":421.495,"body":"So one of the things you have to"},{"startTime":418.645,"endTime":421.495,"body":"do is get a peripheral blood smear."},{"startTime":421.795,"endTime":425.385,"body":"And if you guys remember from that"},{"startTime":421.795,"endTime":425.385,"body":"podcast, on macrocytic anemia, we"},{"startTime":425.385,"endTime":426.645,"body":"check the peripheral blood smear."},{"startTime":426.645,"endTime":428.805,"body":"We look for hypersegmented"},{"startTime":426.645,"endTime":428.805,"body":"neutrophils or not."},{"startTime":429.435,"endTime":433.515,"body":"Well, this found dysplastic"},{"startTime":429.435,"endTime":433.515,"body":"neutrophils, not hypersegmented."},{"startTime":434.055,"endTime":437.685,"body":"So for therefore it's not gonna be a"},{"startTime":434.055,"endTime":437.685,"body":"B12 or folate, but we still got the B12"},{"startTime":437.685,"endTime":439.545,"body":"and folate level and they were normal."},{"startTime":439.695,"endTime":439.875,"body":"Yeah."},{"startTime":440.115,"endTime":442.275,"body":"So it's not B12, it's"},{"startTime":440.115,"endTime":442.275,"body":"not folate deficiency."},{"startTime":442.275,"endTime":443.955,"body":"And then the other thing is"},{"startTime":442.275,"endTime":443.955,"body":"we got the reticulocyte count."},{"startTime":444.315,"endTime":446.925,"body":"And what we know about reticulocyte"},{"startTime":444.315,"endTime":446.925,"body":"counts it is it tells us that the"},{"startTime":446.925,"endTime":448.635,"body":"bone marrow is working or not."},{"startTime":449.175,"endTime":452.745,"body":"The lower the reticulocyte count is,"},{"startTime":449.175,"endTime":452.745,"body":"the less likely that the bone marrow"},{"startTime":452.745,"endTime":455.265,"body":"is actually producing these cells."},{"startTime":455.355,"endTime":457.845,"body":"And it's definitely on"},{"startTime":455.355,"endTime":457.845,"body":"that lower limit of normal."},{"startTime":458.58,"endTime":461.31,"body":"So that makes me a little"},{"startTime":458.58,"endTime":461.31,"body":"bit concerned that this bone"},{"startTime":461.31,"endTime":462.42,"body":"marrow is really struggling."},{"startTime":463.11,"endTime":468.88,"body":"The last kind of giveaway here is"},{"startTime":463.11,"endTime":468.88,"body":"when I see the Psudo-Pelger-Huet"},{"startTime":469.08,"endTime":472.05,"body":"anomaly or neutrophils, which"},{"startTime":469.08,"endTime":472.05,"body":"are these dysplastic neutrophils."},{"startTime":472.77,"endTime":474.66,"body":"If you see that, it's almost like."},{"startTime":475.545,"endTime":480.19,"body":"Pathognomonic for MDS the only way"},{"startTime":475.545,"endTime":480.19,"body":"that we could really, truly kind of,"},{"startTime":480.19,"endTime":484.15,"body":"kind of really get to the confirmation"},{"startTime":480.19,"endTime":484.15,"body":"of this is we'd probably have to"},{"startTime":484.15,"endTime":488.29,"body":"start taking a look deeper into the"},{"startTime":484.15,"endTime":488.29,"body":"kind of the bone marrow and stuff."},{"startTime":488.5,"endTime":488.56,"body":"Yeah."},{"startTime":488.56,"endTime":491.92,"body":"Because right now a lot of things are"},{"startTime":488.56,"endTime":491.92,"body":"screaming the peripheral stuff as a"},{"startTime":491.92,"endTime":494.74,"body":"result of the bone marrow problem,"},{"startTime":491.92,"endTime":494.74,"body":"but we gotta figure out what's going"},{"startTime":494.74,"endTime":498.67,"body":"on inside of that bone marrow really"},{"startTime":494.74,"endTime":498.67,"body":"well, Zach, that is a strong suspicion."},{"startTime":498.79,"endTime":501.61,"body":"What would be the next"},{"startTime":498.79,"endTime":501.61,"body":"key diagnostic step here?"},{"startTime":502.0,"endTime":503.68,"body":"So we gotta get in that bone marrow."},{"startTime":503.68,"endTime":507.88,"body":"So the bone marrow biopsy is gonna"},{"startTime":503.68,"endTime":507.88,"body":"be the probably the best thing to do."},{"startTime":508.39,"endTime":512.59,"body":"So we will aspirate out the bone marrow"},{"startTime":508.39,"endTime":512.59,"body":"because my kind of thing here is, I can't"},{"startTime":512.59,"endTime":515.38,"body":"really 100% confirm that it's not like."},{"startTime":516.19,"endTime":519.1,"body":"Infiltration of the bone"},{"startTime":516.19,"endTime":519.1,"body":"marrow from leukemia?"},{"startTime":519.52,"endTime":520.48,"body":"I don't think it is."},{"startTime":520.87,"endTime":523.36,"body":"'cause I probably see different"},{"startTime":520.87,"endTime":523.36,"body":"things on the peripheral smear."},{"startTime":523.54,"endTime":523.6,"body":"Yeah."},{"startTime":523.84,"endTime":527.56,"body":"I gotta make sure it's not"},{"startTime":523.84,"endTime":527.56,"body":"aplastic anemia or something else."},{"startTime":527.56,"endTime":530.71,"body":"And so I gotta make sure that it's"},{"startTime":527.56,"endTime":530.71,"body":"not like a leukemic infiltration."},{"startTime":530.71,"endTime":533.68,"body":"I gotta make sure that it's not"},{"startTime":530.71,"endTime":533.68,"body":"aplastic anemia and then confirm"},{"startTime":533.68,"endTime":535.09,"body":"my suspicion, which is MDS."},{"startTime":535.48,"endTime":538.78,"body":"So when I do that, what you'll see"},{"startTime":535.48,"endTime":538.78,"body":"is you'll see the hypercellular"},{"startTime":538.78,"endTime":542.68,"body":"marrow, for aplastic anemia,"},{"startTime":538.78,"endTime":542.68,"body":"it's almost always hypocellular."},{"startTime":542.71,"endTime":546.45,"body":"It's filled with adipose tissue,"},{"startTime":542.71,"endTime":546.45,"body":"so that rules out, aplastic"},{"startTime":546.45,"endTime":547.71,"body":"anemia, if that's what it was."},{"startTime":548.25,"endTime":551.64,"body":"So I wanna see a lot of cells, but"},{"startTime":548.25,"endTime":551.64,"body":"these cells gotta look super funky."},{"startTime":551.88,"endTime":555.87,"body":"They gotta be dysplastic appearing, and"},{"startTime":551.88,"endTime":555.87,"body":"on top of that I'm gonna have some blasts."},{"startTime":556.05,"endTime":557.97,"body":"So you shouldn't have a ton blast cells."},{"startTime":558.42,"endTime":561.6,"body":"I want to have usually"},{"startTime":558.42,"endTime":561.6,"body":"less than or equal to 20%."},{"startTime":561.66,"endTime":565.95,"body":"At least less than 20% blast"},{"startTime":561.66,"endTime":565.95,"body":"cells inside of that bone marrow."},{"startTime":565.95,"endTime":569.91,"body":"'cause if it's more than or equal to"},{"startTime":565.95,"endTime":569.91,"body":"20%, that's acute myeloid leukemia."},{"startTime":570.03,"endTime":570.45,"body":"We're done."},{"startTime":571.02,"endTime":573.72,"body":"So I want to see some blasts,"},{"startTime":571.02,"endTime":573.72,"body":"but not to the point where it's"},{"startTime":573.72,"endTime":575.01,"body":"greater than or equal to 20%."},{"startTime":575.01,"endTime":577.05,"body":"So I wanna see weird dysplastic cells."},{"startTime":577.485,"endTime":580.725,"body":"I wanna see a really hypercellular"},{"startTime":577.485,"endTime":580.725,"body":"marrow, and I wanna see, again,"},{"startTime":580.725,"endTime":582.225,"body":"less than 20% of those blasts."},{"startTime":582.225,"endTime":585.795,"body":"And if I see that I'm pretty"},{"startTime":582.225,"endTime":585.795,"body":"much, I'd say, confident that"},{"startTime":585.795,"endTime":588.165,"body":"it's MDS, well, we do the biopsy."},{"startTime":588.405,"endTime":588.585,"body":"Okay."},{"startTime":588.585,"endTime":588.885,"body":"All right."},{"startTime":588.945,"endTime":589.815,"body":"And guess what?"},{"startTime":589.985,"endTime":590.125,"body":"What?"},{"startTime":590.145,"endTime":595.875,"body":"It shows hypercellular marrow, multiple"},{"startTime":590.145,"endTime":595.875,"body":"dysplastic lineages and 5% myeloblasts."},{"startTime":595.995,"endTime":596.385,"body":"Yeah."},{"startTime":596.385,"endTime":599.265,"body":"So that's a, so that's a very"},{"startTime":596.385,"endTime":599.265,"body":"confirming yeah, exactly."},{"startTime":600.03,"endTime":603.6,"body":"Well, then my next question is how do we"},{"startTime":600.03,"endTime":603.6,"body":"stratify the risk and decide on treatment?"},{"startTime":603.99,"endTime":605.55,"body":"That's a really important thing."},{"startTime":605.55,"endTime":611.13,"body":"So at this point, we've determined that"},{"startTime":605.55,"endTime":611.13,"body":"it's MDS, but MDS can be one of those"},{"startTime":611.13,"endTime":612.54,"body":"things that's a little bit tricky."},{"startTime":613.2,"endTime":614.91,"body":"So remember how I."},{"startTime":615.135,"endTime":618.425,"body":"And we kind of talked about if"},{"startTime":615.135,"endTime":618.425,"body":"it was greater than or equal to"},{"startTime":618.425,"endTime":620.495,"body":"20% blast, it would be a AML."},{"startTime":621.035,"endTime":624.065,"body":"That's one of the big"},{"startTime":621.035,"endTime":624.065,"body":"complications of MDS."},{"startTime":624.185,"endTime":627.815,"body":"How when a patient gets MDS,"},{"startTime":624.185,"endTime":627.815,"body":"they're probably 70, 80 years of"},{"startTime":627.815,"endTime":632.285,"body":"age, not trying to be mean, but"},{"startTime":627.815,"endTime":632.285,"body":"your lifespan is a little shorter."},{"startTime":632.765,"endTime":638.285,"body":"The chances of a person developing"},{"startTime":632.765,"endTime":638.285,"body":"acute myeloid leukemia from MDS, you're"},{"startTime":638.285,"endTime":641.735,"body":"more likely to die from other things."},{"startTime":642.35,"endTime":646.85,"body":"Anemia, thrombocytopenia, recurrent"},{"startTime":642.35,"endTime":646.85,"body":"infections before you actually develop."},{"startTime":647.36,"endTime":651.05,"body":"Probably most patients probably"},{"startTime":647.36,"endTime":651.05,"body":"die before that, so they're"},{"startTime":651.05,"endTime":652.845,"body":"not gonna transform in time."},{"startTime":652.905,"endTime":653.685,"body":"It's, yeah."},{"startTime":653.865,"endTime":658.425,"body":"So maybe 10% of them do, but most of them"},{"startTime":653.865,"endTime":658.425,"body":"die from other related complications."},{"startTime":658.425,"endTime":663.45,"body":"But we gotta at least make sure that we"},{"startTime":658.425,"endTime":663.45,"body":"determine which ones are higher risk."},{"startTime":664.275,"endTime":668.235,"body":"And then we can also use this to determine"},{"startTime":664.275,"endTime":668.235,"body":"the prognosis for us, how to treat them."},{"startTime":668.745,"endTime":672.565,"body":"So we use revised international"},{"startTime":668.745,"endTime":672.565,"body":"prognostic scoring system."},{"startTime":673.135,"endTime":676.105,"body":"But all you really know, need to"},{"startTime":673.135,"endTime":676.105,"body":"know about this is you wanna know"},{"startTime":676.525,"endTime":679.145,"body":"what is the percentage of blasts."},{"startTime":679.235,"endTime":682.115,"body":"That's the first thing that you"},{"startTime":679.235,"endTime":682.115,"body":"need to know if it's really high."},{"startTime":682.115,"endTime":684.315,"body":"That's kind of getting you"},{"startTime":682.115,"endTime":684.315,"body":"closer to the risk of a AML."},{"startTime":684.98,"endTime":688.1,"body":"The next thing is you need to"},{"startTime":684.98,"endTime":688.1,"body":"know how severe is the cytopenias."},{"startTime":688.1,"endTime":689.9,"body":"This person's got all the cytopenias."},{"startTime":690.41,"endTime":690.83,"body":"All right?"},{"startTime":691.31,"endTime":693.68,"body":"And then the next thing is"},{"startTime":691.31,"endTime":693.68,"body":"you wanna know cytogenetics."},{"startTime":693.68,"endTime":697.88,"body":"There's one specific type of"},{"startTime":693.68,"endTime":697.88,"body":"like abnormality within the"},{"startTime":697.88,"endTime":701.69,"body":"chromosomes that can help us to"},{"startTime":697.88,"endTime":701.69,"body":"have one drug that can target it."},{"startTime":702.11,"endTime":704.63,"body":"And so you always wanna check the"},{"startTime":702.11,"endTime":704.63,"body":"cytogenetics and we're looking"},{"startTime":704.63,"endTime":709.52,"body":"for specifically what's called"},{"startTime":704.63,"endTime":709.52,"body":"a chromosome 5q locus deletion."},{"startTime":709.79,"endTime":713.75,"body":"And so that has a good prognosis and"},{"startTime":709.79,"endTime":713.75,"body":"we actually have a drug that can target"},{"startTime":713.78,"endTime":717.53,"body":"these kinds of patient populations"},{"startTime":713.78,"endTime":717.53,"body":"to really figure out where they fit."},{"startTime":717.65,"endTime":720.23,"body":"That's what I would do that and kind"},{"startTime":717.65,"endTime":720.23,"body":"of determine where they fall in that"},{"startTime":720.23,"endTime":722.36,"body":"low intermediate, high risk MDS."},{"startTime":722.69,"endTime":724.64,"body":"Alright, well then, hey, we"},{"startTime":722.69,"endTime":724.64,"body":"have some results for you."},{"startTime":724.695,"endTime":725.475,"body":"For you here then."},{"startTime":725.505,"endTime":729.735,"body":"Okay, so the patient has isolated"},{"startTime":725.505,"endTime":729.735,"body":"5q deletion on cytogenetics."},{"startTime":729.765,"endTime":730.305,"body":"Okay, that's good."},{"startTime":730.305,"endTime":733.905,"body":"And moderate anemia requiring"},{"startTime":730.305,"endTime":733.905,"body":"transfusions every few weeks."},{"startTime":733.905,"endTime":735.165,"body":"What's the key treatment in it?"},{"startTime":735.165,"endTime":736.725,"body":"So there is a drug that targets that."},{"startTime":736.785,"endTime":737.505,"body":"Exactly."},{"startTime":737.505,"endTime":740.865,"body":"So at this point, that's again, I"},{"startTime":737.505,"endTime":740.865,"body":"told you the most common presentation"},{"startTime":740.865,"endTime":742.065,"body":"is gonna be macrocytic anemia."},{"startTime":742.065,"endTime":745.005,"body":"And the problem with that is,"},{"startTime":742.065,"endTime":745.005,"body":"is if they get low enough."},{"startTime":745.775,"endTime":748.715,"body":"You gotta give transfusions is"},{"startTime":745.775,"endTime":748.715,"body":"sometimes you can actually check"},{"startTime":748.715,"endTime":751.925,"body":"their EPO levels and look to"},{"startTime":748.715,"endTime":751.925,"body":"see if their EPO levels are low."},{"startTime":752.435,"endTime":754.025,"body":"'cause that can't happen"},{"startTime":752.435,"endTime":754.025,"body":"in this condition."},{"startTime":754.025,"endTime":756.215,"body":"So if their EPO levels get less"},{"startTime":754.025,"endTime":756.215,"body":"than 500, you can give them like"},{"startTime":756.215,"endTime":758.795,"body":"erythropoietin, which is like an ESA."},{"startTime":759.285,"endTime":763.125,"body":"But the best thing to do is if a"},{"startTime":759.285,"endTime":763.125,"body":"patient's having transfusion dependency,"},{"startTime":763.485,"endTime":765.705,"body":"there's a drug called lenalidomide."},{"startTime":766.665,"endTime":770.775,"body":"And it's actually able to really help"},{"startTime":766.665,"endTime":770.775,"body":"with effective erythropoiesis, and so"},{"startTime":770.775,"endTime":774.885,"body":"it helps them to make better red blood"},{"startTime":770.775,"endTime":774.885,"body":"cells so that they don't have to have"},{"startTime":774.885,"endTime":777.285,"body":"this constant need to get transfusions."},{"startTime":777.615,"endTime":778.575,"body":"So that's what I would do."},{"startTime":778.575,"endTime":780.885,"body":"First thing I would do, check"},{"startTime":778.575,"endTime":780.885,"body":"the EPO, make sure it's not"},{"startTime":780.885,"endTime":782.445,"body":"like less than 500 if it is."},{"startTime":782.91,"endTime":785.49,"body":"Start an ESA and try"},{"startTime":782.91,"endTime":785.49,"body":"that for a little bit."},{"startTime":785.91,"endTime":789.19,"body":"But I would also be highly considering,"},{"startTime":785.91,"endTime":789.19,"body":"especially since they have that 5q"},{"startTime":789.21,"endTime":793.15,"body":"deletion, I'd probably start a drug like"},{"startTime":789.21,"endTime":793.15,"body":"lenalidomide because that's actually"},{"startTime":793.15,"endTime":797.2,"body":"gonna help to reduce the transfusion"},{"startTime":793.15,"endTime":797.2,"body":"frequency, even despite me doing EPO."},{"startTime":797.35,"endTime":799.78,"body":"Well, lenalidomide is"},{"startTime":797.35,"endTime":799.78,"body":"perfect for that 5q deletion."},{"startTime":799.84,"endTime":800.14,"body":"Yeah."},{"startTime":800.14,"endTime":802.6,"body":"What if she had a higher risk MDS?"},{"startTime":802.7,"endTime":808.13,"body":"She has adverse cytogenetics or blasts"},{"startTime":802.7,"endTime":808.13,"body":"creeping up toward that 10, maybe 15%."},{"startTime":808.25,"endTime":808.61,"body":"Yeah."},{"startTime":808.61,"endTime":812.3,"body":"So if she had cytopenias like this,"},{"startTime":808.61,"endTime":812.3,"body":"blasts are getting higher and then"},{"startTime":812.3,"endTime":815.39,"body":"she doesn't have that 5q deletion,"},{"startTime":812.3,"endTime":815.39,"body":"then I can't use lenalidomide."},{"startTime":815.66,"endTime":819.32,"body":"Then we gotta use these drugs like"},{"startTime":815.66,"endTime":819.32,"body":"hypomethylating agents, Azacitidine."},{"startTime":819.59,"endTime":822.29,"body":"That's probably gonna be the best one."},{"startTime":822.53,"endTime":825.11,"body":"Sometimes Decitabine can be"},{"startTime":822.53,"endTime":825.11,"body":"used as well, but I haven't"},{"startTime":825.11,"endTime":826.37,"body":"really seen that to be common."},{"startTime":826.37,"endTime":828.47,"body":"It's gonna be more the, as azacitidine."},{"startTime":828.9,"endTime":832.49,"body":"And that's been shown to"},{"startTime":828.9,"endTime":832.49,"body":"potentially slow the progression"},{"startTime":832.79,"endTime":835.13,"body":"of AML, maybe improve survival."},{"startTime":835.38,"endTime":838.92,"body":"And again, it can actually reduce"},{"startTime":835.38,"endTime":838.92,"body":"transfusion dependency for these patients."},{"startTime":838.95,"endTime":842.01,"body":"'cause that's always the goal is to"},{"startTime":838.95,"endTime":842.01,"body":"reduce the need for these patients"},{"startTime":842.01,"endTime":843.09,"body":"having to go and get transfusions."},{"startTime":843.09,"endTime":845.73,"body":"Because imagine if you"},{"startTime":843.09,"endTime":845.73,"body":"got a blood transfusion."},{"startTime":846.345,"endTime":849.435,"body":"Every so many weeks when"},{"startTime":846.345,"endTime":849.435,"body":"you get blood, you get iron."},{"startTime":849.435,"endTime":851.655,"body":"When you get iron, you end"},{"startTime":849.435,"endTime":851.655,"body":"up in increasing the risk of"},{"startTime":851.655,"endTime":853.395,"body":"secondary hemochromatosis too."},{"startTime":853.695,"endTime":855.855,"body":"So that's another potential complication."},{"startTime":856.035,"endTime":859.605,"body":"And then you also run the risk of other"},{"startTime":856.035,"endTime":859.605,"body":"things that can happen with repeated"},{"startTime":859.705,"endTime":862.795,"body":"blood transfusions, as we talked about"},{"startTime":859.705,"endTime":862.795,"body":"in the blood transfusion lecture."},{"startTime":862.845,"endTime":865.815,"body":"It's always a good idea to see if"},{"startTime":862.845,"endTime":865.815,"body":"we could reduce that need and help"},{"startTime":865.815,"endTime":867.075,"body":"them have a better quality of life."},{"startTime":867.075,"endTime":871.305,"body":"So Azacitidine is definitely one of"},{"startTime":867.075,"endTime":871.305,"body":"those that may improve quality of"},{"startTime":871.305,"endTime":876.075,"body":"life, improve survival, and hopefully"},{"startTime":871.305,"endTime":876.075,"body":"help to reduce the need for frequent"},{"startTime":876.075,"endTime":877.605,"body":"transfusions in these patients."},{"startTime":877.605,"endTime":881.685,"body":"But again, problem is"},{"startTime":877.605,"endTime":881.685,"body":"that it's only a bandaid."},{"startTime":881.715,"endTime":883.545,"body":"Just like lenalidomide is a bandaid."},{"startTime":883.875,"endTime":885.975,"body":"It's trying to help them to"},{"startTime":883.875,"endTime":885.975,"body":"make better red blood cells."},{"startTime":886.215,"endTime":889.205,"body":"Azacitidine is trying to help to stop"},{"startTime":886.215,"endTime":889.205,"body":"some of these blasts from continuously"},{"startTime":889.205,"endTime":891.17,"body":"to undergoing ineffective erythropoiesis."},{"startTime":891.965,"endTime":894.305,"body":"The only thing you can really"},{"startTime":891.965,"endTime":894.305,"body":"do is get a transplant."},{"startTime":894.665,"endTime":894.725,"body":"Yeah."},{"startTime":894.845,"endTime":900.005,"body":"Problem is that there's 70, 80-year-old"},{"startTime":894.845,"endTime":900.005,"body":"individuals probably their fitness level's"},{"startTime":900.005,"endTime":904.655,"body":"kind of like lower, it's harder to push"},{"startTime":900.005,"endTime":904.655,"body":"something like that in an MDS patient."},{"startTime":904.805,"endTime":905.015,"body":"Sure."},{"startTime":905.615,"endTime":907.115,"body":"But you could possibly?"},{"startTime":907.115,"endTime":907.745,"body":"You definitely could."},{"startTime":907.745,"endTime":908.015,"body":"Okay."},{"startTime":908.105,"endTime":908.435,"body":"Yeah."},{"startTime":908.435,"endTime":910.835,"body":"In certain scenarios that's"},{"startTime":908.435,"endTime":910.835,"body":"the only potential cure."},{"startTime":910.895,"endTime":913.535,"body":"That's really the only thing that"},{"startTime":910.895,"endTime":913.535,"body":"you could truly do is to get rid."},{"startTime":913.535,"endTime":917.18,"body":"'cause the problem is what MDS does"},{"startTime":913.535,"endTime":917.18,"body":"is, you take a hematopoietic stem"},{"startTime":917.18,"endTime":921.68,"body":"cell mutations occur like the 5q"},{"startTime":917.18,"endTime":921.68,"body":"turns into this weird dysplastic"},{"startTime":921.68,"endTime":923.72,"body":"cell that then becomes the stem cell."},{"startTime":923.72,"endTime":926.93,"body":"That makes, ineffective red"},{"startTime":923.72,"endTime":926.93,"body":"cells, ineffective platelets,"},{"startTime":926.96,"endTime":928.65,"body":"ineffective white blood cells."},{"startTime":928.68,"endTime":928.77,"body":"Yeah."},{"startTime":928.89,"endTime":933.845,"body":"Then what it does is it sends signals"},{"startTime":928.89,"endTime":933.845,"body":"to kill your normal hematopoietic"},{"startTime":933.845,"endTime":936.935,"body":"stem cells, so then if you kill those"},{"startTime":933.845,"endTime":936.935,"body":"hematopoietic stem cells, you don't"},{"startTime":936.935,"endTime":940.925,"body":"have those to make normal red cells,"},{"startTime":936.935,"endTime":940.925,"body":"normal white cells, normal platelets."},{"startTime":941.395,"endTime":944.995,"body":"So that's where we kind of come"},{"startTime":941.395,"endTime":944.995,"body":"in and bring in a normal type of"},{"startTime":944.995,"endTime":949.015,"body":"hematopoietic stem cell, and hopefully"},{"startTime":944.995,"endTime":949.015,"body":"in that goal you'll be able to trigger"},{"startTime":949.015,"endTime":951.025,"body":"the production of normal processes."},{"startTime":951.385,"endTime":953.005,"body":"So we've talked about a few drugs so far."},{"startTime":953.005,"endTime":955.555,"body":"We've talked about a stem cell"},{"startTime":953.005,"endTime":955.555,"body":"transplant being curative."},{"startTime":956.155,"endTime":957.625,"body":"What about supportive care?"},{"startTime":957.715,"endTime":960.715,"body":"What supportive measures"},{"startTime":957.715,"endTime":960.715,"body":"would you advise here?"},{"startTime":960.955,"endTime":964.165,"body":"Yeah, so I would keep trying to,"},{"startTime":960.955,"endTime":964.165,"body":"so obviously I, for this patient,"},{"startTime":964.165,"endTime":965.365,"body":"lenalidomide, would be the goal."},{"startTime":965.365,"endTime":968.575,"body":"If he didn't have the 5q deletion"},{"startTime":965.365,"endTime":968.575,"body":"and stuff like that, then"},{"startTime":968.575,"endTime":970.075,"body":"I'd probably do azacitidine."},{"startTime":970.73,"endTime":973.31,"body":"But the supportive stuff is just"},{"startTime":970.73,"endTime":973.31,"body":"really treating the cytopenias."},{"startTime":973.61,"endTime":974.96,"body":"So if they have low platelets."},{"startTime":975.47,"endTime":978.05,"body":"You obviously have to follow the"},{"startTime":975.47,"endTime":978.05,"body":"thresholds that we talked about"},{"startTime":978.05,"endTime":979.58,"body":"in the blood transfusion lecture."},{"startTime":979.58,"endTime":982.88,"body":"So if it's less than 10,000"},{"startTime":979.58,"endTime":982.88,"body":"and they're asymptomatic, you"},{"startTime":982.88,"endTime":985.49,"body":"can do that prophylactically to"},{"startTime":982.88,"endTime":985.49,"body":"prevent spontaneous hemorrhage."},{"startTime":985.91,"endTime":988.76,"body":"If it's less than 50 and"},{"startTime":985.91,"endTime":988.76,"body":"they are bleeding, then you"},{"startTime":988.76,"endTime":990.23,"body":"can give them platelets."},{"startTime":990.74,"endTime":993.2,"body":"If they're getting a neurosurgical"},{"startTime":990.74,"endTime":993.2,"body":"procedure and it's less than"},{"startTime":993.2,"endTime":995.51,"body":"a hundred thousand, then"},{"startTime":993.2,"endTime":995.51,"body":"you can give them platelets."},{"startTime":995.51,"endTime":998.81,"body":"But otherwise, that's really, it's"},{"startTime":995.51,"endTime":998.81,"body":"just platelet transfusions, just for"},{"startTime":998.81,"endTime":1000.58,"body":"particularly based upon that threshold."},{"startTime":1001.16,"endTime":1003.62,"body":"packed red cell infusions, you"},{"startTime":1001.16,"endTime":1003.62,"body":"could do that depending upon,"},{"startTime":1003.62,"endTime":1004.7,"body":"again, what's the threshold?"},{"startTime":1005.24,"endTime":1008.12,"body":"Are they less than eight and they're"},{"startTime":1005.24,"endTime":1008.12,"body":"symptomatic because they have underlying"},{"startTime":1008.12,"endTime":1010.04,"body":"diseases that reduce oxygen supply?"},{"startTime":1010.46,"endTime":1013.73,"body":"Then you give them  packed red cell"},{"startTime":1010.46,"endTime":1013.73,"body":"Unit for, getting them above eight."},{"startTime":1014.06,"endTime":1015.35,"body":"Are they asymptomatic?"},{"startTime":1016.1,"endTime":1016.31,"body":"No."},{"startTime":1016.31,"endTime":1020.32,"body":"True kind of risk factors that make"},{"startTime":1016.31,"endTime":1020.32,"body":"them need higher oxygen delivery."},{"startTime":1020.59,"endTime":1021.82,"body":"Then you can go less than seven."},{"startTime":1021.82,"endTime":1022.21,"body":"Are they."},{"startTime":1022.405,"endTime":1025.975,"body":"Bleeding out hemodynamically"},{"startTime":1022.405,"endTime":1025.975,"body":"unstable, then you just give them"},{"startTime":1025.975,"endTime":1027.085,"body":"what you need to get them right."},{"startTime":1027.085,"endTime":1028.675,"body":"But that's the big thing for that."},{"startTime":1028.955,"endTime":1030.845,"body":"The only thing I get concerned"},{"startTime":1028.955,"endTime":1030.845,"body":"about is when a patient's"},{"startTime":1030.845,"endTime":1033.425,"body":"getting frequent transfusions,"},{"startTime":1030.845,"endTime":1033.425,"body":"I worry about hemochromatosis."},{"startTime":1033.635,"endTime":1037.925,"body":"So sometimes you may have to give like"},{"startTime":1033.635,"endTime":1037.925,"body":"iron chelating agents sometimes to come"},{"startTime":1037.925,"endTime":1042.635,"body":"in there and like deferoxamine is a"},{"startTime":1037.925,"endTime":1042.635,"body":"good one that we may give to help to"},{"startTime":1042.665,"endTime":1046.205,"body":"bind up some of that excess iron so"},{"startTime":1042.665,"endTime":1046.205,"body":"it doesn't deposit into our tissues."},{"startTime":1046.585,"endTime":1049.505,"body":"Because if that does, it can"},{"startTime":1046.585,"endTime":1049.505,"body":"cause, cardiomyopathies, it"},{"startTime":1049.505,"endTime":1052.265,"body":"can cause pancreatitis, it can"},{"startTime":1049.505,"endTime":1052.265,"body":"cause bronzing of the skin."},{"startTime":1052.685,"endTime":1054.085,"body":"It can do it into the joints."},{"startTime":1054.085,"endTime":1056.365,"body":"A lot of different areas could"},{"startTime":1054.085,"endTime":1056.365,"body":"be affected and that can cause a"},{"startTime":1056.365,"endTime":1057.805,"body":"lot of different complications."},{"startTime":1057.955,"endTime":1062.245,"body":"The iron chelation and making sure to"},{"startTime":1057.955,"endTime":1062.245,"body":"prevent iron overload is really important."},{"startTime":1062.295,"endTime":1066.525,"body":"100%. Just kinda like thalassemia sickle"},{"startTime":1062.295,"endTime":1066.525,"body":"cell anemia patients, those are patients"},{"startTime":1066.525,"endTime":1068.565,"body":"who get frequent transfusions, right?"},{"startTime":1068.835,"endTime":1072.195,"body":"And so we always try to be very cautious"},{"startTime":1068.835,"endTime":1072.195,"body":"and watch out for that secondary"},{"startTime":1072.195,"endTime":1074.595,"body":"hemochromatosis or iron overload."},{"startTime":1074.815,"endTime":1079.525,"body":"And so in those scenarios, we will"},{"startTime":1074.815,"endTime":1079.525,"body":"commonly give iron chelating agents."},{"startTime":1079.525,"endTime":1080.095,"body":"Makes sense?"},{"startTime":1080.155,"endTime":1080.575,"body":"Yeah."},{"startTime":1080.905,"endTime":1083.635,"body":"I haven't seen this used."},{"startTime":1083.635,"endTime":1087.985,"body":"I'm sure it can be, but"},{"startTime":1083.635,"endTime":1087.985,"body":"I, you gotta be careful."},{"startTime":1088.045,"endTime":1093.055,"body":"Sometimes colony stimulating units"},{"startTime":1088.045,"endTime":1093.055,"body":"or colony stimulating factors can"},{"startTime":1093.055,"endTime":1096.865,"body":"be given to help to boost up your"},{"startTime":1093.055,"endTime":1096.865,"body":"production of white blood cells."},{"startTime":1096.865,"endTime":1100.525,"body":"But I don't say that it's"},{"startTime":1096.865,"endTime":1100.525,"body":"a common one that's given."},{"startTime":1100.945,"endTime":1104.815,"body":"But if you do have recurrent infections"},{"startTime":1100.945,"endTime":1104.815,"body":"in your white cell lines really depleted,"},{"startTime":1105.115,"endTime":1108.115,"body":"you could do that to potentially help."},{"startTime":1108.625,"endTime":1111.575,"body":"But that's where I would say in"},{"startTime":1108.625,"endTime":1111.575,"body":"certain scenarios, colony stimulating"},{"startTime":1111.575,"endTime":1113.075,"body":"factors could be potentially utilized."},{"startTime":1113.075,"endTime":1116.175,"body":"All right, well, how do we"},{"startTime":1113.075,"endTime":1116.175,"body":"monitor or detect  progression?"},{"startTime":1116.895,"endTime":1117.645,"body":"Ooh, that's good."},{"startTime":1117.825,"endTime":1123.345,"body":"So I think the key thing is that you"},{"startTime":1117.825,"endTime":1123.345,"body":"want to see if your therapy is working."},{"startTime":1123.675,"endTime":1127.275,"body":"A lot of this anemia is"},{"startTime":1123.675,"endTime":1127.275,"body":"the most common thing."},{"startTime":1127.665,"endTime":1130.305,"body":"So let's say I have a patient who"},{"startTime":1127.665,"endTime":1130.305,"body":"comes in, they got macrocytic anemia."},{"startTime":1130.635,"endTime":1131.985,"body":"We go through the whole algorithm."},{"startTime":1131.985,"endTime":1133.815,"body":"All right, let's check the"},{"startTime":1131.985,"endTime":1133.815,"body":"peripheral blood smear."},{"startTime":1133.815,"endTime":1133.995,"body":"Okay."},{"startTime":1133.995,"endTime":1135.555,"body":"No hypersegmented neutrophils."},{"startTime":1135.825,"endTime":1137.265,"body":"So this is a non-megaloblastic guy."},{"startTime":1137.265,"endTime":1137.865,"body":"Let's look at that."},{"startTime":1137.865,"endTime":1138.465,"body":"Peripheral blood smear."},{"startTime":1138.465,"endTime":1141.235,"body":"Oh, it's got the weird,"},{"startTime":1138.465,"endTime":1141.235,"body":"like Pseudo-Pelger-Huet."},{"startTime":1141.255,"endTime":1142.935,"body":"Okay, then that's probably MDS."},{"startTime":1143.385,"endTime":1145.125,"body":"All right, let me check"},{"startTime":1143.385,"endTime":1145.125,"body":"a bone marrow biopsy."},{"startTime":1145.125,"endTime":1145.905,"body":"Oh, definitely."},{"startTime":1145.905,"endTime":1148.635,"body":"There's lineage and there's"},{"startTime":1145.905,"endTime":1148.635,"body":"a hypercellular marrow."},{"startTime":1148.635,"endTime":1149.685,"body":"There's some blast there."},{"startTime":1149.685,"endTime":1150.195,"body":"Okay, cool."},{"startTime":1150.495,"endTime":1151.545,"body":"Let's check the cytogenetics."},{"startTime":1151.575,"endTime":1152.925,"body":"Oh, there's a 5q deletion."},{"startTime":1152.925,"endTime":1153.765,"body":"All right, let's."},{"startTime":1154.23,"endTime":1156.99,"body":"Transfuse 'em if they need, oh,"},{"startTime":1154.23,"endTime":1156.99,"body":"they keep needing transfusions."},{"startTime":1157.41,"endTime":1159.4,"body":"All right let's check the"},{"startTime":1157.41,"endTime":1159.4,"body":"EPO levels less than 500."},{"startTime":1159.4,"endTime":1162.97,"body":"It is, okay, start them on erythropoietin,"},{"startTime":1159.4,"endTime":1162.97,"body":"oh, they're still needing transfusions."},{"startTime":1163.0,"endTime":1166.54,"body":"Okay, let's give them"},{"startTime":1163.0,"endTime":1166.54,"body":"lenalidomide from there."},{"startTime":1166.54,"endTime":1170.79,"body":"Your goal is the hemoglobin"},{"startTime":1166.54,"endTime":1170.79,"body":"ever becoming stable and do they"},{"startTime":1170.82,"endTime":1173.4,"body":"need less frequent transfusions?"},{"startTime":1173.7,"endTime":1176.82,"body":"So that's the key, is just keep"},{"startTime":1173.7,"endTime":1176.82,"body":"monitoring their CBC and making"},{"startTime":1176.82,"endTime":1178.17,"body":"sure that thing is getting better."},{"startTime":1178.98,"endTime":1183.27,"body":"The other thing is you also wanna keep"},{"startTime":1178.98,"endTime":1183.27,"body":"an eye on their CBC because again, what"},{"startTime":1183.27,"endTime":1186.33,"body":"I told you, the most common reason these"},{"startTime":1183.27,"endTime":1186.33,"body":"patients usually die is because they die"},{"startTime":1186.33,"endTime":1188.31,"body":"from complications of the cytopenias."},{"startTime":1188.7,"endTime":1191.1,"body":"So you wanna watch and make sure that"},{"startTime":1188.7,"endTime":1191.1,"body":"the platelets aren't dropping too much."},{"startTime":1191.1,"endTime":1193.56,"body":"You wanna make sure that the white"},{"startTime":1191.1,"endTime":1193.56,"body":"cells aren't dropping too much."},{"startTime":1193.86,"endTime":1195.33,"body":"So keep a close eye on those."},{"startTime":1195.765,"endTime":1199.665,"body":"And then the other thing, I again, more"},{"startTime":1195.765,"endTime":1199.665,"body":"likely to die from the complications"},{"startTime":1199.665,"endTime":1201.435,"body":"of the disease before developing AML."},{"startTime":1201.795,"endTime":1207.325,"body":"But sometimes you may have to do a like"},{"startTime":1201.795,"endTime":1207.325,"body":"recurrent or at least serial bone marrow"},{"startTime":1207.325,"endTime":1209.935,"body":"biopsies if they're getting worse."},{"startTime":1209.995,"endTime":1214.645,"body":"If their cytopenias are getting worse,"},{"startTime":1209.995,"endTime":1214.645,"body":"you may have to say, did they convert?"},{"startTime":1214.645,"endTime":1218.485,"body":"Is the number of blasts that are in their"},{"startTime":1214.645,"endTime":1218.485,"body":"bone marrow now greater than equal to 20%?"},{"startTime":1218.485,"endTime":1220.035,"body":"If it is, it's AML."},{"startTime":1220.405,"endTime":1223.675,"body":"So that's something to consider is if"},{"startTime":1220.405,"endTime":1223.675,"body":"they start having worsening cytopenias."},{"startTime":1224.455,"endTime":1225.205,"body":"And they're getting worse."},{"startTime":1225.205,"endTime":1227.765,"body":"You may need to ask yourself"},{"startTime":1225.205,"endTime":1227.765,"body":"the question, is this AML?"},{"startTime":1227.785,"endTime":1230.215,"body":"'cause if it's AML, that's a"},{"startTime":1227.785,"endTime":1230.215,"body":"different type of treatment process."},{"startTime":1230.605,"endTime":1233.125,"body":"'cause then we have to start considering"},{"startTime":1230.605,"endTime":1233.125,"body":"potentially like chemotherapy."},{"startTime":1233.725,"endTime":1238.135,"body":"But that would be the most"},{"startTime":1233.725,"endTime":1238.135,"body":"important things to really kind"},{"startTime":1238.135,"endTime":1239.425,"body":"of check on in this scenario."},{"startTime":1239.965,"endTime":1244.525,"body":"So in summation, if you could go"},{"startTime":1239.965,"endTime":1244.525,"body":"through maybe a five step approach"},{"startTime":1244.675,"endTime":1246.715,"body":"in treating MDS, how would you do it?"},{"startTime":1247.525,"endTime":1248.065,"body":"First thing?"},{"startTime":1248.62,"endTime":1250.74,"body":"You get once you get that"},{"startTime":1248.62,"endTime":1250.74,"body":"patient who comes in with either"},{"startTime":1250.74,"endTime":1254.62,"body":"pancytopenia or more often macrocytic"},{"startTime":1250.74,"endTime":1254.62,"body":"anemia, that's non megaloblastic."},{"startTime":1254.95,"endTime":1256.81,"body":"You gotta confirm it with"},{"startTime":1254.95,"endTime":1256.81,"body":"a bone marrow biopsy."},{"startTime":1256.81,"endTime":1258.43,"body":"You have to have tissue confirmation."},{"startTime":1259.03,"endTime":1262.81,"body":"Once you do that, figure"},{"startTime":1259.03,"endTime":1262.81,"body":"out what is your risk."},{"startTime":1263.38,"endTime":1265.58,"body":"You check that by looking"},{"startTime":1263.38,"endTime":1265.58,"body":"at the cytogenetics 5q"},{"startTime":1265.6,"endTime":1267.67,"body":"deletion or not cytopenias."},{"startTime":1267.7,"endTime":1268.75,"body":"How bad are they?"},{"startTime":1269.2,"endTime":1270.13,"body":"Blast percentage."},{"startTime":1270.13,"endTime":1272.83,"body":"That gives you an idea of what"},{"startTime":1270.13,"endTime":1272.83,"body":"you're gonna do for this patient."},{"startTime":1273.16,"endTime":1276.01,"body":"If they're in that low risk,"},{"startTime":1273.16,"endTime":1276.01,"body":"they have that 5q deletion."},{"startTime":1276.67,"endTime":1280.06,"body":"That's the patient who's gonna"},{"startTime":1276.67,"endTime":1280.06,"body":"respond to Lenalidomide and just the"},{"startTime":1280.06,"endTime":1281.65,"body":"supportive care that you would provide."},{"startTime":1281.65,"endTime":1284.56,"body":"Platelet packed red cell"},{"startTime":1281.65,"endTime":1284.56,"body":"infusions, iron chelation."},{"startTime":1284.56,"endTime":1286.69,"body":"If they're getting a lot of"},{"startTime":1284.56,"endTime":1286.69,"body":"transfusions and maybe colony"},{"startTime":1286.69,"endTime":1288.73,"body":"stimulating factors, they're high risk."},{"startTime":1288.73,"endTime":1290.23,"body":"They don't have the 5q deletion."},{"startTime":1290.23,"endTime":1292.24,"body":"They have lots of blast cells, right?"},{"startTime":1292.39,"endTime":1294.1,"body":"They have severe cytopenias."},{"startTime":1294.34,"endTime":1295.78,"body":"That's as azacitidine."},{"startTime":1295.78,"endTime":1300.25,"body":"Continue with the supportive care and"},{"startTime":1295.78,"endTime":1300.25,"body":"figure out with your transplant team."},{"startTime":1300.25,"endTime":1302.14,"body":"Can I get them a bone marrow transplant?"},{"startTime":1303.62,"endTime":1307.46,"body":"Otherwise everything else is just"},{"startTime":1303.62,"endTime":1307.46,"body":"your supportive care measures."},{"startTime":1307.79,"endTime":1310.52,"body":"Trying to make sure that you're"},{"startTime":1307.79,"endTime":1310.52,"body":"helping them to stay where they"},{"startTime":1310.52,"endTime":1312.83,"body":"need to be with their thresholds."},{"startTime":1313.37,"endTime":1315.47,"body":"Do they need a packed red cell"},{"startTime":1313.37,"endTime":1315.47,"body":"infusion because of where their"},{"startTime":1315.47,"endTime":1316.85,"body":"hemoglobin and symptoms is?"},{"startTime":1317.18,"endTime":1320.54,"body":"Platelet transfusion because of"},{"startTime":1317.18,"endTime":1320.54,"body":"their symptom and platelet level, and"},{"startTime":1321.2,"endTime":1324.13,"body":"again, making sure that these things"},{"startTime":1321.2,"endTime":1324.13,"body":"are working by trending their CBC."},{"startTime":1324.49,"endTime":1328.82,"body":"Trending potentially a need for a bone"},{"startTime":1324.49,"endTime":1328.82,"body":"marrow biopsy if they're getting worse"},{"startTime":1328.82,"endTime":1331.94,"body":"and seeing if they've converted to AML.."},{"startTime":1328.82,"endTime":1331.94,"body":"Those are the big things to consider."},{"startTime":1332.21,"endTime":1336.38,"body":"Well then finally, Zach, let's"},{"startTime":1332.21,"endTime":1336.38,"body":"talk about outcomes and prognosis."},{"startTime":1336.65,"endTime":1337.07,"body":"What do you think?"},{"startTime":1337.52,"endTime":1341.74,"body":"Well, again I think this is one"},{"startTime":1337.52,"endTime":1341.74,"body":"of those diseases where sometimes"},{"startTime":1342.16,"endTime":1345.46,"body":"a patient can have MDS and they"},{"startTime":1342.16,"endTime":1345.46,"body":"can be sometimes, pretty much"},{"startTime":1345.805,"endTime":1348.745,"body":"mild, it could, sometimes you could"},{"startTime":1345.805,"endTime":1348.745,"body":"be asymptomatic, and again, the"},{"startTime":1348.805,"endTime":1351.595,"body":"only symptoms that you have may"},{"startTime":1348.805,"endTime":1351.595,"body":"be some symptoms of mild anemia."},{"startTime":1352.045,"endTime":1356.245,"body":"Sometimes it can range potentially"},{"startTime":1352.045,"endTime":1356.245,"body":"to where it's pancytopenia."},{"startTime":1356.635,"endTime":1360.775,"body":"Again, I think the biggest takeaway"},{"startTime":1356.635,"endTime":1360.775,"body":"for this is that MDS sometimes can"},{"startTime":1360.775,"endTime":1364.525,"body":"be relatively asymptomatic and mild,"},{"startTime":1360.775,"endTime":1364.525,"body":"and the only present with anemia."},{"startTime":1364.765,"endTime":1367.615,"body":"Sometimes they can present"},{"startTime":1364.765,"endTime":1367.615,"body":"with severe cytopenias."},{"startTime":1368.15,"endTime":1373.77,"body":"The worst kind of case scenario is the"},{"startTime":1368.15,"endTime":1373.77,"body":"conversion of this condition into AML."},{"startTime":1374.12,"endTime":1377.45,"body":"And so I think the prognosis kind"},{"startTime":1374.12,"endTime":1377.45,"body":"of just depends and their outcome"},{"startTime":1377.45,"endTime":1381.92,"body":"kind of depends on where they lie"},{"startTime":1377.45,"endTime":1381.92,"body":"within that risk stratification."},{"startTime":1381.92,"endTime":1381.98,"body":"Yeah."},{"startTime":1382.34,"endTime":1386.18,"body":"That's kind of crazy to think about"},{"startTime":1382.34,"endTime":1386.18,"body":"how variable of a disease this is."},{"startTime":1386.18,"endTime":1386.87,"body":"Exactly."},{"startTime":1386.87,"endTime":1388.79,"body":"A pretty large spectrum"},{"startTime":1386.87,"endTime":1388.79,"body":"you're working within."},{"startTime":1388.82,"endTime":1389.36,"body":"Exactly."},{"startTime":1389.36,"endTime":1391.19,"body":"And that's the biggest thing to consider."},{"startTime":1391.19,"endTime":1394.01,"body":"And again, I, it kind of"},{"startTime":1391.19,"endTime":1394.01,"body":"goes back that oftentimes."},{"startTime":1394.6,"endTime":1398.8,"body":"We just do supportive care in what we"},{"startTime":1394.6,"endTime":1398.8,"body":"talked about here, just because it's,"},{"startTime":1398.8,"endTime":1403.91,"body":"again, it's sad to say, but most of the"},{"startTime":1398.8,"endTime":1403.91,"body":"time these patients usually die more from"},{"startTime":1403.91,"endTime":1405.83,"body":"the complications of the disease itself."},{"startTime":1405.83,"endTime":1406.7,"body":"From the cytopenias."},{"startTime":1406.82,"endTime":1406.88,"body":"Yeah."},{"startTime":1407.01,"endTime":1408.82,"body":"Than they do from the conversion to AML."},{"startTime":1408.84,"endTime":1412.74,"body":"And once you get AML, you're"},{"startTime":1408.84,"endTime":1412.74,"body":"talking about, leukostasis, you're"},{"startTime":1412.74,"endTime":1415.26,"body":"talking about DIC, you're talking"},{"startTime":1412.74,"endTime":1415.26,"body":"about tumor lysis syndrome."},{"startTime":1415.26,"endTime":1416.91,"body":"You're talking about some severe stuff."},{"startTime":1417.21,"endTime":1420.82,"body":"So I think in that point it's it just"},{"startTime":1417.21,"endTime":1420.82,"body":"depends upon where they lie in that risk."},{"startTime":1420.85,"endTime":1421.18,"body":"Gotcha."},{"startTime":1421.96,"endTime":1425.11,"body":"Well, that really summarizes what"},{"startTime":1421.96,"endTime":1425.11,"body":"we've talked about here on MDS."},{"startTime":1425.11,"endTime":1426.82,"body":"Do you have anything else"},{"startTime":1425.11,"endTime":1426.82,"body":"you wanna kind of go over?"},{"startTime":1427.45,"endTime":1431.05,"body":"I think just the biggest thing is"},{"startTime":1427.45,"endTime":1431.05,"body":"MDS is one of those insidious ones"},{"startTime":1431.05,"endTime":1433.78,"body":"where you don't always think about,"},{"startTime":1431.05,"endTime":1433.78,"body":"biggest thing to think about as"},{"startTime":1433.78,"endTime":1435.22,"body":"a patient either with two things."},{"startTime":1435.25,"endTime":1437.68,"body":"One is an isolated macrocytic anemia."},{"startTime":1438.91,"endTime":1441.55,"body":"Second is pancytopenia."},{"startTime":1441.94,"endTime":1444.55,"body":"Those are the really important"},{"startTime":1441.94,"endTime":1444.55,"body":"things to be thinking about."},{"startTime":1444.85,"endTime":1447.64,"body":"You have to get a bone marrow"},{"startTime":1444.85,"endTime":1447.64,"body":"biopsy to con confirm it."},{"startTime":1448.03,"endTime":1453.42,"body":"Once you see Pseduo-Pelger-Huet,"},{"startTime":1448.03,"endTime":1453.42,"body":"neutrophils on the peripheral blood smear."},{"startTime":1453.72,"endTime":1457.83,"body":"Definitely think especially for the"},{"startTime":1453.72,"endTime":1457.83,"body":"exam, bone marrow is the way to go."},{"startTime":1458.19,"endTime":1459.51,"body":"Determine their risk."},{"startTime":1459.51,"endTime":1460.29,"body":"Where do they fall?"},{"startTime":1460.29,"endTime":1462.21,"body":"How aggressive do we need"},{"startTime":1460.29,"endTime":1462.21,"body":"to be with the treatment?"},{"startTime":1462.51,"endTime":1465.09,"body":"By looking at cytogenetics"},{"startTime":1462.51,"endTime":1465.09,"body":"blast percentage and the"},{"startTime":1465.09,"endTime":1466.53,"body":"degree of their cytopenias."},{"startTime":1467.04,"endTime":1468.21,"body":"Always remember the exam."},{"startTime":1468.21,"endTime":1470.63,"body":"5q deletion, Lenalidomide."},{"startTime":1470.94,"endTime":1471.03,"body":"Yep."},{"startTime":1471.21,"endTime":1472.71,"body":"No, 5q deletion."},{"startTime":1473.1,"endTime":1474.75,"body":"More likely the Azacitidine."},{"startTime":1475.17,"endTime":1478.74,"body":"All the other stuff is supportive"},{"startTime":1475.17,"endTime":1478.74,"body":"care, and that's really what it"},{"startTime":1478.74,"endTime":1480.12,"body":"comes down to for this patient."},{"startTime":1480.45,"endTime":1482.22,"body":"Well then that does it for MDS."},{"startTime":1482.31,"endTime":1483.6,"body":"Yeah, that's another episode done."},{"startTime":1483.6,"endTime":1484.14,"body":"That was awesome."},{"startTime":1484.23,"endTime":1487.59,"body":"I think this is a good quick one, and"},{"startTime":1484.23,"endTime":1487.59,"body":"it kind of gives you the idea that."},{"startTime":1487.935,"endTime":1493.515,"body":"MDS is sometimes it's kind of forgotten"},{"startTime":1487.935,"endTime":1493.515,"body":"and there is very common kind of insidious"},{"startTime":1493.515,"endTime":1497.105,"body":"presentations of it, and we shouldn't"},{"startTime":1493.515,"endTime":1497.105,"body":"miss it just because, someone's a little"},{"startTime":1497.105,"endTime":1501.165,"body":"bit older and it's important to make"},{"startTime":1497.105,"endTime":1501.165,"body":"sure that we identify this and reduce"},{"startTime":1501.165,"endTime":1505.725,"body":"the potential poor outcomes and really"},{"startTime":1501.165,"endTime":1505.725,"body":"help to improve their quality of life and"},{"startTime":1505.785,"endTime":1508.305,"body":"increased survival for these patients."},{"startTime":1508.305,"endTime":1510.765,"body":"Yeah, especially as you're at this"},{"startTime":1508.305,"endTime":1510.765,"body":"age, there's nothing better than"},{"startTime":1510.765,"endTime":1512.415,"body":"helping improve your quality of life."},{"startTime":1512.415,"endTime":1512.805,"body":"That's."},{"startTime":1513.195,"endTime":1513.915,"body":"That's great to hear."},{"startTime":1513.975,"endTime":1514.845,"body":"Yeah, exactly."},{"startTime":1514.845,"endTime":1516.495,"body":"But yeah, I think that's the big things."},{"startTime":1516.495,"endTime":1519.915,"body":"There's a lot of other things that"},{"startTime":1516.495,"endTime":1519.915,"body":"happen with MDS, like there's this World"},{"startTime":1519.915,"endTime":1525.195,"body":"Health Organization like classification"},{"startTime":1519.915,"endTime":1525.195,"body":"system and it gets really detailed."},{"startTime":1525.445,"endTime":1528.505,"body":"And I didn't wanna discuss it here because"},{"startTime":1525.445,"endTime":1528.505,"body":"I don't know if it bears much weight and"},{"startTime":1528.505,"endTime":1532.135,"body":"squeeze into what we wanna talk about,"},{"startTime":1528.505,"endTime":1532.135,"body":"but I really think this gives what we need"},{"startTime":1532.135,"endTime":1534.535,"body":"to know about MDS for clinicians for now."},{"startTime":1534.655,"endTime":1535.645,"body":"Hey, it sounds good to me."},{"startTime":1535.705,"endTime":1536.095,"body":"Thank you."},{"startTime":1536.095,"endTime":1536.155,"body":"Yeah."},{"startTime":1536.26,"endTime":1536.38,"body":"Yeah."},{"startTime":1536.38,"endTime":1539.29,"body":"Thank you guys and I hope that"},{"startTime":1536.38,"endTime":1539.29,"body":"you guys liked this podcast."},{"startTime":1539.29,"endTime":1540.28,"body":"I hope it made sense."},{"startTime":1540.28,"endTime":1542.05,"body":"I hope that you guys truly did enjoy it."},{"startTime":1542.05,"endTime":1545.37,"body":"And again, if you did and you"},{"startTime":1542.05,"endTime":1545.37,"body":"like what we do, support us."},{"startTime":1545.895,"endTime":1550.665,"body":"If it's on YouTube, hit that like button,"},{"startTime":1545.895,"endTime":1550.665,"body":"subscribe, comment in the comment section."},{"startTime":1550.845,"endTime":1554.595,"body":"If you're listening to us on any of the"},{"startTime":1550.845,"endTime":1554.595,"body":"other platforms like Apple or Spotify,"},{"startTime":1554.865,"endTime":1556.725,"body":"again, share this to your friends."},{"startTime":1556.725,"endTime":1559.545,"body":"I think that this can really help out"},{"startTime":1556.725,"endTime":1559.545,"body":"a lot of you guys who are in medicine."},{"startTime":1559.905,"endTime":1561.915,"body":"Also, if you want more,"},{"startTime":1559.905,"endTime":1561.915,"body":"check out our website."},{"startTime":1561.915,"endTime":1564.915,"body":"We have a really good website that"},{"startTime":1561.915,"endTime":1564.915,"body":"we offer notes, illustrations, quiz"},{"startTime":1564.915,"endTime":1568.425,"body":"questions, lots of things that I"},{"startTime":1564.915,"endTime":1568.425,"body":"think are really just all inclusive"},{"startTime":1568.425,"endTime":1569.745,"body":"to you guys knowing the topic."},{"startTime":1569.745,"endTime":1572.745,"body":"So with that further being said,"},{"startTime":1569.745,"endTime":1572.745,"body":"I just wanna say thank you guys."},{"startTime":1572.745,"endTime":1574.185,"body":"Love you guys, and as always."},{"startTime":1574.55,"endTime":1575.145,"body":"Until next time."}]}