{"version":"1.0.0","segments":[{"startTime":1.602,"endTime":3.206,"body":"♪ (music) ♪"},{"startTime":3.206,"endTime":5.575,"body":"(Cathy) Hi, welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.575,"endTime":8.717,"body":"where we discuss important concepts"},{"startTime":5.575,"endTime":8.717,"body":"in internal medicine."},{"startTime":8.717,"endTime":9.802,"body":"I'm Cathy Handy."},{"startTime":9.802,"endTime":11.099,"body":"(Charlie) And I'm Charlie Wiener"},{"startTime":11.099,"endTime":14.055,"body":"and we're coming to you"},{"startTime":11.099,"endTime":14.055,"body":"from the Johns Hopkins School of Medicine."},{"startTime":14.055,"endTime":15.702,"body":"♪ (music) ♪"},{"startTime":15.702,"endTime":20.602,"body":"This is Episode 17, \u003ci\u003eA 53-year-old"},{"startTime":15.702,"endTime":20.602,"body":"with an Elevated Hematocrit.\u003c/i\u003e"},{"speaker":"The question reads","startTime":20.602,"endTime":24.588,"body":"A 53-year-old man"},{"speaker":"The question reads","startTime":20.602,"endTime":24.588,"body":"is sent to you for evaluation"},{"speaker":"The question reads","startTime":24.588,"endTime":28.572,"body":"of an eleveated hematocrit"},{"speaker":"The question reads","startTime":24.588,"endTime":28.572,"body":"found incidentally on lab testing."},{"speaker":"The question reads","startTime":28.572,"endTime":32.126,"body":"He was removing drywall in a house"},{"speaker":"The question reads","startTime":28.572,"endTime":32.126,"body":"and cut his upper arm."},{"speaker":"The question reads","startTime":32.126,"endTime":36.794,"body":"A CBC before his arm was stitched"},{"speaker":"The question reads","startTime":32.126,"endTime":36.794,"body":"revealed a hematocrit of 59%"},{"speaker":"The question reads","startTime":36.794,"endTime":39.886,"body":"and a hemoglobin of 20 g/dl."},{"speaker":"The question reads","startTime":39.886,"endTime":41.742,"body":"What do you think so far, Cathy?"},{"speaker":"The question reads","startTime":41.742,"endTime":46.028,"body":"(Cathy) Well, that's a high hematocrit"},{"speaker":"The question reads","startTime":41.742,"endTime":46.028,"body":"and hemoglobin which has many causes."},{"speaker":"The question reads","startTime":46.028,"endTime":49.231,"body":"Generally, I think about if this"},{"speaker":"The question reads","startTime":46.028,"endTime":49.231,"body":"is relative erythrocytosis,"},{"speaker":"The question reads","startTime":49.231,"endTime":51.599,"body":"like from diuretic use or dehydration,"},{"speaker":"The question reads","startTime":51.599,"endTime":55.114,"body":"or if this is an absolute erythrocytosis"},{"speaker":"The question reads","startTime":51.599,"endTime":55.114,"body":"which can be from a primary cause,"},{"speaker":"The question reads","startTime":55.114,"endTime":57.356,"body":"like a myeloproliferative disease,"},{"speaker":"The question reads","startTime":57.356,"endTime":59.375,"body":"or from a secondary cause like hypoxia"},{"speaker":"The question reads","startTime":59.375,"endTime":61.545,"body":"which is seen in people"},{"speaker":"The question reads","startTime":59.375,"endTime":61.545,"body":"who have bad lung disease,"},{"speaker":"The question reads","startTime":61.545,"endTime":64.112,"body":"or in people who have"},{"speaker":"The question reads","startTime":61.545,"endTime":64.112,"body":"renal disease or some tumors,"},{"speaker":"The question reads","startTime":64.112,"endTime":66.184,"body":"or even some drugs can cause it."},{"speaker":"The question reads","startTime":66.184,"endTime":67.981,"body":"But why don't you tell me"},{"speaker":"The question reads","startTime":66.184,"endTime":67.981,"body":"more about the case?"},{"speaker":"The question reads","startTime":67.981,"endTime":70.874,"body":"(Charlie) Okay. So, his physical"},{"speaker":"The question reads","startTime":67.981,"endTime":70.874,"body":"examination reveals that"},{"speaker":"The question reads","startTime":70.874,"endTime":75.596,"body":"he has a normal BMI, and a normal"},{"speaker":"The question reads","startTime":70.874,"endTime":75.596,"body":"room air oxygen saturation of 95%."},{"speaker":"The question reads","startTime":75.596,"endTime":79.951,"body":"His blood pressure is 145 over 85,"},{"speaker":"The question reads","startTime":75.596,"endTime":79.951,"body":"his heart rate is 70,"},{"speaker":"The question reads","startTime":79.951,"endTime":83.119,"body":"and the only real notable finding"},{"speaker":"The question reads","startTime":79.951,"endTime":83.119,"body":"on his physical examination"},{"speaker":"The question reads","startTime":83.119,"endTime":85.925,"body":"is that he has an easily palpable spleen."},{"speaker":"The question reads","startTime":85.925,"endTime":88.854,"body":"We also find out"},{"speaker":"The question reads","startTime":85.925,"endTime":88.854,"body":"that he has no past medical history,"},{"speaker":"The question reads","startTime":88.854,"endTime":92.38,"body":"is a non-smoker,"},{"speaker":"The question reads","startTime":88.854,"endTime":92.38,"body":"drinks rarely on social occasions,"},{"speaker":"The question reads","startTime":92.38,"endTime":94.271,"body":"and is taking no medication."},{"speaker":"The question reads","startTime":94.271,"endTime":98.246,"body":"The patient reports that his last contact"},{"speaker":"The question reads","startTime":94.271,"endTime":98.246,"body":"with a physician was 2-3 years ago"},{"speaker":"The question reads","startTime":98.246,"endTime":101.824,"body":"and he recalls no abnormalities"},{"speaker":"The question reads","startTime":98.246,"endTime":101.824,"body":"reported on blood testing then."},{"speaker":"The question reads","startTime":101.824,"endTime":104.349,"body":"What do you think based on that"},{"speaker":"The question reads","startTime":101.824,"endTime":104.349,"body":"additional information?"},{"speaker":"The question reads","startTime":104.351,"endTime":106.248,"body":"(Cathy) Well, do we have"},{"speaker":"The question reads","startTime":104.351,"endTime":106.248,"body":"the rest of his CBC,"},{"speaker":"The question reads","startTime":106.248,"endTime":108.37,"body":"like his white blood cell count"},{"speaker":"The question reads","startTime":106.248,"endTime":108.37,"body":"and platelet count?"},{"speaker":"The question reads","startTime":108.37,"endTime":113.258,"body":"(Charlie) Yeah, so we have"},{"speaker":"The question reads","startTime":108.37,"endTime":113.258,"body":"a white blood cell count of 15,400"},{"speaker":"The question reads","startTime":113.258,"endTime":117.559,"body":"with a normal differential,"},{"speaker":"The question reads","startTime":113.258,"endTime":117.559,"body":"and a platelet count of 445,000."},{"speaker":"The question reads","startTime":117.559,"endTime":120.051,"body":"(Cathy) So, the combination"},{"speaker":"The question reads","startTime":117.559,"endTime":120.051,"body":"of erythrocytosis"},{"speaker":"The question reads","startTime":120.051,"endTime":122.074,"body":"with the elevation"},{"speaker":"The question reads","startTime":120.051,"endTime":122.074,"body":"of the white blood cell count"},{"speaker":"The question reads","startTime":122.074,"endTime":123.447,"body":"and the elevation of platelets,"},{"speaker":"The question reads","startTime":123.447,"endTime":126.018,"body":"and you also mentioned"},{"speaker":"The question reads","startTime":123.447,"endTime":126.018,"body":"that he has a palpable spleen."},{"speaker":"The question reads","startTime":126.018,"endTime":130.87,"body":"All of that points to polycythemia vera"},{"speaker":"The question reads","startTime":126.018,"endTime":130.87,"body":"as the cause of his elevated hemoglobin."},{"speaker":"The question reads","startTime":130.87,"endTime":132.19,"body":"The rest of his history"},{"speaker":"The question reads","startTime":132.19,"endTime":135.093,"body":"doesn't point to any of the other causes"},{"speaker":"The question reads","startTime":132.19,"endTime":135.093,"body":"that we mentioned before."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":137.235,"endTime":140.686,"body":"Which of the following"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":137.235,"endTime":140.686,"body":"is the next diagnostic step?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":140.686,"endTime":142.687,"body":"a) arterial blood gas;"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":142.687,"endTime":146.447,"body":"b) erythropoietin or epo level;"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":146.447,"endTime":148.977,"body":"c) red blood cell mass;"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":148.977,"endTime":151.002,"body":"d) pulmonary function tests;"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":151.002,"endTime":153.162,"body":"or e) renal ultrasound."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":153.162,"endTime":155.457,"body":"(Cathy) Well, the next step"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":153.162,"endTime":155.457,"body":"in his evaluation would be"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":155.457,"endTime":157.281,"body":"for measurement of the RBC mass"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":157.281,"endTime":160.361,"body":"because this will tell you"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":157.281,"endTime":160.361,"body":"if he has an absolute erythrocytosis"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":160.361,"endTime":162.837,"body":"or if it's just a relative erythrocytosis."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":162.837,"endTime":165.183,"body":"Again, the clinical history"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":162.837,"endTime":165.183,"body":"suggests that it's absolute,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":165.183,"endTime":167.896,"body":"but that's the first"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":165.183,"endTime":167.896,"body":"diagnostic measure that we would do."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":167.896,"endTime":170.999,"body":"(Charlie) So, the answer to this question"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":167.896,"endTime":170.999,"body":"is c) red blood cell mass,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":170.999,"endTime":174.087,"body":"but are the other tests of any use"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":170.999,"endTime":174.087,"body":"in a patient like this?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":174.087,"endTime":177.223,"body":"(Cathy) Yeah, so usually if we find"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":174.087,"endTime":177.223,"body":"an elevated RBC mass,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":177.223,"endTime":180.093,"body":"then we'll measure"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":177.223,"endTime":180.093,"body":"the erythropoietin or epo levels,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":180.093,"endTime":182.978,"body":"and that helps us distinguish"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":180.093,"endTime":182.978,"body":"between polycythemia vera"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":182.978,"endTime":186.898,"body":"and other causes of polycythemia"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":182.978,"endTime":186.898,"body":"such as kidney cancer or lung disease."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":186.898,"endTime":189.388,"body":"You could also consider"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":186.898,"endTime":189.388,"body":"an arterial blood gas"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":189.388,"endTime":190.895,"body":"to look for hypoxemia,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":190.895,"endTime":193.609,"body":"and sometimes you see that in people"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":190.895,"endTime":193.609,"body":"who have bad lung disease."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":193.609,"endTime":197.164,"body":"Obviously, pulmonary function test"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":193.609,"endTime":197.164,"body":"would also be helpful in that case."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":197.164,"endTime":201.45,"body":"And ultrasounds and PFTs, though,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":197.164,"endTime":201.45,"body":"would be later tests in the evaluation."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":201.45,"endTime":205.189,"body":"(Charlie) Okay. So, we suspect"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":201.45,"endTime":205.189,"body":"this patient has polycythemia vera."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":205.189,"endTime":206.513,"body":"Tell us more about that."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":206.513,"endTime":208.16,"body":"(Cathy) Well, it's a clonal disorder"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":208.16,"endTime":211.413,"body":"that involves multipotent"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":208.16,"endTime":211.413,"body":"hematopoietic progenitor cells"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":211.413,"endTime":215.083,"body":"in which phenotypically normal red cells,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":211.413,"endTime":215.083,"body":"granulocytes, and platelets"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":215.083,"endTime":218.663,"body":"accumulate in the absence"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":215.083,"endTime":218.663,"body":"of any recognizable physiologic stimulus."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":218.663,"endTime":223.483,"body":"The etiology isn't really known"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":218.663,"endTime":223.483,"body":"but most people have a mutation"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":223.483,"endTime":228.351,"body":"in the auto-inhibitory pseudokinase domain"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":223.483,"endTime":228.351,"body":"of the tyrosine kinase, JAK2,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":228.351,"endTime":231.134,"body":"and that replaces a valine"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":228.351,"endTime":231.134,"body":"with a phenylalanine."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":231.134,"endTime":237.053,"body":"So, typically the way this gets reported"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":231.134,"endTime":237.053,"body":"is a V617F mutation in the JAK2 gene,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":237.053,"endTime":240.035,"body":"and that causes constituitive"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":237.053,"endTime":240.035,"body":"kinase activation."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":240.035,"endTime":244.098,"body":"It seems to have a central role"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":240.035,"endTime":244.098,"body":"in the pathogenisis of polycythemia vera"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":244.098,"endTime":247.042,"body":"so, we typcially send"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":244.098,"endTime":247.042,"body":"for a JAK2 mutational analysis"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":247.042,"endTime":249.163,"body":"in anybody who we suspect has PV."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":249.163,"endTime":252.24,"body":"Because almost 95% of patients"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":249.163,"endTime":252.24,"body":"will express this mutation."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":252.24,"endTime":256.089,"body":"(Charlie) Do other patients with other"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":252.24,"endTime":256.089,"body":"myeloproliferative disorders"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":256.089,"endTime":257.726,"body":"have JAK2 mutations also?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":257.726,"endTime":260.329,"body":"(Cathy) Yes. It's also seen"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":257.726,"endTime":260.329,"body":"in primary myelofibrosis"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":260.329,"endTime":264.293,"body":"and then also essential thrombocytosis"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":260.329,"endTime":264.293,"body":"but not necessarily to the same degree."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":264.293,"endTime":267.789,"body":"(Charlie) And that becomes important"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":264.293,"endTime":267.789,"body":"because new drugs are being developed"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":267.789,"endTime":270.338,"body":"to target these specific mutations."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":270.338,"endTime":272.476,"body":"Okay, back to our patient."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":272.476,"endTime":275.358,"body":"How do patients with P. vera"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":272.476,"endTime":275.358,"body":"typically present?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":275.358,"endTime":279.014,"body":"(Cathy) So, the symptoms are generally"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":275.358,"endTime":279.014,"body":"related to the high hemoglobin,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":279.014,"endTime":283.319,"body":"so people can come in with pruritis"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":279.014,"endTime":283.319,"body":"or gout because of hyperuricemia."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":283.319,"endTime":285.992,"body":"Sometimes they'll have"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":283.319,"endTime":285.992,"body":"splenomegaly or fatigue,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":285.992,"endTime":288.752,"body":"and then also sometimes symptoms"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":285.992,"endTime":288.752,"body":"related to splenomegaly,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":288.752,"endTime":291.403,"body":"like abdominal fullness"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":288.752,"endTime":291.403,"body":"and early satiety."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":291.403,"endTime":293.444,"body":"In general, it's a pretty indolent disease"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":293.444,"endTime":295.876,"body":"and most people will still"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":293.444,"endTime":295.876,"body":"live pretty long lives,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":295.876,"endTime":298.184,"body":"but one of the major"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":295.876,"endTime":298.184,"body":"complications is thrombosis,"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":298.184,"endTime":301.728,"body":"which is strongly correlated"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":298.184,"endTime":301.728,"body":"with the degree of erythrocytosis."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":301.728,"endTime":305.153,"body":"(Charlie) How do the thromboses"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":301.728,"endTime":305.153,"body":"or the hyperviscosity present?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":305.153,"endTime":307.729,"body":"(Cathy) So, that can present like clots."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":307.729,"endTime":310.16,"body":"So, sometimes people will get"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":307.729,"endTime":310.16,"body":"neurologic symptoms"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":310.16,"endTime":312.01,"body":"such as vertigo or tinnitus."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":312.01,"endTime":314.286,"body":"Sometimes people can have"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":312.01,"endTime":314.286,"body":"visual disturbances"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":314.286,"endTime":316.39,"body":"or even TIA-like symptoms."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":316.39,"endTime":317.729,"body":"(Charlie) Do strokes happen?"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":317.729,"endTime":319.346,"body":"(Cathy) Yes, that can also happen, too."},{"speaker":"(Charlie) Okay, so the question then asks","startTime":319.346,"endTime":322.543,"body":"(Charlie) Alright, so actually"},{"speaker":"(Charlie) Okay, so the question then asks","startTime":319.346,"endTime":322.543,"body":"there's a follow-up question here."},{"speaker":"And this question says","startTime":324.235,"endTime":327.744,"body":"The patient had a red blood cell mass"},{"speaker":"And this question says","startTime":324.235,"endTime":327.744,"body":"that was markedly elevated"},{"speaker":"And this question says","startTime":327.744,"endTime":330.584,"body":"and was also found to have"},{"speaker":"And this question says","startTime":327.744,"endTime":330.584,"body":"a low erythropoitin level"},{"speaker":"And this question says","startTime":330.584,"endTime":332.968,"body":"confirming the diagnosis of P. vera."},{"speaker":"And this question says","startTime":332.968,"endTime":335.261,"body":"Which of the following"},{"speaker":"And this question says","startTime":332.968,"endTime":335.261,"body":"is recommended therapy?"},{"speaker":"And this question says","startTime":335.261,"endTime":337.201,"body":"a) aspirin;"},{"speaker":"And this question says","startTime":337.201,"endTime":339.361,"body":"b) hydroxyurea;"},{"speaker":"And this question says","startTime":339.361,"endTime":341.381,"body":"c) imatinib;"},{"speaker":"And this question says","startTime":341.381,"endTime":346.139,"body":"d) phlebotomy to maintain"},{"speaker":"And this question says","startTime":341.381,"endTime":346.139,"body":"a hemoglobin less than 14 g/dl;"},{"speaker":"And this question says","startTime":346.139,"endTime":347.959,"body":"or e) warfarin."},{"speaker":"And this question says","startTime":347.959,"endTime":351.658,"body":"(Cathy) Treatment of polycythemia vera"},{"speaker":"And this question says","startTime":347.959,"endTime":351.658,"body":"is generally risk adapted."},{"speaker":"And this question says","startTime":351.658,"endTime":354.558,"body":"Low-risk patients would be those"},{"speaker":"And this question says","startTime":351.658,"endTime":354.558,"body":"who are less than 60 years old,"},{"speaker":"And this question says","startTime":354.558,"endTime":356.821,"body":"who have no history"},{"speaker":"And this question says","startTime":354.558,"endTime":356.821,"body":"of any thrombotic events,"},{"speaker":"And this question says","startTime":356.821,"endTime":360.853,"body":"and those who are older or who have any"},{"speaker":"And this question says","startTime":356.821,"endTime":360.853,"body":"history of clots are considered high-risk."},{"speaker":"And this question says","startTime":360.853,"endTime":363.354,"body":"And our patient being 53 years old,"},{"speaker":"And this question says","startTime":363.354,"endTime":365.958,"body":"with no history that we've heard of"},{"speaker":"And this question says","startTime":363.354,"endTime":365.958,"body":"of any thrombotic events,"},{"speaker":"And this question says","startTime":365.958,"endTime":368.448,"body":"he would be considered"},{"speaker":"And this question says","startTime":365.958,"endTime":368.448,"body":"to have low-risk disease."},{"speaker":"And this question says","startTime":368.448,"endTime":370.735,"body":"So, for that patient,"},{"speaker":"And this question says","startTime":368.448,"endTime":370.735,"body":"the cornerstone of treatment"},{"speaker":"And this question says","startTime":370.735,"endTime":373.275,"body":"is the correction"},{"speaker":"And this question says","startTime":370.735,"endTime":373.275,"body":"of the abnormal blood viscosity"},{"speaker":"And this question says","startTime":373.275,"endTime":376.017,"body":"that's associated with the high"},{"speaker":"And this question says","startTime":373.275,"endTime":376.017,"body":"red cell volumes."},{"speaker":"And this question says","startTime":376.017,"endTime":378.401,"body":"That can really be done"},{"speaker":"And this question says","startTime":376.017,"endTime":378.401,"body":"with just simple phlebotomy"},{"speaker":"And this question says","startTime":378.401,"endTime":381.198,"body":"because that serves to initially reduce"},{"speaker":"And this question says","startTime":378.401,"endTime":381.198,"body":"the hyperviscosity"},{"speaker":"And this question says","startTime":381.198,"endTime":383.641,"body":"by bringing the red cell mass"},{"speaker":"And this question says","startTime":381.198,"endTime":383.641,"body":"into the normal range"},{"speaker":"And this question says","startTime":383.641,"endTime":386.537,"body":"and also allows for the expansion"},{"speaker":"And this question says","startTime":383.641,"endTime":386.537,"body":"of the plasma volume."},{"speaker":"And this question says","startTime":386.537,"endTime":388.342,"body":"(Charlie) So, the answer"},{"speaker":"And this question says","startTime":386.537,"endTime":388.342,"body":"to this question is"},{"speaker":"And this question says","startTime":388.342,"endTime":393.054,"body":"d) phlebotomy to maintain hemoglobin"},{"speaker":"And this question says","startTime":388.342,"endTime":393.054,"body":"less than 14 g/dl, is that correct?"},{"speaker":"And this question says","startTime":393.054,"endTime":395.75,"body":"(Cathy) Yup, that's right."},{"speaker":"And this question says","startTime":393.054,"endTime":395.75,"body":"And just to go over the other options--"},{"speaker":"And this question says","startTime":395.75,"endTime":398.887,"body":"Aspirin therapy is a reasonable choice"},{"speaker":"And this question says","startTime":395.75,"endTime":398.887,"body":"for this patient"},{"speaker":"And this question says","startTime":398.887,"endTime":402.197,"body":"and a lot of consensus guidelines"},{"speaker":"And this question says","startTime":398.887,"endTime":402.197,"body":"like the NCCN guidelines"},{"speaker":"And this question says","startTime":402.197,"endTime":404.673,"body":"or in the Blood Journal"},{"speaker":"And this question says","startTime":402.197,"endTime":404.673,"body":"the \u003ci\u003eHow I Treat\u003c/i\u003e articles"},{"speaker":"And this question says","startTime":404.673,"endTime":406.708,"body":"will recommend using low-dose aspirin."},{"speaker":"And this question says","startTime":406.708,"endTime":410.678,"body":"Anticoagulation, though, like warfarin,"},{"speaker":"And this question says","startTime":406.708,"endTime":410.678,"body":"is not used prophylactically."},{"speaker":"And this question says","startTime":410.678,"endTime":413.95,"body":"Imatinib is a tyrosine kinase"},{"speaker":"And this question says","startTime":410.678,"endTime":413.95,"body":"but that's used to treat CML"},{"speaker":"And this question says","startTime":413.95,"endTime":416.101,"body":"which this patient doesn't have."},{"speaker":"And this question says","startTime":416.101,"endTime":419.495,"body":"Other two therapies that are used"},{"speaker":"And this question says","startTime":416.101,"endTime":419.495,"body":"in patients who have polycythemia vera"},{"speaker":"And this question says","startTime":419.495,"endTime":423.512,"body":"but wouldn't be used in this case"},{"speaker":"And this question says","startTime":419.495,"endTime":423.512,"body":"are hydroxyurea and ruxolitinib."},{"speaker":"And this question says","startTime":423.512,"endTime":425.596,"body":"Hydroxyurea is cytoreductive"},{"speaker":"And this question says","startTime":425.596,"endTime":427.555,"body":"and occasionally used"},{"speaker":"And this question says","startTime":425.596,"endTime":427.555,"body":"in very high-risk patients,"},{"speaker":"And this question says","startTime":427.555,"endTime":430.855,"body":"but it's not a long-term medication"},{"speaker":"And this question says","startTime":427.555,"endTime":430.855,"body":"and definitely not first-line."},{"speaker":"And this question says","startTime":430.855,"endTime":435.518,"body":"Ruxolitinib is a kinase inhibitor"},{"speaker":"And this question says","startTime":430.855,"endTime":435.518,"body":"that inhibits JAK1 and JAK2 signalling"},{"speaker":"And this question says","startTime":435.518,"endTime":436.947,"body":"and is also an approved therapy,"},{"speaker":"And this question says","startTime":436.947,"endTime":439.464,"body":"but it's really only used for those"},{"speaker":"And this question says","startTime":436.947,"endTime":439.464,"body":"with higher risk disease"},{"speaker":"And this question says","startTime":439.464,"endTime":441.816,"body":"that have been refractory"},{"speaker":"And this question says","startTime":439.464,"endTime":441.816,"body":"for other therapies."},{"speaker":"And this question says","startTime":441.816,"endTime":444.983,"body":"So again, I wouldn't use it"},{"speaker":"And this question says","startTime":441.816,"endTime":444.983,"body":"as an initial therapy in our patient."},{"speaker":"And this question says","startTime":444.983,"endTime":447.538,"body":"(Charlie) Great. So, the teaching points"},{"speaker":"And this question says","startTime":444.983,"endTime":447.538,"body":"in these two questions"},{"speaker":"And this question says","startTime":447.538,"endTime":451.34,"body":"relate to the evaluation"},{"speaker":"And this question says","startTime":447.538,"endTime":451.34,"body":"of an elevated hematocrit or hemoglobin,"},{"speaker":"And this question says","startTime":451.34,"endTime":454.033,"body":"the diagnosis of polycythemia vera,"},{"speaker":"And this question says","startTime":454.033,"endTime":457.398,"body":"and treatment strategies"},{"speaker":"And this question says","startTime":454.033,"endTime":457.398,"body":"for risk-adapted strategy."},{"speaker":"And this question says","startTime":457.398,"endTime":459.247,"body":"(Cathy) And if you want"},{"speaker":"And this question says","startTime":457.398,"endTime":459.247,"body":"to read more about this"},{"speaker":"And this question says","startTime":459.247,"endTime":462.846,"body":"you can check out \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"And this question says","startTime":459.247,"endTime":462.846,"body":"on Oncology and Hematology."},{"speaker":"And this question says","startTime":462.846,"endTime":466.258,"body":"♪ (music) ♪"}]}