Now, let's hear from you, our audience. What questions have we not addressed, or on what topics can we take a deeper dive here? Eden, can you hit us with the first question? Sure, Kim. We actually have two kind of like cases for Kim. So the first one is for a patient who has been well controlled with Humira with a normal colonoscopy in the last year, and then has a sudden flare with hematochesia and urgency and whatnot. What would you do, what would be your go-to treatment for flare, and for what duration to re-induce remission? And I'm assuming that I'm seeing this patient at 4.30 on Friday, right, is how this goes? So great question, and I think this is something that a lot of us, and again, I'm a community-based nurse practitioner, I'm sure we all recognize that already, but this is something we see commonly in practice, right? We have a patient who has achieved remission, which is our goal, right? And then suddenly they lose that remission. So and I use these analogies when I talk to my patients and provide education all the time. So what's the first part of this process is regaining, right? We want to turn off this inflammatory process. So number one, what do we do first and foremost? We put them on steroids, right? But as soon as we put them on steroids, what's our thought? How do we get them off steroids, right? But initially, we got to turn off that inflammatory process. So step number one, steroids, right? And I'll tell you, probably in this patient, looks like, of course, I'm assuming, it doesn't say if they've got Crohn's disease or ulcerative colitis, but I would likely put them on prednisone. So here's what, I know we kind of went over a little fast in the lecture, but this is where I would challenge all of us and say, this is where I do a little drug monitoring, right? We know that this patient has had a response to a TNF. So I'm not going to ditch this class right away, right? What I'm going to do is I'm going to check they're at a Lumimab level. I want to see where they're at. Do we have room to go? If they've got a low drug level and no antibodies, guess what? I'm going to try and optimize their drug, right? Because they've had a response to TNF already. So that's probably going to be a part of my paradigm here. Now, if they've got zero drug level, they've got antibodies that are through the roof, right? I'm not going to say I might not stick with this initial therapy, but considering they've had a response to TNF, I'm likely going to stay in that class, okay? So step number one, turn off the inflammation. Step number two, in this patient specifically, I'm going to check their drug and see if I can optimize them before I change anything else. Anybody else have any thoughts on that? Okay, hearing none. I'm going to throw another case at you. It's a little bit long, a couple of questions in here. So in someone who may be 85 years old or older with diarrhea and their calprotectin comes back elevated, but not that high, how do you go about determining next steps, including a colonoscopy in someone who is 85 and who may not be a great candidate? I know calprotectin can be, I may be saying that wrong, sorry, can be elevated in several different things other than a colon cancer, polyps, and IBD. Do you ever just continue to monitor and maybe repeat calprotectin in a few months to ensure it's trending down? So this question I knew initially Jill answered, and I had seen that I was like kind of looking through it, but I have to tell you about a personal case in this situation, because I would agree, right? We've got our more mature population. So I had a patient who had come in who was actually 92, right? Chronic diarrhea. And part of my workup, again, is checking a fecal calprotectin. This patient's fecal calprotectin was well over 1,500. I do recognize that fecal calprotectin can be elevated in many other reasons as well. And you're right, pseudopolyps, infection, but again, think inflammation, right? So what I did is exactly what was suggested. I repeated the fecal calprotectin, and it was about one month, and guess what? It was still high. So did a colonoscopy, and guess what? The patient had pan-ulcerative colitis. First time diagnosis in his 90s. So again, fecal calprotectin is a wonderful and very sensitive test when it comes to inflammation in the colon. Don't let age or being more mature just detract you from what we know from clinical presentation. So again, unless there was a direct contradiction in performing colonoscopy, what I've learned life lesson a little bit here is go with our gut, right? That's what we do. I wanted to add in my thoughts as well. When you decide to order a test, we have to understand what the ramifications are when ordering that test. I'll walk through with my patient, I'm going to order this test, or I would like to order this test. This is the information it's going to give me. If it gives me X, Y, Z, you may need a colonoscopy, because some patients, especially our older patients, come in already with that predetermined mindset of, well, my doctor told me I was too old to have a colonoscopy. And you have to kind of pull that apart. Well, this isn't a screening colonoscopy. You're here because there's a diagnostic problem. That's why I mentioned that shared decision-making. Educate them up front, because if you get a calprotectin back that's over 1,500 versus, say, a borderline of 45, something's going on. Angela, I think that that's an important point to even look at it and say, you have that discussion with the patient. You've already gotten the calprotectin, whether you ordered it or somebody else, and now you're talking to the patient and you decide together colonoscopy is not a good option. Is there really a reason to follow the fecal calprotectin in that scenario? There may not be, because what are you going to do with the information that you get? And so I think continuing to remind yourself and have those conversations as you're reevaluating things as well. Let's turn to colorectal cancer screening. So Dr. Vicari, we'll start with you and you bring in your colleagues as you need to on this series of questions, or as you would like to. What do you say to patients with a history of polyps and some cardiopulmonary comorbidities with that polyp history that insist on doing FIT or Cologuard after age 80? Oh, Dr. Vicari, you're on mute. I would first start, regardless of the comorbid disease, by outlining the age guidelines for screening for colorectal cancer. So I'd start with that. But if you have someone who wants to undergo screening for colon cancer after age 75 and they're healthy, then that's an individualized discussion between you and the patient, and then you can make an informed decision together. Once patients start to have comorbid disease, I become really, really conservative about any screening for colon cancer over age 75. I'm actually looking for an out at that point. So in the scenario you outlined, I would not offer any screening to that patient that has comorbid disease, and I would explain to them that FIT and the Cologuard are screening tests, explain what that means, and that if it's positive, then there could be an important lesion, although small, and perhaps undergoing a colonoscopy is not in their best interest and risky, and then they might have to live with some emotional stress depending on their emotional makeup of maybe I have a cancer. So I do my best to adhere to the guidelines at age 75. I stop. I certainly individualize for healthy people who may live a while, but once they're sick or once they have comorbid disease, I'm looking for an out, and I'm very kind, and I explain it, and it's okay to say no. I know it's hard, but it is okay to say no, especially if you're looking out for their best interest, and if they want to go elsewhere, I'm totally fine with that. I'm going to stick to what I think is the right thing to do for them. Lots of head-shaking. Dr. Kaul, you have a couple thoughts there? Yeah, I'm actually not that kind. You know, that patient, point well taken, Jo. I think that's why you're a legend. These patients, however nice and experienced and well-meaning and intentional they are, they have not made rounds on those 80- and 90-year-old patients who had a procedure done and had a complication and spent six months in the hospital and then passed away. I have. And so we know from experience, years and years and decades of experience, that age and comorbidity is a recipe for problems if there is a complication. And if somebody has had multiple high-quality colonoscopies in their lifetime, I tell them very simply that in this lifetime, it is extremely unlikely that colon cancer will be the cause of your demise. A statistical probability of a cardiac or neurological event will be much higher. And God forbid, if you have a complication, whether it's a cardiorespiratory sedation-related complication or whether it's direct trauma from the scope, it's very difficult for you to make it out of that complication, especially if you end up in surgery or if you end up in the ICU. So why do you want to play that roulette game? So I think that's how I position it. And that's what I meant by not being kind. I'm very transparent because I have seen week after week, these older patients do really, really very, very hard time in a perioperative and a sick-you situation. Thank you, Dr. Ian, can I digress just for one moment? Absolutely. There was a question that came up, and I want to make sure I address this. When I outlined the offerings we have, there was a question about cases of month, how do they access it? Everyone has a membership to HG for the next year as part of this course. You can access practical solutions. You can access the APP case series. You can access IGIE, and you'll have access to lots of other stuff. So you will have access to the case of the month series, which I'm very happy to say has gone really well. So please take advantage of that. Sorry, Eden, I'll throw it back to you. No, absolutely. People wanted to submit the submission processes right there in the journal, right? Yes, and they can certainly contact any one of us if they want to be part of a co-author of the APP case of the month. We've got a list. It's growing. We're more than happy to have you aboard. Wonderful. Wonderful. Okay. We are going to go back to our colorectal cancer screening kind of series of questions here. How do you approach answering a patient's assumptions that their FIT or Cologuard test was positive from hemorrhoidal or fissure bleeding only? I can start in. I'd say, yes, that is certainly possible. You may be correct. However, this test is now positive. It is a screening test and hopefully used appropriately for colon cancer. I cannot tell you that you don't have colon cancer or an advanced polyp because, again, a FIT test. And was it just FIT? I want to make sure I'm speaking correctly. They said or Cologuard, yeah. So FIT is a tier one test. It's got sensitivity a little below colonoscopy. So there could be a colon cancer. There could be a colon polyp. Unfortunately, none of us are perfect. Even if they had a colonoscopy two years ago, there could have been a mislesion and I think we are now committed to colonoscopy and I would emphasize the risk, although low, I wouldn't say mislesion, but I would emphasize that this is a positive test and there could still be a cancer and we need to move forward with colonoscopy. And I'd be more than happy if it was hemorrhoids or something simple. And with Cologuard, a tier two test, you know, between the false positive rate, it goes up a little bit because of the combined test. So again, I'd answer it just the same. The emphasis here that I tried to make in the talk is we really need to use these tests correctly. If I had a colonoscopy last year and now it's three years later, I'm sorry, I had a colonoscopy last year, it was negative and now I'm at my primary doc's office. They click the box to do a fit. I'm not super medically literate. I just do the test. It's positive. We have just created a whole lot of stress for the patient, for the doctor, and likely now to embark in a very expensive workup. Okay. So go ahead and do that. Go ahead. So if a patient had a normal colonoscopy less than three years ago, they do the fit, the patient says, you would go ahead and do the repeat? Yes. I don't think we're stuck unless others feel differently. I feel I think we're stuck, especially depending too on your medical legal risk environment, we shouldn't practice by that. But at this point, we heard from Aaron yesterday, it's the top reason colonoscopy for suits. It really puts us in a very bad position and 99% plus of the time, it's not our fault. Someone else has done that test. Okay. Dr. Call, you wanted to chime in? John Hanson. Well, I was just going to say, I think, you know, any test that you get for anything is a potential Pandora's box. I mean, you know, if you're not willing to act on a test, you shouldn't be ordering the test. Right. And I think that that stands to reason not only from the point of view that we're talking about, but also from the point of view of cost efficiency and stewardship over, you know, the general pot of money that's available to care for the health of everyone in the nation. We shouldn't be blowing money on tests that we're not expecting to use the result of, if that makes sense. If you're getting the test, you're going to act on it. And if you're not going to act on it, don't order the test and waste the money, spend the money on taking care of somebody else. Two very important principles by Dr. Vicari and Martin, number one, for patients on the colonoscopy pathway, don't order the ColoGuard unless there is a real reason to do it. And secondly, be judicious about test ordering. My answer to that, again, you know, I have very good conversations with my patients. I tell them, you know, like what Dr. Vicari said, when it comes down to patient care, you have to assume the worst. Our patients are safer when we assume the worst. What is the worst possibility for this ColoGuard positivity? Now, remember, ColoGuard also has a DNA component to it. So blaming it on hemorrhoids, and by the way, the company doesn't tell you which part is DNA and which part is blood. So ColoGuard, you know, is not an insignificant positive test. So my thing to the patient, you know, we see a lot of patients from underserved communities, patients with varying degrees of patient literacy, I mentioned that yesterday. I say to them very simply, and this is the language they understand, right? If you are sleeping at 2am upstairs, you hear a sound downstairs. Do you think it's a mouse or do you think it's an intruder? What's the worst case outcome? You know, so when you hear a sound downstairs repeatedly at 2am, you are better off assuming it's an intruder. If you assume it's a mouse, the outcome may not be that good. So same way, if you have a ColoGuard positive in a patient who had a colonoscopy three, four years ago, especially at a facility where you don't know by someone, you don't know what their quality was, and especially if it was a poor prep or whatever, then you are better off at taking strong consideration for repeating that procedure, because that's where the patient will be safe. That's how I look at it. I'd like to take it just one step further, because one of the things that we see or we hear a lot is the patient gets referred for a positive fit from a PCP. We didn't order it. Nobody in GI ordered it. And you look back and they had a high-quality colonoscopy 18 months ago. At what point do we say it's been 18 months or two years or three years, we should repeat it? Where is that buffer? And this is assuming high-quality colonoscopies. So you know that at least the cecum was reached, if not the TI, you know the prep was good. High-quality colonoscopy, when can we say it's extremely unlikely and the risk of a repeat colonoscopy is too high? Well, it's got multiple sections to that answer. Number one is who did that colonoscopy, how well-documented was the quality of the colonoscopy? Number two is what is the risk status of the patient? Is this a patient who has Lynch syndrome or is this a patient who is just sporadic coming in for average risk screening? Number three point is what is the comorbidity and age of the patient? You know, if this is a young patient who has long years of viable life and there's a significant anxiety level, the colonoscopy prep quality was not good. This and that and the other thing, you might weigh in the favor of doing another colonoscopy. Number four, is this a FIT test or a GUAAC test or is this a ColoGuard test? And next year, hopefully we'll have a second generation ColoGuard test. So it all depends on which of these variables is weighing in, in which particular manner to help your decision-making. And finally, it's a shared decision-making in difficult circumstances. Like we talked yesterday, you tell the patient, these are the pros, these are the cons. And that's where the, that's how I approach it. We'll switch gears a little bit for a second here. Someone has, is asking about an ultrasound finding of liver cyst, which is less than two centimeters with septation. Should this be followed by a CT scan? The lab had, was normal on the liver tests, no risk factors. Should that be followed by a CT scan? Does anyone like to jump in on that? Did you say two centimeters? Less than two centimeters. Yeah, that's a really small cyst. I mean, you know, honestly, what would I do in practice? I'd look at the CT or rather look at the ultrasound myself and see what else was being called. But, you know, if it's got septations, it kind of leaves a category of a simple cyst and becomes a complex cyst. And I'd probably want to know on a scan, whether there's enhancement of those septations or not, which would then lead me to investigate it further. So I think even though it's small, if it has septations, I'd get the CT. Vivek, you're- Very, very important point, John, you raised is whenever you see on an ultrasound, by the way, the Western world ultrasound is much poor quality than the Far East. Just wanted to put it out there. But whenever you see the two words, complex cyst cannot be ruled out or atypical hemangioma, don't leave that patient just with ultrasound. These are very important radiology terms that are telling you that the radiologist is not sure what's going on. Complex hepatic cyst and atypical hemangioma. These are very, I don't like these words. So we go to a triphasic CT or a MRI with EOVIS or Gadham-Hansen and so forth, so. Okay, so our next question, I'm going to start with you, Kim, and then if anyone else would like to chime in. This person is seeking any information on FMT and rebiota. Super fun. I also love to talk about the microbiota, by the way. So, of course, in November of 2022, of course, rebiota became the first approved microbiota-based live biotherapeutic to prevent recurrent C. diff, okay? So, right, rebiota, so we all know, is, of course, a broad consortium of all kinds of microbes that we have. There's a little bit more of the Firmicutes and Bacteroides family, just so we know, but it is a single dose enema. So given in 150 ml, single dose enema. In our practice, we're still trying to figure out how to actually get this in our practice, but there are codes specifically for administration and for APPs alike, right? This is a way to, of course, generate additional revenue, right? We can actually, there's a code for actually billing for this. There's a nursing and a code for administration. With that being said, of course, the primary endpoint we're looking at the studies course was looking at not having recurrent diarrhea after a total of eight weeks time. I can tell you that I have had to refer my patients to, of course, get therapy such as this because we don't have it in practice, but again, super duper exciting. And just on a side note, in the pipeline, there's going to be an oral, right, an oral microbiome therapy coming in the very near future. So I hope that that kind of answers the question of what we were looking for. Thank you. Let's run back to colonoscopy. Dr. Vickery, is there still a place for virtual colonoscopy? So if we look at the tier system, it's definitely lower on the tier system. We didn't really have much in the way of radiology interest in my area in CT colography, and we were fortunate to be about an hour from Madison, one of the leaders at the University of Wisconsin in Chicago. We specifically, excuse me, we specifically use it to complete a colonoscopy if there's an incomplete colonoscopy. That's kind of how we used it, sorry about that, but we don't use it frequently. I'll turn it over to John because I think I might have aspirated. I think, you know, our experience at Mayo Clinic is exactly the same. All of you that are online are clinicians and you know what it's like, whether you're talking about a CT scanner or an MR magnet. There are a lot of organ systems competing for the use of those machines and the radiology departments have got to decide how they're going to divvy up what tests are getting done on their machines because there's an insatiable appetite for the utilization of cross-sectional imaging studies. As a result, they have to decide, are they going to take up, you know, CT calligraphy or MR calligraphy or are they going to, you know, use those scans for all those other things that you're asking them to image? That along with reimbursement issues, I think led to a lot of lack of enthusiasm for these uses for those machines. And on top of that, you know, as Dr. Vicari emphasized earlier, you know, what is the test that can diagnose these things and treat them? Colonoscopy is it. And if you're going to prep somebody for a non-invasive imaging study, find something and they have to prep again on another day and take more days off from work to come in to get that addressed with the colonoscopy, hard to find buyers for that algorithm of management. So I think that in a nutshell is what kind of led to the demise after initial enthusiasm for these studies. And that enthusiasm was already like a couple of decades ago, right? It's been the majority of our career since those things were a hot topic. And I think, you know, the way the question was posed and both of you have answered it very appropriately is to position virtual colonoscopy as off the bat screening tool. So, and you've addressed that very, very well. It is not currently in that realm, but I do want to leave the audience with two very good indications I feel for virtual colonoscopy. And one is that when you have a genuinely failed attempt at optical colonoscopy, which I've had fortunately or unfortunately a lot of experience with because I serve a large region where these patients are sent to me. There is every two or three years, a sigmoid that Peter Cotton said should not be traversed. And I do not attempt to traverse it anymore. I give it about a 10 to 15 minute shot. It's typically an older petite lady who's got severe diverticulosis or prior radiation or hysterectomies and other surgeries. And I have a very low threshold of sending them on to a CT colonoscopy. The second indication I feel is very useful is when you have a similarly frail patient where there is a high index of suspicion for a colonic malignancy. And anesthesia, colonoscopy, potential risk of perforation and so forth are not acceptable. And it might serve as an option because American patients want to know, they want to know there's a right colon mass and maybe some brave surgeon will do a 45 minute right hemicolectomy and she may make it. That is one kind of borderline indication that I have used it for because the patients will not leave your office unless you give them a plan for ruling out a colonic malignancy. And I'm not prepared to necessarily put them through an invasive procedure and nor are they interested in that. So that is another indication that I've used virtual colonoscopy for, or at least provided that as an option. So Dr. Call, I'm actually going to provide full disclosure here. I know you and I know how you practice. And so I know that after that 15 minutes, and particularly if you've already tried a pediatric colonoscope, you're going to whip out a gastroscope, or you're going to whip out a balloon enteroscope without the overtube. And you're actually going to drive that thing all the way to the cecum and even up the terminal ileum 20 or 30 centimeters and take every polyp you see. Right. So be honest, please. Okay. You know me too well. And you know, whereas I lag behind you for biliary cannulation, I have it in the colon. But, you know, thanks for that compliment. But I think that those are my two indications where I use it. And the second one, I will admit is not, I'm not proud of it, but I think that, you know, if ever you're going to do something with that little frail patient, then that it might serve a purpose. I think many of our patients want closure and they want to know, you know, what's going on. And many of them stop. I can tell you, stop at that. I can tell you many, many pancreatic mass patients. We had one couple of weeks ago that come to me at 92, they have a pancreatic mass, they make the appointment. It's a level four, level five consult. I spent a lot of time with them. And at the end of them, they say, you know, all I wanted to do, it was hear from you what the options are. And I am all set. So you need to afford them every option in the Western world, in the first world that is available. And sometimes these, these type of testing are useful in that regard. I just want to take a second to talk about the patient experience for the CT colonoscopy. So we don't do it often. Like Dr. Cole said, when we do it, we try our hardest to get it same day or day after when we can, if they've been in for a colonoscopy, so they don't have to prep twice. But I think it's important to lay out expectations with the patients. So they are going to take an oral contrast. They are going to get air inserted into their rectum. It is not something that people enjoy. It's not comfortable and they don't get sedation for it. And so I think the biggest complaint that we hear from our patients who come back such as somebody who has severe diverticular disease, you can't navigate their sigmoid easily, but a family history of colon cancer, you don't want to do no screening. They may be a good candidate for CT colonoscopy. They really have a lot of difficulty with it. And so I think laying out the expectations, letting them know exactly what's going to happen, what the radiologist is going to do, kind of talk them through it a little bit. The radiologist will do a good job of that as well. But if they know going into it, I'm going to have contrast, I'm going to have air that goes up my rectum. And then if the radiologist is telling them the same thing, I think they are more successful. We've had quite a few patients who don't tolerate it and they abort the exam. And so in an effort to complete it, if we feel strong enough that it should be done, then I think we also want to make sure we give them the information and the tools that they need to get it done. Wonderful. Thank you. That was a wonderful dialogue on patient-centered care as well. We're going to jump back to Kim, follow up on that FMT rebiota. Somebody's asking how can we order it? Can everyone qualify it for it? Who can administer it? So can you add additional comments there? Sure. Sure. So it's FDA approved. Anybody can order it. You do not need to be an infectious disease any longer. You can order it. I work for a large multi-specialty group, and we just have to actually get it through our P&T committee first. So that's of course why we haven't been able to order it yet. So anyone can order it. Who can administer it? So it actually says on the labeling, if you look up the PI, it says can be administered by a nurse. But also, so with that being said, it can be administered by clinical staff and there is a code for administration. So with that being said, I know as advanced practice providers, I think it's always important to, of course, make the most of what we can do. So if there is an ability, of course, to bill for this, then that might be something you can investigate with your practice. Do you have a little FMT clinic? Something along those lines. And again, the indication is for recurrent C. diff. So they just have to have one episode adults recurrent C. diff. So that's the current indication right now. I think we hit those three points. Thank you. Thank you. Next question is colonoscopy versus sigmoidoscopy with someone with a history of hemorrhoid and having rectal bleeding. Dr. Martin, you want to start us on that? Yeah, I'm going to say that there's a bit of a nuanced answer to that too, because it depends a little bit on things like the age of the patient, which raises the likelihood of, of things that you wouldn't want to miss north of what a sigmoidoscope could reach. For example, if you've got an 18-year-old who's healthy and really doesn't have anything other than a bit of blood on the toilet tissue or something like that once or twice, I think you're less concerned about the possibility of a CEQA malignancy causing that than you might be in someone who is, as Kim put it, more mature. I'm going to use that one for myself the next time somebody says I'm old. I'm just using an extreme point there to suggest that, well, it kind of depends. It depends on some detail there, and I'll probably leave it at that and ask my erstwhile colleagues on the faculty to add to that. Joe, have you? I would agree. I agree with John. These aren't necessarily easy clinical decision situations, and there is no clear data to drive us. There's some. It's nuanced. There's a little bit of the art of the medicine taking into the patient's perspective. How nervous are they? How anxious are they about this? It's nuanced. I think that's a really good approach to it. Agreed. Bowel prep questions. I'm going to direct it first to you, Dr. Martin, since you addressed bowel prep yesterday. What is the safest recommended bowel prep for patients with kidney disease? Yeah. I think that's a really great question, and I'm glad it was brought up. We were saying yesterday that the isosmotic preps, which are polyethylene glycol 3350-based preps, are far, far and away the standard prep, and there's a good reason why that is. We were saying that a 3350-unit polymer of ethylene glycol is a huge molecule that's not going to get absorbed systemically, and that is why every liter of that water-based polyethylene glycol preparation that the patient drinks comes out the other end, and therefore creates a high-volume flush and doesn't disrupt the fine balance of electrolytes in that patient. Imagine if you already have a high risk of electrolyte imbalances, even without goosing the system, because your kidneys, which maintain your electrolyte balance, are awry. That's the last patient that you want to give something that could possibly disrupt that balance. The safest option is absolutely going to be an isosmotic prep, where the net absorption is going to be as close to zero as possible. So you studiously want to avoid the hyperosmotic or hyposmotic preps, and you want to stick with something isosmotic, and that's going to be one of the PEG preps. Yeah, they're higher volume, but at the end of the day, the low-volume preps aren't really low-volume when you consider the total volume of liquid you have to drink, which is usually about three liters, and the difference between three and four isn't that great, and there are isosmotic preps, like the second category of preps that I discussed, that really are three liters, and there are three liters of isosmotic. That's pretty hard to beat. So in this day and age, it's hard to recommend something else unless there's a good reason, and there really isn't going to be a good reason with somebody who has renal insufficiency. That would be my opinion. Okay, we're going to get in two more questions before the end of this. So going back to liver fibrosis, my practice likes to use a fibrosis panel. I know how to look at it to determine if a patient has F04, but not the remainder of the test, but if it is showing F0 or F1 and AO, what does that mean when the apolipoprotein is elevated? Is there anyone who could answer that, and you might want to look at it in the Q&A? Yeah, I'll tell you that that is outside the scope of my clinical practice, and if I were asked that question, I would be turning to the side and asking my colleague, Andrea Gossard, for help with that. She and her team in hepatology would have the expertise to answer that question properly. So we will direct that to Andrea, and we'll put that... We're going to look at... We've got... How many did we get, Dr. Vaccari? Did you count over 200 questions today? Today, I think we're at 210. I think we had 95 yesterday. It lapped last year's questions. Amazing. Absolutely amazing. Well, we will. Our staff is working on kind of formulating a document with all the questions and answers, so we will make sure to get Andrea's response to that. So we're going to end the course on this question, which I think is really important, as they all have been. Do you recommend... And Dr. Vaccari, maybe we'll start with you. Do you recommend colonoscopy for a young patient, let's say they're 32 years old, who is insisting for the scope because their maternal uncle had colorectal cancer, or is it only if it's a first-degree relative? How do you handle that patient? Yeah. So I certainly would review the data with the patient. And for me, a 32-year-old with a single maternal uncle with colon cancer, the guidelines would say that that is not really an indication to proceed at that point. I think a first-degree relative, based on the guidelines, we would follow those and that would change. But a single second-degree relative would not, or maternal uncle would not make me proceed. And I don't know if others feel differently. I agree. I think outside of syndromic presentations, I think we need to stick with the guidelines. And the guidelines are pretty clear at this point. The syndromes, I have a very different approach to the syndromes, Lynch, FAP, attenuated FAP, Cowden's, and all these, Cronkite Canada. There is a lot of syndromes that we end up seeing at the referral center. They need to have a different pathway. But outside of the syndromes, I think we need to really follow the guidelines. Every so often, there is a young patient who has an advanced adenoma. That's just life. And when you do a colonoscopy on a, I had a 30-some-year-old, and he had a ginormous sigmoid polyp. In fact, I have a video of that that I've shown at ASGE many times, and there was no rhyme and reason for that individual to have that lesion. So obviously, he will be followed differently. But guidelines are made from a public health perspective, not from an individual perspective. Okay. And we'll let this one follow-up question in before we close out. What about multiple second-degree family members with polyps and cancer? Would that change your opinion at all, Dr. Kaul? Dr. Bakeri? It gets harder and harder, doesn't it, as the hour winds down? Yes. Multiple members, again, my first approach to that would be, is there something genetic going on in this family? I think that while I'm trying to address that individual's question, part of addressing that individual's question is also addressing the familial situation. Why are seven members in that family having colorectal cancer? And especially if that's occurring at a young age. So I'm more interested in approaching it from a holistic perspective. And then, you know, maybe I'll get a genetic test on that individual, or maybe I'll dive deeper into the family histories and figure out whether that was really colon cancer or colonic paraganglionomas that were removed, you know. So this is a, you know, it's not something that can be answered one-off, so to speak. One has to really dive deep into that kind of a consult and make the right decision based on facts. Yeah. I agree completely. I mean, we see this in our practice. We've got, we actually have a number of familial clusters of some of the diseases Dr. Kaul mentioned, but I would definitely become very curious, start to dig in and be very quick to a genetics referral, genetics evaluation before, you know, scoping someone that maybe doesn't need it. Maybe they do. But I think, again, when we want to do tests, when we believe they're going to change the outcome and change management, and I think that's the way I would view this, starting with exactly what Vivek said. Thank you. Thank you, Joe. I've both agreed with me at least once in this 28 hour period. My life's mission is complete now. I'm good. I think the audience can tell how much we enjoy this course and actually how much we all like each other. It's refreshing. It's amazing. What a perfect way to start wrapping up our day. Would you agree, Jill, Dr. Martin, shall we close it out? Well, I guess if we have to, you know, this really is so much fun. I hate that this is coming to an end because we could all enjoy doing this for many more hours. But I know that a great thing like this does come to an end, but only for today, right? And you know, I was thinking about the fact that I couldn't answer that question. And what an important fact that is that shouldn't be lost on us because, you know, I'm a physician and I depend on the advanced practice providers that I have the privilege to work with. I ask Andrea questions all the time and she asks me questions too. And together we do what we hope is great things for patients to keep them healthy and to restore their health. And so we are partners.

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