So, here we go. The Day in the Life of the Gastroenterologist Part 2. So we're going to start with this again. This isn't specific. We're trying to get a little bit more specific with EOE today in our panel discussion. So of the following areas, and we'll just do a show of hands, which ones do you want to hear more about so we can focus and tailor the discussion in that zone? So the role of biologic coordinators in GI practices. The coordination of EOE care with allergists, pathologists, and dietitians. How financial, patient personal choices, and clinical factors impact EOE treatment decisions. How advanced practice providers function in GI practices. And decision making regarding endoscopy in patients with EOE. Perfect. Perfect. All right. You got that? Everybody memorized? Cool. All right. Here we go. So, the first question is, how do you as a GI specialist work with other specialists? Nutritionists, allergists, dietitians, depending on the diagnosis, whether it's EOE, IBS, IBD, whoever wants the first case, I'll let you go for it. Daryl? So, I won't speak on EOE, but I can speak on IBS and IBD. We're realizing more and more that these complex diseases really require a team response to optimally manage the patients. So we're actually relying fairly heavily on ancillary support for these patients. So for example, an IBS clinic or a motility clinic, we're actually embedding a psychologist in the clinic. We're probably behind most other centers in doing that. We used to refer them out, then we were depending on access to the psychology department, whatever. So now we're going to embed psychologists and trying to embed a dietitian as well. And we're restructuring our IBD practice where we'll have much more of an explicit team approach. So we will have dietitians, psychologists, physical therapists as part of our IBD center, not just doctors and nurses and APPs. Critically important. I think the question partly also depends on what kind of practice setting you're looking at as well. I think it's centers that most of us work at probably will be more likely to have these multidisciplinary clinic or collaborative team. I think probably in the community, it will be a little bit less likely, they're more likely to refer them out. I think most gastroenterologists will probably have a few providers that you closely work with, allergists, nutritionists, dietitians, or psychologists. So I think a big part of it depends on where you're at. Yeah, I'd also agree. Our IBD center, when you meet them for a new patient appointment, you see your psychologist, your nutritionist, and the physician and provider as well too. When you come for EOE, you just see me. So I don't have those same resources. We can tag into our IBD center for our psychology as well too. But we talked yesterday about hypervigilance, and that's real for these patients that have symptoms and despite having no eosinophils, urinary disease as well too. So I'm their therapist, counselor as well too. We definitely need more support as well too from those perspectives as well. I don't typically refer to allergists, I think we've talked about before, either off the line or on cuff as well too, unless they have severe concomitant eczema or ATP that's a driving immune reaction that's in their body as well too that I can't control myself, then I think it's helpful to have them on board. Or if there's mast cell changes in place, I use their help as well too. But I think at one point we're referring everyone for skin testing and injections as well too, that really didn't change the health of needed patients as well too. So I don't use them at all, though they're fantastic when I need their help as well. My pathologists I work with almost every day, I have four that are on my speed dial as well too, so they're very critical. The EOE diagnosis just came up last night, it's not hard to make, it's really the other conditions for mast cells or barrets or changes as well too, but they're the same GI experts that we have, so I find them very helpful as well. I think one other thing I want to add too, it's that especially for nutritionists, some of the other facility providers, they're not the same, the expertise is not the same, especially when you talk about conditions like EOE or even IBS, with their specific diet that we ask patients to take on as part of therapy. Not every nutritionist or dietitian is trained actually in helping someone with an elimination diet or with a low FOMAP diet for IBS, so it's really important for us to find someone that actually has an interest, have knowledge, and trained in it, because otherwise something like an elimination diet would be hard to do without the support. So in our group, I can speak to IBD and IBS, we have a multidisciplinary clinic, and so we don't have a psychologist, we actually have a social worker who will see patients and support them. She doesn't do ongoing long-term therapy, but we also keep a list of psychologists, therapists, and psychiatrists in the community. Many times patients may not have the bandwidth or ability to come to the university, so we also try to keep a list from the psychosocial standpoint. We have a support group that our social worker runs as well, and during the pandemic they did it virtually, and it was actually quite successful that the group decided to continue that support group, and you don't have to be a patient of our center to be part of the group, so we have outside patients come to our support group because they enjoy that peer support. There's another, it's up and coming, it's an online mental health resource that was developed through Mount Sinai through a company called Trellis Health, and right now they're going to be focusing on IBD patients, but they will expand their health coaching and mental health coaching for other chronic diseases, and essentially it's sort of, if any of you guys have heard about Noom for weight loss, it's that whole model, but for chronic diseases, and so patients will get a health coach and an advanced practice provider to kind of coach them through, and they pay a monthly fee, and they go through different webinars. So from the psychosocial standpoint, that's really important. From the medical standpoint, we also have a surgeon, we have pathologists that we work with in radiology as well. I just learned something. So let's see, so I'm the pediatric person. I will say that everything that was just said is totally what I experience as well. I think the pathologists are the group that I have the strongest relationship with of the people listed there. To the psychologists, there is finances involved from the institution standpoint, so we briefly had a psychologist, she just put in her notice. Frankly, she was totally fragmented, so she was giving us like four hours in adolescent medicine, four hours, and I was like, I heard this, and I'm like, this is never going to work. Didn't work. But the business plan around that for the institutions is a big deal, and the psychologists do not make money, so that's just to know. We all want the psychology support, we all want the social support for our families and my patients. Frankly, on all of those diseases, they all need it, but it's hard to pay for it. Actually, I'm fascinated by trellis, so it's very interesting. I think what I have found interesting to talk to you all about is to recognize that gastroenterologists at this time, and I think I said this at breakfast, I don't really need allergists for EOE, so I think what was said by Walter is completely correct. I use an allergist if I think there's an allergy, an IgE-mediated allergy going on, that they need to take care of that, but I don't, frankly, they can make my life with EOE more complicated. They're like, oh, milk is negative, you can go ahead and have milk, and it's like, no, I just told you, don't have milk. So it can be very frustrating, and you're working at odds with them. Of course, I have a couple of allergists that are colleagues that we have over the years, we text each other, and they are on my wavelength, but just to really recognize, EOE at this point, I believe, is diagnosed and managed by gastroenterologists, and the allergists are really recognizing that their role in it is pretty limited. Those are great points. Just in the general scheme, I think the theme that you're hearing from this as well is, these long-term diseases, right, the ones that don't sort of have a cure, but we can manage them effectively, the multidisciplinary approach comes also in the biopsychosocial realm significantly, right? It's like the patients with diabetes, it's a lifelong diagnosis, and there's a lot to handle when you're telling somebody who's young, otherwise healthy, that they have this lifelong condition that you're going to have to take lifelong medication for. It's a lot to weigh on you. And so realizing that and utilizing social services, if you're fortunate enough to have a psychiatrist, we also have complementary and alternative medicine at our institution, which is helpful in terms of reducing stress, anxiety, this sort of burden that you feel, and then never knowing, oh, my God, in EOE cases, like what Rishi said, is this going to be the time I'm going to choke on this chip at this, you know, Super Bowl party? And having to live with that really weighs on you. It taxes you. And so I think looking at these in a way that we can all help each other collectively is figuring out, you know, whether it's putting through webinars for patients or getting support groups together or figuring out how to navigate the long-term duration of a complex multidisciplinary care, not just sort of the medicine or the diagnosis is important. And patients appreciate that. And as a result, physicians appreciate it. Cool. Question two. How do patient personal issues and clinical factors impact your EOE decisions regarding treatment? Dr. Leite, I'll start with you from the pediatric. We'll go around. Yeah, I mean, so EOE has been a disease without an FDA-approved therapy. And even now that there is the FDA-approved therapy, I think it is going to be a question of how it plays into what we have all been doing, which is shared decision-making at this point around, you know, what is important to the patient, and then, frankly, just how severe is the EOE. So, sure, somebody who's having multiple food impactions, I might be more strong in the office about we're really going to have to do something. The kid is totally asymptomatic, and I know they've got 50 EOs per high-power field, but, you know, they're determined to tell me they're asymptomatic, and they're growing, and, you know, the parents are looking at me like, what, how do I force them not to have, you know, whatever, use their medicines or avoid the foods I've asked them to avoid. That's a shared decision-making discussion. So I think that's the bottom line. So it will be interesting to put Dupixent into this mix and say, okay, are you medication-averse? And there will be, I'm in Massachusetts, there certainly will be families that are terrified of any medicine, and so they will not want to use any medicine, and they're ready to insist that their child avoid foods and, you know, that kind of thing. And then there will be medicine, there will be patients who will be like, give me it. So I think it's going to be very interesting. So I don't take care of a lot of EOE, but in the IBD world we do, as Dr. Lightdale said, shared decision-making. And then if there are patients who really don't want to take medicines, I live in California, people like to do a lot of their own things, and so I'll actually explore that. So I do a lot of motivational interviewing techniques and having them, I'm trying to understand where they're coming from so then we can come up with a plan together. Sometimes we're, most of the time we're successful, but sometimes there are patients who are like, I'm not going to take the drugs, I'm not going to do this, I'll take the risks. And I think it's just having, being open and having that conversation with them. And then as you guys heard yesterday, you know, really showing the patients as you do an EOE, this is a high-power field, these are how many EOs you have, this is what, you know, these are the complications if you leave your disease untreated. And so with IBD we look at it, this is, you have mild, moderate, or severe disease, these are your risk factors, and showing them their data, because I think also showing people their data, that empowers them and helps them with that shared decision-making process. Yeah, I agree. I think the beauty of taking care of EOE patients is that they're a young cohort who's motivated and energetic as well too. So we take care of patients who also have long-standing achalasia or are 95 years old, you know, they're going to look at us as more dogmatic providers. You know, for our patients who are younger, you know, they really want to have a decision to have together as well too. To your point as well too, you know, for IBD, when you don't treat disease, we get into problems with colon cancer and resections and surgeries. For EOE, you're going to see me more often probably for dilations, but I'm not going to remove your esophagus for you, you're not going to get esophageal cancer as well too. So the delta is much higher, which gives us some more play about decision-making together. If you want to do an elimination diet for a while, let's try and see what happens as well too. If you want to try a biologic, we can try that as well. We're close to Fort Gamble, so my DOD or veterans or active military, you're not going to be mindful of are they going to be abroad and deployed, and if so, I can't give them a biologic, they have no refrigeration for as well too. Whereas patients who are domestic with me locally, I say this is an option. You have access to refrigerators and maybe you don't want to take a medicine daily as well for you too. Even for pills, some of them get worried about swallowing pills, so we use dissolvable options for them instead. So those things we just talk about life-wise as well. Some of them just have to drink water in clinic and just say, can you even swallow this for me now? And if they can, I'm like, all right, we have some options for you as well. But if you can't swallow for me, it may be injectables or sub-Q or infusions are maybe better options in this world too. I agree. I think, well, I agree on shared decision-making, but I think the big part of it is really be cognizant of social, personal circumstances of the patients that need to play a big part in these EOE patients, especially if we were talking about chronic treatment, they need to stay on long-term. And usually what I do is that during the first meeting with them, when I lay out different treatment options, I really go into details of what they should expect with each treatment. You know, with diet, you will be very busy for a while trying to diet, doing a lot of endoscopy, but potentially if you can get it, figure out which one you should avoid, then that might be all you need to do. And that's a benefit, but you need to invest the time up front. You know, drugs, you can start drugs and you get under control. That's all. That's all you need to do, but you need to stay on the medication for a long term. So there's like pluses and minuses to each one of them. And they should, you know, they should think about and fit in how, you know, someone who's has a busy work schedule, they can't come to endoscopy all the time. Diet might not be a good option for them. Also the other thing that I emphasize on is that at least with current therapy, they can switch. So if they're on steroids, because they can come to endoscopy now, so they can't do diet for now. They can come on steroids first. And when they're ready, we can try to diet and come on steroids at that time. So it's not like a permanent decision up front. So I think that's something to emphasize as well. I don't have a lot to add, but I will emphasize the point that understanding where the patients are coming from, if they're resistant to medications for IBD, that's usually because they're worried about side effects. So we spend a lot of time talking about risk, which is small, but not zero. But the really, really, really important thing to emphasize is that not treating your disease has risk. And when you put that into perspective, they can balance the risk of progressive Crohn's disease with a couple surgeries or an abscess or a fistula coming out of your anus versus, you know, small risk of things like infection with some of the drugs we use. Your drug, I understand, is a little bit safer, so that may not be such an important thing. But for IBD patients, that ends up being a really big part of our discussion. The other thing that IBD patients often talk about is, do I need to go out, okay, I'll go on this drug, but when can I come off? So then it's a difficult discussion of, well, actually, the hope is that it works, and then you stay on it until it stops working. One of my colleagues used to say that it's like a marriage. You start hoping that it lasts. But then he got divorced, so I stopped telling that story. I think the other thing I would add is a lot of the IBD and EOE patients are very young, so they're thinking about family planning. They may be traveling, going to school, going to college, so I think also as providers, you know, asking them what are their lifestyle factors, so that can help them with that shared decision-making process. I have one comment or maybe even question for all of you. So in IBD, it's been demonstrated that one of the risks of noncompliance or nonadherence, not staying on the drugs that we prescribe, is young men. So for those, that demographic, I'll actually see them back more frequently than I might an older woman, for example. But I understand your disease is primarily in young men, so do we have any data on adherence to medications for young men with EOE, and would that play into deciding what drug you're going to use long-term? I don't think it's formal data, necessarily, but I think anecdotally, from our experience, that's the biggest issue. I think that's the group of patient, the young men with EOE, the ones that are most likely to not come back for follow-up or get lost to follow-up. And part of it could also be because of the nature of, you know, I'm in Boston, we have a lot of college students that come through that we diagnose, or grad students, they might come here for a couple years, we treat them, and they go away. And I think that's the other challenging part with this population, too, is they're so mobile. Whatever plan you put in place, you know, if they move to a new place, and either they don't establish care, or don't continue, or don't have the resource to continue, that could be an issue as well. So I think a lot of times when we treat these patients, we actually ask about, hey, what are you doing? How are you doing in school? Oh, you're graduating soon, so where are you going to be moving to? So we need to really think about those things to plan ahead, because sometimes they might not understand the importance of continuing therapy, continuing follow-up. Yeah. I mean, well, I'll add from the pediatric standpoint. I mean, I treat both IBD and EOE, and often comorbid, so kids with both. But, you know, IBD is, I say, my job is that you should get the disease. I'm supposed to get the disease under control, so you don't even know you have it. You get through school with no hospitalizations, and you get through college. I say, once you're through college, I'm passing you to my colleagues, and, you know, I'm going to hope. But the truth is, you know, throwing a kid into the hospital for six weeks in the middle of a semester of college is a big deal. In the middle of high school is a big deal. So I see that. That's my responsibility, is to take care of them. EOE is interesting. It's a little bit more like celiac disease. You're projecting, you're saying, if you do this now, you won't have to see Rishi or Walter when you're 30 or 40. You won't have that meat impaction. You won't need those dilations. That's a lot harder for kids and their families to really deal with. It's much more in the, don't smoke now, because you'll have lung cancer later discussion. You know, it's a much harder reality, so. Another practical tip that you guys may want to share with providers is for those, your patients who are college students or in school, they can sign up with disability services of their university or college or school, and that will give them that extra, you know, time, efforts in case they get sick. Because a lot of, there's a lot of fear from the families and the students or the patients that, I'm going to get sick. What's going to happen? I'm going to fail my class and I'll get kicked out. And so just providing that additional support is actually very useful too. Great. Thank you. Oh, Walt. Yes. Sorry. It's chronic disease diagnoses. You know, I think it's important to say what you can do. We're very good. Oh, you can't do this. Can't do that. Can't do that. And they walk out of their office. Oh my God, my life's over. Especially a 12 year old boy who loves pizza, you know, and milk or whatever. So you can do this. You can have oatmeal. You can have this. And that's where the dietician is critical. They'll go through everything and say, here, here's an average meal you can do. And they actually, I need to have meals. And if they're young, then moms can help. And I took care of the active duty for 20 years. They were the worst. They would just go from meat impaction to meat impaction to meat impaction. It was so hard to manage them. And especially if they go in the field and eat MREs. So I'm not sure this is going to be a medication that's going to be perfect at once a week shot, but it's something that could be at least when they're in CONUS treated and then see how they do. That's going to be tough for the active duty military. And that's a huge group of people, of young men who have EOE. Um, what is the role of biologic coordinators in GI practices? Can you what? Because they didn't want to hear about it. Oh yeah, that's right. You didn't want to hear about it that much. There's a couple. I have a couple. Um, Dr. Pardee. Yeah, I don't know what a biologic coordinator is. Um, I'm going to go with Dr. Parekh then. Um, I will make a point though. I think I know what it is. Um, we have a secretary in our IBD group that is an expert at all the drugs we use. And it's, um, she's really amazing. I wish I could like triple her pay because whenever I have a question, I call Susie. Um, or I say, Susie, I need, you know, patient assistance for this drug. Okay, here's the email for the rep to call. So having someone, one person, the problem is if she ever left, we'd be in big trouble, but really tremendous resource. And the second thing is we have a specialty pharmacy where there's pharmacists who are specialized in this stuff. So we send our biologic prescriptions to them and they know how to work it through the system. Saves me a lot of time with prior odds. Demisha. So I have a team that I work with. So we have three different people who help us with getting these drugs approved. One is our authorization coordinator and that person only works on infusions. And so a lot of times, a lot of pairs will not allow them to have their infusions at our institution because we're hospital based. So then they have to find an outside ambulatory infusion center. So that person works with on those. We have a specialty pharmacist who works with our nurse navigator and the patient to get injectables approved and both. And then we have a weekly meeting to figure out where's the status of their drug approvals amongst the whole team. So everyone's on the same page. And then we have it also delineated who's going to contact the patient once the authorization is done. So the patients aren't getting multiple messages. So we've streamlined our practice that way. I want to work where she works because it's like, wow. Yeah, I think, look, I think some places have figured out probably a lot, frankly, we're all at academic centers. Yeah. So I think it's probably the private practices have figured out they need to invest in these people because and they pay them three times the salary and make sure they don't leave. The insurance companies are playing games. Every year, January comes, they're switching to biosimilars. They're saying, no, you've got to try Humira first before you, whatever. They're doing all kinds of stuff. It's every year it changes what's covered, what's not, how long it's covered for, how often you have to get the prior auth. I mean, it's pretty extraordinary. And so you do need those knowledge experts. We've sort of switched over to our specialty pharmacy. And then honestly, I have nurses, my nurses are doing this. They double check. So kids coming in for infusion, it can't just be that the chair is booked. It also has to be that the medicine has been approved. And then the medicine might be the white bagging, brown bagging discussion. So it's a very complicated world. The physicians do not want to be in the middle of this thing. It is miserable. And you're trying to explain to your families that you know what you want to give them, but you're going to see what the insurance company allows. And that, yes, we do need people in the middle, whatever we call them. So. I think one thing, though, is actually for the EOE populations, I think most of the providers you're going to see, whether it's academic or community, would have very little experience with biologic therapy, because usually it's more in the IBD world. And usually the IBD center or IBD group will have their own person that might be more experienced in it. Most practices you're going to be interacting with probably don't already have this person. And they probably have very little, very anxious about dealing with biologic therapy. So if, you know, I think that's something that, especially if you work with groups that, you know, certain things work would be actually very useful to bring to the different practices, too, including academic practice. I think none of our mid-level providers in my clinic or, you know, even the administrative people would know anything about how to do this. And I think they need to learn how to do the prior auth and everything else, too. Because never do it. That is fascinating. And I will, that could be a big difference between your pediatric group, because I'm extremely comfortable with biologics. And I think all of pediatric GI is. So you guys are down to 12 right now. Yeah, you're going to find it very easy with us. Not that, but we are more prepared for the fight that has to happen with insurance companies. And yeah, you're at the, I mean, Children's to the Brigham is a bridge between the two hospitals and like a totally different world. It sounds like, Walter, so. Yeah, it's, you know, it's similar to what we said yesterday, which is like, how can we all care for the patient together? We made the diagnosis. This is the treatment. How can we take, this is the treatment to getting in the patient. And what is the role that you all can have in the care of the patient? And it's helping facilitate these ends, working with the people at our institution, identifying the person that's going to be the champion or the person who goes through the prior auth, make sure approvals are there, make sure the patient knows this, how you do injectables. This is your calendar. This is your schedule. Handle that aspect, helps everybody out. It's directly involved with making the patient feel better. It's helping us out because we've set a plan, but can't jump through the hurdles. And how do you navigate that? And so I think this, this is actually an important sort of characteristic that collectively we can play together to help promote the health of the individual that we're trying to take care of. And this is an important, you know, especially for you guys coming in with a new product that isn't injectable, et cetera, there. So I would look at your role in it as well as when you say, well, what can we do to be helpful? What would get you the most traction helping with this avenue? And I know just from our experience, Rishi and I, we've prescribed it, you know, a couple of times already. And the process has been streamlined very well through our awesome colleagues there trying to get it through, right? And so that's coordination, that's working together, right? Everybody's working together to get that patient what they need so that they feel better in there. And so this role is something that we either don't have the time or expertise and other people at our institution don't have time or expertise to do. And so collective education and helping navigate that to make it easier is going to be super valuable. We'll do one more thing. Yeah, yeah, go ahead. It's really important for all of us in practice is working with our industry partners. So my entire team knows all the industry partners. They are on speed dial with them. And the other thing is, you know, you guys know about all the different patient assistance programs that your company offers, and that's really vital for the patients and their families. So we've even streamlined our process. When we order the drug, we have a certain person who will be like, I've already contacted the patient to apply for patient assistance. And so when a new drug comes out, we really work with our industry partners to learn what are the steps, what are the forms, what is the paperwork, and we keep it all on a share drive. So that way we always have electronic access to it. Yeah. So the counter though is, which is true for IB center as well, they have a pharmacist and clinic. They do teaching there as well. The patient I got enrolled, thanks to Jordan, I got the pen. I'm doing the teaching as well. I'm filling out the paperwork myself after clinic. I have 22 people to see as well. Like I don't have that same support. We will get at some point to the infusion part as well too. But in GI, we're relying on you as well. The MyWay form is good, but my gosh, it took me 32 minutes to fill out myself. Trying to get insurance cards to copy and paste back and forth. So like I need that because I want someone to teach them how to use it because I don't even know if I know properly how to use it and what the dose, how long they can be out as well. So ways to streamline that for us would be helpful if it's electronic or minimize what needs to be filled out as well. Because my nursing staff are great, but they are not just infusions and injections. We do so many more things and many of these devices as well. So you're going to see a lot of us sort of gun shy a little bit because we don't have the same system and let you see IB centers as well too. That's why we're going to refer everybody to Misha. Yeah. We got time, I think, for one more quick one. How do you interact with infusion centers and what obstacles are there to patients receiving infusion therapies? Darryl, do you want to take this one? Well, so if you've heard of Epic, it's the electronic health record that many of us use. It used to be a pain right in the backside to order infusions. It was like set up intentionally to be difficult. And we push back, I'm sure other centers push back too. Now it's actually really easy. I ordered something last week and you click a couple buttons and it's done. So that's not really a barrier at all anymore. The only real barrier is whether the insurance company covers infusions in our center or is it at someone else's center. If it's somewhere else, then who's going to order it. But it's not much of a problem anymore. All right. And I think that's it. Are there any questions from you guys that you have for our panel before we close the day in the life session? Yes, please. My first question is, if you had, you know, four times a month that you had to be called in, what percentage is a food infection? And my second question is, are you the one actually doing the taking out of the food or are you relying on hospitalists to do it? Do you prescribe a PPI on discharge and would Dupixent be an option for you to prescribe on discharge for that hospital? Because do those patients stay overnight? Do you just walk us through that process, please? Yeah, this is my every weekend. It's always Friday night. Keith and I do more call than most people. Keith and I do more call than most, we have, we do most providers. And so, so yeah, when they come in, so basically we get a phone call. We have a couple of critical emergencies and a food infection is one of ours. Because if it remains in there, they can get perforations, they need a surgery, they need a G-tube, you know, we're in trouble as well, too. It's also unsatisfying to see a patient who can't handle saliva. So they're spitting in a bag, they're not feeling well as well, too. So logistically, what we have to do is get them into a place where we can safely remove the food bowls. So some people have an open access endoscopy center. For us, we have to go to OR and take it out overnight as well, too. A lot of us will then intubate the patient preemptively just to prevent food going in the mouth as well, too, or the larynx as well. Sometimes it's really easy. So we have fellows and they will go through and try first. And then usually they either can't get it or it takes two hours. And so I just push it through myself afterwards. But it could be 20 minutes, it could be three hours of pulling out pieces of steak, one at a piece at a time as well, too. One thing you'll see, which we didn't code too much, is that a lot of these patients don't have insurance. These are young 22-year-old guys and women who are coming in. And so a lot of our standard of care at the time for us, you see one of the esophagus on call, is to biopsy them and dilate them at time of endoscopy because they have a dominant stricture at present. A lot of your community partners feel uncomfortable dilating a food bowl is because if it's too inflamed, it's too much inflammation, we're going to hurt them, perforate them. That's not really been found to be true. In the right hands, I would say. So yeah, depicts it would be an option. The problem is our hospital is not going to pay for it to get them a shot to go home with. They have no insurance probably as well, too. And so PPIs are over the counter for $5 at Costco or Sam's. They can usually get that as well, too. So if they have insurance and we get follow-up for them, that's probably a good option for them potentially. I think we'll talk about the risk and benefits this afternoon as well. But yeah, for us, we're taking the biopsies, we're dilating them, we're moving the bolus as well. And then I'm usually starting a PPI on the front end. And then I bring them back, you know, four to six weeks later to repeat the endoscopy then. I think one of the questions before is that, you know, the important thing, especially if people would never had a diagnosis before and they came in for the first time with a food impact. And I think those are the one that's a little harder because you need to establish a diagnosis first. So I think those cases definitely depicts and wouldn't be an appropriate therapy up front on the spot. I do start PPI, but only if I have a chance to take biopsies first. If for some reason I can't take biopsies, which should be rare, we should be able to take biopsies during these initial endoscopy, then we should just start them on therapy right away and then plan for follow-up. I think in some way, even if they have a diagnosis, they've never been on biologic before, I'm just not sure that in an emergency setting, it's a good time to have the discussion and start them on therapy. So I would still favor doing something like PPI and then bring them back and make sure they actually are going to follow up. Because I think if they're going to show up one time and give them the pigs and they never follow up back, that's going to be an issue as well. Yeah, time for one more. I'll get the octagon. Okay, I'm down. So if you do biopsy and you see that they have EOE, would that speed up your follow-up process with them, or the time between you see them in the emergency room to the four to six week follow-up, would that speed that time up? Would you want to see them in quicker? Generally not, if I already started them on something like a PPI, because you usually wait about two months to re-biopsy to see if they respond anyway. So a sooner follow-up likely is not really going to change what we're going to do. Obviously, if they come back and they say they're still having a lot of trouble having significant foot impaction, that's something different, we might have to try to dilate them sooner, but that'll be more rare. Also very dynamic, once you start them on medicine like a PPI, I mean, you'll see an inflammatory stricture in your esophagus, it's not fibrosomatic, and you either follow up six, eight weeks later, and it's fully normalized. So it's quite gratifying, but it does take some time, so if they have more symptoms, we usually just do dietary modification and let that medicine work. I mean, our response to PPI is actually fairly high, and so that's what we don't give up too quickly on that medicine yet. Okay, and then I have one question. You've mentioned several times dominant stricture. What do you mean when you say dominant stricture? Can you help me to understand that? Yeah, so an EOE can have stricture and disease everywhere in the esophagus, but sometimes it's just one focal stricture that's more prominent than the others. And so a lot of patients, why they don't come see us afterwards, because once we dilate their stricture, it takes months to years to then inflame back again and get stricture disease as well. So I don't blame them for not taking medicine every day, because they feel so much better. For me, 10 years, I'll feel fine as well, and some people as well. It also, when we do trial work this afternoon, you'll see why some patients don't respond symptomatically, their histology got better, because if there's a stricture, that's not always going to be improved by anti-inflammatories as well too. So that's where our role is, to dilate that stricture for them. You'll see one focal stricture at present, either proximal or distal, we open it up, and they have automatic response. So they'll see me the next day saying, I feel so much better in my entire life. Thank you so much. I'm like, I literally took 30 seconds in your esophagus. It was so easy to do. So very gratifying to take care of them as well. But one reason why compliance is not always there, because they feel so much better, and it takes so long to then restructure again for them as well. Thank you, everybody, for being up on the panel. Appreciate all your answers and advice.

eosinophilic esophagitis

treatment

biologic coordinators

infusion therapies

shared decision-making

collaboration

patient care