Okay. Hi. Any questions, feel free to keep going. So, hi, everyone. So, yesterday, we bombarded you with a lot of clinical questions, but we didn't even – because this is called a day in the life of a gastroenterologist, and we didn't even have a chance to humanize you by asking you why you got into the world of GI. That's the first part, and if you could change anything, knowing what you know now, would you still decide to go into GI and be a gastroenterologist with all of the low reimbursement rates and the struggles that you guys are facing in your world right now? I think – I've had this question before, but I really do – so, with what I do in GI, and again, my particular focus is inflammatory bowel disease, so I get to see patients in clinic, and because I treat these chronic diseases, I get to see patients over time, which is nice, because we've been through a lot together with our patients. But also, the really satisfying part, again, is seeing that patient in clinic, hearing those symptoms, and being able to visualize these abnormalities, diagnosing, treating with therapeutics, and then getting that patient better. So, we are able to help a lot of our patients, and it is really gratifying to see the start to the finish and maintaining that relationship over the years. So, being able to do the scopes is really satisfying to just have – I like Friday my day. So, doing the same thing all the time gets a little bit boring, but being able to do the procedures and see patients and talking with them rounds it out. Yeah, completely agree. So, as I was talking to some of you about it yesterday at lunch, so we're all internists at heart, because we all do internal medicine training before we subspecialize in GI, so we really like that balance of we're still internists, but we get that hands-on gratification of doing procedures and, you know, seeing those physical changes that help our patients. So, that's very rewarding for all of us. Yeah, I mean, pretty much the same. I came from – I was an old engineer converted to a physician. So, you know, I saw corporate world and all that, but I really enjoyed the patient interaction, the human touch, and I think that's what draws most of us to go into medicine and being able to help people. But, yes, there's, you know, certainly distractions that have happened in the healthcare industry in general, but I think day in, day in and out, like, it's still the same, and that's what allows us to come back every day, because it's your patients, it's your, you know, seeing the benefit that you can provide them, and you really do make amazing long-term relationships with these patients. You see them very sick or having a lot of other symptoms in a good place where you're seeing them once a year, and they actually get sad when you tell them, I don't need to see you that frequently, and they're like, oh, but I enjoy coming and talking with you, and it's more of a social visit at that point. So, that's also psychologically important for them. So, there's many, you know, nuances to that visit, and you see them, like, hit milestones like marriage, babies, you know, other family, you know, changes. So, it's great, you know, to be part of their life in that regard, and you have a very unique kind of role in that. So, that I think is what drives us to keep doing it. I was going to chime in. Oh, sorry, Laura. It's so awkward. But anyway, thank you first for asking that question. I think that's such an important question and so relevant to kind of challenges that we face every day. And I will say for my own personal experience, I mean, many of us that went into GI, and we really liked internal medicine, but we also like surgery, we like doing, we like doing procedures. And this is somewhat of the perfect balance and the perfect marriage of those two things. You get to do a lot of procedures and also kind of use your mind in the internal medicine setting. I have been so incredibly lucky for the past, like, 24 years to be in the EOE space and to work on this particular disease process and help people swallow. Like, eating is so important to people. It's such a day-to-day part of life. And when patients can't eat and they're sick, it is very, very difficult. And it's been incredibly rewarding to be part of that journey with them. And even though some of us didn't like internal medicine in terms of that day-to-day clinic and this gives us the possibility of doing all these different things, the one really rewarding thing is watching patients kind of evolve over time. Like, I'll give you an example of one of my patients who came to us when he was 15 and watching him grow up. And then him going to college, him asking me for letters of recommendation to law school. He's now graduated from law school. He's gotten married. He has children. His children are being seen at Lurie with EOE. But just watching that whole kind of pathway and being able to help them through that process has been remarkable. Medicine has changed a lot significantly over the years, and there are a lot of different challenges that we're facing. I think if we can try to keep our minds on kind of that north star of what guides us in terms of the importance of what we're doing and who we're treating and the patients, then that allows us to sustain all the noise with the, you know, other bad stuff that happens around us. Not to be negative, but maybe we should talk about maybe some of the negative parts of our job. I would say one of them, so I'm in the IBD space and we've used biologics for years, but I've noticed in the past few years it's honestly getting a little more difficult in terms of having the other player in the room is the insurance company and what they'll pay for. So I guess what I've been seeing is unfortunately the process to get medications approved is a process that does not happen overnight. And we have insurances sort of dictating what a patient should get, unfortunately, to the point I've actually had to have two court hearings with a judge to actually get biologic therapy approved. So it's getting more difficult. So that is a frustrating part because it's just adding more to the burden and just delaying care overall for our patients. I agree. I mean, that's the biggest challenge and the time, right? Like just because it's denied, then my assistant is on the phone trying to figure out why was it denied. We don't get communication, these types of things. So it's paperwork. It's phone calls. It's appeals. And, of course, the patient's messaging in the meantime. What do I do? So it's challenging. But I think, you know, I think I can speak to that. We're blessed. We have a little bit more support in larger institutes. But if you're in a small community-based practice, what I have seen trends, at least in our area, is that people will just stop taking care of those diseases because it's too much for their practice to handle, or they don't have the resources, you know, as readily available, or they choose not to, you know, be bothered by it anymore. So they are letting go of taking care of inflammatory bowel disease. It's like a huge dropout rate. And now the, you know, referral centers are getting burdened by increase in referrals. And, you know, you only have so much time that you can keep trying to capture all of those patients. So it is a big issue, and our societies are doing a lot to support us. But, you know, in a one- or two-doc clinic, that may not be a great place, and you're losing that local community doctor in all of this. One thing I noticed just, like, a week or two ago, I have a really major pediatric clinic in my area. And, like, with the insurance piece, like, I guess with the prior auths, they look at everything the same. And so they're not really taking into consideration, I don't think, the different ways that EOE presents in children. And so they're getting denied, denied, denied, denied. So I'm just like, how can I help them as, you know, in my role to try to get – because there's, like, patients that are not thriving at all. Like, they're not able to gain weight. And, like, they're documenting all of these things. But I don't think the insurance has the clinical mindset to, like, piece together that, yeah, they are experiencing dysphagia, but they didn't write dysphagia in big, bold letters. So it's just kind of interesting. And I was just curious if you guys had any advice or feedback in situations like that to kind of work through that. Yeah. I mean, so we do – you're bringing up a good point. We have to bring – we have to be very thoughtful about how we do our clinical documentation to make sure that the insurance can see exactly what the symptomatology is and the severity of it and what our clinical reasoning for it is. Even when they see that often, it doesn't fit into whatever their predefined tiered system is. Yeah. So you have to fail A before you can go to B. You have to fail B before you're going to C, even with simple meds like proton pump inhibitors. You may have to fail two of them before I can get the other one that really is the one that's stronger milligram for milligram that I need. So this is a ubiquitous issue within classes and between classes of medications. So it really – it's a joint system, right? The physician has to document. The staff has to help with the phone calls that Dr. Mather was talking about. It's a lot of back and forth. We write letters. Sometimes you have to do these court cases. There's peer-to-peers where we speak with the physician directly, the physician who's seeing the patient and the physician at the insurance company. But it's a really complex web to navigate. It's so complex. So there isn't, you know, a great answer to it. So we just have to – we kind of do the best we can. We also – so some of our GI societies we actually meet – we got to go last year actually where we met with Congress so that we can try to adjust. There are certain pathways that are being promoted to try to adjust the tier systems that are used with insurance companies. So there are some changes that can be done on the governmental level. But right now, being in the weeds of it, it's very challenging. So what you're seeing is unfortunately a pretty common scenario. I think you're seeing that in pediatric more now because this is a newer indication. And I feel like any new drug, the reality is one year turnaround. And then you start seeing a little bit more approvals. But, I mean, I can only say that from experience. When I talk to a patient, I always tell them we'll submit to insurance, but it's going to get denied. Expectations. Because, yeah, it commonly does for various reasons. I've noticed in the IBD space and from insurance, so I am careful in documentation. So, you know, in terms of insurance, I really look at those sort of FDA guidelines for the medications I have to document. In my note, I'm very specific. Moderate to severe Crohn's with active symptoms has failed XYZ. And so it's in there. So that is, like, basic. So your documentation has to be sort of on point. Insurance, they change their game all the time. So it's hard to know, like, what they're doing. So I've noticed these days, you know, we used to be able to do a peer-to-peer and actually talk with a GI doctor. But now they get sent to, like, an internist who doesn't even know about the drug or prescribe the drug. And, honestly, what they do is they read from the script. And I'm like, this does not help me. And so it is trying to figure, you know, stay on top of what insurance is requiring. And, unfortunately, there are multiple plans, and there's no uniformity. So it's really a difficult sort of field to navigate. And once you feel like you have it, then they change the game. It's fun. I think one good point that Dr. Yoon brought up is, like, getting a board-certified gastroenterologist to be on the other line if you're going for an appeal. So that's my minimum stipulation. If you're going to put me on a phone call, take me away from clinical care, you need to at least have a board-certified GI doctor on the other line. I'm not talking to anybody else. So I think once I started doing that, my approval rate is higher. Awesome. I just wanted to add something else to what is being said. I think the documentation piece is really, really critical. And so for all of our notes, just like Dr. Yoon was saying, in terms of IBD, they have all sorts of scoring tools and things like that that are built into their notes. We try to do the same for our EOE patients in terms of every note, documenting the severity of their dysphagia, their endoscopic reference score, what their eosinophil counts were, what treatments they were on in the last several endoscopies. So our notes have all of that built in, and I think that's also helped us in terms of getting some of those approvals. But I want to also stress, I mean, one thing that we haven't talked about, that we've talked about in previous sessions, in terms of our day in the life and what we actually do and the time that we spend on everything. And that might be helpful to kind of put in context how little time we have to do all these other things. So if you think about an average week, and I'll just use me as an example and everyone else can chime in. So Monday, I'm in endoscopies all day, so I do about 16 procedures a day. And then Tuesdays, I'm in clinics, so we'll do about 30 patients that day. Wednesday, I'm doing endoscopy for half of the day, so another eight procedures. And then Thursday is an extra clinic, patients that can't come in on Tuesday, we do then. And then the rest of the time is speckled with like academics and a lot of research and some research meetings. But in between all those times, we're giving patients all their results. We're finishing spending two to three hours on our clinic notes after being in clinic. Resulting takes at least like two to three hours when you're sending messages to patients. And then on top of that, you're doing all this paperwork for the insurance and prior authorizations and trying to fill this in. So it's an awful lot. So the more templated notes that your office has to help streamline this, having specialty pharmacies to help streamline this, it's helpful. But smaller practices, I mean, this is a really big challenge. How do you all feel about that kind of workflow in terms of your week to week? Yeah, we'll just finish this topic and we'll take your question in just a minute. So pretty similar as far as the volume. For me, I'm more general and not as research heavy as Dr. Gonsalves. So my day is similar. It's usually full day endoscopy or full day clinic just depending on the day of the week. Or I'll have half day endoscopy and half day clinic. I also do our educational side. So we'll do fellows, continuity clinic, teaching endoscopy, other things, giving lectures to like residents or fellows. That's all during lunch where we're eating and talking and working at the same time. And then all of that, like I completely agree, it's like the amount of time to close a note to result, you know, a result back to the patient, the pathology that you're obtaining from those 16 colonoscopies that you did. And what if something is abnormal? Then you have to talk to the pathologist. You have to coordinate care with other specialists. And that takes, you know, more time than just a routine result. And then we have the advent of EHR. So our patients have access to us in a lot of ways. So we also are like bombarded with lots of like portal messages. Some, you know, you can train your assistants to help you and quick like refill. Those are simple. But a lot of it comes from us. Like they need advice. They need to know what's working. So sometimes, you know, we are also addressing that simultaneously. So there really isn't a lot of time to do what is necessary to appeal. Yeah, that's it. But the, so Dr. Goncalves, I was saying too, so you can hear, was that, you know, you shared that about 78% of the patients with EUV have some sort of overlapping atopic conditions. And looking to the future with, you know, IL-13 products, anti-TSLP and others, you know, we're learning that, you know, some of those work in AD but not in asthma and asthma but not in AD. So what is it telling us about, you know, what cytokines are most important? And how are you thinking through that, you know, to the future when, you know, which products to choose and are you looking at the patient holistically with those overlapping conditions and how those products might help? Yeah, I mean, I think that's a really, really good question. I mean, I think when we look at our patients and we talk about these various treatment options, we are looking at that individual in terms of what additional things do they have, right? What type of atopic conditions do they have? Are they atopic? What does their esophagus look like and what are their symptoms? And then based on that, that's when we try to piece together what might be the best type of treatment plan and kind of come up with that together. I think as you've pointed out, there's lots of other targets in terms of this whole immune pathway. And we know that it's very, the Th2 immune pathway is very important in terms of EOE, but there are a lot of other points to this. And whether or not one direction of this pathway is going to be more beneficial for someone with a fibrotic disease, for instance, maybe one of this direction of the pathway is going to be more important for someone with that mixed inflammatory phenotype. I think we're going to learn more and more about these different directions as we get more data from these clinical trials, as we follow patients moving forward on these clinical trials. I think this is, you know, we steal a lot from IBD. We steal a lot from allergy in our EOE space. But, you know, when we think about IBD, there's not just one biologic. There's a ton of biologics because they're coming at it from different pathways. And I think we're going to see the same thing in EOE. And I think it'll be very important to kind of truly understand, for instance, who are the patients that may be failing dupilumab? I mean, who are the patients that may be failing some of these other clinical trial medications? I think that is the most important thing. Yes, it's great when they respond. But who are the people that aren't responding and why and understanding the mechanisms? Because then I think we can better address which treatment might be better for them. There are some data that I'm sure you know about in terms of the clinical trials that there are certain pathologic mechanisms that still persist despite eosinophils being gone. And maybe thinking about like who is still having that basal zone hyperplasia and why that's still progressing will be helpful to understand your question. But we do all think about people holistically from the standpoint of which treatment might be best for them. Right, so speaking in the IBD space, so we see patients, again, with GI issues, Crohn's and ulcerative colitis, but they can have what we say these extra intestinal manifestations, which are more common in our patients with inflammatory bowel disease, such as psoriasis, rheumatoid arthritis, and multiple sclerosis. So it's very interesting. I think we had a little bit of conversation with some of you in terms of what makes a patient with Crohn's or UC have these extra intestinal manifestations? Why do some people do and some people don't? Again, what is that mechanism? We're not 100% sure, but we have drugs that are approved actually for Crohn's as well as multiple sclerosis. It sounds sort of crazy, but they work for both FDA approved. So when we're evaluating patients, we do take that history, we want to get a whole global view. Do they have psoriasis, rheumatoid arthritis? Do they have multiple sclerosis? Because if they have multiple sclerosis, we can't prescribe a TNF, but we can prescribe Ozanabod. So it's just, we look at the whole picture. We don't totally understand it. And part of it, I think, is for drug development, you know, we have a whole group of patients just with Crohn's, but in terms of Crohn's and ulcerative colitis, there are probably a lot of little subtypes, and then finding those patients only with joint disease, you know, when we do these trials, we group everyone together, but we probably should look at these sort of subtypes too to see what drives their inflammation. Maybe it's a little bit different than someone with eye manifestations. So I don't think we've done enough research in terms of subtyping, at least in IBD, patients with Crohn's with different sort of manifestations. We sort of group them all together. So I think in terms of research in the future, looking at these various subtypes would be helpful. Hi, I have more of a comment than a question, and I just wanted to add to Kelsey's question earlier about the pediatric practice. I think this issue, it brings home some of our partnership between industry and providers, is we in this room are really focused on EOE, and our physician colleagues here with us are pretty specialized in what they do, but a majority of practices that we call on are community practices. They're GI generalists, and I think this is the value that we can bring is that we can be up to date on the latest research and the papers that are coming out, the new guidelines that are coming out. This is the biggest defense that providers can have to go against an insurance company or really have the data to say, this is what the experts are saying. This is what is the right thing to do for our patients, and when we can help our providers be armed with the information, the most up-to-date information, this is where we bring value, and this is how we work together with providers. Thank you. I love her passion. I would totally agree on it, so I've worked with different MSLs, and it's been nice because they go out to the major conferences. They dig through all the abstracts, and they often come to me, and we go through together and talk about some of the interesting abstracts that will change our practice or we can use for insurance to get approval for meds. Often in IBD, we often use above dosing of the FDA approved, so we're always looking for more data to support these different decisions we make, so it is a very helpful sort of interaction, collaboration with industry in that aspect, and also just helping deliver meds to our patients with the patient assistance programs, the nursing support in terms of the education. It takes a village to support these patients and get them started on therapy. An excellent point. So I think I wanted to propose a question for the panel because I've done this before, and it hasn't been brought up, but maybe we'll use that as a segue. How would you like to have the representative from the company interact with you? Because I think some of them from meeting with you guys, some of them are new. Some of them have been doing this for a while, and we all, I think, interact with industry. So what is, I guess, an ideal relationship or communication that you're looking for? Yeah, so one thing that's important for me, especially as a junior faculty, is the relationship with the MSLs in terms of what Dr. Yoon was talking about as well, bringing some of the new studies, new abstracts, new literature to us. That really helps me. So you can advocate for patients by helping me stay up to date on things. So that's really useful. As you've heard, our time is very valuable to us, right? So the 7.30 to 5 p.m. workday, that's when all of the patients are there that we're talking about clinic time as well as endoscopy time. And it's in between in those few minutes that we're trying to fit in everything else. So being able to make sure if we're scheduling meetings or contacting over email, just thoughtful about just like you're busy, we're busy too. So the interactions we do have, we wanna be very valuable. And so even if we're meeting with you for five, 10 minutes, if we can get to the core of what's gonna help our patients, that's gonna be a fruitful discussion for us. I agree. At Northwestern, we're lucky in that we do have a dedicated sort of research time or conference time where we meet once a week. And so we will bring in people during that time period. Like I said, we've had a lot of new drugs come out on the market recently. And so we need to get educated. We need these relationships to figure out sort of the process in terms of what they're saying about insurance. And we have contacts with everyone, getting samples of medications for our patients. So it is a two-way street. We do wanna interact with you. Sometimes for us, it helps to have this sort of dedicated time where we bring in people once a week. So I would add to that. I think Laura, you guys have that very unique situation in the IBD space and the GI clinic in general. They tend to be closed to the pharmaceutical refs. Like people just can't pop in. I think what's been talked about in these sessions in the past are really like focused on dedicated snippets of time, like five to 10 minutes, whether or not it's email and get five to 10 minutes on our schedule or like an in-person five to 10 minutes, really keeping things very short. I think the relationship is so, so very important. And I think you all provide such wonderful information to us and vice versa, but really utilizing that time very mindfully just because we don't have a lot of extra time. The other piece of advice I would have to use also, spend a little bit of time getting to know the person that you're going to be meeting and making sure that you know them well, because I remember a situation where someone tried to come chat with me and very delightful person, but they were giving me all this data and information and trying to talk to me about a paper. And I was the first author on the paper. And I was just like, oh my, okay, thank you very much. So just basically just know who you're going to talk to. I would be mortified. I was a little mortified. Excellent point. Yeah, I think our institute is similar where we have a good working relationship. We have a large IBD center too. So kind of, we're used to working with industry, but I agree like a quick email or an arranging of time, like when is she free with my assistant, like where I can just like drop by or even drop the article and then follow up with a meeting later, things like that are more effective than just hang out in the break room waiting for somebody to show up. And we keep talking about how a lot in the EOE world has been stolen from Dr. Huynh's IBD world. We're trying to kind of mimic them. So another way you can bridge is to try to help practices, whether they're academic or community, to have those esophageal folks or whoever's seeing the EOE patients to help them learn from the IBD groups, because that's going to be critical, especially the nursing staff, the nurses that are going to be helping with dupilumab can train with the IBD nurses. So when you're coming in, if there's a way that you can connect those groups in the practices, that will help us learn since the IBD folks know a lot more about it. And it's been a longer running course for them. So we can learn from them too, if you can connect that as well. So I appreciate everybody's advice and guidance on all this. And I had a question. One of the biggest lifts that I feel we've got is helping our providers navigate this shift and how they manage this disease. It's not related to drug or therapy, but simple things like I was shocked at the resistance to bringing patients back to re-scope and assess for efficacy and everything, especially as gastroenterologists, heavily procedure-based. There's a lot of pushback on that. And I don't know if you had any tips that we might be able to take back to the field to help them kind of migrate to manage this disease properly versus just treating it hands-off, they're feeling fine. What are they telling you are the main reasons for not doing the follow-up? I don't have time, space in my schedule and insurance is not gonna pay for the procedures. Okay, so there's multiple layers. So one is an educational piece. There's clear data that shows the discordance between symptom response and histologic response. So part of it could be printing out those articles maybe and giving them to the community docs to show them that that symptom response is not adequate. Another part of it, time is always an issue, right? No matter whether it's academic or community practice. And certainly it's important to do a careful esophageal exam but once you've done enough endoscopies and have seen the features of EOE enough, you can really learn to target those biopsies pretty efficiently. So if they haven't enough of a patient flow with EOE, they should be able to hopefully fit that into their practice. But that's a logistical issue that depends on each individual practice. So and then the insurance question, so I haven't had an issue with that. So insurance should be covering follow-up endoscopies. I've never had an issue with that and I would presume it should be the same in community practices. So that's something that likely they can be reassured on but that's not gonna be an issue because it's in guidelines. Sure. I've never had a problem with that coverage either and we do a ton of scopes as you know from diet and whatnot but we always fall back on those guidelines. So if there was ever a concern from an insurance standpoint, there's three different guidelines that you can say and point to that this is standard of care. The other flip side is I know you're saying that the physicians are the ones that are saying that patients are feeling fine and they don't have room in their schedule. The other flip side and the pushback is patients themselves don't wanna come back for an endoscopy. So they feel great, procedures might be expensive for them because whether or not insurance will cover they have a large co-pay. So my own patients sometimes won't come back for a follow-up endoscopy and then we just have to follow them in clinic very, very closely and query them on their symptoms but a lot of it is also kind of patient driven from a cost standpoint unfortunately. Yeah, that's exactly what I was gonna add is I have not had any denials but I will say that insurance is getting worse with even approving, especially EGDs have had a higher rate of denial just even for reflux. Have they been on PPI for like eight weeks before you're doing an EGD? I mean, that's not appropriate, right? So yes, I think having the guidelines like Dr. Gonsalves said is very important but I have never had a denial for EOE. You had to appeal then you could get it. Last thing I was gonna say is follow-up. So I don't always just diagnose them and take them to a follow-up EGD like three, four months later because you will lose some of those patients especially sometimes you're meeting them in the ER, you don't have a relationship. So I tend to schedule a follow-up soon after initiating therapy just to check in with the patient, make sure like they're understanding the diagnosis, they're understanding how this disease works and why we're doing the future steps that we will be recommending. So I kind of lay out the plan for the next one year and how this will work at that follow-up meeting and I think then you get better compliance. Sure. It's interesting. So in the IBD space, so I don't know if it's maybe an education among physicians but so I've been in the IBD space a while now and so within the space and different disease states there's various themes. I feel you get presented over the years. So one of them in our field is what we call mucosal healing. So we know there is a disconnect in terms of patients' symptoms and inflammation and so I think most of our GI physicians understand and we do know that if a patient able to heal their mucosa their chance of flaring in the future is decreased. And also I always tell patients too is that when the colon's inflamed it's hard to look for other things like polyps and cancer because it can be so inflamed, it just obscures everything. And so they're pretty willing and ready to get a colonoscopy and also they like to see like is it back to normal or not? You know, so I guess in the IBD space I think part of it is education among physicians that this is sort of standard now. So after you start a therapy six months after, roughly six months to a year depending, we routinely do scopes even if a patient feels well to evaluate for mucosal healing. So I don't know if it's just maybe evolution or education. So I can tell you what some of my physicians have told me specifically with that. We've tried for about two and a half years to correlate the two IBD patients and EOE inflammation in the GI tract, right? Like why wouldn't you just treat it the same? And my, I guess objections that I hear from the physicians are the stakes are higher in the colon and if untreated inflammation leads to cancer, leads to death in the colon. That is not the situation in the esophagus. Nothing has been proven to be that way. So therefore they take that kind of as like a pass to treat it with a less, a little bit more, a little less aggressive I should say. I think that's education. We're learning. This is a younger diagnosis within the field of GI and it's gonna take time to bridge that gap for folks who are just slower to adopt a new guidelines. But I mean, I think I look at it like, well, looking at esophageal disorders, you have Barrett's and those are the same doctors who are following guidelines today, at least I would hope so. And they're bringing patients back every one, three, you know, whatever it might be years. So they are doing it for a asymptomatic disease, but they know, yes, there may be a cancerous risk because I think they're wanting to, by what you're saying, they may want, be willing to bring those back more frequently, but, you know, same thing should be applied to these patients. Barrett's is the one thing they take seriously in the AGE. But it took time. Barrett's guidelines have been adopting and changing for a while. Yeah. And here we are 60 days out from ACG. Can, I think Dr. Goncalves, you're part of these new guidelines that are coming out. And I'm so sorry. I mean, three maybe as well. Can you allude to any sort of new updates that may be released or any changes, even just like a mild, moderate, severe scenario being in there? Yeah. I mean, I think it's very timely that these guidelines are going to be coming out. The old ACG guidelines were over 10 years old. So there's a lot of updates, a lot of things relevant to new approved medications. There's a lot of clinical scenarios in there in terms of patient severity, like you're talking about. So I think that'll be very helpful for the general GI community to read through and understand. And I think it's in a much more, no pun intended by digestible format in terms of having these clinical scenarios and recommendations. And it is all evidence-based as well. I think one of the things that you point out and is the difference between EOE and IBD. I think they're more similar than they are different, but there's years and years of information knowing that colonic inflammation can lead to colon cancer and dysplasia. And therefore there's regular surveillance for these patients. In a lot of the prior trials with IBD, mucosal healing was a very important part of this. There's a lot of push right now in the EOE community in terms of research and thinking about different endpoints on the same thing in terms of mucosal healing, which will hopefully change things. Very excited, cannot wait. Thank you. So we have five minutes left. So a couple more questions and then we'll be moving on to lunch. I have a quick question if you guys can hear me. I'm regarding endoscopy. Do you guys utilize a washout period when you're assessing EOE? And is that helpful to assess the severity, the esophagus from PPIs and steroids? Do you wanna start Dr. Gonsalves? Dr. Gonsalves with that one. Okay, if I can understand the question, you're asking about a washout period. So, I mean, I guess I can throw that question back towards you. I mean, are you asking if someone was on a topical corticosteroid or a PPI, do you stop their medications and then have them come back for a true baseline? Yes, so on re-scoping, do you have them go off of their PPIs or steroids and then have them come back for a true baseline? Yes, so on re-scoping, is that helpful or does that matter? That's something in my territory, a lot of physicians have been curious about. Are you saying if they're diagnosed in another institution and then come to you on therapy? Mm-hmm. Okay. So, yeah, I mean, I will say if someone has come to me and we have, I'm sure just like many of our panelists, we have patients come from all sorts of different institutions who have been previously diagnosed and I can't really take them off their therapies and repeat their endoscopy because of that washout, I will go back and re-look at their prior endoscopy reports and try to get a sense of what's going on there. The one caveat I would say is that if someone came to me and I had some question on whether or not this eosinophilic signature in their esophagus was truly reflux and not this primary allergic EOE, then in some cases I will stop their PPI and I'll do a baseline endoscopy on them. But for the most part, no, I don't take them off of all therapy and then repeat a baseline on them unless I have any question about that initial diagnosis. And when I question that is when I look back at that initial report and they will comment on LAC-grade erosive esophagitis, they have a four-centimeter hiatal hernia, they have some furrowing and edema in the lower part of the esophagus, high eosinophils in that lower part of the esophagus, that patient probably has reflux. They probably don't have EOE. So that's when I would really kind of hone in on that diagnosis. But if you're thinking about a washout period for whatever reason, typically what I would do is for PPIs, I would wash them out for about two months. The topical corticosteroids based on clinical trials, we'd wash out for about six to eight weeks. Foods, if they've had exposure, they would do a washout for about six weeks. Yeah, our practice is the same. And as I mentioned earlier, a lot of it is streamlining therapy. So not peeling off completely for a washout, but they come to me on three different type therapies, PPI part, some topical steroids, some diet elimination. And I have to wean down and objectively examine what's going on with the therapy that the patient I discuss is gonna be the initial therapy. Thank you.

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