In the United States, about 1.4 million individuals have Inflammatory Bowel Disease. BMC provides expert care in helping patients with Crohn's or Ulcerative Colitis manage their complex disease.
Dr. Francis Farraye and Dr. Jason Hall discuss living with IBD, treatment options available, and how they work together to provide the best possible medical and surgical care for patients with any form of IBD.
Selected Podcast
IBD Management and Care
Featured Speaker:
Learn more about Jason Hall, MD
Francis Farraye, MD clinical interests are in the care of patients with inflammatory bowel disease and the management of colon polyps and colorectal cancer. He is studying Vitamin D absorption in patients with IBD, the management and diagnosis of dysplasia and cancer in patients with IBD, and predictors of pouchitis after ileal pouch-anal anastomosis (IPAA).
Jason Hall, MD, MPH and Francis Farraye MD, MSc
Jason Hall, MD is an accomplished surgeon with expertise in colon and rectal surgery. Hall is board certified by the American Board of Surgery and the American Board of Colon and Rectal Surgery and received fellowships from the American College of Surgeons and the American Society of Colon and Rectal Surgery (ASCRS).Learn more about Jason Hall, MD
Francis Farraye, MD clinical interests are in the care of patients with inflammatory bowel disease and the management of colon polyps and colorectal cancer. He is studying Vitamin D absorption in patients with IBD, the management and diagnosis of dysplasia and cancer in patients with IBD, and predictors of pouchitis after ileal pouch-anal anastomosis (IPAA).
Transcription:
IBD Management and Care
Melanie Cole (Host): Welcome. Our topic today, is inflammatory bowel disease which can affect up to one and a half million people in the United States. My guests are Dr. Jason Hall, he’s the Chief of Colorectal Surgery and Dr. Francis Farraye, he’s the Clinical Director of Gastroenterology and they are both at Boston Medical Center. Welcome to the show gentlemen. So, Dr. Hall, I’d like to start with you. Please explain what is inflammatory bowel disease and how are Crohn’s and ulcerative colitis, how do they fit into this umbrella?
Jason Hall, MD, MPH (Guest): Well first of all I would like to thank you for having us both here on the podcast this morning. It’s a real opportunity to tell folks about what we do and the services we can provide to patients with inflammatory bowel disease as well as a variety of other conditions including colorectal cancer and diverticulitis. Inflammatory bowel disease is composed of a couple of conditions or actually more than a couple of conditions, but all of these conditions are autoimmune conditions where the body essentially attacks the gastrointestinal tract. And we don’t understand exactly why that happens, but it is quite prevalent in our society. Ulcerative colitis is an inflammatory disease that usually we think of as being restricted to the colon or the large intestine. Whereas Crohn’s disease can affect any part of the GI tract from the mouth all the way down to the anus. It’s my personal belief that in 150 years we will probably figure out that both of these diseases are the same disease and just represent a different spectrum. But we aren’t quite there yet and there are some differences in the way we treat Crohn’s and ulcerative colitis.
Melanie: Dr. Farraye, have you been seeing a rise in these autoimmune diseases and I’m just asking for your opinion here; do you have an opinion on if we are seeing a rise why that might be?
Francis Farraye, MD, MSc (Guest): Well despite many theories, the causes for Crohn’s disease and ulcerative colitis remain unknown. I want to point out to the listeners that these diseases are not contagious. You really can’t catch it from a friend, family member or acquaintance. And we think that a combination of familial issues like genetics as well as exposure to something in the environment are associated with the development of both ulcerative colitis and Crohn’s disease. Some of these include smoking, the use of nonsteroidals, where you live in the world, and the presence or absence of intestinal infections. It’s a very important question that you asked. I like to point out that we have seen an increase in both the incidence of ulcerative colitis and Crohn’s disease over the last twenty or thirty years. Genetics don’t change that fast, so therefore, it has to be something in our environment and there are a number of different theories, none of which have been completely supported at this point. I do want to point out that both these diseases affect young individuals. The majority of people with ulcerative colitis and Crohn’s disease are diagnosed before the age of 35, though you can develop it at any age and this disorder or these disorders affect both men and women.
Melanie: Dr. Farraye, I’m going to stick with you for a minute. As long as you are talking about both of these diseases and who is at risk; what are some of the symptoms that people might experience that would even alert them to go see a gastroenterologist to get checked out?
Dr. Farraye: The symptoms of ulcerative colitis are typically the development of diarrhea that becomes bloody and most people who develop blood in the stools realize that that’s not normal and they will seek out their primary care doctor who will probably send them to a gastroenterologist for further evaluation. Patients with Crohn’s disease the symptoms can be more subtle. It can be nonspecific abdominal pain, looser stools, perhaps some weight loss and I think we will have the opportunity to talk about irritable bowel syndrome and how that differs from ulcerative colitis and Crohn’s disease. Now both of these disorders are systemic disorders. What that means is that it involves the entire body, so in addition to the gastrointestinal symptoms that I just mentioned; you can have arthritis, swollen joints, pain in the joints, skin rashes, ulcers in the mouth, eye problems, liver problems. So, this truly is a disease that affects the entire body and many different symptoms can lead to the initial diagnosis of ulcerative colitis and Crohn’s disease.
Melanie: Dr. Hall, why don’t you speak to us about how it’s diagnosed?
Dr. Hall: Well, as Dr. Farraye just mentioned, most folks who develop concerning symptoms such as diarrhea or bloody diarrhea or abdominal pain usually will present to their primary care doctor who will do an initial battery of tests maybe involving some blood tests and then typically if the symptoms are concerning, refer them to a gastroenterologist or a colorectal surgeon depending on what their symptoms are. If they are referred to me, I’m a colorectal surgeon; many of those symptoms tend to involve symptoms that present around the anus such as abscesses or pain or diarrhea and usually they evaluation would constitute something like a colonoscopy or a flexible sigmoidoscopy which is an examination of the left side of the colon or sometimes if they have an abscess or infection, and exam under anesthesia and drainage of the abscess. If they were to see a gastroenterologist, there are again a variety of tests they might order. One of the more common ones that they might perform themselves is a colonoscopy which is a complete examination of the colon, a CT or MRI enterography which are ways of getting imaging of the small bowel and a variety of other blood tests that can either help confirm or strengthen our idea about what the diagnosis is.
Melanie: And Dr. Hall, just kind of answer the question that Dr. Farraye mentioned about the difference between IBS. People have heard about this in the media. You see it on commercials. What is the difference between irritable bowel syndrome and inflammatory bowel disease?
Dr. Hall: Well the difference is that irritable bowel syndrome is really a diagnosis of exclusion. These are typically patients who present with alternating diarrhea and constipation. They could have either one of those predominate but usually they have both to some degree and it’s often set off by anxiety or a bunch of other things that we don’t understand. But you have to have ruled out a number of other things before you can say that somebody has irritable bowel syndrome and there is a very strict set of criteria for how you make that diagnosis. Inflammatory bowel disease we can see definitive changes in the small bowel or large intestine or we can see extra intestinal manifestations as Dr. Farraye mentioned. So, again, irritable bowel syndrome is something that we would diagnose a patient with after we have excluded all other causes such as cancer or inflammatory bowel disease and they have to meet very strict criteria for it. Whereas inflammatory bowel disease is usually readily observed within the bowel or outside of it.
Dr. Farraye: I would like to add to Dr. Hall that we mentioned earlier that 1.6 million Americans have either ulcerative colitis or Crohn’s disease. Irritable bowel syndrome is extraordinarily common with 15% of the US population having symptoms of IBS. So, someone walking into your office with abdominal pain, bloating, gas and a change in bowel habits is more likely to have irritable bowel syndrome as opposed to inflammatory bowel disease. I mentioned earlier that IBD affects men and women equally, but IBS is much more common in women with 70% of people who have IBS being female as opposed to just 30% of men.
Dr. Hall: I would like to add to what Dr. Farraye just said. I find in my office that many people who have been diagnosed with IBS really have some dietary intolerances to certain types of foods and often that sort of thing is sorted out by just doing some intensive work with their diet. It’s not all of them, but it is fairly common.
Melanie: So, Dr. Farraye, tell us about the goals, main goals in medical treatment of inflammatory bowel disease and as I would love to do a whole separate segment on irritable bowel syndrome and its related things like stress and such; for this purpose, speak about the medical treatments that you might use once you have diagnosed someone with irritable – with inflammatory bowel disease. What are some of the main goals?
Dr. Farraye: So, there are a series of goals. The number one goal is to make the patient feel better. And so, we want our patient’s diarrhea to go away, their rectal bleeding to go away, if they have lost weight, or become anemic; we would like them to regain weight and their blood counts normalized. So, that’s called symptomatic remission. Patient’s symptoms go away, but in 2018, and over the past several years; we now realize there is a higher goal that we need to attain and that’s resolution of the inflammation. As Dr. Hall pointed out, we do a colonoscopy or a CAT scan or an MRI. We see an abnormality in the intestinal tract, their symptoms improve and then we need to do a repeat examination either a scope, perhaps a stool test, blood test, to show that the inflammatory process in their intestines has resolved. We believe that if we can make the inflammation go away, we can arrest the progression of the disease and avoid some of the complications that Dt. Hall has to operate on like abscesses and fistula and other complications that we see in ulcerative colitis and Crohn’s disease.
Melanie: Do the diseases ever go away Dr. Farraye?
Dr. Farraye: No, these diseases basically go into periods where they are active and then they go into remission. Our job as gastroenterologists and surgeons are to induce remission either surgically in some situations or medically and then once they are in remission; continue them on medicines and most people do need to stay on medicines to keep the disease from coming back. But unfortunately, for Crohn’s disease, it never does go away. Dr. Hall could potentially comment on what happens after we remove the colon in patients with ulcerative colitis, because if their colon is gone; they really can’t have ulcerative colitis but there are other consequences that they may develop after surgery for ulcerative colitis.
Dr. Hall: We always tell patients with Crohn’s disease that we can’t cure their disease with surgery, we can simply manage it. So, if they have a fistula or an abscess or an obstruction; those things can be ameliorated with surgery. But we always know that there’s a chance that the disease might flare again as Dr. Farraye just mentioned. Ulcerative colitis is a little bit different. Because if they have true phenotypic ulcerative colitis; we know that it’s going to be restricted to the colon and we can cure that by removing the colon. But there are consequences to that. So, in order to remove the colon, we have to have the stool exit the body somewhere and some people and many people it is possible to do an operation called a J-pouch where we remove the colon and then we make a new rectum out of the small intestine and we connect that to the anus. But that’s typically at minimum, two operations in order to accomplish that and at minimum it takes about six months to get over a big operation like that. Some people are not candidates for a J-pouch and then they would need to have something like a end-ileostomy which is a permanent bag. So, again, all of these folks are very, very happy after surgery. They do not have a recurrence of ulcerative colitis, but there are functional changes that they undergo because they have had to have a major operation or two in order to get over the condition.
Melanie: Dr. Farraye, I’d like to start with you in our summary today. If you could wrap it up for us with your best advice as a gastroenterologist, what you would like listeners to take away from this as far as treatment, lifestyle, and things that might even trigger their Crohn’s disease, just what would you like them to know about living with and managing these types of disorders?
Dr. Farraye: I think the first thing it’s important that we make a diagnosis. So, individuals with a change in bowel habits, blood in their stools, weight loss, or even some of the extra-intestinal manifestations that we mentioned like swollen joints, and funny skin rashes need to seek out their primary care provider who can then in the appropriate situation refer them to a gastroenterologist or colorectal surgeon to make a definitive diagnosis. That’s the first point. The second point is that in 2018, we have wonderful medications to treat ulcerative colitis and Crohn’s disease. We can really turn the disease around in as short as four to eight weeks in some individuals and put them back on the road to health. Again, it’s very important that you realize that colorectal surgeons and gastroenterologists work hand in hand to treat these patients in fact Dr. Hall and I sit in the same physical space several times a week so that a patient who is referred to him in which an issue comes up, he can just walk over to the other side of the hall and speak with me and vice versa, so these diseases are managed by both colorectal surgeons and gastroenterologists. It’s truly two is better than one in terms of managing of these folks and again, there are many, many different options both medically and surgically and it’s important that you don’t give up hope. We do work with other healthcare providers like dieticians, psychologists, gynecologists, dermatologists, to really offer one stop shopping for patients with ulcerative colitis and Crohn’s disease.
Melanie: And Dr. Hall, last word to you. Along those same lines, give us a wrap up as a surgeon what you would like the listeners to know and this comprehensive mode of care that you and Dr. Farraye have?
Dr. Hall: Well listen, I can’t emphasize more what Dr. Farraye just said. When a patient comes to Boston Medical Center, they should really expect this seamless continuity of care between the surgical service and our IBD specialists in gastroenterology. Whenever we are contemplating a decision about surgery; that decision never happens without a conversation with Dr. Farraye or some of his staff about whether there are any other medical options that can be pursued before we pursue something invasive like surgery. It’s fairly – it’s frequent that we can’t do anything more medically, in which case we have to pursue surgery. But we really, really try to work as a team in order to come up with the best decision for the patient.
Melanie: It has been such great information. Thank you, gentlemen, so much for joining us today and for sharing your expertise in this situation that so many people suffer from and clearing up some of the treatment options and diagnoses and how you work together. Thank you again for joining us. This is Boston Med Talks with Boston Medical Center. For more information you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.
IBD Management and Care
Melanie Cole (Host): Welcome. Our topic today, is inflammatory bowel disease which can affect up to one and a half million people in the United States. My guests are Dr. Jason Hall, he’s the Chief of Colorectal Surgery and Dr. Francis Farraye, he’s the Clinical Director of Gastroenterology and they are both at Boston Medical Center. Welcome to the show gentlemen. So, Dr. Hall, I’d like to start with you. Please explain what is inflammatory bowel disease and how are Crohn’s and ulcerative colitis, how do they fit into this umbrella?
Jason Hall, MD, MPH (Guest): Well first of all I would like to thank you for having us both here on the podcast this morning. It’s a real opportunity to tell folks about what we do and the services we can provide to patients with inflammatory bowel disease as well as a variety of other conditions including colorectal cancer and diverticulitis. Inflammatory bowel disease is composed of a couple of conditions or actually more than a couple of conditions, but all of these conditions are autoimmune conditions where the body essentially attacks the gastrointestinal tract. And we don’t understand exactly why that happens, but it is quite prevalent in our society. Ulcerative colitis is an inflammatory disease that usually we think of as being restricted to the colon or the large intestine. Whereas Crohn’s disease can affect any part of the GI tract from the mouth all the way down to the anus. It’s my personal belief that in 150 years we will probably figure out that both of these diseases are the same disease and just represent a different spectrum. But we aren’t quite there yet and there are some differences in the way we treat Crohn’s and ulcerative colitis.
Melanie: Dr. Farraye, have you been seeing a rise in these autoimmune diseases and I’m just asking for your opinion here; do you have an opinion on if we are seeing a rise why that might be?
Francis Farraye, MD, MSc (Guest): Well despite many theories, the causes for Crohn’s disease and ulcerative colitis remain unknown. I want to point out to the listeners that these diseases are not contagious. You really can’t catch it from a friend, family member or acquaintance. And we think that a combination of familial issues like genetics as well as exposure to something in the environment are associated with the development of both ulcerative colitis and Crohn’s disease. Some of these include smoking, the use of nonsteroidals, where you live in the world, and the presence or absence of intestinal infections. It’s a very important question that you asked. I like to point out that we have seen an increase in both the incidence of ulcerative colitis and Crohn’s disease over the last twenty or thirty years. Genetics don’t change that fast, so therefore, it has to be something in our environment and there are a number of different theories, none of which have been completely supported at this point. I do want to point out that both these diseases affect young individuals. The majority of people with ulcerative colitis and Crohn’s disease are diagnosed before the age of 35, though you can develop it at any age and this disorder or these disorders affect both men and women.
Melanie: Dr. Farraye, I’m going to stick with you for a minute. As long as you are talking about both of these diseases and who is at risk; what are some of the symptoms that people might experience that would even alert them to go see a gastroenterologist to get checked out?
Dr. Farraye: The symptoms of ulcerative colitis are typically the development of diarrhea that becomes bloody and most people who develop blood in the stools realize that that’s not normal and they will seek out their primary care doctor who will probably send them to a gastroenterologist for further evaluation. Patients with Crohn’s disease the symptoms can be more subtle. It can be nonspecific abdominal pain, looser stools, perhaps some weight loss and I think we will have the opportunity to talk about irritable bowel syndrome and how that differs from ulcerative colitis and Crohn’s disease. Now both of these disorders are systemic disorders. What that means is that it involves the entire body, so in addition to the gastrointestinal symptoms that I just mentioned; you can have arthritis, swollen joints, pain in the joints, skin rashes, ulcers in the mouth, eye problems, liver problems. So, this truly is a disease that affects the entire body and many different symptoms can lead to the initial diagnosis of ulcerative colitis and Crohn’s disease.
Melanie: Dr. Hall, why don’t you speak to us about how it’s diagnosed?
Dr. Hall: Well, as Dr. Farraye just mentioned, most folks who develop concerning symptoms such as diarrhea or bloody diarrhea or abdominal pain usually will present to their primary care doctor who will do an initial battery of tests maybe involving some blood tests and then typically if the symptoms are concerning, refer them to a gastroenterologist or a colorectal surgeon depending on what their symptoms are. If they are referred to me, I’m a colorectal surgeon; many of those symptoms tend to involve symptoms that present around the anus such as abscesses or pain or diarrhea and usually they evaluation would constitute something like a colonoscopy or a flexible sigmoidoscopy which is an examination of the left side of the colon or sometimes if they have an abscess or infection, and exam under anesthesia and drainage of the abscess. If they were to see a gastroenterologist, there are again a variety of tests they might order. One of the more common ones that they might perform themselves is a colonoscopy which is a complete examination of the colon, a CT or MRI enterography which are ways of getting imaging of the small bowel and a variety of other blood tests that can either help confirm or strengthen our idea about what the diagnosis is.
Melanie: And Dr. Hall, just kind of answer the question that Dr. Farraye mentioned about the difference between IBS. People have heard about this in the media. You see it on commercials. What is the difference between irritable bowel syndrome and inflammatory bowel disease?
Dr. Hall: Well the difference is that irritable bowel syndrome is really a diagnosis of exclusion. These are typically patients who present with alternating diarrhea and constipation. They could have either one of those predominate but usually they have both to some degree and it’s often set off by anxiety or a bunch of other things that we don’t understand. But you have to have ruled out a number of other things before you can say that somebody has irritable bowel syndrome and there is a very strict set of criteria for how you make that diagnosis. Inflammatory bowel disease we can see definitive changes in the small bowel or large intestine or we can see extra intestinal manifestations as Dr. Farraye mentioned. So, again, irritable bowel syndrome is something that we would diagnose a patient with after we have excluded all other causes such as cancer or inflammatory bowel disease and they have to meet very strict criteria for it. Whereas inflammatory bowel disease is usually readily observed within the bowel or outside of it.
Dr. Farraye: I would like to add to Dr. Hall that we mentioned earlier that 1.6 million Americans have either ulcerative colitis or Crohn’s disease. Irritable bowel syndrome is extraordinarily common with 15% of the US population having symptoms of IBS. So, someone walking into your office with abdominal pain, bloating, gas and a change in bowel habits is more likely to have irritable bowel syndrome as opposed to inflammatory bowel disease. I mentioned earlier that IBD affects men and women equally, but IBS is much more common in women with 70% of people who have IBS being female as opposed to just 30% of men.
Dr. Hall: I would like to add to what Dr. Farraye just said. I find in my office that many people who have been diagnosed with IBS really have some dietary intolerances to certain types of foods and often that sort of thing is sorted out by just doing some intensive work with their diet. It’s not all of them, but it is fairly common.
Melanie: So, Dr. Farraye, tell us about the goals, main goals in medical treatment of inflammatory bowel disease and as I would love to do a whole separate segment on irritable bowel syndrome and its related things like stress and such; for this purpose, speak about the medical treatments that you might use once you have diagnosed someone with irritable – with inflammatory bowel disease. What are some of the main goals?
Dr. Farraye: So, there are a series of goals. The number one goal is to make the patient feel better. And so, we want our patient’s diarrhea to go away, their rectal bleeding to go away, if they have lost weight, or become anemic; we would like them to regain weight and their blood counts normalized. So, that’s called symptomatic remission. Patient’s symptoms go away, but in 2018, and over the past several years; we now realize there is a higher goal that we need to attain and that’s resolution of the inflammation. As Dr. Hall pointed out, we do a colonoscopy or a CAT scan or an MRI. We see an abnormality in the intestinal tract, their symptoms improve and then we need to do a repeat examination either a scope, perhaps a stool test, blood test, to show that the inflammatory process in their intestines has resolved. We believe that if we can make the inflammation go away, we can arrest the progression of the disease and avoid some of the complications that Dt. Hall has to operate on like abscesses and fistula and other complications that we see in ulcerative colitis and Crohn’s disease.
Melanie: Do the diseases ever go away Dr. Farraye?
Dr. Farraye: No, these diseases basically go into periods where they are active and then they go into remission. Our job as gastroenterologists and surgeons are to induce remission either surgically in some situations or medically and then once they are in remission; continue them on medicines and most people do need to stay on medicines to keep the disease from coming back. But unfortunately, for Crohn’s disease, it never does go away. Dr. Hall could potentially comment on what happens after we remove the colon in patients with ulcerative colitis, because if their colon is gone; they really can’t have ulcerative colitis but there are other consequences that they may develop after surgery for ulcerative colitis.
Dr. Hall: We always tell patients with Crohn’s disease that we can’t cure their disease with surgery, we can simply manage it. So, if they have a fistula or an abscess or an obstruction; those things can be ameliorated with surgery. But we always know that there’s a chance that the disease might flare again as Dr. Farraye just mentioned. Ulcerative colitis is a little bit different. Because if they have true phenotypic ulcerative colitis; we know that it’s going to be restricted to the colon and we can cure that by removing the colon. But there are consequences to that. So, in order to remove the colon, we have to have the stool exit the body somewhere and some people and many people it is possible to do an operation called a J-pouch where we remove the colon and then we make a new rectum out of the small intestine and we connect that to the anus. But that’s typically at minimum, two operations in order to accomplish that and at minimum it takes about six months to get over a big operation like that. Some people are not candidates for a J-pouch and then they would need to have something like a end-ileostomy which is a permanent bag. So, again, all of these folks are very, very happy after surgery. They do not have a recurrence of ulcerative colitis, but there are functional changes that they undergo because they have had to have a major operation or two in order to get over the condition.
Melanie: Dr. Farraye, I’d like to start with you in our summary today. If you could wrap it up for us with your best advice as a gastroenterologist, what you would like listeners to take away from this as far as treatment, lifestyle, and things that might even trigger their Crohn’s disease, just what would you like them to know about living with and managing these types of disorders?
Dr. Farraye: I think the first thing it’s important that we make a diagnosis. So, individuals with a change in bowel habits, blood in their stools, weight loss, or even some of the extra-intestinal manifestations that we mentioned like swollen joints, and funny skin rashes need to seek out their primary care provider who can then in the appropriate situation refer them to a gastroenterologist or colorectal surgeon to make a definitive diagnosis. That’s the first point. The second point is that in 2018, we have wonderful medications to treat ulcerative colitis and Crohn’s disease. We can really turn the disease around in as short as four to eight weeks in some individuals and put them back on the road to health. Again, it’s very important that you realize that colorectal surgeons and gastroenterologists work hand in hand to treat these patients in fact Dr. Hall and I sit in the same physical space several times a week so that a patient who is referred to him in which an issue comes up, he can just walk over to the other side of the hall and speak with me and vice versa, so these diseases are managed by both colorectal surgeons and gastroenterologists. It’s truly two is better than one in terms of managing of these folks and again, there are many, many different options both medically and surgically and it’s important that you don’t give up hope. We do work with other healthcare providers like dieticians, psychologists, gynecologists, dermatologists, to really offer one stop shopping for patients with ulcerative colitis and Crohn’s disease.
Melanie: And Dr. Hall, last word to you. Along those same lines, give us a wrap up as a surgeon what you would like the listeners to know and this comprehensive mode of care that you and Dr. Farraye have?
Dr. Hall: Well listen, I can’t emphasize more what Dr. Farraye just said. When a patient comes to Boston Medical Center, they should really expect this seamless continuity of care between the surgical service and our IBD specialists in gastroenterology. Whenever we are contemplating a decision about surgery; that decision never happens without a conversation with Dr. Farraye or some of his staff about whether there are any other medical options that can be pursued before we pursue something invasive like surgery. It’s fairly – it’s frequent that we can’t do anything more medically, in which case we have to pursue surgery. But we really, really try to work as a team in order to come up with the best decision for the patient.
Melanie: It has been such great information. Thank you, gentlemen, so much for joining us today and for sharing your expertise in this situation that so many people suffer from and clearing up some of the treatment options and diagnoses and how you work together. Thank you again for joining us. This is Boston Med Talks with Boston Medical Center. For more information you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.