Okay, good morning. We're going to get started with our GreenRound presentation. And this morning, we have Ron Hobbs presenting. He's one of our Retina Fellows. He's the first-year fellow, and he's been so great to work with from a resident perspective. It's been really awesome. And I went to the mid-year forum recently and talked to some of the Oklahoma residents, and they shared with me that Ron was actually the chief chief last year, which he would be too humble to tell us, but apparently he was elected the chief of the chiefs when he was a resident. So it's a pleasure to hear from him today, and he's going to talk about what to present. It is so hard to pick. Talk a little bit about pick today. Thanks for having me. Wanted to post this picture. I love this picture. I think our own Jim from here took it. He was explaining it to me where he takes an underexposed and over-exposed picture and combines them with it on a tripod. One of the things that I was just blown away with when I came and interviewed here for fellowship was just the beauty of this building. It's a gorgeous building. It's a gorgeous backdrop. I think everyone who comes here is first blown away by that and then amazed by it once they get to see the great things that are happening inside the building, of course. I love that picture. And then quickly, financial disclosures. I have none, but this is where most of my finances go here. It's probably the Halloween costumes. So the patient is a 27-year-old female. One week before presenting to us, she said she started seeing shimmering lights in her left eye. And with that, she also described this spot kind of in the center of her vision in her left eye. She states that during that week that spot increased in size and she felt like the vision around the area of the spot was also dim in her central vision. She really denied any pain or erythema or other changes with the eye. Past medical history, she has a history of asthma and she has a history of migraines. In fact, the evening before we saw her, she was seen in the emergency department complaining of severe headache. She said she had tunnel vision at that point, dizziness, and she had difficulty speaking. So she was seen by neurology there. She had an MRI, which did show one small lesion in the right frontal lobe. It was questionable over whether or not that might be a small demyelinating lesion. She was given the migraine cocktail and her symptoms improved. So she was diagnosed at that point with a complicated migraine and sent home to follow up with us the next day. She had no surgical history. She does have a sister with keratoconus and she herself has mild myopia. She's a minus one and a quarter in each eye. As far as her review of systems goes, she about two weeks prior had an upper respiratory infection. And then she states that over the past month, she's been having a big increase in her migraines. She states she used to have about two to three migraines a month. And over the past month, it's been almost daily with a couple of times a week having nausea, vomiting, light sensitivity. Medications, she uses an albuterol inhaler as needed in Yasmin. And she says she was recently finished oral steroids for her upper respiratory infection given to her by her PCP. And then no known drug allergies. So when she presented to us visions good in both eyes, just 2015 in her right eye, 2020 in her left eye. And the remainder of her external exam is normal in both eyes. Her anterior segment examination also is within normal limits. There's no inflammation noted in either eye. And on her dilated funoscopic exam on her first appearance, there was questionable old rare cells in the anterior vitreous. Here's a picture of her right eye. It's kind of small, so I'll point out. There's a questionable little hypopigmented spot there that you see. Maybe another one right down here. Not very glaring when you first look at her right eye. Here's her left eye. Much more obvious here. You see a couple hypopigmented spots here, here, here. One up here if you look real close. So here they both are together. Obviously more involvement of the left eye. And this is the eye she's having her symptoms in. Here's infrared images. Infrared images are good at showing some subtle pigmentary changes that we might have a hard time seeing in color at this little amp. But these images of the right eye, you can see a little more impressive. Just a couple little pigmentary changes in the right eye. And then in the left eye, a similar picture with a couple more lesions that weren't quite so obvious on the color photos. And then funosodil fluorescence. Before describing this, I'll just run through it real quickly. Because I know this is kind of newer images that we're using. But the way I think of funosodil fluorescence is underneath the retina in the RP we have lipofluscin that deposits as a product of breakdown of the photoreceptor cells.  And that's kind of this light gray, this baseline hyper-autoflorescence. So things that don't have lipofluscin will have hypoautoflorescence such as the optic nerve, your arteries and veins. And just the way the phobia is set up, you don't get hyper-autoflorescence there because of the way the pigment is absorbed. So anytime you see hypoautoflorescence other than that, such as these spots here, those would be areas where you have RPE loss.  And then areas where you have increased hypoautoflorescence, such as right here, you see this lighter band here, is areas where you have probably sick RPE around where you have an increase in the lipofluscin deposit. So the RP isn't working as well to clear that. You get increased lipofluscin buildup and you'll get hyper-autoflorescence. So just after that brief review on this right eye now, on this we see maybe even a couple other spots that we didn't see on the color photos at all and on the infrared. And on the left eye, same picture.  And then surrounding those areas you have this hyper-autoflorescence which is showing us accumulation of lipofluscin. Here's the OCT from the right eye on an initial presentation and it looks great. There's really no abnormalities seen there. And here's the left eye. You'll notice just some subtle changes here at the level of the RPE. There's a little indentation with some loss of the ISOS, border junction just above that. And again, you can see that here right through the central cut through the phobia. Red-free images again show what we've seen. And here's the fluorescent angiogram of the right eye. So this is the early, 45 seconds, 3 minutes, almost 7 minutes. You see these early hyper-autoflorescence spots. They don't expand at all at 3 minutes or at 7 minutes. So that's very consistent with window defects there. Again, dead or lost RPE. And we're seeing right through it to the fluorescein underneath in the choroid. And then the left eye, early photos here and here and then 3 minutes here and 6 minutes here. And again, it just shows more spots than we're clinically evident looking at the patient. No leakage on these areas of hyper-florescence. They seem to stay the same throughout. And then ICG on the right eye. If you look carefully, you can see these couple hypo-florescence spots centrally. We term ICG kind of as we break it into early, mid-frames and late-frames. So early being 0 to 4 minutes, it's different than fluorescein angiogram. Mid being more of 4 to 8 to 10 minutes. And late-frames kind of that after 8 to 10 minutes. So in this case, this patient has in early these hyper-florescence spots that you see in the mid-frames and stays there in the late-frame. And then the left eye, similar picture, just more pronounced, more hyper-florescence spots centrally. Patient had a multifocal ERG performed. So just quickly review that this is the normal reference down here. The blue ones, you expect to see how the A, B wave. Pretty good in the right eye. In the left eye, if you look close, you have some subtle changes here. But overall, that's a pretty good multifocal ERG. Not a very impressive loss. But there's a little loss of the wave pattern centrally in the left eye corresponding with fluorescein angiogram. And then here's the cone of this. Again, these are the normals you would expect down here in the bottom four. On this right eye here, you can see it's not the nice cone peak you would expect to see. That's more consistent with these spots like this with she probably lost fixation for a little bit. It would give you appearance like this, not so much that she has lost there. And the left eye, actually the eye that we see more involvement in looks better. And both eyes there look pretty stable. So not much change seen there. So differential diagnosis at this point, just for the sake of being very complete, I put a lot of things on here, but punctate interchloridopathy would be right on the top of our list given a presentation, the lack of vitreous cell that we're seeing. Multifocal chlorideitis and panubiasis would look very similar. You would expect to see vitreous cell. But there is some debate over people if these are just as variations of the same disease process and maybe this is burnt out or early, we're not seeing that vitreous yet. Of course histoplasmosis can look very similar without cell as well. Amudes would be considered on there as well. Of course you'd expect it to be unilateral, but she is a young myopic female. 25% of them can be bilateral, so it's worth considering. Retinal pigment epithelitis or Krill's disease would be another consideration. It can give you these creamy, small lesions. Again a little more common in male, two-thirds in male, but you can have a third of the patients presenting as females, and it could be an early indication of that. And a few sub-retinal fibrosis would be bilateral, and this could be early changes seen with that. Inflammatory on a systemic level then, sarcoid, and we're always talking like just about anything, so I always wanted to consider maybe an early inflammatory disease to fit the right profile for a tenu or for inflammatory bowel or riders, maybe early changes seen with that. Infectious, I think the herpes also can look like many things. Post-viral, the Epstein-Barr virus, you can see changes like this that usually then resolve. These are thought to be more of immune complexes that deposit in the cord that you might see after a viral illness like Epstein-Barr or cytomegalovirus or coxacvirus.  And then the masquerade ones, I don't think it really looks like any of these, but for the sake of just completing this, I think you always should remember trauma when you see pigmentary changes in the retina. Myopia can cause those, although she's pretty mild, and then retinal dystrophy is early can give you pigmentary changes. So her initial laboratory workup consisted of an ESR, an RPR, ACE, PPD, they were all normal. And of course, in the evening before she was seen, she had this MRI ring. And as I mentioned before, it had a small lesion, which was a questionable demyelinating lesion in the right frontal lobe. So we called this a PIC, and just briefly to review PIC. It's an inflammatory disorder. It was first, it's only 29 years old, recently celebrated its 29th birthday after being described by Dr. Watski in 1984. In his initial cohort, he described 12 patients. And the youngest was 16, the oldest was 40, and that's really stuck, you know. Most people still kind of stick to those numbers. You see it in between those age groups. 90% of the patients who you'll see with PIC are women.  So it's really a disease of white women. And most will have a history of moderate myopia with the history of a, without a history, sorry, of a preceding illness. And then it's considered to be less common than its cousin, multifocal corditis and pan-uviitis, which presents very similarly, but with inflammation seen. The incidence is estimated at roughly 100 to 200 in the U.S. This is, it's a big guess. This came from a study recently in Iowa. They went back and looked over 16 years worth of patients that they had who presented with PIC and they had 16 in 16 years. So they consider considering themselves the tertiary referral center for the state of Iowa. They said, let's consider we get every new patient for the state of Iowa who presents with PIC and our population is 2.6 million. And it's one out of 2.6 million per year. And they just then carried that out to the country in which case they said, well, you get about 150 a year then in the country. Clinical features, the three main complaints you'll see are blurred vision, central or paracentral scatoma and photopsias. Usually just in one eye, even though they have involvement in both eyes, usually they're just noticing it in the eye that's mostly involved. The blurred vision, of course, would be due to clustering of lesions in the macular. They can't present even with the crudal neovascular membrane. Even though the more prominent science seen on visual field is enlargement of the blind spot, most people don't notice that. So they're coming in with central or paracentral scatomas just like our patient and photopsias just like our patient. In addition, they can get these serous retinal detachments surrounding these PIC lesions as well. What you typically see are these yellow-white lesions. They'll have indistinct borders. They're at the level of the RPE or the coroid, usually pretty small, around 200 microns. And located almost exclusively in the posterior pole. It's very rare to see them in the mid periphery. In fact, if you see very many in the mid periphery at all, you should question your diagnosis. No vitritus or at least very little vitritus can be associated with it. Bilateral and 80% and usually asymmetric. At the initial presentation, often you'll see a hyperemic optic nerve. And then as these progress, you'll be left with this atrophic scar with the halo surrounding the scar. And, you know, what I put down here is these crudal neovascular membranes are associated in 30 to 75%. Most people will say around 40 to 50%, but there's just so many different numbers that have been found in different studies. So test what you expect to see. On our patient, it was quite a classic presentation. Early hyper fluorescence. And then you can have variable leakage or staining associated with that, depending on the presence of neovascular membranes. And then often you'll see many more lesions than you can see on exam with it. I thought our left eye was a great example that you could see a lot of lesions there that weren't obvious on the color photos. On ICG, you'll get these hypo fluorescent lesions, which is thought to correspond with hypo perfusion of the choroid and mostly involving the small choroidal vessels. And then on the OCT, we're really just starting to get a picture of this, and I'll talk about one study that they try to describe the classic changes in PIC, but you get kind of this homogenous thickening of these coriorentinal lesions, and you'll get deposits of a hyperreflective material between the RPE and, sorry, underneath the RPE and Brooks membrane. And it can also cause changes in the outer retinal layer. And then you can have defects in Brooks membrane and loss, classically you'll see loss of the ISOS junction during the active phase, and then that seems to reappear as the active phase calms down. Amza grid can be helpful as well, showing some scutomas, and then visual field. Most often you'll see enlargement of the blind spot or temporal visual field loss surrounding the adopted nerve, but you can also get central and paracentral scutomas. So the etiology of PIC remains unclear. It has been linked to HLADR2, like multiple sclerosis and some other eye diseases as well, but it's a pretty weak link. Some people have questioned if it's just a variant of multifocal coriorentitis and panubiitis, since they're very similar, maybe just a little different presentation of the same disease, and some question if it's just associated with myopic degeneration. In fact, in Watski's original cohort, the myopia ranged from minus 3 and a quarter to minus 10. So they were all quite myopic. And then, of course, another thought has been that it's just an inflammatory or an infectious thrombosis. So similar to histoplasmosis. It's the same process. We just don't know what the bug is that's causing it yet, and we'll figure that out and then be able to link it. Those who... So the linked Epstein-Barr virus has been proposed as well. Tiedman, back in 1987, he did a study and showed that 10 patients with multifocal coriorentitis had high IgM-Titre-Srepstein-Barr virus, and so that... You'll still hear that today in the literature quite a bit. But a couple studies since that point, and one on my side here would by Spade, since that point it had not found that same finding. So it's been rather debunked a couple times since then, and so not considered quite as much. This was a study that was done recently in the United Kingdom I thought was interesting. So they're trying to show the link between PIC and MCP. And so what they did is they took 61 patients who had MCP or PIC, and they compared them to 92 population controls in the UK. And they were looking at 12 polymorphisms between the TNF-alpha and the IL-10, which is a region which is associated with a lot of UV-itis. They've recently been shown to be associated to have a high correlation with UV-itis. So what they show, they show two conclusions that contradict themselves a little bit. The first was they said that there's clear differences in the clinical course between patients with MCP and PIC, and in the prognostic significance. So they said the MCP patients usually have this more non-remitting course that continues on, and they require higher levels of immunosuppression to try to keep the disease down. So in that case, they said they're quite different. But then at the same time, they said that the patients had identical IL-10 and TNF haplotypes between the MCP and the PIC patients when compared to the general population. So, again, supports the thought that these diseases are very closely linked, and maybe that PIC just happens to be a less aggressive form of the same disease, and that's why we get less vitritus. Yes, to each other, between MCP and PIC. Yes. That's a good question. And they were vague on this one. I tried to look at it and see are they saying that's a statistical significant difference between the two of them, and they didn't say that. The way they worded it was they said, well, they're identical, and so I don't have a better answer for you on that. It is relatively small. The problem is, you know, it's hard to get 61 patients anywhere with you. That's by far the biggest one I could find of any of them. But, yeah. A recent study that was put out just in the last year also tried to identify typical lesions on OCT. So, they looked, this was out of Wilmer. They took seven patients, six females one male, and they looked at 27 PIC lesions located in those patients, and they tried to classify OCT changes you would see between active and non-active lesions. So, they characterized them as active if the patient had either a visual disturbance, if the lesions of the border were changing, or they could see a DEMA surrounding the lesion, or if there was hyperfluorescence on fluorescent angiograms. So, they had pretty strict criteria for what was active. And so, using that criteria, they said 24 out of the 27 lesions all showed involvement of the RPE. And one of the interesting things that they found from it was they could only show one lesion that had involvement of the coriocapolaris on OCT. Even though we hypothesize that that's the coroid and the coriocapolaris are what's involved with this. And so, just an interesting tidbit. So, the ones that they deemed clinically stable about using this criteria then, they found two main patterns noted on OCT. One was they'd have this RPE elevation with sub-RPE hyperreflective signals, and I'll show you some pictures of this. And then on another one, they had no RPE elevation, but they had disruption of the outer retinal layers. And one other interesting tidbit was of those that they called clinically stable. Seven of those lesions demonstrated alteration so they could show that the lesions were actually getting bigger and smaller during this time, even though they couldn't show that the lesions were active by forcing angiogram or by patient noticing changes. And then of those that were clinically active, the main other finding they had was that the photoreceptor cells, this ISOS junction, would not be visible during active disease. And then as things settled down, that junction usually came back into view where you could see it again. And I'll show you some examples. So, here's some clinically inactive. And this is baseline here. And these are the months. So, here's three months and four months on patient, right? This legion number six. So, here's our arrow where we're going through. And you see it, baseline, flat area, looks pretty routine. And this is, again, an inactive patient.  And you can see Brooks' membrane here runs contiguous, it stayed intact. The patient comes back a month later. That's flattened back out. And here's your ISOS junction. You have it run here and here, but you lose it during this phase of this material deposit. Comes back a month later. ISOS junction looks good and things have settled down. And this isn't a patient who really had no symptoms. Again, just a similar pick. Another patient here, legion seven, but you get the same picture. Again, this hyperreflective sub-RPE material flattens out. ISOS junction looks much better when it flattens out. Patient never had any idea that anything was going on. And then here's some that were clinically active. And really, the appearance is very similar. So, it leads to a question of what's active and what's not, I think. Here's a patient, Legion 14 at baseline. Pretty smooth running RPE here. Come back one month later. They now have some hyperreflective material deposited beneath RPE. 20 months later, it's gone. And then this one, this patient right here, Legion 27, a similar appearance, but it also correlates with these photos right here. It's the same patient. So, you see a color photo of the spot we're talking about. And then an early fluorescent angiogram and a late fluorescent angiogram. And they argue it's active because we get a little bit of late leakage around it on the late fluorescent angiogram. But obviously, not much leakage and not much activity going on there. One other interesting case. This was a patient who had originally presented and had anti-vegeth treatment given. Responded initially and then had a recurrence. So, she has this coronial vascular membrane you can see right here. And with further anti-vegeth, didn't have any response. So, they went in and surgically removed the coronial vascular membrane. Here she is a month out from surgery. And here she is a year later. You can see they bought a new OCT machine in the meantime. But she looks great. I think they wanted to show off the surgery a little bit at the same time, toot their own horn. But the main finding that came from it was helpful because it gave us our first look, our first chance to use light and electron microscopy to look at one of the coronial vascular membranes associated with Pitt. And I know Dr. Mamelis is probably the one in here who looks at this and thinks it makes sense. No, you don't. Well, good. Because that's what it looks like to me. But I'll explain to you what they were explaining in the chart. But they're showing this is the pigment epithelial layer here. And this is your Brooks membrane. And so beneath it, this is the main picture they were interested in. But beneath it, in the coroid level, they're showing these lymphocytes. And so they're saying this supports the hypothesis that this is an inflammatory process involving the coroid. Even though on the OCT, we're not seeing much coroidal change. So management of Pitt. I think Pitt really has a lot of interesting management questions. And so first of all, most patients don't require treatment unless they have involvement in the other eye with vision loss or unless they have a crotonial vascular membrane that develops. Most of them do well unless that happens. But obviously about half of them have that happen. So treatment options, there's a lot. Since this is more of an inflammatory disease, one of the best treatment options is systemic steroids. So these are a couple of different case series, small case series and a case report. There are not big numbers to look at on this. This first one was from Brown out of Iowa. They went back and looked at some of their patients. And so they said, well, we've treated four patients with Pitt with either oral or subtenon steroids. And three of the four didn't have any improvement of their crotonial vascular membrane. So the very first study is to come out talking about treating it with steroids. Two years later, then, out of the United Kingdom came this study and it really changed the way we treat it because they said, well, we took 12 eyes that had these subfoldial cronial vascular membranes from Pitt and we put them on oral prednisone at a big dose, you know, 60 to 80 milligrams and they started a wean after that. And they said 10 of the 12 eyes had improved or stabilized vision after that. And nine of them had resolution of leakage on fluorescent angiogram and three of them had improvement. So all of them had some improvement. Nine of them had completely stopped. And then of those four patients ended up needing more steroids. So that really changed the way Pitt was treated at that point. And then Levy, just another one in 2005, showed another patient who had vision of 660, which improved to 6.9 with treatment of oral steroids. And he noticed that the lesions in the posterior pole became much smaller and the leakage stopped on forcing the angiogram. Another treatment option then is intravitral steroids, trying to get it just that medicine right to the area of the inflammation. Holocant, this is the only study I could find, but he's the only one I could find who's used a reticert device for Pitt. So he put it in saying, well, this is a long disease and we'll put it in and for 36 months they'll have coverage. So he put one in on a patient and they ended up having a relapse of the cronial vascular membrane for 18 months in and had PDT, which was successful, but it didn't stop a recurrent neovascular membrane from developing. And then Sam did a study where he talked about using intravitral trimestinal loan on a couple different patients who were pregnant and had good results, one stabilized, one division approved substantially. PDT and steroids probably up until a few years ago were probably recognized as the main treatment option. PIC lesions, PIC neovascular membranes seem to be quite responsive to PDT. This was a study that was published and written in 2008, probably right at the time when VEGF started to really overtake PDT for the treatment of this, but they had 14 eyes, followed over a 12 month period who were given both triumphs, intravitral trimestinal loan and PDT and they had a substantial improvement in the best corrected visual acuity from Logmar from 0.5 to 0.2 a year, one year follow up. Many studies supporting that. And then anti-VEGF in the last few years has been kind of the main treatment we've seen. This was the largest cohort I could find. It came out of China, but they had a lot of people in China, so probably more PIC, but they took 12 patients, which I thought was interesting as a side note just because they say 97% of the treatment is Caucasians, but in China he had a cohort of 12 diagnosed with PIC, so he either gave them he gave them a Bevacizumab and they came back if they had any recurrent activity or leakage and they were all followed for 12 months and he had an improvement in baseline corrected vision from 2062 to 2034 and all eyes he said it stabilized or improved. Nine eyes it showed grid and two lines of improvement and vision. And one other interesting thing was that they had to take a trisil phase after 12 months. It varied per patient so when they came back if they were considered to have continued activity they received more. So every patient was different but 12 months followed, they were followed monthly and if they had fluid on OCT or they had leakage on FA they were given another injection. Yes. But again they only have 12 months of follow up and then immuno modulation. Turgoglue in Wilmer has recently started treating most of his PIC patients with cell set. And so I thought this was an interesting study but he had, he showed 8 patients who he had followed who had at least 2 recurrent episodes in the previous 12 months and had 12 months of follow up prior to being started on cell set and 12 months of follow up after. And so of these patients they experienced 19 attacks of recurrent disease. I think the main point on this slide during mycophenylate mycophenylate the main point though was the attack frequency. So before being treated they had about 1.09 attacks per year per patient and after treatment decreased about 4 times to 0.23 and that's what the year of follow up on cell set. He's a big proponent of treating him with a lot of modulation to try to slow this down. So here's our patient back to her. She returns 3 months later her headaches continue to worsen and now she has these constant flashing lights in the left eye. She did have gallbladder surgery 2 weeks prior and felt like that. Just sped everything up. She also complains of more metamorphopsia and more darkening in the left eye. A vision has decreased now in that left eye to 2050 and the remainder of the exam is normal. Here's our color photo. You can see quite a bit more hypopigmented lesions over there in that left eye compared to previous. And here's our funnesotofluorescence I'll point out. So here's her when she came in the first visit and here's 3 months later you'll notice just a dramatic increase in the hypoautofluorescence spots and also in the hyperautofluorescence surrounding that. Definite advancement. The right eye really looks pretty darn stable. Again forcing angiogram in the right eye now you have additional lesions here. Questionable if there might have been a little bit of leakage here but we didn't think we didn't think so at that point. ICG in the right eye has unchanged a couple hypoautofluorescence spots and in the left eye much more dramatic change. OCT again looks great in the right eye. Now in the left eye you see these sub-RPE hyper florescence spots hyper-reflective deposits I should say. Visual field at that point shows this enlargement of the blind spot and temporal loss in the left eye. So at that point she gets a more thorough work up. She has a lumbar puncture done. It's normal. She started on oral prednisone after doing these other studies. Her partner for Angola was negative. Bartonella was negative. She had Epstein-Barr virus titers drawn. The IgG was high which is interesting quite high but the IgM not much to make of there. The rest of the work up was negative. So she started on oral prednisone 60 milligrams. She comes back six weeks later. She's feeling a little better. Vision's a little better in that left eye. She saw that gray spot in the center of her vision but it's better. She thinks and some photophobia. Vision's improved. So last time she was 2050 in that left eye. Now she's back down to reading the 2020 line and she has this definite central scatoma on fields in the left eye. So here you can see prior visit and now today six weeks later you can see that those hypopigmented spots have kind of settled down. Things look a little more stable in that left eye. And on the fundosodal fluorescence you probably see the most impressive documentation of that. You can see just how that hyper and hypoidal fluorescence has improved dramatically there with the oral steroids in the left eye. The right eye remain the same. At this point though when we look at her fluorescing angiogram in the left eye she, here's early and here she has this continued hyper fluorescence that seems to expand a little bit centrally there. ICG really is impressive in the left eye how much better it looks. So here it is today and here it was the visit before. So quite an improvement on those hypo fluorescence spots. OCT stable in the right eye again and much improved in the left eye. So we continue her at the prednisone wean she's now down to 40 and at that point she gets an avasin in the left eye because we were concerned about that hyper fluorescence in the left eye there on the fluorescing angiogram. I think one other thing I wanted to show was just on the ICG you see it again a concern there maybe there's some hyper fluorescence which would be consistent with a muscular membrane. So she comes back another six weeks later. Vision continues to improve mainly she's just getting some symptoms now from the steroids. So she has ulcer and anxiety she has new colsores but she's doing great so we're not ready to stop and we're going we're going to push ahead. Vision wise she's 2020 we're all thrilled and I'll just tell you this looks the same as before there's no change. Fluorescence you do see some more spots here though now you know you look at it and you could say well we're seeing some early changes. Fluorescing angiogram there's no more leakage we were concerned about this little area right here that we thought was leaking before that's definitely not leaking on here. OCT continues to look better. So we continue the wean we start her on valcyte for the colsores and plug ahead. Six weeks again she's still doing well she's down to ten on the prednisone things look pretty much the same so we're going to keep following her. Comes back six weeks later vision's down a little bit she says I feel fine but we can only get her to 2040 and now she's pregnant and this is what Dr. Vitaly's head did when he heard that that's when you got to be kidding me. So the game changes a little bit. Really on the funnest auto fluorescence again you know even though she's down a little bit we settle changes but they're not much different you know and so you start debating how aggressive do we be. She's off all steroids we say let's watch come back in six more weeks we'll take another look. She comes back six weeks now she feels she's much worse vision color changes are bad she's a college student she says I can't do my work because I can't see to read her it's all the time and I'm 11 weeks pregnant. Vision wise she's down in both eyes now she's 2040 minus in the right 2060 minus in the left and now she's got a bilateral central scatoma she's describing on AMSLA and here's her funnest auto fluorescence so in the right eye you can see that these hypopigmented areas which correspond to RP drop out are much darker and you see this hyper auto fluorescent area here which we haven't been seeing before in the right eye this is sick RPE and then in the left eye you can really see the sick RPE centrally right here in the fovea some expansion of these spots she's doing worse. OCT here's her right eye this is the first time we're starting to see changes in this I think it's a great photo that describes some of these outer retinal layer changes that you see described with active disease in the one paper I cited and then the left eye again you have these sub-RPE hyper reflective deposits bigger now than they've been ever so we have a long talk with her because she's pregnant and so it really changes some of our options and what we recommend is intravitual Tri-Amcinolone Tri-Essence we tell her we think this is very safe with your pregnancy we put the medicine right where we want it she comes back four weeks after that and really feels like she's doing a lot better she's 15 weeks pregnant at this point vision has gone from 2040 back to 2020 in the right eye and vision has gone from 2060 minus to 2040 plus in the left eye so we're pleased with that funnesotl fluorescence you see some improvement these lesions here are smaller again and this here does look better it's quieting down here's her OCT really you just have that spot that was there before and she has just kind of a loss of her ISOS junction right there and these are settling down here in the left eye they're smaller than they were so we say well let's you've got the Tri-Essence in let's see you back in four weeks the frustrating thing when she comes in and she's very careful at this point she says I saw you guys you gave me the Tri-Essence you told me it was pretty safe I went to my OBGYN a couple days later and he tells me it's class D and there's a very good chance so just an interesting side note Tri-Essence on a C at night is pregnancy category C Tri-Essence is just the exact same thing minus the preservative yet in everything I can find it's listed as pregnancy category D which I'm sure is what her OBGYN looked up and told her all of this with she don't want that in I briefly just put the drug categories I won't go through them for you but in study C animals have revealed adverse effects in study D they say there's positive evidence of human fetal risk and so the risk with steroids we all know is cleft palate in fetuses but so we pull up this study we had a conversation with our OBGYN about it to try to prevent further problems but this is the only study really that goes into this it was done in 2004 but what they did was they took 20 consecutive patients and after giving them 20 to 25 milligrams we don't really do that anymore they drew their blood and they checked the serum levels of Tri-Essence the problem was it wasn't done perfectly so they drew it at 13 plus or minus 19 days after this was not the best design study it ranged from 4 to 92 days but in 18 of those eyes 90% they couldn't find any Tri-Essence alone in the serum in 10% 2 of the 20 patients they found these were samples taken in 5 and 7 days they found 0.5 micrograms and 0.8 micrograms which is nothing when you consider that our average daily production of cortisol is about 15 to 20 milligrams even though this is 4 to 5 times stronger than that it adds up to nothing from what we make and so we tried to reassure her she's not really hearing it very well she's saying well I won't do another injection I'll go blind before I let you know and so anyway just a point on that it should be quite safe I just wanted to make that point and we made that with her and sent a nice letter to OBGYN informing him of that but that bridge was burnt at that point and then another thought on anti-vegeta I wanted to briefly touch on this in pregnancy so this came out of Terontola is one of the retinocris in Iowa came out with this but in 2010 so they they took 4 patients those 4 patients had a total of 5 pregnancies and these 4 patients they treated with a total of 13 injections of Avastin during their pregnancy 2 were treated during the first trimester 1 woman in fact had 3 injections given during the first trimester and then 2 were treated 2nd trimester 1 was just 3rd and then they also had a patient who got 5 injections while breastfeeding and so they said well we did this and 5 patients we had no adverse events as we all know that's a very small number yeah it's they published it but no one feels comfortable now giving Avastin after having seen this one other thought I thought it was interesting they used Avastin so I did quite a bit of reading on this but most small drugs cross the placenta by simple diffusion so bigger drugs have to be carried across by active transport so the classic example they always use insulin which is 5.8 kilodaltons it has to be actively transported across the placenta to the fetus so Avastin is 149 kilodaltons much bigger even Lucentis is 48 kilodaltons and then the other way that fetus is obtain these antibodies is by an FC receptor that binds the FC portion of the IgG so it makes a lot of sense that Lucentis would be much safer because they've removed that FC portion from the molecule whereas Avastin still has that FC portion of course there's no study that's been done on this to show the levels that cross the fetus but just theorizing on it would make sense that Lucentis would be much less likely to cross it is a little bit smaller but it's still much bigger than insulin and it doesn't have that FC portion to help carry it across and then one other study I wanted to cite here was just this came out of Italy I thought it was really interesting so they unknowingly gave Avastin injection to two women who were pregnant both women one was four weeks pregnant one was five weeks pregnant at the time of injection and we're not aware of it both women then had spontaneous abortions one week after the injection of Avastin and so again it's all anecdotal but this is just the other study we have that's been reported on this no it doesn't tell us much because then you have this question this was the other one I cited Wilcox in the New England Journal of Medicine in the 88's that you know the incidence of spontaneous early abortions is 31% so it's hard to read much into any of this one last couple of last studies I wanted to mention just the levels that we see change with Avastin injections in the eye so this is one where they gave Avastin injections in the eye in patients with type 2 diabetes and then 30 non diabetic control patients and then they sampled the blood for serum VEGF levels at one day, seven days and 30 days after the injection so the average VEGF level before was 114 at day one it was 9.7 after the injection 11.7, 25.9 so they had a substantial decrease in serum VEGF levels correct I'm sorry it was part of the 114 I don't know I don't know what it was after I don't remember I'm sorry but this other study kind of did the same thing I think it was a little bit better done and it was just published this month but they took 30 diabetics, 30amd patients and they randomized them to 10 Lucentus, 10 Avastin, 10 Machigin which I thought that was a dinosaur but they did and then so here are the diabetes patients at baseline 72 this is the serum VEGF levels again 72.2 day 7 is 13.7 day 37 dramatic, highly significant difference in the serum VEGF levels after injection whereas in the Lucentus and in the Machigin levels the changes was not significant they couldn't show a difference so I thought that was the better done study again showing a dramatic decrease in serum VEGF levels associated with Avastin one other question that came up in her you know if it's safe to use fluorescein angiography during pregnancy it's kind of a trick question because no one knows it's like everything in medicine no one tests it so the only study we have exactly so the only information we really have came from this study in 1990 they sent out 399 retinas specialists a questionnaire saying have you used fluorescein angiogram 309 said no, 77% 90 said yes they had so then they wanted to know what results did you see of that so of the 90 or the 23% who had used it they got detailed information on 116 patients the main side effects were nausea, vomiting like you would expect with fluorescein angiogram birth anomalies they had of those 116 they had one on the scented testicle one syndactylin and then they went and further broke it down to 41 of the 116 had the FA perform in the first trimester so of those 41 they had four deaths 10% two were thought to be due to severe eclampsia one was months later they didn't think it was related to that at all but it's hard to know and then one occurred three days later and a healthy woman who was four weeks pregnant so the authors of this studies they also pointed out eight children were born to mothers with eclampsia had birth weight, low birth weights of 116 and then with that information they said well we conclude that fluorescein angiogram is one of the main implications so that's really been challenged in that study their conclusion they made is what got them in trouble people have had a big problem with them saying that from that one study anyway so she comes back now four weeks later again and she's doing much better she's 2015, she's 2025 plus in the left eye small central scatoma in the left eye but doing better than she had been fluorescence is pretty stable she continues to look a little better OCT in the right eye again you have this little ISOS loss but that does look better than it was before and these are continuing to settle down that's all this is why you don't let your kids watch nacho libre in case you wanted to know but questions at all nothing that I saw the only things I saw that were interesting with her was most authors speculated that pregnancy would kind of be immunosuppressive and decrease the flare up of there were two case reports I saw individual case reports of patients who had flare ups during pregnancy much like our patient but nothing regarding eosinophils there's definitely involvement there we're just not seeing it


Good morning. This is the House Health Care Committee of the Vermont House of Representatives. It is Wednesday, February 17th. And this morning, we are continuing our, we continue to hear testimony on a bill at H 210 that was introduced on the floor of the house last week and has been taken up for consideration by the House Health, by our House Health Care Committee. Last week we heard from, we heard the introduction of the bill from Representative Chena, who is the lead sponsor and from the Racial Justice Alliance, a number of members of the Racial Justice Alliance who helped craft the bill, had a lot of input into the bill. This morning it's our intention to hear from the Department of Health, the Vermont Department of Health, about S 210, because in fact the bill touches on directly on the Vermont Department of Health. And so with us this morning we have Heidi Klein, and then we also have, from our own Joint Fiscal Office, Nolan Langwell, who will review with us a fiscal note on the bill. So, but first let's hear, let's turn to Heidi Klein. And I see you are with us, but there you are. Okay. Yeah. Good morning. Good morning. I'll thank you for having me today. I'm very pleased to be here. Is the audio strong enough? It sounds great. Yeah. You're loud and clear. Okay. All right. Well, I have met some of you before. And as introduction, I am Heidi Klein. I serve as Director of Planning within the Commissioner's Office of the Department of Health. I've been that position for about four years now. The Office of Planning includes four major areas, includes long-range planning for the department, so our strategic plan, as well as development of the State Health Improvement Plan, which you'll hear me reference later. It also includes workforce development, performance management, and probably most relevant to the discussion is it includes our efforts related to health equity. So I'll tell you a little bit about how we've looked at this bill and the ways in which it aligns nicely with a lot of the work that we have been working towards over the last few years in ways in which I think it pushes us into new directions and requires some new thinking. As I understand it, the bill proposes first to establish an Office of Health Equity within the Commissioner's Office to establish the Health Equity Advisory Commission, to issue grants for the promotion of health equity, to collect data to better understand health disparities in Vermont, and also to invest in growing our medical profession and continuing medical education. I would say in general and in concept the Health Department supports this bill. As I said, it's very much in line and I will share some of that alignment with the direction of the governor over the last few years and certainly also with our Health Department. I think our only concern is the ability to carry out the differential duties, both of the Director of the Office of Health Equity and providing the necessary supports to the Advisory Commission, recognizing that what's outlined in the bill really requires a long-term commitment by multiple staff and over multiple years. So this would require a long-term investment and right now we just need to call out what that would look like. So for alignment, I think probably you've already had a chance to review, but I would call your attention to the State Strategic Plan, which was developed under Governor Scott. One of the areas of import for this conversation is the vulnerability theme, which I think speaks very directly to looking at populations. They use the word vulnerability, but if you look at it directly it really is about looking at populations that have higher risks for poorer health outcomes based on historic injustices, historic investment, and based on a variety of factors. It also fits very nicely with alignment with the work that we've done in the Health Department. Some of you may be aware that in 2018 we carried out what we called our State Health Assessment and followed that with our State Health Improvement Plan. This is something that we produce every five years and the last time around we chose specifically to focus on health equities. Historically our State Health Assessment looks at what are the most important or concerning health conditions across all populations and this time we decided to say instead of looking at it across populations to look at what are the populations that are most likely to experience poor health outcomes and when we flipped that switch we were able to say that actually if we look closely at our data we can say that there are disproportionate health impacts among our populations of color, our populations, people living with disabilities, people living in poverty, and people who identify as LGBTQ and I that we see persistent differences in health outcomes among those populations in focus. Can I interrupt and just ask you to just list again those particular populations because absolutely I think they're familiar to us but I think it's important to hear that as part of the broader context that absolutely that you the Department of Health has itself identified. Yep and so when we looked at our data to try and see where are there populations that consistently are experiencing poorer health outcomes compared to their counterparts what we looked at when we looked at our data to the extent that we were able we identified what we called our four populations in focus and the first population were our populations of color and so that included our black indigenous people of color included and so that that was the first one the second were people living with disabilities, populations that identify as lesbian, gay, bisexual, transgender, queer, or LGBTQ. Right and then our people living in poverty and so historically in Vermont we often look and we can tell that we have disparities based on poverty everybody knew that and we sort of took that as a given but we wanted to really look at our quantitative data to tell us what is it that we are seeing quantitatively in terms of both poorer health outcomes and poorer health opportunities right and so we looked at the outcomes we looked at the opportunities and then of course we looked at the behaviors but one of the things that was really important in the way that we address this is recognizing that behaviors often present themselves in the context of opportunities and we have disparate opportunities amongst different communities right and it's not just graphic communities because we are comfortable with geographic communities but we were also talking about communities of identity and these are the ones that we found by looking at the data and we also did some qualitative research in in our assessment to figure out sort of what we're what helped us to understand why the why not just the what but the why and if we were to begin to think about how to make change what would change look like and so the state health assessment and I'll I'll be glad to I'll send you the links after this meeting and really outlines what we learned in terms of people's experiences and both with their own health and then also very much with the interfacing with the healthcare system and so from that data we developed what was called the state health improvement plan which laid out a number of strategies that are intended for us as a state not as a state health department but as a state to be able to move forward to address the persistent health problems and look at the changing changing the conditions of people's lives to make it it more possible for all the monitors to obtain healthy living and I think one of the things to be that's really important and I think it really reflects again some really nice alignment with the direction of this bill is that in the development of both the state health assessment and the state health improvement plan we actually pulled together a group of over 90 state entities whether and some of them were other agencies some and many of them were non-profit entities that are serving populations the populations in focus and then we had we struggled much more actually reach people with lived experience those who are not paid to show up and advocate on behalf of themselves or be part of an organization but that was why we did our our qualitative data mining because what we did is we had representatives for example and from the Abenaki tribe or from the Pride Center who were part of our our advisory group but then what we when we really wanted to figure out what people's experiences were we asked to be invited to sort of mini focus groups with those organizations and their members in order to be able to hear more directly from people with lived experience and use that to inform both what data we should look at as well as what strategies would be useful and in many ways it sounds you know that sounds very akin to what this bill proposes in terms of the role of an advisory commission the ways in which we used the advisory committee for the state health improvement plan so I think there's really nice alignment there and I think the other piece that I would say in terms of alignment is the health department as you see has committed some resources within our department by having health equity as an as a priority in our state health assessment in the planning office and I I report within the executive committee to the commissioner and with trying over the number of years to continue to build more capacity understanding within our own staff and to promote health equity and we I think it really is highlighted by the work that we've been able to do in our COVID response and I know we will continue to struggle to meet all of the needs and be as responsive as many including ourselves would like to be but given how fast and furious we are going I wanted to share with you and you know the ways in which I think this response to our current crisis with COVID highlights the need for spotlight on equity and it also highlights the need for greater investment in staff and funding to really meet the needs and so as I said while we feel like there's great alignment between what this bill proposes to do the concern is that it is under resourced in order to accomplish what it is and I'll give you just an example of why I would say that in our COVID-19 response we started off with one person assigned to trying to look across the enterprise of our response within the health department for health equity to make sure that we were in everything that we did had a health equity lens right however we are now up to eight staff who are focused specifically to our COVID response and we could probably use more but I'll give you an example of what we've been able to accomplish with those eight staff and I think again it's a microcosm of what is being asked for in this bill because we have been able to publish data we have weekly summaries on the health of our monitors and the differential impacts of COVID-19 on our different populations we've been able thankfully with some additional external federal funding to fund community partners specifically for carrying out activities related to COVID and those have included the Abenaki helping Abenaki racial justice alliance the association of Africans living in Vermont the Vermont mental disabilities council and I write Vermont to name a few we've also been able to target special testing opportunities in our English language learning communities and we've really focused on translation and that's just a tiny bit of what actually is needed and I think that is the message that I would love to continue to share is that this is work that is going to require long-term investment of time money and staff and we're there with you if we can make it work and that is part of the I think we've built some of the frameworks within state government the strategic plan of the governor the state health improvement plan of the health department but what we haven't been able to do is go this next level that this bill is asking for and I would say this bill is asking us to do a lot of new things that we haven't been able to do so by creating an office of health equity and the we would the issue of providing grants requires us to have grants to give out it up we realized when we did have the luxury of new grants because of covid it was a full-time job of someone to manage that money and be able to do all the pieces in terms of reaching out to individuals and organizations that frankly the ones that we were trying to reach may not have the infrastructure and support yet to be able to catch the money to be able to spend it so creating and providing grants out remand requires also providing some support to those entities to be able to receive and manage the grants in ways that we as the state or the federal government will require for tracking reporting support etc so I think it's it's not just grants out but it's a lot of capacity building that we would need to invest in and what else would be new is developing the plan to increase the number of BIPOC and LGBTQ individuals in the healthcare systems that's not something that we have traditionally done and I know it is a mandate that would need to be looked at more closely in terms what it would take to both do that as well as the pieces related the other pieces related to healthcare that is not something that we have been actively involved in the other piece that would be very different is the advisory commission and it was a you know the advisory commission has a fantastic set of entities it seems to cover the key portions of state government as well as those organizations outside of government who would need to work together collaboratively in order to achieve what the bill puts out to be and our concern is that that the role the staffing of that advisory committee would require a full-time person as well as you probably know given the work that you all do what it takes to wrangle and support whether it's the public hearings or the review of legislation and then providing assistance to a commission to do its work requires some support and so I guess I'm going to wrap up so that you have time to ask me questions but I think you know again bottom line I think we're we're excited about the direction because it very much aligns with the work that we've been pushing for for many years and aligns with what our data tells us about disproportionate health impacts of remonters and that that's we are committed to ensuring that we continue to address that I think the however we are concerned that if the committee would like to move ahead with this that you consider what it would take to actually support all the work that is required here and so in my mind having you know lived in the state health department for the last seven years when I you know a quick read of what I've seen are the responsibilities I would imagine we would need a director as as identified I also think the advisory commission would do well to have its own staff support and that if there are to be the level of grants that are identified and the ability to get those out to the communities who need them most that a grants manager position and having data analysis is critical as you know we should always be data driven and evidence informed as we do our work and the data itself is critical to this work and then it looked like there was a lot of policy analysis so when I look at that knowing what I know of working within the health department within our state health system I think that there are a number of different positions and responsibilities that are outlined here in order to support this work that really is you know a multi multi-year effort but probably in line with what we have been talking about needing throughout the state so I'm going to end right there and I I don't know how your process works I see that I'll take charge of the hands I said that's your job right yeah that's my job okay thank you and thank you it's great uh it's great to hear from you this morning and before we're going to take questions but let me just say initially it's actually very hopeful to hear how much in alignment this bill is with the work that the department of health has been undertaking for some period of years both in terms of your policy analysis which the areas of on where poor health outcomes are seen aligned I think directly with what what this committee has been thinking about at times in terms of COVID relief emergency relief but also with the the bill as outlined but I'm going to turn and then there we so anyway I could I could go on but let's turn to some of the questions we have and so I'm going to turn first to represent Cina then represent Donahue represent page um first I just want to thank you for for um for giving us like a like sort of an honest assessment of the of the costs that would be involved in implementing this idea because you know if we're going to do something we should do it right and it's always good to have somebody share like sort of what we're missing to do this right and it sounds like we would need to build more um capacity for staffing and we would and we would need to appropriate more resources to this work if we're going to do it the right way um a question I have though is you know anytime we're spending money on something is sort of what impact will that have in the long term on what we you know in other words by doing this are we in some way saving money or is there a cost that is going to be reduced that's currently happening with the way the system is for example by addressing health inequities are we actually investing in um are we investing by investing in in in addressing health inequities are we reducing the costs on people that's happening under the current system do you see what I'm saying I'm curious if you could speak to that you know to sort of like what's the trade off of by doing this what is the benefit like what are we saving by spending money on this so yeah yeah I appreciate the question and and I'm a true public health professional which means I believe in long-term change and recognize that like investments today often don't yield immediate results right that the the the way in which you have to measure success can be 15 to 20 years down the road right and it can be intergenerational as opposed to immediate and so the immediate reduction in cost it's it's hard to quantify except if you look at the conditions of people's lives and I mean when we talk about health we mean both physical and mental health and um some people call behavioral health a different category but when we look at the ways in which people are currently suffering if there's anything that by doing you know investing in this way we can bring down the physical and mental angst to the individual that's important if we are able more importantly and more likely to create better systems of support change our approaches so that we're investing a little bit further upstream in those conditions that are creating the health outcomes we are doing that not only for the individual but more importantly for the the community so that we are not perpetuating the the the problem or the cost down the line that's a generational change right and so it is it would be hard for me to to specifically quantify but we do know in public health that when we make investments like examples so if we you know stopping smoking was a 20 to 30 year campaign but look what it's yielded us right we also know investments in making it easier for people to walk or ride their bicycle in a community improves the community value it includes it improves health outcomes so that investment in an infrastructure to make health easier to obtain makes a huge difference now again it's an investment not in health care but it's further upstream so i got a little bit big on you with my answer representative but i but i think that it's just it's really hard to quantify and i think where we have been looking in the work that we're doing in the health department is also about the changes in how we think about what data we look at what programs we fund what's what policies we put forth that will set forth changing the default expectation to be inclusive and that that's i don't know how you measure that that the the funding that is saved that way but that's the investment that we need thank you i'm going to let me throw out a question which i'm not going to ask you to respond to right now but just to have in your mind as others are asking questions as well along the lines of because there is in fact a current investment in the department of health around addressing health disparities one would think that it would not require simply new additional resources but the realignment of some current resources in addition to new resources and so i would ask that we be thinking about that as well because clearly the department of health has made some significant investment to come to the place where it is currently although this bill as you accurately say would and it wouldn't be the bill would have no purpose if it did not actually take us further and require the department to move further but i think there are some perhaps there are some reorganization or realignment of current resources in addition to additional resources that would help underwrite this initiative so let's let's be thinking about that as we as as the committee and and invite your help to think about that as well along the way represent donahue thank you i first want to thank you for your your reference to the distinction between mental health and health behaviors which go across mental and physical that people use the term behavioral health and and don't apply it in that way in that correct way so thank you a general question which turns into a focus on a specific and that is the relationship between the work of the health department and how closely you work with the green mountain care board on health system initiatives and then very specifically in terms of data gathering whether you've seen the proposal of the green mountain care board to be able to capture data related to race and ethnicity in order to help guide this work and whether that seems to be you know a good or a not so good way of jump starting some of that specific data gathering oh sure yeah um i have to confess prior to coven um we did a lot of work with the green mountain care board so prior to coven um i would say a significant part of my work in particular was actually about health systems reform uh and working with members of our health care communities uh to look in ways in which they could expand the way they thought about health care to include population health which is i think really what the green mountain care board is looking at in ways of thinking beyond individuals to populations being on treatment to prevention right and and looking at ways of supporting people in community in different ways so that we did a tremendous amount of work with green mountain care board prior i have to say in the last year um it's been all coven all the time and so eyes have not been as as closely there um so i don't know exactly what they're asking about the race and ethnicity data i will tell you though um when we were doing our state health assessment we were asked by many to give much more detailed information about differences in the data uh based on a person's race ethnicity um and self-identification and the problem is we can't look at the data if it doesn't exist right and so most of health data is collected through the health care system we're able to bring a survey data where people self-identify but we don't have health care data um and it's that and we don't have the power to at this point to and require in the same way uh the collection of um race and ethnicity and health care data and so um i would say if that is something that the green mountain care board is doing it'd be interesting to look at and whether that would fill the gap that we found when we were trying to get at the data in the specific way we wanted for the state health assessment so so i um i can forward to you um what those are but it is very specific the the first phase is uh passing enabling um regulations to require health the health care system pieces to submit that data so that the ability to gather it would be there um and and uh they also had some some recommendations related to the data gathering requests in this legislation so i would love to share those with you and maybe get your reaction thank you okay right and interestingly um we do have the authority to require that so that's at least within certain scope uh we don't have as much authority as sometimes as we wish we had in terms of uh federal preemption but but there we have a i'm always always get a kick and this is not i'm not this is not saying that you've said this but i've always gotten a kick out of someone who's saying to me well we'd like to do that but we can't because the statute says we can't and they go statutes rs that's what we do we change statutes so we're looking uh so the green map care board testified last wednesday afternoon and representative donahue appreciate you being willing to send on that information to um i declined to look at and clearly there would be it sounds like it would be it would be clearly important to have some further alignment in terms of uh understanding how to how to really align the collection of data across our health system so that we could in fact uh so that you and others could analyze that data on behalf of issues of increasing the health and reducing health disparities so that that that has an exciting prospect uh that holds i think that holds holds uh real possibilities that we we we are i should say many of us are very interested in taking some initiative there represent page yes thank you chair um director kline um following up with uh the chair how many people how many individuals do you think your department will be required to have for this bill and and do you have any idea how much funding will also be required and as as the chair asked could you not just do some realignment of your uh your personnel to um to uh take care of this some of the requirements within this bill yeah yeah i mean i think what you know i rough it left i roughly was thinking maybe you know up to five different distinct positions um to carry it off over time and effectively the the two that i think are and the data we are doing a lot anyway so i think that one we probably could absorb if we needed to we required and made changes internally that um suggested that anytime we are doing a health analysis that we also are looking um and breaking it down uh to the extent that we can to be able to identify any inequities so i think that's underway as you will see in the data that we're producing now for covid um the support and management of the advisory committee is a full-time job the support and management of an office across government is a full-time job um we don't so and as you probably understand it's a combination of funding and positions for us uh that aren't always in line sometimes we have money in no position sometimes we have positions and no money uh so it has to be kind of both and almost all the positions as you will probably know in the health department um are assigned and and frankly most of them come through federal funding rather than state funding our ability to do our work and if that's true then we have federal requirements for and deliverables for the grant monies that we come in so we do our best to make sure our mission and the broader public health mission is can always and the needs of the state are always front and center but it also comes with a specific deliverable and scope of work and we have definitely worked within our all of our positions to say that health equity is a priority within the department and that staff will be trained and look at the work that they're doing through lens but to coordinate across the department our own department but then what this bill does is require coordination across multiple departments and then support of a commission that's really quite new and that that requires a lot of time and energy i'll have you know that um you know i just say from experience when i was responsible for the um development of our state health improvement plan which had many aspects as i said similar to this um this this bill it was a full-time job for me and i had to find other people to do my other responsibilities i mean we always make it work when we have to because that's what we do in public health and that's what we do in state government but if you want this you know sort of in the if you want this to be successful it needs to be sufficiently resourced and how much are you thinking um that amount would be you know i have no i don't but i'd be happy to consult with others and come back to you with that it you know honestly this was you know tidy clients look on the back of a notebook um but figuring out you know the level of position the resource that would be needed i'm happy to consult with the folks if that would be useful to you okay um also you talked about a person that would be dealing with grants submitting grants writing grants how much do you actually think um you would be able to obtain and in uh in grants each year oh that's a fascinating question and as you know it depends on the disease dessert um so um right now we have uh a lot because we have a huge need and i don't know what what i'd love to do is check in with our finance office if that's okay and just find out what we've been able to do over time uh the funding piece is not really my sweet spot to talk about yeah it would be interesting to know yeah whether the grants that would be brought in by such a person would more than uh take care of that person's salary if you know what i mean right right and it depends on exactly they're getting grants to do their salary or anything like that but whether we do no you're absolutely right that we when we put together grant proposals we have to put in some amount of funding to get the proposals in and then out the door even when we're granting out to others can i can i end up here for a second i think i think you might absolutely be kind of crossing wires here i uh represent page uh when as i was hearing uh haiti talking she i think you were talking about a grants manager because the bill calls for granting out monies to other organizations and that that would require a full-time position to do the grants managing but you've touched on something as well which i had actually made a note as well to see to think about what other resources might be leveraged from outside of state government perhaps federal monies or other uh philanthropic dollars or other other dollars through a grant writing process as well and i think i think so i just want to clarify i think when we're talking about grants management i believe haiti was talking about the position to be able to manage and do capacity building out going am i correct in that haiti thank you yes indeed to be overly familiar with yes yeah and and let me say it was um when we were gifted the opportunity to get some funds out to community through um covid related out to the community from the last legislative session it was an enormous amount of time and left to be able to get that out uh and required multiple people who um man you know both got out but then also provided support to the grantees to be able to carry forth and do the necessary reporting back because we have a fiscal responsibility that to be closed that loop okay and then my final question i swear um uh could you tell me what exactly what data are you going to be looking for when it comes to health care data can you can you go into a little more detail about what exactly that data is so we when we look at data in the health department um we look at we're primarily looking at health outcome data as opposed to health care services data right and so it is really our department of vermont health access um and the department of financial regulation that tends to be looking more at that health care the health care data meaning the data that describes what is happening in the health care system so data related to whether or not people have access to insurance access to providers um etc we do we um so let me just stop and ask when you say what kind of health care data do you have something in mind are you talking about the health of the health care system or you're talking about the data about individuals who are interfacing with the health care system uh i guess it would be the data that individuals are interfacing oh my i lost you on that i couldn't could you repeat that please the data that you would be getting from individuals uh what type of what type of data would it be right right so you know we when we are looking at individuals from um data that health care providers might be collecting in addition to what they are tracking there are some basic um items that we've been um working with actually the green mountain care board and others to try and ensure it are asked throughout primary care and others to give us a sense of not only an individual's physical um manifestation in uh when they go for a health care appointment but what else is going on in their lives that would help us to be able to describe the circumstances which aren't creating those health outcomes so for example uh you may know we now ask we're asking our health care partners to not only be able to ask demographic data which is different in representative um Donahue mentioned that you know getting be able to break down by race and ethnicity and by socioeconomic status but we're also interested um about whether or not people when they come in with with um particularly complex health conditions um are there concerns about food security are there concerns about housing security are there concerns um about their personal safety as you know we changed those questions many years ago to make sure people we were asking people about their personal safety because those are the those are the conditions in people's lives that might lead to their health outcome or their ability to manage their own health situation and so it's really important to have the context of people's lives in order to both understand trends but also most importantly how to figure out how to support either through treatment or prevention that individual from um having their health condition worsen I don't know if that was specific enough for you um sorry but I can certainly get you more specificity if you'd like in I'm immune thank you and uh I again I would uh ask uh Nolan from our joint fiscal office to contact you to to add to his current fiscal analysis of h210 based on what you said so that we have a a range of ideas um and let's turn to represent Peterson yes thank you uh director Klein thank you for your presentation most informative um my questions uh some of the questions I have on the bill are around duplication of effort uh redundancy uh of what you're already doing um I'm concerned that we're we're establishing something where maybe there's not really a need and I'm wondering how much of the outcomes outlined in the bill that you will you folks already are in progress of doing are partly doing and wouldn't it make sense to maybe add a couple people there to get us to where we want to be rather than establish a whole new uh commission and and and bill I wonder if you could speak to that I know that's involved but yeah no no I think it's a fair question because as I you know I started with you know I think it's very much an alignment with where where we've been aiming towards uh and what we've been trying to do with the resources that we have and so I think it's a very fair question to be asking I think um the pieces that the commission add that are different right um is it formalizes a structure that doesn't exist right now so right now we do a lot of individual reaching out we do a lot of work on our own but we don't bring people together on a consistent basis for routine and ongoing conversation so that that's something that would be different okay could I interrupt you there what people are we talking when you say bring people together give me an example of what that is so right now we we as the health department uh for example may have work that we're doing on cancer prevention and we may then look and see like oh my goodness the rates of can't a certain type of cancer are much higher amongst um certain populations so whether it's our indigenous populations or it's uh black men we might try and reach out individually to organizations that represent those groups and say hey we see this problem can you help us think about how to better design the program understand what's going on use our resources what we wouldn't be doing however is bringing together those groups with us on a sustained effort right and so and only we would be hearing it when really so this is what we learned through the state health improvement plan um all the issues are interconnected it's all the same like if we really go back to like what's driving these poorer health outcomes it's the same bottom drivers it's poverty right it's it's racism poverty and genderism that and so what we do for one community should benefit others but we're not getting that intersection that was a really mouthy way of saying the difference that this commission would bring is that it would create a space that it's not just the health department but the department of housing and community development that the department of children and families and the health department and the other state entities are together and hearing directly from the um the abinacchi from pride romant from the mental health and disabilities group all together in a way that's looking at how the same issues drive multiple health outcomes so that that's one piece that's different the big the other big thing honestly is that point um grant funding out into community right that is definitely new and different it's not what we're doing now right we try through small grants when we have the ability to do that but we don't have a routine and systematized way of ensuring that we are looking for grants we're catching them you know when there's as Representative Lippert was saying outside grants whether they're federal or philanthropic and having a way to bring them into this state and then just first them throughout the state in a way that hits the populations of concern so that is that is new and different I think a lot of the other stuff is it's an addition to what we are already doing but those two pieces are significantly new and different okay bringing groups together and coming up with a strategy is what you're saying yeah so individually handling problems exactly so I would I would say you know I know that the legislator legislature often will have like a summer commission or a special study group because you realize you need certain thinkers in the room to problem solve something together rather than separately that's the way that I imagine there's some some some correspondence thank you thank you let me just say this is not the only time we will be looking at this bill but we are we are putting it in front of us at this point because we are also being asked to make some budget recommendations both short term today and for the buy for the first half of the biennium we were being asked to make at least our initial recommendations by Friday so this is actually helpful it's also the case if I so we're going to come back and once we finished with this testimony this morning which I hope we will finish up which we will finish up in the next 10 to 15 minutes because we have other work that we have to do but this is very helpful and I think it contributes to our consider our deliberations there there are there are ways to get from here to there if I put it that way that you don't necessarily have to have everything in place fully in order to start something and I think many of us have been down that road with different initiatives over the years so but this is but it's very helpful to have your perspective on this as well so I'm going to turn to so I had so Brian before I turn to you represent China we had also invited Nolan from the Joint Fiscal Office to do a presentation which you know and now this is in some ways impacted perhaps differently and additionally based on the testimony we've heard and that's why we have testimony and but I thought I might have Nolan we'll hear hear what your question is and then have Nolan run through that in a brief in a brief manner knowing that it may very well need to be further updated based on some of our testimony today and if I could just say one last thing in closing because I would be remiss if I didn't say right now at this moment and I think you heard me say we are all COVID all the time and significant and so just in terms of the difference between where we are today and what we want to accomplish as a state and in public health I would be remiss if I didn't have you know the extent to which our current staff are significantly stressed under resourced proud of the work we're doing but exhausted yes and I think you all just need to know that as we think about what we can do versus not a lot of the information that I shared with you in terms of what we were doing is pre COVID all that is work that we hope to return to at some point but right now we are beyond max with our ability to address this epidemic which has to be first and foremost and hopefully is done with an eye towards the disparate impact on different populations but I just placing it I think is really important I think that's very important and I really appreciate you making that explicitly clear we certainly I think many of us have deep appreciation for the enormous work of the staff at the Department of Health from your commissioner on down through all the line staff which have contributed greatly to Vermont perhaps being the safest state during this pandemic it's making a huge impact and we have deep gratitude for that and I think we do need to take that into consideration as we contemplate asking the department or the staff to take on any new initiative in the midst of this at the same time I think there may be ways that we can consider setting some things in motion which allow for allow for things to move forward without adding that level of stress but but so with that no or Brian so I would actually welcome you to stay with us if you can whoops yeah but you go off screen if you like that's fine but I'm gonna my goal right now is to hear from represent China then to turn to the Joint Fiscal Office analysis briefly and then bring this to a close take a break and then have our committee come back to our ongoing discussions that we started yesterday and with that Brian yeah so I'm hesitant to ask the question but at the same time I think I will and maybe director Klein I'll try to be brief on my question maybe you can give us a short answer today because it might lend itself to a big answer I'm just curious like during the pandemic can you give us an example of how you've seen systemic racism affecting people and how might this bill improve that coming out of the pandemic yeah I've seen a few things I think when we're running so fast and furious we think of the majority and you know the old 80 percent 20 percent rule like if you can get the 80 percent you're doing great and then you'll worry about the 20 percent later right and it's the 20 percent this is a terrible analogy but it's the 20 percent that are the individuals who are the hard to reach or the people who are vulnerable or the you know whatever term we tend to use for that and so but we focused on the majority and then come back to the manager minority or and so it has played out a couple of times not only in our work but with the with the rest that in our rush to move quickly and expeditiously we don't necessarily lead with who is who are the populations that are going to be hardest and how do we design and implement based on that first knowing if we do that well everybody else will be well served it's sort of turning the paradigm upside down and I think that's a place where we have not done as well as we could have because we came back later I think we've learned a lot we've done really well and correcting what we've learned in terms of not leading with the most vulnerable and coming back to them later and and the difference and having said that we went first with people who are most likely to die as opposed to people most likely to get sick we've done a really good job with people most likely to die people most likely to get exposed we continue to struggle in making that the priority because it's more complicated right and it's the more complicated that tends to it takes more time it takes more investment and when we're running full speed and we don't have somebody who's calling us and has the authority to say the most complicated is where you need to be it might not be heard as as strongly as the get it done as fast and as much as you can when you're in a crisis and so I think that's that's the difference of what we've learned I don't know if that really answered what you're saying but it's about inverting the where we focus and you know holding ourselves accountable to that which we care deeply about but when in crisis we move fast um and we move with what's easy and then come back to what's complicated yeah would it be fair to say that like what I heard you say is the difference this bill might make is it might build a new piece of accountability into the system coming out of the pandemic to it simply said okay thank you and I would just add to that what I'm hearing is that it would actually put in place some additional infrastructure that would allow that to happen that when you when you're in the midst of rushing which you do need to do when you're in a crisis we've been in uh that you have you don't have to you're no longer having to build the infrastructure that's going to give you the information and the accountability that you need when you're in the midst of crisis absolutely like having you know this is a part of building that infrastructure into an accountability into place yeah and we now exactly we now do have for example some not enough but some some really stronger relationships with community organizations that have the the ability to reach the people that need to be reached or to help us design the program in a way but we don't have enough of that but this is the this is the way it would be ready for us and we wouldn't as you said represent the part we wouldn't be building at the same time that we were in crisis right so with that I would like to take uh I mean we're we're all pressed for time but I think it'd be useful to have uh Nolan run through uh his initial uh analysis based on the bill as introduced and um and then um I might just add that I think given where we are in the midst of this health crisis national health crisis international health crisis uh we might actually also there there may there may be some opportunities at the federal level where the underfunding of public health generally which has exacerbated this crisis all across the country uh perhaps there will be some additional attention to that which might benefit some of all of this uh moving forward but with that uh Nolan would you run us through your presentation sure and then we're going to take a break yep uh for the record Nolan Langwell the joint fiscal office um as representative Lippert said I'm going to be brief um I'm going to put um the fiscal note should be on the website for those who want to look at it um and you should have it up now yes it's on the screen okay perfect um so um this is based on the information I have at the moment and so concerning the office of health equity the language says um the shall hire a director director of health equity and may hire other personnel so what I did was I looked at different pay grades that I thought would fit into those various ranges and came up with what I what would be a range estimate of uh the cost for a director of health equity which would be anywhere between 102 and 147 thousand dollars roughly when you take into considerations not just salary but benefits and FICA which is social security tax and other um and then we heard Heidi talk about how other personnel would need to be hired as well and I took a pay grade 24 which is an estimated salary range 52 to 85 thousand and then you add in the benefits you know it could be um that includes health insurance which could be a single could be a family plan so there's a range in there so that plan that particular other employees could range between 65 thousand 117 thousand when you add in where they're on the pay scale um what they're hired at what their benefits are um I also make the point and Heidi made this point too that much of the health department is funded through grants those grants are tied to different things so people are hired to do the work of that grant so we can't take money that's being used for another grant for this so I'm assuming for now it's pure general fund unless other funds or grants could be identified but that again would be that would be something that would have to be figured out so for now I'm assuming it's general fund for the health equity advisory commission um we heard Heidi talk about how that would also need to be staffed I didn't put that in there but what I do is the per diems because there's language in there that says public members so there's 26 members of which 18 are public members so the other people that aren't public members we assume would be paid through their jobs so the public members because the language in there would we'd be entitled to per diems and we have a standard calculation that we use for diems I'm assuming that there would be three in-person meetings so when you add that all up it's about $6400 for per diems which is not a ton of money and that would come out of the health department budget grants for grants and promotion of health equity again there's no appropriation for the grant in the bill so if you were if you want to do this we would actually have to have an appropriation in order to do this but there's no appropriation there we also heard Heidi say that this position would likely need a grants manager so a future fiscal note might address that and then the data responsiveness to health equity inquiries we heard from the green mountain care board the other day that it would be they would need $165,000 that's gross of which 66,000 would be general funds because they have a bill back so they would bill back for 99,000 and would need 66,000 dollars in general funds at the time and actually currently still I don't know what other costs would be incurred by other departments and agencies across the government you know would the health department need to change some of its contracts or could I do it within their system budget which I think I might have heard them say what about other departments so those are the areas that are sort of up in the air we don't really know a lot about what those needs would be and then the final finally this is the summary of what I just put it into a chart in the summary of what it sort of said in the fiscal note so that's a quick high level overview as chair Lipperton has said you know this is based on the information we have today I hope to continue to work with Heidi and David Langelander and other folks at the health department and across HHS to get more information and to continue to update the fiscal notes that we can come into more specific numbers to move forward great thank you Nolan I really appreciate your work there and I would ask you to be in touch with Heidi and to maybe make a subsequent fiscal note based on some of the testimony we heard here today I'd be happy to check in with you as well but I think if you could if you could do that in the near term that would be great well I think this is this has been valuable this has been valuable to help us understand this bill and also put some context in terms of some of our broader work as I said we're not this is not the conclusion of testimony on this bill but it helps us as we frame some of the questions we have in terms of budget recommendations and etc so with that according to my clock it's a 10-04 I'm going to suggest that we take a 15 minute break let's well let's come back at 10 20 and reconvene and Colleen you can take us off YouTube during that period of time as well I don't know if there we've ever figured out how to let people know when we're coming back but we'll take a 15 minute break and then when we can oh in the interim I took the liberty to take some of the work we did yesterday as a committee and took a look at what we had done and I looked at them and said oh there's some obvious categorization that we could do and so I have asked Representative Houghton and she again did her magic and reorganized that for us with some headings that I suggested and so I'm going to ask her if she would send it out you can take a look at it during the break if you like or take a complete break and we'll look at it when we come back as we continued our process of uh uh budget recommendations so um yeah let's let's let's come back at 10 10 let's say let's come back at 10 25