1 00:00:00,021 --> 00:00:03,417 (electronic intro music) 2 00:00:05,610 --> 00:00:08,850 - Hello, this is Lab Medicine Rounds, a curated podcast 3 00:00:08,850 --> 00:00:11,490 for physicians, laboratory professionals and students. 4 00:00:11,490 --> 00:00:12,720 I'm your host, Justin Kreuter 5 00:00:12,720 --> 00:00:15,051 at The Bow Tie Bandit of Blood 6 00:00:15,051 --> 00:00:17,880 Transfusion Medicine Pathologist at Mayo Clinic. 7 00:00:17,880 --> 00:00:20,400 Today, we're rounding with Dr. Bobbi Pritt, 8 00:00:20,400 --> 00:00:22,540 Professor of Laboratory Medicine and Pathology 9 00:00:22,540 --> 00:00:24,120 and Division Chair 10 00:00:24,120 --> 00:00:27,090 for the Department of Clinical Microbiology at Mayo Clinic 11 00:00:27,090 --> 00:00:28,830 here in Rochester, Minnesota. 12 00:00:28,830 --> 00:00:31,840 And we're gonna be talking about this year's tick season 13 00:00:31,840 --> 00:00:33,989 and what it means for individuals 14 00:00:33,989 --> 00:00:35,910 working in the hospital setting. 15 00:00:35,910 --> 00:00:38,190 So thanks for joining us today, Dr. Pritt. 16 00:00:38,190 --> 00:00:40,680 - Oh, it's my pleasure to be here. 17 00:00:40,680 --> 00:00:43,749 - Hey, so what does this season, tick season look like? 18 00:00:43,749 --> 00:00:47,823 I've been hearing that it's predicted to be severe. 19 00:00:48,963 --> 00:00:50,050 What is that? 20 00:00:50,050 --> 00:00:53,490 - Yeah, well, that's what the predictions are right now. 21 00:00:53,490 --> 00:00:55,110 Of course, that could change, 22 00:00:55,110 --> 00:00:57,660 and it's hard to what the weather's gonna be. 23 00:00:57,660 --> 00:01:01,530 But yes, it looks like because of our milder winter 24 00:01:01,530 --> 00:01:05,160 and that's gonna allow the ticks to survive, 25 00:01:05,160 --> 00:01:07,821 more ticks to survive our cold Minnesota winters 26 00:01:07,821 --> 00:01:11,130 and other parts of the world, or parts of our country, 27 00:01:11,130 --> 00:01:14,610 that, yeah, there may be more ticks out and about this year. 28 00:01:14,610 --> 00:01:16,590 And we're certainly seeing that in the laboratory. 29 00:01:16,590 --> 00:01:19,920 We've received a lot of tick submission so far. 30 00:01:19,920 --> 00:01:20,753 - I see. 31 00:01:20,753 --> 00:01:22,170 So, I mean, you mentioned 32 00:01:22,170 --> 00:01:24,973 some of the weather kind of patterns changing. 33 00:01:24,973 --> 00:01:28,740 What are the different things that make it 34 00:01:28,740 --> 00:01:31,770 that kind of influence on the tick season? 35 00:01:31,770 --> 00:01:34,140 I guess not being, you know, 36 00:01:34,140 --> 00:01:37,781 working as a subspecialist in in microbiology, like you are, 37 00:01:37,781 --> 00:01:39,300 I'm not really attuned to, 38 00:01:39,300 --> 00:01:42,300 or I don't recall hearing about, you know, 39 00:01:42,300 --> 00:01:45,480 the tick season being severe or not. 40 00:01:45,480 --> 00:01:49,170 - Yeah, you know, it's complicated, it's multifactorial, 41 00:01:49,170 --> 00:01:52,290 and weather is indeed a pretty important part of it. 42 00:01:52,290 --> 00:01:55,320 So if you have warmer, wetter winters, 43 00:01:55,320 --> 00:01:57,630 you're going have more ticks survive. 44 00:01:57,630 --> 00:02:00,060 And that means that they are come out 45 00:02:00,060 --> 00:02:01,680 and if you have an earlier spring, 46 00:02:01,680 --> 00:02:02,940 they're going be out earlier. 47 00:02:02,940 --> 00:02:05,220 They come out as soon as the snow melts. 48 00:02:05,220 --> 00:02:07,261 But of course, they need to feed 49 00:02:07,261 --> 00:02:10,830 and they feed on small animals, initially, 50 00:02:10,830 --> 00:02:12,960 small rodents, for example. 51 00:02:12,960 --> 00:02:15,510 So if you happen to have an abundance of rodents 52 00:02:15,510 --> 00:02:18,072 because perhaps there was an abundance of acorns, 53 00:02:18,072 --> 00:02:22,110 then you may have more food source for the ticks. 54 00:02:22,110 --> 00:02:25,290 And then that may increase the number of ticks. 55 00:02:25,290 --> 00:02:28,830 And then last, but not least, you also have human behavior. 56 00:02:28,830 --> 00:02:31,620 If humans are out and about and going out into the woods 57 00:02:31,620 --> 00:02:33,150 because it's safer than, you know, 58 00:02:33,150 --> 00:02:35,772 being in close contact because of COVID, 59 00:02:35,772 --> 00:02:38,970 then that could also increase 60 00:02:38,970 --> 00:02:40,860 the risk of tickborne diseases. 61 00:02:40,860 --> 00:02:42,741 So it's really the ticks themselves, 62 00:02:42,741 --> 00:02:45,960 what they feed on, the so-called reservoir host, 63 00:02:45,960 --> 00:02:49,680 which includes small mammals, rodents, deer 64 00:02:49,680 --> 00:02:51,210 and humans, of course. 65 00:02:51,210 --> 00:02:52,890 And then human behavior 66 00:02:52,890 --> 00:02:56,490 and what we're doing as far as expanding into populations 67 00:02:56,490 --> 00:02:57,960 where ticks may be. 68 00:02:57,960 --> 00:02:59,400 If we're out mowing our lawn, 69 00:02:59,400 --> 00:03:04,290 if we're creating new housing development in forested areas 70 00:03:04,290 --> 00:03:06,480 and we're infringing upon that region 71 00:03:06,480 --> 00:03:08,613 where ticks, and deer and rodents are found, 72 00:03:08,613 --> 00:03:10,860 there may be more contact. 73 00:03:10,860 --> 00:03:11,700 - Yeah, certainly. 74 00:03:11,700 --> 00:03:15,232 I know my family, we've been doing a lot of these, 75 00:03:15,232 --> 00:03:18,870 I've been enjoying our post-dinner walks during COVID. 76 00:03:18,870 --> 00:03:21,540 But yeah, we have been getting out quite a bit more 77 00:03:21,540 --> 00:03:26,540 than maybe we have in previous kind of pre-COVID summers. 78 00:03:26,880 --> 00:03:28,770 - Yeah, it's been really interesting, Dr. Kreuter. 79 00:03:28,770 --> 00:03:31,221 So we follow all of the infectious disease, 80 00:03:31,221 --> 00:03:34,770 all the organisms in the laboratory that we test for. 81 00:03:34,770 --> 00:03:36,270 Some have taken a real hit. 82 00:03:36,270 --> 00:03:38,732 Influenza was down during COVID, 83 00:03:38,732 --> 00:03:41,640 probably because we were masking, and social distancing 84 00:03:41,640 --> 00:03:43,470 and that's a respiratory virus. 85 00:03:43,470 --> 00:03:46,500 Enterovirus is down. Bordetella pertussis is down. 86 00:03:46,500 --> 00:03:49,080 But tickborne infections is up. 87 00:03:49,080 --> 00:03:51,840 And I think that's because it is something 88 00:03:51,840 --> 00:03:54,690 that people can do while they're socially distancing. 89 00:03:54,690 --> 00:03:55,943 And yet the ticks don't care about COVID, 90 00:03:55,943 --> 00:03:57,780 they're gonna bite you regardless. 91 00:03:57,780 --> 00:03:59,201 They don't socially distance 92 00:03:59,201 --> 00:04:00,750 (Dr. Kreuter laughs) 93 00:04:00,750 --> 00:04:02,352 - Much to our chagrin. 94 00:04:02,352 --> 00:04:03,540 - I know. 95 00:04:03,540 --> 00:04:06,750 - So you mentioned, you know, working in the laboratory, 96 00:04:06,750 --> 00:04:08,250 what you're starting to notice. 97 00:04:08,250 --> 00:04:12,990 And I'm curious for, you know, what does that mean for, 98 00:04:12,990 --> 00:04:15,480 you know, all of us, you know, who work 99 00:04:15,480 --> 00:04:17,760 and also for our students who might be listening 100 00:04:17,760 --> 00:04:19,950 that are learning in our hospitals. 101 00:04:19,950 --> 00:04:24,240 What does the severe tick summer mean for all of us? 102 00:04:24,240 --> 00:04:26,040 - Well, I think it means that we're going to see 103 00:04:26,040 --> 00:04:30,000 more laboratory tests surrounding tickborne diseases. 104 00:04:30,000 --> 00:04:33,330 So in my laboratory in clinical microbiology, 105 00:04:33,330 --> 00:04:34,950 that may mean seeing more ticks 106 00:04:34,950 --> 00:04:37,410 being submitted for identification, 107 00:04:37,410 --> 00:04:39,930 more tickborne pathogen tests 108 00:04:39,930 --> 00:04:43,860 for things like Lyme disease, anaplasmosis, babesiosis. 109 00:04:43,860 --> 00:04:44,910 But it's going to impact 110 00:04:44,910 --> 00:04:47,280 other areas of the laboratory as well. 111 00:04:47,280 --> 00:04:50,520 So for example, one of the hallmark findings 112 00:04:50,520 --> 00:04:53,610 in the laboratory for many tickborne infections 113 00:04:53,610 --> 00:04:57,283 is leukopenia, specifically lymphopenia, 114 00:04:57,283 --> 00:04:59,880 thrombocytopenia, 115 00:04:59,880 --> 00:05:02,100 and elevated liver function tests. 116 00:05:02,100 --> 00:05:03,900 So those are some basic chemistries 117 00:05:03,900 --> 00:05:07,770 that people may see increased in orders for, 118 00:05:07,770 --> 00:05:09,120 to evaluate patients 119 00:05:09,120 --> 00:05:11,580 that potentially have a tickborne infection. 120 00:05:11,580 --> 00:05:12,413 And then of course, 121 00:05:12,413 --> 00:05:15,990 some infections have non-infectious entities 122 00:05:15,990 --> 00:05:17,160 in their differential. 123 00:05:17,160 --> 00:05:18,720 So we may see more ordering 124 00:05:18,720 --> 00:05:20,850 for things that could be tickborne 125 00:05:20,850 --> 00:05:22,364 but could be something else. 126 00:05:22,364 --> 00:05:26,730 So it could impact across the laboratory in different areas. 127 00:05:26,730 --> 00:05:30,804 - Oh, have you been getting some invitations to kind of talk 128 00:05:30,804 --> 00:05:32,670 with some of our clinical colleagues 129 00:05:32,670 --> 00:05:34,950 about that differential diagnosis? 130 00:05:34,950 --> 00:05:37,530 I imagine that's something to kind of revisit 131 00:05:37,530 --> 00:05:39,870 with the learners periodically over time. 132 00:05:39,870 --> 00:05:41,520 - Yeah, I try to do that every year. 133 00:05:41,520 --> 00:05:44,550 We always host some educational events 134 00:05:44,550 --> 00:05:46,860 for tickborne pathogens in general. 135 00:05:46,860 --> 00:05:50,100 And we do it for laboratorians, for our clinical colleagues 136 00:05:50,100 --> 00:05:52,020 and also for the general public. 137 00:05:52,020 --> 00:05:54,750 I usually give at least one talk every year 138 00:05:54,750 --> 00:05:56,640 on how to protect yourself from tick bites 139 00:05:56,640 --> 00:05:58,620 because that's so important. 140 00:05:58,620 --> 00:05:59,843 - Oh, that's awesome. 141 00:05:59,843 --> 00:06:03,060 Hey, so you mentioned about the infections 142 00:06:03,060 --> 00:06:04,950 that are associated with ticks 143 00:06:04,950 --> 00:06:06,900 and about that differential diagnosis. 144 00:06:06,900 --> 00:06:10,410 And maybe I'm going off in the wrong direction here. 145 00:06:10,410 --> 00:06:12,450 Please let me know if to reel back in. 146 00:06:12,450 --> 00:06:15,285 But, you know, a lot of times with microbiology, 147 00:06:15,285 --> 00:06:17,460 I guess with bacteriology, 148 00:06:17,460 --> 00:06:20,100 I think about kind of superbugs and kind of 149 00:06:20,100 --> 00:06:21,990 is there any concern with something 150 00:06:21,990 --> 00:06:24,600 about severe tick season? 151 00:06:24,600 --> 00:06:28,590 You know, are these infections going to be worse 152 00:06:28,590 --> 00:06:31,410 and more severe in the same kind of way? 153 00:06:31,410 --> 00:06:32,760 - So, great question. 154 00:06:32,760 --> 00:06:35,520 At this point, the tickborne pathogens, 155 00:06:35,520 --> 00:06:38,640 at least the bacteria that cause tickborne illness, 156 00:06:38,640 --> 00:06:41,970 seem to be susceptible to our standard drugs we use, 157 00:06:41,970 --> 00:06:45,884 which is mostly doxycyline, which is an antibacterial agent. 158 00:06:45,884 --> 00:06:49,394 Having said that, we always are monitoring 159 00:06:49,394 --> 00:06:52,020 to look for cases that don't respond 160 00:06:52,020 --> 00:06:53,670 to your typical therapies. 161 00:06:53,670 --> 00:06:55,230 And I will also mention 162 00:06:55,230 --> 00:06:57,390 that there are things like viruses and parasites, 163 00:06:57,390 --> 00:07:00,090 which don't respond to antibacterials at all, 164 00:07:00,090 --> 00:07:02,970 and we don't have any effective treatments for. 165 00:07:02,970 --> 00:07:05,190 We're seeing more cases of viral diseases, 166 00:07:05,190 --> 00:07:09,180 like Powassan virus, Heartland virus, Bourbon virus. 167 00:07:09,180 --> 00:07:10,923 Babesiosis is a parasite 168 00:07:10,923 --> 00:07:14,160 that also doesn't respond to antibacterials. 169 00:07:14,160 --> 00:07:16,680 So to answer your first question, 170 00:07:16,680 --> 00:07:20,880 we are not seeing any superbugs, yet, hopefully never. 171 00:07:20,880 --> 00:07:23,310 But we are seeing things more and more 172 00:07:23,310 --> 00:07:25,290 that we just don't really have good treatments for. 173 00:07:25,290 --> 00:07:27,510 And that would be right now the viruses. 174 00:07:27,510 --> 00:07:29,400 - Hmm, I gotcha. 175 00:07:29,400 --> 00:07:34,400 So, you know, going forward, I'm trying to get a a sense 176 00:07:35,220 --> 00:07:39,660 of this kind of this cycle on what are some of those factors 177 00:07:39,660 --> 00:07:41,910 that make this, you know, 178 00:07:41,910 --> 00:07:44,164 a worse or more severe tick season. 179 00:07:44,164 --> 00:07:47,160 And, you know, is this gonna be 180 00:07:47,160 --> 00:07:50,490 kind of undulating, oscillating over time going forward? 181 00:07:50,490 --> 00:07:52,440 Or is this something where, you know, 182 00:07:52,440 --> 00:07:55,500 it's likely to get progressively worse? 183 00:07:55,500 --> 00:07:59,280 I guess what are experts in the community saying? 184 00:07:59,280 --> 00:08:00,870 - Yeah, it's complicated. 185 00:08:00,870 --> 00:08:02,730 I wish I had a crystal ball to predict. 186 00:08:02,730 --> 00:08:06,030 But we do well understand some certain patterns. 187 00:08:06,030 --> 00:08:10,110 So first of all, warmer, milder and wetter winters 188 00:08:10,110 --> 00:08:11,970 means that more ticks survive. 189 00:08:11,970 --> 00:08:14,820 So with global warming and climate change, 190 00:08:14,820 --> 00:08:17,010 if we continue to see warmer winters, 191 00:08:17,010 --> 00:08:20,790 that's going to increase the risk for tickborne diseases. 192 00:08:20,790 --> 00:08:23,340 Earlier springs mean people are out and about. 193 00:08:23,340 --> 00:08:27,390 Longer summers and falls mean people are outside longer. 194 00:08:27,390 --> 00:08:29,580 So anything that's gonna change those patterns 195 00:08:29,580 --> 00:08:32,100 is going to influence tickborne diseases. 196 00:08:32,100 --> 00:08:34,290 And then also ticks are migrating. 197 00:08:34,290 --> 00:08:37,290 They're expanding their ranges substantially, 198 00:08:37,290 --> 00:08:39,390 from the Northeast, the Upper Midwest, 199 00:08:39,390 --> 00:08:41,790 up into Canada, we have the Blacklegged tick. 200 00:08:41,790 --> 00:08:44,550 And those ranges continue to expand every year, 201 00:08:44,550 --> 00:08:45,990 putting more people at risk 202 00:08:45,990 --> 00:08:50,070 for things like Lyme disease, babesiosis and anaplasmosis. 203 00:08:50,070 --> 00:08:51,444 Now, there's a caveat, though, 204 00:08:51,444 --> 00:08:55,770 that as the warm weather gets very hot and dry, 205 00:08:55,770 --> 00:08:57,540 then the ticks will often go into hiding, 206 00:08:57,540 --> 00:08:59,400 'cause they out very quickly. 207 00:08:59,400 --> 00:09:01,320 So hot weather in and of itself 208 00:09:01,320 --> 00:09:03,390 doesn't necessarily mean more ticks. 209 00:09:03,390 --> 00:09:06,450 But when it's accompanied by high humidity and moisture, 210 00:09:06,450 --> 00:09:09,690 then that's perfect weather for tick survival. 211 00:09:09,690 --> 00:09:11,040 - I see. 212 00:09:11,040 --> 00:09:12,175 You know, one of the things 213 00:09:12,175 --> 00:09:14,910 that our audience may not know, 214 00:09:14,910 --> 00:09:19,910 I guess I've seen photos of you doing research in the field. 215 00:09:20,580 --> 00:09:21,600 So, you know, a lot of times 216 00:09:21,600 --> 00:09:25,680 we think about medical researchers with Erlenmeyer flasks 217 00:09:25,680 --> 00:09:28,590 in a very sterile lab, 218 00:09:28,590 --> 00:09:32,880 but you do a lot of research in the field. 219 00:09:32,880 --> 00:09:35,415 I was curious if you have a favorite story 220 00:09:35,415 --> 00:09:38,580 about those experiences 221 00:09:38,580 --> 00:09:41,284 of leading some of these students and other colleagues 222 00:09:41,284 --> 00:09:45,150 into the field to do some of this tick based research. 223 00:09:45,150 --> 00:09:47,580 'Cause I think this is just fascinating 224 00:09:47,580 --> 00:09:51,000 in an aspect of your practice 225 00:09:51,000 --> 00:09:53,190 that just most people aren't aware of. 226 00:09:53,190 --> 00:09:57,404 - Yeah, thanks Dr. Kreuter. It is a fun part of my job. 227 00:09:57,404 --> 00:09:59,400 So I'll give you a little background. 228 00:09:59,400 --> 00:10:02,310 I was able to do a Mayo Foundation Scholar Program 229 00:10:02,310 --> 00:10:04,320 right after my fellowship here. 230 00:10:04,320 --> 00:10:05,153 And I went 231 00:10:05,153 --> 00:10:07,110 to the London School of Hygiene and Tropical Medicine 232 00:10:07,110 --> 00:10:10,204 and took classes in entomology, parasitology. 233 00:10:10,204 --> 00:10:13,500 Got my master's degree in medical parasitology. 234 00:10:13,500 --> 00:10:15,540 And learned how to go out into the field 235 00:10:15,540 --> 00:10:18,990 and sample for ticks and mosquitoes. 236 00:10:18,990 --> 00:10:21,600 And then you could take those ticks and mosquitoes, 237 00:10:21,600 --> 00:10:24,840 and go back to the lab and test them for various pathogens. 238 00:10:24,840 --> 00:10:27,930 So I was very fortunate once I came back to Mayo 239 00:10:27,930 --> 00:10:30,360 to be involved in discovery efforts 240 00:10:30,360 --> 00:10:34,080 for two new tickborne bacterial pathogens. 241 00:10:34,080 --> 00:10:36,420 And because they were brand new, we knew nothing about them, 242 00:10:36,420 --> 00:10:39,150 we didn't know what type of tick transmitted them. 243 00:10:39,150 --> 00:10:40,754 So we wanted to ask those questions 244 00:10:40,754 --> 00:10:43,530 of, what is the tick that's the culprit here? 245 00:10:43,530 --> 00:10:44,790 Who's the vector? 246 00:10:44,790 --> 00:10:47,250 So for several years in a row, 247 00:10:47,250 --> 00:10:50,340 I went out into the field and collected ticks 248 00:10:50,340 --> 00:10:53,250 using those methods I learned back in London. 249 00:10:53,250 --> 00:10:54,540 And I would bring with me 250 00:10:54,540 --> 00:10:57,660 undergrad students, internal medicine residents, 251 00:10:57,660 --> 00:11:01,380 pathology residents, clinical microbiology fellows. 252 00:11:01,380 --> 00:11:03,796 And I even would team up with the CDC, 253 00:11:03,796 --> 00:11:07,080 and the Minnesota and Wisconsin Departments of Health 254 00:11:07,080 --> 00:11:09,300 and University of Wisconsin. 255 00:11:09,300 --> 00:11:11,316 So we've had kinda tick parties 256 00:11:11,316 --> 00:11:14,010 where we all go out and drag for ticks. 257 00:11:14,010 --> 00:11:16,170 And then we, you know, have a big cookout 258 00:11:16,170 --> 00:11:17,730 and have fun afterwards. 259 00:11:17,730 --> 00:11:20,225 And then we sit down at the microscopes, identify the ticks, 260 00:11:20,225 --> 00:11:22,905 and then I would bring them back to my laboratory 261 00:11:22,905 --> 00:11:27,090 and test them like we would test a human sample. 262 00:11:27,090 --> 00:11:30,930 Not something we routinely do, but can do for research. 263 00:11:30,930 --> 00:11:34,140 So those have been great experiences 264 00:11:34,140 --> 00:11:36,000 and it's allowed us to really understand 265 00:11:36,000 --> 00:11:38,910 our two new emerging pathogens a bit more. 266 00:11:38,910 --> 00:11:41,520 So haven't done it in a couple years since COVID, 267 00:11:41,520 --> 00:11:42,390 but I don't know, you know, 268 00:11:42,390 --> 00:11:43,920 there's always new pathogens out there. 269 00:11:43,920 --> 00:11:45,233 And if we discover something else, 270 00:11:45,233 --> 00:11:48,060 I'll be right out into the field again. 271 00:11:48,060 --> 00:11:50,520 - Yeah, absolutely. Thanks for sharing that story with us. 272 00:11:50,520 --> 00:11:52,687 I think it nicely captures this, you know, 273 00:11:52,687 --> 00:11:56,073 interprofessional, you know, multi-specialty nature 274 00:11:56,073 --> 00:12:00,030 that is laboratory medicine and pathology. 275 00:12:00,030 --> 00:12:02,280 And we've been fortunate to have you 276 00:12:02,280 --> 00:12:04,860 as a guest on this podcast a few times, 277 00:12:04,860 --> 00:12:05,972 but I think this is the first time 278 00:12:05,972 --> 00:12:09,831 we've broken out the phrase tick party. 279 00:12:09,831 --> 00:12:10,664 - Tick party. Who wants a tick party? 280 00:12:12,751 --> 00:12:14,640 (Dr. Kreuter laughs) 281 00:12:14,640 --> 00:12:16,680 - So thank you so much, Dr. Pritt 282 00:12:16,680 --> 00:12:18,540 for talking about this with us today, 283 00:12:18,540 --> 00:12:20,850 rounding with us about the ticks 284 00:12:20,850 --> 00:12:23,343 and helping us get our head around, 285 00:12:23,343 --> 00:12:25,710 why it's gonna be a severe tick summer, 286 00:12:25,710 --> 00:12:27,870 what this means for us in the laboratory. 287 00:12:27,870 --> 00:12:28,980 - Well, thanks Dr. Kreuter, 288 00:12:28,980 --> 00:12:31,683 I appreciate the opportunity to talk ticks anytime. 289 00:12:32,610 --> 00:12:33,690 - To all of our listeners, 290 00:12:33,690 --> 00:12:35,010 thank you for joining us today. 291 00:12:35,010 --> 00:12:35,910 We invite you to share 292 00:12:35,910 --> 00:12:38,430 your thoughts and suggestions via email. 293 00:12:38,430 --> 00:12:43,430 Please direct any suggestions to mcleducation@mayo.edu 294 00:12:43,500 --> 00:12:45,510 and reference this podcast. 295 00:12:45,510 --> 00:12:47,820 If you've enjoyed Lab Medicine Rounds podcast, 296 00:12:47,820 --> 00:12:48,732 please subscribe. 297 00:12:48,732 --> 00:12:50,550 Until our next rounds together, 298 00:12:50,550 --> 00:12:53,970 we encourage you to continue to connect lab medicine 299 00:12:53,970 --> 00:12:57,633 and the clinical practice through insightful conversations.