Time Stamps

  • 02:40 Deep Dive #1 Anticoagulation
  • 08:50 Deep Dive #2 DOACs
  • 14:08 Deep Dive #3 IVC Filter
  • 17:49 Deep Dive #4 Biopsy
  • 25:13 Recap

CME-MOC

Show Notes

  1. Deep Dive #1 – How long should I anticoagulate for a PE before doing a time-sensitive liver biopsy?
    1. For patients with proximal DVT, the risk of having a recurrence or progression of the DVT or PE without anticoagulation in the first 30 days is about 50% from a 1979 NEJM trial
    2. Within the first month of being on anticoagulation for DVT you get fibrinolysis and endothelialization so theoretically after 1 month there should be decreased risk of embolization
    3. A 1995 NEJM trial showed that there was decreased VTE recurrence with 6 months as opposed to 6 weeks of anticoagulation
  2. Deep Dive #2 – What do we know periprocedural interruption of DOACs?
    1. The PAUSE trial looked at holding DOACs prior to surgery in patients with AF and showed:
      1. Holding the DOAC for 48h was associated with low stroke and low bleeding risk
      2. But that’s all the data that we have for holding DOACs periop that we’re aware of !
    2.  In the trial of apixaban vs low molecular weight heparin, for cancer associated thrombosis 0.7% of the patients on apixaban had a recurrent clot in the first 6 months while they were still on the drug. And it was even higher for low molecular weight heparin
  3. Deep Dive #3 – Should we place an IVC filter to prevent further embolization of her DVT?
    1. The PREPIC1 trial compared anticoagulation alone vs. anticoagulation plus IVC filter and showed no difference in mortality
    2. The PREPIC2 trial also compared anticoagulation alone to anticoagulation plus IVC filter but looked symptomatic PE and there was also no difference
    3. Both trials found an increased rate of DVT in the IVC filter group
  4. Deep Dive #4- When should we do a liver biopsy in a patient with an active clot who has failed outpatient interruption of anticoagulation?
    1. There are interventional radiology consensus guidelines that are used to estimate patient bleeding risk and procedure bleeding risk to decide what best to do with a patient’s anticoagulation
    2. Generally speaking, urgency of a biopsy depends on the differential for the mass and how rapidly growing it may be
      1. Any active or imminent organ compromise e.g tumor lysis syndrome or compression of a vital structure

Transcript

J: Hey Ali, I’ve been thinking. We spend so much time talking about diagnosis.

A: Which is wild, because if I think about my week … maybe once a week I have a really perplexing differential diagnosis but mostly we’re spending our time making tough management decisions. So, why don’t we switch things up this time. Welcome to Grey Matters, the podcast where we unpack how medical management is rarely black or white.

J: I’m Jason Freed a Hematologist at Beth Israel Deaconess Medical Center

A: And I’m Ali Trainor, a pulmonary and critical care fellow at the Harvard Combined Program at Mass General and Beth Beth Israel Deaconess.

J: Okay Ali, so I know there’s a case that has been weighing pretty heavily on you.

A: Yeah, I’m really grateful to be able to bring this case to grey matters. And just to clarify before we start, this is a pretty upsetting case and I did change some of the details.

J: So what happened?

A: We had this patient come in, 64 year old male … really not much in the way of past medical history just some hypertension and diabetes. And he came in because he had some leg swelling, fatigue, and anxiety. So, we ordered an ultrasound and a CTA which showed he had both a DVT and a PE. But sure enough, his CT chest shows the upper portion of his liver which showed a mass. So he got a dedicated MRI which showed a 15 cm liver mass.

J: Wow 15cm mass, that’s the size of a cantaloupe 

Ali: YEAH!

J: What immediately jumps out to me about this case is You know, we order so many CTS of the chest, to rule out PE and then all the time it’s annoying because it gets a slice of your neck and you find an incidental thyroid nodule that you need to deal with, which is practically never important. And you get a slice of the abdomen and there’s an incidental adrenal nodule, which again is virtually never important. And then this one time getting a slice of the liver, it turned out to be like really, really valuable. 

A: I agree, I also find most incidental findings to be frustrating, but this one we can’t ignore. So at this point I felt pretty confident that we need to biopsy this liver mass. So that brought me to the first deep dive for this case…. how long should I anticoagulate him for PE? When is it a safe window to interrupt his AC for a biopsy? So to dive into that a bit more, I sat down  with Dr. Brett Carroll, a cardiologist and the Director of the Section of Vascular Medicine and creator of the PE team at  Beth Israel Deaconess.

Dr. Brett Carroll: It’s a good question because we don’t have a lot of high quality kind of natural history data in patients like this, because we’re not going to do a randomized trial where someone doesn’t get anti-coagulated. So it goes back several decades where they did look at before anyone really appreciated what a DVT or PE was and what the role was of anticoagulation. They found for patients with proximal DVT, the risk of having a recurrence or progression of the DVT or PE without anticoagulation in the first 30 days is about 50%. So about half of patients is going to, are going to have some worsening of their venous disease, um, and possible PE. So that’s where that kind of first month we really want the patients to be anti-coagulated. It goes down substantially after that to 10, then to 5% after three months. And that’s where we get the general, you know, we want to get at least three months of anticoagulation for provoked DVT or PE. And then after that point, the risk is substantially lower. 

A:  I also sat down with Dr. Allyson Pishko, who is a hematologist at the University of Pennsylvania. She gave pathophysiologic rationale for why one month might be a time point to consider

Dr. Allyson Pishko:  within that month, you’re starting to get fibrinolysis or breakdown of the clot and also some endothelialization or that, you know, that clot is kind of getting, um, smushed up against, against the vessel wall. So it’s less likely in the case of a DVT to, to embolize.

A: Ok so I have natural history data and pathophysiology both telling me that after about 1 month the risk of VTE recurrence goes down. But Dr. Pishko also brought up how the risk of recurrence doesn’t completely go away.

Dr. Allyson Pishko: 1995 in the New England Journal of Medicine, um the DURAC trial looked at with acute VTE who were randomized to therapeutic anticoagulation for either six weeks or six months. And it was really interesting rom that trial is the recurrence risk of VTE after six weeks of, of anticoagulation really goes immediately up once you stop, after the six weeks of anticoagulation. So most of the recurrences are early recurrences. So although we say, you know, one month is kind of like our minimum. it’s still lss risk, but it’s still risky because as soon as you discontinue the anticoagulation, they’re going to be at elevated risk.

J: The one thing about these studies that I can’t help but point out is that the is that the endpoints they looked at were recurrences in general – that would be a composite of DVT and PE. But do we really care if the DVT gets a little worse with our brief hold and then we just get them back on anticoagulation? But of course, if the recurrence is like a worsening PE that could be a really big deal. 

A: Yeah that’s a great point,  so with that in mind how would you think about his risk with stopping anticoagulation?

J: Yeah. I mean, my reaction to this case is that we’re thinking about dice rolls. That at the end of the day, we are trying to figure out  what is the probability that someone will have worsening PE if anticoagulation is held for three days. And in this case, those probabilities are really hard to determine. So we’re doing the best we can, but we really have no idea which type of dice we’re rolling. Are we dealing with where if you roll a 1, it’s a bad outcome – but is a six-sided dice, where if you roll 2,3,4,5,6 you’re fine … or is it like a 20 sided dice from dungeons and dragons?

A: Jason, did you play dungeons and dragons?

J: We are gonna edit that part out. Maybe it’s a thousand-sided dice? Because you know, in the BRIDGE trial, which was atrial fibrillation patients, we know the daily risk of having a stroke with atrial fibrillation, unless you have some like really, really high CHADS2 score is like one in a thousand. So, you know, you’re like, it’s a dice roll when you stop anticoagulation. But like that dice is so big with so many sides that rolling a 1, which in that case is having a stroke is rare. BUT on the other hand, your patient Ali  had a clot really recently.. and then stopping early that is like maybe like a six sided dice. I don’t know.  

A: It’s easy when the patient has afib, we have the data, but my patient with a DVT, PE and this huge cantaloupe sized large liver mass, he doesn’t fit into a trial! So how can I figure out what his daily risk is with stopping anticoagulation?

J: Even though this is really hard to do, I do try to calculate out their daily risk when I’m trying to make a really high stakes decision where there’s no guideline to hang your hat on. 

A: So how would we attempt to do that for this patient?

J: If we go back to that 1995 New England Journal study where they compared stopping anticoagulation after 6 weeks vs. 6 months it showed that if you stop at six weeks, it’s like an 11% risk of recurrence of clot in the next 4 months after. Now cancer patients have much higher rates of recurrent clots than the patients in this study, but still averaged out on a day to day basis. It’s fairly low, like on a per person per day basis.

A:  Ok, so big takeaway is the longer I treat my PE, the less likely it is to recur with stopping AC … the number of sides on my di goes up, and it becomes a 1 in 20 chance or a 1 in 50 change that the PE progresses.

J: Ali, you keep saying the word di, but I just looked it up and apparently you can use dice to mean singular or plural now.  

A: I don’t believe you. My high school english teacher drilled this in to me.

J: I don’t want you to disappoint your high school English teacher! Anyway, on top of that we haven’t talked about the other dice roll here, which is rolling another dice by delaying the biopsy. And there’s a lot of bad things that could happen by delaying, the cancer could go from curable to incurable. And it’s even harder to find data on the probabilities of those things. 

A: And not only that, but I actually don’t even know which cancer di I’m rolling which would change the number of sides and how quickly they change.  

J: So what happened next Ali?

 A: We start him on apixaban and planned to have him on the apixaban for one month, and then hold it for 3 days prior to his outpatient liver biopsy. I should add here that did get a triple phase CT scan before, which did not have the classic imaging findings of hepatocellular carcinoma which would have allowed us to forego a biopsy. So, at this point, we were still worried about malignancy and we still needed tissue.

J: That seems reasonable. I think I would have done the same thing. Usually 4-6 weeks after a new clot is when I feel OK briefly interrupting anticoagulation for a really good reason like this. As long as someone’s had full resolution of the symptoms of their clot. So what did the biopsy end up showing? 

A: So a month later, he came in, he felt completely fine, but his HR was in the 120s so they cancel the liver biopsy and send him over to the ED for evaluation. He ended up getting a CTA which actually shows extension of his bilateral pulmonary emboli in his main PAs. He also had a troponin elevation, and right heart strain on his ECHO, but he was hemodynamically stable at that point. 

J: So he basically now has a submassive PE. What was running through your mind at this point?

A: What went wrong here? He was on anticoagulation, it was only held for 3 days so how in the world did he have clot propagation. So this brought me to the second deep dive…. I was trying to figure out what went wrong? I was wondering should we have done something differently with her anticoagulation leading up to this procedure?I haven’t seen bridging done with DOACs before, but should we have bridged his DOAC with heparin and LMWH? And was this the right amount of time to hold his anticoagulation for?

Dr. Allyson Pishko: So the PAUSE trial was not bridging, but it’s just like, how long do you stop the blood thinner? It showed two of the more common drugs used apixaban and rivaroxban that generally you can stop two days before a high risk bleeding procedure, which I would consider a liver biopsy like in this patient you’ll be at higher risk for bleeding.And they showed very low rates of, you know, recurrent events or bleeding with just stopping everyone with normal… pretty normal renal function at two days.

Ali: And the crazy thing is that’s all the data that we have for holding DOACs periop that we’re aware of.

Dr. Allyson Pishko: All those trials though, don’t have this patient, which is a very high risk patient who has had a major clotting event within a month. So, that patient is not in the studies. Um, so generally because DOACs are so short, I very rarely bridge them.

A: Ok, so Jason, it sounds like although there really aren’t any trials we can apply to this patient’s situation, based on the pharmacokinetics of DOACs, the apixaban would have only been out of his system for about 48h. S, I’m still having a lot of trouble understanding how he could have still had clot propagation after being on apixaban for a month and then only holding it for 3 days.

J: I guess you could ask this question about why any drug fails. I mean, of course the first one is, did the person actually take it, and there are many reasons someone might not take a drug. Or was it that they were taking it, but the drug wasn’t getting absorbed for some reason like a gastric bypass. Or was it just not the right anticoagulant for the situation for some reason- like did he have antiphospholipid syndrome, or was it just someone who was really thrombogenic. 

A: Right so he was taking it everyday, there’s no reason to think he wasn’t absorbing it, and he didn’t have antiphospholipid syndrome but he still had clot propagation on apixaban which bring me back to my original question, was a DOAC the eight choice?

J: The other thing I’ll say is that even in the clinical trials of apixaban vs low molecular weight heparin for cancer associated thrombosis, 6% of the patients on apixaban had a recurrent clot in the first 6 months while they were still on the drug. And it was even higher for low molecular weight heparin. So that 6% recurrent clot rate while on treatment is high. And that 6%  is like 3 or 4 times higher than the studies done with DOACs for non-cancer patients. So it’s not such a rare thing that a cancer patient’s clot worsens while on anticoagulation. 

A: That’s such a great point, because aside from like antiphosopholipid syndrome, if I put a patient on a DOAC I’m like “they’re good”, but it’s helpful to remember that even patients on DOACs can have a recurrent clot.

J: So it seems like for your patient, the DOAC was pushing pause on clot extension, and then as soon as it was held and the levels of anticoagulation went down, the clot started progressing again.  

A: So I guess what I’m taking away from out second deep dive is that it’s hard to say that the DOAC wasn’t the right choice, or that we should have bridged him, but going forward I’ll remember to consider clot formation in patients on anticoagulation, especially in patients who may have cancer.

J: So Ali, your patient was in the ED right now and we know he had extension of his PE involving both main pulmonary arteries. he was tachycardic, had a troponin elevation and RV strain on TTE but was hemodynamically stable. So what happened next?

A: So, we call our PE team and they take him to the cath lab to do catheter directed thrombolysis and place an IVC filter.

J: I thought this was a submassive PE, so what was the rationale for the catheter directed thrombolysis?

A: Great question! That could be an hour long talk in itself and nothing about it is textbook. This one was about taking into account a bunch of nuanced pieces of information, for ex his HR was in the 120s-150s.

Dr. Brett Carroll: I think it didn’t look so good on exam and given his extensive Clot burden and it was felt it was probably worth being aggressive to decrease his risk of decompensating. In the short term, we don’t have high quality data that being aggressive upfront at this point improves longterm benefits of things like chronic thromboembolic, pulmonary hypertension, or recurrent VTE. It’s really how they look when they  first come in and do we think we need to do something because often we don’t want to wait for them to really decompensate cause it can be very difficult to get those patients back. 

J: Okay, what about the IVC filter?

A: Ugh IVC filters. This is where we need to have our third deep dive, which is when should I be putting an IVC filter in? After talking to our IR colleagues I learned it’s not even clear if we should be putting IVC filters in in the first place. Here is Dr. Jeff Weinstein from Interventional Radiology at Beth Israel Deaconess.

Dr. Jeff Weinstein: We found that the filter does not affect a decrease mortality. And if they’re on anticoagulation, there’s no real benefit. And so we’ve now… it’s like learning by what not to do. That is how we determined what to do. So because there is no benefit  of a filter in someone who’s on anticoagulation, we say people on anticoagulation shouldn’t get filters. And so by like logic, we’re saying people that can’t get anticoagulation, there may be a benefit of getting a filter.

J: What was notable to me about these prospective trials on IVC filters is that on top of having no benefit in mortality or symptomatic PE, there was an increased rate of DVT in the IVC filter group!

A: So it seems like based on what we just talked about we shouldn’t be placing IVC filters. But, there are some cases one can argue for doing an IVC filters.

Dr. Brett Carroll: Some will argue that, and those that are quite sick, those that require advanced therapy, a filter is reasonable to give you a little bit of a backup, backup option in patients that if they were to throw another clot, even on anticoagulation, they wouldn’t tolerate it very well.

J: You know if ever there was a time you were going to use an IVC filter to me, this is it.. because we know he has DVTs, we know he’s extremely thrombogenic from his cancer or at least suspected cancer, and we also know he already has very little hemodynamic reserve. So that one more PE could push him over the edge. So I feel like if in that patient, you still must interrupt the anticoagulation, which is the whole crux of this case… should we shouldn’t we, if so, when? But if you must, then that is the situation in which I feel like  you could get the most agreement amongst people that an IVC filter is probably a good idea. It doesn’t seem like any of the studies perfectly maps to this situation, but if ever there was a time for an IVC filter, I think it’s this time. 

A: So it seems like the running theme of our episode is that our patient doesn’t fit trial data! We did use similar logic to what you just said and decided to place an IVC filter. But at this point, I actually want to bring it back to the liver mass, this cantaloupe sized mass that is just hanging out in the background. So we’ve understandably been paying a lot of attention to her PE, but at this point she’s been in the hospital for 7 days on anticoagulation and is stable. So what do we do about this liver mass?

J: Well, I mean, we already tried outpatient interruption of anticoagulation and he has this mass just sitting there.

A: Right, so we’re worried this could be a malignancy that could be driving this hypercoagulable state, but, we still need to decide how do we balance the urgency of making a diagnosis of this mass vs. treating his DVTs and PEs which are likely being driven by a suspected malignancy. So does the biopsy need to happen now and how do we think about urgency for lesion biopsies?

J: I mean in general with suspected cancer there are two main tasks one is figuring out the best site to biopsy and the other is determining the urgency. Figuring out which site to biopsy is easy in this case because there’s only one site to biopsy, it’s that huge mass in the liver. Determining urgency is about figuring out whether it can go from curable to incurable.

A: And urgency depends on the differential. We already talked about it not being hepatocellular carcinoma because of the CT findings, but on the differential are rapidly progressing etiologies like Non-hodgkin’s lymphoma, but there are also things that progress over a few months like cholangiocarcinoma, and then also non-malignant etiologies like infection and benign tumors. So we’re in a bit of a bind because urgency depends on what this thing is, but we don’t know what it is without a biopsy.

J: Right, and urgency of the biopsy is also looking for any active or imminent organ compromise whether it be tumor lysis syndrome or compression of a vital structure. So Ali, for your particular patient, a worry is definitely that the mass will compress a bile duct and cause her to have jaundice or cholangitis.

A: So essentially what you’re telling me are there a lot of factors that need to be considered and it’s really not a straightforward decision to make.

J: Yeah, and I mean, just to put on my oncologist hat for a minute, the thing we haven’t talked about is does this biopsy need to happen? So I’m going to get on my soapbox here, because I’m sure people have experienced at some point some pushback from an oncologists saying “call me back when you have the biopsy” and this is something that keeps me up at night. There is no rule and should be no rule that an oncologist can only consult when there’s a tissue diagnosis. It is totally appropriate and encouraged to ask oncologists a question like this “What do you think are the most likely diagnoses in this case and how dangerous would it be to delay the diagnosis?”

A: So we did take your advice and call heme/onc and they must have been your fellows because they did not give us pushback about the lack of tissue.

J: Good

A: So at least this time, tissue was not the issue here. And again, this is really complex… so we did end up speaking with cardiology, hematology/oncology, IR and the patient and ultimately decided that the best way to balance his clotting risk and need for biopsy is to keep him inpatient on a heparin drip and to then briefly interrupt the heparin drip for the liver biopsy. So after this point I was no longer on service so I checked his chart a week later to see how he was doing and got that alert in the EMR that I was entering the chart of a deceased patient. I mean, I knew he was really sick, but it was still a little bit of a shock so I talked to the team to find out what happened. Turns out he was scheduled for his biopsy so they turned off the heparin drip for 6 hours prior to the scheduled procedure time. But, unfortunately he had to be bumped to the next day because of an emergency that came in so they resumed his heparin drip. 

J: What happened next?

A: This is where the case gets heavy. So the team holds the heparin again and only 4 hours after the heparin drip was turned off he had a cardiac arrest so they started CPR and their first thought was that this must be a PE causing his arrest. So, they did a bedside echo which showed a clot in his RA on its way to his lungs, so presumably some other clot had already embolized and caused the arrest. So they gave him tPA, but unfortunately despite that and after an hour of coding him they still weren’t able to get a pulse so they called the code and he died.

J: Wow… so he was only off heparin for 4 hours?

A: Yeah, this was really troubling and upsetting  for everyone involved which is why I brought it to the table.

J: Yeah I’m so glad you did. It’s so important we talk through these cases that sit with us. 

A: Or the cases that we frankly feel burned by.

J: Yeah we gotta talk them outloud with people so we can take away the right lessons. I know for me, I had a case a couple years ago. I had this person who we restarted coumadin 2 weeks after a major spine surgery, and then they had this huge delayed bleed into their spine requiring emergency surgery. And afterwards I had to talk to a lot of people before I could convince myself to anticoagulate after spine surgery again.

A: Yeah I mean just the other day, I started therapeutic lovenox on a patient for a regular old DVT and the next day he ended up in the ICU with hemorrhagic shock from a rectus sheath hematoma. I don’t think there was anything done wrong in this case, but just like with the case we just discussed, it gives me a healthy respect for the constant struggle between bleeding and clotting risk and how it can be challenging in both nuanced and seemingly clear cut cases like treating plain old DVTs.

J: A big part of our jobs is trying our best to picture those invisible dice, and sometimes  you roll a one and you are trying to understand did you still make the right decision that just went wrong this one time, you rolled a 1 and a bad outcome happened.

A: There’s also an emotional process we go through with these difficult cases. Because even if we rationally know we did the right thing and we just rolled a 1, it just feels awful when our patient has a bad outcome.  I asked her discussants how they cope with difficult situations too.

Dr. Jeff Weinstein: I think that there’s a real emotional evolution and process that you have to go through. I think that I try to make sure with every day that I, and every patient that I feel that I did everything, I sort of left it all out on the court, so to speak. So for myself personally, uh, when something happens that that’s untoward, I take some time, I may beat myself up over it, but I give myself a time limit. And then I decide that I really need to move on and try and help the next person.

Dr. Brett Carroll: Yeah, it can be difficult. And I think we in society have increasing expectations of what we can offer in the hospital. You know, we have all these fancy new tools and we are trying to mitigate risks by making them safer and maybe intervening more frequently in patients we think are at higher risk to decompensate. 

Dr. Allyson Pishko: It’s hard not to blame yourself like, oh, if we stopped the blood thinner, if we went longer? But it’s an impossible situation to be able to know what’s the right move because you don’t the answer, you delay it further, the cancer may progress. I tried to, you can’t help, but feel guilty and in a case like this, but I try to remember that it’s, it’s the disease we should be mad at.

A: So this was a tough case at multiple stages of his care. So maybe let’s just take a second to recap the questions that came up and our deep dives:

J: In our 1st deep dive, learned that we typically think of at least one month of anticoagulation being an important time point, and that after a month you’re better but you’re not good. If you stop at 6 weeks your risk of recurrence goes immediately up as compared to stopping at 6 months.

A: Right, and when this patient DID get 1 month of apixaban and gets this brief interruption of anticoagulation to have the first attempt at the procedure he had clot progression. And our second deep decision drive, we talked about that 6% of patients with cancer associated blood clots will progress even while they’re still ON anticoagulation.  

J: We then grappled with management after clot progression and what we know about IVC filters. Interestingly the study shows that most patients who already on AC don’t benefit from an IVC filter and actually have a higher rate of DVT than those don’t have an IVC filter.

A: And the last decision point we went over was what are the factors that go into how urgently we should get a biopsy when cancer is suspected? We talked about how if something potentially rapidly progressung is on the differential OR if there’s any  organ compromise can affect the urgency of the biopsy.

J: But this case was a heavy case with more than just medical decision making, reflecting back, what will you carry with you next time? You want to carry away the right things and not the wrong things that will make you practice anxiously, nervously, conservatively. You want this terrible outcome to be something that will help you take care of patients better in the future.

A: In hindsight i don’t know if this is was the right time to biopsy but then i don’t know if there was ever a right time to biopsy.

J: I honestly dont know if i would have done anything differently. If we’re ever going to get a tissue diagnosis we’re going to have to interrupt anticoagulation at some point. The question is what do we count as our start point for anticoagulation.

A: Although it had  been 6 weeks since his initial PE, it was only been 2 weeks since progression of PE. I wonder, and it’s much easier to say this in hindsight, if we should have reset his clock and counted this as only 2 weeks from a submassive PE.

J: Yeah its like when you have a nosebleed and they tell you, hold pressure for 10 minutes and absolutely no peaking. And then inevitably after 5 minutes you want to check if it’s still bleeding and it is, you don’t just hold for 5 more minutes, you reset the clock back to 10. But on the other hand, there is no clock reset for the cancer, and if ever there was going to be chance at cure for him and that clock is still ticking. Can you imagine being this patient with this unknown large mass and they are basically being told by their doctors “We think it’s bad, but we don’t know how bad, we don’t know if you’ll live or die, and we can’t even tell you when we’re going to know.”

A: It seems  like this case was just so complex and the deck was stacked against us. Jason, thank you so much for talking through this case with me. I could talk about medicine with you all day.

J: My door is always open. And I mean that quite literally, the lock on my office is broken, I need to do something about that. 

A: You should get that fixed or I’ll be by asking questions all the time. And that is wrap for today! If you have a case that you want to bring to the table please let us know. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! 

J: If you have a case you’d like to bring on air, please email us at hello@coreimpodcast.com. Thank you to Daksh Bhatia for the audio editing. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.

References

 


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