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Um, I'm really humbled to be here to speak to you today. These are my disclosures. I'm, um, speaking about the, the last objective uh for this session, um, which is I'm gonna be talking about the importance of monitoring joint health in patients with non-severe hemophilia. Um, we're gonna look at, um, why it is important, um, even in the absence of overt bleeding signs. Um, we're gonna talk about physical exam, uh, patient reported outcomes, and imaging to detect early signs of joint bleeding. And lastly, we want to talk about how to integrate joint health monitoring into a multidisciplinary um care plan and how that is the most ideal, um, standard of care for patients, uh, with hemophilia of all severities. So why should we do joint surveillance in non-severe hemophilia? Hemophilia is um a disease that produces, um, joint, joint disease, um, in light of even one joint bleed, um, in the lifetime of a patient. Um, this is well, a well-established fact and, um, you know, we wanna do our best to try to prevent this process from even starting. Um, the patient's joint will deteriorate over a long period of time, um, which is one issue and making it difficult to study. Um, but, you know, we wanna try to preserve on the, like on the screen there, a normal joint, um, so that they can have the best outcomes. What initially happens is that the joint begins to bleed. So looking on the right side of the slide is blood is introduced into the joint. And there's like a hypervascularization. Inside the joint. Then the synovium becomes inflamed, it becomes hypertrophied, and you begin to get synovial changes. That's like the first stage. Then after that, the, the blood that stays in there that is not, that is, has that affinity for cartilage, then the Cartilage is at risk, um, initially for um deterioration. Um, there's also some fibrosis in the joint, that's what sort of contributes to the range of motion issues that we're gonna talk about. And, um, these, these changes, you know, are the second, the 2nd level of changes. And then once that Um, what, the, the final issue is more what we're typically, you know, we typically see with patients with arthritis is they develop the bony changes, so the cyst and the osteoporosis. So I'd like to divide this into short and long-term effects of joint bleeding. And again, just to emphasize, this happens over years and um, you know, so this is why this, this long-term monitoring um is necessary to make adjustments in the patient's care to prevent joint bleeding, um, and prevent progression if there has been joint bleeding. So you see on the left side of your slide, there are short-term effects, um, in this, you know, very healthy knee in the first picture on the left. Um, and then blood enters the joint as we were talking about on the previous slide. And then there's the swelling state. So if we're at the state of seeing swelling, there is a problem, um, because we know that that means that there is blood likely in that joint and the longer it stays there, the worse are the problems. Um, the long-term effects, um, you can see on the right side of your slide is that as, um, that swelling can become permanent, um, and then as we talked about, over time, it can lead to wearing away of the bone. And in worst-case scenarios, and definitely what we're trying to prevent in this day and age with the products um that we have to manage this disease is that we wanna prevent this permanent damage. So the next few slides just give us some visuals. Um, I think this is, if you've been taking care of patients with hemophilia for a long time, this is something that we don't see typically, um, in patients, especially on prophylaxis, um, anymore. Um, but I think it's a good reminder that we need to keep vigilant, um, even in our patients with non-severe hemophilia. So this is, um, what a patient would present with. Um, they even might be more flexed at the knee if the, depending on the acuity of hemmoarthrosis. This is that synovitis, that sort of boggy cantaloupe, um, size, uh, joint. If the, if the inflammation, if they, if they're late to get, um, factor replacement treatment, um, this, this is, um, this can persist and, um, this is often pain, painless. And then ultimately end-stage arthropathy and we're hoping, you know, hopefully, you know, none of our patients are, you know, you know, being treated now, um, you know, are going, you know, going to be at this stage, but we have several patients, um, that are in adulthood that, that do have these types of changes and, um, it really impacts their activity and participation in life. So, we wanna talk about severe hemophilia and how bleeding presents and then mild and moderate hemophilia, so the non-severe hemophilia. So in severe hemophilia, um, they can present, uh, as many of you know, with, um, spontaneous bleeding, um, injuries, um, and there's clinical symptoms. You can usually locate that on a clinical exam and, um, it can usually confirm joint bleeding, um, not all the time. But, um, there's usually some correlation. And, um, but I think we have to think about many of our severe patients are on prophylaxis, on, um, non-factor, um, products as well, and, um, it's sort of, you know, it's created, um, a patient, the patient, you know, in Uh, at a level of um non-severe hemophilia, um, keeping their levels steady. Um, so I think even more so a reason to, to think about these considerations, um, of monitoring, um, patients with more mild or moderate hemophilia. And I think this is where things get gray. Um, if there's an injury, um, often, often, uh, a patient will not stop participating in their activities. Their, their symptoms can be tolerable. Um, there can be a level of underreporting, uh, which, which leads to delayed care. And often when they come in, uh, the clinical exam can be inconclusive without, without adding in specific imaging. And then there's this issue of subclinical bleeding, um, when the clinical exam, maybe on an annual comprehensive visit, is not, um, you know, it's not really showing any clinical signs. OK. So I wanna take a minute to look at the most recent um papers that, um, you know, support this joint surveillance um and close joint surveillance in patients with mild, um, mild or moderate hemophilia. Um, the, the last systematic review on this was done in 2011 and I think it really speaks to um the changes we have seen in the use of, um, point of care ultrasound, uh, and now that we're seeing, you know, using that more frequently in our clinics, um, we're able to kind of see what, what is a little bit more information about what is subclinical bleeding. Um, so this first article Um, was an MRI study, uh, looking primarily at adults and, um, The, the, the major finding is that even without, without patients, um, without, uh, without report of bleeding, I think out of 51 subjects, uh, 19 of these patients had moderate hemophilia, um, 32 had mild hemophilia, and they had all low annual, um, bleeding rates, almost were all were 0. Um, and a total in, in this cohort of 51 patients with, with, um, non-severe hemophilia, there were only 12 lifetime, um, bleeds in the moderate patients and 1 bleed, uh, reported in their lifetime in a, in a mild patient. Um, so I think that Well, you know, even in, in light of that, there were clinical, um, clinical signs, um, of hemosiderin, especially in the ankles. Um, so paying really close attention to all the joints, the elbows, the knees, um, and the ankles is really important. Um, there were some, um, comments in this study about, you know, we have to also consider these studies, all these studies actually here were done on adults, and, you know, there is a, a, a level of Um, development of arthritis that occurs with age and some age-related changes, um, which they noticed more, um, could be conflicting, um, with the, the knee involvement, um, of patients. But again, most of the involvement was in the ankles. Um, another study