Reportable?

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Attending1985

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67 year old female comes to me being seen my family NP at private psych clinic. History of depression with very questionable bipolar diagnosis. No mania. No hospitalization, no suicide or self harm. She’s on trazodone 100 mg, geodon 20 mg tid, Klonopin 2 mg at hs, Cymbalta 120 my daily, gabapentin 300 mg at hs. Adderall 10 mg in am just added due to “lack of motivation.” TD movements developed a few months ago and no one addressed it. Family expressed concern about number of medications and her cognition. I’m considering contacting the nursing board. This is just dangerous and negligent.
 
WisNeuro said:
If this is reportable, I'd be contacting nursing and MD boards on a monthly basis.
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Spot on.

It's wrong and bad medicine. You'd be saddened by how common it is and it happens by both docs and NP. Just once, I'd like these people to say "oh you're having this symptom? Let's get rid of one of your meds and see how you do".
 
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Attending1985 said:
67 year old female comes to me being seen my family NP at private psych clinic. History of depression with very questionable bipolar diagnosis. No mania. No hospitalization, no suicide or self harm. She’s on trazodone 100 mg, geodon 20 mg tid, Klonopin 2 mg at hs, Cymbalta 120 my daily, gabapentin 300 mg at hs. Adderall 10 mg in am just added due to “lack of motivation.” TD movements developed a few months ago and no one addressed it. Family expressed concern about number of medications and her cognition. I’m considering contacting the nursing board. This is just dangerous and negligent.
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Dangerous? Yes. Negligent? Debatable. Seems like all of those meds are within reasonable dosing ranges and look like their prescribed for a valid indication (minus maybe the Adderall). I've seen psychiatrists prescribe much worse regimens. Sad for the patient, but this is not uncommon and is a major reason that I'm not worried about job security in our field any time soon.
 
No. Unfortunately this is very common to see in the community. Even with kids/teens unfortunately... 😔
 
I must live in a area with good practitioners because I don’t see this commonly
 
Attending1985 said:
I must live in a area with good practitioners because I don’t see this commonly
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You should consider yourself fortunate, then. I've been in 4 different major cities in 3 distinct geographical regions and see this commonly in my patient set.
 
Attending1985 said:
67 year old female comes to me being seen my family NP at private psych clinic. History of depression with very questionable bipolar diagnosis. No mania. No hospitalization, no suicide or self harm. She’s on trazodone 100 mg, geodon 20 mg tid, Klonopin 2 mg at hs, Cymbalta 120 my daily, gabapentin 300 mg at hs. Adderall 10 mg in am just added due to “lack of motivation.” TD movements developed a few months ago and no one addressed it. Family expressed concern about number of medications and her cognition. I’m considering contacting the nursing board. This is just dangerous and negligent.
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5-6 psychotropic medications for a person almost 70 and no hx of....anything? Is that right?

And what's the "Geowater" for, exactly? And the Clonazepam? Dextroamphetamine "for motivation" might just mean we need some Behavioral Activation, Pleasure and Mastery, and other Beckian style work? Can be less than 20 sessions. But who knows when the former provider just gives a med for each symptom, right? How is her heart?

Bipolar Disorder can be tricky, of course, but it can probably be relatively easily evaluated at this stage if you have family cooperation and participation? What's the "question" about, exactly? If it is a history that is substantiated, then that's what it is. But If it was like 20 years ago and nothing since, I think we can let that be and just monitor? It's not like a remote hx of "Bipolar Disorder" should carry any kind of life sentence of multiple psychotropics in the absence/doubt of the diagnosis in the first place....or any recent problems/impairment? Right?

IF IT WAS ME:: SCID-V and include fam. Treat. Call former provider and ask what they are/were thinking? If they are a complete and total dummy on the call.... report to their board.

I DO recall that there is a Psychiatrist/Physician poster on here who has VERY openly bragged about reporting many, many providers/colleagues for being dummies. I do not recall their screenname at this time. And I don't know how that has worked out in the end.
 
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Not reportable, this throw everything at them approach is rather common
 
Sushirolls said:
Still plenty of room in this cocktail. No Trinitellix? Lamictal? Wellbutrin? nor Rexulti?

/sarcasm
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Klonopin, Trazodone and Gabapentin so you sleep at night, then Adderall to give you that little kick in the AM. Bet most of my patients would love that combo.

I like the way the “lack of motivation” was interpreted as “you need a stimulant” rather than “I’m sedating the **** out of this person”
 
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Outside of GROSS boundary crossings or negligence, which this most definitely is not...we shouldn't be going to boards. Even when I've seen repeated prescribing of opiates to patients with repeated overdoses and hospitalizations, I've made several attempts to personally modify the behavior of the other prescriber before involving any sort of board. Talk to the NP! Our responsibility as a profession for self-policing involves first actually talking to one another. Further, you're going to get a lot more done for your patient that way. A nursing board is not likely to view this as a priority, if they consider it at all.
 
Stagg737 said:
Where is this Shangri La where you live and how to I get ahold of an application or recruiter?
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I wonder if this Eden also has properly diagnosed Borderline PD and Bipolar DO as well?
 
erg923 said:
And what's the "Geowater" for, exactly
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I actually think this is one of the more reasonable meds they're on. 60mg daily is an okay (but low) dose for a geriatric patient. If they're not bipolar, Geodon could actually be a good choice for depression augmentation as this is one of the antipsychotics with very high binding affinity for 5-HT2A, 5-HT2C, and 5-HT1A. Given that she's already at max dosing of the Cymbalta, it's not a bad choice for augmentation.


erg923 said:
I DO recall that there is a Psychiatrist/Physician poster on here who has VERY openly bragged about reporting many, many providers/colleagues for being dummies. I do not recall their screenname at this time. And I don't know how that has worked out in the end.
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Pretty sure that's @TikiTorches , they're still around so could probably ask.

erg923 said:
IF IT WAS ME:: SCID-V and include fam. Treat. Call former provider and ask what they are/were thinking? If they are a complete and total dummy on the call.... report to their board.
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Sounds like the right plan. Honestly though, I wouldn't report this case to the board as is regardless of how dumb the NP might be. This would actually be one of the more reasonable med regimens from NPs in my area, which is especially sad because I'm in a state that requires NP supervision. My general thoughts on each med:

Cymbalta 120mg: Reasonable and likely indicated if it's unipolar depression or anxiety. Given Gabapentin is also on the list I'm also guessing this patient has neuropathy. Would probably build medication treatment around this.
Traozodone 100mg QHS: Reasonable for insomnia, though not ideal. I'd pick this or Gabapentin for sleep depending on efficacy and side effects.
Geodon 20mg TID: Reasonable dosing for a geri patient and possibly beneficial regardless of bipolar or unipolar depression. Could also help with mood stabilization if a significant personality component is present. Ideally would get her off, but if there's truly bipolar this may be the thing keeping her stable so wouldn't taper until I got more solid history/collateral.
Gabapentin 300mg QHS: Seems unnecessary given other meds, but could justify if there's neuropathy present and the Trazodone alone is inadequate for sleep. Might also be a good 2-for-1 for sleep and neuropathy. Again, would pick this or Trazodone depending on efficacy and side effects. Could also frame it as acting on the same molecule as Klonopin to get more buy-in to get off the benzo.
Klonopin 2mg QHS: Not good, but also not that egregious. I wouldn't prescribe it to her and definitely would not have 3 sedating meds for sleep. If she's clutching her pears about it being discontinued, I'd give her the option to keep it but d/c the Gabapentin and Trazodone. The polypharmacy is very likely unnecessary.
Adderall 10mg QAM: Again, not good but not that egregious. I can see this being a reasonable option for depression augmentation with a focus on anhedonia/motivation. However, like C&H said, I wouldn't try this until we minimized her sedating meds and she fails other treatments (behavioral activation/therapy, other depression augmentation, reassessment for unaddressed issues, etc). Low doses of stimulants can do wonders for some patients, but my first priority is always to minimize the polypharmacy.

Ideally, I'd get her off both controlled substances and try and taper the Geodon and Gabapentin, but only after obtaining further history. If the lack of motivation is from polypharmacy, I may keep the Gabapentin instead of the Trazodone d/t the shorter half-life. Regardless, my goal right off the bat would be to cut the number of psych meds in half (keeping the Cymbalta, Geodon, and Trazodone OR Gabapentin). Would also set goals to start therapy and further taper if possible (specifically Geodon).

I'd be interested in other approaches to this patient, but this actually seems pretty straight forward given the information given and current meds.

Edit: Forgot she was developing EPS, would prioritize gathering further bipolar history and consider switching Geodon to a non-antipsychotic mood stabilizer if necessary.
 
Stagg737 said:
I actually think this is one of the more reasonable meds they're on. 60mg daily is an okay (but low) dose for a geriatric patient. If they're not bipolar, Geodon could actually be a good choice for depression augmentation as this is one of the antipsychotics with very high binding affinity for 5-HT2A, 5-HT2C, and 5-HT1A. Given that she's already at max dosing of the Cymbalta, it's not a bad choice for augmentation.
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There are a non-trivial number of reports of mania induced by geodon, and I have worked with someone who had a pretty well documented manic episode that did start not too long after being started on geodon. I say this in support of the idea that it certainly can be an effective augmentation for depression, sometimes too effective.
 
clausewitz2 said:
There are a non-trivial number of reports of mania induced by geodon, and I have worked with someone who had a pretty well documented manic episode that did start not too long after being started on geodon. I say this in support of the idea that it certainly can be an effective augmentation for depression, sometimes too effective.
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Huh? Geodon is literally FDA approved on label for acute mania AND maintenance sooo not sure about the case reports but I'd be pretty hesitant to ascribe a manic episode to geodon. Maybe sub-theraputic dosing of Geodon.
 
calvnandhobbs68 said:
Huh? Geodon is literally FDA approved on label for acute mania AND maintenance sooo not sure about the case reports but I'd be pretty hesitant to ascribe a manic episode to geodon. Maybe sub-theraputic dosing of Geodon.
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In addition to 5-HT receptor binding it also inhibits both NET and SERT. Though the extent/affinity to which it does this is varied in the literature, with some suggesting it is nearly as potent in this regard as SRIs/NRIs and TCAs (e.g., Ghaemi - acknowledges the variability in the data and offers this as a possible explanation regarding its clinical benefits and the observed issues regarding mania) and some suggesting this property is trivial (e.g., Stahl - takes a more absolute stance). From that standpoint the case reports of ziprasidone induced mania and its use as an augmenting agent in depression make sense.
 
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Taddy Mason said:
In addition to 5-HT receptor binding it also inhibits both NET and SERT. Though the extent/affinity to which it does this is varied in the literature, with some suggesting it is nearly as potent in this regard as SRIs/NRIs and TCAs (e.g., Ghaemi - acknowledges the variability in the data and offers this as a possible explanation regarding its clinical benefits and the observed issues regarding mania) and some suggesting this property is trivial (e.g., Stahl - takes a more absolute stance). From that standpoint the case reports of ziprasidone induced mania and its use as an augmenting agent in depression make sense.
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Yeah I know about the binding affinity. My point is that you're comparing case reports to randomized control trials that demonstrated proven efficacy for acute mania and proven efficacy for adjunctive maintenance treatment . One is much stronger evidence than the other.

Although I think I misread @clausewitz2 initial post, for some reason I thought he was suggesting this lady's "bipolar" d/o was caused by the Geodon making her manic, not supporting the antidepressant augmentation effect. So maybe that was my misreading of that.
 
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calvnandhobbs68 said:
Although I think I misread @clausewitz2 initial post, for some reason I thought he was suggesting this lady's "bipolar" d/o was caused by the Geodon making her manic, not supporting the antidepressant augmentation effect. So maybe that was my misreading of that.
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No, sounds like you were initially right. I wouldn't be surprised if there was a small number of cases where the high serotonergic activities of Geodon could induce paradoxical mania, even if it is typically used for mania treatment.
 
Stagg737 said:
Klonopin 2mg QHS: Not good, but also not that egregious. I wouldn't prescribe it to her and definitely would not have 3 sedating meds for sleep. If she's clutching her pears about it being discontinued, I'd give her the option to keep it but d/c the Gabapentin and Trazodone. The polypharmacy is very likely unnecessary.

Great input overall but the bolded is brilliant. A contemporary twist on an old saying cause nobody really wears pearls much anymore anyway.
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Stagg737 said:
No, sounds like you were initially right. I wouldn't be surprised if there was a small number of cases where the high serotonergic activities of Geodon could induce paradoxical mania, even if it is typically used for mania treatment.
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Yes the person in question definitely already had bipolar d/o but went from being in-bed-all-day depressed to running-for-citywide-office-because-of-communications-from-Jesus manic within a week or two of starting geodon. Entirely possible it is a coincidence, but as @Taddy Mason points out there is at least some neuropharmacological reason to believe this could have been what was going on.

The acute mania indication just suggests that it is not going to be a common enough effect to swamp the dopamine blockade at whatever doses they were using in the studies that got initial approval.
 
I commonly say this. Half the psychiatrists I see practicing are terrible, making what I consider rookie mistakes. E.g. start Paxil as the first SSRI despite that out of all the SSRIs it has the most side effects. So why give it out first? Or doctor gives out Zolpidem for chronic sleep problems despite that the data shows it's often times worse for the patient with chronic use.

I'd be reporting as written above half of everyone in the field.
 
Can’t say I’m a huge a huge fan of ziprasidone – it always feels like there are better options available for almost any indication. Still, I did have one patient where a planned reduction led to a savage re-emergence of their OCD symptoms.

Gabapentin, unless there’s epilepsy or a chronic pain indication is also another one I’m not that enamoured with – the abuse potential also doesn’t help either.

With the OP’s patient, I’d probably look at getting them off the nocte clonazepam – suspect that it’s probably having some follow through effect in the morning impacting on cognition and motivation. Sort that out and the stimulants probably aren’t required either.
 
clausewitz2 said:
Yes the person in question definitely already had bipolar d/o but went from being in-bed-all-day depressed to running-for-citywide-office-because-of-communications-from-Jesus manic within a week or two of starting geodon. Entirely possible it is a coincidence, but as @Taddy Mason points out there is at least some neuropharmacological reason to believe this could have been what was going on.

The acute mania indication just suggests that it is not going to be a common enough effect to swamp the dopamine blockade at whatever doses they were using in the studies that got initial approval.
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Sure but that's what I'm saying, I'd consider it more of a subtheraputic dosing problem rather than a geodon causing mania problem. Which matters in terms of where you go next with the patient (ex. the right choice for a patient you're trying to avoid other antipsychotics for other SE/metabolic reasons might be to crank up the dose instead of d/c'ing it...although probably not if you're at the point the patient is running for citywide office and getting communications from Jesus). Similar to Abilify's partial dopamine agonism seeming to cause different effects at lower vs higher doses.
 
Liquid8 said:
Can’t say I’m a huge a huge fan of ziprasidone – it always feels like there are better options available for almost any indication. Still, I did have one patient where a planned reduction led to a savage re-emergence of their OCD symptoms.

Gabapentin, unless there’s epilepsy or a chronic pain indication is also another one I’m not that enamoured with – the abuse potential also doesn’t help either.

With the OP’s patient, I’d probably look at getting them off the nocte clonazepam – suspect that it’s probably having some follow through effect in the morning impacting on cognition and motivation. Sort that out and the stimulants probably aren’t required either.
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Why tho? I think people write off the metabolic syndrome effects of all our other antipsychotics wayyy too easily. Obesity related diseases (HTN, DM, CAD) are the leading cause of death in psychiatric patients. I see so many obese guys put on risperdal, zyprexa or seroquel (seroquel especially gets given out like candy) without half a thought and kept on this forever. Abilify and Geodon are basically your two generic options for little/no metabolic side effects, since most insurance companies will still give you a hard time with Latuda and even more with Rexulti.

The biggest pains with Geodon are making sure your QT stays good and dosing BID with food but it can be very very helpful when you're looking for another option that won't cause sig weight gain/HLD/glucose problems.
 
calvnandhobbs68 said:
Why tho? I think people write off the metabolic syndrome effects of all our other antipsychotics wayyy too easily. Obesity related diseases (HTN, DM, CAD) are the leading cause of death in psychiatric patients. I see so many obese guys put on risperdal, zyprexa or seroquel (seroquel especially gets given out like candy) without half a thought and kept on this forever. Abilify and Geodon are basically your two generic options for little/no metabolic side effects, since most insurance companies will still give you a hard time with Latuda and even more with Rexulti.

The biggest pains with Geodon are making sure your QT stays good and dosing BID with food but it can be very very helpful when you're looking for another option that won't cause sig weight gain/HLD/glucose problems.
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Technically there's Mohan/molindone as well but I am assuming the patchy availability in pharmacies in this area is broadly representative of how hard it is to find a steady supply elsewhere. It does of course also have the drawback of being an FGA for whatever that is worth.
 
calvnandhobbs68 said:
Why tho? I think people write off the metabolic syndrome effects of all our other antipsychotics wayyy too easily. Obesity related diseases (HTN, DM, CAD) are the leading cause of death in psychiatric patients. I see so many obese guys put on risperdal, zyprexa or seroquel (seroquel especially gets given out like candy) without half a thought and kept on this forever. Abilify and Geodon are basically your two generic options for little/no metabolic side effects, since most insurance companies will still give you a hard time with Latuda and even more with Rexulti.

The biggest pains with Geodon are making sure your QT stays good and dosing BID with food but it can be very very helpful when you're looking for another option that won't cause sig weight gain/HLD/glucose problems.
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For straightforward psychosis I usually pick amisulpride if I’m looking to avoid metabolic issues – usually fairly well tolerated if they don’t develop akathisia. I would then typically consider aripiprazole and then ziprasidone. We don't tend to have the same kind of access issues getting Rexulti or lurasidone which probably also bumps ziprasidone down the list.
 
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calvnandhobbs68 said:
The biggest pains with Geodon are making sure your QT stays good and dosing BID with food but it can be very very helpful when you're looking for another option that won't cause sig weight gain/HLD/glucose problems.
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Even with the BID dosing, Ziprasidone had the highest rates of compliance in CATIE. Surprisingly, that’s actually been reflected in the few patients I have on it.
 
calvnandhobbs68 said:
Why tho? I think people write off the metabolic syndrome effects of all our other antipsychotics wayyy too easily. Obesity related diseases (HTN, DM, CAD) are the leading cause of death in psychiatric patients. I see so many obese guys put on risperdal, zyprexa or seroquel (seroquel especially gets given out like candy) without half a thought and kept on this forever. Abilify and Geodon are basically your two generic options for little/no metabolic side effects, since most insurance companies will still give you a hard time with Latuda and even more with Rexulti.

The biggest pains with Geodon are making sure your QT stays good and dosing BID with food but it can be very very helpful when you're looking for another option that won't cause sig weight gain/HLD/glucose problems.
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Don’t know about everyone else but anecdotally I have seen substantial weight gain with Abilify in both pediatric and adult populations.
 
nowaysanjose said:
Don’t know about everyone else but anecdotally I have seen substantial weight gain with Abilify in both pediatric and adult populations.
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long term aripiprazole therapy can be the same as quetiapine regarding weight and the weight benefits are mostly non existant past a year of use
 
nowaysanjose said:
Don’t know about everyone else but anecdotally I have seen substantial weight gain with Abilify in both pediatric and adult populations.
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Sikrouf said:
long term aripiprazole therapy can be the same as quetiapine regarding weight and the weight benefits are mostly non existant past a year of use
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Man if only we didn’t have to rely on anecdotes and had, you know, data to base our decisions on.

Oh wait….

Almost All Antipsychotics Result in Weight Gain: A Meta-Analysis - PMC

Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
calvnandhobbs68 said:
Man if only we didn’t have to rely on anecdotes and had, you know, data to base our decisions on.

Oh wait….

Almost All Antipsychotics Result in Weight Gain: A Meta-Analysis - PMC

Antipsychotics (AP) induce weight gain. However, reviews and meta-analyses generally are restricted to second generation antipsychotics (SGA) and do not stratify for duration of AP use. It is hypothesised that patients gain more weight if duration ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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I m sorry what makes you think im not using a study myself to make these claims ? (granted i m considering abilify vs quetiapine on bipolar patients because we quetiapine doesnt make much sense on schizophrenia)
 
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Sikrouf said:
I m sorry what makes you think im not using a study myself to make these claims ?
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That’s better than the meta-analysis which also specifically breaks them down by length of time on the medication?

Fire away.

I agree that quetiapine is often overblown in terms of weight gain (and this study suggests that as well, esp if you look at the antipsychotic naive breakdown) but overall doesn’t look quite as good as abilify.
 
calvnandhobbs68 said:
That’s better than the meta-analysis which also specifically breaks them down by length of time on the medication?

Fire away.

I agree that quetiapine is often overblown in terms of weight gain (and this study suggests that as well, esp if you look at the antipsychotic naive breakdown) but overall doesn’t look quite as good as abilify.
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Certainly you know that various meta analyses can be used and they all have their limitation, i think of them as complementary rather than which one is "better" ; in this case since were talking about quetiapine and abilify i think compairing within the mood stabiliser class is just as important

pubmed.ncbi.nlm.nih.gov

Acceptability of Acute and Maintenance Pharmacotherapy of Bipolar Disorder: A Systematic Review of Randomized, Double-Blind, Placebo-Controlled Clinical Trials - PubMed

All medications studied in bipolar disorder were relatively well tolerated during different phases of treatment; however, the risk for short- and long-term WG and somnolence varied widely among included psychotropics.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Looking forward to read your opinion
 
Sikrouf said:
Certainly you know that various meta analyses can be used and they all have their limitation, i think of them as complementary rather than which one is "better" ; in this case since were talking about quetiapine and abilify i think compairing within the mood stabiliser class is just as important

pubmed.ncbi.nlm.nih.gov

Acceptability of Acute and Maintenance Pharmacotherapy of Bipolar Disorder: A Systematic Review of Randomized, Double-Blind, Placebo-Controlled Clinical Trials - PubMed

All medications studied in bipolar disorder were relatively well tolerated during different phases of treatment; however, the risk for short- and long-term WG and somnolence varied widely among included psychotropics.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Looking forward to read your opinion
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Cant read the actual paper cause it isn’t open access and I ain’t paying for it.
 
whopper said:
I commonly say this. Half the psychiatrists I see practicing are terrible, making what I consider rookie mistakes. E.g. start Paxil as the first SSRI despite that out of all the SSRIs it has the most side effects. So why give it out first? Or doctor gives out Zolpidem for chronic sleep problems despite that the data shows it's often times worse for the patient with chronic use.

I'd be reporting as written above half of everyone in the field.
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You use the term Rookie mistakes but are there more younger psychiatrists than older ones actually doing that? I highly doubt it. And it’s not like these people are doing this in secret. We all know who has suspect regimens. Whenever the job market starts to tighten, these folks will feel it.
 
erg923 said:
I DO recall that there is a Psychiatrist/Physician poster on here who has VERY openly bragged about reporting many, many providers/colleagues for being dummies. I do not recall their screenname at this time. And I don't know how that has worked out in the end.
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See, see, *this* is why I over-document! You never know if someone like that is reading your charts or inheriting your patients. (Only half-kidding).

Seriously, though, you could report if you have time but I doubt the board will do anything. I sometimes read my state's MD licensing board to reassure myself that I am not as bad as some people out there. I get the sense that the board only acts if there's a catastrophic bad outcome, like a cancer missed, birth mismanaged, permanent and severe disability, death, etc.

The only time I've heard colleagues discuss reporting someone to the board was when problematic prescribing was happening again and again. We're talking a "developmental pediatrician" prescribing doses of stimulant 2-3 times the FDA limit to young kids. I don't know if they ever did report them.

Also, as an attending in residency told me, he's inherited a lot of patients on highly questionable regimens and he's learned that there is often some method to the madness, and to investigate rather than jump to the conclusion that someone is a "dummy." Not talking about OP's patient in particular, but sometimes what seems like a controversial or textbook-wrong approach actually makes sense in context. Now, for the clear sense of polypharmacy and emerging side effects in the OP's case, I'd just focus my efforts on cleaning up the mess. Maybe the regimen made sense at one point, but it doesn't at this time.
 
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Like most of the others in this thread, I don’t know that I would take the time to report this. However, I’ll play Devil’s Advocate for a second:

Isn’t it actually the board’s job to decide whether a complaint is actionable? Given that the board is the entity that is deciding the merits of a given case, how much of a responsibility does the reporting physician have to decide whether an action merits board involvement? What does that mean for what our thresholds should be for reporting?
 
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