All right. Thank you and thank you for the opportunity to speak today. I'm gonna talk about red, white and blue fingers. I don't have any relevant disclosures. So, it's important that we understand what normal vascular physiology is and everybody has a Visa constrictive response. The purpose of that is to maintain core temperature and limit heat loss. That will cycle through after about 10-15 minutes of cold exposure. After you cycle through a cold response, you will get rewarming. That's called the hunting response. Many people will have this and they'll complain sometimes bitterly about having cold hands. The reason for that is that code is much more uncomfortable to us. We may not realize that it's just really a cycling response. Um When patients continue to um experience continued Visas construction, then that may become more of a problem. So cold hands really are is for the most part that normal Visa constructive response. It's really a highly complex, very regulated process that sympathetically mediated. And it re consults in changes of our normal vascular size. When we have Bezos spasm that's different. That is an unexpected accentuated response that's inappropriate. It is typically reversible. But it it creates that true white discoloration that we see on fingers. Now, that's what we refer to as rainouts phenomenon or rainouts disease. It's not the cold hands. It's not the vessel constriction. But it's that true unabated response of Visa. Of vaso spasm. So, there is a classic triad. When we talk about rain out phenomenon. The white bezel spasm blue, which happens early. Is the cyanotic phase. It's really a de oxygenation phase. And then red is the re perfusion phase. That's where we get the red, white and blue type response. And you can see this is actually my hand having come in from outside. That's not a rainouts phenomenon. Yes, I'm a little white there. Um that is a re perfusion phase. I was just too cold. All right. So it's just important to really identify and recognize and frankly take a really good history when your patients start talking about cold hands or the concern for rainouts and make sure you know what you're identifying. There are two types of renowned phenomenon and renowned syndrome. Primary renounce. This is pretty much usually a normal phenomenon. Any of us if we are too cold you can spasm, there's no doubt about that. Um typically the pulses are intact, they're not going to have trophic skin changes, they will rarely have ulceration and it's relatively common in young women. My threshold for knowing or deciding is this really a problem is when you ask them, how long has it been going on and they tell you three years, four years, five years, three years, four years, five years, no secondary findings. It's probably a primary issue. Secondary rainouts on the other hand or secondary renowned syndrome has a number of different causes. We always think about limited sclerosis or scleroderma. But there's actually a number of different other ideologies that you really need to look for in these patients, you can see the picture on the on the bottom there. This is one of my ladies who had that typical if you will visa spastic response you can see the fifth digit actually has a deeply cyanotic appearance and even had an ulceration. She had policy theme mia and once I sent her and she was adequately lobotomized, her hands were completely normal. But you want to make sure that you look at all of the components of the patients. So you can identify what the underlying ideology maybe. So we can see secondary rainouts. Here's just a sort of a laundry list. If you will, we think about connective tissue disorders. Don't forget about vascular disease or vascular injury like thoracic outlet syndrome. Um chemical exposures, we don't see this often. I will tell you one of the places I see it frequently is in with patients who are sympathetic to medics for A. D. H. D. And I see it actually in Children in that setting. So you want to make sure you pay attention to that trauma and vibration induced injury, motorcycle riders. I've had a hockey player that had uh secondary rainouts from just vibration of his hockey stick. So there's a number of different conditions and don't forget about the hyper viscosity states diagnosis. Uh typically you you I would like to elicit that very classic history. Again, not just cold hands. I want to hear history that I had demarcated spastic changes because that really helps me. I think you have a a number of different things you can do from a laboratories perspective. I think from the role of the vascular lab, it's really very limited. Certainly we can do cold immersion studies. I don't think they helped me in most cases when I'm thinking about either primary or secondary right now changes frankly. Um how do we treat these? Well minimize cold exposure and preserve that core body temperature. That's sort of our mainstay. We have a number of different medications that we may try in these patients. All of this is off label, whether you're using calcium channel blockers or phosphor diasporas inhibitors or other Visa dilator. That's all off label in very severe cases, will sometimes use our plastic surgery colleagues and do some botulinum toxin. And then for patients who have severe ulceration or at risk for digit uh loss, we may consider prostaglandin fusion, uh our endothelial receptor antagonist infusion and even surgical sympathetic to me. Um I think in the interest of time actually I'll stop there. I'm gonna say one word about ponyo, the weather we have been having here of late. This is our perfect pernia weather. So ponyo is this sub super freezing, wet related exposure, very classic lesions that you'll see on typically the tips of the toes, you can also see them on the digits or the nose, but usually we think about this as the tips of the toes. Many of these uh will heal just by taking the patient out of the inciting event and they'll do just fine. Alright. And not all color changes are vascular. This was a case that I saw in the hospital a couple of years ago. It looks like a very blue, very ischemic. Can. This was chrome hydro sis, which is basically blue sweat. So the patient was admitted and got a nice vascular work up. Thank you.