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00:00:00
so d. m. i found actually d. set picture quite quite
00:00:05
inspiring systems fate what an artist's uh feels uh
00:00:10
uh when uh she has a a a vein troubles the deep thing troubles is
00:00:16
and uh and and you see the the the degree of saw friends and uh uh especially
00:00:23
uh uh in the treatment of this kind of fumble this is a very standardise and
00:00:28
very advanced uh something similar happens in the in
00:00:32
the portal vein of jesus and despotic area
00:00:35
but we we don't know exactly what's the consequence are in this in this area
00:00:40
and we are absolutely not advanced in terms of standardisation of treatment and even
00:00:45
less uh in terms of onto cooperation so what i wanted to
00:00:49
a good tool would you worked three points the mechanism veterans of
00:00:52
a new a class of rocks the affects of these uh
00:00:56
direct alright i've ah to quite blunt especially in patients presenting with
00:01:01
a chronic advance lever disease and uh i'm finally some
00:01:05
words about uh the indication if there is one about monitoring
00:01:10
and uh which dog is good for which patients
00:01:14
we have our uh free directing beaters or factor twenty we have one any better off from being
00:01:21
and the acting the final part of the cascade indy
00:01:25
are currently i'm used for the prevention of stroke
00:01:29
for the treatment of venus from where embolism for the prevention of a trim waist one is after
00:01:35
me or heap are purposely not thing to do would portal vein proposes the real novelty
00:01:42
is that uh tends to set a a degree of a of a safety is that we
00:01:47
can uh antagonists this we can do with with a a ten a uh um yeah
00:01:54
to um uh antidote switches uh and excellent we can utilise that we get front with an antibody
00:02:02
and uh in uh probably the next month we we have a a
00:02:06
a new one which is syrup around talk which is a
00:02:09
a general uh an antidote for orange quadrants that we are uh
00:02:14
currently uh using of course not for vitamin k. antagonist
00:02:19
so the evidence that uh these trucks are good calms for or
00:02:24
from a big registration studies use here dear
00:02:28
dear dear uh it being housings of
00:02:30
patience and what what it is interesting is that in terms of uh
00:02:35
of us for core systemic timberlake events compared to vitamin
00:02:40
k. antagonist when you want to quadrants are better
00:02:43
okay in terms of building a the pieces
00:02:48
to this is to be differentiated because yeah you see that
00:02:52
uh there are two oh uh drunks which are pick
00:02:56
seven and it took someone which are clearly better so less bleeding then on to vitamin k. into drugs
00:03:03
that we get from the river oaks of and where this evidence is not based
00:03:07
clear so if we um focus on a efficacy and
00:03:12
safety outcomes we can clearly see that's a docks
00:03:17
are better in terms of a more logic stroke they are better
00:03:21
in terms of uh inter crying out hemorrhage but interestingly
00:03:26
uh and this is relevant to particular eleven for
00:03:28
us as far as gastrointestinal bleeding is concerned
00:03:33
probably dogs are more dangerous than uh on t. vitamin k.
00:03:39
uh these are data from a registration study what to use uh in in the
00:03:44
real word in the real word you see that if we uh compare
00:03:50
seventy thousand two more than fifty thousand patients treated with dogs or
00:03:55
we'd harder and requirements in terms of g. i. bleeding
00:04:00
there is no difference so we can conclude okay there is no problem however if we have a closer look
00:04:08
uh to this data we see that the reading crystals of major j. believing
00:04:13
that are associated with that be that front plus twenty seven or
00:04:17
revoke seven plus forty percent but not for the other ones there are
00:04:21
some risk groups which are patients over for a seventy five
00:04:24
patients presenting liver dysfunction uh impaired the party functional we've come
00:04:29
back to this end concomitant use often to brackets
00:04:33
and finally uh h. two receptor antagonists or p. p.
00:04:36
i. appears to be protective against uh against building
00:04:41
and if we compare uh uh relate to each other the
00:04:45
different uh dogs in terms of risk of gastrointestinal bleeding
00:04:51
you see that uh and i'm not going to details but
00:04:54
compared to the other um docks optics upon seems
00:04:59
to be better than the be the trend and the bigger trend seems to be better than remarks about
00:05:06
so taking together this uh data shows us that uh that be that
00:05:11
trend and vivid rocks upon in terms also major baiting overall
00:05:15
are the same as vitamin k. antagonist while at big seven hundred and that talks about her better
00:05:22
major ga bleeding is uh is higher would that be that front
00:05:26
ends weaver oxygen but not too with with the other two
00:05:29
and it's major inter cranial buildings is lower with all the locks compared
00:05:34
which is a a and t. vitamin k. uh um
00:05:39
medications once again in the real word in the
00:05:42
state of more than forty thousand patients uh
00:05:47
this is our confirming that a a major bleeding events uh ochre less
00:05:54
frequently in a in a the locks than in a war firming
00:05:58
hear the difference is not really a significant inter cranial
00:06:02
bleeding of course less uh but you see that
00:06:06
yeah it should be eating uh uh at least for
00:06:09
uh the b. that final course uh more frequently
00:06:14
so while it occurs where uh those it's does it do so
00:06:18
in the upper g. i. tract it's a a pack teach also disease in
00:06:23
the lord your track to see that uh the vertical are um
00:06:27
the article or bleeding but interestingly if you look at uh the
00:06:33
percentage of patients who has to have to be osprey televised uh as you can see
00:06:39
that this percent is is a fifty percent impatient with docks a while it
00:06:43
is a a much higher in patients with conti vitamin k. and also the duration
00:06:49
of uh or speech energy hospital decision is screw shorter in patients treated with
00:06:53
a dog so clearly a an advantage these study is a excluded as the vast
00:07:00
majority of the other studies is excluded patients with zeros is so we have
00:07:06
to look into the studies to find out patients with zeros disease or a survey
00:07:12
uh all of a a gastrointestinal bleeding after endoscopy each interventions and uh
00:07:18
uh we see that in general uh the incidence of
00:07:22
bleeding is higher in patients treated weights or suffering
00:07:27
compared with docks this is not a statistically significant but it's
00:07:32
always it's always the saying trends and uh if we
00:07:35
look closer to an indication which we found we find
00:07:39
that uh endoscopy should various allegation is also included
00:07:43
meaning that she or a a a sorority patients must be included
00:07:49
and and and treated with with the uh with dogs disease uh
00:07:53
fifty versus a a fifty four and you see that uh
00:07:57
there is here also a a march of uh uh security
00:08:01
if you want to but this is not a significant
00:08:04
but this is something that fits that happens so the frequent situation is uh that we use
00:08:11
dogs uh when you we assume that the reason only the disease for a very common
00:08:17
uh conditions that i'm not related to advance chronic liver disease and this is a rare situation
00:08:22
where we know that our patients are a um a lever sick and we
00:08:28
treat conditions that are associated with this disease support having trouble this arbitrary
00:08:34
of course patients with advanced liver disease can also be treated in these
00:08:39
in these indications but in the studies this patients have been excluded
00:08:45
what are the effects of the works uh in these patients we
00:08:49
have to uh scenarios on the left side you see the
00:08:52
changes that we observe in patients with stumbles is primary most
00:08:57
places is disturbed cooperation is disturbed fibre analysis is disturbed
00:09:02
we have to take into account this and on the other hand former co kinetic
00:09:07
um uh situations are different and i'm i'm going to show you an example
00:09:12
and a farmer coding on each uh aspects as also
00:09:15
different because there wasn't a an increased or did
00:09:19
might be an increase plus my plasma level of this uh drugs but data are very um
00:09:26
very uh controversial you see here the levels of
00:09:30
a river rock seven impatient had to subject
00:09:34
patient with mild or moderate the political impairment meaning child a in child you and you
00:09:40
see as expected that's the levels of a a plus money the rocks about our higher if
00:09:46
the lever is stick in that action of a uni beating tiny is a um
00:09:52
is more is higher and it probably the pro probing time is higher here so expected for iraq's about
00:09:59
for a for a box upon we have the country you see you see
00:10:04
here that there is no difference in concentration but uh if uh
00:10:08
if you see uh the data in moderate departing payment you see that
00:10:14
uh in the head the subject uh uh the the the level
00:10:19
orthodox someone is higher dan in a a lever such a subject so we don't know exactly what
00:10:24
the mechanism uh are but we we we we cannot conclude uh with with generally that uh
00:10:31
zero to patients have higher level of these drops another point of course is drug
00:10:37
induced liver injury it is expected enough to one percent of the patients
00:10:43
it's less frequent than with low will occur are way temperance or vitamin k. antagonists it's
00:10:49
more able to sell were then course static injury and it is more frequent
00:10:53
with river rocks about dan would that be that front or uh peaks
00:10:59
which is relevant what is relevant for us is that uh we
00:11:02
are using some some dry conservative patients in when we
00:11:06
decide to want to cooperate we have to uh draw attention to the fact that especially with the big upfront
00:11:13
and in some cases wait it talks about we have to call c. there i read option
00:11:18
when we use a beta blockers when we use stay things and when we use um
00:11:25
a thankless boring or probably most in our transplanted patients
00:11:30
one of course the in only only really really uh zero to but
00:11:36
keep in mind that uh uh this can be an issue
00:11:39
in another issue can be lever injury you see that's a d. u. um attitude should be different
00:11:45
that electron is the lesser a safe drought in this uh uh context you see that
00:11:52
uh in levels of cutting the clearance less than a a fifty meters
00:11:57
per minutes we should decrees any level it's a on of less
00:12:01
than thirty meters of uh uh per minutes you have to decrease
00:12:06
the those two fifty percent whichever also wanna know doc seven
00:12:10
and also here to to fifty percent and consider that basically in patients with a crafting enough
00:12:16
not threatening clearance of less than than a fifteen
00:12:21
it's basically a no go for four blocks
00:12:25
the data uh about the safety as if it and efficacy
00:12:28
patients with it's uh s. roses are very rare
00:12:32
you see here all the studies that are available low number of patients a little uh or
00:12:38
short a duration of a followup major breaking occurring
00:12:44
in a proportion that he's actually uh
00:12:47
in the same range and is the proportion observed in anti vitamin k. a.
00:12:52
or a low wicker way to point but remember that these studies a
00:12:55
retrospective and then not have not been designed for for a process this and
00:13:01
what what is of course a problem for us is that the
00:13:05
the the proportion of security patients child see is uh
00:13:10
zeroing the majority of the study and fifteen percent only only in one in one study so
00:13:17
uh did the data uh showing that major bleeding uh
00:13:21
easel covering more or less uh with the
00:13:24
same frequency as a as a the other on
00:13:27
squadrons must be taking very very cautiously
00:13:32
um it is interesting to see that uh in a in the context of truth in a strong one policeman uh
00:13:39
in patients presenting with uh elevated serum i mean the
00:13:44
try a trans i mean is is um docks
00:13:48
our our uh um i think the study where um prescribed much more frequently
00:13:54
then uh uh on t. vitamin k. e. uh medications it's not clear
00:14:00
why but uh it's also interesting to see that in intensive care
00:14:04
uh uh the treatment of uh i'm actually things from what
00:14:08
is is that really really uh done with dogs
00:14:12
in contrast emergency care station this is the most the use of the
00:14:17
drug probably because uh uh with dogs you reach a a very
00:14:23
rapidly uh uh the the right speech a plasma levels and uh
00:14:27
this is the distribution of the use of our uh products
00:14:31
a deluxe entities probably what we also do does more uh more or less at fifty percent to rocks
00:14:38
about forty percent the big seven weeks upon and uh a bit uh docks upon and the bigotry
00:14:45
in the there are two other considerations that i would like just to mention and it is that the locks
00:14:51
in not all basically uh it can be used but they can cut a accounts that there is
00:14:57
a a a large volume of distribution and basically what
00:15:02
you should consider is that in patients with a
00:15:05
b. m. my of more than forty or more than one hundred and twenty children body weight
00:15:11
you should not use a a dogs uh and gore
00:15:14
other for a vitamin k. antagonists and uh
00:15:19
this is a concern was all in patients who are a little weight
00:15:24
impatience of less than sixty kilograms you should reduce
00:15:28
uh those at least for a big seven and the docks about but there are no recommendations were all fisher recommendation in
00:15:35
this area but consider that a frequently uh see what the
00:15:38
patients presents a a sock opinion and this should be
00:15:43
uh uh taking into account the locks may be good for security patients
00:15:49
because they have some and if i brought each uh um
00:15:54
action you see that they contributes in an animal model
00:15:58
to uh improve into t. i. dysfunction they are associated with last fibrosis as a
00:16:05
see that uh by quantification of us i'll have a small monsieur acting
00:16:10
ends they can lower puerto pressure although this is a a um
00:16:15
this uh use uh mm it's in statistically
00:16:20
significant but it's it's uh uh uh
00:16:25
only only point four percent and this is not a good uh only for
00:16:30
the lever the antibiotic effect is uh uh was observed on carpet fibres
00:16:36
results of sort of i don't go into details up except on is uh
00:16:41
also in a beating fibrosis in pulmonary fibre blessed in that we
00:16:45
get found a decreases in you know in v. form or the five
00:16:50
boroughs is of the longs in people so it it appears
00:16:53
to be a general uh and if i brought each effect and uh
00:16:58
i'm going to a close my presentation with the last part which
00:17:03
is uh important because you cannot money toward your d. d. d. the
00:17:07
efficacy of the tree to me docks however you should know
00:17:11
that uh especially locks upon is increasing uh do here in our uh
00:17:17
value of your patients but you can use the n. r. as as up
00:17:22
as i'm a marker all funky cooperation in that case and that that
00:17:27
electron is prolonged in the g. d. yeah a p. t. t.
00:17:31
so uh i just taking two into account decent this is another a way of seeing these things you see
00:17:38
that uh a pity and the input from in time are increased but uh you see that uh
00:17:45
pro and speak levels are overlapping here for that you
00:17:49
get from any particular for a pick someone so
00:17:52
if you measure the the the the plasma level of the straps you cannot
00:17:58
the say where where you are if you are in a in a in a a
00:18:03
in an area where you are um therapeutic rather choppy twentieth efficient or or not
00:18:11
and uh you see again the very larger interval of concentration
00:18:18
in a in a in class model for all the for
00:18:22
a dogs and you see here that when you know
00:18:26
uh the concentration is increasing the un t. ten a action
00:18:33
is uh is uh not not morning or so
00:18:35
you do the she messages that you can you you
00:18:38
cannot use plasma levels to uh evaluate the
00:18:44
efficacy so basically the recommendation that we have for the
00:18:48
use of dogs anybody's are that you should evaluate
00:18:51
your function test before starting and consider that there are practically no data in shied see patients
00:18:58
you should monitor liver function during the treatment especially the elderly patients or patients taking other um
00:19:05
people to talk such a drunk forty you should adapt the doors according to the renal function
00:19:12
and you know that uh security patients are have a very variable a kidney function
00:19:18
and consider stop docks in case of a step of uh was position for drug related it but the
00:19:24
toxicity tried a is a is a green area
00:19:28
a caution is needed for child be patients
00:19:32
and for child see patients um caution is is is recommended
00:19:38
uh i think we very rarely treat these patients and if we do so then
00:19:43
that we limit it's at a c. ten or or or or eleven
00:19:49
uh and this is my i think almost three seconds last slide how do you select
00:19:55
the right the ox considering the patients profile uh when the release euros is
00:20:01
is the reason i risk of gastrointestinal bleeding in this
00:20:04
does not include uh viruses that includes uh
00:20:09
a risk of bleeding in vices which is the dimension
00:20:13
and the right size but not viruses percent uh
00:20:17
it's better to use a a big seven or the bigots running reduced those if there is a
00:20:22
high risk of general bleeding then saying kings but you can use all the docks upon
00:20:29
if you have a uh an advanced liver disease child be then a core or
00:20:34
maybe it's good to avoid river rock seven for a a a decrees uh in a renal function
00:20:42
yes then uh fifty meters per minutes curtain clearance then you should
00:20:48
decrease or consider decreasing the dot's en it's uh if
00:20:52
for the patients is not fully compliant or once only one uh p. per day then the
00:20:58
river oaks upon or it looks upon should be should be selected so into close
00:21:04
uh i would like to to to conclude by saying that currently available data
00:21:08
so just the dogs are safe and effective uh in the presence of mind
00:21:13
to more the right advance chronic liver disease so opt to try it
00:21:17
b. b. nine or c. ten data are needed in stage see patients
00:21:23
in addition to liver function we i figured right interaction asian be
00:21:27
yeah my should be considered before starting this treatment docks may
00:21:33
have also on to fibre optic treatment so they could be indicated
00:21:36
in the um uh five brodie diseases including zeros is
00:21:40
in serum levels are not sufficient for monitoring
00:21:45
our soap here and i thank you for your attention
00:21:54
hannah lisa mm thank you very much and uh it's really a difficult topic at the end because
00:22:03
i always ask myself what to do when we have a patient
00:22:06
with a child c. is on the way to respond transplantation
00:22:09
bean develop those are nice for the winter mosey beneath not
00:22:13
complete that we want to preserve the papacy or the
00:22:18
a conference and you because you you need to receive a transplant then
00:22:22
we need to treat then we cannot use the works then um
00:22:28
mostly this patient have a good reason features you so they
00:22:31
are not ideal candidate anyway what do you do personally
00:22:38
it's it's it's a very complex situation might personalised experience but i think we
00:22:43
can share its or maybe blowing i dunno bits this safest order
00:22:50
easiest to to to to use triage are a little more like are
00:22:54
we temperance uh if you have a ah unacceptable kidney function
00:23:02
uh i'm speaking about really zero to patients the the patients on
00:23:06
the least uh with uh because of h. c. c.
00:23:09
are different they can be use with dogs they can be treated with dogs but they re us robotics are are
00:23:15
are really difficult and uh i think personally i tend to to switch to um
00:23:22
to look for what happens but they have to to to to inject it
00:23:28
and uh and this is not that easy and you have a two c.
00:23:31
d.'s patients very frequently because if they uh develop it but we'll syndrome
00:23:36
or any kind of like you have have as we have seen this morning this is a this is a major problem because then you should
00:23:43
go for for a non fraction it it forms a whimpering and this is this is
00:23:49
this is complicated so my personal preference is a fax
00:23:55
repairing or clicks on is that ordering your
00:24:02
more freedom to tie traded those those with low manipulates freezes this page and often have a
00:24:08
if not to mention the low platelet counts soul how how
00:24:13
lowell you'll there to goal with uh and columns because most of
00:24:19
these at least anybody we cannot prescribe when you want
00:24:22
to call warrants a bit direct and problems for a portal
00:24:26
in trouble just because that existed only for uh
00:24:29
prevention most rock and for our and we'll probably embolism so the second question is
00:24:36
in case use it for both of interim balls is do you think that this
00:24:39
same those is the recommended because really the the others are life threatening conditions
00:24:46
portal interim was used as a that was said not always is a life threatening condition um so
00:24:51
it might not even be directly their functions so it is really needed that would give the
00:24:56
full dawes or we might maybe after one mansell words will be those that the nobody no the
00:25:02
present so but if you have your personal opinion it would be nice to hear it
00:25:10
mm that i that was mentioning it and that has been always be
00:25:15
that paschal from boxes near the call for and that then
00:25:20
then what we do all is a trial of low weight a
00:25:24
plane and if he doesn't work we go for tapes
00:25:30
that that's what it back to you and uh
00:25:40
to complete a form thing from e. d. but really if it's lacking in pregnancy we
00:25:52
don't have data so for the history and the companions this don't you see
00:25:58
well it ended with vitamin k. it's always the question it favourite so let's
00:26:01
say in the past week like the switch to the l. x.
00:26:05
it it the data is it clear what i bought probably because it wasn't like
00:26:09
it's coming on the market or a cox our dates on the market
00:26:13
uh the problem it let me know this disturbing you
00:26:17
can smash and that makes it more complicated in
00:26:20
in levers in in in surrogate patients i'll try that c. i. c. patients had to say
00:26:27
i'm a strong believer in that part but i mean we say
00:26:32
single pill for all patients except for the extremities i'm in body weight
00:26:38
and just for us real something we most frankly see as a as a country indication that
00:26:47
you know what it would be yeah at that site apology patients so we had this this this
00:26:56
is not a with with that out with chemotherapy i bought that even with vitamin k.
00:27:01
i mean that that thing is like family well kinetic so that it's like a little more
00:27:06
like away hap right so so even after intake and you have a complication i mean
00:27:11
four two forty six hours late at the half life is already
00:27:14
gone so all the discussions on and you got someone is
00:27:18
bullying and you don't even like to too late so he
00:27:22
you have even with vitamin k. antagonistic allow that matches
00:27:26
and and he i mean until the patient in the hospital have like ten what gone and you're dealing
00:27:31
with something we all know follicle wait happens and we don't just discussed that inside the as well
00:27:38
so so my fault it's it's in favour wrap up the problem is ah
00:27:43
there are no they they nail recommendation for the sake of
00:27:46
the industry and and ah e. for legal issue
00:27:53
or any other questions
00:27:58
i'd together with the patient to use dog and we have we have patient
00:28:03
mean don't even mean waiting list on the drawn transplantation these very important
00:28:08
to discuss with patient the pros and cons and to have a return
00:28:11
documentation stating that the patient wants to go and accept the reason
00:28:18
and to discuss interdisciplinary also with the code except the weight is because for instance
00:28:23
um is this your reduced at that issue with a patient that was
00:28:27
on the rocks one and it was called the unexpectedly for transplant
00:28:31
and then they could not antagonist so that's why now for these
00:28:34
very specific cases we do not longer use them so it's
00:28:38
i think it's very important to be very open and close by and go to the discussion does unknown an unknown yeah yeah
00:28:46
o. e. k. o. e. c. d. how flat it's so short and we don't think about well michael way
00:28:55
hap right so so even in tight see personally i would vote for deluxe except the special situations
00:29:04
four
00:29:05
as a few relation and pulmonary embolism you might stop if you'd was the first occurrence
00:29:12
in the the situation as disappeared if you the second instance you goal long life
00:29:19
if you use a for portables rumbles which is your time you knew how long should be should be taking
00:29:25
yeah and the calculation because for instance for oracle wait a plane
00:29:30
initially we tended to so expand it a one to two months after the disappearance of the
00:29:36
traumas but we had a thirty four percent of recorders so now we have we baiting
00:29:42
how long whether you this is the yeah i don't have any as
00:29:49
but you know that's i was it on to the any answer but my
00:29:52
attitude or how well you don't monitor them soul you save a
00:30:01
physician consultations u. c. v. in our measurements every week so in the
00:30:06
end i'm i don't know if it is really more expensive but
00:30:11
okay okay you know right
00:30:20
want to come to your to your question i think that uh if you identify
00:30:25
risk factor for puerto having troubles isn't is risk factor is to present
00:30:31
as you mentioned so a trouble free yeah oh or or or
00:30:35
or or whatever the including in my opinions you roses
00:30:39
is that on the field factor then uh probably to make sense to continue
00:30:45
if you have a local factor that is eliminated or issue have a a point of
00:30:51
income poses due to c. m. v. infection it should seem infection or or
00:30:55
or something that you can you can see and you can demonstrate that it's over the risk is over
00:31:02
then my opinion it's justified to stop a treat and but in zeros
00:31:07
this if we accept the two roses approach for multi condition
00:31:11
then i would tends to continue although it's true that we have
00:31:14
for this to seventy percent of cases of spontaneous resolution
00:31:19
of composes which would not justify articulation
00:31:24
i think that the the more importation is paradoxically to see whether
00:31:31
and the well once can improve zeros is it they improved because we will
00:31:35
use them all over and when we land in every single situation
00:31:40
if this is not the case they need a little bit of to to gonna
00:31:43
catch say so it has to have an impact and probably orgies and
00:31:50
and uh the the the the studies of a recovery like that was in these as i think
00:31:57
has not been depicted it typically has been said that many more people will do the same
00:32:03
as the the the gunfire with the night but it's it's not and so um
00:32:09
we need such information on a block it's occupations you always good with opera genders could be
00:32:19
oh
00:32:23
i don't do it's a always i. e.
00:32:32
yeah i get that workers is in the home
00:32:40
because the corporations states
00:32:43
what it did to your study would factor seven demonstrate that if you change corporation you don't improve anything
00:32:49
in terms of of of outcome of bleeding right
00:32:58
then no we we should then we should
00:33:06
yeah and if we have if you have viruses are introduced me to brokers in then you want to go with it
00:33:19
ah
00:33:24
uh_huh
00:33:27
there are various questions
00:33:37
i just increase the flow dramatically i do create up it imposes but
00:33:45
the change in the speed the plough with but that locus about probably to circle
00:33:52
then you have other effects of that will that be a a farewell and it'll be
00:34:01
the product of like ox right you can you can modify the things i
00:34:09
okay i think each we stop here thank you very much to all i
00:34:14
would like to say two things the first one is that uh
00:34:18
we have the we have the opera which is the most important thing up arrow and it occasional
00:34:24
uh events are supported by the industry so thank you very much to uh your support we
00:34:30
could not do this if uh you were not here
00:34:33
so thank you very much um for the
00:34:37
people who need star here um participation so uh
00:34:42
uh documents so just take one copy
00:34:47
thank you very much for your for your contribution rupert to see patients so you will

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