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for this kind invitations my first time to the interest in those because ah uh looking for what
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so having a look around here in this beautiful fifty so my topic assault unit but titus
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um it's one of our favourite uh topics in hamburg since we have a
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large all patients uh this will do you mean the the diseases as well
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and we're focusing right now research also on what you mean
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appetite as what human liver diseases and immune regulation in the lever
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so whenever you have questions uh feel free to interrupt me at any time
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and uh these on mine disclosures and i would like to start with a few bullet
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points why do i think that what you mean appetite is important for all of us
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i think you all know that it's with differential diagnosis of might be elevated liver enzymes
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sometimes sometimes times up to form and liver failure
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and that around thirty percent of the patients already present with should roses
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uh which makes the i. h. unimportant differential um for
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unclear three projects can be a semiautomatic most often is symptomatic
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and uh i think it should be considered in any age group and i will come back to that a bit later
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so all the incidence is rising we have good data from denmark we have similar data from germany
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we have a point prevalence around twenty per hundred thousand
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a few years ago it's exactly the same number as we have in germany right now
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why that is we don't really know what it's it holds true for many old human diseases
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and uh on the right hand side you can see the age distribution of k. i. h. it
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often as a disease of the young females but you see that it most often
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is a disease of the elderly woman so
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i think we may have overlooked in the
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past one or the other seventy seventy five year old patient uh with what unit but titus
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so i'd like to start with the emerging in future therapies the
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future i think it's antigen specific tolerance induction that's the holy grail
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um however i think that is still far away since we
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don't have a clue what we ought to antigen is we
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don't even have a clue what he antigens on if it's
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not all tall so all i think that's for the far future
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but we're working on that on the experimental side
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so the close of future i think is understanding the
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net works that go run a yeah h. profit genesis and whenever we show such a network it means
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we don't really have a clue right i mean we put all the says inside the kinds we know wanna picture and link them
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um how i think we are starting to get some ideas
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on the sentence title kinds involved in a yeah ha patrick inflammation
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and i would like to point your interest to the th one
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t. cells and especially to the side to crime t. n. f.
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y. t. n. f. p. costs and this is unpublished work from t. now i love from our group
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when you isolate the liver infiltrating lymphocytes from
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liver biopsies obtain from yeah h. patients at diagnosis
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and compare the site so kind expression of these little infiltrating lymphocytes
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to controls you can see there's hardly any as seventeen eighty expression
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there's some lines of young got my expression a sticky th one side or kind
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but you have significantly increased t. n. f. expression in
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the c. d. for positive t. says isolated from the other
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and similar results we could recently identify four and not the ah
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said time in the liver where in humans we don't really know what
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they do that's the n. k. t. type to sell its every asset fraction
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and he um muscles it would or could show that also these says
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express high amounts of t. and f. in here h. s. compared to controls
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so the bottom line is this something with t. n. f. and why do i mention that
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because blocking t. n. f. actually is a very
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effective rescue treatment for patients with a uh h.
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this may sound a bit surprising because we know that id patience sometimes develop immune
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mediated hepatitis on the blocking of t. and have but it's not wanting an hepatitis
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if you take it away it stops that's easily treatable with with steroids
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here included a few patients with really difficult to treat
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disease many of the most of them actually serve optics
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who had prior emails oppressive treatment regimens at least two
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of them and you can see that they responded nicely
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and that prompted us to um perform a proof of
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concept study which we are currently performing in hand work
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where we try to replace the stay avoids in the initial treatment of forty minute but
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titus i think this is of utmost importance for patients for patient safety for quality of life
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and i can tell you know so far it works so this may
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be the not too far future for for the induction of remission inopportune appetites
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and i think michael will later talk more about the cup liver axis i just want to
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highlight of few findings we recently obtained
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also unpublished from the got michael but your
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time what you mean hepatitis we sampled a notch quart of patients at the controls
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control patients with p. d. c. and assertive collide to us and we
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observed that specific bacterial species the
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feudal bacteria were reduced unfortunate but titus
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and they were specially apps and in those patients who did not reach biochemical remission
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so all we're looking deeper into that at the moment and we think that
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this may also be a target for future modulation therapies
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definitely i think will not be the only treatment option
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okay let's step back to what we have today i think there are a
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lot of unmet needs in the treatment of a uh h. even today so all
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when should we diagnose it when should we consider the diagonals as
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i think i mentioned in the beginning in any form of chronic fluctuating
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elevation of chance i mean eases in any
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patients with unclear hepatitis cute carrick appetite as
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if your overall tomorrow hepatitis then the next
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step in diagnosing it is determining or to antibodies
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most centres in europe i think to work with in direct immune of fluorescence testing
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you can do with with eliza somewhat on him you know lots but they
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are knoll really comparative trials to tell which is the best method to use
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i. g. g. is frequently selectively elevated in h. i think it's a
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key feature of a yeah h. going around eighty percent of our patients
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if you have the altar antibodies and i. d. g. it is very
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likely that you have a uh h. but you still need the biopsy
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you can discuss that maybe we can discuss that later if you really need it but it's the only way to
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obtain information about being inflammatory activity and the exact stage
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of the disease and also to rule out concomitant other diseases
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if you have negative also antibodies repeated you think about
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the diagnosis in b. and you also performance of a biopsy
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if you are not show about the diagnosis you can use a simplified
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school which was developed a few years ago by our group bans couples that
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and you can see this call on the contains four variables yalta antibodies
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but you have to use i have to in order to score
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correctly we don't have points for eliza cut offs at the moment
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you determine the quantitative i. g. g. levels organic law billions and you need little
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histology and astrology is not easy point in the school because you really need a pathologist
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that would give you the information this is a typical a. i. h. was it is compatible
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and if the pathologist has not experienced in seeing these patients you will never get
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a diagnosis of it typically i. h. so you can basically forget these to see um
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i mention that because i think it's very important in hamburg and probably do the same we regularly enough
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on a weekly basis it together without pathologist and discuss the cases i think this is of utmost importance
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okay these are the authentic got is none of them is a liver specific
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um you see them in between um five and sixty percent you can differentiate
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type one from type two type tool more aggressive more kids and use
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type one why that's then you have as a positive patience sometimes referred to as type three
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doesn't really matter because the course of this type is similar
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to type one so we start a summarise these as type one
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and we have a serious of interesting um i'll the or to antibodies i mentioned them because
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be in a out antibody sometimes um
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uh cause confusion uh with remote apologists
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because like you th can also cause joint pain and if you
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have double stranded d. n. s. n. t. i. d. n. a. antibodies
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it gets confusing we have antibodies that uh associate with the disease activity that may
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or may not be to a certain degree degree pathogenic but it's not standard testing
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we perform now the first study comparing i. f. t. with
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the license and uh this will be shown at the the meeting
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in in boston and you can see that it compares very well
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so all we will be able to be finalised like cutoffs for the simplified school
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i mentioned that astrology is very important for the diagnosis um
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this is a typical histology showing them for static infiltrate it's
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very portal hepatitis so caught interface activity and then a lot of other
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things like was acting and reproduces way you need then the
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specialist apologies about probably about all the jeep apologised for the pathologist
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so we we like to perform the liver biopsy using many lap ross copy
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and this picture shows you why because if you do an ultrasound guided biopsy and here you have a macro
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not you less euros is like this once it's typical for yeah age you have a very high sampling bias
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if you had to regenerate of not you you don't
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see any scarring tissue although you have microphone modular cirrhosis
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and this information is important because zero says in h. as in
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most other diseases is associated with the worse prognosis as has been shown by several groups
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but i started g. is insufficient in
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differentiating acutely carrick yeah h. from cute billy
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because both forms have these century lobby long neck roles
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because i will have all lack all to antibodies frequently in the i. h. i. g.
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g. tends to be low often absent at the time of back notices and the correct diagnosis
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um most often can only be i'm done after spiro it with drawl
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so what we did was we give steroids and use remission withdraw the steroids
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look for the relapse if it relapses it's yeah age doesn't relapse it's most likely billy but you can never be sure
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okay if you have the diagonals of a h. then the next not so easy question is whether to
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treat or not it's not an easy question in
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advance or what takes wall in the low activity patients
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so in the guidelines is defined as lower
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than for eighteen modified hepatitis activity index points
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if you don't treat the patient which i think is fine to
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discuss with the patient then you have two more need to i'm lifelong
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because the disease tends to fluctuation activity and then i would definitely
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survey using non invasive fibrosis marcus so that we don't miss
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fibrosis progression in spite of very low trends i mean nice levels
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any activity above three should lead to treatment
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full imminent a age very difficult cases contact with the transplants and so i think that's it
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so i i h. was the disease um with the first controlled
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um try and showing lifesaving treatment with steroids
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small numbers but stairwell it's us the the mainstay of
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the induction a half of remission in h. even to date
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the guidelines say we shouldn't use remission what's the rights and we should maintain
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the mission using is a five train i think the european guideline is very reluctant
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regarding what are some night but german uh all string guideline is a bit
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more progressive i would say i think put this night is not a bad drug
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for especially younger patients all the patients with diet
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beaches and a suspicion of side effects of conventional steroids
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it's not quite as effective it's our feeling uh compared to conventional steroids but
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i think um it's worth a try if there's no circles that's a contra indication
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it's not hard green the doors one to one point five milligram
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standard poles but lower than for the treatment of i. b. d.
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so if you diagnose a patient to tell them all we're going to
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treat you with high dose steroids you're not very popular um so all
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he says the doctor prescribes a lot of toxic stuff including asbestos
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and lead and other things and the patients as uh it doesn't matter
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as long as it's not state role it's so i don't think it's
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that bad but avoiding high dose steroids is uh it's an important call
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not only for patients so these are the data from the wood
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doesn't i control trial that's the only control try in h. treatment
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we had for over forty years published already uh nine musical it
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shows you would that would doesn't i use effective in in using remission
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in this trial it was even better than a fixed those of cat is on a fixed also forty milligrams per is on
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and uh the criticism here was that most centres would not
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use a fixed dolls but an individual nice those according to
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um h. come abilities and body weight but uh that's the data that
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is out and uh it's not so bad if you compared with uh
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other data published on the um real
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life effectiveness effectiveness of steroids for induction information
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so i said reducing that also steroids may be an important goal especially for patients um
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and that is why i brought the very reason study which was
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performed by simon about the phone i'm a on a multi centre study
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also have contributed and it's trying to dissect whether hide
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those is really better than no those initials to avoid treatment
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and you divide it into two groups the one receiving
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less than all point five milligram per kilogram body weight
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and the other group more than all point five milligram per kilogram body weight
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and you can see that and then not school want four hundred fifty
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patients normalisation of trends i mean is that six months was very similar
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and also complete biochemical remission meaning also normalisation of i. d. g. i. g. g. levels
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was not different and he then that the propensity
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matching scroll saw the two groups there really comparable
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um but the steer white those besides the stay what tools
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and here hundreds and uh this is on the ten patients
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you see no statistical difference in the rate of normalisation
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of chance i mean is is after six months of treatment
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what does that mean it probably means many
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of us including ourselves in hamburg have used
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two hi steve oils as in the past i
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still believe some patients needed especially the very prominent patients
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but um i think many patients be country but what what was of conventions what's
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what should we tell the patient when we start treatment i think it is wise to tell them the chance that
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this is a lifelong diseases very high and the chance that it needs to be treated lifelong is also very high
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these are the dutch data showing the high relapse rate after trying to withdraw treatment
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in patients with a age and it also may rose on
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experience relapse rate is around ninety percent if you try to withdrawal
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now can you improve that could fiction off a successful treatment withdraw yes i think you can
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so all we're we investigated whether
00:18:02
patients that remained incomplete biochemical emission
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for at least two units and um although therapy
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meaning most cases medium to low those is that happy
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then you have a chance of around fifty percent of remaining
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in remission without treatment i think this is not too bad
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it's not the majority of the patients clearly it's relatively
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few patients but i think should be offered all of them
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so what's the goal of treatment it's trained yours complete biochemical remission
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why that is the best so or gate for his topological remission we have
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we don't regularly perform followup biopsies anymore
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so that will be idea to secure the
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school but we take biochemical remission now is that good or is it not good
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it's in between i would say these are the data also from
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from hand work a few years old but it shows you all
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how well biochemical remission correlates with this to logical remission
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if you have a a t. n. i. g. g. mormon
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the likelihood that you have a moderate to high has
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to logical activities so six to eighteen points is quite low
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and it increases if you have one of them elevated and if both elevated
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the majority of patients have an activity that requires um more intense treatment
00:19:38
and we have one study that shoulders that this
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differentiation between patients in his to logical be machine and
00:19:47
with an m. high of more than four or more than three really met us comes from the u. k.
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and you can see that on the long term patients with moderate astrological activity
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we'll have a worse prognosis compared to those incomplete is the logical permission
00:20:05
but this is a small single centre study think
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it requires confirmation but it's also very difficult bit adopting
00:20:15
okay what can you do to monitor the disease you can use non invasive fibrosis measurements
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five hours can is the best validated i don't know whether you have it you know probably do
00:20:27
and we could show that if you reach biochemical remission in yeah h.
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but over that period of the next few years
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let us stiffness significantly declines in those patients
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where you don't achieve biochemical emission levels difference increases and interestingly
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patients with services at diagnosis after steepest decline and stiffness
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and the treatment and this is not reduction of information so
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these are patients that up more than six months uh treated
00:21:03
this is important because in the first months after treatment initiation
00:21:08
the best deafness to a large degree correlates with inflammatory activity as you can see here
00:21:14
these are the patients with the same colours the stephens goes
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down here t. values going on this is induction of remission
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but the other study was looking at the long term development of a process and
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if you look at patients bill which are treated what treated longer than six months
00:21:34
piper scan is excellent for the production of advanced fibrosis
00:21:40
okay so all the goal is induction of remission maintenance of emission do we actually that in real life
00:21:50
the states are maybe you do and down in the u. k. we don't
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at least forty percent of patients not in remission and i can tell you
00:22:00
now it's and so it's not much different than in germany it's not much different
00:22:06
so we have to be better because not being in remission i showed your diverse deafness
00:22:12
not being in remission decreases survival i think this is an extreme example from um
00:22:19
then that pleases group but clearly i think remission is the goal
00:22:26
so what do we do if we don't achieve it
00:22:30
we have basically two groups of patients weren't role is the easy one
00:22:37
it's about ten percent of the patients we don't tolerate the initial treatment
00:22:41
so i think here we have a relatively clear definition and we have um
00:22:48
good jokes better then in using the mission underwear tolerated
00:22:53
the other patients with insufficient response to standard treatment um much more difficult
00:22:59
here we have a huge unmet need um we don't have
00:23:02
a validated to finish what is insufficient response on the long term
00:23:07
um we have very heterogeneous paper and patient populations if you look at
00:23:12
the case devious the studies you cannot really compare these regarding preach treatment
00:23:17
um and we have a huge reporting bias because we only have
00:23:22
positive case serious and all the rest will not be published so
00:23:26
it's very difficult um and to tell what tool i recommend here so in patients with intolerance
00:23:34
i think we could determinism and have a light levels i think the greater value of
00:23:40
doing this is in controlling adherents of a younger patients transition phase patients we regularly that
00:23:47
you can think of continuing stay what mortal therapy but then also this is not very well tolerated
00:23:53
'em on the long term with this the night maybe an option that very little data on that
00:23:59
um and then the two main jocks for the maintenance of permission i think
00:24:05
it's in the cup to pure and and michael fan late i think both
00:24:09
ah but tolerated even m. p. in patients
00:24:13
with a is that intolerance in seventy percent
00:24:16
would be tolerated similar to the experience for my b. d. treatment it's much cheaper it's not
00:24:23
i would say it's not zero to janet but in brackets um so
00:24:27
we don't have evidence that it's total janet in in uh in humans
00:24:34
and and then have side eater agenda which often precludes it's using a few minutes
00:24:40
these are some data and then have in is that
00:24:44
intolerant patients twenty five half answer emission half um no remission
00:24:52
and this is concerned and some other studies now
00:24:56
intolerant patients high rate of permission using m. m. f. patients but non response
00:25:03
probability of achieving complete biochemical remission in these patients as much
00:25:08
lower let's not the drug of choice in patients with insufficient response
00:25:14
so these are the data for the cup to pure and you can
00:25:17
see only six of twenty eight patients did not tolerate and p. when they
00:25:23
when taller and uh to as a time green and again i'm a high rate of complete or partial remission
00:25:33
now what should we think off in be insufficient responders
00:25:39
maybe we missed diagonals the disease what part of
00:25:43
the disease maybe there's a concomitant nash we will
00:25:47
um deteriorate with intensifying treatment so i think
00:25:51
the uh the biopsy has a great value
00:25:55
we should always question adherence i think it's a largely neglected area in the treatment of a.
00:26:00
i. h. i. think okay just one of the diseases in that but other g. would probably
00:26:06
the highest rate of non adherence because
00:26:10
we use quite an unpleasant and toxic drugs
00:26:15
increase his idols up to two two point five milligrams per kilogram
00:26:20
we then also like to determine examined to have a lights um because we
00:26:24
sometimes then combine out of four in all the phase of i mean it's so
00:26:30
it's a bit experiment thought but it works if you have a compliant patient you
00:26:36
can do it but you have to frequently controlled especially in the beginning the blood counts
00:26:42
it's always individualised and um i think basically you can try any jerk you
00:26:50
have experience with especially from the transplant field a very few drugs i would not
00:26:56
i would say they're definitely not work
00:27:00
so i'll show you some of the data published
00:27:03
mostly case reports case serious than not control trial data
00:27:07
uh concerning second that line treatment here using the addition
00:27:11
after crawling most published from the birmingham cool it works
00:27:17
using ever only most it works only five patients
00:27:22
but anyway it eating told me some of them have remained in recognition for many years
00:27:29
targeting be sounds which looks him up it also
00:27:33
works nodding all patients i'll only experience is not
00:27:38
that positive but we've tried it in only few patients but targeting be sets clearly is of interest
00:27:44
because there's now an ongoing trial being but try uh from the barges
00:27:50
uh with the bath receptor antibody very interesting trier
00:27:55
but it has great difficulties in recruiting and that's always
00:27:59
um uh in danger of being stopped prematurely
00:28:04
so i think we should all try to support this trial we do our best
00:28:07
but we have not included a single patients off it's a very difficult right after it
00:28:14
so the conclusion regarding second and third line treatment um there's very low level
00:28:19
evidence it should always be individualised treatment and almost in brackets everything can be tried
00:28:29
so if we don't achieve complete remission or if during the
00:28:33
course of disease called a static liver enzymes rise we should
00:28:39
all was also think the possibility of variance and drums meaning
00:28:44
patients are they i. h. will develop signs of p. u. c. l. p. b. c.
00:28:49
or the other way around we initially had p. b. c. patient with very high inflammatory activity
00:28:54
which reach the age with immune suppression but the call the status remains
00:29:00
um we have a very variable degree of
00:29:03
inflammatory activity in these colour static the diseases and
00:29:08
in doubt i think we should repeat what antibody testing we should look at the large bile
00:29:13
ducts using m. r. c. p. especially in the younger patients with with the h. and um
00:29:20
in doubt even do a biopsy during follow up
00:29:25
it really isn't clinic an e. p. yawn be
00:29:28
induction of a biochemical remission and disease progression and
00:29:33
and this will be probably on the line but patients and their representatives we should
00:29:38
aim at avoiding long term side effects of treatment short term related side effects of steroids
00:29:44
osteoporosis skin cancer on the long term and we should
00:29:47
recommend a regular a check for that and in the end
00:29:52
all patients improving quality of life is of utmost importance we're doing really badly with that
00:29:58
because we don't even know what in yes the quality of life in our age patients
00:30:05
just one example we recently completed a study on um cost to process
00:30:09
and all still paying me ah it's frequency now i i. h. patients
00:30:13
and the major missed factor not surprising me poster prose as opposed to avoid use another
00:30:18
argument to spear steve or it's in in this paper you can find the risk calculator
00:30:24
um how to um identify those patients at highest
00:30:29
risk of developing osteoporosis but i think in general
00:30:33
at least we try to do that at our sense i think we should it's
00:30:36
can do a bone scan in every patient without human appetite is to start with
00:30:43
so quality of life is reduced the mental
00:30:46
component the physical component shown now in several studies
00:30:51
and um i mention that because i think we
00:30:55
and the existing made the psychological burden of this disease
00:31:00
the feel of side effects on the long term the feel of disease progression
00:31:05
um and also get that this leads to the
00:31:07
really increased rates of anxiety symptoms also of depressive symptoms
00:31:13
um and it's about four times as high as in the general population comparable to
00:31:18
other chronic rheumatic diseases and one of the
00:31:22
major risk factors dan is still white treatment
00:31:30
not the guidelines say we should try to withdraw
00:31:33
steroids within the first six to twelve months of treatment
00:31:38
we carried a very large german insurance company registry from the t. k. k.
00:31:44
uh the t. k. uh insurance company with over eight might million injured people
00:31:49
we identified the patients with a h. and then we um
00:31:52
compare that to the data we have on prescriptions and scaring the
00:31:59
in germany over fifty percent of the patients
00:32:03
that are continuously treated with partners all buttons along
00:32:08
ten percent with buttons on and another twenty five percent with this online
00:32:14
meaning in the and the vast majority of patients in real life still is treated
00:32:22
what's the what's so we really not doing well in
00:32:26
that respect and another interesting feature of this uh study was
00:32:30
the high rate of personal use um so i think what happens and in in tractors is that
00:32:37
patients not answering remission of frequently a given or so in addition
00:32:43
to uh into the biochemical remission which may not be
00:32:46
too bad we know from japan but they treat yeah age
00:32:50
only with various all um we we're not big friends of that but i don't want to say it doesn't work
00:32:58
so i'll let me summarise the unmet needs in what you know
00:33:01
but types is we should uh and void treatment related um side effects
00:33:08
avoid to steer whites first and second line working on that
00:33:13
i think we need more effective treatments to interview was and maintained remission with less side effects
00:33:20
we need treatment which improves health related quality of life and doesn't make it worse um this is
00:33:27
difficult because we don't have a disease specific tools
00:33:31
to measure quality of life we desperately need that
00:33:35
we have unmet needs because we still have patients will progress to cirrhosis in
00:33:39
spite of treatment sometimes because they stop treatment for a few months really yes
00:33:45
and um mainly in patients with zeros is insufficient
00:33:48
treatment response and lack of remission we have disease progression
00:33:53
so let me stop uh this presentation um by mentioning the european reference net work
00:33:59
for a diseases we just had a meeting in hamburg and some of you attended
00:34:04
and i think this is a unique opportunity to improve
00:34:09
the life of patients with a h. in the future
00:34:12
because it's the first initiative starting on my two
00:34:15
cents a perspective high quality the registry which will then
00:34:21
give us information on different types of second and
00:34:24
third night treatments which big and then compare and decide
00:34:28
which ones would be best for our patients if you want to contribute that
00:34:32
you're very welcome you don't have to be a member of your in reference network
00:34:37
you can be a collaborative partner and a contact our data manager or myself if you're interested
00:34:43
and with this i would like to thank the t. one be the funding agencies and or if
00:34:49
you want to come off and uh learn about a broad spectrum of
00:34:53
separate or the g. very welcome to attend or apology course in homework
00:34:58
in november it's not the best time of the year to be in hamburg but uh it's always nice and i'm
00:35:03
so thanks very much and i'm happy to answer questions or e. e.
00:36:02
so how to differentiate really from acute picked eric yeah age it's extremely difficult
00:36:09
even flux but a pathologist uh have apology apologised for
00:36:13
the pathologists we've we've just finished a study involving for experts
00:36:21
into the pathology
00:36:23
and you cannot believe how how high the variation was so there was basically no consensus down
00:36:29
um and the one thing i can tell you an hour that may be
00:36:33
worth looking at this the number of class must cells in the liver biopsy
00:36:39
all the rest is very difficult video signal fills you see in both uh
00:36:44
the century lot below than much of the liver you seen both of them
00:36:50
probably in the end you can combine the number of persons says in the biopsy and the level of i. g. g.
00:36:56
that's our gut feeling at the moment but it's i think one
00:36:59
of the most difficult really topics if you wanna know what right away
00:37:05
but i'm sure in the future they'll be molecular signatures differentiating the tool
00:37:12
but there's no date was off on that
00:37:33
so um we don't wait too long if the
00:37:36
patient has achieved by chemical remission we within the next
00:37:42
two to four weeks withdraw to stay what's completely we don't keep it in for six or twelve months
00:37:49
and many patients remain in remission so i think it's uh i
00:37:52
mean there's a big debate actually whether you really need the voids
00:37:58
q. really this is another difficult topic uh clearly
00:38:03
many patients respond people to fully however i don't know
00:38:07
any control trial comparing steroids but most airports and many
00:38:12
patients respond beautifully with us to what's going on that
00:38:41
yeah so all what uh my personal preferences for that line treatment so i am mum
00:38:48
i'm a small fan off the combination of other pouring organism
00:38:54
i'm in selected patients and then um i
00:38:59
think the addition after calling was is an option
00:39:04
continue treating with a slow
00:39:07
and uh the third one that um we have now quite a
00:39:11
lot of experience uh with is a switch to in fixing up
00:39:17
and interestingly when you block t. n. f. you should use in fixing up and not utterly warm up
00:39:24
why we don't know but it seems to be
00:39:29
well we we guess it's the binding of the antibody to to says correctly
00:39:35
and not just a blocking soluble tina
00:39:40
but this is now speculation
00:39:45
clearly i think these patients at increased risk of infectious complications we should always be
00:39:52
very cautious and especially in elderly patients uh you
00:39:56
see a lot of viral complications stands also reacted haitians
00:40:02
um so i think it should always be weighed against the risk
00:40:06
and that that holds i think especially true for the full moon and a yeah each patient um
00:40:12
whom we treat with high dose steroids on the i. c.
00:40:15
u. was it had an enormous risk of infectious complications underneath it
00:40:21
so i think that is that is one of the most difficult treatment decisions
00:40:28
whoa something between i think fifty and a hundred milligram i. v. right and so on that's what we do
00:40:36
we tend to give for example three days hundred milligrams and if there's no
00:40:40
response after three to five days than it was in the direction of transportation
00:40:54
i mean those really critically ill
00:41:02
but maybe it's with that
00:41:04
let's wait for the date of this on the ongoing of the ongoing study
00:41:33
no to be honest no i don't know any data and um we're not checking
00:42:16
yeah i i would miss so kansas abeyance and uh vaccinations i think it's a very
00:42:24
important topic we uh recommend to every patient on the immune suppression the yearly skin check
00:42:29
um although the insurance companies in germany only paid every two years um mm
00:42:35
we recommend the vaccinations flew you mccorkle
00:42:40
vaccines arm and now also onto ourselves also
00:42:46
who i think that's very important especially for the elderly patients with intense thing it's a question
00:42:51
and um i think all the all the data suggests that the risk is not too high
00:42:57
i think uh yeah h. server takes should also be a survey for
00:43:01
h. c. c. if not every six months i think every twelve months