LAHCS 2026.1 - AULA 3

Added: 2026-05-11

[00:00:10]Okay, I think we've started now. I'll send the link to the staff and wait for them to join. There are already two people here.

[00:00:38]Guys, as you join, please interact here in the chat so we can see exactly who's joining.

[00:00:53]Okay, there are 17 people. I think we can start the broadcast now. First, I'd like to introduce myself. My name is Ian. I'm new here on the league's board of directors. Good evening to everyone who's sending goodnight messages. Aha. So, if I make a mistake, if I stutter a little, I just ask for your understanding.

[00:01:16]Ah, let me see what else. Therefore, today's lesson is on managing patients experiencing homelessness.

[00:01:25]Our guest today is Dr. Miguel Ibraim Bold Hana Sobrinho.

[00:01:35]He holds a medical degree from UFPR, a master's degree in cardiology from UFPR, and specializes in intensive care. He is a professor at PUCPR in the field of internal medicine and also a professor at UFPR, working in the areas of cardiology and internal medicine.

[00:01:52]So now I'm going to hand the floor over to our speaker today.

[00:01:59]Goodnight.

[00:02:02]Good evening everyone. Good evening, Ana.

[00:02:04]Thank you very much for the kind invitation to discuss this topic with you, about people experiencing homelessness.

[00:02:15]A topic that I confess is very challenging. I have no conflict of interest in addressing this topic. And all the references that I'm going to use were identified through the PubMed website, right? So we have some articles from this year and some articles that are a little older.

[00:02:38]In order for me to put this presentation on the platform, it was necessary to shorten it a bit. So, there's some information I'm just going to share with you; we won't have a slide to show you. I am available to help. Whenever we can begin, I ask Ian to put the material on the screen.

[00:03:05]So, we're going to try to address a condition in which we have extreme vulnerability.

[00:03:14]These are people who, regardless of the reason—and the reasons are quite important—live in a condition where their diet, their self-care, their health care, and their mental health care are severely compromised.

[00:03:39]There is easier exposure to alcohol and drugs of various types and in various quantities. And that's more or less what we're going to try to discuss with you, to try to do a structural analysis of this approach, using the material I mentioned to you. I created a summary of 12 articles and used artificial intelligence, a platform from the notebook, to create some images that I will present here.

[00:04:19]So, within this context, we have a paradigm shift in social conditions, right? We always have a clinical view that's very focused on the disease, right, on the reason why the person sought care.

[00:04:39]And I'm going to talk about the care provided in the hospital, which is where I have some experience with patients in this situation.

[00:04:46]But we have to consider that this view is a very simplistic one, because the social issue, this issue of extreme vulnerability, is a clinical accelerator for various conditions.

[00:05:02]We mention here the cardiovascular system, the cognitive condition of these patients, mental health, emotional well-being, their way of life, the risks to which they are exposed, metabolic and renal issues related to diet, fluid intake, chronic degenerative diseases that these people also have, regardless of their situation, and above all, psychiatric issues.

[00:05:39]This set of information shows a reality that causes us to accelerate these processes, and this leads us, in a way, to blind ourselves to seeing these people as a whole, focusing care on the person and not primarily on the specific condition that motivated the hospitalization, right? So, one of the articles we cited suggests that this might be a form of social blindness, and that when we approach these patients, it's very important that we remember this and that we are able to look at the person holistically, right?

[00:06:30]Well, we have a condition that is invisible, which is this condition that's back here, right? And we try to focus on the skin, the lungs, the heart, the infection, in short, on whatever motivated the person to be in the hospital. But it is very important that we try to understand this person as a whole and believe what the person says, because there is, in a way, a stigma, a stereotype that can lead us to a diagnostic error, not only the diagnosis of the person as a whole, but an error in the interpretation of that person.

[00:07:21]And this contributes to the social blindness that was discussed later, right? Some serious symptoms may be ignored or attributed solely to, for example, a condition the person has. And here we're talking about drug use, right? But the fact is that eventually the person doesn't have a regulated diet, right? Not eating regularly at various times throughout the day is another factor that can mimic or mask a more serious condition.

[00:08:04]Well, we have a statistic.

[00:08:06]Unfortunately, these articles were not published here in our country; they were published primarily in the European Union and the United States, which show a significant prevalence of cognitive decline of 6.8 percentage points, including early-onset dementia.

[00:08:35]Well, if we analyze only this aspect, we realize how vulnerable these patients are, right? They are in a condition where they depend on walking, they depend on speaking, they depend on having some kind of relationship to get food, to get a blanket, to get some specific place of shelter to stay.

[00:09:01]We have a metabolic disease that develops because of all these conditions, right? due to repeated infections, inadequate hydration, and insufficient nutrition in every sense, not only in terms of calories but also nutrients, ultimately leading to a metabolic disease. And at the heart of this metabolic disease, we have primarily diabetes mellitus and chronic kidney disease.

[00:09:33]Well, and along with that, we also have the issue of dependency, right? The issue of alcohol use, the issue of crack use, of other drugs that a person may have access to. And this intoxication, these symptoms resulting from chemical dependency, can and often do mask various systemic symptoms that lead, as already mentioned, to the possibility of diagnostic error.

[00:10:08]So, we have here an interconnected triad, meaning that this set of factors, regardless of why a person went to the hospital, and I can say that at Cajuru Hospital, the patients I have the opportunity to treat—this is a personal perception and statistic, not from an article—are much more victims of violence and trauma, patients who are beaten, patients who are assaulted, or who get involved in fights, regardless of the reasons.

[00:10:45]And that's what the focus is on, the trauma care, uh, on resolving the fracture, uh, on trying to functionally rehabilitate the patient so that they can be discharged. And often this focus on the care that led the person to the hospital prevents us from seeing the entire context presented here. So that's the main point I'd like to draw attention to, right? And in addition to this triad, we also have an important point, which is the premature aging of the brain.

[00:11:24]Because aging depends on several factors, right? So, our sleep patterns are very disrupted. We've talked a lot about the issue of food, the issue of chemical dependency, the metabolic issue, but it's as if life on the streets acts as a biological accelerator, as if we have a longer aging process than people who are not in that condition. So, we have a time period, an average onset of this premature brain aging of approximately 63 years, right? So, this is a fact that also makes it difficult for us to approach this patient.

[00:12:26]And that's something I'd like to discuss with you in the next few slides.

[00:12:32]I hope that, for now, I've managed to be clear, right?

[00:12:38]Well, this situation, as I mentioned, it's a biological accelerator, right?

[00:12:44]So, uh, cognitive decline itself causes the person to lose the option of seeking new alternatives, and we have a bidirectional cycle, right? It's trauma, substance use, cardiovascular risk, executive dysfunction, financial disorganization, eventually job loss, and family instability. We have many people who had families, including marriages and children, and that becomes dysfunctional at some point due to this cycle.

[00:13:26]And the situation of being on the street increases or accelerates cognitive impairment, making it less likely that these people will be able to reintegrate into their families, find housing again, have job prospects, and so on. What we have here is a mathematical equation that specifically relates to kidney failure.

[00:13:56]showing that these patients have a drop in glomerular filtration rate, and would eventually need to use dialysis and require hospitalization due to either hypervolemia or hyperkalemia. We also see patients with severe acidosis, and these patients have difficulty accessing a nephrologist.

[00:14:23]This process unfolds gradually in the context of homelessness, following a bidirectional cycle that worsens over time, leaving the individual with little opportunity for self-management.

[00:14:37]And identifying a homeless patient with a reduced level of consciousness or oliguria, or specific symptoms of hyperkalemia, is always more difficult.

[00:14:53]so that the person can receive help and can find an access point.

[00:14:57]So, we have a condition that actually facilitates and accelerates the renal condition of these patients by up to three times more. And we have something similar to kidney disease in diabetes itself, a cascade, right, a progressive systemic failure, right, we start with the environment we are in, right? So, we could say here about the issue of sleep, the use of alcohol as an energy source, and this perhaps attempts to mask, in some way, the lack of control over eating.

[00:15:40]If a person already has a diagnosis and is prescribed insulin, they may even try to obtain the insulin, but they have no way to store it.

[00:15:50]Well, it's difficult for that person to have regular check-ups for screening, so that the complications that diabetes can cause can be identified and eventually addressed.

[00:16:05]And we have a condition, right, that is perhaps considered in the article as a rupture peak, which is when we have volume overload due to kidney disease. This leads to a cardiorenal syndrome with associated heart failure, right?

[00:16:25]Well, then there's the vulnerability of being on the street, plus the difficulty of accessing medical appointments and screenings. And when you have access to the consultation, when you have access to the medication, there is the difficulty of storing the medicine and of having regular access to its cost.

[00:16:51]We have a need to have a pharmacological adaptation, right? So, uh, try in some way within this context to see if we can improve the condition of withdrawal or chemical dependency, if we can work a little more on the cognitive aspect, see if there is any factor that may be hindering progress so that we can try to reduce harm, achieve stabilization, and try in some way to bring to this patient the conditions to treat diabetes, kidney failure, and cardiovascular conditions. Therefore, it is very important that we keep in mind the need to work on abstinence or work on dependence.

[00:17:47]And when these patients are admitted to the hospital, this should be a very important point in the approach. We have some medications that aim to help in this context, right? So, pain management, trauma treatment so that the patient doesn't need to ask for medication or experience associated suffering. We have hospital treatment with opioids, right? This article is an English-language article from the United Kingdom, and it talks about methadone and buprenorphine. We don't use buprenorphine here in Curitiba, here at Cajuru Hospital. We take morphine or methadone when we need it.

[00:18:34]And benzodiazepines are still the most commonly used medications for alcohol withdrawal, and for the prevention of delirium and tremors. And we have a protocol, the Maldonado protocol, an article, a work that was published by this psychiatrist in 2017, which also takes into account the use of anticonvulsants as important elements in preventing withdrawal. And at Cajuru Hospital we work a lot with gabapentin.

[00:19:08]We combine benzodiazepines and gabapentin, giving preference to gabapentin. So, if we have to increase the dose, we increase the gabopentin dose to use the minimum amount of benzodiazepine possible.

[00:19:24]So, we try to predict relapse, and sometimes patients get very agitated, we have to administer rescue medication, and we lose a bit of track of what is a side effect of the medication and what might be a major side effect. That's why we always have to pay attention to intoxication from the withdrawal treatment itself. And for that we use son analogs, right? Yes, today we have support from a multidisciplinary team. Shared decision-making is very important.

[00:20:00]Often these patients need chemical restraint, and this chemical restraint is fundamentally based on pain control, using antipsychotics, specifically first- and second- generation antipsychotics. We have haloperidol, gabiapine ( sorry), and risperidone at the hospital.

[00:20:27]And we can use others like chloromasin, for example, right?

[00:20:32]We avoid mechanical restraint, not only out of respect for the patient's dignity, but also so that the patient can move around to prevent pressure injuries and to maintain mobility.

[00:20:47]Immobility can cause the patient to develop venous thrombosis, and it can also lead to constipation.

[00:20:55]So, there's always a need for a multidisciplinary team to work with this, but often we don't have the capacity to control this agitation, or even the aggression, if we don't use shared chemical and mechanical restraint and don't have the support of this multidisciplinary team.

[00:21:20]This is a major challenge, because when the patient realizes they are abstinent, craving the drug, craving alcohol, they ask to be discharged.

[00:21:31]So, many times we can't help the patient or refer them to a hospital where they could try treatment for this intoxication, this addiction, because they ask to be discharged, they go back to their old environment and relapse into the drugs they use, right?

[00:21:54]So, we always have it on the tip, right? And we see this in the hospital, this acute intoxication, the withdrawal symptoms, and the agitation.

[00:22:07]This is usually what causes these people to be stigmatized.

[00:22:15]And that's the big problem. We look at this and understand that the patient is confused, we understand that the patient sometimes has hallucinations due to addiction and doesn't realize what's hidden, doesn't realize the cognitive decline, doesn't realize diseases that are chronic and degenerative, like chronic kidney disease, like diabetes, and their own complications.

[00:22:46]Yes, it's common to attribute elevated creatinine levels, or kidney damage, to the patient eating poorly or drinking too little fluid.

[00:23:03]In this context, you know, in the context of chemical dependency, over a long period, the patient has no need to eat, without understanding that these are illnesses that accompany patients in this condition and that can be masked by the effects of chemical dependency. So, uh, I hope that in this first topic I've managed to show you a major difficulty with this blindness that we discussed, which the article calls social blindness, that leads us to stigmatize these patients in a context of chemical dependency and prevents us from seeing what's behind it, which is often more complex and will require a shared decision and treatment moment.

[00:23:58]Well, the topic is very complex, and I acknowledge my limitations to you all. Well, there are several publications; I didn't have time to look at all of them that I wanted to come here and discuss this with you, but social determinants are extremely complex, right? Ah, the anatomy of this vulnerability, the very question of the dignity of these people is extremely complex, uh, in itself, right, uh, because of the reasons why people ended up in this condition, right?

[00:24:38]So, we have here, uh, a cycle of hypervigilance, right? And within this cycle, we have the condition of homelessness, the neurological condition, the metabolic condition, kidney problems and diabetes, and the cardiovascular risk.

[00:24:56]Well, this cardiovascular risk is not small. These people have a three-fold increase compared to those who are not homeless. If we only consider this condition, that risk increases. We have a mortality rate from cardiovascular disease that is two to six times higher.

[00:25:18]So, we take this cardiovascular disease, we take the context of cognition, psychiatric illness, diabetes, kidney disease, metabolic disease. And we see the complexity of this patient and the vulnerability of this patient, returning after hospitalization to the condition he was in before being hospitalized, right?

[00:25:44]So, just to reiterate, we don't have guidelines, and I reviewed the latest guidelines from the Brazilian Society of Cardiology on hypertension and epidemics, and there's no mention of people experiencing homelessness, no strategy for approaching these patients, let alone for medication use or prevention.

[00:26:11]Just to reiterate, three times more diseases, disease prevalence, and two to six times higher mortality from cardiovascular disease.

[00:26:25]Well, then we come to a reality that is a different reality.

[00:26:30]If we are going to provide person-centered care, it is very important that we seek to understand their reality. And we don't always manage to see that person the way they should be seen, do we? This is also part of social blindness. So, sometimes for this hyperlipidemia, for heart disease, we prescribe loop diuretics. And these patients don't have access to bathrooms, right? These patients have a lot of difficulty in achieving even a minimally dignified condition of having privacy to use the bathroom, right? Well, if there's an indication to use insulin, we can't be sure, not only about its use but also its storage, right? They don't have the means to have a place where they can store this medicine, do they? Well, if you have kidney disease, if you have cardiovascular disease, you have to have a diet, right? If you have diabetes, you need to have a diet with a predominance of certain foods and a restriction of others. Here I'm mentioning salt, right? But these patients are able to eat occasionally and won't be able to restrict their diet. I'm not going to eat that. I will eat what is available to me and what I have access to.

[00:27:59]So it's very difficult to control, both with medication and lifestyle changes, any situation that these patients have, right? And that's a dissonant condition, isn't it? Regarding what is intended, what is envisioned for the follow-up care of people after hospital discharge.

[00:28:23]Well, that's a strong term, anatomy of abandonment. Well, but in reality, if we really think about it, it's ultimately a case of abandonment, isn't it? We have a cascade of situations here that make it unlikely that the prescription, however well thought out and reasoned it may have been, will be followed.

[00:28:49]We have a prescription, for example, with more than one medication, when the patient has diabetes, kidney disease, cognitive impairment, psychiatric disorders, cardiovascular disease, we will need to prescribe a series of medications for the combined treatment of all these morbidities that he has. Well, we're going to have an environmental barrier, right? We're going to have difficulty storing it, we're going to have difficulty keeping it. These medications could be stolen, right? You can't protect them all the time. Yes, these patients can get worse, they can have severe symptoms. We won't be able to identify this in real time, and perhaps the patient won't even be able to see themselves reflected in it. We have a breaking point, which is the most acute complication that will take them to the emergency room, but even then, this will be done either by the police or by someone who notices that the person hasn't woken up and calls for help, and then the patient will already arrive at the hospital in a condition of hypervolemia, hyperkalemia, and possibly intense acidosis.

[00:30:05]And all of this leads us to seek treatment for what is being observed, and after this treatment is done, the patient will return to the same condition, will relapse into this cycle, and the tendency is for this to accelerate the worsening and complication of diseases to a greater extent than in a population that is not in this condition.

[00:30:42]So, we have some barriers that are structural barriers, right? Well, people need to survive, and when you're homeless, every day is a day of survival, right? So, uh, I'll look for the shelter I can find, I'll try to keep warm however I can, sometimes even sharing things with other people, so we can have disease transmissions that way, uh, I 'll eat however I can, I'll hydrate however I can. And sometimes what allows me to endure all this hardship is drug use. It's alcohol use. So, I'm not in a position to have a certain lifestyle, I'm not in a position to get the proper treatment for what I have. I have less access, or when I do have access, sometimes I'm discriminated against because maybe I'm not very hygienic. My clothes may not be completely sanitized. The odor I give off might not be the best odor. And this causes people around them to somehow discriminate and sometimes even be afraid, right? And sometimes even aversion, uh, considering that person as a lesser person, right? That's when we see that the dignity of that person is not being fully respected.

[00:32:23]Well, we always like to remember, and I remind myself of this every day, that the right to health is something that precedes any document, any bureaucracy that may exist. It's a right not only under the Constitution, but also under the Universal Declaration of Human Rights, which was promulgated in 1948.

[00:32:50]So, everyone has a right to it and has the right to seek it in whatever way they can, right? You have the right to be treated, even if your body odor isn't pleasant, even if your clothes aren't the best, even if you have alcohol on your breath, right? So, I'm not going to consider that person a lesser person, I'm not going to discriminate against that person because of that, right? It's very easy for us to discuss this here in academia, isn't it? I had access to all those documents, so I was even able to get some guidance on the matter. I'm trying to share with you what I've been able to review, but in everyday life, human beings have their fears, they have their difficulties, right? And this isn't always clear to them. For those of us who work with people, it might be easier to understand this, avoid discrimination, and provide the best possible care, focusing on that individual, right?

[00:33:58]Uh, I'm going to share with you some experiences that we've had [clearing throat] in the United States, the United Kingdom, and the Netherlands— specific experiences. As I said, I didn't find anything about our country in that PubMed review, right? Perhaps there are some documents that we could study, but I haven't found anything from Brazil, right? So, the issue here is that we need to create an adapted form of medicine.

[00:34:30]So, regarding refrigeration, we try to replace that with medications that can be kept at room temperature, right? So, instead of using diuretics, we try using calcium channel blockers, for example, to treat hypertension, right? We try not only to look at the biology of the infection, the trauma, and eventually the issue of chemical dependency, but also to look at the biopsychosocial context, right? These patients, when they are in the hospital, usually ask for a lot of food. Well, it's just that they don't eat much, they ask to eat and we try to give them a double diet.

[00:35:16]Well, they try to sleep, so we try to keep track of their wake-up time because their sleep is very fragmented on the street due to the discomfort of their situation. So, we try to work on that, you know, to really look at the issue of chemical dependency and how we can approach it, avoiding the treatment itself from somehow causing complications for these patients, right? So it's always about trying to adapt, even if it's not the first choice or the ideal solution, so that the person can have access to the medication, can keep it, and can store it with some degree of safety, right?

[00:36:05]And that's something I have the impression will never change. I hope not.

[00:36:13]Well, it's the way we welcome them, right? When a person feels respected and valued, that's a great incentive for them to want to change, right? Sometimes we can't do everything we want because we don't convey to the person the need for them to seek alternatives to the option they have, which is being on the street. But the welcoming atmosphere, the eye contact, that breaks a cycle of invisibility that these patients usually experience.

[00:36:52]Often, to avoid fear or embarrassment, we don't look; we try to ignore that it's happening, so that we can feel good about ourselves. So this is a reflection that we all, as individuals, need to make: how can we confront people in this situation?

[00:37:15]And that's why we're always looking for inclusive care, you know. So, uh, we're going to try to approach situations mainly related to trauma, build a bond, try to ensure that these patients have access to outpatient consultations, but explain how this can be done, facilitate their arrival at these places, and try to verify, as far as possible, if the person is willing to do so, what the root cause is that motivated them to be on the streets, right? Yes, I've witnessed this before at Cajuru Hospital, the attempt to reunite with family, to reunite with parents, and sometimes with a spouse. It 's always very difficult, there's always a lot of hurt, but sometimes it's an opportunity for the person to look at themselves and eventually try to make that reunion happen, right?

[00:38:23]Well, we'll always try to approach this in a way that puts the patient at the center, right? And it's very important that we try to adapt not only to trauma management, but also to addiction, adapting medication, sometimes a single medication, right? Well, instead of multiple medications for just one thing, even if that's not ideal, it's what's possible, it's what can be done, and it's important that we can address this issue.

[00:39:01]I'm going to move on now to some experiences that we've had. I'm going to take the liberty of moving this to the next slide, which is a matter of integrated cultural security, right?

[00:39:17]Well, especially in terms of housing, right? We're going to try to understand that housing might be a reward, and sometimes people choose not to have housing. Everyone has their own reasons for seeing things that way, right? I think this is a very important approach that we need to take, and seeking this support and housing from institutions and organizations, such as the Social Assistance Foundation, may be necessary for some people, if they want it, so that they have time to recover, have access to medication, have the conditions to have more regulated sleep and a regulated daily diet so that they can change this clinical condition they have. We have this global scenario, so, as I mentioned to you, which I'll try to show quickly—my time is running out— regarding some experiences that some countries have. So here we see that there is an integrated pharmacy in the United States, an effort to try to give these people access to medication.

[00:40:35]Well, in Australia there's work focused on cardiovascular disease, just like in the United States, there's work focused on lifestyle.

[00:40:43]There are health education programs for people like that, using gamification.

[00:40:50]In Denmark, we have sporting activities aimed at bringing these populations together, fostering integration.

[00:40:57]Well, in the United States we have telehealth, and in the United Kingdom we have, uh, the search for mobile tracking to identify where these patients are and to follow up with them, right? Well, I think that finding a cure will always be a pursuit we have, but we have to understand that we have several vulnerabilities, such as access, time, adapted management, and social empathy itself, which can hinder this, but we should always seek it with the greatest efficiency and effectiveness possible.

[00:41:37]These are innovations. Well, two articles brought up these comments, which is why they're here. Well, hybrid digital health, I think here in Brazil we're still far from that, right? And what about street cardiology, through, uh, specialist care, right? I think that's a point where perhaps we need to move forward a bit more.

[00:42:04]Well, that's a quote that I think is always important for us to remember when we think about people's dignity, right? We all have equal rights, regardless of where we are. And dignity will always be at the heart of any approach we may take towards these people. It will always be at the center, and we can't forget that.

[00:42:29]And we, uh, have a neuroscience of empathy, right? That's typical of every human being, right? We have areas of the brain for each situation, for confidence and distress, for social reward, for altruistic decisions, right? And I think it's important for us to understand that, in addition to technical assistance, we need the biology of compassion and virtue, right? And we are gifted with that. We just need to remember that. We need to know that they exist and put them into practice, right? And empathy isn't just a moral choice, is it? But it is an ecosystem anatomically designed to react to the other person's human condition.

[00:43:23]Time is running out, but just so you understand that dignity has certain components, right? And it is both intrinsic and extrinsic. We can't forget that.

[00:43:34]This is a quote from the former Minister of Health, Incio da Silveira. To swim against the current requires rare qualities, a spirit of adventure, courage, perseverance, and passion. If we truly want to confront this situation, I don't have a solution. What I can't bring to you here today is a protocol of how we should act. I think we have to start by looking at people as human beings, with their dignity, and try to think together with a multidisciplinary team about what we can do to change and improve things.

[00:44:13]Well, guidelines always assume stability, but the reality will demand adaptation. I think all those articles talked about that. It 's not the same rationale as with a patient who goes to the outpatient clinic, where you know they're going to take the medication; we'll have to adapt. And so this is an invitation for all of us, health professionals or professionals from any other area, as a society as a whole, to look into how we can help these people.

[00:44:51]I'll conclude with this quote, saying that excellence in healthcare practice doesn't reside solely in the technical skill to repair the biological body, but in the neuroplasticity of our own empathy, the ability to regulate our own emotions and fears in order to continue seeing the individuality of the other, not as an object to be evaluated, but as a humanity that is unconditionally respected.

[00:45:28]I would like to thank you all again for taking the time to watch this presentation.

[00:45:36]Many thanks to Ian and to my colleagues at the Humanization League of PUC for the invitation.

[00:45:42]I hope I have managed to convey to you clearly what these articles summarized, and I remain at your disposal. Thank you very much for your attention.

[00:45:56]Well, I think I speak for everyone when I say that the class was excellent and it's very important for us to know all this information that was passed on today, because I believe that most or all of those attending class today are in the health field, and throughout our future careers we will end up encountering all kinds of people. So learning how to cope is extremely important. I would also like to thank Dr. Miguel once again for making this time available to us. It was amazing.

[00:46:29]Oh, and I'd also like to thank everyone who came here to watch today. And I think that's it.

[00:46:34]Thank you very much.

[00:46:36]Thank you, everyone. Good night to you all. Have a good week. Good evening everyone.