The Silent Danger: Detection and Management of Clots

追加: 2026-05-31

[00:00:00]if there's no clot. So, when it's negative, it's extremely useful because we are very certain that there is no clot.

[00:00:07]However, it is not as reliable in telling us whether there is a clot or not because sometimes it can be high in other conditions. And to our right, we can go through them. So, it raises as we grow older.

[00:00:23]If you're black as opposed to if you're another race, you're likely to have a high D-dimer for that reason.

[00:00:31]Uh people who smoke it is high in pregnancy and when people have just delivered and when people have also just been operated.

[00:00:40]Uh when people get injured uh trauma, when people get eclampsia, people have cancer and other infections and many other inflammatory states that are listed there, we might um have a high D-dimer from those causes.

[00:00:58]As you can see, the list is long. So, stroke, heart failure um sickle cell disease uh and many other conditions can cause a high D-dimer. So, when patients come in with a high D-dimer, we don't ignore it but we also want to be sure that it is not from something else. So, we check for the clot according to our protocols but we also try to look out for other causes which might be the likely ones in certain cases.

[00:01:28]Okay.

[00:01:29]When we diagnose clots, we we go on to manage them.

[00:01:36]And uh management really depends on where they are.

[00:01:41]Um I'll start to the left where we are managing the clots in the legs, which we've called deep vein thrombosis.

[00:01:49]Um there are medications we give as I will elaborate later.

[00:01:55]Um we sometimes accompany that with other things. We can do we can give them compression stockings.

[00:02:03]This usually help us preventing further clots, but also preventing the remolding that happens.

[00:02:09]We can do surgery. In certain cases, the clots really, really cause uh bad effects and we might have to operate including compartment syndrome where the legs swell.

[00:02:19]And uh surgeons have to come in and sometimes even remove the clot.

[00:02:23]Or minimally invasive procedures where we insert catheters and look for these clots and probably remove them if they are accessible.

[00:02:31]For clots that form in the lungs, we have medications. We also have procedures we could do to remove them.

[00:02:38]Uh some people form clots so large, especially in the large vessels of the abdomen.

[00:02:45]And uh we might in- insert a filter. A filter is some kind of umbrella that sits in those vessels and prevents those clots from going up.

[00:02:56]So, the clots will form in the legs, but we shall prevent them from going up to the lungs.

[00:03:02]Um so, that uh we protect the heart and the lungs and we continue breathing well.

[00:03:08]We discussed dissolving clots last time for stroke.

[00:03:14]So, for clots in the lungs, we might also dissolve them using thrombolytics that are listed down there. These are drugs that we inject.

[00:03:24]And they will go in and dissolve a clot if I should literally say that. And we discussed uh their usage last time.

[00:03:35]So, in terms of treatment, what might we use? And there are different medications. The left one is unfractionated heparin, which comes in different dosages.

[00:03:46]It has its advantages and disadvantages.

[00:03:49]It's an older drug. We tend to use it in strictly in hospital for certain people, especially those with kidney problems.

[00:03:58]But there are other forms of heparins, and uh the ones we tend to use these days, there's tinzaparin, there's enoxaparin, and others. I don't think we have a lot of tinzaparin here. We have enoxaparin, which we know as Lovenox.

[00:04:14]Uh these usually have an advantage that you can give them without monitoring uh as opposed to uh the unfractionated one, where we have to monitor.

[00:04:26]To our right are the oral medications that we sometimes use after we have given you the um the heparins, because we tend to use them for a short time, because they're injectable.

[00:04:39]And uh of course, injections come with challenges. So, some of the tablets we have come across that we might use after the injections uh include rivaroxaban, that comes in various brands. I think Xarelto is commonly known to us.

[00:04:56]Uh we have apixaban, we have dabigatran, uh edoxaban, and many, many more. Each of these um has advantages. They're tablets. They have recently been expensive, but they've become quite available.

[00:05:13]So, the treatment plans are usually we give you heparin, and uh if we think you don't need injections anymore, we switch you to tablets.

[00:05:23]But some people can't use tablets. I'll quickly talk about um warfarin.

[00:05:29]We have always used a drug called warfarin, and uh I haven't included it here.

[00:05:34]Um we are moving away from it in certain cases because of its challenges. Uh it requires a lot of monitoring using a test called an INR.

[00:05:45]It also is also something that a lot with so many things including food. So, we still reserve it for certain conditions, especially people who have um valves, artificial heart valves.

[00:06:00]Um but generally these days it's more convenient to use these directly acting oral anticoagulants, which we have talked about.

[00:06:11]Um I had talked about compression stockings. Basically, they don't They're not leggings. They are designed to apply high pressure at the base, which is usually the foot, and the pressure goes on reducing as you go up.

[00:06:28]So, they are graded pressure stockings, if we were to call them correct.

[00:06:32]So, they will try to push blood a little bit harder at the lower part.

[00:06:38]And as you go up, the pressure reduces.

[00:06:40]This tends to help the veins move the blood upwards. And they are used in both care, but also prevention. But in hospital, we have these DVT devices.

[00:06:50]These are devices that we use uh for management, but also for prevention.

[00:06:56]These tend to pump a certain pressure and then release.

[00:07:02]Uh in our hospital setting, they would be similar to to to the air mattresses we use. So, they basically pump a certain pressure and release.

[00:07:11]Uh and sometimes some can wave it upwards, so that it pushes the blood.

[00:07:15]This usually help in in prevention as well.

[00:07:21]Um what are the complications we might get when we get clots?

[00:07:26]Uh basically, which we've called DVT and PE.

[00:07:31]So, for clots in the legs, which we've called DVT, they what we fear most is the clot moving up and going into the lungs, which we've called pulmonary embolism.

[00:07:41]But they might also inflame the legs so so bad uh that it turns color. And some legs will turn dark, others will turn red. Uh I don't want to mention those terms, but I think it's phlegmasia alba dolens and phlegmasia cerulea dolens, which mean that uh literally.

[00:08:03]Some people will end up with chronic insufficiency uh where uh you find after the clot has healed, the leg stays swollen.

[00:08:13]Uh and uh this is very common. Usually, the vessel has been damaged and it's no longer transmitting the the blood back sufficiently.

[00:08:24]So, that's one of the complications that might happen. Some people might get a repeat clot.

[00:08:30]Some people will be uh varicose veins, but you can also get complications from the treatment. When we give you tablets or injections, you might bleed.

[00:08:40]Uh you might get wounds and so many other things. You might get allergic reactions uh to these drugs.

[00:08:50]What complications might we get from clots that form in the lungs, which we call pulmonary embolism? A number of people never reach hospital.

[00:09:01]They suddenly die.

[00:09:04]Uh clots can actually lead to heart attacks.

[00:09:08]Some lead to heart failure. Some can result in strokes.

[00:09:13]Some result in lung infarction, where a part of the lung no longer functions or no longer receives blood, which we call infarction. And if it's a significant part of the lung, we might um uh get very uh poor oxygenation um especially if people have other illnesses.

[00:09:35]You can to cardiogenic shock, where the heart really fails and sometimes this results in death.

[00:09:41]But another thing I tend to see with the cardiologist I saw Dr. Mzoki on on on on on the presentation. When I get pulmonary hypertension, this is common where people present with uh breathlessness and chest tightness and when we check, usually the cardiologist does an echo and he finds there's a very high blood pressure on on the right side of the heart. It's a very difficult condition to manage.

[00:10:04]So, whenever we get a chance, it would be good we either prevent uh or treat clots appropriately so that it doesn't happen.

[00:10:16]Cuz it requires long-term treatment.

[00:10:18]Sometimes it recovers, but generally tends to be progressive and can be very very burdening on the quality of life.

[00:10:26]Uh these are the complications I could say, but there might be many many more.

[00:10:31]So, when we try to say we look out for clots, look out for their causes, and check ultimately, we want to treat them properly and uh prevent these complications.

[00:10:47]Thank you.

[00:10:50]>> Thank you very much, Dr. Dr. Luzinda.

[00:10:58]>> Yes.

[00:11:03]>> If you can uh mute uh user iPhone.

[00:11:10]So, thank you very much, Dr. Luzinda for the presentation. We have looked at what clots are, what are the risk factors for the clots, how do they present, what ills can come and mimic a clot, the various investigations, and the treatment.

[00:11:30]Of course, among the clots, uh one of the reasons clots have become a major issue is the clot in the lungs, which is what we call the pulmonary embolism, which sits at the center of several disciplines, hematology, pulmonology, cardiology.

[00:11:48]But, for this particular session, uh I would like to invite our senior consultant hematologist, Dr. Salim, to add some more on this topic of clots before we go into the question and answer session.

[00:12:07]Thank you.

[00:12:21]>> Um yes, Steven. Apologies.

[00:12:25]I think Dr. Sali is not on the call, but I will request Dr. Sam Tyaba to to intervene and um uh present on this topic, and then Dr. Msoke, and then after we shall have the question and answer session as we get Dr. Sali in.

[00:12:44]>> Okay. Okay. Thank you. Thank you.

[00:12:58]>> Yes, Dr. Innocent. Are you there?

[00:13:13]Okay, I'll quickly go to Dr. Msoke Charles to give his comments. Uh yes, Dr. Msoke. Please um go ahead.

[00:13:44]>> Okay, other ways to get the other members on board.

[00:13:48]Uh, maybe a comment would be in the presentation. Anyway, I'm not sure whether it was going to be highlighted by the other presenter.

[00:14:01]Previously, there was mention of the preclinical probabilities and assessments with use of uh of the scoring systems, the Wells score.

[00:14:14]If Dr. Luzinda, are they still relevant or relevant in current practice or they have been overshadowed by the uh or they have been overshadowed. If you can give us some more clarity on this.

[00:14:39]>> Uh, I thank you very much, uh Dr. Walakira.

[00:14:44]So, I I tried to to really keep it um down to non-clinician level, but yes, um I had um uh alluded to uh the processes that clinicians go through while looking at risks of us having clots.

[00:15:07]And uh there are different scores that we tend to use.

[00:15:12]Uh, and one of them is the Wells score that basically store scores the risk uh of um a particular person uh having a clot before you investigate.

[00:15:25]Uh they could work for for DVT.

[00:15:29]And this give you a confidence on whether you're dealing with clot or not. There are scores also for for pulmonary embolism.

[00:15:42]Uh they might vary according to different bodies.

[00:15:47]Um They are really scores that give you a probability. They use different factors, including previous history, uh cancer, and many other things.

[00:16:00]Uh however, at the end of the day, sometimes we would prefer that sometimes we use judgment, clinical judgment, and high indices of suspicion even when these scores might not give us uh uh ranges that uh result in us suspecting a clot. So, yes, in our settings these days, we probably don't use them a lot uh because many times we've seen clots that occur even when our scores would have not scored it as likely.

[00:16:33]So, briefly, that's what I could uh say about that.

[00:16:38]Uh I would welcome uh other inquiries.

[00:16:44]>> Thank you very much, Dr. Luzinda. But, I do I mean I need to get Dr. Mchila over or Dr. Msoke.

[00:16:53]Or we just jump into the question and answer session.

[00:17:06]As we wait more, there's a question in the chat uh from from Paul.

[00:17:15]The question is, are there any recommendations in terms of diet that can be used to dilute or mitigate the diverse effects of the threat of clots?

[00:17:27]So, is there any particular diet which is known to help in that complicated situation mitigate the risk of getting clots?

[00:17:38]Over to you, Dr. Nzim.

[00:17:41]>> Well, that's a very interesting question.

[00:17:45]Um, are there any diets which we would undertake or if we were having those diets, they would reduce our risk of having clots?

[00:17:56]Um, here is what I could say. There are no particular foods you eat that will reduce the chances of you having a clot.

[00:18:07]However, what I could say is if you have obesity, which would result from a person having an intake of calories more than they are likely to burn, is that would result in you increasing the risk of clots.

[00:18:27]So, I would recommend that we for diet, we look at any diets that help us avoid having high BMIs. And of recent, we have become so big in the world because we take in a lot of calories and have become obese.

[00:18:45]So, a balanced diet that avoids us being malnourished or overnourished on the side of obesity would be the appropriate one. But, I know particular foods that I know or have heard of that if you ate them, uh you would reduce the risk of clots.

[00:19:03]And generally, the less the meats, the less the alcohol, the less the tobacco in terms of other lifestyles, uh the less the salt, the less the fats from other sources, the more likely we are to avoid clots.

[00:19:21]Uh briefly, that's what I could uh respond to that in simple terms.

[00:19:28]>> Thank you.

[00:19:29]Um Any other questions from the members?

[00:19:35]Uh we have another question from the chat.

[00:19:38]From Can blood clots be tied to particular family backgrounds? Is it hereditary or Yes, are they tied to particular family backgrounds and is it hereditary?

[00:19:56]>> Uh thank you very much, Stephen.

[00:19:58]Um it is possible for certain clots to be hereditary.

[00:20:05]Uh one of the slides that discussed the risk factors and causes of clots um showed certain conditions that can be passed on from generation to generation.

[00:20:22]And one of them is uh deficiency of um uh protein C, protein S, factor five Leiden deficiency, uh and many others. So, yes, there are clots that can be genetically passed on.

[00:20:47]Uh however, we also have these clots that come from other multiple risk factors, uh which will catch anyone sporadically regardless of whether the the the parents or uh people who are born in the same family have them. So, it really depends. And sometimes when we test for certain causes and we think it might be worthwhile checking other family members, especially if you have more than one person in the family suffering clots, especially when we cannot identify other causes. We might sometimes test for these.

[00:21:21]They are sometimes complicated and expensive, but they might help prevent clots in other family members if they have those deficiencies.

[00:21:32]>> Uh thank you very much, Dr. Lung'ayia.

[00:21:35]Of course, we're in a generation which has largely thrived because of vaccine.

[00:21:41]But ever since uh COVID, there have been some rumors which have been circulating, especially around those who got the COVID vaccine, as you have highlighted.

[00:21:52]There is a question in the group highlighting how to treat this, and is there a particular medical explanation for it, or it is just an association that has been noted?

[00:22:08]>> Uh thanks very much, Stephen. I actually thought um all of us could discuss this further.

[00:22:14]Uh the early days of um COVID, as we were trying to find our way, were um colored by us seeing people die suddenly, and it was later found that actually they had um extensive clotting.

[00:22:31]And uh COVID-19 itself had like just like the graph I showed, increases the list uh the risk of clotting.

[00:22:39]And um it is probably how it causes some of the mortality.

[00:22:46]Uh during the trials that resulted in in us having vaccines, which were really rolled out very quickly, people took up these vaccines.

[00:22:57]And I remember we had AstraZeneca rolling in first, then we had Pfizer, then Moderna, and the Sinovac and many others.

[00:23:07]Uh people noticed that uh the rate at which we got clots, even for people who hadn't suffered COVID, uh was higher, and I think we agreed.

[00:23:17]So, it is true from even population studies that uh people have received vaccines uh have shown more tendencies to clot, and actually have been more clots in such people. But, I think it's for particular vaccines, and I think the process is the same for both the disease and the vaccines.

[00:23:41]The changes that happen for them to create immunity result in inflammatory processes that probably involve endothelia in particular places, but also increase um the levels of uh coagulation factors.

[00:23:59]So, it is true people who have received vaccines have had higher risks of clots.

[00:24:05]However, the argument is, if we remember the COVID times, it is safer to vaccinate and avoid a disease uh than suffer from it and die. And that has been the rationale for all vaccines.

[00:24:23]Prevention better than cure or treatment.

[00:24:29]And at a population level, any authority or any government would um roll that out.

[00:24:36]Uh my biggest um disappointment has been that this has been carried on even to other vaccines that probably are not involved in this.

[00:24:48]So, a number of people have even avoided vaccinating their children for preventable diseases uh alleging that um these vaccines cause that.

[00:24:59]Yes, we know vaccines cause a lot of side effects and and and we understand them, but at a population level they are more beneficial than they are detrimental.

[00:25:12]So, I will suggest that yes, it's true.

[00:25:17]Diseases like COVID and vaccination cause a higher risk for clotting, but I really think it is better to have vaccinations than have diseases for treatment. Eventually, it is cheaper and prevents both morbidity and mortality for individuals.

[00:25:39]>> Okay. Thank you very much, Dr. Lubinda.

[00:25:43]I think we'll have three or four more questions, and then we can uh come to a close. The rest of these are interesting topics, and the discussion can always continue offline.

[00:25:58]On that note, there's another question from the chat.

[00:26:02]Of course, with when someone has clots, they have they are going to be on treatment for a prolonged period of time.

[00:26:09]And some of the concern is what are the monitoring protocols for patients who are receiving these medications?

[00:26:19]And what should they look out for while on treatment with these medications to ensure that they can safely go go through the treatment period.

[00:26:29]Thank you.

[00:26:30]Dr. Lubinda.

[00:26:31]>> Thank you very much for that question.

[00:26:33]So, people who are receiving treatment for clots uh have follow-ups. I think that's what they meant.

[00:26:42]And the protocols would go like this.

[00:26:44]So, when a clinician sees you, they will choose a mode of treatment.

[00:26:50]Uh and like we say, treatment could start with injectable uh, anticoagulants such as heparins.

[00:27:00]Uh, when we use unfractionated heparins, we have monitoring that is done to reach the appropriate thinning of blood.

[00:27:10]We normally do a test called an aPTT and would usually want it to be within therapeutic range, which might vary from lab to lab.

[00:27:20]I have seen people requesting for prothrombin time.

[00:27:26]The actual test for heparins is PTT or aPTT.

[00:27:36]Uh, when we use other medications, and one of them is warfarin, a clinician might decide that you start on tablets.

[00:27:46]Warfarin is one of the drugs that requires you reach a therapeutic range.

[00:27:51]The therapeutic range uses the PT instead of aPTT for the unfractionated heparin.

[00:27:59]It uses the test that we call the PT, which looks at the factors made by the liver, because that's where it works.

[00:28:07]So, usually the target treatment for DVT would be two to three over an INR, which basically is an extension of the PT.

[00:28:20]And uh, clinicians will adjust the dose upwards and downwards to maintain that.

[00:28:26]So, for warfarin, usually they will measure the INR for the duration of treatment.

[00:28:33]And uh, it is a very tedious process, sometimes requiring people to come in uh, several times a week, once or twice a week to have it measured all through.

[00:28:43]And we tend to treat people for three to six months, depending on the cause. So, that would be a long time.

[00:28:50]Um For other types of medication, which I had suggested, and one of them is uh the uh low molecular weight heparins, these usually do not require monitoring. So, if people are on an enoxaparin, we usually won't monitor them. We give them a fixed dose.

[00:29:15]In certain circumstances, maybe we might measure to see if they've gotten a complication, but generally, it is not a requirement.

[00:29:23]Likewise, people we put on rivaroxaban or dabigatran uh or apixaban they generally do not require monitoring. So, along the treatment duration, uh we will find ourselves treating them without doing lots of tests, except if they get a complication.

[00:29:48]Uh clinicians might also measure other organ functions while patients are on treatment because the dosages might need adjustment. So, they might do uh kidney or liver function depending on the drug used.

[00:30:03]Uh clinicians might also test um >> [clears throat] >> for other illnesses which might need treatment.

[00:30:16]Uh a CBC comes in handy because one of the side effects of heparins is thrombocytopenia, which we call heparin-induced thrombocytopenia. Basically, it knocks down the platelets to levels that are catastrophic. So, basically, the short answer would be the clinician who chooses a drug will follow it along the way and will choose which things to monitor. Generally, treatment is 3 to 6 months depending on the cause.

[00:30:52]And alongside that, the tests might be done according [clears throat] to judgment. Thank you.

[00:30:58]>> Thank you very much, Dr. Zimba.

[00:31:01]Uh I think for we have another question that I have.

[00:31:07]>> Pulmonary embolism because of >> [clears throat] >> blood clot.

[00:31:11]It go to the lung.

[00:31:13]I've been known to mimic very many conditions. Sometimes I feel good.

[00:31:23]I have a So, that require you to understand medical line of treatment and diagnosis.

[00:31:34]>> Somebody knock on the door.

[00:31:36]>> Yes.

[00:31:36]>> Little bit.

[00:31:38]>> It will be sometimes the only thing that you have to do is take a pill.

[00:31:46]What do you do?

[00:31:58]No.

[00:32:10]23 years Of course, it depends on the situation.

[00:32:18]Sometimes it's not much better.

[00:32:23]Treatment with rivaroxaban But I chose this one the treatment with the anticoagulant.

[00:32:30]It don't benefit in them rivaroxaban.

[00:32:33]Post capillary stabilization.

[00:32:36]It depending on what you do.

[00:32:39]It is really the pulmonary embolism.

[00:32:58]So I think that let me just go through one more question in the chat.

[00:33:06]Does age have anything to do with blood of current and how high is the probability of someone getting blood again if they have suffered some blood before?

[00:33:18]Because this one is it goes down to the factor of blood which one may may have depending if they the blood clot had a a reversible trigger or otherwise. For example, if someone the trigger was a long flight from destination A to destination B, the main thing that is a clear trigger. So it is just about putting in place intervention on how to activate the muscles of the legs during the long the long flights. Otherwise it is only in situations where you have hereditary factors where where you may be you may be may be inclined towards towards uh placing the patient on anticoagulation for a prolonged period of time.

[00:34:13]Um there are also models which are used which can be used the DASH predictions for Vienna prediction model to help predict the risk of recurrence. So all this is likely individualized.

[00:34:29]Uh so there is no one formula fits all.

[00:34:32]Um Yes.

[00:34:37]I think as we come to the conclusion of this, of course the topic is big and other discussions will continue.

[00:34:44]We cannot forget about talking about exercise.

[00:34:49]In this particular uh patients.

[00:34:53]Of course with the rise in the in the non-communicable diseases and the core of their control being lifestyle adjustments which include that and exercise. Of course the question becomes the person needs that needs to exercise but they have gotten a clot.

[00:35:12]What should one do?

[00:35:14]This becomes uh uh a question on everyone's minds.

[00:35:22]By and large, ideally the ideal is for someone to go through a a pulmonary rehabilitation. This uh usually means uh exercise that is structured and guided by a health professional with emphasis on on uh symptomatology.

[00:35:42]So, exercise can be resumed once the symptoms have reduced have resolved.

[00:35:48]That is if you had uh pain in the calf muscles and swelling, they too have improved. If you came in with chest pain, the chest pain has resolved. That's when you know, okay, you can initiate exercise but it has to be supervised.

[00:36:04]Of course you can have the discussion with the your physician on how much you need your physician cardiologist or or pulmonologist on how much you can do. Cuz usually it is based off the heart rate. If your baseline heart rate is higher than the what you the ex- the amount of exercise you can do maybe limited.

[00:36:28]Um but on that note uh Dr. Luzinda Are you back on?

[00:36:43]Yes, yes.

[00:36:45]Um so do you have any final remarks as we conclude the discussion?

[00:36:56]>> Uh I'll thank everyone who has spared time to join in and I would like to thank you for accepting to moderate the discussion.

[00:37:06]I would like to thank Julius and Angel for preparing this.

[00:37:13]And I would like to thank all the participants who spared their time this evening. It's a broad topic. I tried to simplify it as much as possible.

[00:37:22]But uh I'll now say clots are great discussion. We need to prevent them but in a hospital we need to have a high index of suspicion.

[00:37:35]Um so that we uh we suspect them and treat them.

[00:37:40]Uh I'll hand over to to to the team to uh to take over. Thank you. Over to you.

[00:37:51]>> Thank you very much, Dr. Luzinda. As we conclude this uh today's session on clots as I highlighted it's a huge topic.

[00:37:59]Uh the major clots you got to highlight are the clots to the lungs as much as wherever there are blood vessels a clot can form.

[00:38:07]The most important thing usually in this our setting is seeking medical attention the moment you notice any sign.

[00:38:16]Uh of course much as the discussion today is for clots in case you notice chest pain, tightness, swelling of the leg. The general principle is to seek seek medical attention at the earliest opportunity. As long as you feel something is not okay, because currently at least most medical conditions are easily manageable if you come in time.

[00:38:40]But in relation to today's topic of clots, here it is important to emphasize that here at Nakasero Hospital we are committed to the highest standards of patient safety.

[00:38:52]We have the protocols to cover for for clots in all patients, those who come in and those who are hospitalized.

[00:39:01]So, do not hesitate to come and uh benefit from the services we have.

[00:39:08]Uh other than that, the discussion can always continue. You can always find Dr. Lubinda, but feel free as as a take-home message, feel free to also look at the American Heart Association 2026 guidelines for the evaluation and management of acute pulmonary embolism, right? This is for the clinicians who have attended. Uh but there's also there's also the 2026 uh American Society of Hematology guidelines on anticoagulant prophylaxis in the pediatric patients. So, these are important documents for those with a medical good. Otherwise, thank you everyone for attending and have a nice evening.

[00:40:15]>> Yes, Dr. Alakija.

[00:40:18]>> Yes.

[00:40:20]>> Uh you still saying something?

[00:40:23]>> I don't know. We have concluded.

[00:40:25]>> Okay.

[00:40:26]Okay, thanks a lot, doctor, and uh have a good night to everyone. Thank you very much.