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Good morning everybody. And thank you for coming. Uh, today we're talking about depression and uh for some people, this can be a very triggering topic. So if it's causing you distress, please feel free to leave the meeting. Feel free to contact me on Facebook is my full name. Uh, as you should have on your, um, lecturer lists. Uh, don't send me a friend request. I ignore them. Uh, send me a direct message and I'll get back to you, uh, whenever I've got a free moment. Okay. So if you feel triggered, if you feel distressed, do feel free to leave and also feel free to get in touch with me again after the event, we do have a second year, a second um, session booked as well. So we've got plenty of time to just chat through as usual. Um There are no power point slides. You get plenty of those in other sessions. I've sent you, um, just a, just a kind of revision spider if you like rather than a full mind map. And you can either use it as a structure for making notes or you can print it out later and then um probably as we get to the end of the second session on depression, I'll send you a suggested completed version. Okay. As usual, I expect you to do all the work and as usual, we're going to start with a common scenario. Okay. So you are the junior doctor on court in the emergency department and you get a message from the triage nurse to say that you've just had a young woman come in who has taken a deliberate overdose of paracetamol. Can you please review immediately? Okay. So go and see the lady. What's the first thing you want to find out from her? There are no trick questions. Be brave, join in and um there aren't wrong answers. There are perhaps just answers that require a bit more discussion than others. Okay, so be brave. Get in there and have a guess. Okay. What's the first thing you need to know? Ladies come in. She's attempted suicide. She's taken paracetamol. How many paracetamol she has taken? Would want to know. Yeah, probably not the first thing you want to know, but certainly very, very important. How is she like to ask her how she's feeling, man? Very important. Not and not the first thing you need to know. This is a tricky one. Has she done this before as well? Why are you here? We asked, why are you, why are you here? Always a good question. Okay. And she tells you she doesn't want to come. But her friend made her the most important thing with paracetamol is how long ago did you take it? Okay. Anybody know the answer to that one or think they can make an informed guess if it is before six hours, the levels would be different. So the reversal, those in changes based uh reversal dose doesn't change for paracetamol. The importance of the four hours is that, um, if you look up management, it's, you're given a curve which has both a vertical and a horizontal Asymptote before four hours. Um Because of the assam tote, it's not informative, it's not accurate enough. And after about 8, 10 hours, you're starting to, to lose accuracy. So optimally, you want to try and get in there around about the four hour mark. That's where you'll get the most accurate reading balanced against time. Why is time important in this case? It's not just about. So we need, we need to wait four hours to get levels that actually mean anything. Why are those levels so important because you're going to take those levels, whatever the patient tells you, they've taken, we could introduce the antidote. Shout. Mhm uh So we could introduce the antidote. Yeah. Basically you're buying time, the quicker you can get in there if they need the antidote, the better your chances of saving their liver. Yeah. Delayed would cause more hepatotoxic. Yeah. Yeah. Okay. And obviously it's far preferable to save their liver than to then put them in a situation where they're on an urgent waiting list for a transplant. Okay. So you need to know where am I on that timescale? Before four hours, you're not going to get a meaningful result. After 10 hours, you're probably going to rely more on assuming that it shows that the patient has actually got paracetamol on board. Then you're probably more likely to treat empirically. If you're working from old textbooks, just be aware that recommended protocols in the UK have changed. In the last 23 years. There were some experiments um about 34 years ago, it was quite fashionable to, to try a very accelerated treatment with, with an acetylcysteine. Um cutting down the, the 21 our arrangement, but it's since been discovered that that actually um the risk of adverse reactions is too high if you use the, the rapid system. So anybody know um what the the kind of the guesstimate mass of um paracetamol would get you really, really worried about a patient. There's a cut off, there used to be two cutoffs. It's been changed to one because doctors are completely rubbish, estimating risk of hepatotoxic city. So anybody know what, what's the the kind of best guess safe dose? 75 mixed per kilo? Okay. If your patient weighs more than about 100 kg for a woman or more than about 100 and 20 kg for a man assume they have a, a mass of 100 because if people are overweight, um because some parasite more will, will go to fatty substrate, you'll, you'll get inaccurate results. Okay. So anybody who comes in and you need to do, not necessarily to weigh them, some people know what a little bird worried if she's taken 32 paracetamol than a big bloke with plenty of muscle on him, kind of pushing 6 ft. So you want to know how long ago she took it, you want to know what she took you at that point? If she's going to need treatment with Acetylcysteine, you do not do a psychiatric review because you're reviewing for capacity and um capacity as you know, is labor, it changes its time and decision specific. So somebody that you're talking to right now that you deem has capacity may turn out to not have capacity in about 10 hours time. Okay. So don't jump in too quickly to do a formal psychiatric evaluation. It must be once the patient is medically cleared because you'll just have to do it all again. Um When they are medically clear. Okay. So ladies been treated with Acetylcysteine. She was, she was just across the border line for, for treatment. She's had local protocol treatment with Acetylcysteine and you're going to see her and she tells you that she had a massive row with her fiance. He said that in that case, he thought they ought to call the wedding off when storming out. And so she was so upset, she decided that she would rather be dead. Took up a whole bunch of paracetamol. Are you going to prescribe her an antidepressant? And why? And I'll give you a clue. Both answers are right. I don't need advisor for, can be the present uh your Europe treater for the Palestinian but not for the, for those she can manage your biking. That situation. Can't remember. Okay. So you're not going to give you an antidepressant, is that right? You're a bit fuzzy. That's all I'm somewhere where I don't have great internet to say, to say sudden, uh, if the marriage has broken suddenly, uh, if this was a recent incident and she has taken the Paris to most suddenly, then we could say try to think about it, counsel her. But if, uh, the, uh, the time between the breaking of the marriage and the paracetamol event is long, then I would say a spending 100% might be necessary. Yeah, she's decided all of a sudden one day election. Yeah. Yeah, there is an intention to end her life. Well, was there an intention to end her life? Well, she has, uh, you know, in a, we've gone and taken some paracetamol. That means she does want to at some point. I don't want to continue. Uh, it's also whether there was an underlying depression which wasn't been noted that this has just propped up suddenly when there was a negative situation. So, but mhm And this is why I say both answers are right and both answers are wrong because you actually need to know much more about the situation before you make that decision to put somebody on medication long term that has potential quite serious unwanted effects. So mostly people who pitch up at E D and it's very common having taken what appears to be an impulsive overdose, you're probably not going to be jumping in and starting treatment. Okay. You're going to make sure they're safe, you're going to make sure that they can keep themselves safe overnight. And you're going to refer to someone like me who works with the crisis team and we do exactly that we work with people in crisis when she's a little bit calmer and hasn't been up all night because you've been treating her and who sleeps in hospital. And so she's had a bit of a sleep. She's had a bit of a breathing space to think about what's happening. That's a much better place to, to be starting to talk to somebody about. Are they depressed? Was this an impulse? What she really feeling? If you think your relationship is ticking along very nicely, then you have an argument about what color you're going to pay the bathroom and the guy goes off in a half and you decide to kill yourself. The chances are that there's lots of emotions going on, but there isn't depression, there's anger, there's frustration and so on and that's about their relationship. Some people will make Paris suicide what we call parous suicidal attempts as a means of trying to explain to the world how distressed they are rather than because they have an actual in tension to kill themselves. So on one spectacular night in E D among it was a busy night among my patient's, I had two who had specifically taken paracetamol overdose deliberately. One was a woman in her twenties who had taken, I think she'd taken something like 24 or 30 50 mig paracetamol and I had a link. Did they really think they were going to die? And as it turned out my 80 year old lady, because it says on the back of the packet that if you take more than the stated dose, you must see your doctor believed that she had taken enough paracetamol to kill herself. Very sad. Elderly lady. Husband had died previous week. No Children of an age where most of their friends are now very frail or dead. And she had decided to kill herself to join her husband and she was afraid that if she died at home, nobody would find the body. And so she came into hospital so that when she died, people would know. Whereas my lady in her twenties was a lady with um known personality disorder. Fairly recent diagnosis of personality disorder. She'd taken a pretty hefty dose of paracetamol, but not enough to tip her over the treatment line because she came in about once a fortnight with a deliberate paracetamol overdose. So even though her gesture looked much more serious, if all you do is look at what people have taken, once you start to think about why they took it, what they believed would happen. You actually get much richer information about whether they're suicidal or whether they're just trying to explain to you how distressed they are and that they need help, that they need your help, that they believe in some way that you can fix it. And that's a very common contrast that you're getting needy that a lot of people with personality disorders in their, in their desperate search for somebody to help them will often be frequent attenders and, and may or may not need treatment. They're usually once they've been three or four times, they're pretty good. But knowing what dose will require treatment. Some of them need that to help them kind of stabilize their mood. Others, I don't want to be treated. They just want to be in a place where for a short time they feel quite safe. So when did they take it? What did they take? Why did they take it? What were they expecting is what you need to think about? Okay. So important and useful vocabulary because in psychiatry, these things have quite fine meanings, deliberate self harm. This can be anything from the person who gives themselves a scratch that looks like a kitten. Did it a very small scared kitten to somebody who actually cuts their own throat. So it covers the whole range of deliberate self home. Okay. It is something that people have done deliberately to themselves up to and including suicide. Yeah. What's the difference between suicidal ideation and suicidal intent? Uh, maybe one is for, uh, letting people know that they are depressed and that is really depressed to end it on. Yeah, I think ideation is maybe on the basis they won't let others, you know that they want to die. Uh, they're thinking of it and in tension is, comes with actions as well. I think that's right. So, ideation, lots of us experience suicidal ideation and for most of us, I'm glad to say it's what we call fleeting suicidal ideation. So you just have a brief thought that's like, oh, maybe I should just kill myself and then you, you don't think any more of it and you might get that coming up. You know, if you're unhappy, if you're in a tough place, you might get that coming up more and more frequently, I'm becoming quite intrusive and at some point as you correctly said, it will change to a plan at which point you've decided you're going to die and you have intent to commit suicide. And then alongside that, we have the paras suicidal behavior that we've just talked about where people are trying to explain to the rest of the world just how desperate they are for some kind of help. Okay, if I say I see D 10, does everybody know what I'm thinking? What I'm talking about? International classification of innovations? That's one we're just in transition between I C D 10 and I C D 11. However, for um depression, I C D 10 in lots of ways is more helpful because it gives you a list of 12 quite specific signs and symptoms to be looking out for when you're working with somebody who has depression and these are the signs and symptoms that help us to work out. Um These are the questions that help us to work out. Um how severe and how risky a patient is okay. So there, there are 12 and if you look on the spider diagram, um top left hand corner, there's a bit of space there. So let's brainstorm. Uh If you don't already know it, what do you think crops up on that list of signs and symptoms that will help you to decide how whether or not somebody has depression and if they do how severe that depression is going to be. Ok, shout are answers or type them in the um type them in the message box. And let's see how many we can come up with uh alienation or isolation can be one of isolations in. Um Yes, it's, it's important but it's not on one of the I C D 10 first. And most obvious is that people are telling you that their mood is low. Okay. So low mood. What goes along with low mood? No appetite, less appetite. Yeah, they might have less appetite, they might have more appetite. So, a change in appetite. Absolutely right. Neglect, self neglect. Yes. Problems with what we call activities of daily living. So, a useful question to ask somebody when you're doing a review of depression is, you know, are you managing shower ing, washing your hair? Are you eating? Okay? Are you putting on clean clothes? Yeah. Activities of daily living. Very important one. Or else do people report or experience? Yeah. Lafarge or sleepiness. Yeah, lethargy. So reduced energy, reduced activity quite the same thing. Altered sleep. So I say altered sleep because like appetite, you can sleep too much. You can have trouble getting to sleep. So it's something that you always need to talk about is what's your sleep? Like? Sleep is terrible. I'm only getting two or three hours a night. Is that because you're having trouble getting off to sleep because you're having trouble staying asleep. What's keeping you awake? What's waking you up? So you just need to explore that a little bit because in session too, when we start to talk about medication changes in appetite changes in sleep pattern will feed into how you decide what antidepressant you're going to recommend. Okay? Are they having a good time. Are they enjoying stuff? What do you think if you're depressed? Are you enjoying life? You know? No, there might still be bits of life that you're enjoying. But again, a really useful question is, what are you enjoying? Uh, nothing in the past when you were? Well, what sorts of things did you enjoy then? Okay. So it's worth looking at the change. Okay. Stuff that you were interested in, in the past, some people don't really seem to be interested in very much. So, if they've never really had an interest, there's not going to be a change. On the other hand, if they are somebody who had a passionflower for collecting jigsaw, then that tells you something. So we're looking at, what else might we see or they might tell us about, would that be a performance probably in the workplace of Yeah, how you're getting on in the workplace is so, is a risk issue? Okay. I'll run, I'll run you through these because you can look these up really easily. Okay. So I see D 10 again. Sorry, I lost signal for a moment there and my back. Can anybody hear me? Yeah, we can hear you. Thank you. Sorry, I'm, I'm at one of our remote sites that I'm relying on a, a SIM card on the laptop because there's no, for various reasons. There's no wifi here. Okay. So I see D 10 common signs and symptoms, reduced mood reduced energy, reduced activity, reduced enjoyment, sometimes referred to as anhedonia, reduced interest, reduced ability to perform activities of daily living, altered sleep, altered appetite, psychomotor retardation. So this is something that is separate from energy levels, mood and so on. Just literally. Okay. Hello doctor. You there. Hello. Really profoundly distressed. So you got cut off for a few minutes ago. Yeah, that's okay. So, psychomotor retardation is something you observe. This is a symptom of a very severe depression. So you do need to watch out. Are they responding to me at an appropriate rate? And in again, in very severe depression, you'll find that people self esteem falls, they're no longer have any confidence in themselves and they may well tell you that they're worthless that they're experienced increased guilt about some real or imagined event or circumstance. Okay. So severity comes at four levels. And if you have a quick look at the spider diagram, I've given you those four levels mild, moderate and to severe. So you can have severe depression without psychotic symptoms. And some very unfortunate people will experience severe depression with psychotic symptoms. If you've got a severe depression with psychotic symptoms. Are you going to treat the psychosis or are you going to treat the depression against the declaration? Going to treat the birth depression? Yeah, we're going to treat the Depression Council but not uh if they're not showing any psychosis, then I think. Mhm Tomato, if we treat the combination of both treat depression. Nation well done. Yeah. You want to treat both psychosis much easier to treat than depression with uh antipsychotic. With most of them, you'll see significant improvement in psychosis within a small number of doses. Depression is the commonest thing we treat and it's the hardest thing we treat way, the most complicated thing. And one of the challenges is that we do not have any antidepressants that will reach a therapeutic level and start to have apologies for keep losing signal. I think I'm back with you. Can somebody just just say yes or no? Yeah. Brilliant. Thank you. Um Okay, when, whenever it pops up on my screen that we've been cut out, I stopped talking. So yeah, get in their treat the psychosis because you can get that sorted really quickly with an antipsychotic in a way that if you just wait for the depression to, to stabilize, um you keep your patient psychotic for weeks. Okay. So mild severity, how many symptoms do you reckon you need for somebody to be defined as having mild depression? Have a wild guess. It doesn't matter if you're wrong. Less talkative. How, how many, how many symptoms for, for mild depression be? One or two? Yeah, two or three symptoms. And mostly people are distressed. They've come to tell you that that they're depressed. Um, but they're managing to continue with most of their normal activities. Okay. So moderate, I think we can all assume that you've got more symptoms. So, for a moderate, moderate depression and onwards, we're looking at more than four symptoms, four or more for moderate, more than four, for the severe ones in a moderate depression, people will be distressed. They've come to tell you that they distress but, and they'll be starting to struggle with managing life. Yeah. Um, so they might be, they might tell you that they're snappy with their Children. Um, they might tell you that they're struggling to get up in the morning to go to work that they can sort of manage it. But they're getting late for work quite a lot that the Children are getting upset because they're grumpy with the Children all the time. You know. So, so it's starting to impact and then you get to the severe levels and they will have several symptoms. Um, and will almost invariably one of those dominant symptoms will be a severe loss of self esteem, loss of confidence or a strong sense of worthlessness. There's no point in me being here, they would be better off without me. That kind of thinking I can't do my job anymore if I can't do my job. What am I? I'm letting people down all of those kinds of really intrusive thoughts. And then there is the added distress for some people that they actually develop a psychosis with their depression as well. And we just talked about how important it is for those people to jump in there and, and get that a bit sorted for them, start to improve things. So what are the risks of depression? So if we just think initially about the kind of the mild to moderate people are starting to struggle with daily life. Yeah. Um what's, what's the risk at that level? And you kind of already mentioned one at this level, we start to see negative impact on relationships within the family. Often, even with people that they love very much, we start to hear that they're having trouble at work, um, that they're having trouble getting on them because they're tired, they're lethargic, they're not getting through the work. They used to get to. Um, one of, and also one of, one of the, sorry, I, I've managed to skip over concentration is um, loss of concentration is a common sign or symptom. So if your job involves operating heavy machinery and you're tired and you haven't got much energy and your concentration isn't up too much. So we're talking risk of accidents, things like that. So even quite a mild depression can have a very profound effect. Anybody who is actively suicidal, you must assume that they have a severe depression. Okay. If, what you've got is somebody with, with an isolated suicidal bent who denies all of the other common signs and symptoms, you might have something else going on there, but it, that would be vanishingly rare. Anybody who's telling you not just that they're having thoughts that maybe they should just kill themselves. You're, you know, you're worried you're paying attention. But if somebody tells you that there's no point being alive that they're getting really intrusive thoughts that they're going to be, that being dead would be better. That is a person who is now a very high risk of death. And you would be looking to try to find them a bed, uh, in a psychiatric ward if they can't reassure you that they can keep themselves safe. And sometimes you, you negotiate, you know, can you keep yourself safe till tomorrow morning? Yes, he did. It's one o'clock in the morning. This is not a good place to be working out what's going on for somebody with a psychiatric problem. Basically, your decisions in the E D R. Am I going to send this person home? Am I going to get them admitted to an acute psychiatric ward? If you decide to send them home, you must be sure that they can keep themselves safe overnight. And you make the referral to the crisis team who are an emergency service. And in Britain, we are expected to, to do a full medical review within 48 hours of referral. And certainly the team that I'm with at the moment, we will send a senior nurse to review the patient. Um basically as soon as office hours open. Okay. So risk to life in the severe depressions is not just death by suicide. What other things might cause somebody that unwell to die? They might complete those funds and you know, completely go off food and thanks to that. And yeah, what happens if you stop eating? It's not a trick question. If you stop eating after Tony, you become very weak, you become catatonic. You may die of dehydration. You may die of starvation. Yeah, you may, if you're just lying in bed, you're not eating very much. You're not drinking very much. Any patient in hospital, any patient who's not getting out of bed very much. We worry about bedsores and we worry about bedsores because they very easily become sepsis. Yeah. And so these are all reasons why we might think about sending a patient hospital. Does a patient who's suicidal? This is a hard question. Okay. Does a patient who is actively suicidal have capacity? Maybe. Yes, maybe, yes. Not really. I mean, they're trying but somehow one day they might get lucky or successful in their attempts. Yeah. Somebody there said not really. This is a subject door of huge debate amongst psychiatrists, certainly in Britain because it's not illegal to commit suicide anymore used to be, but it isn't anymore. That's a historic thing. And yet the Capacity Act says that if somebody is actively suicidal, you can override capacity and still legally detain them to a psychiatric unit. So yeah, they were um patient's, you know, are extremely well. Uh You need to do some intervention. If they are not able to consent by themselves, you override that and take the decision to go ahead and do procedures on them. They, their symptoms, if someone is on severe uh suicidal thoughts, that means they're severe depression. So that is equal. So yeah, good construct that as they lacked capacity. So in that sense, and the old, it's a really complicated ethical question. The law says that if I know that somebody has severe depression and you, and that there is significant risk to their life, irrespective of whether or not they have capacity. I have a professional duty to save that life. And so we tried to comfort ourselves with the thought that maybe they'll change their mind that if I save them, maybe they'll be grateful down the line. And I can tell you from experience somebody who's that ill. They are not grateful that you save their life for a very long time. So it is a tricky one. And there are some psychiatrists who say, look, this person has capacity, this is not illegal. They should be allowed to do this. And so there's a uh conflict of personal opinion, personal faith systems, personal belief systems. Are you starting to get a picture for yourselves of why? Although it's very common, it's actually really difficult to manage depression. It's probably the hardest thing I do. Yeah. So we've got maybe five more minutes. Does everybody. Now, this is a bit of a trick question. I always say, I warn you if it's a trick question, does everybody who comes to you with, say five symptoms of depression from my CD 10? Are they all depressed? And if they're not depressed, what might be going on instead? So what can you come up with first? We might have to get to know whether it be, might have these five signs are deliberate or potentially as well. Sometimes, I'm sorry, I, I can't, some of them can be intentional. So we have to know that uh, some, some might be intentional, but some might be genuine. We have to first differentiate that. Yeah, because if it's intentional, then it's the seeking for help or if it's not intentional, then, then it's a real severe case. But we have to also know how they came in to know that came into a, come into awareness that something is wrong with them. Okay. So personality disorders, people will present as having those symptoms. They will tell you that they're so depressed. They keep thinking about killing themselves and so on. They're not depressed symptoms of their disease, mimic depression, almost invariably be their first contact is when they go to the GP, tell the GP they want to kill themselves and their GP, because he's a GP and not a psychiatrist, we'll start him on an antidepressant. Half of people who complete suicide will have seen a healthcare professional in the preceding fortnight. Ok. Life Israel life is serious. So, personality disorder mimics depression. What else? Mimics depression. Maybe some physiological problems, you know, uh it could have a brain condition. Brain tumor. Yeah, brain tumor. It's not on my list. I do have 13 other things on my list that it could be. But you're quite right. Changes in, in brain structure itself. Some um curable diseases such as E L S uh towards stage cancer. So they might take the step knowing that uh before the suffering, it's better to end it before. Yeah, I societies increases society. So chronic disease. Um Doctor I have a question. Can hypochondria sometimes mimic depression. Yes, very much. So, another one not on my list. See, I rely on you. My list is not perfect. What else? You might just be unhappy. Yeah. If you are single parent living in a tiny, depressing damp, flat, full of mold and the only outside space you've got is used by the local drug dealers and you've got a three year old that you're trying to cope with on your own. That's an unhappy circumstance. Yeah. And you may well have signs of depression, you may well have a depression. But if I can't change your circumstance, unofficially, very, very, unofficially, I mentally refer to that as shit life syndrome. Some people just have a horrible life. Okay. Somebody mentioned infectious disease, mononucleosis, Epstein barr virus. Yeah. Think about the symptoms, low energy, low activity lack of interest in ability to complete activities of daily living, disrupted concentration, altered sleep patterns, altered appetite. Yeah. They all, they all take the un depressed box but giving them an antidepressant isn't going to fix their EBV, what else should be on your differentials list? The depression changes in weather. Yeah. Some people get seasonally affected depression. Mhm. What about thyroid, thyroid disease? Yes. Hello. Metabolic is, um, so, yeah, altered metabolism could lead to the question. Yeah, it could lead to depression. You get changes in appetite, both hypo and hyper. Remember get changes in appetite. You get changes in sleep pattern. With hyper, you may have increased energy but with hypo you'll have all of the decreased energy patterns. Yeah. What about grief? His grief, depression. No, but it mimics, yeah, I can mimic not exactly a sudden loss of a sudden loss of. But yeah, but it's the, how long you're going to be in grief, isn't it? So, that's, yeah. So normal breathing would be a differential diagnosis because one thing that we know about normal grieving is that if you disrupt that process of giving them an antidepressant, for example, it is more likely to become prolonged and abnormal breathing. The grieving process is very, very important and there's a lot of evidence that if you live in a culture where you have kind of a very structured way of grieving. So, you know, if you're Jewish, you sit on the floor, people come to visit you, they bring you food for a very specific period of time. Um So any, any kind of religious structure for grieving for, for dealing with that, that first episode uh is actually very positive and enormously helpful. And so it's very important that just because people are saying that they're very sad that you don't actually disrupt that process. Talk. Yeah. Listen to them, give them that space but don't give them drugs to try to make them happy. Ok, grieving is normal. You can think of it as a specialist, specialized kind of depression. Okay. What? Postnatal depression comes under that? Yeah. Yeah. Postnatal depression, postnatal depression is slightly different because you now have two lives at risk and post natal depression, particularly with psychosis, you actually get in there with almost extreme treatment which is electroconvulsive therapy. And if we have time in our next session, we'll talk about that. If you're coming to the next session. Have a quick look at the spider, um have a bit more thinking about differential diagnoses because there's lots of them have a little bit of a thing you can see down the right hand side or of the spider I've given you pretty well three quarters of the page to talk about things that increase your risk of developing depression and suicidal intent and about a very small box in the bottom right hand corner for protective factors. So have a bit of a think about those and next session we'll, we'll talk around those and we'll talk a little bit as well about management. Thank you very much for coming. My apologies that we've had trouble with the internet today. I hope that wherever you are, you managed to have a good day. Thank you for coming. Thank you, ma'am. Ok.