Navigating the Challenges and Treatments of Lupus

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:16

Thank you for coming. I'm actually pleasantly surprised we have all this interested in lupus, and lupus is one of those diseases that we talked about during internal medicine training by saying, well, none of us really understand what it is, so we're going to take the smartest people in the internal medicine group and make them study it and explain it to the rest of us. So, as a cardiologist, I was so happy that we had smart people like Dr. Shah that would actually learn what this is and teach us, and we used to joke about it in residency. You had diseases that were caused by infections and you had diseases that were caused by atherosclerosis and diseases that were caused by cancerous cells. And then you had them, their diseases, where you're not sure exactly what the heck is causing it, and lupus would be one of those diseases. So I'm really excited to learn from you in terms of what lupus is and we'll break that down for people. And, of course, we are interested in helping people resolve symptoms related to lupus and improve their prognosis when they have lupus, which is not always a great prognosis, as we'll learn and as we speak, there are studies in the community to help people with this particular condition using certain medications and we'll dig into that a little bit more. So that's a little bit of an introduction. So let's jump into lupus, okay.

Dr. Swati Shah: 1:40

First of all, thank you very much for a nice introduction, Dr. Koren. And yes, lupus has been a little mysterious disease and it has been considered a mysterious disease where it can do multiple things. It can be very damaging to the body, but it can be very mild as well. So there is a lot of misconception about lupus and we would try to unveil some of the mysteries and understand it a little bit better. The more you understand, the better you feel about it, the calmer you feel about it, and that helps with the treatment.

Dr. Michael Koren: 2:17

So let's dig in. We're going to go to our first slide, I guess, to dig in. So why don't you tell everybody what this mystery SLE is? What does that mean? What's that term?

Dr. Swati Shah: 2:26

So we call it SLE for systemic lupus eridometosis. It's a chronic inflammatory condition. It's an autoimmune disease. That means your own immune system is attacking your body or your cells, your organs, and it causes inflammation wherever it attacks and it can cause pain throughout the body, multiple manifestations, and it is systemic.

Dr. Michael Koren: 2:50

So you see a picture I'll go back to that last one and you see a picture of a woman with a butterfly on her face. And Sharon, you're not supposed to tell my secrets that I sleep at night with a butterfly mask on. I thought that was just between you and me. I'm only joking. So that actually means something. So I want to point that out to the audience. Why that picture is there.

Dr. Swati Shah: 3:12

So the very characteristic rash we see with lupus or SLE. You can use that term SLE versus lupus interchangeably to make it simpler, so I call it lupus. It's a type of lupus. SLE is a type of lupus but it's the most common type, so I call it lupus. But you can see in any or every types of lupus. You can see this rash on the face. We call it malar rash. It can also be called a butterfly rash because it can look like a butterfly, because the bridge of your nose is involved, which would be the body of your butterfly, and the wings, which involves the rash on the eyes and the cheeks. And that's a very common rash which is one of the diagnostic features.

Dr. Michael Koren: 3:58

Yeah, so that you can be an amateur diagnostician and if you see somebody that has that type of rash on their face, you could actually help them make a diagnosis, really get them to the right place. But it is a characteristic rash of this particular condition. We call it butterfly rash. So that's a nice little tidbit for you. Go ahead so explain systemic to the patient.

Dr. Swati Shah: 4:22

So systemic is the name suggest for the SLE. It involves multiple systems, not just one organ, so it doesn't limit itself to the rash. It can involve other organs heart, kidneys, lungs, liver. It can involve every organ in the body aspect actually. So that's why in multiple organs, not just one organ. Let's say, somebody has lupus in the kidneys, they can have lupus in the blood vessels too, in the brain and the heart too, so just to know that we don't miss anything else. That's why the name says systemic itself.

Dr. Michael Koren: 4:58

And so here are some statistics, so these are actually pretty impressive.

Dr. Swati Shah: 5:03

So if we look at the stats, it kind of tells us that it's not very uncommon 1.5 million of Americans have diagnosis of lupus. Most of this diagnosis usually comes around the age of 15 to 44. So prime years, youth and adult years are involved, and it is seen two to three times higher in certain ethnicities, especially African Americans, Hispanics and Asians, and also female 9 out of 10 people with lupus are female. And why is that so? There is no clear data to show. Why is it there? But we have understanding that probably hormonal changes and estrogen has a lot to do with it. And why we think that is because during adolescent and perimenopausal phase, that's when lupus gets diagnosed or flares very frequently. So we think that there has been some association with hormones. There might be the cause.

Dr. Michael Koren: 6:02

Alright, next slide what we got. So explain, though this may look a little intimidating, but we're going to break it down for you in terms of the immune system.

Dr. Swati Shah: 6:11

It is. So this just shows that the genetic predisposition is a key feature in lupus. It's kind of you need to have that genetic predisposition and then the environmental triggers can trigger it. Why does genetic predisposition? What happens with the genetic predisposition or with genes is faulty or altered genes can affect immune systems. Immune cells become overactive, their communication becomes altered, dead Dead cell cleanup becomes altered and that's where the manifestations come from. Autoantibodies are produced because of all of that.

Dr. Michael Koren: 6:51

So, getting back to the slide, autoantibodies is a very important concept, and we all know that our body produces antibodies against diseases and other foreigners, but in some occasions our immune system provides antibodies against our own cells, and that's when bad things happen, and lupus is believed to be a disease that falls into that autoimmune category.

Dr. Swati Shah: 7:16

Correct. So yeah, that's where the name autoimmune comes from too, that your own immune system or own immune cells act up against you by making autoantibodies.

Dr. Michael Koren: 7:28

So types of lupus. Why don't you run that so?

Dr. Swati Shah: 7:32

As we talked briefly earlier, is the main type of lupus and that affects almost 70% of patients with lupus diagnosis are with acid, they have SLE and that means multiple organs are involved. Cutaneous lupus, as the name suggests, and it involves skin and that is mainly where you have skin involvement everywhere, not just the face anywhere. And drug-induced lupus is another one which we want to keep in mind all the time because it's caused by certain medications and the simple treatment for that is to remove that medication. So it should be always considered, but it's only 10% of lupus diagnosis. And neonatal lupus is something we don't like to see newborn babies affected from it. But if the mother has active lupus, sometimes newborn babies will have those autoantibodies and they will have features of lupus. They don't necessarily get diagnosis of lupus and within six months the symptoms are gone and they'll never have any consequences in the future.

Dr. Michael Koren: 8:29

Yeah, the drug-induced lupus is an interesting thing. When I was in my training in cardiology, a commonly used drug for arrhythmias was called procanomide, and procanomide was probably the classical drug that caused lupus. And it's a shame because procanomine was an incredibly effective antirhythmic drug, meaning if you had atrial fibrillation or if you had ventricular tachycardia we can use procanomine, and it worked really well and was safe in the short run. But so many patients would develop rashes and other signs of lupus after six or 12 months of exposure to the drug that we basically have stopped using it, even though otherwise it's effective.

Dr. Swati Shah: 9:08

So these medications which can cause drug-induced lupus don't have to cause lupus in every individual they're exposed to. It might be because of genetic predisposition. Again, certain genetic predisposition with certain medications can cause it. So you don't necessarily have to shy away from using the medications, but be careful and aware of that. That's very.

Dr. Michael Koren: 9:30

Are there other medications that people should be aware of that could be associated with lupus in general?

Dr. Swati Shah: 9:35

There is one medicine for blood pressure, hydrolysin, which is very commonly used, can cause lupus as well. Some thyroid treatment medications methamysal, propyl, thioresil. Those are used by endocrinologists for hyperactive thyroid or sometimes underactive, and that can also cause lupus. So blood pressure medicines can too, which are used very frequently.

Dr. Michael Koren: 9:59

All right. Signs and symptoms.

Dr. Swati Shah: 10:01

So we talked briefly about the butterfly rash and before I go into symptoms and signs, I want to say that symptoms differ in individuals very much and so you don't want to categorize your symptoms and say I don't fit into those or my friend had these symptoms, I don't have that. That means I don't have lupus. We usually joke around and say there are about 40 types of lupus or 40 types of presentation for lupus. So any symptom and you kind of you can ask me any symptom and say can this be from lupus? My answer 99% of the time is going to be yes. So it can present very, very early and common symptoms include fatigue, fever, muscle or joint pain, sun sensitivity, which is also a big thing in lupus, skin rashes renaz. Renaz means the your hands go or some of the fingers go dead white looking. It's not just whitish, it's dead white, and they hurt and burn and tingle at the same time, so you wouldn't miss it. And shortness of breath, chest pain, eye symptoms, headaches, memory issues, blur clots, mouth ulcers and hair loss are some of the common ones.

Dr. Michael Koren: 11:13

Okay, so who in this room has had one of those symptoms at any time in the last five years?

Dr. Swati Shah: 11:20

We all probably do.

Dr. Michael Koren: 11:21

So how do we know that we don't all have lupus?

Dr. Swati Shah: 11:23

That's the main thing. Yes, so that comes to, how do we diagnose and what are the risk factors? So symptoms are is one of the factors to diagnose lupus. Blood tests and specific symptoms and skin biopsies. When you combine all of it, that's when we can clench the diagnosis of lupus or we can rule it out. So just because you have symptoms, you don't need to worry about it. Have it checked.

Dr. Michael Koren: 11:51

So you do blood tests then to confirm the diagnosis based on these risk factors. Correct, so if I forget something, it doesn't mean you're gonna check me out for lupus or feel fatigued. But, if I fit into this category of patterns, then you may then do some blood testing to specifically look if I have this condition.

Dr. Swati Shah: 12:12

Blood testing and some other symptoms too, some specific symptoms. So fatigue is a vague symptom, but there are more specific symptoms, like fluid around the heart or lung and renaut. Those don't happen based on your lifestyle or based on overworked or something. So some specific symptoms also help you clench the diagnosis. And you wanna keep the risk factors in mind too. So female patients are at risk. 90% of sufferers are women, so we wanna be careful about that. Age 15 to 44 is the age where you get diagnosis most often. Certain ethnicities, genetic predispositions, genetic factors or family history of lupus is important that we don't wanna miss. And then environmental triggers. Environmental triggers include viruses, chemical exposures, smoke, silica, sunlight, UV rays mainly UV rays, unprotected UV rays exposure. Certain medications, as we talked about, and stress. Stress is another very well-known trigger for many autoimmune diseases, including lupus. Physical stress, emotional stress, all of it.

Dr. Michael Koren: 13:20

Very nice. Complications, so let's jump into that.

Dr. Swati Shah: 13:26

Complications of lupus come from its involvement to the organs and it depends what organ is involved. So most common organ to be involved is kidney. So if the kidney is involved and has inflammation of the kidneys, then kidney can't work properly, can't get rid of the toxic waste and causes swelling, itching, facial swelling, leg swelling that call lupus nephritis. That is one of the complications. If it involves brain you can have memory issues and fuzziness, foggy brain. If it involves the blood vessels, which can involve brain as well, then you can have seizures. And plus we think that the base of all autoimmune diseases chronic inflammation, unnecessary, uncontrolled chronic inflammation, and that is the basis for heart diseases and you know it very well. So heart attacks, heart diseases, atherosclerosis is seen in all autoimmune diseases, including lupus. And skin rash is not just on the face. You can have ulcers and blisters and bullies formation. So different, different types of skin rashes. Infection is very common in all autoimmune diseases for a couple of reasons. One is because it's an autoimmune disease, your immune system is weaker and it cannot fight infections very well. So that's one of the reason and sometimes the medications we use to treat lupus with that also suppresses immune system so it increases risk of infections. Cancer probably comes from chronic inflammation and death of bone tissue. That is one of the ones we wanna be careful about too. You can have severe, certain onset of joint pain, and blood clot in the bone or the inflammation of the vessels in the bone can cause death of the bone tissues and pregnancy complications. All kinds of pregnancy complications has been seen, with lupus, preeclampsia, preterm labor and other malformations as well fetal malformations, and so we usually recommend that patients, before they try and get pregnant, their lupus should be quiet for six months. That's an ideal time to consider pregnancy.

Dr. Michael Koren: 15:38

Yes. So just to jump in with a little heart trivia, fact is that people who have lupus, compared to the exact same type of person that does not have lupus, have twice the risk of heart attacks and strokes. So it is a pretty significant risk factor for heart disease and certainly I have plenty of lupus patients that have had cardiovascular complications.

Dr. Swati Shah: 16:01

So again we'll get back to how do we diagnose it. So lupus diagnosis can be a challenging diagnosis because it is called the great imitator, because it can mimic a lot of diseases. It can mimic infections and sometimes the first symptom is heart attack and that's how they get diagnosed with lupus. And so sometimes patients are not diagnosed for years because maybe their symptoms were not specific or classical. So we have all this multi-pronged approach for diagnosis of lupus where physical examination and history is very important. History of blood tests, urine tests and biopsies help us.

Dr. Michael Koren: 16:51

All right, so let's talk about treatment.

Dr. Swati Shah: 16:53

So treatment of lupus. We have multiple therapies available for lupus and we're still utilizing very old medicine which is anti-malarial hydroxychloroquine for many decades and it's a very benign and safe medicine. It helps reduce flares and reduce organ damage as well. Then we use steroids for flares. The steroids are usually not a permanent treatment, but they're used for flares and as a bridge before the therapy works. Non-steroidal anti-inflammatories are used for flare-ups and for pain as needed, and main therapy is immunosuppression or immunomodulation. We have multiple therapies which can suppress immune system and that's how we control organ damage and lupus activity. If you have that blood clotting disease which is called antifospholipid antibody, which can be associated with lupus many times, then you may need blood thinning medicines as well blood thinners. Sometimes you don't have to have that disease and you still have high risk for blood clots just because of lupus. And if you have history, then you should be also on blood thinning medications. Monoclonal antibodies are the medications which are developed in the lab and they are similar to autoantibodies, but these are targeted towards the factor which causes lupus or symptoms of lupus. And then there is a medicine called actar gel which acts like prednisone. It makes you produce your own prednisone, but we use that as a bridge as well sometimes.

Dr. Michael Koren: 18:25

So hydroxychloroquine is as a trade name of Are there other trade names? So that's pretty much the only one. That's the only one. Yeah, so you might have heard of that, because there was a lot of discussion about that for COVID and plus minus for COVID, but unfortunately we have better things for COVID at this point. But that was advocated as one of the things to try to use for COVID initially and that's still very effective for lupus, isn't it it?

Dr. Swati Shah: 18:52

is very effective. I usually say if you have lupus or you think you have lupus, you should be on hydroxychloroquine on top of any medicine, unless you are allergic to it or have side effects. Because a huge study was done many decades ago where thousands of patients with lupus and without lupus were put on the medicine and not and the group which was on the medicine did very well for flares and organ damage involvement and long-term safety data was really good.

Dr. Michael Koren: 19:21

Now, how about other anti-inflammatory? Is any data for non-steroidal anti-inflammatory agents or Colchicin or nothing close to ?

Dr. Swati Shah: 19:31

So anti-inflammatories? We only use it for flare-ups and some symptoms as needed. But Colchicin I'm glad you brought it up. Colchicin is also anti-inflammatory, which if Lupus is involving your heart and pericardium the layer around the heart, and it gets inflamed off and on and the other medications are not controlling it very well and you don't need strong immune suppressive medicine because other organs are doing fine, then Colchicin is a wonderful medicine for that. Y ou can take it for a long term rather than ibuprofen like medicine. Long term is too many side effects, so Colchicin can be taken long term.

Dr. Michael Koren: 20:09

How about Colchicin for lupus, nephritis or other inflammatory conditions that affect organ systems?

Dr. Swati Shah: 20:18

I don't know if any study is done for that, very reliable studies for that.

Dr. Michael Koren: 20:22

So no, it's not been used for that, or sarbitis, nothing for that. Okay, interesting. So we have some decent treatments, but there's definitely room for improvement. It sounds like.

Dr. Swati Shah: 20:32

Absolutely. Lupus is one of the autoimmune diseases where we would love to have more medications because of multiple reasons. Patients are very heterogeneous, presentations are very different and some of the refractoriness medicine refractory lupus is also there, so some more medications will be very beneficial.

Dr. Michael Koren: 20:55

Okay, so you take care of a lot of lupus patients, so you're the expert to help people live with lupus. So why don't you give people hear a little bit of insight into that.

Dr. Swati Shah: 21:04

So that's exactly right. When I see the patients, we also talk about how to live life to the fullest with lupus, because lupus is not the death sentence anymore at all. Lupus does not mean you have to alter your lifestyle significantly. You can still enjoy and do everything you want to do. Just having few things in mind will help you big time with the flares and organ preventing organ damage. So first of all, I would say follow your guideline, follow your doctor regularly and follow the recommendations. If you have any questions or if you feel like we're not on the same page, then have an open communication. Ask questions about why certain medications. The more you guys talk, the better it will be, but continue with the treatment plans because it is unpredictable disease, so some therapy might still be needed, even if you're doing well. And then rest and sleep enough. Rest and sleep is very important because it improves your immune system. As it's an autoimmune disease, we want to strengthen our immune system. As a background, and rest, sleep, improving the stress are very much key factors for improving your immune system. Manage your stress. Sometimes stress is not in your hand, but how you manage, how you react to stress is, and if you're slept well. If you're doing breathing therapies, meditations, yoga, you can handle stress better and that itself is pretty good. Balance diet is a huge thing. I believe in diet, helping diseases very all the time. So having balance in the diet lots of fruits, vegetables, greens, whole grains, lean meat and healthy fats. Then regular exercise, because exercise also improves your immune cells, immune system. Pace yourself. Sometimes we overwork ourselves and that also damages our immune system, at least for short term. So pace yourself, plan ahead. Sun protection is one huge thing. Sun protective clothing, sunscreens, stay hydrated. And pain management. Pain management with pain management, with heating pad, ice pack, stretching. Yoga helps a lot.

Dr. Michael Koren: 23:22

Question. I'll finish this up and I'll give you my questions. Go ahead.

Dr. Swati Shah: 23:26

So support group is also very helpful If you meet people who are also dealing with a similar disease and find out what tricks and tiny tricks they were doing which helps. That's very important too. Knowing meeting people who are going through the same things gives you emotional support as well. Keep a health journal. I usually say, keep a flare journal. So rather than having to write every day and getting confused with all that huge data what to do with it, you can keep those days when you have a bad day. Then you look back and write down what happened the day before and you compare those bad days and you can find some triggers for yourself. So you don't have to worry about. Everything is a trigger. What do I do now? You can find out what's your trigger and avoid them. Mindful planning. Smoking is one of the triggers for all autoimmune diseases. Avoid that and limit the use of alcohol, and the more you know, the better you feel.

Dr. Michael Koren: 24:20

So, in terms of the management in general, we have diseases that we manage just by looking at symptoms and asking our patients about symptoms, and there are other diseases that we manage looking at biomarkers. We look at lab tests and other data that we have to analyze through some sort of chemical means or imaging or what have you. So is lupus something that's strictly managed by symptoms, or are there biomarkers that you check when you're trying to treat patients?

Dr. Swati Shah: 24:50

Both. It's a wonderful question. So biomarkers are very helpful telling us whether the disease is active. Certain biomarkers are helpful trying to predict organ involvement. Certain biomarkers are helpful trying to see if inflammation is active. We also want to not neglect symptoms. Symptoms are superior than every other lab. If you have constant symptoms and biomarkers are not showing it, then we just go by your symptoms and say, well, we can't rely on biomarkers in your case and we need to treat it based on the symptoms. But both are very helpful.

Dr. Michael Koren: 25:26

So give folks an example of a biomarker that you would track in a lupus patient.

Dr. Swati Shah: 25:30

So double-stranded DNA is a test we do which can predict kidney involvement. If it goes higher and higher, that means lupus is becoming active and it has predisposition of the kidneys. Certain other biomarkers, like RNP and RNA, has involvement with the skin. More involvement, more predisposition to the skin. And one other one, ribonucleoprotein, has predisposition for the brain. Complements are another test we do which are utilized in inflammation. So if you have active inflammation, compliments will be low in your bloodstream. So that can also tell us that, yes, there is inflammation going on.

Dr. Michael Koren: 26:11

And do you look at general markers of inflammation like HSCRP, or you can expand that to people also-

Dr. Swati Shah: 26:26

They also increase in infection and other conditions, heart attack and everything. So you want to be careful when you're using the CRP and SADRATE. We call it for short form as a biomarker, but if in the right condition, right setting, they can help immensely for lupus activity.

Dr. Michael Koren: 26:44

Thank you. All right, so we're research people and we'd like to share the latest and greatest and, most importantly, what does the future look like? So why don't you give us a little bit of information about what research is being done and what the future outlook is?

Dr. Swati Shah: 26:58

So lupus is a very exciting field at this time because a couple of medications are recently approved and a couple in the research for lupus treatment which we needed for last many years, many decades. Recently, there has been two medicines approved which are infusions Cephanel and Benlysta and this new medicine called JAK inhibitors or Janus Kinase inhibitors, and the great part about this JAK inhibitors is their pills. You don't have to be injecting yourself or committing yourself to infusions once a month. It's a simple pill you can travel all around and it has already been FDA approved for many other autoimmune diseases, including rheumatoid arthritis, psoriatic arthritis, ulcerative colitis and certain skin conditions. So we have experience with this medicine for many six years or so and it is pretty safe as well. And it has recently been studied for lupus and we're starting a study for lupus with this JAK inhibitors.

Dr. Michael Koren: 28:03

That's when you speak in our community.

Dr. Swati Shah: 28:04

That's pretty powerful. Correct the name of the medicine RINVOQ. The name of the medicine again RINVOQ, it's RINVOQ.

Dr. Michael Koren: 28:17

That's the trade name for a Jack Kinase inhibitor or a JAK inhibitor.

Dr. Swati Shah: 28:27

R is in rainbow. IN VOQ.

Dr. Michael Koren: 28:36

Typical drug name. That doesn't mean anything.

Dr. Swati Shah: 28:40

So its generic name means a lot, but it's a . But it's much more difficult. RINVOQ is much easier.

Dr. Michael Koren: 28:47

Yeah, a bottom line is that it's used in a lot of autoimmune diseases.

Dr. Swati Shah: 28:53

We already have knowledge about it. We already have experience in other autoimmune diseases.

Dr. Michael Koren: 28:58

So all those other diseases that were listed were also autoimmune diseases and this drug breaks through the cycle of the immune system, attacking our bodies, so that's really really important and really exciting that we're looking at it for another possible disease.

Dr. Swati Shah: 29:17

And so, basically, JAK inhibitors suppress immune system, suppress inflammation, decrease the cytokines and the chemicals which produce inflammation, and that's how it helps with autoimmune diseases and the way it works. It works on multiple cytokines or multiple chemicals and that's how it is used in multiple autoimmune diseases and I'm very excited to see if it works on lupus. It should. There has been some preliminary data about other JAK inhibitors being used in lupus. In the past the study wasn't very conclusive because of some other factors, but I'm pretty positive, I'm pretty optimistic.

Dr. Michael Koren: 29:58

So I think we have some final thoughts here. Go ahead.

Dr. Swati Shah: 30:01

So this is the last few slides. I think that if you are interested in it, then fill out the form or let us know, talk to our staff members, schedule a free evaluation. Our research costs nothing for the patients and it may offer compensation too. And then I had just a fun fact here. Go for it the lupus. I want you to go with something nice to remember. How did the name come about? In 13th century one of the physicians, rogerius, thought these lesions in the face were wolf marks, wolf bite marks, and that's how we call it lupus, which is a Latin word for wolf. And at that time we didn't know that it's immune system bite marks. Immune system is biting you, I guess.

Dr. Michael Koren: 30:47

Interesting, yeah, so just one little point on the research in general is that with all research, we're looking at both helping people with the underlying disease and then helping people deal with the complications of underlying disease. So, for example, we talked about the fact that lupus is an inflammatory condition and an autoimmune condition and we're studying JAK inhibitors to see if they work in this condition similarly to the way they work in other autoimmune conditions. Correct, we're also doing studies in patients that happen to have lupus that have cardiovascular risk. So if you had a heart attack and you want to prevent a second heart attack and you have lupus, you may be able to help you with that. People with lupus are also more prone to infectious diseases and other infectious complications and we have studies that are looking to protect people from those complications. So it's not only treating lupus directly, but also the downstream effects of lupus and other autoimmune diseases is an area of interest of our research group. So you may end up seeing a cardiologist not because of the lupus exactly, but because the lupus puts you at risk for a heart attack, which raise your cholesterol or created some lipoprotein problem that is unique to your particular circumstances that we can help you with. Thank you very much and a fabulous session. We're here to answer questions in terms of getting involved in the future.

Dr. Swati Shah: 32:09

Thank you very much. Thank you so much. It worked out really well.