Without further ado, I'll introduce our first speaker for today,

Associate Professor Fred Joshua.

So he's a dedicated physician for the treatment of rheumatic diseases.

He has expertise in rheumatoid arthritis, ankylosing spondylitis,

and psoriatic arthritis, having completed a PhD in the use of ultrasound for

rheumatoid arthritis and presenting research internationally in these areas.

Associate Professor Joshua has pioneered Rheumatological ultrasound in Australia

And developed a degree for rheumatologists Through the Australian Society for

Ultrasound in Medicine Of which he is currently the President-elect,

Associate Professor Joshua has been involved In teaching med students and junior

doctors For many years, having previously been awarded The Prince of Wales Clinical

School Teacher of the Year Which is a fantastic achievement,

and he's now involved in developing undergrad medical programs at Macquarie

University where he is the Associate Professor of Medicine and the Rheumatology

Clinical Discipline Head. Fred, come up.

Thank you. Thank you very much for the opportunity and particularly to Jodie. She was fantastic.

I was perhaps not trying to be as helpful as I could have been in getting everything

set up and she really helped me to do this.

I have to echo the comments that were made about the orthopaedic group here. It's fantastic.

And not just the hospital, because I go up to level five quite a bit to the ward.

Clearly, I never go into the operating theater. You never want me in there.

But they do a fantastic job, particularly after the surgery as well.

So we have a great team of doctors in affiliated specialties to help if there are any issues.

So I've just found it fantastic actually working here because most of my work

had been in Ramwick and Cogger and I came here primarily for the university

and then being part of the hospital has just been fantastic really.

I am going to talk about now inflammatory diseases and how we can best assess them.

And I've got a couple of cases and I'll go through some of how we think about

it and how we can improve patient care through both recognition,

management of the drugs and assessment.

So I've been involved in clinical trials in the past as well as advisory groups

and medical education for pretty much everyone and I don't do as much now as

I'm primarily at the university but I have still done some medical education

primarily with them now.

So I've got two, this is the first case, and you'll recognize the first case

is similar to the second case, okay, and there'll be a few little differences.

So this is not an uncommon presentation. A 32-year-old young woman,

painful hands for about three months, swell across her right and left hand,

PIPs and MCPs, reducing her grip strength.

Notice she's been more tired. So fatigue and systemic upset is really how we

sort of differentiate these sort of problems.

So we think inflammatory disease, not just swelling, I also feel tired,

I feel a bit worn out, then considerable difficulty moving in the morning,

and our feet have been more painful in the morning for the last six months.

So often people will say, oh, I remember my feet were sore, but I changed shoes,

I did all of these things, and it seemed to keep on happening.

Then the swelling, but actually rheumatoid, in example, starts in the feet,

and then you get the grip strength problems. and then the fatigue is part of

that and an offer will proceed.

Otherwise, well, married, no kids. Yeah.

Okay. Oh, sorry. So you examine her.

General examination is sort of normal. Tenderness and swelling across the MCPs

and PIPs and MTPs. Got to take shoes off.

What do you think the diagnosis is and what differentials? Thoughts?

Good. So first up will be rheumatoid. What would be differentials?

Psoriatic arthritis. Anything else?

Lupus. And so these are the common things, right? So we would think rheumatoid one.

We will think possibly spondyloarthritis. And I want you to think of spondyloarthritis

rather than just psoriatic arthritis.

And then lupus. So these are our criteria.

So you're clearly well-versed. So this is how we think of it.

So rheumatoid criteria. And if you have a look, it's one joint with clinically

swollen or synovitis not better explained by another disease.

And the reason we have that is you can also use ultrasound or other imaging

techniques to prove that they have swollen joints.

So we don't always have to be able to see it.

Sometimes you can do another imaging technique. The imaging technique,

my PhD is about ultrasound which is a method of trying to determine whether

a joint's swollen or not, and an MRI can be done.

Now, when you do the ultrasound, you must specify that you're looking for inflammatory

arthritis because otherwise sometimes the radiologist won't be as well-versed.

Colin Chong, who works at Macquarie here, is really good at it.

He's pretty good at the imaging, so we ran a symposium with him.

Then serology, if you can prove rheumatoid factor or CCP antibody,

So rheumatoid factor will be positive in about 70% of patients.

CCP antibody also will be positive in around that level, but it's much more specific CCP antibody.

ESR and CRP, but have a look at this. This is important.

You don't have to have ESR and CRP being elevated to have rheumatoid arthritis.

You do not have to have ESR and CRP being elevated.

And then duration, early disease is six weeks.

That's what we call early disease now. Now, psoriatic arthritis,

and this is important in the classification, if you notice here in the story

here, you do not have to have psoriasis yourself anymore.

So the newer CASPAR criteria does not require you to have psoriasis yourself.

You can have a family history and then you can think, okay, maybe this person

has psoriatic arthritis based on that newer criteria.

And you can have more specific features for psoriatic arthritis,

which include dactylitis, sausage finger or toe, which does not happen so much in rheumatoid.

So you can say, I think psoriatic arthritis based on that.

And remember, the bigger group is spondyarthritis, back and joint diseases,

which we subdivide, psoriasis-related arthritis, ankylosing spondylitis,

reactive arthritis to an infection,

such as chlamydia or gastrointestinal illness, and then related to IBD.

So we've got that grouping, the subgroup is psoriatic arthritis.

Now lupus, before you could have ANA negative lupus, you can no longer have that.

By definition, you must have an ANA that's positive.

And the reason that was happening is because other diseases need to be thought of.

And there are newer ones such as IgG4 disease that may present like Sjogren's

or lupus, but it's actually a different condition.

So if the ANA is negative, by definition, they do not have lupus.

They may still have an inflammatory joint disease, but it cannot be lupus.

It might still be a connective tissue disease, so it could be something else in that pathway.

So you might have a different one.

Sjogren, sometimes the ANA is very rarely. Sometimes Sjogren is negative,

but you've got to think about other conditions is the key.

Okay, so in this scenario, we do blood testing and we come up with these tests.

ESR and CRP are elevated.

Rheumatoid factor, CCP, x-ray is nothing to see, which is extremely common.

You will not see anything on x-ray and this is a disincentive for people to get treatment.

So you've got to remember, please tell people just because your x-rays look

good, it's a window to the past.

X-rays are a window to the past.

Newer imaging, MR ultrasound is a window to the future, then what would you

do? What drugs do you reckon?

What would you do? Any ideas, guys?

Yeah, so you could do some anti-inflammatories DMARDS, the anti-inflammatories

for pain, the disease-modifying anti-rheumatic drugs to try and prevent future

harm, and sometimes we use prednisone.

People say, well, I hate prednisone. I don't like it either. But you've got to work.

You can't tell the rickshaw driver, go on a holiday. You're going to put food on the table, like me.

You're going to put food on the table, yeah? And so if you need food on the

table, you might take some prednisone in the short term to get through the problem.

So prednisone, why? Reduces pain, joint tenderness, improves grip strength,

better than anti-inflammatories.

It can reduce joint damage. It can.

So it's not like it's completely useless. It is actually a good drug.

You just can't keep doing it.

So once you've used it, do it. And when you're using it, I use 15. 1-5.

1-5. not 5-0. 5-0 is called the police, but in the American movies,

5-0 is that, but it's also asthma.

So don't use the asthma protocols. Use the rheumatological ones, 15.

Useful for flares. So you can say to people, use 15 for a couple of days,

then drop it quickly every three days and get rid of it.

You can use 50 if you have to, if it's really severe.

So chronic use, no good. Short-term, not really an issue. Longer-term,

all of those problems you already know.

So, you know, longer-term, you don't want to use it. So this is not telling anyone to anything.

You guys all know this. Weight gain, osteoporosis, diabetes, cataracts.

When you're using prednisone for a while, more than three months at greater

than 7.5 milligrams, that's when we start thinking about osteoporosis prophylaxis.

So she comes back. She says to you, thank you so much for the anti-inflammatories,

a short course of prednisone. I want to get onto disease-modifying drugs.

What pre-screening do you do to check before? Because you could do methotrexate

yourself if you wanted, if you feel comfortable.

Of course we're here to help. But if you wanted to, you could.

What would be the pre-screening and what medication would we choose?

And that depends a lot on what we're doing.

So pre-screening with hepatitis B, C serology and a chest x-ray.

The reason the chest x-ray is important is if they've got lung disease,

which some people will have, methotrexate can worsen that.

So it's well worth doing the chest x-ray as well.

Why do we do methotrexate? Reduces joint pain and swelling, reduces joint damage,

reduces disability. And this is the bit people forget to say,

you do not die as quickly.

You do not die as quickly from rheumatoid. Rheumatoid should not be called rheumatoid arthritis,

it should be called rheumatoid disease because it's a multi-system disease at

an increased rate of mortality, but we call it arthritis, which makes it seem less serious. Yeah.

If I said to you, you've got, and we know this with cancer.

If you say someone's got a skin cancer or a pre-cancer, you get more treatment.

The patient will beg you for more treatment.

If I say you've got a benign lesion in your skin that might be developing to

cancer one day, less treatment.

So this is a misnomer. You start with 10 milligrams of methotrexate,

increase each few weeks.

You can go by 5 milligrams or even 10.

Top dose, usually about 25. Folic acid, 10 milligrams, two tablets the next day.

Blood tests every month to three months.

What are you, this is a, you can use the Rheumatology Association leaflets to

give to a patient to say, what do you got for a rheumatoid?

What drugs can do? Go to the, there's a website there and this,

it's got all of our drugs.

You will know as much as me by the end of this, because you'll just know all

the websites, yeah, and you just go to the website.

Generally, I talk about, I tell people, I am not here to sell a drug.

Bug, I'm here to sell you a solution, but it's not perfect.

But if you do this, you will live longer. You will have less joint pain.

You will have less disability.

So it can cause hair loss. It can cause nausea. It can cause lymphopenia.

Liver function tests can occur.

Skin cancer risk, that's important.

The longer you're on it, the increased rate of skin cancer. So you've got to have screening.

Increase the folic acid if they get a bit of hair loss. You can also use minocyclin,

spironolactone, all of those other things for female pattern baldness.

Nausea usually gets better. Infections, you get an infection on methotrexate, stop the drug.

Yep. If on prednisone you continue, but if you get an infection,

stop methotrexate, restart once they're off antibiotics.

You cannot get pregnant on it and you cannot breastfeed on it. Yep.

You can father children on it.

You can father children on it. Just the women who can't have it.

Vaccinations. What do you do? Live vaccines? Out.

Can't use live vaccines. That's the list of the live vaccines.

Can have flu vax. Can have pneumonia vax. Can have shingrix. Should have shingrix.

COVID-19 can have. Yep. If you want to get the best response,

you miss the methotrexate for two weeks. Yep.

So if you miss the methotrexate for two weeks, then give the vaccine,

you get a better response.

But you might not do it because they're really suffering. Remember the rickshaw

driver. Got to work. Yep.

Yeah, they can. Because you might say, well, I want to reduce your problems

by using methotrexate, and your vaccine response might be slightly lower,

but that's better than nothing.

Otherwise, they flare, they hate the vaccination process. You make it easy.

Progress. She comes back, she says, it worked for a while.

The prednisone helped me with the flares. I want my disease under control because

I'm supposed to be perfect.

So more painful swollen joints, ESR and CRP rise, what's next? What do you think?

We've already got methotrexate on board. Anything else? We've got heaps of stuff.

We can move from methotrexate actually by a government.

I've simplified things a little bit. But actually by a government,

you've got to have a second drug for three months and then you can move to all

of these different biologics targeting different parts of the immune cascade.

We have TNF blockade, which we've got five different drugs.

We've got CTLA-4, agonist, avatacet. We've got CD20 drugs, which target B cells.

We have JAK inhibitors, which are not really a biologic.

The reason we call these things biologics is we, it's a very royal we,

it's not me, drug companies.

Drug company produces these anti-cytokine therapies by infecting a virus into

a bacteria that produces the antibody that we scoop up and inject.

And that's then a JAK inhibitor. Sorry, IL-6 and those.

JAK inhibitors are a targeted synthetic, so they're a tablet.

Targeted synthetic, so they're slightly different. But under government,

they fulfil the same sort of criteria to get them, but they are slightly different.

So you can see everyone should be fixed. We've got a heap of drugs.

This is where I was just going through the, oh, yeah.

Yeah.

Yes. Yes.

But you wouldn't do that. You would say, this is too difficult.

You would say, I'll send them along, because that's the complex person.

The person that doesn't have that, who is straightforward, that's what you would

do. The person that's more complicated, you say, that's the person that really

needs someone else to help to make sure.

It is brave, but you get proof.

Yeah, it is brave. But where would my truth come? I get an MRI,

show some swelling of joints, show joint destruction.

Go for it. But it's brave. You've got to do stuff. People are suffering.

So I get what you're saying. I don't like doing it, but I get some proof around it.

It's consultants' fees beyond their reach. That's a hard part.

That's the hospital part. I can't control that component.

But it is difficult. That part is really difficult. And so that is where we

need to have a health system that is better equipped. Yeah. Yeah.

This is more like a, thank you, this is more like a criteria because of the

PBS and money side. So if money was no object, Then, yeah. Would I go onto a

biologics straight away? It's always careful what you wish for.

Yeah, that's what I would like. Because sometimes these drugs can cause side effects too.

So, you know, we have experience of methotrexate for people on it for 50 years.

So it's a good drug. But if you get biologics faster, the chances of going into

a drug-free remission at two years is 50%.

But it means 50% at two years also relapse. So if we do it faster,

there's the possibility, there's even thoughts of using rituximab and changing

the course when people are pre-symptomatic.

So there is changing scale of this.

So it's possible as the drugs come down, we would use it faster.

And if people have ultimate money, sometimes we do it faster.

So we'll say, you know, you just pay for this and you can get it, but it's expensive.

So ideally, that would be the choice. Generally, yes. If you have biologic plus

drug faster, you do better. Thank you. Plus methotrexate.

These are the practicalities of it. Other immune disorders with TNF blockade

could occur. Like I could cause someone to get MS.

I could cause someone to get lupus.

It's great in pregnancy, however. It works in pregnancy.

It increases the risk of skin cancers. And it's coming down in price.

And you can switch medications and have effectiveness.

These are like most of these are subcut, so just do a little pen, pop it in.

These are the sort of common problems that you might face when people are on it.

Injection sites, this is what you do. Ask people to rotate the injection site.

Antihistamines may help. Cold packs can help. It does not relate to the drug working or not.

It's a short-lived histamine reaction but those histamine reactions can be quite

severe and we might have to change it but we just say, well,

that was not good for you next.

IL-6 blockade. So that was TNF blockade, right? So TNF blockade,

MS-like syndromes, lupus-like syndromes can occur.

Those are probably the biggest differentials. IL-6 blockade,

weekly subcadding injection.

It doesn't need methotrexate as much as TNF blockade does.

IL-6 blockade, the major risk is shingles, neutropenia, diverticulitis, cholesterol.

Remember, I'm not selling drug. I am selling solution.

And remember, people die from the problem. People get disability.

This stuff works, but it comes with risk. And we have to be ready for that.

Those are the common risks. Does it increase heart attacks with the increase

of hypercholesterolemia? No, it does not.

So it doesn't increase heart attacks. The cholesterol goes up,

but the heart attack rate does not. If you've got significant risk factors,

you do need to worry about it.

Oh, sorry That was me saying I should get a smiley face.

So CTLA-4, this is arentia or abatacep.

So this blocks co-stimulation of white cells to reduce rheumatoid.

It again, it can be used IV, it can be used subcut.

You have to use methotrexate with it. Without methotrexate, it's less effective.

It again increases skin cancers. All of these drugs, all immunosuppression increases skin cancers.

But it doesn't give you all those other issues I was telling you about. It's a pretty safe drug.

So it doesn't cause the TNF type problems. It doesn't cause the neutropenia. Pretty safe drug.

Rarely associated with, so if you look at rituximab, CD20, rarely associated

with like a multifocal leukoencopathy.

That's like mad cow disease.

Exceedingly rare. Really, really rare. We got bad problem.

This is useful, B cell depletion. Six monthly infusion.

So yes they've got problems yeah but

on average the problems are not so great

and do not occur especially if you're

young when you get older sure bad things

can happen but you stop it and if you stop the if you stop the illness early

you don't get all the other problems that used to happen okay jane says i've

responded well to tnf blockade and i gave a tnf blockade because Jane has not

had any children and she wants to have children.

She feels, is there longer term risks, however, of having rheumatoid? Oh, I keep doing that.

Oh, thank you. So, longer term, if your disease is active, you have less chance of falling pregnant.

Yeah? Important.

Pregnancy gets your arthritis better in 60% of people. Hypertension,

preeclampsia increased.

These are the people to contact to help with managing rheumatoid in pregnancy.

You can contact Deborah Kennedy, yeah, and she will help the patient feel comfortable about taking drugs.

These are some doctors in different areas of Sydney that help with obstetric medicine.

Yeah, like I just get everyone on board to help.

Yep, and you can look up on our Rheumatology Association what to tell people

in pregnancy. But basically, get disease under control, use TNF blockade.

Yep, that's basically it.

Osteoporosis rheumatoid increases osteoporosis disease itself but increased

medications especially prednisone increase the rate,

biologics is superior to conventional medicines for bone health they've got

to do strengthening and exercise that improves that have you heard of the Onero

program so the Onero program is the only physiotherapy program that has clear

proof of improving osteoporosis.

And you can look up different places. It's spelled O-N-E-R-O,

O-N-E-R-O Academy, and you can work out where those practitioners are.

But it's an accredited program.

This is important. Heart attacks and stroke are increased in people who have

inflammatory disease, particularly rheumatoid.

So people who have rheumatoid have more heart attacks. The more active your

disease, the more likely you are to have a heart attack from it.

Inflammatory disease increases cardiovascular mortality. So I send people for coronary screening.

I say, go see the cardiologist and get it sorted or speak to your GP and ask

them what we've got to do for cardiac screening.

Stress test alone is not good enough because a lot of people are fit.

So if you're fit and you go to a stress test, of course you pass.

It's a functional test. It doesn't tell us what your heart vessels are like.

It's additive to your traditional risk factors. So think of it as completely

separate, just like you'd think of smoking as completely separate.

Rheumatoid, risk factor of heart attacks and stroke.

Malignancy, it is increased in people with rheumatoid, not just from the drugs.

Everyone talks about the drugs, the drugs are going to give me cancer. No, it's the disease.

The disease increases the rate, especially lymphoma. But one of the things we

don't talk about is the lung cancer risk.

Lung cancer is increased in people with rheumatoid.

Got to check.

Yep, got to check. And the lung cancer screening protocols are in flux,

right? They're just changing now. Yep.

How long has it taken for the respiratory physicians and cardiothoracic surgeons

to go with the data? 15 years.

The data came out in 2010 for low-dose CT.

Yep, we've got to be ahead of that.

So non-melanoma skin cancers. So melanoma, we don't have proof,

but non-melanoma skin cancers.

Okay that's rheumatoid now janelle

so that was jane it's janelle bit of a play on

words but this is the same sort of story 32 year old lady painful hands for

three months the difference dip joints right fourth finger swollen reduced grip

strength more tired for six months that's systemic upset,

Difficulty moving in the morning Remembers her right ankle has been swollen

Otherwise well Married with no children Family history of psoriasis She does not have psoriasis.

You see how, you've got to ask. She's not going to come in and say,

yes, my father's got psoriasis. You've got to ask.

And then I look like a genius. Not really a genius, I'm just a hard worker.

Yeah, but I ask a lot, talk a lot. You can see I talk a lot.

When you do the tests, this time her inflammation markers are still elevated,

but the only difference is the rheumatoid factor and CCP are negative.

Same thing. Yeah. Yep. But when I showed you the story, they were asymmetric joints.

Yep. In the rheumatoid case, it was more symmetrical. This is asymmetric joints.

I think DIP involvement, that doesn't happen with rheumatoid.

One finger, that doesn't happen with rheumatoid. The ankle swelling,

why isn't it on the other side? Why isn't there some symmetry to this?

But the other features are the same. Systemic upset. I feel tired.

I feel worn out. I feel stiff.

Are there other problems with comorbidities? There absolutely is, and this is important.

Psoriasis is associated with all of these bits.

Joints, skin, spinal pain, so sacralitis or even fusion of spine, inflammation of eye,

tendonitis, which is really the join between tendon to bone,

inflamed to the point where you can get a hole in your heel.

Because the enthesis is eating away the bone.

Dactylitis, sausage toe, sausage finger, nail changes. I've got this fungal

infection that won't go.

It's not fungal, it's psoriasis.

IBD, or even just colitis indeterminate can occur.

This is what you've got to think of when someone presents with psoriasis.

But beyond that, look at this list. cholesterol,

blood pressure, depression diabetes,

obesity that is the metabolism and the mental health of someone with psoriasis

so when I think of people with psoriasis I think of psoriasis and inflammatory

disease in one component and all the different systems on the other component

I think of the metabolic consequences,

so I have dual goals Inflammatory disease, metabolic disease.

No point having great joints if you die. Yeah.

And they will die of the metabolic disease. That bit, you guys are fantastic at.

Fantastic. Yeah. But sometimes people don't think of it because they're thinking

of psoriasis as not a risk factor for heart attack and stroke.

Just like with rheumatoid, not thinking of it as a risk factor for heart attack and stroke.

Initial therapy, it's pretty similar. Use a bit of prednisone,

get people out of problems.

It doesn't work as well, and it's much more of an issue from the metabolic risk.

The weight gain in diabetes, more common. Yeah.

DMARTs, these are the ones we use. We talked about methotrexate already.

For government restrictions, you use leflunamide, which is very similar,

sulfasalazine. And then again, you go to biologics.

You can use 2 grams twice a day in combination with methotrexate if you need.

So she tried the methotrexate, didn't respond very well. She asks you,

is there any newer therapies? Yeah.

And you say, of course there is. Look at them all.

TNF blockade. IL-1223 blockade. IL-23 blockade.

IL-17 blockade. I made these slides one month ago.

In that one month, there's a new IL-23 blocking drug, Skyrizy.

JAK inhibitors, similar but different.

So TNF, JAK inhibitors were in the same, both in rheumatoid as well.

IL-12-23, IL-23 and IL-17 are specific for psoriasis and spondyloarthritis.

Yep, so there is differences. And that's because those drugs seem to work on the enthesis more.

Aisle 1223 and aisle 23, really safe.

They work well for skin, joints, enthesus, bowel, spine a little bit.

Very safe. The main problem is sinusitis.

Aisle 1223 requires you to draw it up, whereas the aisle 23s,

you just inject it again. Yep. Every two months.

Skyrizi, the newest one, is every three months.

Imagine that. Three months gets rid of your skin, joints, pain, feel better.

Three-monthly injection, and all you're going to get a risk of is sinusitis.

Realistically, it's just fantastic.

IL-17, fantastic for skin.

So if things are not working, skin disease, joints, and theses,

spine, main side effect is fungal infection. That's real.

Fungal infection is a problem. And it can make colitis unmask.

So you can get colitis. So you've got to be a bit careful. So you might do a

fecal calpropotectin before starting that.

JAK inhibitors. These are tablets. They are tofacidinib, baracidinib,

upadacidinib. Daily tablet.

The major risks are similar to IL-6, herpes, zosterone, neutropenia,

hypercholesterolemia.

But this is the big thing.

DVT pulmonary emboli are increased.

Cardiovascular diseases increase. Yeah.

So you've got to think about it. So I don't use them first line.

I would use the others first.

If you have, it's males and smokers that are the biggest risk for that,

for getting this problem.

But if you have uncontrolled disease, that's worse for your health from a cardiovascular

perspective than the drug.

She returns well and returns feeling when asked if there's any concern for the

future with psoriatic arthritis this time.

The comorbidities that we've touched upon, the metabolism, obesity,

diabetes, cholesterol, a zempic and, you know, wagovi, munjaro,

these are good for these people.

That's the way to fix this. Get rid of the obesity and diabetes and metabolism improves.

Takeaways, steroids, methotrexibologic, inflammatory arthritis is important

diagnostic considerations. to suggest what treatment will work.

Prednisone, conventional DMARDS can be used safely. So you guys could use those

drugs if you feel comfortable.

Don't do things you don't like. You know, if you don't like it, don't do it.

Do what you like to do. Get comfortable and then ask. We're here to help you.

I'm a bit busy, but of course I'll do my best.

There are multiple biologics that can help improve symptoms,

signs, and long-term harm from rheumatic disease.

Integrated care makes a difference. You, me, subspecialists.

Getting someone that can help

the skin, getting someone that can help the gut, it's cost prohibitive.

So we try and coordinate and I try and restrict how many times people come to see me.

But best health is costly. And so, you know, but if you do, and you can say,

okay, well, it's not as necessary because I've got this bit and it's all cost differential.

But you've got to talk about it, give people options. These are the things you can think about.

We have the hospitals, we have private health, we have all of these systems

to try and help. But we must talk about it and try and make things better.

Oh, this is my office. Don't worry about that so much. All right.

Thank you very much. I really appreciate the opportunity and the time. Thank you.