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Overlap syndromes: cholestatic liver diseases and auto-immune hepatitis
Prof. Olivier Chazouillères, CHU Paris Est, Saint-Antoine Hospital, Division of Hepatology, Paris, France
Thursday, Sept. 6, 2018 · 6:50 p.m. · 47m 21s
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okay so says thank you for this current introduction of course i'd like to
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the funk a proposal possibly for for for a few invitation and i'm
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very pleased to to do this lecture today in your niceties
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and i'm very sorry because uh i got plastic in your a huge house before so how
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one cleaning to after baby can and so one but finally yeah i'm there and thank
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to to christy no room we can sure sure sure so presentation so
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overlap syndromes uh huh a complex issue and a higher who
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you won't be confuse the idea of of my talk
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so um
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just to
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oh so sorry cause it on the
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um i can't hear my ah my disclosures
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and as you know uh the three men lever
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disease are usually very uh this thing so
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p. s. e. v. d.s yeah with three new and uh it applied to it
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but in in some uh uh patients some patient may present with a
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feature of quit doing unit but i tease on one and the
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and features a whole a p. v. c. o. p. s. c. on the
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other hand that and that these patients are cool huh uh how
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overlap syndromes but still general bit definition is is very big
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and with the on not a p. b. c. p. s. c. overlaps in room
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exists it's a controversial issue but very few if any convincing with uh
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have been published show uh i want to get through this
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so with the overlaps and there was a there is a
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a number of issues first oh what is the
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the practical definition uh and uh as a a underscored
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by a journey he's got two years ago
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overlap syndrome is one of the most abuse descriptive term currently use you in
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a better g. and ice are i think it's still over right
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uh the segment issue uh he's uh about pattern is this
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hard really to distant disease uh presented in one patients
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maybe maybe in some cases is it a distinct in p. p. probably uh not
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and is it a volume form off user disease i i think it hits
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yesterday in most cases and ah has i can seconds he's along
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i recommended to to to use now is that
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the preferred that terminology should be volume forms
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of a lever altering and colour started diseases with what we knew in a protective features
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so to turn the volume forms but the uh uh in the recent a very recent u.
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k. and a sample the yeah you see guidelines is to use the term overlap
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and the the the last issue and maybe the most important
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it uh what are the therapeutic consequence there is
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because from a clinical point of view i think for a treatment the pit or
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ring in the main reason for it i don t. find a overlap
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so uh uh let's start with the uh
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characteristic offices autoimmune diseases so uh
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immunological biological uh is the logical characteristic
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and as you noticed challenge is
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that no you're neither disease as an absolute diagnostic
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test and especially watering unit but like this
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how to new car onto but is that i have really excited for wanted you
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to to to turn and on t. s. piece i have no uh specificity
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and uh he than uh uh and the mitochondria a lot on the body
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on the bodies are have not an absolute specificity for a p. b. c.
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and regarding yeah uh histology to uh changes
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so uh be very changes uh uh for a hot of course characteristic of the
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d. c. but it can be seen in or so in autoimmune hepatitis
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and regarding yeah uh interface apartheid is that is characteristic of putting unit but it is
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uh this appetite is is very or beeper present
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maybe there'll be present in p. d. c.
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and uh p. s. c. and uh these at e. p. correlations in the in this setting up
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asked so it to to re present a a kind of
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corridor or injury a mediated by a bystander mechanism
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so uh i as a result are a a
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number of uh of allah overlapping features
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and uh uh depending on these overlapping feature a a
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a number of violent i've been this cried
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for i as listed here for example a t. v. c. without
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onto my to control anti but it but with uh and
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this most most auntie but is and and my son's some uh call them what when you encounter like this so
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it's a little confusing what doing unit but it is always
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a something that that might look a lot of antibodies
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but uh really uh progressing tool to b. b. c.
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other as nicely show shown in this recent paper
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and as a little already uh mentioned out doing human
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uh appetite is with billy are really uh injury
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that is injury is rarely destructive or uh
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'kay probably active current like this and that but biochemical caressed basis or a
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prison stuff onto not might before antibody are very uh and come on
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and uh of course uh a t. s. even yeah i've uh i i
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had the but it's not a specific overlap and we know that
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uh you you may have an a in a significant increase in any
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t. i. c. early phase of any like you'd careers that process
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and of course in place of b. d. r. e. yeah infection
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but the point is that as it is is volume forms listed here generally
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be right typical forms and improving response to the stand up after
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and uh as as you you you and this and there
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is a a an intrinsic intrinsic scope for uh
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people to present with overlapping feature all of more than
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one is is what do you mean conditions
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and in this uh uh exxon true you review uh years
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ago woodward and never go proposed to be staying wish
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on one and crossover all how claudia syndromes in one korea diagnoses
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well adding one feature associated with another from true overlap with
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i'm more than not only a one uh uh overlapping features
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and uh we have to to keep in mind that is
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all over lap features have a very value and significance
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and please never use a put on the bodies in isolation
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for making a magazine of uh a lot of overlap
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but again uh there's a real need it is to the you don
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t. five errands that require treatment tailoring another chance through overlap single
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and uh interface appetite these uh this of
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a special uh attention as of as
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shown on this slide the uh describing is is
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the degree of interfaces eh appetite these
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in a a forty minute but i tease of calls but also in
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p. s. seen green and the uh t. v. c. fifteen blue
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and as you can see there is a a significant degree
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of in deficit but that is not only ah
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no you know doing unit but that is but also in a p. v. c. and p. s. c.
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but in terms of a significance but the physiology and or response
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uh to treatment is the security with the interface to protect itself within
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you know a bad like this in is not well established
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and the a four banger these of overlaps syndrome uh uh uh
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it's a row uh assumes that a liver biopsy is
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mandatory for that bag of these off of it
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and it may seem but a simple and they use the ah on this car to an
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uh in the the uh when comparing overlap ways a few p. p. v. c.
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the overlap is there is a prominent interface the better it is
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and also additional uh local are uh activity
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but leave or uh bob c. uh there uh oh there are difficulties with
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the the about c. and ah am commenting uh on them first
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got two tires or a piecemeal across is the first one
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forces early for city interface it event that a pet that is where is
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it and inflammatory this friction of it but the sites associated with uh
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uh the main force info is just to take you into into questions
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and i in the big our interface a pet a activity that
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really seen in major cool contest is is of course
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was still the destruction of it but the sides
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but with the uh make sure of uh in four sides
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a notre fail math macrophages and the doctor off proliferation
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and of course you know overlap we are talking about the lane for to be with
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me in the nick was this but the intuition with a major colour spaces don't
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uh make it would agree to go for overlap on just interface it but but
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and the uh also the feature goodies are what hours uh that because
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it's the criteria for moderate all see the interface appetite these
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and in the in the in the p. d. c. n. t.
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s. c. guidelines yeah there with no no clear cut criteria
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in the total unit but i'd is easily guidelines the uh it that type is activity
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in the next uh i didn't propose that the the very old school that
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to be good either hidden or but it's in not specific to and as not being
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the clearly very dated in totally new and uh it but i'd it's an recently
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two other school i've been proposed for grading interface it but i tease
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because the net can you mass coding system but to its ransacked a complex
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and the other one is the l. b. f. b. i. scoring system and a
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bit of a french court is marked as a as a as a name
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and but unfortunately uh as a rubber disability of disco are far
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from a excellent as a as shown if she uh so
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uh ms are the question is not reasonable
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and uh also difficult is uh that uh if that be the relations get candy
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absent in the about stuff patient with the v. c. r. p. s. c.
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so we we know or when was that for from
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a long time and as already stated below relations
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i can be seen in but i mean bob c. of vision with what when
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you're in a a batteries with a a very uh active hip appetite
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so to conclude only the biopsy because we go see is really a
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a t. a. exam in the data is awful off overlap
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so the better this can not make the the diagnoses on this uh on his own
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of course the quality of leave about c. is ski but
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even more uh important is the quality of interpretation
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and there is a an interesting paper the recent interesting
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paper or uh trying to to answer the question
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uh i is any value uh in a special is review offline about about c. so it's
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uh you case study with a huge number of a biopsy and they found that
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in in the our this is off into interact directly resulting
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in about thirty so off a vascular uh a disease
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that's a dangles these differences local in malls and seventy percent between
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jen your batteries and they share a specialist eh petr watches and uh um over
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uh he inpatient ways uh uh is the but the radical difference
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a a pretty to change inpatient some management
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uh was it in more than half of the patients so
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i think the need for really uh expert review awfully uh but
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boxes in difficult cases it's really uh uh when you
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so finally uh for making a bag is of
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a overlaps the uh which criteria so i
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first from the uh glance uh the uh uh to us but at his school
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uh are on attractive uh tool but they were not independent faucet shoes
00:15:07
as a a sensitivity and specificity are below below eighty person
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and the according to is a user international doing really but that is a group
00:15:19
the uh the user this call is not recommended that in this uh sitting
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and the last point is that the p. church trend
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can change over time and the appraisal should not
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be perform at a single point in time
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so uh for maybe see a overlap
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uh easel made a proposal for the the the the diagnoses
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and uh still recognise the things that standardisation the is still not a much either
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user handles the the so called paris crap
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criteria so based on the presence
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also at at least two of there's three the major gripe
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the idea of p. d. c. and o. two in unit but that this will be busy so
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uh but okay cool colour code is the these prisons of onto
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that that we are antibodies and for a viable declare relation
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and for doing a naked by these high at the i i. g. for
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a essay may oppose it to you and moderate boss c. via
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uh interface it but i piece but easel
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uh mentions that he's the reject your uh if you don't sort of
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this interface to protect this is mandatory for the bag movies so
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uh increasing the right you wait off is the logical visions
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rescues the biological and human immunological uh features that and
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i think the you know it's the same
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and uh use uh uh so sometime uh some paper can
00:17:07
uh are able to to do to boost your ego
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so it's not a everyday but uh when it uh if we happen and that's so you you appreciate
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and uh in in this paper so as the the power
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is a criteria i seen a really a magic age
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but uh we have to keep in mind that the uh in the absence of a gold
00:17:33
standard it's difficult to access a a bag news
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is a performance of all the tools
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and the last point is that the that the uh a high rate of the uh
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double stranded d. n. i. as being reported uh in the b.
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b. c. the overlap the scene rooms and so i think
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the the of you to be good shape it in the in the into work up all the easy
00:18:07
for a p. s. c. overlap it's even worse bit because uh
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there was no uh of issue or a criteria so
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uh my policy is to to use the same pay template i mean uh at least two
00:18:21
of this relatively thirty yeah to yeah but he uh for p. s. c. so
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instead of uh of the that the country are antibodies for
00:18:31
a p. d. c. it's typical country graphic at abnormalities
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and as a of course leave about c. p. still uh on that so
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and regarding uh current geographic features they are also potential pitfalls
00:18:50
and please be cautious about interpreting and
00:18:54
often over integrating my changes
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uh in the uh in try to get a buy backs
00:19:02
and that because we will wrap shows that uh uh
00:19:07
in patient ways uh add ons fibrosis of any kind if yeah it's it altering
00:19:13
unit but it is nice yeah it's in a a pet i. t. c.
00:19:18
you you may observe the uh kind of
00:19:23
a scream rousing pattern and uh it's
00:19:27
a a creamy correlated with
00:19:29
the the five fibrosis in inside to the earlier so
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be be cautious before making a good movies of if
00:19:38
he just on on this apology graphic s.
00:19:45
and uh so clearly there are still a number
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of uh of questions and so it's uh
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uh from the last the a. p. v. c.'s or b. b. c. guidelines
00:20:00
clearly what what are the uh optimal cut off for high g. g.
00:20:05
yeah and gamma goblins and from that i mean is is
00:20:08
between the it lead about c. and uh now i use the the
00:20:13
the cut off of a twenty to room bit barely to fall i. g. g.
00:20:19
because in the initial picture i it wasn't much higher i think to to hide
00:20:24
of course what oh what uh the optimal weight of it but
00:20:28
that is activity to indeed between we know a suppression
00:20:32
unless importantly uh well what the the degree of it you still really cool by the damage
00:20:38
to define piece inpatient without doing unit but eighties and to indicate you've reviewed it
00:20:44
but of course you for the same the right decisions that to
00:20:48
indicate you mean if you press the batteries are you see
00:20:55
so uh what all the providence and clinical uh
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for presentation and of all the depending
00:21:03
on these uh as uh the criteria on the
00:21:06
the populations uh prevents a very for
00:21:11
b. b. c. o. to uh put cool for p. b. c.
00:21:14
overlap from two two nine nine fifty uh nineteen persons
00:21:20
and uh for p. s. you have a overlap from a seven two two fourteen
00:21:26
lawfully it around the ten percent but in children for p. s. u. overlap
00:21:32
e. e. it's much i uh have to buy a fifty year s. and
00:21:37
and uh i come back later on this uh point and again
00:21:44
eh in these papers as there is a a considerable it eroded
00:21:48
the despite the the same uh thing the same designation
00:21:53
and uh the uh singleton it was for me is is the most reckons uh in
00:22:00
that made it down with the of the with these is at the same time
00:22:05
but uh less frequent three you may have a second show a
00:22:10
disease and uh one the the onset of one a disease
00:22:15
uh it being a this just hated it uh in
00:22:18
in uh in time and it we uh
00:22:23
you make the the than a sick or what you think about this then is easy
00:22:28
actually away when the phenotype is changing all
00:22:31
employees of resistance to use will treat
00:22:39
and uh in terms of clean the corporate presentation
00:22:44
usually uh one primary disorders one on one
00:22:50
pride i mean and this is one uh it's one domain and this is a is often identified
00:22:57
so we can uh and a cold uh because then uh
00:23:01
according to the the mean and this is the user p. b. c. of p. c. with little unit but it is feature
00:23:08
or doing an event like this with b. b. c. of the a. c. yeah if each of okay it's over that
00:23:15
and uh depending yeah uh on the diseases of
00:23:21
presentation is different for instance for example
00:23:25
uh i mean b. b. c. usually it's b. b. c. the domain and the disease
00:23:32
and the hamburger or broke years ago uh eh propose to tune in
00:23:37
this uh from v. a. patty take form of it if
00:23:42
and uh for p. s. e. eva a reverse and usually it's what doing unit
00:23:49
upright is the the mean and is that at least in uh children
00:23:53
and uh this is a special form name so
00:23:58
it's a little you'd be maybe uh
00:24:02
uh could confusing but uh the name is altering humans closing co current right
00:24:08
just to spite on this uh form that has been uh describe as
00:24:13
addicting school age so years ago and uh in this uh paper
00:24:19
so this start from a fifty five uh uh children always a a
00:24:24
peach uh avoiding unit but it is i mean i'm not only
00:24:27
got test and presence of uh oh don't be but is and
00:24:30
to perform a highly uh in all this uh actually it's
00:24:35
uh uh leave about c. and a current geographically on it at this
00:24:39
time it was not and i think people write programs uh
00:24:43
roger referees so uh i think uh we can we can make it uh on on the uh
00:24:50
and in our for the patient and as expected that uh
00:24:54
uh current jo jo referee was no more but in the other house
00:24:59
to find the uh features suggestive compatible with
00:25:03
uh primaries closing uh a co occurrence eighties and the name these
00:25:10
rules or telling you in scale as input on site is
00:25:13
and uh uh a quarter of these of these kids
00:25:17
despite ah i'm no morgan geographically i had no signs of biochemical products to it
00:25:26
and the uh or at least a in a mid term the the a
00:25:33
response to the new suppression was similar bit between the the two groups
00:25:39
and but in terms of current geographic findings so i in the what doing is closing current
00:25:45
right is group there was a i think a
00:25:49
worsening of all religions and very very
00:25:53
in uh in those with the fuel to unit that tight is
00:25:58
and more importantly at ten yes the estimate
00:26:02
of the the the prognosis was was
00:26:04
a in in this group so uh a photo news goes in contact so
00:26:10
uh some of propose that finally a kerosene adults maybe
00:26:15
it's the uh add on to bent out
00:26:19
uh for more of a altering installed in
00:26:23
conduct these with the uh no no
00:26:26
longer any inclination that not only as the noses out of the but expect
00:26:32
it's not a a step h. so a a
00:26:35
and in turn off clinical uh consequences
00:26:39
m. l. c. p. e. recommended unit or children with the identities of with doing unit but i just
00:26:45
to to make that dying is is all these from but it's not true in in adults
00:26:51
it's uh i don't know if you've yeah uh i. d. d. or a
00:26:56
chorus that the uh feature with the increase a a helper inferences
00:27:06
but on the other i'll just say read the the do not
00:27:10
confirm this was probably six and so it's so huge
00:27:15
the americans as series with more than a a
00:27:19
seven uh a hundred a p. s.
00:27:22
c. and as shown here association resulting in it but it is but it was
00:27:27
uh the new ones that of patients with uh the probabilistic was
00:27:32
not a had cheered me in this yeah this fall
00:27:40
so in in add those what what is the the problem of this so in
00:27:44
this uh u. k. series so it seems that the the proper prognosis
00:27:50
so the uh in green it's a shooting in it that they tease and in uh
00:27:57
in a read a overlap but p. a. p. d. a. c.
00:28:01
and uh so it seems that the problem problem is this was uh
00:28:06
who was then in a few orderly when a
00:28:10
pet i tease and bike contrast in this
00:28:14
uh italian series comparing the out come off
00:28:19
of a p. s. e. overlaps in rome treated with the
00:28:22
u. d. c. a. and the news depressant yeses
00:28:26
a classical l. p. s. e. pretty just you wish you this year
00:28:31
you see that's the is it by the probabilities wasn't major in patiently with the overlap
00:28:38
but anyway in other series and from a gemini a
00:28:43
development of c. was this okay to in
00:28:46
the manner my majority of patients you during really an uh i agree see a cool
00:28:55
for b. b. c. o. overlap and again remote
00:28:59
most series might not not all uh
00:29:02
suggests that uh the outcome is a easy was so he uh it's the uh
00:29:10
the mayo clinic a series and in uh as you can see in the
00:29:16
red uh the problem is this is a inflation with overlap was uh
00:29:22
worse than in a fishing we spew p. c. and yeah it's a rest and
00:29:28
a a chinese a series sit suggesting that against it
00:29:33
as a as a probabilistic is worst another uh injury interesting point is
00:29:40
that when you you look at presentation patient ways uh overlap
00:29:46
uh i have more uh accent to five or this
00:29:50
and uh despite the younger age so suggesting really
00:29:54
that uh as an actor or the core courses the small uh above
00:30:00
so uh i the the big and the the most important question
00:30:05
say how to treat a three cents so of course uh
00:30:12
she we use even use each received a c. right b. u. d. c. a. l. uh bows
00:30:18
but unfortunately as you know because the is a
00:30:21
nokia uh rest was because answer because
00:30:25
of course because it's a a subgroup of uh read this is so so
00:30:31
uh the number of patient you is very small
00:30:34
and on no control a truck trials
00:30:38
and the only me a small right perspective uh unknown on the mice that is a
00:30:43
ah a a available and as a consequence so treatment is largely a i'm here
00:30:52
so here uh is our experience may it may maybe for
00:30:58
uh you know the uh parts of the world so
00:31:02
uh just for for an example so we we started with a seven
00:31:07
team patients who is a a a t. v. c. overlap so
00:31:11
uh yeah then we're treated the at baseline a ways you
00:31:16
d. c. uh a load and a six ways
00:31:20
of a combination of uh you see and even those
00:31:23
depressions and as you can see uh uh uh
00:31:30
h. of the heathen patiently to do is you you really see a a alone
00:31:36
do not to reach a a rest nineteen ten of altering unit but i tease
00:31:41
uh features so only sweet a rest phones and but by contrast in
00:31:48
into the receiving yeah a combination treatment would we got a
00:31:54
raise funds in all cases including so that too is
00:31:58
uh any initial nonetheless phones do you see a a a low so it but
00:32:04
so retrospective study with many potential bias but we found or
00:32:09
so that impression we easily that would help see
00:32:12
uh we say only that up c. available is that five
00:32:16
roses increase it in the uh out of all
00:32:20
the patients which isn't which you just see a real yes is knowing piece of fibre this into
00:32:27
a receiving a a combination a freak and and
00:32:31
the the last interesting point is that
00:32:34
a successful with all of the news question files
00:32:39
with lois is that's cool i mean uh uh
00:32:43
and nearly a one third of patients
00:32:47
okay he's a higher rate that uh in and you would do in human it up right
00:32:54
and uh the the largest i experience
00:32:59
sewage treatment a of a overlap
00:33:03
come for from from this uh international a series so it's eighty
00:33:08
eight bit patient define uh using it a paris could quite
00:33:12
yeah yeah so it's a bit uh a basis a slide which
00:33:15
is is the main uh the main message is that
00:33:20
in patients uh and so is is a uses the same design as our
00:33:25
our steady i mean the treaty the ease the by u. d.
00:33:28
c. a load all bought all by only nation and in in those
00:33:33
treated which you would you see a a a a low and
00:33:37
uh when s. say the interface appetite is was presence
00:33:42
uh eh only me uh me the the very small minority of patients who responded
00:33:49
a bike on a contrasting with a high rate of response
00:33:53
uh in those receiving combination a treatment
00:33:58
so the message was uh in case of say the interface evaporated
00:34:04
three a ah to first sign with a combination therapy and again
00:34:10
the observe a high rate of sips suspect first which will
00:34:18
and what all was a of usual we commendation so
00:34:22
according to uh is on so combine therapy
00:34:26
that is a recommend the the option especially excessive yeah interface it at that
00:34:32
i hate these and we didn't i don't know of also an option in on fewer patients
00:34:40
but that's that's so that it was an interesting point that
00:34:44
uh as i mentioned at least in uh in the
00:34:48
first uh guidelines at an ad data approach
00:34:53
especially if moderate interface to protect this is presented to start
00:34:57
with we we you does to a low and
00:35:01
and uh the stairwell it's only is about here in a cordless phones at this
00:35:06
stream and sees a unit equip extreme and and uh it's an uh
00:35:12
it's my policy uh at this time it inflation with
00:35:17
moderate into i think that that is i stop
00:35:20
only with you d. c. a. and three months later
00:35:23
we we we we switch to combination therapy only
00:35:28
if a response is inadequate and of course in seconds
00:35:33
or overlap combination therapy you on that or
00:35:39
four of p. s. c. the overlaps so both the diesel and
00:35:44
as as uh the use the uh he knows depressants
00:35:49
a weasel without uh you d. c. a. depending on yeah if
00:35:54
you leave it in the us all in in europe
00:35:57
and uh but uh rest and he's autoimmune
00:36:01
guidelines so especially if it's yeah that
00:36:06
impatient with them in and out playing in it but that is feature
00:36:10
uh so just like in p. d. c. we can start
00:36:14
with uh we use the you see the streams to
00:36:19
to see the is easy outcome so you can
00:36:22
start with the minnows depressant only and then
00:36:26
add the uh you see if he if uh you you keep a coke honesty
00:36:34
and uh finally uh regarding your transplant patients so
00:36:39
of course experience is a is a
00:36:41
limited but i in this series so regular
00:36:45
rounds off at this one uh uh
00:36:49
uh but then you need a disease so rate so
00:36:52
uh so was a higher than in patients
00:36:56
uh getting ref for only one uh uh oh doing you and diseases
00:37:01
and into a singly so you can recover as of uh huh
00:37:06
and of that is of course a very uh rather yes
00:37:12
so uh to sum up uh my presentations
00:37:18
so one considering overlaps always keep a critical uh i
00:37:24
approach approach use as strict uh quite yeah yeah
00:37:30
as a possible and uh i think that the power spectra yeah
00:37:34
provide a useful that template in the everyday a life
00:37:40
and uh the very important point eight that you have to
00:37:46
to tell may treat to use tell me treatments based on this is fun o. type in all
00:37:52
the tame in in other tens so in case
00:37:55
of dominion disease trip previous visits first
00:38:00
and uh by using so he's a a inches of
00:38:05
clicks this is of course if you see a
00:38:08
and uh in case of a a a
00:38:11
petty t. k. features even use depressions
00:38:15
and a very important point it that you have to adjust according to the
00:38:21
restaurants and so uh uh close followup he's the one that though
00:38:27
so to to to conclude yeah easy to my uh very last us side
00:38:33
so clearly a a and i said bye i'll bet designs idea years ago
00:38:39
overlap easy easy easy easy be fine but
00:38:44
it's a clinical at eighty and that
00:38:47
not be accepted refined treated and state so
00:38:51
uh i agree and i could uh
00:38:55
about the the name of overlap ah i agree it maybe it's not a
00:39:00
good name because it's only suggest to present off to this thing diseases
00:39:05
and that the reason one maybe well moving to two tons violence form
00:39:11
and it's a potential overlaps a button shown is number but it's very popular popular so
00:39:18
and uh and mostly more importantly so we
00:39:22
drove was the physician attention to
00:39:26
special features with clinical consequences and uh i'll go to go for
00:39:31
the of course we need international collaboration with large database
00:39:37
so we have to really uh define a
00:39:41
scoring system for the interface appetite this
00:39:45
and uh again collaboration and each for the twenty five a
00:39:50
specific guessing issue including gino makes and what they are
00:39:55
to thank you for your uh attention
00:40:13
which
00:40:23
a yeah
00:40:30
yeah
00:40:33
ooh
00:40:36
ooh ooh ooh ooh
00:40:42
so uh probably see uh the i think in a re centres so you uh you
00:40:47
you bob c. we no longer a a biopsy a p.
00:40:52
v. c. e. in a classic or fall so but
00:40:56
uh inches of suspicion of uh i to be colourful yes we we we we
00:41:02
perform uh about it just to to see uh of course is there a
00:41:08
a significant interface it by authorities so yes we b.
00:41:12
b. c. we perform uh the about c.
00:41:15
and sometimes i bit line no one you were suspect an overlap syndromes and in
00:41:20
case of inadequate rest from just to to understand what he's got going on
00:41:30
yeah yeah sure
00:41:38
and i'll all we are convinced that is that a fibre scan it is uh
00:41:44
and many fish and the two for for the p. d. c.
00:41:48
and even in in p. f. c. uh or so
00:41:51
so in in overlap we don't know a exactly
00:41:56
and you have to to keep in mind that yeah of course yeah
00:42:00
impatiently is a mock inflammation uh values
00:42:04
are uh how high so
00:42:10
yeah
00:42:11
ooh ooh ooh
00:42:15
ooh
00:42:20
oh
00:42:24
ooh
00:42:29
oh yes issue and uh in the the uh when
00:42:33
we treat joe overlap even wheeze steroids we
00:42:37
but only with the we use a maybe a thirty or thirty five milligram
00:42:43
uh yeah they say start the huge joe's and ah as a
00:42:47
uh found by a ourselves and uh i was uh
00:42:51
uh the the ways roll off even use passions is successful and maybe
00:42:58
in the ones that to one half of patients so it
00:43:02
it doesn't it's not uh the usual a feature that in a
00:43:06
few of going in and it it it it it
00:43:09
so but of course we need the the you know the long term for
00:43:13
ought to to be sure that a reasonable uh reckons yeah i
00:43:22
so we we we use is so even a with his question the
00:43:26
the target is uh it but it take activities so we use
00:43:31
a raw faces the same criteria other than for a autoimmune a a appetite is
00:43:37
i mean the the dole target is no more towns i
00:43:41
mean is is and uh no more i g. t.
00:43:47
ah
00:43:49
so we did that and now i'm moving while performing live
00:43:54
uh lies about c. eh into that of
00:43:58
a good uh okay chorus ones
00:44:03
oh yeah for one year
00:44:12
one you know and then you you you to a good pepper of course to take
00:44:17
time so while i at least one you know one to one to two years
00:44:27
oh
00:44:30
yeah yes it's yes show
00:44:33
so we we tried to do to trappers zero it's a quickly just in
00:44:39
awe of doing an interview with the unit but i please so uh
00:44:44
or from a two receipts to to to twelve ones and
00:44:49
then you we use uh uh uh uh the supreme
00:44:56
and so uh so we we call it the uh
00:45:02
at least two or three years of uh no
00:45:06
more a level because uh uh i think
00:45:10
you uh talking only about zero it so we need a longer time of no more
00:45:16
uh and the time before uh stopping a hearing those push a
00:45:26
i
00:45:29
uh yeah yeah is ah yeah yeah it's a difficult place so uh
00:45:36
maybe in the situation we we perform any live about it
00:45:43
ooh i and at this point we we don't know yet if
00:45:47
uh uh a bit because he cassie the it may
00:45:51
be a useful yeah in the situation as well as of
00:45:55
five ways to we we don't we don't know yet
00:45:59
uh not even overlap but who are uh working on the uh
00:46:05
wow on a on a national basis on people treat you do with the of current
00:46:12
uh what perspective is somehow the uh all overlap so uh
00:46:17
looking at the rest was but of course to get a a
00:46:20
reggie white prospective study but just to have to pay to
00:46:24
a beginning if maybe of how often and so because uh a big
00:46:28
college is supposed to have it he minnows you precis the properties
00:46:33
and uh i know on the guy is a very interested in the sport
00:46:40
uh_huh you have experience with a of it we could we can see that he in this in in overlap wow
00:46:50
okay yeah
00:47:01
no
00:47:09
yeah
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