00:00 – Dr. Khazali: Endometriosis, by definition
00:02 – is the growth of tissues similar to endometriom,
00:05 – outside the uterus.
00:06 – And therefore,
00:08 – removal of the uterus is not a treatment for endometriosis.
00:11 – Melissa: Hi! Welcome back to the channel.
00:13 – My name is Melissa,
00:14 – and I’m talking with Dr Shaheen khazali about endometriosis and UTI.
00:19 – This is part 2 of the interview,
00:20 – and we’ll be discussing diagnosis of endometriosis,
00:23 – and treatment options.
00:25 – Be sure to check out part 1
00:26 – for more information about what endometriosis is,
00:29 – and symptoms.
00:30 – If you’re new to this channel,
00:31 – check out the description below
00:33 – as we’ve linked to some resources you might find helpful.
00:35 – And lastly, if you enjoy the videos,
00:38 – and think they’re important, and wanna support what we do,
00:40 – be sure to hit subscribe
00:41 – and check the bell so you’ll be notified of new videos we post.
00:45 – And other than that,
00:46 – thanks for joining us on this journey to making change in women’s health.
01:02 – Melissa: This is part 2 of our interview with Dr. Khazali
01:05 – on endometriosis and urinary symptoms.
01:08 – Thanks again for joining me for this chat.
01:10 – Dr? Khazali: Thank you for having me.
01:12 – Melissa: I wanted to see a jump into
01:14 – some questions about the diagnosis of endometriosis.
01:17 – What is the most accurate way to diagnose it?
01:22 – Dr.Khazali: It depends on the type of endometriosis.
01:25 – For example, Endometriomas
01:28 – can very easily be diagnosed with a simple ultrasound scan
01:32 – And even in…
01:34 – in experienced hands of ultrasonographer
01:39 – Hum, uh…
01:41 – An endometrioma is obvious,
01:43 – it’s very easy to pick up.
01:46 – It’s much more difficult when…
01:50 – when we are dealing with superficial endometriosis.
01:53 – Still, with superficial endometriosis,
01:56 – ultrasound scan can sometimes help
01:59 – giving us clues that we may be dealing with endometriosis.
02:04 – But ultimately,
02:06 – being able to see inside of the pelvis and the abdomen
02:10 – is the most accurate way.
02:13 – And for many years it was called the gold standard
02:16 – of diagnosis of endometriosis.
02:19 – Melissa: And when you say “see”, you mean surgery?
02:23 – I mean […], yes.
02:26 – Melissa: And, so…
02:27 – What should someone do if they have an ultrasound
02:30 – and it has come back clear?
02:32 – Is there a natural escalation
02:34 – before you get to that point of Laprascopy?
02:37 – Dr; Khazali: So, I believe…
02:40 – My colleagues do things perhaps, you know, err…
02:44 – Every one of my colleagues may be doing things differently.
02:49 – My way of approaching
02:52 – a patient that comes to me with pelvic pain and no diagnosis
02:57 – is that I start with a baseline like live
03:01 – of endometriosis.
03:03 – So…
03:05 – A person
03:07 – doing shopping on the street
03:10 – has around ten per cent
03:12 – in that each brackets,
03:15 – between fifteen and forty-nine.
03:17 – As around ten percent likely without having endometriosis.
03:21 – As soon as they are in my clinic,
03:24 – That, likely, has probably trippled.
03:27 – So if somebody has come to see me
03:30 – It’s not a social call
03:33 – they’ve taken time out
03:35 – and they’ve made the effort to come and sit in my clinic
03:38 – so that mediately put them
03:40 – in the bracket of
03:42 – Having more likely to have endometriosis.
03:45 – But then what I do is
03:47 – I put all the different clues that I get
03:49 – and ultrasound is one of them.
03:51 – Not the most significant one,
03:53 – not the most important one, only one of many.
03:57 – Perhaps the most important one is the patient’s story.
04:01 – And the history, Ok.
04:03 – So I listen to
04:05 – the character of the pain,
04:07 – the relationships of the pain with different things
04:09 – that happened in the persons’ lives.
04:11 – When did it start?
04:13 – What is the pain like, what’s its density?
04:17 – Is there any…
04:22 – Pain with defecation, is there any pain with sex?
04:26 – And…
04:27 – each of these will be a piece in that puzzle.
04:32 – And then I examine the patient
04:34 – And that will give give us a lot of information as well
04:37 – about what’s uh…
04:41 – What the likelihood of endometriosis is.
04:45 – So…
04:47 – Sometimes we need further tests,
04:49 – like an MRI.
04:51 – Sometimes we need a more specialised
04:54 – ultrasound scan.
04:56 – And I put all of that together
04:58 – And then come up with some likelyhood
05:01 – of… or estimate of likelyhood
05:02 – of this patient in front of me
05:07 – Uhhh…would have endometriosis.
05:10 – And then we use that likelyhood
05:12 – for decision making on what to do next
05:15 – to get to the diagnosis.
05:18 – Melissa: what’s your advice for patient who suspect they have endometriosis
05:22 – but is having trouble moving that conversation forward with their doctor.
05:30 – I would suggest that we imagine we are the doctor.
05:34 – And then that would give us a clue
05:36 – to how to
05:38 – Approaching and how how we would win with our doctor.
05:43 – And I don’t want to take sides here,
05:45 – but hum…
05:47 – the reality
05:50 – I don’t think any Doctor
05:53 – Up in the morning
05:54 – Wanting not to be helped
05:58 – There their they’re
05:59 – They want to
06:01 – But there are you numbers
06:05 – Useful
06:06 – How to remove
06:08 – 7
06:09 – 10
06:11 – Will have painful period
06:13 – One of the
06:16 – So
06:17 – If we were to do a laptop
06:19 – Every
06:20 – Has been
06:22 – We would be doing 6
06:25 – Completely pointless season that comes with
06:29 – All sorted
06:31 – Cost is one but the
06:34 – Risk of
06:37 – Order
06:39 – To the clue that the key is to find
06:42 – Maybe not that one
06:46 – Maybe
06:49 – Bring that seven
06:51 – Two or three and then do the la Crosse
06:57 – What is very different
06:58 – For a general practise
07:00 – Add 10 minutes to talk to her
07:03 – And sees many many patients who come to them
07:08 – And is not a
07:11 – Not an endometriosis specialist to be able to do
07:15 – The Natalie
07:16 – Ford Edge
07:18 – The Logical thing to do is to say well
07:22 – Go away and have this medication or have this form or maybe Maybe that will get there or have this
07:31 – My advice
07:38 – Don’t
07:39 – Get the conversation
07:41 – To appoint that
07:43 – Feels like that you are sitting on two opposite
07:47 – Reality is it support
07:54 – Need to explore where
07:56 – Is it that
07:57 – Your doctor is not believing you and things that you’re making it up I just want to take a
08:04 – Is that the problem
08:06 – Is it
08:07 – That
08:09 – I’m not confident in this area and maybe you need another Doctor Who
08:16 – Or is it simply because they are doing their best and maybe
08:21 – It’s not
08:22 – Illogical what are such a
08:24 – Maybe you know if your pain only started 2 months ago
08:28 – You haven’t tried
08:30 – Maybe it would be right to first try simple things first
08:35 – That would be my
08:37 – And
08:39 – My experience still there
08:41 – It’s difficult for me to say because I’m
08:44 – Sort of the final stock from patients that
08:49 – See me because
08:51 – They’re seen others order gynaecologist Africa
08:56 – Come and see it is too complex or their GP knows that anything you need
09:04 – If you’re seeing a general gynaecologist
09:09 – Sometimes the right thing to do
09:12 – M and M Direct
09:16 – What else can we do to get to the bottom of
09:18 – And to get to diagnosis and explain that
09:21 – Negative
09:23 – Diagnosis would be
09:31 – And again remember as I said
09:33 – Meaning of Dr said that
09:36 – With some very few
09:39 – They’re all there to help
09:42 – And they are all
09:43 – They’re all doing their best
09:48 – What is currently the time to diagnosis
09:50 – Endometriosis
09:52 – Around 8
09:55 – In the UK
09:59 – I heard some
10:01 – Very exciting
10:02 – I just came back from
10:04 – Lisbon I was I was at a conference Legacy
10:07 – Lisbon and European cytokine
10:10 – Yeah I heard a very think tool
10:13 – About a very promising
10:17 – Method or
10:19 – A biomarker
10:22 – I’ve listened to many of these
10:25 – This one was different
10:27 – So they are using a technique similar to how the code Baxi
10:32 – Was developed
10:34 – To and using artificial intelligence
10:37 – Wray and the
10:39 – Pinpoint what set of biomarkers we can look
10:43 – To pick up endometriosis
10:46 – This be a blood test
10:51 – Are you even more exciting than that because they are now looking at Salah
10:58 – Messenger RNA
11:01 – That they’re looking at that is most expected in saliva
11:07 – Don’t know you may spit into a tube tomorrow and be able to get a diagnosis
11:14 – Do they have any information about when this might be on the market
11:18 – Early status
11:20 – Status
11:22 – I would be very surprised
11:24 – It will come out in the neck
11:26 – Before years I haven’t been very excited
11:32 – Yeah it would be a game changer I’m sure a lot of patience
11:37 – Who has their diagnosis what is the gold standard for treatment of endometriosis
11:44 – There is no one size
11:51 – Considering what
11:53 – The main problem is that the patients
11:56 – For some
11:59 – The only one said there is nothing wrong there is nothing serious
12:04 – Or some
12:06 – Fertility
12:08 – Issue others
12:10 – Other
12:12 – Pain during sex is
12:14 – Very important for some it may not be empty
12:18 – So we need to tailor the treatment
12:21 – Each individual expectations
12:24 – There their main issues
12:27 – Their understanding of the whole whole story
12:32 – Andy Allo
12:34 – Of chair is that we use the least
12:38 – Aggressive
12:39 – Message
12:41 – Miss
12:42 – Invasive
12:44 – That he sees the result
12:46 – That we won
12:47 – So
12:48 – Endometriosis
12:49 – Diagnose it doesn’t equal
12:51 – Meeting
12:54 – For some doing nothing maybe
12:57 – For others medical treatment
12:59 – May be suitable
13:00 – And for some it may
13:03 – Maybe so
13:06 – When it comes to surgery
13:08 – Can you explain the difference between Excision and ablation and a Excision is usually
13:14 – Approach
13:16 – So ablation
13:18 – Is
13:19 – Applying g
13:23 – To the endometriosis lesion
13:26 – Sometimes it’s diathermy sometimes laser
13:30 – Sometimes it
13:32 – Le col as maturity comes in all sorts of different to have
13:37 – Names
13:38 – Buddy
13:40 – Is that the surgeon will apply
13:44 – 2
13:46 – That bass
13:48 – Maybe ok if we are dealing
13:52 – Truly
13:53 – Official disease
13:55 – And we’re losing using something like laser that evaporates the whole of that layer
14:00 – But
14:01 – The problem is in most cases the disease is deeper than
14:07 – And therefore again today I can give you examples from my today’s
14:12 – All yours
14:15 – Dad said you’re only
14:17 – A year ago and I can see the pictures
14:20 – She had a place that’s probably
14:22 – Set up my practise is patients who had a PlayStation multiple time the record is being
14:31 – And I saw a patient
14:39 – So
14:44 – This patient had surgery
14:47 – October
14:48 – And the Surge and had a belated disease
14:51 – Applied Isme look at the pictures and you can clearly see that these are
14:59 – She got better the pain went away for 45 months but now it’s come back investing for and this
15:05 – Very typical
15:07 – Picture that I see all the time
15:09 – Any surgery ablation or disguised gnostic that crossed
15:15 – Often
15:16 – Helps with pain for a fume
15:19 – You don’t understand why it maybe
15:22 – Maybe a true
15:24 – Dunnes Stores because of the distension
15:29 – And
15:31 – So that’s a place
15:33 – Excision is when we cut away
15:36 – The abnormal area
15:39 – Excision is a much more
15:41 – Challenge
15:42 – To do it requires
15:44 – Skills training
15:48 – So typical
15:51 – Laparoscopy preparation of endometriosis may take 10 minutes
15:56 – Excision of the same disease mate
15:59 – 2 hours an hour and a half to do
16:02 – So
16:03 – And also that
16:07 – The Anatomy of that area very well and being gay
16:10 – Separate
16:11 – Vital structures
16:13 – From the disease and then cutaway the disease that’s cool exit
16:19 – Is that used when you have this deep infiltrating endometriosis that I might be going
16:27 – That’s one scenario in which it is used but
16:31 – My practice I exercise
16:34 – Even if it’s official
16:38 – Because I believe I can’t be 100% certain this
16:43 – Is superficial and also
16:45 – I worry about skip lesions between
16:50 – How many patients are what percentage of patients to organs need to be reflected or removed
16:56 – Oh it’s a small
17:01 – All that again my practice
17:01 – Bit on YouTube because I
17:05 – Operator those who need that kind of operation
17:10 – For that
17:14 – Let’s go
17:15 – The definition of m
17:18 – And then go to organs one by one
17:21 – So
17:23 – Endometriosis by definition
17:25 – The grocer
17:26 – Issues similar tendermeets
17:28 – Outside
17:29 – And death
17:31 – Removal of the uterus is not at
17:34 – So
17:35 – Organ that start from the
17:38 – Removal of uterus is not part of
17:43 – Only
17:44 – Caviar
17:45 – Is the
17:45 – Features an atom
17:49 – And if you do have
17:51 – I don’t know in a patient
17:53 – Last completed their family
17:55 – Or have also bleeding problems or have
17:58 – Then it makes sense to remove the uterus at the same time
18:04 – Bladder will never remove
18:07 – But we do something all the parcel is texting me again I can give you an example
18:12 – Today
18:14 – Where is has grown inside the bladder he is going to me Park
18:20 – The bladder removed because the disease has come through the wall of the bladder
18:25 – And he’s actually busy
18:26 – When we look from the inside of the bladder at just asked you can see
18:31 – So is our
18:34 – One.com
18:35 – My practise I see a lot of
18:38 – General
18:39 – There around 1
18:45 – Bowel endometriosis is a bit more common
18:48 – The Bell Inn
18:50 – This is up to
18:55 – Again the difficulty is
18:56 – We have different definitions
18:58 – Bowel endometriosis bowel endometriosis that when it has
19:03 – Inside the muscle
19:06 – Not if it’s just sitting on the settee
19:10 – So
19:11 – In a small percentage of those when endometriosis
19:15 – Has completely invaded
19:16 – Into the master of the Bell
19:18 – Then we need to remove that
19:21 – The symptoms are
19:26 – Same with the euro
19:27 – If the disease has gone into the ureter or is compressing the US in a way that can’t really said
19:34 – From
19:35 – To remove either part of
19:38 – Uratex
19:39 – Or
19:39 – Qatar Europe
19:41 – The hot before the area of Ben
19:45 – Obstruction
19:46 – An implant security
19:48 – In
19:50 – What are the potential consequences of not removing of endometriosis in most cases
19:57 – It’s very much depends on
20:02 – So we need to remember endometriosis
20:06 – The aim of
20:09 – Treatment is to
20:11 – Give the patient quality of life
20:15 – And
20:17 – We have done an operation we thought we were complete but and the patient is much better and
20:23 – Is gone
20:25 – Whether or not they have some
20:28 – Microscopic endometriosis left number
20:34 – But
20:36 – Problem is when we do in complete the operation
20:39 – When we know you
20:42 – Capri
20:43 – Nasty issues example
20:45 – Going to remove
20:47 – And endometriosis and we see that red dealing with a full thickness
20:51 – Calendar
20:56 – Which in some circumstances
20:58 – Is the right
21:00 – Dental disease can grow festival the symptoms don’t get better and
21:06 – The Grove father and brother and it can cause
21:11 – Bigger
21:12 – Something that could have been
21:15 – Buy a smaller operation now needs
21:23 – Do you have patience where does involved the roll or the urinary tract do you then have
21:28 – Gastroenterologist to re-register the surgical team
21:32 – Yes not a gastroenterol
21:34 – Colorectal surgery
21:36 – So again it depends
21:40 – If I need to remove part of a urinary tract
21:45 – Tickly on the ureter
21:47 – What if I need to do a segmental bowel reset
21:50 – Then I do have a urology
21:53 – Or a colorectal
21:54 – What’s sometimes in France
21:57 – But if the disease is sitting on top then I deal with
22:01 – In the UK
22:04 – We tend to
22:07 – Involved
22:09 – You can do the operation on your own
22:12 – But it’s preferable
22:14 – To bring your friend in and do the operation together we call it a multi
22:26 – We sometimes use a
22:29 – Trans
22:30 – When I do implantation
22:33 – The bladder
22:34 – And that is because there’s transport virgins of very
22:38 – Guild in
22:39 – Putting your test into bladder
22:42 – Because that’s what I do
22:43 – Duwende
22:45 – When they do kidney transplant
22:48 – But they are often or not
22:50 – Topics for robotics
22:53 – The arrangement
22:56 – Is that they are there to make sure that I’m doing a good job and the agreement is
23:00 – If at any point they feel that actually this will be better
23:04 – Data cover and open
23:06 – That has never happened so far
23:09 – They will do
23:10 – We put the patient
23:12 – At the centre of all of this and do what’s right for the pill
23:15 – And if the Excision has been fully comprehensive what are the chances someone might need a repeat surgery later
23:23 – The numbers that have been quoted or
23:27 – Widely
23:29 – Fairy
23:31 – I’m looking at my own
23:33 – Number so we are looking at my outcome of 10 years
23:37 – I started October 2011
23:40 – So we are coming
23:42 – 11 years now
23:44 – And it looks like just
23:47 – Very rough
23:48 – Looks like that
23:51 – Operated
23:52 – Unless then
23:53 – 5% of my patients more than one
23:57 – Maybe even less I’m just being very
24:02 – Pessimistic that number
24:04 – And often when I’ve operated on them it has been to do something else not to do the same
24:11 – Example
24:13 – Try
24:15 – Try to see if we can get away without doing any strict to me
24:19 – Innovations water had
24:21 – I don’t know my sister
24:23 – And we did the operation to exercise the endometriosis she’s not better than we go back and Judaism
24:30 – Endometriosis can repair and sometimes
24:33 – Do opera
24:36 – Did you ever find a man your patients that the surgery has an impact on the menstrual cycle or on their home
24:43 – Balance
24:47 – Yes but
24:49 – Not all of those are a diary
24:52 – For example
24:54 – Accept
24:55 – Heartless
24:56 – Because I’ve removed
24:58 – Endometriosis
25:00 – It’s likely that you will enjoy
25:03 – Because
25:04 – If it hurts you’re not going to want
25:08 – And therefore you know that that that
25:15 – Reading yes there is a there is an interesting relationship between the time
25:21 – Leaving the amount of bleeding
25:23 – A lot of it is still don’t understand
25:26 – We’ve always thought
25:28 – The abnormal bleeding comes from the adenomyosis rather than
25:33 – Bradley
25:34 – It looks like that and me presents around the beaches
25:38 – Cell
25:39 – Good impact
25:43 – In 4 patients who had urinary symptoms prior to surgery do you find that Familiar of those the symptoms
25:49 – Site post surgery
25:52 – Depends on the type of endometriosis they had but yes very
25:56 – So if you had
25:59 – Even superficial endometriosis on the surface of the bladder on
26:03 – Call you through the cycle full
26:05 – Often the pain will disappear completely
26:08 – In those who had people disease it even more likely that surgery will confirm
26:17 – Sometimes that would come with other symptoms
26:22 – After sex
26:24 – Often they were
26:28 – A question about hormone replacement therapy is it safe for people with endometriosis to use that or
26:35 – Vaginal oestrogen therapy
26:37 – Yes it is Dave
26:39 – With
26:42 – This weekend too
26:43 – Suggest that they go on a combined preparation for hr
26:46 – Being
26:49 – If you don’t need it
26:52 – But if you need HRT then having had anime
26:56 – This is your having a
26:57 – Yes
26:57 – Is not a country
27:00 – Speaking of
27:02 – Medications are there any medications that can treat endometriosis or are they mostly
27:06 – Two boys Ruby
27:09 – Well that is a tree
27:11 – Relieving symptoms is a treat
27:14 – If I treat
27:16 – You mean
27:17 – Taking away endometriosis so getting rid of endometriosis
27:21 – We know that
27:23 – Some medications will reduce the size
27:28 – Endometriosis
27:30 – Including size of the endometrial mod
27:33 – But but
27:36 – There is no
27:38 – There is no reason to believe
27:41 – And medication can actually take away and get rid of endometriosis
27:46 – What percentage of patients do you think you’ll benefit from symptom relief when I go on Orange
27:53 – So
27:55 – Something around 60% of
27:58 – Anterior pain
28:01 – Will
28:02 – Significant improvement in nursing
28:04 – When they go on home
28:08 – If a people that do expiry
28:10 – I have not been diagnosed with endometriosis but then take another contraceptive pill
28:17 – Could there be an indication that endometriosis
28:20 – No
28:21 – No
28:23 – We have something called the primary dysmenorrhea
28:27 – So we doctors have the Habit of
28:30 – Just hearing the patient story and then give it some giving it a Latin name and giving it back as diagnosis
28:36 – Primary dysmenorrhea
28:39 – Your periods hurt and I don’t know why
28:45 – Will get better with the pill because it stops the period or it it takes away the
28:51 – Natural Cycles
28:53 – Of the
28:55 – So those patients will get better
28:58 – Without her
29:02 – What hormones do they just take away the scent of the natural
29:06 – That’s all they do
29:12 – People
29:14 – I’m in this community on long-term Enterprise
29:17 – Recurrent or chronic UTI do you think that can have a detrimental
29:22 – Endometriosis giving the possible association with the microbiome or for any other reason
29:28 – I’m not aware of the
29:30 – If there is I don’t know
29:35 – It’s a long shot
29:38 – Ok
29:39 – Is the accept that we have a direct
29:42 – Too much bran
29:44 – Then we accept that we are directly
29:47 – Belong tournament
29:49 – And that’s the t slur
29:50 – You know my trip said that would be
29:55 – Relatives 2012
29:57 – What is possible with endometriosis will never say no
30:01 – There was one more question actually that was there any natural supplements that can
30:08 – The symptoms of endometriosis
30:11 – You know are you
30:12 – A militant and tea supplement
30:16 – Person
30:20 – I’m
30:21 – I’m Leicester
30:22 – I draw the line at home
30:25 – Homoeopathy is nonsense
30:28 – And I would encourage
30:30 – Anyone who’s on homoeopathic medication even if it’s helping just throw it away because
30:36 – It’s just eating
30:38 – Pseudoscience
30:40 – But apart from that
30:43 – If it if something that you’re taking is helping
30:48 – Make
30:49 – I’ve learnt to now stay
30:52 – I don’t know what the
30:54 – Between
30:55 – Sickness supplement and you getting better my feet
30:59 – But I can’t say there is no
31:02 – And there are some
31:04 – Have been
31:06 – To be effective but none of the
31:09 – None of the research has been conclusive
31:13 – Chinese medicine
31:16 – Treatments have been looked at and we haven’t found any any benefit
31:22 – The bottom line is
31:26 – Most
31:27 – Tottenham
31:29 – Are online
31:30 – To do any significant
31:33 – Apart from to your pocket
31:35 – So if you find something
31:38 – That is
31:39 – Call Ben
31:43 – Do you work with patients in the UK and international patients
31:48 – Yes I see you
31:51 – Significant number international patients and they come to see me
31:56 – What does solely because the
31:58 – This is not available in the country
32:01 – Treated someone from Canada couple of weeks ago
32:04 – It was under the care of
32:07 – Ratesetter
32:11 – The problem is the waiting list and being horrible sector etc
32:16 – I see some patience
32:19 – From countries where
32:22 – Particular multidisciplinary team setup is not available they may have a great surgeon
32:32 – An endometriosis surgeon that works with the neurology
32:36 – Andy plastic surgeon and a neurosurgeon that something that’s that
32:42 – Some of my international patients company
32:46 – Can patients get in touch with you if they like to reach out to make an appointment
32:51 – Contacting my office is the best way they can find my
32:57 – Details online
33:00 – Website dresses
33:02 – Endometriosis consulting.co.uk
33:05 – And through their they can email the
33:07 – What is the film The Office Centre
33:10 – Boston for international
33:12 – I usually
33:14 – Do virtual appointment
33:18 – I will try and do all the investigations that are necessary closer to home
33:25 – And then
33:26 – Get ourselves
33:29 – To plan
33:30 – As possible
33:32 – Before asking them to come over
33:35 – Examined
33:37 – Sexy
33:38 – Introduce based in the UK do you work in the NHS and private
33:43 – Not anymore I work privately only at the moment
33:48 – As I left
33:50 – Left the NHS in March I still
33:54 – Help when help is needed
33:58 – At the moment I’m only
34:01 – That’s good to know
34:02 – Will put a link to your website in the description for the video
34:05 – Thank you again so much
34:07 – First time with me today to answer a question
34:09 – Not a problem thank you very much for the pleasure
34:16 – Search for whatever your next steps are
34:22 – VTi free for in-depth articles
34:28 – Of course if you like this channel subscribe and check the bells will be notified of a future
34:35 – Thanks so much for watching until next time keep asking questions important for better Solutions