[Music] welcome back to a different first and 15 our guest today is Professor Sarah wise which is the professor of Otolaryngology and ethnic surgery from Emory University of Atlanta good morning sir good morning thank you thank you too for attending our grounds so today I'm briefly introducing the topic of sorrow which is the interesting paper published years ago about the international consensus statement of other GA ryuh ology and she's going to talk about allergic rhinitis and highlights about that topic today so I'm leaving the torch to her and please do remind that all the questions should be asked at the end of the meeting and please go ahead with your presentation thank you so much it's my absolute honor and pleasure to have been invited to participate in this session and as you all heard I'm going to discuss largely a document that we published in 2018 called the international consensus statement on allergy and rhinology allergic rhinitis this is a large document so today will really just be having some highlights and I'll talk a bit about the methods that we use to put this document together some of the interesting findings and some of the areas for further investigation and research in the future I am from Emory University in Atlanta Georgia so hello from the US it's wonderful to be on this session and I appreciate everyone tuning in these are my financial disclosures I don't believe any of these are particularly relevant to what I'm discussing today and as I said we're gonna talk a bit about some of the the methods behind this document as well as its some of its recommendations and where we might look in the future so what is the current state of evidence in allergic rhinitis I think this is something that we all frequently asks ourselves as we look to provide the best treatment for our patients with this disease process it's important that we understand the evidence in allergic rhinitis so that we can have a foundation on which to build the individual treatment recommendations the citation from our document the international consensus statement on allergy and rhinology allergic rhinitis and as you can see from the primary author list it is a it's a conglomeration of several nations several different specialties really an international effort put forth for this document one thing that I will highlight is that the document the primary document is very long it is intended to be a reference document and I'll talk a little bit about some of the features that we included to help make this easier to use as a reference document I've included at the bottom of this slide a link that can be used for a free download of the documents on there that you can see so I car as we call it I car allergic rhinitis took us about 18 months to prepare it's nearly 250 pages and involved over a hundred authors 72 primary authors you saw the list on the previous slide as well as 35 additional consultant or junior authors and as I mentioned this was an effort of otolaryngologist allergist and immunologist we had contributions from pediatricians pulmonologists Ryne ologist folks and environmental health nursing and various others we included eight broad content areas which I'll outline in just a moment and a total of a hundred and three individual topics related to allergic rhinitis if you download the PDF electrician from the electronic links that I provided you look at the table of contents you're actually able to jump to each individual topic related to allergic rhinitis so that you really truly can use this as a reference identify the topic in the table of contents and go straight to that topic through an electronic link so really you can use this kind of on the fly in your practice if you have any questions related to a specific area we also have an executive summary that was put together by the three primary editors of the document myself Sanderlin and Alana's Haskalah and this is a summary that basically goes through the the purpose of the document methods its primary content and recommendations and I'd like to say an extraordinary thank you to Sandra Elena and all of the authors that were involved in this efforts we really could not have done it without the input from everyone so this the eight broad content areas or sections that I mentioned before I include the definition and differential diagnosis of allergic rhinitis its pathophysiology and mechanisms epidemiology and risk factors really what the disease burden is and that includes things like socioeconomics effect on sleep and quality of life we address methods for evaluating and diagnosing allergic rhinitis as well as managing the condition through things like environmental controls or allergen avoidance pharmacotherapy some alternative therapies and of course immunotherapy methods as well and then finally we some associated conditions things like rhinosinusitis nasal polyps allergic conjunctivitis cough laryngeal manifestations auto logic manifestations things like that so really what is the best document it's I would say it's a critical summary of the existing evidence related to allergic rhinitis it really is a systematic review but it's not a meta-analysis because the data the data was not reanalyzed it is intended to be a resource for evidence-based recommendations and each of these recommendations as we'll see can considers not only the effectiveness of that particular diagnostic modality or therapy but it also considers the benefits the harms and the cost of each intervention in making the individual recommendations and then finally what I think is one of the most important things is that it's not um it's not important for us enough for us to just know what we know we have to know what we don't know right or we have to think about what we don't know so that we know where we can research in the future where our knowledge gaps are and where we can direct our investigations in order to understand this disease process better so the methods that we use are based on the evidence-based review with recommendations process that was developed by Luke Rudnick and Tim Smith and for anyone who's familiar with the international form of Allergy and rhinology journal this is something that we see appearing with some frequency this method has become fairly popular in analysis of the literature and there are several publications within the ipar journal that use this methodology so basically what this involves is reviewing the literature and looking specifically for high-quality evidence all of the evidence is assessed but the high quality evidence kind of given a little bit more I guess it's it's considered more highly in evaluating the possibility of recommendations so things like systematic reviews and meta-analysis clinical practice guidelines high quality randomized control trials etc so once the other evidence is gathered it is summarized and put together in a structured literature table that we'll look at here in a moment based on all of that evidence and the level of evidence an aggregate grade of evidence is assigned and then a recommendation comes from that again considering benefit harm and costs and then once that's developed by an initial author to go under those subsequent iterative reviews by additional authors in a blinded fashion so that those additional authors can ensure that what is being presented is appropriate based on what the what the status of the evidence is eventually a final consensus is reached amongst all the authors and then the manuscript goes to publication so this is an example of an evidence summary table that's included in evidence-based reviews with recommendations and you can see here that this very very succinctly describes the studies that are included the level of evidence the study groups exactly what was looked at in the study and then eventually the endpoint and conclusion and that's included for each study that's evaluated and then based on all of those studies together an aggregate grade of evidence is determined and so you can see that the aggregate grade of evidence is going to be highest for things like well-designed randomized control trials and then things like observational studies expert opinion case reports are going to fall lower at aggregate grade of evidence as well as considering the benefit and harm of that particular diagnostic modality or intervention ultimately a recommendation is developed and depending on the balance of benefit haunt and harm as well as the evidence quality the recommendation will come down somewhere between a strong recommendation for or against that intervention you can have things like a recommendation option or even no recommendation if the if there's not enough evidence on which to base by the final step is to summarize the literature in this manner so the aggregate grade of evidence and the number of studies that those are based on is listed a summary of the benefit harm and cost and then kind of a balanced assessment between the benefit and harm and ultimately the policy level so the policy level is the recommendation and then and then listing what the actual intervention is so some existing evidence-based reviews with recommendations are listed here these are just a few there are many many more out there and then as I said that evidence-based review with recommendations process was actually used for each individual topic within the iCard documents the first iCard document that came out was the rhinosinusitis document many of you may be familiar with this this was led by Richard Orlandi and it was an incredible effort and then several additional ipart's have come out or are in the works so are alerted second and then just this summer the skull base I car came out there are additional ones in works such as for sleep nasal obstruction and then we're coming up on the fifth anniversary fifth or sixth anniversary of the Rhino sinusitis documents soon and so there will be an update of that one coming out in a couple of years so as I said the iCard documents are really a summary of the existing evidence and then recommendations that come from those we have to take those recommendations and as kind of our foundation on which we build our treatments for our individual patients we still need to treat our patients as individuals we need to use our clinical acumen as physicians to determine the best treatment for them but we should really be familiar with what the evidence says for these processes so again from the ipar process we learned what the current state of allergic rhinitis evidence is we learned what we know we learned what we don't know as I said that's really important as well we also in in learning what we don't know we're able to kind of put together what the knowledge gaps and areas for future research are and I'll discuss a few of those later but first let's talk a little bit about what the current evidence for allergic rhinitis is and some of our treatment modalities so things like antihistamines I think we're all pretty familiar with the fact that histamine is a major mediator and allergic rhinitis and so antihistamines have been used for many many years to treat allergy allergic rhinitis and other allergic manifestations so the evidence for the use of antihistamine itis is incredibly strong for oral antihistamines there have actually at the time of publication of this document there were 21 studies that were actually meta analyses that looked at oral antihistamines they tend to be relatively low cost in the US the vast majority of these not only the original first-generation antihistamines but also the generation non-sedating antihistamines are the vast majority are available over-the-counter without a prescription the benefits outweigh the harm especially for the second generation non-sedating antihistamines and ultimately these these had a strong recommendation for their use in allergic rhinitis the oral antihistamines tends to be a favorite of patients because they prefer to generally prefer to use a pill rather than a nasal spray and they are also very beneficial for patients that may have other allergic manifestations skin manifestations for example the intranasal antihistamines at the time we put this documents together had very strong evidence in the form of randomized control trials they tend to be low to moderate cost for us in the u.s. they are prescription but they are they weren't great for things like sneezing itching rhinorrhea ocular symptoms the downside of the intranasal antihistamines as they do tend to have a little bit of a foul taste which some patients have some difficulty tolerating but they are great medications to use and recommended for allergic rhinitis intranasal corticosteroids have been a mainstay of treatment for allergic rhinitis for for many years as well in the u.s. they are relatively recently over-the-counter but they are well supported by evidence 15 meta-analyses and then additional additional study at randomized control trials as well very strong benefit for seasonal allergic rhinitis benefit for perennial allergic rhinitis as well and these obtained a strong recommendation they really tends to be a first-line therapy for allergic rhinitis other therapies that have very strong evidence in level a evidence include nasal saline in various forms intranasal corticosteroids listen and a histamine combination this for us tends to be a little bit of a second-line treatment if patients do not tolerate or if their symptoms are not fully controlled by an intranasal corticosteroids own we tend to use the combination it does tend to be a bit more expensive but it actually has great the synergy of the two common this synergy of the two medications together tends to be great for allergic rhinitis and then certainly subcutaneous immunotherapy has a long history of benefit sublingual immunotherapy clearly has been in use in Europe and very well studied for many years we're a little bit behind in the u.s. with a adopting sublingual immunotherapy but in the last 15-20 years it has really taken off we have tablets sublingual tablets available here since 2014 and then also aqueous drops used off-label as well so the studies for subcutaneous and sublingual immunotherapy and allergic rhinitis generally tend to be single antigen studies usually not multi antigen mixes but they do show excellent benefit and there is some variability depending on the antigen depending on the patient's age etc so I would encourage you all to really look through the documents to look at the specifics of those things but I think we can say in general subcutaneous and sublingual immunotherapy have have been great therapies for the treatment of allergic rhinitis and are really the as far as immunotherapy goes in comparison to things like pharmacologic treatment or allergen avoidance they're really the only therapies that can affect a more long-standing potentially permanent change in the immune system allowing allergen tolerance in the long term definitely of benefits for our patients we do have to think about things like anaphylaxis with these these therapies or other systemic reactions but that that tends to be relatively low incidence and both subcutaneous and sublingual immunotherapy are considered very safe therapies and the properly chosen patient so what about some of the therapies that tend to have a little bit weaker evidence we talked a bit about some of the pharmacotherapy treatments and I've touched on just a few especially those with strong evidence we address many many others in the document things like leukotriene receptor antagonists chromel in therapies etc we've talked about allergen immunotherapy and given the amount of data that's out there for for allergens immunotherapy I really just rushed the surface with my comments here what we haven't talked about yet in kind of the triangle of allergic rhinitis treatment is environmental controls or allergen avoidance so where does the evidence stand on that it is a bit weaker than many of the pharmacotherapy and immunotherapy treatments and I think that there are a couple of reasons for this and this is something to really to pay attention to because our patients are often very interested and for example dust mite covers or hepa filters and how they can avoid allergens in their home or how they can control their environments one of the one of the problems with a lot of these studies is that they they look at allergen levels and a lot of them so they'll look at the allergen levels prior to institution of the environmental control lab measure and then they'll look at allergen levels post institution of the environmental control level but a lot of the studies don't really address respiratory symptoms especially in the allergic rhinitis literature and I think that that's really what our patients are interested in right we're trying to make them feel better we're trying to make their nose less stuffy less rhinorrhea less itching the patients themselves probably are not as interested in the actual antigen level so we need to think a bit about that in future studies really addressing the respiratory symptoms in our study of environmental control measures we do know from a meta-analysis that was done in house dust mites that using a combination of therapies tends to be better than using a single therapy alone so that there is some evidence to support that these interventions can cost various at various levels depending on the specific intervention and and also how many things are put into place at one time but these are considered an option so I think one of the things that's that tends to be most exciting for us as practitioners and our patients our discussions of what's new what's exciting what's coming out next what are people talking about at the cocktail party is in relation to allergic rhinitis and I think that's not you you know I that that sounds a little bit facetious but you know certainly people do talk about their allergies especially during allergy season and so I think we as practitioners need to be aware of what our patients are interested in what is you know what is the hot topic in medicine or potentially some of the alternative therapies that they're talking about and it's important that we know what the evidence is surrounding us so some exciting you know potentially recent developments and allergic rhinitis and things that may need to investigate more but we may be hearing more about in the future so one of those things that I'll mention is intra lymphatic immunotherapy so this is basically allergen injected directly into the lymph nodes specifically the inguinal lymph nodes under ultrasound guidance and the typical protocol for this is three injections total each separated by about four weeks and so as you can imagine this is reduced time in comparison to our standard immunotherapy protocols things like subcutaneous immunotherapy which start with weekly injections and then progress to monthly injections and involve three to five years of treatment sublingual immunotherapy although it can be dosed at home it's also several years of treatment this specific treatment intra lymphatic immunotherapy involves less allergen injected and tends to have lower risk adverse events so there have been several randomized control trials most of them are relatively small but there is there tends to be some benefit seen so this is something that we may be hearing more about in the future actually I feel like we very likely will be hearing more about in the future and I think it'll be interesting to see where this goes I think we do need some larger studies specifically randomized controlled trials more subjects enrolled I think it's also going to be important to specifically assess the safety and efficacy of intra lymphatic immunotherapy compared to other forms other more commonly practiced forms of immunotherapy such as subcutaneous and sublingual immunotherapy and then certainly in an era of rising healthcare costs it's important to look at economic comparisons as well what about local allergic rhinitis and nasal specific IgE so local allergic rhinitis I think is something that most of us are aware of at this point this is specifically nasal symptoms and it does involve allergen specific IgE mediated inflammation in the nasal cavity the symptoms are classic allergic rhinitis type symptoms but when patients undergo allergy testing in the skin testing or systemic methods that are typically used hypersensitivity or positive reactions are not detected and so this typically involves doing a nasal provocation test or actually detecting the specific IgE from nasal brushings or nasal washings a positive basophils activation test and again there's no systemic reactivity that is seen so I think this is going to be something that we're again probably going to see even more about in the future there have been some excellent studies done in Spain by one of our authors on the iCard document as as well as some immunotherapy interventions for patients with local allergic rhinitis but certainly here in the US we don't really have a commercially available easy way to do this it's typically done and kind of research protocols we don't really have a lot of normative data how to how do the levels of specific IgE in the nasal mucosa compare to those that we potentially see systemically and so this I'm hopeful that we'll see even more about this in the future and be able to offer this to our patients what are the things that we as clinicians and practitioners may not talk about much but perhaps we should what topics are important to our patients again what are the cocktail party conversations potentially that we could better address what about things like acupuncture or some of the alternative therapies for allergic rhinitis and I'm just going to I'm just mentioning acupuncture here but there are others that have been studied things like these of honey etc so my acupuncture has been studied in the treatment of allergic rhinitis there too have actually been several randomized control trials of actual action acupuncture versus sham acupuncture there have been two meta analyses that have have looked at the results of these studies the initial one in 2008 included seven studies and at that time did not identify a benefit for acupuncture and allergic rhinitis but in 2015 there were actually 13 studies included in this meta-analysis and they did note a significant reduction in nasal symptoms improvement of quality of life questionnaires and the and reduction in the use of rescue medications so this may be something that your patients may ask about what about probiotics so this is also something that I think we hear about in the rhinosinusitis realm potentially in the allergic rhinitis realm there's you know certainly a lot more interest in the microbiome research lately there's a huge probiotic market in the u.s. nearly 3.3 billion dollars in 2015 so people are definitely interested in this and there have actually been some studies looking at this ultimately when when we reviewed this as part of our document it was found to be an option and I and that was largely because when we say probiotics that's a really large encompassing term there are lots of different individual products that our market marketed as probiotics and so there haven't really been enough studies of individual products so that we could say you know a specific product is beneficial so I think more research needs to be done in this realm as well and I'm excited to see where this goes so finally I'm just gonna mention some of the things that we might need to work on in the future our knowledge gaps and this is certainly something that will be you know looking looking at looking for people to publish in this area these are things that I will certainly be interested to see if we've had additional evidence show up by the time we potentially do an IKE are allergic rhinitis update in a few years I think we need to understand a bit more about the genetics of allergic rhinitis we know that allergic rhinitis runs in families so we we definitely need to understand a bit more about the genetics and potentially environmental interaction and that leads me to my second comment things like climate change climate change is happening and we know that allergens are affected by the climate so where will climate change take us in the future with respect to the prevalence patterns geographically etc we certainly could learn more about the diagnosis of allergic rhinitis I mentioned nasal specific IgE basic cell activation test which is an ex-vivo laboratory test that it has had some research behind it looking at at allergic rhinitis as well as really our skin testing techniques there's a lot of debate around the role of a an intradermal test following a negative prick test in skin testing techniques treatment of allergic rhinitis I've mentioned several treatments today in fact that was the really the thrust of this entire talk was focused on treatments we need to better understand economic comparisons of immunotherapy modalities sublingual versus subcutaneous immunotherapy each of those potentially versus intra lymphatic if inter lymphatic does turn out to be a useful method of immunotherapy widely in the future and there are many many others we addressed several knowledge gaps in our in the document and I would encourage you to take a look at those especially if you are a young researcher with an interest in this field I would love to see people publishing in this and include some of your work in future updates of the document so I think it's important as I've mentioned that we understand the evidence that exists for the conditions that were treating and use those as our foundation to treat individual to on which to build individualized patient management wait we have we have not in this document dictated what you absolutely should or should not do we have have given recommendations based on the evidence but again we are practitioners and clinicians and we should use our knowledge and our experience to individualize patient management so thank you again for Jung I'm very very honored to be here and I hope that I've provided some useful information for everyone thank you Sarah for your brilliant presentation which summarized the document that you presented and I'm encouraging to the colleagues to download this document if they didn't and I just want to point out two things the first one when you were talking about the the tests for the non-allergic I mean the nasal allergen we had the comedy we had a topic which was discussed from the past president of the yaki jr. come on yeah Ramona Gillis was talking exactly about the nozzle allergen challenge the methodology and the clinical usefulness recently in June and we we discuss about this thing and I'm glad that you also point out once again at the importance of these tests and the importance of these diseases which are struggling those patients when they are not figuring out anything on systemic tests so thank you again for this and the second thing is that we also had one of the our ground routes with Johanna gawky which she were talking about the endo type driving approach for the for the precision medicine and the she where she was actually comparing the asthma and allergic rhinitis and because of that I would like to start with with the questions which which the first one is coming from Portugal and they are asking so because of those all these documents do you think that they are your documents still valid I I do I think you know I think we we have to realize that evidence progresses right and we need to really look at what's coming out in in new evidence but it is important I think I think the Aria document is incredibly important because it definitely has a focus on asthma as well we address as relatively briefly in this document as an Associated condition but I you know I definitely use the Aria document as a reference and yeah I mean I think it I think it is helpful you can you give me back yeah I lost your volume for just one minute but I can hear it I'm sorry the the second questions is coming from Mexico and colleagues is asking what's your opinion about allergic rhinitis and Grammatik rhinitis and I'm sorry gravida cry nighties he's asking I think that's the pregnant yes I'm just telling you what what are they they type him so I mean clearly yes it we clearly have different terms depending on our language and culture so I believe that the question is about what we would call me us rhinitis of pregnancy so you know I think we definitely see that many not all but but many pregnant women do have increased nasal symptoms especially congestion during pregnancy and what I what I tend to see in my patients is that if they have a baseline nasal condition especially one that's associated with congestion prior to pregnancy and then they do and then they add the rhinitis of pregnancy to that they become substantially more symptomatic so whether it's allergic rhinitis or rhinosinusitis especially nasal polyps it they they generally in my experience they tends to be more symptomatic even with their baseline condition during the pregnancy that brings up you know another sort of thoughts about the treatment of these patients you know a lot of the medications that we tend to use for allergic rhinitis things like antihistamine nasal steroids etc can be used in in pregnant women but there are some you know if we if we look at the pregnancy safety greeting that that we use here in the US there there are some that have been graded safer for pregnant women for example for us we tend to use the budesonide nasal spray rather than others because that carries a category B or safer category for pregnant women so just something to keep in mind I hope I've answered the question I guess in any case I'm addressing your if you if if it's possible your personal I mean the office email for any of other questions that we cannot provide during this certainly of course yes I I would be happy for you to pass it along absolutely the other question is from Russia and the colleagues is asking would you suggest nasal spray or nasal Duchenne so with steroid with steroid yes yes so um you know I think that that depends on the disease process that we're treating and as well as what the patient's response has been so we so here in the US we have commercially available you know FDA approved nasal sprays for allergic rhinitis when we use a steroid in a nasal wash that's considered an off-label use and we disclose that to the patient I think that we I think we also know that the distribution of the actual medicine is very different when we are using a nasal spray versus a nasal rinse with the nasal spray the distribution tends to be mostly in the anterior nasal cavity so that can be very helpful in allergic rhinitis you know the allergens are they tend to come in first contact with the anterior nasal cavity the airflow then will arch over the inferior turbinate and kind of contact that the anterior aspect of the middle term in it and the nasal septum that is in that region and then kind of arch post eerily over the inferior tournament mostly variance thing influence then related to allergic rhinitis in the anterior nasal cavity nasal sprays can be very very helpful if you're treating something more that's that's more diffuse or if the sinuses have already undergone sinus surgery if the assi are open you're trying to get the steroid further into the sinus cavities then a nasal douche or an irrigation with a steroid can be very very helpful in those situations I also think that I've had certain patients even in the absence of having prior sinus surgery that have only been partially responsive to nasal sprays and then I'll try a nasal Duchenne they are much happier and their symptoms tend to be better controlled cert for certain patients so so a little bit of it depends on the disease process their anatomy what your goals are and their response to prior therapy and I think when you put all of that together you can determine whether spray or douche is better here we come with the with another and question which is coming from Spain or colleagues is asking what is your choosing for empty nose syndrome even people suffering from allergic rhinitis well I can say that I don't have a large population of empty nose syndrome patients but in general you know moisture tends to be very important for that that population of patients and so I definitely recommend nasal saline in irrigation spray or gel form and then you know for allergic rhinitis we know that nasal saline can be a benefit as well you you know you potentially could try adding in in those situations you could try adding the steroid to the to the irrigation as well I can't say that I have a large population of patients with that particular combination of disease processes so you know I I don't I don't know that I can reach back into a lot into a lot of experience with that so I certainly have seen patients that have them separately but but the combination is not something that I have seen with extraordinary frequency in my practice we're going to talk about this topic for the empty nose syndrome in the third segments in 2020 great and I'm coming to the last question due to lack of time and these colleagues from Africa is asking we cannot afford the immunotherapy in Central Africa so what are you're suggesting well you know in those so so immunotherapy for people that have access to it you know can certainly be an option but you know for allergic rhinitis specifically it's not a life-threatening condition it can be it can be quality of life impairing certainly but many patients do very very well with pharmacotherapy I've discussed several of them there are some additional ones in the document as well and then you know trying our best to control the environments although the evidence is a bit lower for that there you know there has been some some benefit shown so you know ultimately while allergen immunotherapy is an option in in several areas of the world it is certainly not an option everywhere and you know in my practice it is not something that every patients is is willing to undergo it's not something I even discuss with every patient you know it's certainly individualized the treatments for the for the individual patients I have many many patients who are very well controlled on medications Nadel saline some environmental controls if they want to do them and you know do not want to do immunotherapy or or I think they're you know disease is controlled enough that we don't even necessarily need to bring up immunotherapy as a as an option perfect I'm less thing for me it's can I can I just ask how much are you using the combination of a nasal spray composed by steroids and anti stemming because in Italy it's very the price of this of this terror of this spray are very high compared to other places in other states and for example Germany or United cake so are you using frequently the combination of nasal spray composed by steroids in an Testament or you prefer to use just steroids right so so for many patients we are most patients we will start with one either the intranasal steroid or the antihistamine depending on you know whether symptom our pattern of exposures and as well as the patient's you know desires and past experiences and then if they're not entirely controlled then we'll consider adding the second component so you know if we start them on an intranasal steroid then we may add the in the intravenously and histamine later or vice versa it is the the actual marketed combination spray is also very expensive in the US and is not for many of our patients that is not covered by their their insurance so in those cases I will if I think that using both intranasal medications would be a benefit to the patient I would prescribe them separately and then have them you know use them at the same you know in the safety setting or or sometimes you know well they'll just use the intranasal antihistamine as needed which is you know perfectly perfectly good option and then the intranasal steroid we try to have them use it on a more regular basis at least for periods where they have symptoms so thank you for your participation for your brilliant explanation and i would recommend to all the colleagues to send in their personal email to sorrow for asking any other question i'm sorry for the lack of time this is just a quick reminder for the next upcoming Grand Rounds which is going to be for the 15 of November our guest is going to be honest Costantini this is going to talk about the approaches to the frontal sinus and this is the actual president of the European radiologic society and because of that I would like to advertise the upcoming 2020 year s meeting which is going to be in Thessaloniki for a nice planned for and and I'm going to attend that and I think that sorry is also attending we actually actually ask her if she's going to attend and she's going to be in a panel for this he's joined it and and Thessaloniki is a nice place so if anyone would like to attend the arrest meeting don't forget that during that meeting our association is going to provide two grants we usually provide the junior grand sub because of our collaboration and support from the US a-- Reiner logic society juniors so if anyone under 35 years of age it's participating please subscribe to the ers and you will get all the benefits and you can participate to our sessions so thank you sort of once again for your participation I hope that you will be able to join once again in 2020 for our ground lines thank you and see you for the fifteen of November yes thank you see on thessaloniki thank you [Music]