00:00:00: Hello, everyone.

00:00:00: My name is Aglent and I'm the host of UEG Talks.

00:00:03: Educational and hopefully fun dive into GI world and beyond!

00:00:07: We are happy to have you with us for another exciting episode.

00:00:11: So today we're talking about excellence in functional disorders For that were going to Belgium And will be guided by the Equilibris of the Gutbrain Axis.

00:00:27: Hi, Eglia.

00:00:27: Very nice to see you and happy to be here!

00:00:30: Full disclosure I'm the happiest because this is a very self-serving episode... ...and i feel like it's a bit of abusive power.

00:00:38: And i have to confess that functional disorders are neither my favorite nor something i excel at.

00:00:46: So please do guide me and the whole audience through their functional disorders.

00:00:52: I think your not alone.

00:00:53: It can quite challenging

00:00:54: Indeed indeed.

00:00:57: First of all, I mean the concept of functional disorders is quite complex.

00:01:02: There's a lot things that we do not know.

00:01:05: but in layman terms how you define what's a functional disorder to your patient?

00:01:11: Yeah i think here you really start with most important point already and then explain.

00:01:18: And this is often where we fail.

00:01:20: I'm not saying you failed, but as a medical community we often fail because what we tend to do was run tests until the patient nothing's wrong and they can go home relax their life.

00:01:32: This is not what we should do, because the patient is experiencing real symptoms which are very bothersome having a major impact on their quality of life and so one.

00:01:41: And so when I always do as I start by repeating their symptoms restating their symptoms acknowledging there's symptoms So that they realize that I understand at their symptoms or reel?

00:01:53: My fellows will confirm this.

00:01:55: i always use the phrase I hear you And this is really helpful because otherwise patients, they may start repeating their symptoms time and again as if you weren't listening.

00:02:06: So I tell them...I hear you!

00:02:08: You mentioned to me that you have really bad pain and it feels like your going to faint?

00:02:12: I hear

00:02:13: you!".

00:02:14: Then i started explaining a few tests but the test came back normal But doesn´t mean that the symptoms are not there.

00:02:20: It just means that your brain perceives so many different inputs That can be confusing or painful And what often helps is that you use a kind of analogy, which is simple and can be understood by patients.

00:02:35: I really like the analogy of a filter.

00:02:38: so when i mean this in normal conditions You would not feel What's going on?

00:02:43: In your gut right because This Can Be Really Bottosome if you Would Feel What Happens in Your stomach in Your Gut and So On and This Is Because all Of These Signals are being filtered as it is Before They Reach Your Brain before they Are Perceived Consciously.

00:02:56: However, in patients with a functional gastrointestinal disorder there is a problem with this filter and actually the brain is continuously bombarded by these signals coming from the guts.

00:03:07: And many patients may be perceived as very unpleasant or even painful.

00:03:13: so in that way patient will understand well you did few tests they're negative but still I'm having symptoms.

00:03:18: why?

00:03:19: Well because my filters are not working properly.

00:03:23: Often it depends a bit on the patient, but if you have a patient who can grasp this concept I will also throw in the term.

00:03:28: This is what we call hypersensitivity and this can be caused by something in your guts.

00:03:33: or It.

00:03:33: can I always like to address this duality between the gut and brain, in the first clinic.

00:03:43: Because if you do that your patient will understand why they are having more symptoms when they're a bit more anxious or stressed.

00:03:53: because it's true!

00:03:54: All of these patients or majority of them feel worse while working against their deadline as things go bad at work.

00:04:05: Maybe it's in my head is all between my ears and that's not true.

00:04:08: It just there isn't interaction, you can be the gutter brain animals patients a bit of both and this really speaks to most of these patients.

00:04:16: okay so your balance saying between biology and psychology.

00:04:23: I would never use the term insanity.

00:04:26: I think this is a reflection on my practice that if i try to explain it in simple terms and all the treatment options, one of the steps might be SSRI.

00:04:38: they will say to me.

00:04:40: I

00:04:44: see what you mean.

00:04:45: The problem is, if a patient comes in and is explaining to me that they have terrible pain in my stomach region... ...and I've been to five different physicians but it didn't find anything... And your first question was are you stressed?

00:05:00: What will be the message that you're bringing across right?

00:05:03: then the patient thinks okay.

00:05:04: another one this is the sixth doctor who's not believing that my symptoms are real.. ..and actually all of them are in my head.

00:05:11: so I'm exaggerating here, iIm sure you don't do it like that.

00:05:15: But its really about balancing when to address these psychological components.

00:05:20: It's very clear.

00:05:21: not addressing is also being done by many colleagues because they're afraid the patient will think well this physician is not understanding what im saying.

00:05:30: but not addressing isnot what should be addressed Because patients feel that plays a role aswell But you have to find a way that your comfortable with.

00:05:39: And often I will address this after my physical examination, so i'll discuss the symptoms and all tests they've gone through... ...I will wait or examine them.

00:05:50: We go back into the desk.

00:05:51: then we will address how do you feel when things are busy at work?

00:05:57: Do you think your symptoms may get worse?

00:06:00: And ninety-nine point nine percent say yes absolutely!

00:06:05: And then it's up to you tell them, this is really normal.

00:06:09: This what I hear with many of my patients because if they are more stressed and anxious... ...it's normal that your brain will suffer from symptoms.

00:06:21: We call the interaction between what happens in your brain or guts?

00:06:25: At this moment we'll start using a treatment working on our gut like spasmolytic, prokinetic or whatever but possibly in future When these treatments are not very effective, we may want to consider a treatment which can also have an effect on the pain signaling through your brain.

00:06:44: And so in this way you already introduce this concept that maybe in the future will use a neuromodulator or psychological therapy because if only mention it at time when ready to prescribe it is too late!

00:06:59: It's important to address as early as possible within your clinical routine.

00:07:03: This might help.

00:07:04: I hear you, Tim.

00:07:05: Fantastic!

00:07:06: Okay so could you explain the balancing act in functional disorders?

00:07:11: Because in my mind their functional disorder is a diagnosis of exclusion.

00:07:17: and how do you find the balance between over-investigating and under investigating?

00:07:24: because the possibilities are actually endless.

00:07:27: up to porphyria for stomachache

00:07:30: Yes, or Takayasu vasculitis.

00:07:32: Or chronic pancreatitis on neuroendocrine tumor and so forth... So this is really important that it's always what I try to teach the junior doctors that functional gastrointestinal disorders are not a diagnosis of exclusion!

00:07:48: Sorry for correcting you here, Agli but this is key because if using functional GI disorder as a diagnosis you will run way too many tests.

00:08:00: And, You are absolutely right!

00:08:02: You need to do a few tests... ...to exclude very important conditions for example bad inflammation like in the case of IBD or celiac disease Or in certain age group cancer.

00:08:13: But we should not do all these tests and especially not for rare conditions Like one mentioned In old patients.

00:08:20: We have to do this in balanced ways.

00:08:23: So what I try is listen to my patient as I mentioned, and i make a positive diagnosis.

00:08:30: If there are no red flags if they're no alarm signs or symptoms... ...if this is the young patient especially.. ..I will make a POSITIVE diagnosis of a functional gastrointestinal disorder like IBS or functional dyspepsia Or functional constipation And so on.

00:08:44: but I would also explain that we will do a few limited tests to exclude a few other conditions.

00:08:50: But I'm very convinced what you have is herbal bowel syndrome for example.

00:08:55: So make a positive diagnosis.

00:08:58: If I can turn the question around, what message am i giving you if you would come to me with lower abdominal pain and some changes in your stool pattern?

00:09:06: And I will keep ordering new tests!

00:09:10: The first time that I do a colonoscopy or CT scan on my blood test is when they are normal again... ...and then I'll do a PET scan, an MRI, a metabolic profile.

00:09:18: They become negative next times.

00:09:20: more tests and more tests.... What message Am I Giving To

00:09:24: You?!

00:09:25: How does this make you feel?

00:09:26: You think not

00:09:28: very good.

00:09:29: And I also have received patients like these where they are exhausted after years and years, and no one either explained to it.

00:09:38: No one found anything.

00:09:40: It's still not very nice.

00:09:42: what we're feeling

00:09:43: exactly is very confusing to the patient.

00:09:47: And it makes them very insecure because a message that your getting across is that You're just throwing more and more tests on them, hoping that one of them will be positive.

00:10:00: If you as a doctor are in doubt the patient will go find another physician who may start to repeat all these tests.

00:10:13: So it is important for young people without this red flag.

00:10:20: But you have to explain your patient.

00:10:22: Why are doing these tests and which test is going?

00:10:26: If they understand why, that the diagnosis will most likely be herbal bowel syndrome.

00:10:33: usually they'll buy this but... You've

00:10:38: already touched upon red flags.

00:10:41: The traditional ones are quite clear cut But the thing is we have increasing numbers as well as functional disorders, cancers in young people that are very hard to detect early.

00:10:57: They're very aggressive.

00:10:58: they might Have very different presentations.

00:11:02: do you have an algorithm of that would sift through those patients?

00:11:07: Do you have your own red flags besides the traditional ones that would warrant you to further investigate and maybe do a colonoscopy in a patient, in young patients for instance?

00:11:20: It's great question.

00:11:21: And this is why many of our colleagues find these disorders of gut-brain interaction which are new names for functional GI disorder so challenging because it very likely has herbal bowel syndrome But you never know, maybe it is a young onset rectal carcinoma for example.

00:11:40: And this why we are always doubting what am I missing?

00:11:44: but still... You need to go buy the alarm signs and symptoms.

00:11:48: if there's no rectal blood loss The patient isn't losing weight.

00:11:52: If there's not familial history If normal blood test comes back normal If the fecal cal protectant is normal Then its fine!

00:11:59: We don' t have to do additional tests.

00:12:02: However And this is important, I will always tell my patients that we keep our eyes open.

00:12:07: This is where you are at these moments and what you have is irritable bowel syndrome.

00:12:12: but if your symptoms do not respond to the first or second line treatment as i would expect too Or If Your Symptoms Are Changing Or Getting Worse Or You Are Developing New Symptomes Well We May Need To Do Additional Testing.

00:12:25: So It's Important That The Patient Understands That You Will Stay Focused.

00:12:30: But it would be wrong to do a colonoscopy in all patients.

00:12:33: It's not feasible, Not for the health care budget... ...not for you as gastroenterologist and also its' not an benefit of the patient

00:12:41: And also which comes with all the risks.

00:12:44: I mean one in a thousand will get a bleeder One in three thousand will Get a perforation?

00:12:50: Its rare but is something too.

00:12:52: take into account Let us honest most of the patients coming To Us As Gastroenterologists with bowel syndrome, they have not had just one colonoscopy.

00:13:03: They've had three or four or five colonoscopies.

00:13:05: so this is bad practice and it's not what we should do.

00:13:09: Do you think that we can address these?

00:13:10: because I sense there are a part of patients who have functional disorders like cancer scare and all the media drive them to at least my colleagues treating colonoscopy for instance, where you do the exam not because it's indicated but because the patient is so anxious of getting cancer that you need reassurance and there's no other way to reassure than just to picture the colon.

00:13:39: Yeah!

00:13:41: The truth is actually doing a colonoscopy isn't reassuring patients.

00:13:45: It's what we think, right?

00:13:46: We do the colonoscopy because a patient is demanding to have a colonoscopy and both the patients that are physicians will be more reassured.

00:13:53: But unfortunately studies have looked at this.

00:13:55: whether a patient has never had a colonoscope or had recent colonoscopic or had a coloscopy further down line it doesn't make any difference.

00:14:04: The patients are as reassured in all of these groups.

00:14:08: Doing colonoscopy will not reassure them.

00:14:10: That's one thing.

00:14:11: the other thing is you need to explain The symptoms.

00:14:13: You need to explained to the patient that these symptoms that they are presenting with or not the symptoms?

00:14:18: That you would expect in case of a colorectal cancer.

00:14:21: But again, if the symptoms were changed and there will be blood in this tools If the patient is losing weight that something else.

00:14:28: In that case you may do a colonoscopy but nothing everyone.

00:14:32: Well, I guess most of your practice is incredible communication skills and knowledge.

00:14:38: But what else do you use?

00:14:40: What's your favorite adjunct in managing functional disorders?

00:14:44: to have some secret weapons last resort?

00:14:48: good question.

00:14:49: but let me start by repeating again that communication education and taking your time is so important.

00:14:58: So when I see these patients often it will be thirty, forty-five or sixty minutes that i spend with this patient listening to them confirming their symptoms.

00:15:07: This really a big part of the treatment of disorders of gut brain interaction and also making positive diagnosis telling them the diagnoses.

00:15:17: We are aware that the diagnose we're thinking about is irritable bowel syndrome but think how do you communicate this to your patients?

00:15:25: Often we say well, we did a few tests.

00:15:26: It's all reassuring.

00:15:27: so I will give you a spasmalitic drug But you haven't actually named the diagnosis irritable bowel syndrome and you have not explained what it is.

00:15:35: So that's one thing.

00:15:36: made a diagnosis tell to diagnose an explain it but then in terms of other tips and tricks That you can use.

00:15:44: What i think is important?

00:15:45: Is that as a gastroenterologist We should all be comfortable using neuromodulators so anti depressants antipsychotics to treat abdominal symptoms.

00:15:56: And we tend to be a bit hesitant, right?

00:15:58: Because we think this is more for the psychiatrist and that's not what you're trained to do.

00:16:03: but it isn't so difficult if... You know of each in every class an SSRI or Tri-Cyclic Anti-Depressant, the Serotonergic Anti-depressant.

00:16:11: If you know one or two products and you know dosage and which indications It's not hard.

00:16:18: So you should comfortable using these drugs also not being afraid to combine a few drugs, and this will really improve your practice.

00:16:26: And this is why at UGW there are many sessions about the use of neuromodulators in the postgraduate course but also on the main program.

00:16:34: these are important sessions.

00:16:35: This something that we're less familiar with But it's something should be knowledge you have as gastroenterologist as well

00:16:42: Karen.

00:16:43: very right because I only used sulparid and I made tryptolin for the lower And everything else, I would own stores to a psychiatrist.

00:16:54: That's a pity.

00:16:54: Because there is so much more, right?

00:16:57: Amitriptyline is fine but there is duloxetine that you can use for pain if you are stuck.

00:17:02: You start combining amitriptiline and pregabalin For example for pain.

00:17:07: If the patient is really complaining of fullness And weight going down, you could use myrtazepine or sulparitis But it has such richness in these neuromodulators.

00:17:21: It's a whole new world, but you should understand how they work.

00:17:25: So this is definitely something that is really important in disorders of gut brain interaction and also nutrition.

00:17:31: so let us not forget nutrition as well.

00:17:33: we as gastroenterologists tend to neglect what our patients are eating more or less.

00:17:39: what a low FODMAP diet is, I hope.

00:17:42: But there's so much more than just the low FodMAP diets as well that it's about fiber content and processed food.

00:17:50: taking your time to eat regular meal times.

00:17:54: this also an important part of history-taking.

00:17:59: we look into anxiety stress depression but let us not forget how you eat.

00:18:06: This is also an integral part of what you should address during your medical history taking.

00:18:11: I was really like, because i face a phenomenon where the patient is so consumed by what he's eating and self-reflecting on what their food does in each product And they eliminate more until there existence is miserable Because they don't drink coffee Nothing spicy nothing tasty.

00:18:33: What do we do?

00:18:33: How did it get out from that?

00:18:35: That's a very important point as well, and it is important that you pick this up.

00:18:39: As a gastroenterologist This what we call arphid right?

00:18:44: I think you've heard about this abbreviation.

00:18:46: It's arphids called avoidant and restrictive food intake disorder.

00:18:50: And this really what your describing.

00:18:52: patients are associating certain of their symptoms to specific food item which then they will eliminate.

00:18:59: Of course they will still have certain symptoms, associate this with another food item and eliminate as well.

00:19:05: And so that's why you are eating less and less and in the end drinking water and eating gluten free crackers!

00:19:12: This is not where we should be.

00:19:17: if your patient likes it.

00:19:19: really a multidisciplinary treatment is key.

00:19:22: And so it's US gastroenterologist, but you need to involve dietitian who understands this very well and also psychologist that knows what RFID is?

00:19:31: We should be aware of the problem as there are risks for certain elimination diets.

00:19:37: if we put too much emphasis on what they shouldn't eat because these may cause symptoms then some of these patients will be pushed into this condition called ARFIT.

00:19:48: So we are making their lives miserable, so you should be aware that there is a danger to certain elimination diets absolutely.

00:19:56: Kent

00:19:57: I think the stress over eating causes aggravation or symptoms because it's very stressful!

00:20:08: Absolutely it's stressful, its anxiety.

00:20:11: They want to stick with what they call safe food items and they will not eat anything else just because you feel comfortable having your gluten-free cracker.

00:20:21: one or two additional items then start losing weight.

00:20:26: give them artificial nutrition, entral feeding sometimes even parenteral feeding.

00:20:30: this is a road where we don't go in.

00:20:33: so pick these up early enough at work together with a dietitian and hope that they will not enter into this eating disorder.

00:20:41: And it's so.

00:20:42: nut-tasty, like Italian cuisine is out of the window with the FODMAP!

00:20:47: It just devastating... Well..

00:20:51: it can be difficult but with a low FODMAB diet if you have a dietician who knows this You could eat many things I mean Italian cuisine as possible But in this case prefer spelt pasta over the regular white wheat pasta, for example.

00:21:06: Because this contains less fructans will give less fermentation and less bloating.

00:21:10: so there are definitely options but it is not something that you can put into a patient's hands.

00:21:15: You need to dietitian who'll help with your reintroduction phase because everyone can do elimination phase.

00:21:21: I can look up on Google what should i eat?

00:21:23: What should i NOT eat?

00:21:25: And then i will develop ARFIT.

00:21:27: But you NEED A DIETITIAN WORK WITH YOU how to reintroduce certain food items and then see whether you can tolerate or not tolerate specific food items.

00:21:37: So don't try it at home, You need a dietitian.

00:21:40: Okay I will try because yeah up until now It would be control P. This is the sheet

00:21:47: I understand, but you should never do that.

00:22:12: So don't do it anymore.

00:22:13: In my defense, I do explain that this is not something you have to eliminate completely.

00:22:18: but if you have a choice maybe choose something from THAT column instead of the AVOID column?

00:22:24: That's NOT bad at all!

00:22:25: It's not unacceptable.

00:22:27: But THIS will keep the patient in the elimination phase as well.

00:22:31: And so... The reintroduction phase is really key.

00:22:35: and then the third phase where the patient has his or her diet which works is also important.

00:22:41: So it's good to have a dietitian in your team.

00:22:44: Noted!

00:22:45: Okay, so how will we measure?

00:22:46: Because what constitutes successful or at least meets the expectations?

00:22:52: functional clinic in your mind?

00:22:54: How do you define success and functional disorders?

00:22:57: It depends on the patient And this is also why it can be challenging.

00:23:02: Our goal is not To lower the fecal cal protectant below one hundred.

00:23:07: Our goal is to have patient satisfaction.

00:23:10: And this something that you need discuss with your patients and set expectations.

00:23:14: right, it's also important because if we ask a patient what do they want me?

00:23:20: They will tell them I wanna get rid of my symptoms.

00:23:24: but be realistic.

00:23:25: so often i'll mention Patients that there will always be some degree of symptoms or usually you will experience something and this may get worse when your stress around your anxious.

00:23:36: So the goal should not be to be completely symptom-free but to reduce these symptoms to a manageable level.

00:23:43: And if You address this in Your first, second clinic patients Will understand This?

00:23:49: Sometimes it can help.

00:23:50: If you mentioned like A number Like what if I could Reduce your Symptom by a third Would this Already Be Helpful?

00:23:57: And then you can use this to define success.

00:24:00: Maybe if, for example... You have started one treatment it did help and the symptoms are better by thirty-forty percent?

00:24:07: Well maybe we could add something else!

00:24:08: We may get to fifty or sixty percent.

00:24:11: This will also help patients rationalize their symptoms so they see where am I. Also often i'll talk with my patient about remember when first saw each other a year ago.

00:24:24: Oh yes now i'm much better Because even I do have symptoms, i can predict when I will have symptoms.

00:24:32: When I have more stress but also when I'm out eating in a restaurant and I'm eating more of these challenging foods... ...I eat it, I have symptoms But he doesn't scare me anymore!

00:24:42: I could live my life And I would not avoid social activities and so on.

00:24:46: Of course we should be honest.

00:24:47: It doesnt work for everyone.

00:24:49: I am NOT trying to tell you that every patient Can Be Helped Perfectly Even In That Case.

00:24:55: In that case, what I will tell them is... ...I cannot promise you this first treatment would be the perfect one.

00:25:00: But I can't promise to keep following and we'll work together trying to get better.

00:25:07: Even if it doesn't work out well for me….

00:25:10: This commitment of keeping up with patients no matter their symptoms are also important.

00:25:16: Patients feel safe when they know not being sent away

00:25:20: demands a lot of mental and emotional energy out of you, those clinics.

00:25:26: I cannot deny that it takes time It takes patience And it does requires mental energy But it also gives you lots of satisfaction.

00:25:35: Let's not forget that because these are patients who have been suffering for long times often young individuals Who have stopped studying or Retreated from social life and so on.

00:25:46: if you can help them a little bit getting reintegrated again, living a reasonably normal life.

00:25:52: They are so thankful!

00:25:54: So it is also very satisfying subdiscipline in gastroenterology and I would really recommend that you do this as well if you know how to do it... If you learn the communication skills or the treatments.

00:26:07: It's also a very satisfying Subdisciplined to be in.

00:26:11: Wrapping things up You've already talked about what success in functional disorders.

00:26:15: but Regarding outcomes, it's a weird and particular field in gastroenterology because we do not have objective measures.

00:26:26: The main outcome is patient-reported outcome.

00:26:30: so everything from the guidelines to our practice... ...is a bit weird compared with other guidelines where for instance skull protectant or histological remission in IBD Yes.

00:26:44: How do you think it affects our evidence-based practice in every day?

00:26:50: Yeah,

00:26:52: It may sound a bit weird and it is different from other subdisciplines but in the end... ...it's all that matters right whether your patient is feeling better or not.

00:27:02: And as you know also patients with IBD even if they're cal-protectinous normal They can still have very bad symptoms.

00:27:08: so Even there Communication, treating your patient.

00:27:12: Treating the symptoms and not just to call protect in his key as well And also there an IBD patients reported outcomes are becoming more important and rightfully so.

00:27:22: In the end it's all about a symptom.

00:27:24: So for me this is another disadvantage of disorders or gut brain interaction.

00:27:28: It makes you focus on what matters?

00:27:30: Symptoms and it makes you listen to your patients.

00:27:34: How does this affect the guidelines?

00:27:35: while we look at validated questionnaires ways to measure their symptom burden in the most objective way with questionnaires that are validated in clinical trials.

00:27:47: But this is absolutely feasible, it's just something you need to understand and also requires a different set of skills as we discussed previously.

00:27:56: By the wait!

00:27:56: Just quick questions because when talking about patient outcomes like where were they one year ago?

00:28:03: Do get

00:28:04: those

00:28:05: questionnaires so have a starting point and follow up.

00:28:12: Do you do that in clinical practice besides research?

00:28:15: Yeah, of course!

00:28:16: In Leuven where I work we are big centre for this sort-of brain interaction so we do lot's of research.

00:28:21: many our patients will be some kind of research studies or use alot these questionnaires but even your regular practice there Questionnaires that you can actually use and there are screening questionnaires for anxiety or depression, which can be very useful.

00:28:37: And do not take too much time to Bristol's tool form scale.

00:28:40: we all know this right now.

00:28:42: You showed in the different forms of the stool on your patients will indicate.

00:28:46: is also a patient report at outcome Avery useful in your clinical practice?

00:28:50: There are others.

00:28:51: For example We have developed together with professor tak develop this this questionnaire where the symptoms Are shown as a kind of a pictogram to explain them what is post-prandial fullness, what is epigastric pain?

00:29:04: What is nausea?

00:29:05: because patients may understand these symptoms very differently from what we as physicians think that nausea means.

00:29:12: And so this is what we call the waiting room questionnaire and it's something you can already ask a patient to fill out in a waiting room.

00:29:18: they will also indicate which one has the most bothersome symptom for him.

00:29:21: then he comes to use his questionnaires indeed on basis of start from.

00:29:25: It could be quite useful absolutely!

00:29:28: Thank you so much for your time, your advice and knowledge.

00:29:33: And your patience!

00:29:35: It's a pleasure thank-you.

00:29:36: I hope it was useful to the audience as well... ...as much of what is meant by me.

00:29:42: So thanks Tim!

00:29:44: A pleasure, thank you Eglis.

00:29:45: Let us see where we are.

00:29:48: in six months We will re-evaluate our outcomes.

00:29:52: Perfect give it a try.

00:29:53: You'll like this.

00:29:54: Thanks for joining us.

00:29:56: See you next time

00:29:58: Bye!