Well, thanks a lot, Bruce. I'm really honoured to, to be part of the webinar of VETs. I would like to thank the whole organising committee for a great and professional support.

My talk about, this evening will be about degenerative joint disease and horses, and where are we at the moment and where are we going to. So first, I want to, declare my conflict of interest. It's, a bit more updated since, the CV that, that you just, mentioned, Bruce.

So I'm still indeed, founder and, and shareholder of, GST, the inventor of the patents with, with All the families. We, we have now 31 scientific publications, published. I'm the associate editor of Frontiers in Veterinary Science, which is now number 18 on the list of, veterinary, journals, right behind the equine veterinary Journal.

Indeed a board member, of different societies, such as the Scientific Society of Equi Health. I am now the promoter of 7 PhD students, so it's going quite fast, Bruce, and I'm also appointed, a professor at the University of Ghent for 10%, because we are doing a lot of research and we have a lot of collaborations with the university, and I'm a co-founder of Villanova Equine Hospital. So I'm very passionate about, horses, because I'm a horse rider myself.

I know they, they have, and they develop a lot of injuries. On average, 1.4 million horses in Europe suffer from joint problems and 1.2 million from tendon injuries and these are really, complicating the life of, horses, because of the pain and result in, quite big economic losses.

This is, this was my great, horse at the European Championships in, 2004. We won the bronze medal. This was my other horse where we also won a medal at the European Championships two years before.

And then I had in total 5 really promising horses where we did, the junior and the young rider international classes with and show jumping. But from these 5 horses, I was only able to, to ride and to compete 2 of them at the same time, because the other 3 were suffering from osteoarthritis and tendinitis. So that, became a real, pain in my ass, at least when I was, riding and competing, with my horses.

At one point, so this was my big stallion, called Takashi, and we were at the Europeans in, in Vilamura, where we won the bronze medal. But at the day of the finals, he woke up with a swollen limp. The boxes were rather small for him, and he's a very big horse.

And we went to a local shop and we bought an off the shelf flexium gel to put on his, on his swelling. And afterwards, he was, tested positive for an anti-inflammatory drug that apparently was present in the jail that we were not aware of and, entered in the blood system of my horse. So he tested positive on the doping test.

And that was, for me, really devastating as a rider. And that really drove me towards my vet training, towards, my PhD, towards understanding better how medicinal products work, what we can do, what we can give, what we cannot give, and, towards biological treatments, which are a valuable alternative in some cases, at least for the conservative therapies that are present today. And that's the main reason why I'm so interested in degenerative joint disease.

And, that's the reason why I'm also talking to you, this evening, and I will start about, pathophysiology, then elaborate more on, on the treatment possibilities today, making the link to stem cells, how they work, and, comparing them with other traditional treatments at the moment. So here you see an image of a normal synovial joint where you can see the normal structures, which are, cartilage, the synovium, and the joint capsule, and also the joint fluid. And then you have, the bony, surfaces on, on the side.

When you zoom into cartilage, there are actually two main components, and the cell component is actually the smallest component. There are only 1 to 2% chondrocytes in cartilage, which is a very low percentage. And when you look at the extracellular matrix, you can see that the main component is water and the water has the function to exchange nutrients within the cartilage.

And then, by linking to, to negatively charged glucose aminoglycans, which, which are proteoglycans, which are present in the extracellular matrix, and then collagen is also a very important aspect. The main collagen type is collagen type 2. And you can see that the orientation of the collagen fibres are actually depending on the layer in the cartilage.

So in the surface, you can see a more horizontal orientation of collagen, and that's actually for, resisting to pressure when the, when the joint is, is in pressure, when the horse is working. And then you have the deep layer, which is a more perpendicular layer, so more vertical orientation, and this actually serves as a connection between the cartilage and the bone, which is beneath, and as a secondary resistance to pressure when there is a lot of pressure in the joint. The proteoglycans are on the, the, the second biggest part, so like, glucose aminoglycans are the most important part and indeed they help in exchanging water and nutrients from the cartilage and then the smallest.

Part in the extracellular matrix are the glycoproteins, and these are mainly linking proteins, and also lubricating proteins. So lubricine is an example and it lubricates, the, the cartilage and. Mainly the joint, fluid, and this is how it structurally looks like and these proteoglycans and glycoproteins together with the collagen and the water, they form the extracellular matrix, which is basically the biggest part of the cartilage.

So, when there is an increased pressure on the joint, then there can Result into inflammation and into pain, and this inflammation can result in an increase in pressure again, and then you get the fisscious cycle and the progressive iteration of articular cartilage, that can also result in bone and soft tissue injuries, and mainly clinically seen as a synovitis and joint swelling in the first stage. This is a very interesting, graph from Machora from Wayne Magora, and he actually basically states that there are two main pathways from joint trauma to cartilage degradation. And they're both linked to stress and to cartilage.

So you can have on the one hand, abnormal stress or normal cartilage that can be created by a reduced stability due to ligament injuries, for example, or bone fractures, or a trauma. Or microfractures. On the other hand, you can also have normal stress on cartilage, but with an abnormal cartilage consistency.

And that is mainly being seen with ageing, osteochondrosis, but also as a secondary effect on athletic, injuries and see when there is too much, stress, and then you can secondary have also, abnormal cartilage. Both these pathways, they result in an increase of inflammatory proteins, and these proteins result in a degradation of the extracellular matrix and a breakdown of the articular cartilage. When looking at these degradative enzymes.

There are actually many pathways involved. In general, inflammation origins from the synovium. So in the joint synovium, you have two types of cells being called synoviocytes, so you can have a synoviocyte A or a synoviocyte B and the the A is mainly the fibroblastic type and the B is the the more inflammatory cell type.

And these cells create an inflammation and it's a very complex pathway, resulting in a lot of cytokines being up regulated. So some examples are interferon gamma, tumour necrosis factor alpha, interleukin 1, interleukin 6, matrix metalloproteinases, and these are actually the inflammatory cytokines and they result in a lot of damage. You also have some anti-inflammatory cytokines such as Interleukin one receptor antagonists, so the IRA proteins, and interleukin 10, for example.

And then there are also growth factors that are very important, such as insulin-like growth factor, fibroblast growth factor, and the bone morphogenetic proteins and transforming growth factor, beta, for example, as well. So it's a very complex system, and I just want to show you this system. To indicate that when we are only focusing on one of these interleukins, that that will by far be efficient to interrupt the in a complete vicious cycle of inflammation in the joint.

So this again was the healthy joint, and when you then get the inflammatory process with the joint distension and in the end a synovitis that is being shown by clearly, hyperemic joint capsule, so very red because the vascularization is increased. So which treatments are possible. So there are, there are different types of traditional treatments.

The physical therapies, I consider them more as supportive for the other therapies. The food supplements, are being administered quite frequently. I, as a writer, I had many, pots and, buckets of, food supplements because I always thought, what doesn't kill them makes them, stronger.

But in the end, When I did some more research on, the food supplements, I noticed that there is quite some discussion on the bioavailability on whether or not these, substances are actually reaching the joint and the levels are very, very low when we look into literature. So it's, it's not always that easy to, determine whether or not it's, advised, to give it to the horses. Then the topical treatments with my bad experience with my cooling gel, I, I'm actually not that fond of the topical treatments, anymore.

I also believe that we have very low levels in the joint when there is a topical application. And then the systemic treatments and the intra-articular treatments, I think the most important are the hyaluronic acid and glucose aminoglycans and the non-steroidal or steroidal anti-inflammatory drugs. Where you can see here in systemic treatments, currently licenced, to use as an anti-inflammatory and analgesic, product for, joint, disease, degenerative joint disease are, meloxicam, phenylbutazone, and soxybuzone.

The main aspect of these products is that they're mainly being used in the early stage, so when there is a strain or limited inflammation. And, and they mainly focus on alleviating the symptoms and not really the cause. When looking at the intra-articular treatments, the corticosteroids are being used the most as far as I know at least.

And are very traditional as a first line intra-articular treatment. They do have some withdrawal times to take into account before using them at the competition. And triamcinolone and methyl prednisolone are, as far as I know, most used where triamcinolone has a more shorter effect and it's more cartilage, sparing than a methylprednisolone, which has been reported to be quite, negative, have, have a negative influence on cartilage quality.

They both mainly focus on, reducing the symptoms as well. And not really the cost. The advantage is that, the positive effect is being seen rather quickly.

The disadvantage is that at the long term, in general, it's being reported that horses are coming back more frequently and in the end, getting less and less responsive to the inarticular treatments. So the other intra-articular treatments are polysulfated glucose aminoglycans, and they are reported to reduce inflammation and degradative enzymes. Also, the bisphosphonates are being reported.

They're actually registered for nafibular disease because they reduce the osteoclast activity. And osteoper cells that actually break down the bone. So if you can reduce these cells, then you have an increase in bone formation.

So it's, it's not really applied for cartilage. Yaluronic acid. For the lubricating effects and to reduce inflammation and polyacrylammate gels, as far as I know, they're not registered in Europe.

I know that in New Zealand, there is a drug registration. I also know there is one ongoing in the UK, but they're mainly being considered as a medical device, although in Europe, there is not a medical device legislation for veterinary medicinal products. So for me, it's a bit of a grey zone, product.

These are marked as potentially disease modifying these products, and, they, also claim to have a more supportive role. Since the polyacrylamide is not, registered, I looked a little bit more into the literature, and here is a study. And quite, some horses where they followed them for 24 months.

And, there you could see, some interesting clinical results. I was actually quite, impressed because I thought 79% at 6 months is, quite a lot. I went a little bit deeper into the study, and there are some limitations in my opinion.

And the lack of a placebo control. We also do not know if they got any concomitant treatments. So then the longer follow-up is actually less reliable.

But also not blinded, and there was a loss of follow-up in the middle of the study, which is also quite remarkable. We have a loss of follow-up in clinical trials, it's usually at the end. So that's also a question mark to me, and there was another study reporting also similar results and and a safe use.

Also, how to combine the products is also an interesting question. I also talked to, to, Janni Deros from Utrecht to publish this study, and, it was a study with 80 clients who owned horses and 13 clinics where they compared, the injection of triamcinolone versus triamcinolone, combined with uronic acids. And at the 3 weeks' time point, they had, a lower, success rate with the combination therapy.

Well, at 3 months, all horses in all groups, had a similar, improvement rate. There are two remarks that I want to give with this study. On the one hand, I think it can be explained that the short-term effect was less because when we look at the mode of action, Triamcinolone works through glucocorticoe receptors reducing the cyclooxygenase and the fiscal lipase production.

Resulting in COX 1 and 2 reduction and prostaglandinin reduction. Well, the heururonic acids as a mode of action through a CD44 receptor, which is a neuronic acid binding receptor and reduces IL1 beta and matrix metalloproteinases. So they have a different mode of action, which might explain the reason why it seemed a bit antagonistic at the 3 weeks' time point.

I do believe that it's, it, it, it is still interesting in certain cases to combine uronic acids with triamcinolone, especially looking at a potential, long-term, less positive effects for the cartilage. So I think a lubricating substance, adding to it does make sense, but definitely more research needs to be done to, to investigate, in which cases the combination is important and in which cases. single, triamcinolone or hyaluronic acid treatment, because that's the group that I was actually missing in this study, that was the heuronic acid treatment alone.

I think that would have been interesting. And of course, a placebo group, because we never know the effect of the training and management. So the pros and cons of the traditional treatments, I think, .

They aim at the symptoms, so that can, that, that can be a calm, in case when you look at disease modification at the long term, it is a pro at the short term for sure, to show the owner that you, you found the the cost as a vet and that you, you made the horse more comfortable. They are relatively inexpensive and, they require ongoing repeated use where we know, that there is the trend of a reduced, effect. And when using them repeatedly, and also a possible negative effect on the cartilage, for example, and the withdrawal times for competition, I experienced it myself as a rider, that, when your horse tests positive, that that's really the worst nightmare a rider can have when you're doing competition at a high level.

And the literature has shown quite some variety in efficacy in certain of these therapies as well, so there's not really a game changer in the process of the of osteoarthritis. When looking at biological treatments, there are, I classify them in two ways. So the non-cell based and the cell-based, just to make it easy.

The non-cell based are mainly looking at scaffolds and carriers and anti-inflammatory antibodies cytokines or growth factors, and the cell base can be classified in autologous from the horse itself, and mainly adipose tissue and bone marrow. Allogeneic MSCs that also include peripheral blood and umbilical cord blood, and xenogeneic where stem cells are being transplanted from one species to another species, and, that is only being reported at the moment, successfully from peripheral blood. Mainly because the rejection protein levels when you compare them of the different sources are reduced in umbilical cord blood and in peripheral blood.

We also did, in Villanova, a small experiment looking at IRAP, an or to, system, and, because they're, being used quite frequently. And when I talked to different vets, I get quite different opinions. There are vets swearing by, IRAP systems and their vets, calling it a crap because they don't believe it has any efficacy.

So it's very difficult to judge the effect. So we did a small experiment in 4 horses. Where we took the blood in the, in serum tubes, and, we incubated them at 4 degrees and at 37 degrees for, 2 hours and 24 hours at 4 degrees, and 2 hours 6 hours and 24 hours.

At 37 degrees where the ortoine gets indicated 24 hours at 37 degrees, and there we could actually see that at 4 degrees, there is no activation of the white blood cells to produce the anti-inflammatory IAP. Well, when we look at 37 degrees, that actually the serum controls at higher IRAP levels than the actual or, tubes. We compared it with other studies from the University of Berlin from Crystal.

Felicia's group and from Alicia Bertone's group in the Ohio State University, and they actually had similar results where the serum control tubes incubated at 37 degrees also show an increase at IRAP levels. Then we went one step further, looking at these glass beads, because apparently they're very big and, it can cause cellular stress for a white blood cells. So we also looked at the system with microglass beads that have the same size of white blood cells and create less system and a better carrier for cell adhesion.

And there we noticed that, and we called that system Cytoes, and there we noticed that we could actually increase the IRAP levels and compared to the serum controls, clearly, and also the interleukin 10 levels compared to the serum controls. So there is, of course, still a lot of research that needs to be done because this was only done in 4 horses and it needs to be repeated. We see that there is quite some individual, variability.

So each horse has A different level of white blood cells in the blood, and they respond also differently to these treatments. And I think that's a major cause, for having, variable results in the field when using, these biological, treatments. So the pros and cons, they aim at the symptoms and potentially disease modification.

They're a bit more expensive to use in general, and, they're being hypothesised to, a less repeated use, although when you look at the instructions for, the IRAP systems, they also advise to do repeated injections at several weeks in between. But also everyone is doing that differently. We noticed people injecting every week for 3, to 4 times.

Others inject only once, and then every 3 months. They're even, vets injecting twice a week. So it's very, very difficult to really judge these, biological, blood, treatments.

So there is also limited scientific evidence, and, the advantage is that there are no withdrawal times, and it's a natural, treatment as well. But of course, the wide variety in products and the composition, and it is a, is a big issue at the moment and requires a lot of scientific research. So also, there is, in my opinion, no game changer in addressing the osteoarthritis process.

What would be the ideal treatment that's a treatment that is disease modifying would reverse any damage and has no adverse effects or limited adverse effects, is readily available and would be affordable for all. Of course, scientists all over the world are looking for the ideal treatment, and there are over 1700 clinical trials in stem cells in humans at the moment, so there are a huge amount of researchers believing that they would find the hole. Holy grail in the stem cell therapy, and that's why there is a lot of research being done, but what are stem cells, first of all, there are cells that can replicate, so they can duplicate and form daughter cells by symmetrical division, for example.

Or they can also form more adult cells and specifically mesenchymal stem cells where we're looking at are cells that can form bone cells, cartilage cells, tendon cells, muscle cells, and other cells of the mesodermal germ layer. And for that reason, we believe it's important to give them the correct signals in the lab before they are being used, because they can make a lot of different cell types. And that's why we believe it's very, very, crucial that they get the right, signals and that they also can produce the right signals also in an inflamed joint.

Because in the early days of GST we we use a different last resort treatment of with conditioned cells, so with stem cells that were not primed towards cartilage, and we noticed that the results were actually lagging behind. And, the main reason is that when there is an inflammation in the joint, the cells do not get the correct signals. They can even, go, into apoptosis, so they can die faster.

And it's really important to prime them, beforehand, give them the right signals, and inject them in an, in an environment that protects them. And that's also the reason why, for example, an allogeneic plasma is added. To the cells to protect them and revitalise them after freezing.

But how do they work? I think the person who specifically unravels the actual mode of action of stem cells will be the next Nobel Prize winner. And there are many hypotheses.

The first one is that they would replace the damaged cells and injured tissue. But most of them, most of the, the research at the moment is getting back from that hypothesis. So it's not that they see that cells really integrate for a long time.

There are hypotheses on cell fusion, but also that one is being abandoned more and more. The next three are more likely, so the paracrine that they produce certain factors and have an influence and, and make the local cells work, like a director directing the, the orchestra. The second one is that would actually form microtubuli and and connect with other cells and transfer the signals and, and, also, nutrients and, and genetic material.

And the last one is they that they would excrete, for example, exosomes or microphysicals also containing a genetic material, and targeting other cells to do the job for them, basically. So comparing them with traditional treatments, the pros and cons, so the registered product RT cell forte, is indeed anti-inflammatory as traditional treatments. The underprotective effect is present, so there is a disease modifying effect that I will show later on.

While with traditional treatment there at the moment, there is no clear evidence of real, enhancement of the metabolism of the cartilage and enhancement of the extracellular matrix. It is a biological treatments, while traditional treatments in general are not or they're not registered. They're ready to use as traditional, treatments, but a proper diagnosis is very, very necessary with, chondrogenic-induced MSDs.

Well, with the traditional treatment, the general administration, the correct diagnosis is less crucial. So it's really important for, a high-tech product that it's really knowing what the diagnosis is, before using it. The known, the mode of action, is partially known while in traditional treatments.

It's, in general, it is known. Short term improvement, I think in the traditional sense, it, it has an advantage. Like, for example, the painkillers, you see a very short term improvement.

Well, that's not the case. An, an acute improvement in stem cells, while a short term, looking at, 123 weeks later, it is the case. So it it depends on how you define, short term.

The long-term improvement is in general not present in traditional treatments, while it depends on the severity with, stem cell products. So there are, quite some cases with the long-term sustainability of the joint after treatment. So short term adverse events can occur in both treatment groups, and long-term adverse events have not been reported so far with RT cell 4 while they also can occur when you think about, for example, methyl prednisolone, where they have long-term cartilage damage.

Well, the opposite is actually the case with RT cells. This is a study published by our group in combination, with, the group of Amars of the University of Ghent and Alicia Burton from the Ohio State University, and published in equine veterinary journal where, 12 horses, were enrolled and then, and machondral fragment was induced at the P1 at the dorsal medial aspect. So in the fatlock joint.

And at the opposite side, there was a groove induced at the medial condyle of the femur, sorry, of the metacarpal bones, so in the, in the fat lock. And these horses were trained for 5 weeks, and then half of them were treated with, placebo, with saline, and the other half with RT cell fortis or chondrogenic induced MSCs with equine allogenate plasma. And that was a blinded study, so someone from the university injected the horses and did also did the surgeries while a blinded person did all the evaluations, including, also lameness locator, evaluations.

So when you look at the lameness, you can clearly see they entered healthy, and the lameness wasn't used and when training the animals, the lameness, increased. So between two. And 3 on 5 mainly more to 2 on 5 in the AEP scale, which means that there was a consistent lameness under certain circumstances.

So not on in the straight line, but under certain circumstances, and this circumstance you can nicely see with the lameness locator that when they were trotted on the left circle. You can see that, the lameness was clearly present. It was the right front limb, but it was a medial lesion.

So when the medial compartment is more, compromised when they trot, on the left circle, because there, the medial, aspect has more pressure. When we looked at the right circle data, they're not included. There was, no lameness, steam because, there was not enough compression of the medial.

When you look at the the treatment versus the placebo, you can clearly see that from the moment they were treated, so from 2 weeks later, that these lines opened up, so that the IVP so, which was RT cell 40, the investigational veterinary product. What gave a clear reduction in lameness, which after flexion was also statistically significant. In the left circle there was quite some variation, so the statistics didn't show the significance, while it was very clear on after flexion, in comparison to the placebo controls that actually remained lame or even increased in lameness.

After, 6 weeks. And when we looked at the AEP score, we also saw statistically significant improvement after 2 weeks, so you can see it's a short-term improvement, but not an acute improvement. So, when looking at a product to inject the horse the day before the competition, of course, this is not a suitable treatment.

It's really aimed at the long-term improvement and the sustainability. When we look at the joint swelling, we can see the same trend with significant differences from 3 weeks after the treatment. So in the 1st 12 days, the swelling can occur after an injection with RT cell forte.

And we can clearly see that from 3 weeks after the injection was statistically significant reduction in swelling. And when we look at the joint fluid here, you can nicely see left and right joints, 6 weeks after treatment. So this is, the sham operated, so they went in with the scope without inducing the lesions.

And this is the lesioned joint in the control product group. So in the saline group, and you can clearly see that the joint fluid was, not, nice, nicely clear and had a reduced viscosity score. When you see in the RT cell forte group, the viscosity reduced, so this was the right of one of the 6 horses in the RT cellortic group, but in all 6 horses, the same reduction was seen in the joint fluid score which normalised these horses.

When we, did, an autopsy, we could clearly see that the placebo group, had quite some hyperemia. If you remember the introduction, you can see the, the inflammation, which corresponded nicely with the, with the effusion. There were secondary rare lines that created.

So this is the chip fragments. You can see it was not nicely aligned. And secondary, more cartilage was present, so the pathologist from the University of Ghent, which was a professor who was blinded as well, he, he wrote down, basically in, in all the placebo horses that the chip was not nicely aligned.

Well, when you look at the IVP group, which was RPal Forte, and in all horses, he wrote down that the chip was nicely aligned, and in 4 out of 6, there was no more inflammation while in the placebo, all placebo horses still had hyperemia. And then RT cell 44 out of 60 and 2 miles. And when we looked at the wear lines, 3 out of 6 did not show any more wear lines, and the other 3 had only one wear line.

It could have been that this is one wear line, but I can't really, determine it on the picture, but you can clearly see the difference in both, groups. When we then further investigated the cartilage of the chip and of the opposite groove, we could, we did a glucose aminoglycan staining, or at least in the university of Ghent, they did the staining. And they calculated which area percentage of the chip was actually stained with glucoseamminoglycans, and we could see that in the RT cell forte treatment group, that the, the chip here, so that you can see here with the black circle, and it's very nice and shiny, but also normal levels of glucose immunoglycans that you can compare to the healthy joints.

At the same region, there was no chip created at the other side. It was only sham operated, but it was the location where the ship was on the right side that we also took cartilage on the left side, just to have a comparison with normal healthy cartilage. And you can clearly see that the glucose aminoglycin levels of the art 40 treated groups were, were normalised in the chip, not yet in the groove.

So we saw an improvement in the groove. It was a bad groove. But we didn't see a complete, restoration there.

So it actually shows that, We, we see a reduction in damage and in further damage, and we see an improvement, a small improvement, which was not significantly different in the areas where there were damage for glucose aminos. When we look at cartilage matrix protein, we saw the same trend. So also clearly increased the matrix proteins in the cartilage of the chip that was very shiny, so you can see it with your bare eye that this cartilage is much more healthy than the cartilage in the placebo group.

And the same trend in the groove. When we looked at collagen type 2, we saw a statistically significant increase in, both the chip and the groove. So we can, we actually concluded that the RTL 40 treatment was underprotective.

So it, it protects. To join from further damage when the horses were trained for another 6 weeks when there was a chip present and cartilage damage in the groove. And we noticed that there was a partial restoration of the groove itself, but not a complete restoration.

It was only 6 weeks, which is also very short. So, I think it, it would have been interesting to look for a longer period of time. I think that's definitely a limitation of the study.

That it was only 6 weeks. For me, another limitation was that the pro-inflammatory cytokines were only up regulated for a few time points, so not during the entire study, which clearly shows that it's a model so that it's not actual, actually the exact same thing as in, in the field, but it allowed us to do some fundamental research that was needed, in order to obtain, medicine registration. When we then looked at RT cell 40 in a clinical trial, we could clearly see in 75 horses, that there was, a clear improvement from 3 to 18 weeks after the treatment.

I will show you some graphs in the next slide. So there were different study centres. There was a blinded, investigator, and there was another vet, called the dispenser, giving the injections.

50 of the horses received RTL 40, so the IVP, the investigational veterinary product. And 25 received a placebo, so and, and was randomised. So when a horse entered in the study, it was predetermined what treatment this horse would get so that it would not be influenced, by the order, for example, in, in the enrollment.

And here you can see that the the lameness score in the RT cell for the group clearly was significantly better in comparison to the placebo, where you can see at 6 weeks after treatment, so it increased up to 12 weeks. There was 78%. Lameness improvement, and that's an improvement of a score going from 2 to 3 upon enrollment, which is a consistent lameness under certain circumstances or at a straight line, which is the 3 on 5.

Going to a 0 or 1. That was actually a relevant clinical improvement on the AEP score, and here you see that 78% at week 6, improved consistently. So from 2 to 3 or 5 to 0 or 1, which, which is, no lameness or a mild lameness, which is inconsistent.

And that was also, determined to be irrelevant and to allow horses going back to work and, back in training. Where you see in the placebo 24%, improved, which is also important to mention it. There is a placebo effect that you can see, and that's the reason why I think it's very important when studies are being performed, that there always is a placebo group and that this is being done in a blinded way, because, owners as well as vets can be, biassed.

Because they thought they gave a treatment or because they do or do not believe in a certain outcome. So that's very important and because management in a study is also determining the outcome in many cases or certainly partially, where you can see here up to week 12 until 35% versus up above 90% improvement. Also, the joint diffusion score followed the same trend.

I have to mention that these were all fatlock horse fatlock injuries, and that these horses were positive on the flexion test, positive on the intra-articular anaesthesia. And they showed a sign of pain, swelling or heat at the fat lock joint. In 27% of the horses, there were also radiographic abnormalities, so it means that they were osteoarthritic.

While the other, 73% of the horses, we do not know if there was a cartilage injury or not, or if they were at an early stage. So it's important to mention that. And I am also convinced that early treatment is crucial in the outcome and the success rate.

When you compare the placebo group, there were 24% of the 25 horses with retrographic changes and in the IVP group, 28%. There were 50% in the IVP and 25%. In the placebo group, so an average of 27 on total 75 horses.

So that actually meant that in the in the Aralorte group, there were a little bit more horses with radiographic abnormalities, but it's, that's a coincidence because they were all randomised at the enrollment. I also want to take you through the literature, basically, some interesting work, I think from Alicia Purto, where she looked at other stem cell types like the bone marrow misanymal stem cells, and, they Investigated the immune response through CD4 positive cells, and CD4 is a marker for T lymphocytes that create a cellular immune response. And, they looked at, different horses and they injected the four fat locks.

And they had different treatment groups. And when you compare autologous allergenic and xenogeneic, you can see that in all treatments, there was an increase of T lymphocytes, even up to 40,000, which is quite a lot. But, I have to that when, when, a joint puncture is being done after a stem cell injection of several million cells with the same size as a lymphocyte or a monocyte, that in some cases, you also have the count of the actual stem cells in the machine.

But since they stained it for CD4, we're actually sure that that was not the case because stem cells are CD4 negative. So this is very important, to, to mention because when you do a normal white blood cell count with a normal blood machine, then, the white blood cells can be, falsely counted, elevated while they were actually stem cells. So that's important to know.

But what they saw here was that the xenogeneics from another animal species gave an increase in cellular immune response, but not the autologous or the allogeneic treatment or even the untreated ones. When we look at the inflammatory effects, it's, it's the same study from Malaysia Bertone, They looked at interleukin 6, which is a pro-inflammatory cytokine, and at the monocyte cell counts, and there they saw that the autologous had the lowest inflammation and then the allogeneic followed by the enogeneic. It was only 1 and 2 days after treatment, and after that there were no differences, and clinically they could not see any differences between the different treatment groups.

This is a very interesting study as well, from a French group where they injected different doses, and also looked at different sources, and, and they compared autologous bone marrow with allergenic bone marrow and allergenic umbilical cord blood. And, and I mentioned earlier that the umbilical cord blood as the peripheral blood, is a source which is very low immuno immunogenic. They don't have a rejection proteins on their surface.

And you can clearly see that in this study that, the allogeneic, umbilical cord blood scored actually the same when they looked at joint fluids, so synovial, effusion scores. You can see that nicely here at day 137, and so on after the injection, while the allogeneic bone marrow MSC clearly gave, an increase at day one. After the injection.

So the source does matter, that's, that's for sure. This is a study from Michael Schramme's group, where Carmelo Mari, investigated the repeated injections of, misanymal stem cells. They also used umbilical cord, misanymal stem cells and horses with OA that was confirmed through a radiographic examinations in the fat lock.

Joints and they noticed that a repeated injection did not give more clinical signs of inflammation or swelling or pain or lameness. So that was really, an interesting study as well. We, we are, we now, just submitted a study, .

Where they, to frontiers in veterinary science, where we looked at 10 horses that we repeatedly injected with Ralforte, and we also didn't notice, an increase in, swelling or pain or lameness. And we also saw that the cellular, as well as the humeral immune response was not being activated by the repeated injections. Although it doesn't mean that when you inject, in the joint that there cannot be swelling, pain and lameness, we see that in 1 to 3% of the horses that are being injected, that, that can occur, that also a flare reaction can occur, and that that can be treated medically.

And that's, something that needs to be taken into account with any type of intra-articular, injection. In our studies, we noticed that these percentages are the same in both the controls as in the Aral Forte treated horses. But it's, I think as a practitioner, it's important to know that that can happen and to inform the owners not to, worry when it does happen and that they can follow the horses, closely after the, the injections.

So as a discussion, I think it's very important what therapies are being used. That they are being combined wisely. So whether you, you use a traditional therapy or a biological or stem cell therapy, the mode of action is very important.

It's, also determines the outcome, as you could see in the the the house study, where they combined, trimsinolone with HA and, versus trimsinolone alone, that in certain cases that might be interesting in other. Cases, it might not be a wise decision, to, to use them separately. So I think it's very important to combine wisely.

Also, with stem cells, we get a lot of questions. Can we add certain hyaluronic acid types? We did quite some in vitro work.

For example, adding, polyacrylamide cells in early stages, that the age was, was quite acid and was really toxic for the cells. Also, there's certain HAs that, that are, have a more acid pH and then it's also toxic, but we, we've tested several, uronic acids, like yonate and Legend, for example, and they are really suitable to, to the cells and they don't damage the cells, which is also very important, to know when things are being combined. So different stem cell sources, they have a different inflammatory profile that's also important to know.

I think regeneration is a big word. I don't think we can demonstrate regeneration at the moment. I think disease modifying is more suitable.

I don't think that the disease modifying osteocritic drugs that have been identified earlier on really merit the title of disease modification. I would also dare say. More symptom modification because they, they are being, needed repeatedly and, and at the long term, not really being sustainable.

Well, I, I do believe that in successful, therapies with regenerative, medicine, as they are being called, that, that, that they warrant the title disease modification. The efficacy in a way, depends on, on the four Ds, as I call them, the degree of lameness. We see that really end stage lameness, of very lame horses and end stage away horses when the development stages is far, beyond the normal treatable cases that, of course, the prognosis gets more reserved in any type of treatment.

The 3rd, the diagnosis, which is, which really needs to be correct and specific. When, when there is a, a collateral ligament injury, then, of course, a product that enhances cartilage metabolism will not be the correct way, to treat, a horse. Which sounds very logical, but in the field, I do understand it's not always that easy when a vet is in a stable and has to do a clinical examination and, can only take an X-ray and do an intraarticular block.

That's, that's also not always that, that practical. I talked to Sue Dyson about it, and, and her opinion was that when you do an inarticular block, and after 2 to 5 minutes, so very early on, they, they block positive, then you can actually be sure that it didn't go outside the joint and that it makes sense to use, an, an, product that enhances cartilage metabolism. So that's maybe an easy, trick, to, to use, in the field, but still, a good diagnosis is very, very important.

The joint as well, we, we see the, the best results in fat locks, more than in posturing and . And, and then in coffin joints, we know that coffin joints are very complex with also different structures, so that probably is the main reason for seeing a difference in, in results. In stifled joints, it's also important to exclude meniscal problems or cruciate ligament problems, or at least to treat them, as well, in a separate way and, and only use RTL 40 to treat the cartilage.

Injuries and the long term effect really, really depends on the rehabilitation, the supportive care, how they're being handled, the horses, and if they get enough time to, to, to recover. So I would like to acknowledge the different universities that collaborated. So the University of Ghent, University of, California, Davis, the Ohio State University, the University of Padova, ETH, which is the Swiss Federal Technological Institute in Zurich and the University of Louva, and I would also like to thank the European Union for our crossroads, grant and the Flemish Agency for Innovation and Entrepreneurship and the entire GST team, here, with, our horses and, and dogs, and I would like to thank you for your attention.

Jan, that was absolutely fascinating. I, I'm sure all our attendees agree, your, your presentation was amazing and the, the insight, has brought us a lot of knowledge. So thank you for that.

Catherine, if you would like to activate your screen now for us, please. And into slideshow mode, that would be great. So folks, we will come back to the questions that you have posted.

There are a whole lot that have come through for Jan. But right now, we are going to hear from Catherine. Catherine, is part of Bohringer Ingelheim, who make the Artiel Forte and who have very kindly sponsored tonight's webinar.

So, Catherine, thank you very much to you and your company and it's over to you. Thank you very much. Thank you to the webinar vet for inviting me to talk this evening and thank you, Jan, for such an informative and enlightening talk.

I'm just gonna take a few minutes now just to talk through our new stem cell joint medication our cell Forte. I'll cover what our cell forte is, what it's used for, how we store it, and just give an overview of what it's been used to, used for thus far. So a cell 40 was the world's first licenced allergenic intra-articular stem cell treatment.

So to clarify, allergenic means these cells are taken from donor horses, which means the stem cells used are of the highest quality. And the source is peripheral blood samples rather than bone marrow fat. So there's no surgical procedure is required for either the donor horse or the patient.

So why do we want to use stem cells? I know Yan has covered most of the bases behind stem cell therapy, so I just want to highlight the three main areas which enable stem cells in our product to treat genital joint disease. They can differentiate into different cell types, as in our cell Forte, they are pre-differentiated stem cells, so they're giving them a higher affinity for cells of the cartilage lineage.

They regenerate diseased tissue which is required in any injured joint. And they can regulate inflammatory mediators, which is vital, as we all know, inflammation and degenerative joint disease goes hand in hand. All of these attributes enable the stem cells to treat the disease process rather than just addressing the symptoms.

A cell 40 is a treatment that comes in two vials. The first vial with a purple top contains the stem cells. They have between 1.4 and 2.5 million stem cells in every vial.

And these, as mentioned earlier, are specialised stem cells which allow them to have greater affinity for the cartilage within the joint. There are also excipients such as DMSO which allow the stem cells to be protected during the freezing process. The second vile contains equine allergenic plasma, which acts to improve the viability and it actually enhances the stem cell action once it's injected.

As I've already mentioned, the stem cell treatment is for genitive joint disease in the horse. This means it's licenced for the reduction of mild to moderate recurrent lameness associated with non-septic joint inflammation in horses. So let's talk a little bit more about genitive joint disease.

That's with everything, I find it easier to relate to a topic if a suitable definition is given, and I, I know that Yan's already covered this quite comprehensively, but I think it's really important to emphasise the extent of how much of equine lamelessness can be attributed to genitive joint disease. 60% is a really powerful figure. So I just wanted to show you this schematic just to illustrate the cyclical mechanism of degenerative joint disease within the joints.

I've shown in the top right hand corner the area of disease in which current treatments are focused, but you can see from the diagram that there is a very large area totally uninfluenced by current medications. This is mainly at the cellular enzymic level, which are responsible for the actual breakdown of cartilage and the subsequent. Instability of the joint.

This is where there is a huge potential for regenerative treatments to come into play, and in effect, this will help hopefully halt the halt the progression of degenerative joint disease, which up until now has not been thought possible. It is in this area that our self water is focused. So what cases are ideal for our self for treatment?

Ideally, we're looking at early to mid onset of disease where there is still a reasonable amount of cartilage remaining. However, anecdotally, more severe cases have responded very well to treatment. So here you can look at cases such as non-septic synovitis or mild to moderate lame score of between 2 to 3 out of 5 or 1 to 6 out of 10 depending on what lame risk score you're using.

You're looking at diagnostic imaging that has mild to moderate or no DJD changes. And also you can look at the joint space, either be on a on a radiograph showing normal joint space or at least not less than a third of the original joint space. A lot of people ask me what joints are appropriate for treatment of self-140.

And, and a lot of the 2014 break at our paper showed a variety of different joints responding well to self 40. Recent use is always helpful, so we now have quite a lot of experience in the UK. And use of our self-water, and this includes good reports back with coughing joints, pasting joints, betlock joints, carpal joints, tarsal joints, stifle joints, and includes one shoulder joint.

All of these reports have shown extremely well results good results. With cartilage degradation, we've always acknowledged that this is a continual irreversible process and that any healing of damaged cartilage that does occur will be with the formation of fibrocartilage. However, recent evidence has shown that the use of arte forte has resulted in the regeneration of cartilage, and this healed cartilage, once examined, has been shown to be of high in cartilage composition.

The evidence for this is shown here, where I think you've seen this picture earlier, this is taken from the paper that Jan was talking about. You've got the gross pathology pictures from the fetlock joint, the one on the left was treated with the placebo sterile saline. And the one on the right was treated with art cell forte.

You can see there's quite a distinct difference that we can see grossly that even with the severe cartilage flat formation and beerlines on the art cell forte fetlock, the, the reduction in beerlines is quite significant and as Jan already talked about, the healing of that cartilage flap and the appearance of the heart and cartilage overlying it is really quite distinct. Another image I'd like to share with you is of an 18 month old warm blood filly who was diagnosed with severe OCD lesion in her right in her right stifle. Post-surgery, the joint was treated with cell 40 and 6 weeks later, a second arthroscopy was performed, which showed remarkable healing, but most significantly, the healed region had biopsies taken, which when analysed, showed hyaline cartilage formation and with no evidence of any fibrocartilage formation.

So this is pretty exciting and it really helps cement what we're in learning about how our forte works. So I just want to talk quickly about the storage of our cell 40. Our surf water will arrive on dry ice and it's kept at a -80 temperature within that box.

You can either keep that for up to 24 hours before if you want to use it straight away, or you can move it to a -80 freezer or into liquid nitrogen if you want to keep it for a future case. It's quite important to remember that you can move the product from -80 down to a liquid nitrogen temperature, but what you can't do is move it from liquid nitrogen back to -80 prior to being used. It's really important that it's kept in this way because it allows for the cell viability to be preserved and also for the long shelf life of 2 years from manufacture.

Once you're ready to use the cell 4, it just needs to be defrosted and then it can be injected immediately. So, with us with any intra-articular injection, sterility is of the utmost importance. We would advise that a 24 hour period is observed between any intra-articular analgesia and the intracell 40 medication.

This is because the cells could otherwise be damaged by exposure to the local anaesthetic. So when you want to defrost, the two vials should be thawed and then reconstituted immediately, ideally within a 5 minute time frame. After you've treated with cell 4D, whichever rehabilitation protocol you want to follow, the most important part to remember is the initial 3 days box rest.

This allows for the stems stem cells time to adhere to the cartilage within the joint, and it gives them the time to do their work most effectively. So thank you for listening to me this evening. I hope I've managed to give you a comprehensive overview in Article 40, and if you'd like any further information, please contact your Behringer Engleheim territory manager.

Alternatively, you can contact us directly at Bohringer Ingleheim Animal Health. But in the meantime, I'm really happy to answer any questions that you might have. Catherine, thank you so much for that.

Whistle stop tour through what is a fantastic product. So thank you to you for coming in tonight and talking to us, and thank you to Boring Engelheim for their sponsorship via the RTL Forte product. We do have quite a few questions.

I know we have run quite far over, so if people drop off, we do understand, but I'd like to try and get through these questions because there really are a lot of them. So, most of them came in, while Jan was talking. Jan, you started your presentation by saying that about 60% of equines in in Europe have lameness.

And there's a question here saying, is that supported by research facts or is that just an opinion? So, indeed, there are some studies, there was one study from, Wayne McElrai in 2012 that he published in, bone and joint research about the, the horse as a model of naturally occurring osteoarthritis. And in that study, he mentioned, the 60% of lameness, due to, to joint disease.

So, that's actually a number that, that comes from this publication. And there, there are also other studies, looking at the prevalence, of, joint disease and of course, depending on the study, these numbers also vary, but the 60% is from a publication from, from the Colorado State University. OK, fantastic.

Jose wants to know, are essential fatty acids beneficial in the treatment of joint disease in horses as they are in dogs? Yeah, I'm, I'm actually also wondering that. I, I also did some research on that and, and in 2016, Fen published, a paper, from a university in Boston where, where they looked at, omega 3 fatty acids, and they looked at, at high and low, concentrations in 202 patients, human patients with MOA.

And they noticed that at a long term, I think it was 18 and 24 months after, the treatment that the pain was significantly reduced, but only in the, in the low dose, fatty acid. They did some further research and apparently low doses fatty acids, omega 3 also contain, other types of products, like, for example, the omega 9 might be also present because it's not a pure fatty acids that they use. So, there is quite some discussion.

There, there are some interesting findings. I'm, I'm not really sure if it's, if, if we're there yet. But I think it, it could be possible, to look at these, these aspects as well.

OK. Another one for you, Jan. Can the administration of either systemic NSAIDs or corticosteroid injections at the same time as stem cells interfere with the activity of the stem cells, for example, by acute reduction of inflammatory signals, which would contribute to the activation of the stem cells.

Yeah. What we see with systemic applications, we, we do not see any interference. In fact, the, in the field study with the 75 horses, all the horses got a single injection of an NSA, so that can be, metaca, meloxicam, or, or another NSAID.

So they got one injection, especially for, the owners to make sure that if there would be a swelling, that they would not, withdraw the horses from the study. So we do not, we do not see a negative, effect of them. We also know when there is, for example, a flare reaction in 1 to 3% of the cases that then a steroidal anti-inflammatory drug is being given to the animals to reduce.

The pain and inflammation, and we see a recovering, a good recovering and also a clinical improvement after, this administration, for example. So we don't see a negative effect with the systemic applications. What we do see is when they, when the horses got a lot of intra-articular corticosteroid treatments before, that then they are, in general, getting lower and lower.

Responsive stem cell treatment. Is that related to the corticosteroids? We do not know.

It can also be related to the fact that they're really getting end-stage OA patients, but we always advise, to respect the withdrawal time, and the washout period of the corticosteroids, when they have been inarticularly injected. OK, and Catherine also mentioned about with 24 hours withdrawal for of the local. Catherine, here's one for you.

Would you recommend treating the stem cells post-surgically or is it only as a, used as a preference over surgical treatment? I think it's got a very important part to play post-surgically. I think we've seen some really good results, especially post arthroscopy, when we have, cart lesions with the joint.

We tend to say, I mean, everyone's different, but a lot of surgeons quite like. To leave 3 weeks, 2 to 3 weeks after surgery, and then use the medication and that's when we say using our self which is a really good time. But, you know, that's totally up to the, the surgeon's preference, but I think that it's definitely got a part to play in in post-surgical lesions, definitely.

Excellent. Catherine, I think this one is for you again. How long do these stem cells live after being injected in the diseased arthritic joint?

Because it's an abnormal environment after all. And if and when they die, are there any forms of intracytoplasmic content, release that causes deleterious effects in the joint? I mean, I think I'm gonna ask Yan as well to jump in on me this because obviously he did an awful lot of the scientific experimentation early on.

I mean, we know that from there was a really nice cartilage explant study that Yan's group performed that showed that the chondrogenicuced stem cells had a much longer duration on the cartilage experts compared to, to native stem cells. I think we were looking at over 14 days, isn't that right, Jan? Yeah, yeah, that's correct.

When we look at, at the in vivo part, we, we did, analysis at 6 weeks after the injection. At that time when they were not present anymore. So they, they really have a hit and run effect, as you can call it.

So they, they induce, an effect in the local cartilage cells to increase their metabolism. And then they actually take off, let's say. That's what we know.

And indeed, in the cartilage, explant studies that we did in the Swiss, tech Federal Technological Institute using bioreactors, mimicking an actual joint, there we could see that the, the, the chondrogenic-induced MSCs were actually able to homogeneously attach to lesions and go into the lesions for two weeks. Well, when we looked at, at uninduced at normal MSCs. That they, that they fell off these X plans and were not able, to stay over, 5 days.

When we look in vivo, we expect that this period would be shorter because you also have the inflammation and the environment, which is more hostile to the cells. But what we do, know is that they, are, are more able, to attach to the cartilage and exert their functional, function, in the joint. And there's been no evidence as well, just to answer the second part of that question, there's been no evidence at all to suggest there's any, any inflammatory reaction later on, supposedly when these contingent cell 40 stem cells drop off or or absorbed or.

Yeah, can't even talk. Yeah, there's been nothing to suggest that there's, there's any inflammatory change going on when that happens. I always compare it to the billions of cells that are daily being renewed, even in the skin or in other parts in the body.

And, and it's also a biological products that consists of cells and And when, when these are being phagocyed by the immune system, that that's also a biological reaction that is actually very normal in the body. Right, right. OK.

Jan, here's one for you. And Natalia wants you to comment on the efficacy and the use and whether it is problematic or placebo-based when using products like glucosamine and chondroitin. My personal opinion or what is present in literature.

Go on, give us both, short version. I think in, in, in literature, they're very limited studies, only there are a few studies showing certain benefits, of oral, applications, but, not really huge benefits and not on the type that a horse that is lame, it will become suddenly not lame anymore. Mainly the bioavailability is an issue of the oral supplements that we do not know how much of these levels are actually in the joint, and that it's, it's almost, impossible to get very high joint levels, in the actual joint that we need it to be when you administer it orally.

My personal opinion, as a writer, I had kilogrammes of joint supplements. My, I, to be honest, at the end, my horses were not eating anymore. So I dropped the whole thing and, I, I went back to normal, Power food, you know, and, and, and normal food for the horses and, and just take care of them in a good way.

And, and, I, I don't, I actually don't, use it personally myself. I think it's one of those things where mom's cold, so the child has to put it on a jumper. If the riders, the horse is doing better.

Yeah. Another one for you. Any research and comments on platelet-rich plasma therapy into joints for regeneration?

Yeah. Well, we did a small study in 2014 that we, that we published in plus one, where we, where we had a group of, 20 horses with fatlock joint problems, and we, we divided them in four groups of 5 horses. So it's a small study.

And, one group got a PRP injection, but actually with low platelet counts, which is similar to the allogeneic plasma that we now at. Another group got, ananymal stem cell treatment, and then the third group got the combination. And the 4th group got the chondrogenic induced MSCs with the PRP.

And what we did notice was that, at the first time point, a few weeks after injection, there was, there were a few horses responding seemingly to the PRP, but we didn't have a placebo control, so we cannot really say if it was. Something statistically, significant. But what we did see was that when, when, using the homogenic-induced MSCs with the PRP, that there was a significant, higher clinical effect in, in comparison to the PRP alone, for example, so that we could, see that, that if there is an effect that, that, that it's only there, for a short term and, Yeah, it all, it all depends on the type of PRP, leukocyte rich, leukocyte poor.

That's also a very big discussion in literature at the moment. I, I, personally believe that leukocyte poor is the most interesting because we Don't want to inject white blood cells that can also respond in a, in a more negative way when, joints are being injected, that we prefer to have lower platelet levels, but also no red blood cells and white blood cells present, to have a clear effect. I also don't believe that very high platelet levels is therefore better.

In my opinion, there are a certain amount of receptors that can really be bound with platelets, and there is no, physiological healing condition where there are billions and billions of platelets, present in the body. So, it's also, yeah, very strongly believed that, there, there is a certain optimal amount of platelets, needed. But mainly, what, what do they heal or improve is, is the local, local tissue.

And for example, in tendons, we see that when, when plate PRP is being injected, that the quality of the tissue in general is, a bit, lower, in comparison to, for example, cells that can really, mediate the, the tendon quality. So the short quick answer is rather stick to R cell forte. It's a better product.

There you go. Catherine, here's one for you. Can R forte be used in small animals such as dogs?

I won't be able to answer this because, our self-force is not only licenced for use in horses, so I'm not at liberty to discuss any off-license use of our self 4. So I'm afraid I won't be able to comment on that question. There you go, a definite maybe on the fence.

OK. Well, Bruce, if it would be for your grandma, then maybe. What are you saying?

She's the size of a horse? OK. Right, let's move on, move on.

Right, one more, we've run very far over. It's been fabulous. Ja, here's the last one for you.

How about using a cell forte in ligament injuries? Well, I would definitely not recommend that. First of all, because it's out of the scope of the label.

And secondly, because the cells are chondrogenically primed, so they really want to, improve chondrogenic, induction and, and cartilage metabolism. So I don't think it's, it would be a wise decision to inject. Excellent.

You see, Katherine, that's how you sit on the fence. I know, sorry. Katherine Jan, thank you so much for a fabulous webinar tonight.

It's been hugely interesting. It, it sounds like you have an absolute winner with Artie Salorte and once again, thank you to Boringa for their proud and, and generous sponsorship. Of tonight's webinar.

So thank you both. Thank you to all the people who attended tonight, folks, thank you so much for your time to fill my controller in the background. Thank you for making everything run seamlessly.

My name is Bruce Stevenson and I wish you all a very good night.