Welcome everybody to the next in the series of the care in the face of COVID-19 webinars from virtual veterinary specialists. Today our webinar is focusing on common neurological presentations, what is an emergency and what can wait. And our speaker is Doctor Simona Radeelli, who is a specialist in veterinary neurology and a neurology consultant with virtual veterinary specialists.

Hello, my name is Simona, and today I'm going to talk to you about, common neurological presentations. What is an emergency and what can wait. We are talking about neurological emergencies in light of, of, the recent, guidelines and restrictions due to the COVID pandemic.

On the BBA guidelines, we know that we should treat only urgent and emergency cases. We should avoid or unnecessary contact with the clients and we should respect social distancing 2 metres apart as per government guidelines. Of course we all we already.

We are aware that this is quite complicated to achieve because of the nature of our job, but we have to do our best to make sure that we comply to these guidelines. In the BVA guidelines I have found some definitions that might be useful to. And to selected to triage our patients.

So emergency is, a disease that is an immediate threat to life for the patients. So if we leave this condition managed, this is gonna have a significant impact on the health and welfare of the patient. It is likely to deteriorate.

So these cases are the ones that we, we would see anyway on the day or even, out of hours. An urgent case is a case that needs to be seen quickly, because if we leave the disease untreated, it's gonna have a significant impact on the health welfare of the patient, but at the moment it's fairly stable. Everything that is non-urgent routine is could and should be left for the moment routine appointments for checkups for vaccinations, for example, this can be postponed for the time being.

Because in any other condition that has a minor impact on the health and welfare of the patient for neurology, I went through all the examples and I tried to look for neurological conditions that were listed in the guidelines, and I found amongst the ones that warrants physical examination I found severe trauma. I had spinal. These are the major, let's say traumas that might have an impact on the nervous system, seizures, especially clusters and status epilepticus, significant weakness and collapse.

This will include, of course, paresis paralysis and acute severe lameness. We are going to look at these conditions in more details later. And then the condition that can be assessed remotely include non-acute lameness and non-specific lethargy.

So, triage tools, the WSAVA has given us ideas, on, on triage for, a lot of conditions including of course neurological diseases, so. The urgent cases. So again, the ones that if we don't see, they can have a significant impact on the life or welfare of the patients are new onset of seizures, especially for more than 10 minutes or if the animal has seizures.

More than once, in 6 hours, and especially if they are not already on antiepileptic treatments and any anyone that is collapse or unable to stand, they can include parasis and paralysis and nonresponsive, patient or patient that is becoming quickly less responsive, potentially urgent signs of pain. It is difficult to judge pain in a patient, especially if we can't assess them directly. We will rely on the owner's ability to judge and to report pain, but pain needs to be addressed pretty quickly.

Collapse, especially if it's recent intermittent collapse or inability to stand. Because again this can all deteriorate and get worse, a deterioration in condition, a neurological condition that is already known but is getting worse at the time being, and again we are afraid that if we leave it, it's gonna have a big impact on the animal's, welfare. An easy example is an animal that we suspect might have a slip disc.

We'll do a conservative treatment. He has been on painkiller's cage rest for a few days, maybe a week or two, and how his gait is getting worse. So we are afraid that if we live it for longer, the animal might end up off legs.

So we need to make sure that we address these cases properly. Or when the owner is running out of important medications in our case is the anti-epileptic drugs. We can't leave a pet without antiepileptic drugs.

So if it's a patient that needs this antiepileptic medication, we need to find a safe way to make sure that the owners have. A stock can buy can have more medication for their pets as with any emergency, the important thing always is to evaluate vital function and life threatening conditions. So let's not forget our ABC.

When we examine a neurological patient, always, we know that as with most emergencies, especially if the nervous system is involved, we need to to to make to make decisions very quickly and the decisions, of course, they need to be accurate to the condition that is affecting the animal. Especially in cases with trauma, we need to make sure that when we manage neurological patients that we know how to handle and how to move them. Ourselves and how to advise the owners as well, so advise on how to manage a patient that is surgery, but also advise how to manage a patient that might have a slipped disc or a fracture somewhere along the spine that we know that if we do the wrong handling, the condition can deteriorate and of course what we should be.

Mustn't forget always is to find, to ask a bit more information about the patients. So we need to know the history, the amnesies or history of the patients. So we need, because there are, information as simple as exposure to toxins or previous treatments or habits that might be actually quite useful to.

To, address the actual condition and also address other ongoing diseases. For example, if the animal is on other type of treatments that might be relevant to our, choices. So what do we do when we have a neurological emergency?

So we have seen a little bit what are the cases that might need to be seen. Urgently during this time we need to advise the owner on how to take them to us to the practise and then we need to assess the patient because of course we rely on the owner's information but we need to do a neuro exam ourselves so . I'm not going through the whole neurological examination by all means this is not exhaustive, but I just wanted to give you a few ideas on, on the key aspects of the neurological examinations.

So, are designs due to a neurological disorders? We probably have already a rough idea when we talk to you, to you on the phone when we get the patient in. We need to be able to localise to understand what part of the nervous system is affected that will allow us, allow us to list differentials and then decide what are the tests that are required because especially at this time we need to be able to sell.

At the right tests that we can do in house, whether the patient then needs to go, to be seen by a specialist. And then, of course, that will help us to give to the owner an idea of costs and, and prognosis for the patients. Weight at all.

Yeah, no, I see that. Just, just checking for if he has any knees. Movement.

OK, doesn't look this much in there, right on both sides. OK, just gently, there you go. And with with the other hand, you just swing the hammer like this.

There you go, on on the knee. So this is out to. Was left, right, left, right, and just moved down gently.

So if you get a contractiony because otherwise it'll sit down. That gives you excellent there. Perfect, that's the movement.

That you manage to get a little bit more now. The more you do it, the easier it becomes because your hands learn how actually how it works. Once you get it, then you learn where to hate with the.

So let's start with the mentation and the behaviour of the patient mentation, the consciousness. Can be altered, can be different. We have, different definition from obtundation all the way down to coma where the animal is actually non-responsive, not even to pain.

We know that, changes in mentation of the patients and the consciousness, I, in most cases, related to a disease to the cerebral hemisphere. Normally diffus or mmfocal and, and the brain stem. An animal that is circling, could have a disease affecting the vestibular system, so the balance system that makes them circle, or sometimes to the forebrain.

This type of circle is slightly different between the two because normally it's, it's again a general rule on the forebrain. The circling is wider and more compulsive, and the vestibular system is normally a tighter circle, but again, that's a general rule. There is another, presentation, another, behavioural change that we notice in, patients that have, a disease affecting the forebrain, the diencephalon, that is called the heintension or hemi neglects syndrome.

These patients ignore. Half of the environment, so they consider only one half of their environment. So for example they eat only half of the food in a bowl or if there is a sound, they react to the sound always towards the same side, even if the sounds come from the other side.

So, again this is. Quite frequent in a forebrained diencephalic lesion and as a general rule, the lesion is contralateral to the site that is being ignored by the animal posture. Emergency patients can present with, especially the ones that, are of the legs can presented, with, different, postures, again they're quite pathognomonic typical of certain conditions.

Shift Sherington, we know that a patient with shift Sherington. Has suffered recently, from an acute severe toro columbar, lesion. The forelimb, the front limb have an extensive hypertonia.

The hind limbs have a flaccid paralysis and, what so. This is, this is all the information that we have from this positions, so acute severe thoracolub lesion, but the chiff Sherington doesn't have a prognostic value. So this ch Chaon will not tell us whether the animal will recover or the degree of recovery.

It's just typical of an acute terracolumbar lesion. Then we have two other types of postures are quite typical. One is called, is called the the celebrate rigidity.

Again, this is, common in patients that have a rosal brain stem, lesion. And all limbs are extended, all of them rigid. The animal has opistotonus.

You, you can, you can see, so the cat in this picture has the cerebulate rigidity, but we can see the opistottonus. So the head is, back arched back, so the spine is all arched back and the leg, the head, sorry, is lifted up. So that's the opistottonus in the the cerebrate rigidity.

So the first one, the brain stem region. All, all the limbs are enriched in extension, and what's really typical of this is that the mentation of the patient is not normal while in the the cerebellate rigidity we have epistoons, the front limbs are extended, but the the hips are flexed. And this is typical of a a disease of the cerebellum and the mentation of the patient is normal in this case.

Of course, the animal can't move properly, but his mentation is normal. To evaluate the gait, especially if we want to try to evaluate the gate remotely, technology can help us, so we can ask the owners to send us a video. If we think that we can wait the time that it takes in order to send us a video, the patient, patient can wait, we can ask them to record at the gate of the patient.

So owners, of course, need a little bit of information on how to do a gate, how to, walk the animal to to allow us to evaluate the gate. So we need to tell them to put the animal on a lead, ideally on a harness, especially if we suspect a cervical lesion, on a non-slippery floor, so we can. See the gait of the patient properly if the animal needs a sling as well under the belly because it's it's not really walking very well, we can advise the owners on how to do that and the animal needs to walk.

We don't need the animal running or strutting or moving around sniffing. Ideally back and forth, away to or from the camera and on on a leather harness and sling if necessary. What type of gait abnormalities do we have in our pages that might need to be assessed?

So as a general rule, we have two main types of gait abnormalities ataxia, which, we can define as a lack of coordination. And paraplegia, which is more weakness related so ataxia and ataxa is divided in general propriceptive and vestibular taxi. Again, lack of coordination and paresis paralysis plegia are related more to an upper motor neuron or lower motor neuron disease.

And again, there are more weakness. To be honest, we can, especially with upper motor neurone disease, we can have actually also on coordination and parasis is more common with the lower motor neuron disease. But it is important to be able to describe the difference between the two.

So again, ataxia, lack of coordinations and paralysis is more weakness. For what concerns lameness, I would say in general lameness is quite, is more common with orthopaedic, conditions, but there are some, neurological conditions that can, give lame. And one of them, for example, is, a trap nerve.

So if we have, what we call a nerve root signature, so if, there is, a lateralized protrude, protruded or extruded disc, we can have, an impingement on the nerve root, and that can give lameness. It's because it is actually particularly painful for the patient. And then we move on to the postal reactions.

At this point we are going into what we call the hands-on assessment of the patient. So at this stage, we will need to assess the patient ourselves because, these are tests that might be, they are often quite difficult for an. To perform even if we guide them to to do that.

And the postal reactions, will help us answer the question if it is a neurological condition, they will help us, evaluate very mild deficits that might not be, present, when we evaluate the gates and And the behaviour and lamentation and then they will help localise within the nervous system, the, the disease. There is one, test that I would like to talk about. So I'm not going to into details on, spinal reflexes, because it goes beyond the, the, the aim of, of this presentation, but I would like to spend, just a minute on, on the deception on what we call deep pain.

Nociception in a spinal patient is very, very, very important. It has, it has a prognostic value, for the patient. So, on our, BBS website, I have put a blog on noception.

So for more information. You can refer to that and have a read. It's not very long, on, on exception, so you will have more information there.

But what I would like you to to make sure that you assess on a patient that you suspect that has, a spinal. Lesion, a slip disc, a fracture even more. We're gonna see in a minute, is if the animal has no deception, the pain, if the animal is feeling the toes.

So this is a conscious response. So withdrawal is not. Nociception.

So if we suspect that the animal is not feeling the back legs because of a severe thoracolumbar lesion, for example, and we wanna test aceception, we pinch the back legs. We first we compress them with our fingers if that's not enough, of course we move into using mosquitoes, for example, that will have a will elicit more pain and therefore more effective in the response, . The animal needs to show a conscious response.

It needs to try to bite, to cry, to turn the head towards the leg. If the animal only has a withdrawal, so pulls the leg away, that's not no deception. That's a local reflex.

That's the withdrawal. OK? So make sure when you test an exception that you test a conscious, risk.

Of of the patients and in the in this in these cases it is always very important to check the, the control of the bladder and the feeling of the tail, the movement of the tail sensation around the tails and the anal tone cranial nerves cranial nerves are . A lot to test and of course in an emergency situation we don't have to go through ideally yes we should do the whole new exam, but we are in an emergency situation so we need first to select the relevant ones and we are going to see some for the heart trauma because they are the ones that will give us information on the status of the patient so Menace, and PL are very important and cranial nerves, that well so nystagmus, positional nystagmus, spontaneous stagoculocephalic reflex. All these tests that will help us have more information on the on the vestibular system as well.

And again, there is, there is a Q&A on to question and answer. Document on, the VBS website that that I have put together and then you can address the in and assess as well to have more information on how to assess the vestibular nerve palpation, very important. Palpation will help us, localise in some cases the source of pain.

So palpating in the the spine from head, from cervical. He spine all the way back, first gently and then a bit more deeply will in, in some patients, can help localise an area where it's particularly painful on the spine and it helps to localise the lesions together with the rest of the neuros. We can palpate the heads as well and the muscles cause the animals can have also, pain in the muscles.

What do You next, once we have localised the lesion, we can list the differential diagnosis. So we sus what we suspect has happened or is happening, at that level of the nervous system, and that will help us again select the right diagnostic tests for our patients and give, an idea on to the owner of prognosis and help us decide what treatment can be done, to, to the patients, considering, again, the actual COVID situation. Seizures.

I have put together again an essential clinical guide for emergency treatment of seizures. So there it's a clinical guide for the treatment of status epilepticus and clastic seizures. There is information also on advice that you can give the owners and one important thing is that you, you make sure that the owners of dogs that are known epileptic.

Especially the ones that tend to have clusters that they have emergency intrarectal diazepam to use at home as a first of treatment so that then, they, you know, they are advised that they have the medication available, they can start the treatment if their pet starts a seizure that actually having more than 2 seizures in 24 hours. Another thing that I think is important from Experience is that if the animal needs to be transported, whether needs to be transported to you, and, and especially when it needs to be transferred to a referral service, is that the animal that there are at least 2 people in the car. So of course if the animal is and status and the owners can't control the seizures, you need to see the animal as quickly as possible.

You can't wait for the animal to be stable, so the animal needs to be taken to you straight away. But once you have the animal with you and you are conscious that you can't look after the patients for lots of practical reasons, make sure they stabilise the, the patient and then when the patient is stable, they can be be be transferred to referral. Practise and there are at least 2 people in the car because if the animal for any reason starts seeing or being unwell in the car there's any problem, at least, one of the two persons can address assess the animal, and, it would be dangerous even for the person.

Alone, if there was one person alone in the car, it would be dangerous for the person to be left with an animal to start seizuring and you know if the person is in the motorway, for example, it can cause actually car accidents. So again, I think these are important information to manage these patients as an emergency in cases that are not seizuring too frequently, but the owner still want advice and you're not sure whether actually the patient is seizuring or not. What could help is to ask the owners always for a video footage of the events.

Again, this only if the the seizure frequency is not too severe. Some patients have vestibular syndrome and because they are unsteady on their legs tend to fall, the owners might think they might think that these are seizures, but actually they are not they can mistake a vestibular attack, for seizures, and again we need always to follow the guidance on triage, regarding progression and animal welfare. Advice for owner all this information is given as an advice for the owners because the owners need to be able to know how to manage their patients so.

That we need to they need to look for signs of deterioration. Of course they need to, make sure that they don't get injured during the seizure, so we need to inform them on the guidelines, there is something about hypoglycemia. So if there is any risk that the animal can be hypoglycemic, they can feed them, for example.

Whenever possible if they can eat and then again as we said before, the availability of rectal diazepam, so the signs of deterioration are mainly related to the animal's mentation and of course the frequency and the severity of the seizures. Paesis and paralysis we have defined paresis paralysis earlier on. What is important is to try to identify the limbs that are affected, so monoporesis paraparesis, tetraparesis, hemiparesis, depending on.

The limbs affected, the progression, as we said before, if the animal is getting worse, we need to make sure we have to find a way to monitor the progression or to address the progression as quickly as possible. If there is muscle atrophy, muscle atrophy, happens pretty quickly with neurological conditions and a bit slower with orthopaedic conditions. So see if that is obvious and how, how quick was the progression of that.

And of course if the animal has also other systemic signs, so if the the gait abnormality could be related to a more metabolic condition, a general condition than actually a neurological condition, pain is very important, as we said before. Spinal pain can help us localise the lesion. The function of the tail.

The bladder and the anal sphincter can give us an idea of the extent of the lesion. Very important if nociception we said that before presence or absence of inception is quite relevant because we know the absence of nociception carries a poorer prognosis in our patients, so we need to be able to assess properly the noiceception. And always consider if the animal has some underlying condition again that can have an impact on the gates and on the guidelines is mentioned, dimensional Arctic thromboembolism which is .

A condition that can affect, the high limbs mobility, especially in cats, and often the patients that have aortic thromboembolism have cold poses, and, and this is not a neurological as such urgency. It is more, medical in the sense that, the animal is not walking. Because of a more circulatory cardiovascular problem than actually neurological condition, actions need to be taken when the disease is progressive and becomes severe, when it is very painful, or when the animal starts to show urinary and faecal incontinence.

All this will. Warrants, a quick action as per again guidelines. Some animals might need imaging for diagnosis and treatments.

X-rays in some cases may be if we suspect this coondylitis, X-rays can help. Make sure that we rule out the concurrent lesions, especially if we suspect a trauma, to make sure that we check the bladder integrity if there are other fractures or hernias, and another thing that we need to be aware of is that these patients might need nursing care if they are recumbent too, and that will have an impact on the organisation and . The management of the antenna management of the the practise where we are working, so this is something that needs to be considered if we want to manage this, this case, these cases properly to the owners, the advice, as we said at the beginning, is the advice on transportation to make sure we don't deteriorate the animal and the animal's condition, we can give them advice on what type of analgesic, can be used.

The guidelines say that if we suspect rombo. Embol in cats, the owners can give 75 milligrammes and 1/4 of a tablet of aspirin. So if we suspect thromboembolisms, if it's a cat that might have a heart condition and has cold pores, it's not moving them.

These patients can have a quarter of a of a 75 milligramme tablet of aspirin, but the case needs to be seen because often these patients have underlying conditions, so they need to be seen anyway. As a signs of deterioration, they list as other systemic signs changes in mental status and of course deterioration of pain if it gets worse. Spinal trauma, spinal trauma is an emergency.

So handling and transportation are very important. The use of a spinal or backboard very important to keep the animal still. As possible.

Don't forget our ABC. We need to make sure that if, especially if the animal has suffered from, RTA or any other type 4, any other type of trauma, we make sure that the, the, the rest of the body doesn't have other severe signs of trauma. So, so we need to check, the whole animal.

The neuron needs to be done very carefully so there are we, our main goal is not to deteriorate the condition, so we have to choose how we do the neuro exam, what, what we do to make sure that we don't worsen the condition. Radiographs now X-rays can be useful because there are situations when if there is a fracture or a severe luxation of the vertebrae. Together with the clinical science, we can already give an idea to the owners on the prognosis.

For example, if there is an instability, a severe luxation fracture and means a quite severe instability of the bones, the vertebrae, and on the near exam, the, the patient doesn't have no Cception, doesn't have the pain, and we are sure about it. Sure about the pain, then this patient has a very poor prognosis. So when it is a trauma and there is a stability in absence of nociception, there is poor prognosis to make sure that we are convinced that there is no nociception.

If the animal is paraplegic, said the condition is affecting the high limbs, we can compare with the front limbs. It always test all the digits, we test both legs deeply with the mosquito, and then to be sure that the animal is not stoic, we pinch the front limbs as well. So if we have an obvious reaction with the front limbs and nothing in every digit in both legs in the hind limbs and nothing in the tail, then this tells us that the ception is not there.

If the animal has received opioids has already received analgesia, then this can have an impact on our assessment of nociception. So make sure you assessing a nociception when the animal is not on opioids or the cars are weaned off, otherwise we can make a mistake in that sense. We do not recommend the use of methylprednisolone as they used a long time ago in patients they have.

For the, spinal trauma. What happens with spinal trauma is that the animals can deteriorate because we have a secondary injury that happens hours after the first injury that involves a cell death. So we have the primary injury that happens at the time of impact, but the, the.

Injury can worsen and can progress with time and therefore give a secondary injury of cell death. And of course, if there is instability, there is a high chance that the animal deteriorates. So if there is instability, these patients, especially if the clinical signs and neurological signs are quite severe, they will need, surgery.

These patients need nursing care, very, a lot of nursing care. They need, they will need bladder management. They will need, of course, feeding and turning when possible if it's done carefully, of course, but of padding, at least so bedding and being able to move them.

A little bit if not turning completely in a way that that we avoid pressure sores. Head trauma, we again talk about transportation and ABC with head trauma, and we need to make sure that there are no concurrent lesions. These patients can have skull fractures.

They can be relevant. They might need surgery as well. Eyes, the eyes can be affected as well.

It can have also trauma to the eyes. These patients might lose the control of their, body temperature and therefore we can have hyperthermia in these patients, so we may need to make sure to avoid hyperthermia. Again for a head trauma, we have a similar process for the spinal trauma.

We have the primary injury that can involve skull fractures, haemorrhage. Edoema and then a secondary injury. There are biomolecular events at the cell level that can deteriorate the clinical sign.

So we need to be able to monitor the clinical status of the patients and, and especially when we have, increased intracranial pressure because of haemorrhage and edoema, of course, the clinical signs can deteriorate. So we need to For a proper neurological examination in these patients. And there is the modified Glasgow Coma Scale that we can see in the next slide that, helps us evaluate neurologically the patients.

So the modified Glasgow Coma Scale is taken from, from your medicine and has been adapted to our patients. Dogs and cats assesses the motor activity, the brain stem reflexes, and the level of consciousness. So there is, A scoring system for each of the three group of tests and depending on again the response, there is a number related to them and then we do a total score.

So we, our aim our aim, what we hope for is that the animal has a score between 15 and 180 because if the score is low, of course there is, there are less chances for the animal to to recover. So this is helpful to use, at the. Of the assessment of the patient, but also for monitoring, for progressive monitoring of the, the conditions of the patients.

In the head trauma, it is important that we maintain, the nor the volemia. So we need to maintain the normal volemia of the patients. So we need to start proper fluidal therapy and because we need the cerebral perfusion to be done.

We need, we need blood to get to the brain. So the, the cereal perfusion needs to be maintained. If needed, .

This animal will need oxygen therapy or even ventilation in patients that can't oxygenate properly. There is the chance that this patient can develop seizures, and in a patient with an increased intracranial pressure, we can, give monitor if needed at 0.52 gramme per kg slowly, IV over 1520 minutes.

These animals will need nursing care and accurate vet monitoring. And the prognosis is given by the modified Glasgow coma scale because this is the one that will give us an idea on, especially on the progression of the secondary injury in the patient. .

Pain, pain again we said before, pain is very difficult. It is very difficult to access because, we need to be able to localise the area affected while trying to do a careful manipulation of the spine. We can ask the owners to give us an idea on the pain of the patient, but again, it is different when we actually can assess the pain ourselves.

We can score it, we can localise, and we can do the proper manipulation to, to, to do this. And then we put together the pain with the, presence of absence of neurological deficits. Sometimes the posture can help us and sometimes patients that have a cervical discomfort, they normally have a low head carriage and.

Patients that have a terrocolumber, the pain, they tend to have a bit more hatched back. They are general rules rules that are, you know, might not always be the case, and again they are quite difficult to judge as well, especially by the owners. It is important to know the progression of the pain, whether it's getting worse, whether the animal is actually responding to the treatments that we have given.

And we need to understand, of course, the cause, because if there is a history of trauma or or something else we need to find out so good again history from the owner is important and the radiographs as we said before could be helpful if we suspect something like again fracture, luxation or discospondylitis analgesia. Can the owners give analgesia home? Yes.

We can eventually, if the dons have paracetamol at home, we can advise them on a paracetamol, how to give it the dose the frequency, make sure, they don't give it to cats. If you feel confident that the owner can safely do that, make sure they don't give household analgesics. They don't start using their own medications, and otherwise you will need to prescribe medications depending on the type of pain, the severity, the progression.

So you can choose between opiates and nonsteroidals for gabapentin very useful as well for the neuropathic pain. A crate rest important if you suspect the animal might have a neurological condition, make sure that together with the analgesic. The the owners control the exercise short walks 3 or 4 times a day, and then the animal doesn't jump, does run around, is on a rest, very important as well.

The last condition that is listed is the mental status and the mobility. On the guidelines they mention intracranial disease, postictal, or metabolic condition. So we should try to understand what is the cause, the progression.

It is important because if it is severe or deteriorating, we need to intervene and try to understand the source of the change in mentation and mobility. The first thing to do in these patients is after the assessment run a food blood tests or at least electrolytes, the glucose glucose, and rule out on a pathic condition with ammonia and bust. So just as as a.

First screening to rule out the major more most common conditions. Monitor the patients. If you suspect hypoglycemia, try if you see if you can feed the patients, and then review the medications, then yeah, is receiving whether there is a correlation to the actual treatment.

So I've tried to cover as much as possible the diseases that have been listed by the in the guidelines and to give you a bit of tools to evaluate and to manage these patients. We are available for you for further advice, so you can call us and we can give you phone advice or we can do a full consultation with the patients, of course, for a full list of what we. We have available for you.

You can have a look at our website. We have help that is specifically put together for this time, and then of course our services will be available to help you in any way as possible for any advice. If you have any questions related to this, webinar, feel free to contact us at [email protected], and I hope you enjoyed it.

Thank you. Bye.