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Journal Club 21/7/2020

Hello everyone! Welcome to this evening's Journal Club with tutor Dr Kirolos Michael.

The article for the week will be released at 18:00 on our Journal Club Facebook event. This gives you 25 minutes to analyse the paper mimicking the time given for AFP interviews. We will then begin promptly at 18:30 for our discussion which will take place on our online chatroom.

Link to Journal Club event page:https://www.facebook.com/events/284941986049616

Link to this evenings chat room: Journal Club Discussion

Daniel Ahari

Jul 21 / 6:29 pm
Hi

Ashka Moothoosamy

Jul 21 / 6:30 pm
Hello

Graeme Burt

Jul 21 / 6:30 pm
Helloo

Lily Helston

Jul 21 / 6:30 pm
Hi all

Becca Vitarana

Jul 21 / 6:30 pm
Hello

Kirolos Michael

Jul 21 / 6:30 pm
Hello everyone, Kirolos here. I'll be you're tutor today

Alexandra Brooks

Jul 21 / 6:30 pm
hello

Trisha Alexandra

Jul 21 / 6:30 pm
Hi

Nadin Hawwash

Jul 21 / 6:30 pm
Hi all

Rox M

Jul 21 / 6:30 pm
hi

Roosindu Peris

Jul 21 / 6:30 pm
hello!

Ali Tariq

Jul 21 / 6:30 pm
Hi everyone!

Beth Clayton

Jul 21 / 6:30 pm
Can you please let us know your year of study and email addresses 🙂

Graeme Burt

Jul 21 / 6:31 pm
Year of study going into or just completed?

Trisha Alexandra

Jul 21 / 6:31 pm

Becca Vitarana

Jul 21 / 6:31 pm
Hi, becca.vitarana@gmail.com, going into year 4

Roosindu Peris

Jul 21 / 6:31 pm
roosindu@gmail.com Ill be going into my 4th year

Akshara Sharma

Jul 21 / 6:31 pm
Hello

Lily Helston

Jul 21 / 6:31 pm

Graeme Burt

Jul 21 / 6:31 pm

Alexandra Brooks

Jul 21 / 6:31 pm

Cameron Lynch

Jul 21 / 6:32 pm

Callum Docherty

Jul 21 / 6:32 pm

Daniel Ahari

Jul 21 / 6:32 pm
daniel.ahari@student.manchester.ac.uk just finished 4th year, intercalating now

Rox M

Jul 21 / 6:32 pm

Akshara Sharma

Jul 21 / 6:32 pm
180000142@aston.ac.uk going into 3rd year

Kishan Pankhania

Jul 21 / 6:32 pm

Mustafa Hussain

Jul 21 / 6:32 pm

Ali Tariq

Jul 21 / 6:33 pm

Beth Clayton

Jul 21 / 6:33 pm
Thanks everyone! Before Kirolos takes over for this weeks discussion, just wanted to let you know if anyone has any suggestions at all for these sessions feel free to message me on Facebook, I quite actively post in the events and the AFP group. Kirolos hasn’t got time to offer specific AFP advice but he’s just going to go through analysis skills and queations they are likely to crop up! Hope this is alright

Annabel Chadwick

Jul 21 / 6:33 pm

Shamia C

Jul 21 / 6:34 pm
shamia.chowdhury@student.manchester.ac.uk going into intercalation having finished year 4

Hassaan Ahmed

Jul 21 / 6:34 pm

Kirolos Michael

Jul 21 / 6:34 pm
Thanks Beth. Welcome everyone who's joined us before & to anyone who is new

Nosa Uwadiae

Jul 21 / 6:35 pm

Kirolos Michael

Jul 21 / 6:35 pm
Today's theme is vascular surgery. I picked this article as it's quite short & concise so should have been plenty of time to read through

Kirolos Michael

Jul 21 / 6:36 pm
So can somebody describe what this study was looking at?

Daniel Ahari

Jul 21 / 6:37 pm
mortality and morbidity for TEVAR and open approaches to thoracic aorta surgery in End stage renal disease patients

Trisha Alexandra

Jul 21 / 6:37 pm
Evaluate the outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients

Alexandra Brooks

Jul 21 / 6:37 pm
it was looking at the postoperative and long term outcomes of open vs. endovascular repair of descending aorta pathology in ESRD patients dependent on dialysis

Kirolos Michael

Jul 21 / 6:37 pm
Great

Kirolos Michael

Jul 21 / 6:37 pm
Everyone clear on what TEVAR is?

Graeme Burt

Jul 21 / 6:37 pm
Yes

Daniel Ahari

Jul 21 / 6:38 pm
assuming it's just thoracic EVAR haha (endovascular aortic repair)

Roosindu Peris

Jul 21 / 6:38 pm
Yes - Thoracic Endovascular Aortic Repair

Kirolos Michael

Jul 21 / 6:39 pm
So as you guys mentioned, it was to compare open thoracic aorta repair vs. thoracic endovascular aortic repair (TEVAR) which is a non-invasive technique. Its the equivalent of an EVAR, but for the thoracic aorta

Kirolos Michael

Jul 21 / 6:40 pm
A little background, patients with renal impairment are a particular problem in vascular surgery. They tend to be very high risk, especially those on dialysis. TEVAR is often used in higher risk patients, hence why this study was comparing both techniques in an already high risk group

Kirolos Michael

Jul 21 / 6:40 pm
What was the study design?

Daniel Ahari

Jul 21 / 6:40 pm
retrospective cohort?

Akshara Sharma

Jul 21 / 6:40 pm
retrospective cohort study

Graeme Burt

Jul 21 / 6:40 pm
As in a retrospective cohort study?

Callum Docherty

Jul 21 / 6:40 pm
Retrospective cohort

Trisha Alexandra

Jul 21 / 6:41 pm
Retrospective cohort study

Kirolos Michael

Jul 21 / 6:41 pm
I want to see everyone contributing today especially those who haven't in the past

Kirolos Michael

Jul 21 / 6:41 pm
Does anybody think anything other than cohort study?

Trisha Alexandra

Jul 21 / 6:41 pm
Based on last time I feel this was the same design...but I could be very wrong!

Kirolos Michael

Jul 21 / 6:41 pm
Those who think its cohort, can you briefly explain why that is?

Kirolos Michael

Jul 21 / 6:42 pm
That's right Trish, it's a very similar design to the last paper

Becca Vitarana

Jul 21 / 6:42 pm
comparing two methods (open and TEVAR) and measuring the outcome (morbidity and mortality)?

Callum Docherty

Jul 21 / 6:42 pm
It's a longitudinal study looking at an exposure of interest (in this case open or TEVAR repair)

Rox M

Jul 21 / 6:42 pm
because 2 groups are being compared...mainly. TEVAR and open

Shamia C

Jul 21 / 6:42 pm
I agree with Trisha and cohort because of the large group size and because comparisons are made between two groups in this study

Graeme Burt

Jul 21 / 6:42 pm
It's looking at a specific population set by defined limitations over a longitudinal period, retrospectively

Roosindu Peris

Jul 21 / 6:42 pm
they select a bunch of people who have the condition and record their response ?

Nadin Hawwash

Jul 21 / 6:43 pm
it is comparing individuals that had TEVAR and open retrospectively

Nadin Hawwash

Jul 21 / 6:43 pm
or*

Akshara Sharma

Jul 21 / 6:43 pm
they compared pre-existing haemodialysis patients who underwent open/TEVAR vs a control group (who werent dependent on dialysis before the approaches

Kirolos Michael

Jul 21 / 6:44 pm
That's right. It is a cohort study. You have 2 groups of patient with 2 different exposures (i.e. one group were open surgery and the other group was the TEVAR group), you then compare them in terms of different outcome, hence it's a cohort

Kirolos Michael

Jul 21 / 6:45 pm
You'll find in surgery, a lot of the studies are observational, and often cohort, just because of difficulties & ethical dilemmas with doing things like blinded studies or RCTs etc.

Kirolos Michael

Jul 21 / 6:45 pm
What was the population of interest in this study?

Akshara Sharma

Jul 21 / 6:45 pm
patients with ESRD

Becca Vitarana

Jul 21 / 6:45 pm
Haemodialysis patients in the US

Roosindu Peris

Jul 21 / 6:45 pm
Individuals who have ESRD who are on dialysis

Lily Helston

Jul 21 / 6:45 pm
Patients who had preexisting ESRD on HD

Georgia Savvides

Jul 21 / 6:45 pm
patients with end stage renal disease on dialysis

Alexandra Brooks

Jul 21 / 6:46 pm
ESRD patients dependant on dialysis with thoracic or thoracoabdominal aortic pathology

Nadin Hawwash

Jul 21 / 6:46 pm
Males with ESRD on dialysis that only had thoracic aneurysms

Kirolos Michael

Jul 21 / 6:46 pm
Fantastic. So not just end stage renal disease (ESRD) patients, but those who are on haemodialysis

Graeme Burt

Jul 21 / 6:46 pm
Patients who underwent either TEVAR or open repair of the descending aorta who were on renal dialysis prior to their operation

Callum Docherty

Jul 21 / 6:46 pm
Patients with ESRD requiring haemomdialysis pre-intervention with any uniquely thoracic aortic pathology (i.e. no other artery) undergoing repair

Becca Vitarana

Jul 21 / 6:46 pm
Not just males I think but majority were

Akshara Sharma

Jul 21 / 6:46 pm
also particularly descending thoracic aortic repair

Kirolos Michael

Jul 21 / 6:47 pm
Nadin, is it only males & is it only just paitents with aneurysms or did they include other pathologies like dissection?

Mustafa Hussain

Jul 21 / 6:47 pm
haemodialysis patients with ESRD

Kirolos Michael

Jul 21 / 6:48 pm
So they were looking at different pathologies of the descending aorta (thoracic aneurysms, thoracocabdominal aneurysms & aortic dissections)

Kirolos Michael

Jul 21 / 6:48 pm
Were they looking at emergency cases or elective cases or both?

Nadin Hawwash

Jul 21 / 6:48 pm
The subgroup analysis excluded dissection but yes the overall analysis included aortic dissection

Roosindu Peris

Jul 21 / 6:48 pm
64% were male

Callum Docherty

Jul 21 / 6:48 pm
Both

Becca Vitarana

Jul 21 / 6:48 pm
Both

Alexandra Brooks

Jul 21 / 6:48 pm
both

Lily Helston

Jul 21 / 6:48 pm
Both

Roosindu Peris

Jul 21 / 6:48 pm
the rest were female

Akshara Sharma

Jul 21 / 6:48 pm
both

Rox M

Jul 21 / 6:48 pm
both

Mustafa Hussain

Jul 21 / 6:48 pm
both

Kirolos Michael

Jul 21 / 6:49 pm
That's right Nadin, so they split off the pathologies in their analysis

Graeme Burt

Jul 21 / 6:49 pm
Both

Trisha Alexandra

Jul 21 / 6:49 pm
Both

Kirolos Michael

Jul 21 / 6:49 pm
That's correct everyone. Good spot because it wasn't initially very clear but they looked at both elective repairs & emergency ruptures (very different settings)

Kirolos Michael

Jul 21 / 6:50 pm
Right, shall we summarise the results

Kirolos Michael

Jul 21 / 6:50 pm
Starting with the demographics, were there any differences in the demographics between the TEVAR & open surgery groups that were significant?

Kirolos Michael

Jul 21 / 6:50 pm
Table II

Rox M

Jul 21 / 6:51 pm
the age of patients in tevar group was significantly higher than open surgery

Roosindu Peris

Jul 21 / 6:51 pm
most of those who had TEVAR were older than those who had the open repair

Alexandra Brooks

Jul 21 / 6:51 pm
the TEVAR subjects were older than the open repair patients

Graeme Burt

Jul 21 / 6:51 pm
Age

Akshara Sharma

Jul 21 / 6:51 pm
the age gap and PAD?

Lily Helston

Jul 21 / 6:51 pm
age would be significant given the p value

Hassaan Ahmed

Jul 21 / 6:51 pm
Older patients with tevar influences 1 year mortality

Callum Docherty

Jul 21 / 6:51 pm
TEVAR patients were significantly older

Graeme Burt

Jul 21 / 6:51 pm
(TEVAR older)

Trisha Alexandra

Jul 21 / 6:51 pm
TEVAR were older

Kirolos Michael

Jul 21 / 6:51 pm
Great

Kirolos Michael

Jul 21 / 6:51 pm
So as Akshara mentioned, there was a difference in nterms of peripheral arterial disease

Kirolos Michael

Jul 21 / 6:52 pm
However, as Lily highlighted, only age was stastically significant

Kirolos Michael

Jul 21 / 6:52 pm
Okay, moving on to other variables such as mortality

Kirolos Michael

Jul 21 / 6:53 pm
& 30 day complications

Akshara Sharma

Jul 21 / 6:53 pm
the TEVAR group had a significantly lower rate of 30 day complications

Akshara Sharma

Jul 21 / 6:53 pm
but they had a higher rate for strokes

Rox M

Jul 21 / 6:54 pm
but a hifger rate for stroke in tevar

Rox M

Jul 21 / 6:54 pm
higher

Alexandra Brooks

Jul 21 / 6:54 pm
TEVAR had a lower 30 day mortality than open but by 1 year the mortality between the two options was no different

Graeme Burt

Jul 21 / 6:54 pm
The Kaplan Myer shows lower early mortality in OPEN but by just under 4 years the overall mortality rates were similar (fig 2)

Kirolos Michael

Jul 21 / 6:54 pm
Good spot. Was this higher rate of stroke stastically significant?

Akshara Sharma

Jul 21 / 6:54 pm
no

Kirolos Michael

Jul 21 / 6:55 pm
what was the p-value Akshara?

Graeme Burt

Jul 21 / 6:55 pm
pneumonia, rest failure and stroke all p<0.05

Graeme Burt

Jul 21 / 6:55 pm
resp*

Kirolos Michael

Jul 21 / 6:55 pm
I agree Graeme with the Kaplan Myer curve

Akshara Sharma

Jul 21 / 6:56 pm
oh my apologies the p value is 0.018 so it would be statistically different?

Kirolos Michael

Jul 21 / 6:56 pm
So TEVAR had reduced rates of pneumonia & respiratory failure, but higher rate of stroke (all statistically significant)

Kirolos Michael

Jul 21 / 6:57 pm
There was no statistically significant difference in the rats of ileus, sepsis & paraplegia (because the p values were > 0.05)

Kirolos Michael

Jul 21 / 6:57 pm
and the 1 year mortality rate as Alexandra mentioned was no different between the 2 groups

Kirolos Michael

Jul 21 / 6:58 pm
Everyone happy with that? These are the main results. They dive further into regression analysis of factors implicated in mortality & they undertake sub-group analysis of different pathologies, but if everyone is happy, we can move on to strengths & weaknesses

Graeme Burt

Jul 21 / 6:59 pm
Sounds gooood

Akshara Sharma

Jul 21 / 6:59 pm
Yes I agree.

Trisha Alexandra

Jul 21 / 6:59 pm
Yes

Nadin Hawwash

Jul 21 / 6:59 pm
Yes

Kirolos Michael

Jul 21 / 6:59 pm
* the only other thing to add is that TEVAR was associated with a better 30-day mortality (in the regression analysis & this was statistically significant)

Rox M

Jul 21 / 7:00 pm
yes

Kirolos Michael

Jul 21 / 7:00 pm
What are the strengths of this study?

Roosindu Peris

Jul 21 / 7:00 pm
Kirolos Michael, just to clarify - how does the Kaplan Meyer. curve show this

Kirolos Michael

Jul 21 / 7:01 pm
So the Kaplan Meyer (survival curve) does not show that TEVAR has better 30 day mortality

Roosindu Peris

Jul 21 / 7:01 pm
the fact that the overall survival rate didnt chnage by intervention type after a year

Roosindu Peris

Jul 21 / 7:02 pm
so since P=0.4 for that comparison, there is no significant difference?

Kirolos Michael

Jul 21 / 7:02 pm
Its the regression analysis that suggests (when you factor in every other factor) that having a TEVAR had better 30 day mortality. the odds ration was o.41

Roosindu Peris

Jul 21 / 7:02 pm
oh okay

Kirolos Michael

Jul 21 / 7:03 pm
However, the Kaplan meyer survival analysis was not significant & in fact showed as you said there was no statistically significant difference between the 2

Kirolos Michael

Jul 21 / 7:03 pm
So they are analysing essentially the same thing in several different ways

Roosindu Peris

Jul 21 / 7:03 pm
that makes sense, Thankyou! was confused for a min there

Kirolos Michael

Jul 21 / 7:03 pm
It is a little confusing because they've analysed things in multiple ways

Kirolos Michael

Jul 21 / 7:03 pm
Any strengths or weaknesses?

Daniel Ahari

Jul 21 / 7:04 pm
Strength: similar demographics between the two groups (besides age) which makes comparison more accurate

Becca Vitarana

Jul 21 / 7:04 pm
I don’t understand why they looked at data from 2005-2008 when the study was presented in 2016. why couldn’t they use more recent data?

Graeme Burt

Jul 21 / 7:04 pm
Found it strange that they included trauma patients as their were so few and trauma was non-specific and so could potentially have many different outcomes for patients

Trisha Alexandra

Jul 21 / 7:05 pm
Data taken from 2005–08? I did think this too

Kirolos Michael

Jul 21 / 7:05 pm
All very good points

Lily Helston

Jul 21 / 7:05 pm
Would a weakness be that its a nationwide analyses? - as it is harder to minimise bias accounting for different surgeons/ after care of the centre etc

Nadin Hawwash

Jul 21 / 7:05 pm
In terms of weaknesses - I find it much easier to read studies which incorporate their tables within the text itself.

Callum Docherty

Jul 21 / 7:05 pm
I like how they framed their results with the discussion/conclusions - I think they were quite modest and make it clear there were a number of limitations to the study

Trisha Alexandra

Jul 21 / 7:05 pm
Also they used a national bank this time rather than one centre like in the last paper so i thought this would me more generalisable to the population?

Kirolos Michael

Jul 21 / 7:06 pm
I'm also intrigued by the wide variety of pathologies. Elective & emergency. And inclusion of traumas too

Lily Helston

Jul 21 / 7:06 pm
^ but also like trish said, it could be a strength

Kirolos Michael

Jul 21 / 7:06 pm
Fanatastic comments everyone

Kirolos Michael

Jul 21 / 7:06 pm
in their defence, they have been very modest about their claims

Callum Docherty

Jul 21 / 7:06 pm
One big problem I think is their Cox regression shows increasing age is associated with significantly increased mortality over time, but the TEVAR group was significantly older on average compared to the open group

Kirolos Michael

Jul 21 / 7:06 pm
even the title I found interesting

Trisha Alexandra

Jul 21 / 7:06 pm
Yes Lily, I feel you it can be used either way as now its not just the same surgeon

Kirolos Michael

Jul 21 / 7:07 pm
Very good point Callum. So TEVAR was essentially reserved for the patients who were already at increased risk anyway

Becca Vitarana

Jul 21 / 7:07 pm
Why is the title interesting?

Kirolos Michael

Jul 21 / 7:07 pm
I mean the title is interesting because the already admit that both treatments are already high mortality

Becca Vitarana

Jul 21 / 7:07 pm
I see

Kirolos Michael

Jul 21 / 7:08 pm
so they're not trying to sell TEVAR as a low-complication rate alterantive etc.

Trisha Alexandra

Jul 21 / 7:08 pm
excluded those who had concomitant arch, root, or ascending aortic repair - no idea what effect this has

Kirolos Michael

Jul 21 / 7:08 pm
Which I respect. They could have tried to spin this article as TEVAR being much better in terms of short term complications

Kirolos Michael

Jul 21 / 7:09 pm
So Trish, they excluded them because these factors make surgery more complicated and the pathologies themselves have different morbidity & mortality rates associated with them

Kirolos Michael

Jul 21 / 7:09 pm
They tried to focus on pathologies of the descending aorta ONLY

Kirolos Michael

Jul 21 / 7:10 pm
and avoided pathologies that involve the root of the aorta (close to the heart) & arch which would have resulted in more confounding factors

Kirolos Michael

Jul 21 / 7:10 pm
Any other comments?

Trisha Alexandra

Jul 21 / 7:10 pm
Thank you, Kirolos can you please explain about the data being used from 2008? Is this a weakness or something that cant be avoided

Shamia C

Jul 21 / 7:10 pm
How would using older data be seen as a weakness?

Callum Docherty

Jul 21 / 7:10 pm
As has been pointed out I definitely think data taken from 2005-2008 is a bit odd - endovascular surgery seems like a rapidly evolving field and presumably skill and technique has changed since 10+ years ago

Kirolos Michael

Jul 21 / 7:11 pm
I totally agree with you on the outdated data

Kirolos Michael

Jul 21 / 7:11 pm
they only followed patietns up for max 4 years in the Kaplan-Meyer analysis

Trisha Alexandra

Jul 21 / 7:11 pm
Also is this study better as they did 1 year follow up? compared to just 30 days?

Kirolos Michael

Jul 21 / 7:11 pm
TEVAR has come a long way since 2005 etc

Kirolos Michael

Jul 21 / 7:11 pm
So yes, definitely the longer follow up, the better

Kirolos Michael

Jul 21 / 7:12 pm
As you guys might have noticed, when I pick these papers, I pick ones with a lot of holes in their methodologies that make for more interesting critiques

Kirolos Michael

Jul 21 / 7:12 pm
Very strong studies are much harder to rip apart

Kirolos Michael

Jul 21 / 7:12 pm
Any other comments, thoughts or questions?

Kirolos Michael

Jul 21 / 7:13 pm
Or shall we wrap up?

Graeme Burt

Jul 21 / 7:13 pm
They didn't specify cause of renal pathology. I assume vascular causes of renal diseases will affect outcomes

Trisha Alexandra

Jul 21 / 7:13 pm
Also I've realised having read the other paper from last time you can compare it to that and it makes it easier! maybe I will get the hang of it in 10 weeks time!! Thank you!

Roosindu Peris

Jul 21 / 7:13 pm
ive a question regarding the cox regression that was mentioned in a previous comment

Kirolos Michael

Jul 21 / 7:14 pm
Very true Graeme. Although in general as well dialysis is generally associated with adverse cardiovascular outcomes overall anyway

Kirolos Michael

Jul 21 / 7:14 pm
Fire away Roosindu

Roosindu Peris

Jul 21 / 7:14 pm
why is the cox regression used here to show increasing age being associated with higher mortality

Roosindu Peris

Jul 21 / 7:14 pm
like does it make the claim more valid?

Kirolos Michael

Jul 21 / 7:15 pm
So cox regression is a form of analysis which looks at all the different factors and teases which ones impacted the outcome & by how much

Kirolos Michael

Jul 21 / 7:15 pm
They included age, because it's a really important factor & it's assumed to increase risk anyway so this further demonstrates this

Shamia C

Jul 21 / 7:15 pm
I wonder if they have used outdated data as in Figure 1 there appears to be a general trend of greater number of endovascular vs open interventions with each year, thus would it make it more difficult to accurately compare the outcomes of the interventions?

Roosindu Peris

Jul 21 / 7:16 pm
Oh I see that makes sense

Kirolos Michael

Jul 21 / 7:16 pm
but then TEVAR patients were older, but in cox regression had better 30 day mortality, yet age suggests worse outcomes

Kirolos Michael

Jul 21 / 7:16 pm
so they're trying to say, these TEVAR pateints should have had much worse outcomes just because of the age alone, but the outcome ended up being the same anyway. That's I read into it

Kirolos Michael

Jul 21 / 7:17 pm
Very fair point Shamia. I don't know if they just had the data lying around

Roosindu Peris

Jul 21 / 7:17 pm
That makes a lot of sense

Kirolos Michael

Jul 21 / 7:17 pm
Right

Kirolos Michael

Jul 21 / 7:17 pm
Thanks for attending guys. I’ll be grateful if you could fill in this quick feedback form: https://forms.gle/nAHa4tqG4Rv9yNZj6

Kirolos Michael

Jul 21 / 7:17 pm
Next session's theme will be neurosurgery

Shamia C

Jul 21 / 7:17 pm
Thank you!

Trisha Alexandra

Jul 21 / 7:17 pm
Thanks, bye!

Kirolos Michael

Jul 21 / 7:17 pm
feel free to email me any suggests for articles at kirolosmichael@gmail.com

Graeme Burt

Jul 21 / 7:17 pm
Thanks 🙂

Kirolos Michael

Jul 21 / 7:18 pm
and feel free to email any questions we didn't cover

Nadin Hawwash

Jul 21 / 7:18 pm
Thank you

Kirolos Michael

Jul 21 / 7:18 pm
Thanks guys

Alexandra Brooks

Jul 21 / 7:18 pm
thank you!

Ali Tariq

Jul 21 / 7:18 pm
Thanks!

Daniel Ahari

Jul 21 / 7:18 pm
Thanks!

Becca Vitarana

Jul 21 / 7:18 pm
Thanks Kirolos !

Callum Docherty

Jul 21 / 7:18 pm
Thanks!

Akshara Sharma

Jul 21 / 7:18 pm
Thank you!

Roosindu Peris

Jul 21 / 7:18 pm
Thanks Kirolos!

Rox M

Jul 21 / 7:18 pm
thank you

Lily Helston

Jul 21 / 7:19 pm
Thanks once again !

Georgia Savvides

Jul 21 / 7:19 pm
thank you!

Kishan Pankhania

Jul 21 / 7:19 pm
Thanks
thanks