Quote from Scalpel on 3rd August 2020, 10:30 pm

		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?
		Nadin Hawwash Jul 21 / 6:31 pm Year 3 nadine.hawwash@student.manchester.ac.uk
		Trisha Alexandra Jul 21 / 6:31 pm Final year – pvinchenzo01@qub.ac.uk
		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
		Ashka Moothoosamy Jul 21 / 6:31 pm Year 3. Ashka.moothoosamy@student.manchester.ac.uk
		Leah AB Jul 21 / 6:31 pm leah.argus@student.manchester.ac.uk Y4
		Akshara Sharma Jul 21 / 6:31 pm Hello
		Lily Helston Jul 21 / 6:31 pm olivia.helston@student.manchester.ac.uk, heading into 4th year
		Graeme Burt Jul 21 / 6:31 pm graeme.burt@student.manchester.ac.uk going into final year
		Alexandra Brooks Jul 21 / 6:31 pm alexandra.brooks@student.manchester.ac.uk, going into 5th year
		Cameron Lynch Jul 21 / 6:32 pm Final year. cameron.lynch@student.manchester.ac.uk
		Callum Docherty Jul 21 / 6:32 pm Hi! Year 5 callum.docherty@student.manchester.ac.uk
		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 roxana.moscalu@student.manchester.ac.uk, final year
		Akshara Sharma Jul 21 / 6:32 pm 180000142@aston.ac.uk going into 3rd year
		Kishan Pankhania Jul 21 / 6:32 pm kishan.pankhania-2@student.manchester.ac.uk, final year
		Mustafa Hussain Jul 21 / 6:32 pm going into 4th year, muhammad.hussain-9@student.manchester.ac.uk
		Ali Tariq Jul 21 / 6:33 pm ali.tariq-4@postgrad.manchester.ac.uk, final year
		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 annabel.chadwick@student.manchester.ac.uk, fifth year
		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 hassaan.ahmed@student.manchester.ac.uk going into 5th year
		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 nosa.uwadiae@student.manchester.ac.uk Going into finals.
		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
		Mustafa Hussain Reply thanks