The MEN1 Mosaic

#43 - Getting MEN1 Parathyroid Surgery Right First Time (Professor Fausto Palazzo, Leading UK Endocrine Surgeon)

• Lizzie Dunn • Season 1 • Episode 43

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What does good parathyroid surgery look like for someone with MEN1? In this rare interview, leading UK endocrine surgeon Professor Fausto Palazzo shares what really matters — from timing and surgical options to what you should know before and after the operation.

Whether you’re newly diagnosed or weighing up next steps, this episode will help you feel informed, empowered, and ready to ask better questions.

You’ll learn:

Why MEN1 surgery isn’t the same as non-MEN1

What “success” means for MEN1 parathyroid surgery

The biggest pitfalls to avoid

Recovery tips most patients don’t hear

When surgery during pregnancy might be necessary

ABOUT OUR GUEST - Professor Fausto Palazzo is a leading UK endocrine surgeon specialising in parathyroid, thyroid, and adrenal surgery. Based in London, he is known internationally for his expertise in complex endocrine conditions and syndromes like MEN1. Professor Palazzo leads the endocrine surgery service at Hammersmith Hospital and regularly contributes to research, education, and multidisciplinary care.
Website - click here.

Join my MEN1 community & receive the free guide that helps keep me out of surgery, off medication and asymptomatic. Click here.

*Here I share my personal experience as a MEN1 patient. Nothing is intended to provide medical or holistic health advice. All opinions are personal, including those of my podcast guests. Always consultant a qualified medical professional.*

Hello and welcome back to another brand new episode of the MEN1 Mosaic Podcast. My guest with me today is Professor Palazzo, who is a leading endocrine surgeon here in the UK. I have asked him on because he is really an expert in terms of parathyroid surgery, which is one of the massive areas of interest for MEN1 patients, and today we're going to chat about how surgical decisions are made, what actually goes on in the operating theatre that we may not know about, and what we as patients can do to help ourselves both prepare before surgery and look after ourselves after surgery as well.
So Professor Palazzo, it's really really lovely to have you on. Thank you very much for so generously offering your time today. It's an absolute pleasure to be here, and I'm very impressed with your pronunciation of my first and second name, so thank you. You're most welcome, you're most welcome. I have a little bit of a background in languages, which is why I do like to make the effort — I think it can make all the difference. So the first question I wanted to lead off with is probably one that I think any MEN1 patient is probably going to come and ask you, which is that at some point in our trajectory as patients, the parathyroid starts playing up. When is the right time for parathyroid surgery in your opinion? When might an MEN1 patient consider this to be the right move for them? 
Well, this is obviously a very, very good question. And I think it's worth remembering, however, that we don't always know when a patient is an MEN1 patient. So we have to start with the fact that if we have a patient who is young with primary hyperparathyroidism, or has a family history of hyperparathyroidism — which may be more or less known to the patient — then of course we come to MEN1 patients from a different point of view. In other words, they become the index case. So that's one group of patients. And then there's the other group of patients, which I think you're referring to mainly — the ones that present to us with known MEN1 syndrome, genetically proven. And then we have to decide what to do.
Now, as you know, primary hyperparathyroidism is usually the presenting disease, because almost everybody with MEN1 will get hyperparathyroidism at some point. The penetrance is about 95%. What I mean by that is that an individual has a 95% chance of having hyperparathyroidism if they have MEN1 syndrome. So the peculiar thing about MEN1 hyperparathyroidism is that it is a multiple gland disease — sooner or later, it’s a multiple gland disease. So that's one aspect of it. And the other aspect of it is that — there's a sort of subtext, almost, to your question — which is: if you have primary hyperparathyroidism, which is sporadic (in other words, not associated with a known genetic abnormality), then the indications for surgery and the timing for surgery is basically not so relevant. Because you expect to operate on the patient, to cure the patient, and then it’s resolved. When you operate on MEN1 patients, other things come into play. The first thing is, in most MEN1 patients there’ll be some sign of primary hyperparathyroidism in their teenage years, and certainly in their 20s. So you could intervene as soon as you make the diagnosis. But the question is, is that in the patient’s best interest? Or if we treated them like a sporadic hyperparathyroid patient, then we — you could say traditionally — “oh, let's wait for evidence that this disease is doing you some harm,” so: loss of bone density, or kidney stones, or very high levels of calcium. 
But in MEN1 patients it’s a different thought process. Because when we operate, we almost certainly know that we will end up operating again. So the earlier you operate, the longer you provide the patient to have a recurrence — and the harder the operation. Because the parathyroid glands, as you know, are small. And if you intervene when the disease is very early in its trajectory, the parathyroids will be even smaller than later. 
So in terms of the right time — there isn’t one. That’s really the short answer. And I think the way you make the decision is an open dialogue with the patient. And these consultations are not easy because there’s a lot to understand. Now, most patients — especially thanks to podcasts like this — are pretty informed. However, not everybody is. And not everybody understands what the surgery will involve, and what the risks really are, especially in re-intervention. So in my practice, it’s an open dialogue with the patient, often with the involvement of our endocrinologists who would have primed the patient. We often have a conversation at a multidisciplinary team meeting — the MDT, which you’ll have heard lots about — and then we come to a conclusion. I'm really glad that you made the distinction there between MEN1 hyperparathyroidism and then, let's just call it, non-MEN1 hyperparathyroidism. I think it's so important to remember — particularly as you said — because there is the topic of recurrence for MEN1 patients. And again, I'm glad you've touched on this. You pre-empted my next question, and I was going to ask you: in talking about recurrence for MEN1 patients, and this idea that the longer we delay that first surgery, the longer we're then delaying the possibility of the parathyroids kind of “playing up again,” as it were — very untechnical language, but that's how I think of it — how is it that you as a surgeon yourself, but also with your medical team and the people you work with, how is it possible to minimise surgeries but maximise positive outcomes, if that makes sense? 
Because I think in a very logical way of thinking about it, it might look as though, “Well, we just operate each time we need to,” but obviously that’s not necessarily the case, I assume? 
Yeah — this ties in with the first question, really. Because theearlier you intervene, the harder the operation. But the later you intervene, the more likely the patient’s going to have end-organ damage — so, have kidney stones, have loss of bone density, and so on. How can we minimise the problems? Well, effectively it's about getting, number one, the timing of the operation as optimised as possible. And it's not always easy to get it absolutely right. And the second thing is to choose the right operation. Now, not infrequently, patients have a parathyroidectomy not knowing they have MEN1 syndrome. So the surgeon will do an operation which will involve, often, removing a single parathyroid gland which they found on a scan. Now the problem then is — the patient then has a recurrence, inevitably. And you're doing a reintervention.
So that's one end of the spectrum. Another end of the spectrum is the patient is known to have hyperparathyroidism related to MEN1, and you choose a strategy. And there are different strategies — maybe you will ask me about — but there are different strategies in parathyroid surgery in this context. And also it's very geographically different — in different parts of the world, people do different things. But to optimise the benefit to the patient, we've got to remember what we're trying to achieve. What we want is to cure the patient of hyperparathyroidism — and cure them for as long as possible. So what would we describe as success in primary hyperparathyroidism in MEN1 patients? Well, the perfect operation is one where you do a parathyroidectomy, you normalise the patient’s calcium and PTH, and it stays normalised for the rest of their lives. Unfortunately, this is not that common. What's more common is that the patient has a recurrence. Now, one way of eliminating the risk of recurrence is to do a total parathyroidectomy — so, in other words, removing all parathyroid tissue. But the problem with that is you provide the patient with a new problem, which is being hypoparathyroid — in other words, having to take calcium and vitamin supplements for the rest of their lives. So let's eliminate that from the options, even though it has been used in the past. So what we try to do is, being mindful of the fact that you're not going to achieve the perfect operation, what you want to do is prolong the period of normocalcaemia — in particular — for as long as possible. And if we can achieve at least a decade — at least a decade — I think that's a success. Now, of course, we do have some patients who’ve done fantastically well — that 20 years down the line, their calcium’s still normal. But depending on the surgical strategy you adopt, you can have recurrences quite early. So the way in which you achieve the optimal outcomes — and minimal damage to the patient — is: choose the timing right, and choose the best surgical strategy. Thank you for that. I wondered — I thought I might sort of simplify a bit, because there are many listeners to this podcast who might have just been diagnosed with MEN1, or they have come across the podcast without MEN1 but there's some relative content. Can you explain to us what actually happens during parathyroid surgery, and why is it being done? What is that desired outcome — in as simple terms as you can? Right. So, everybody has four parathyroid glands. MEN1 patients have a higher rate of what are called supernumerary parathyroid glands. In other words, the chance of you having five or more parathyroid glands is higher if you have MEN1 syndrome. In the general population, it's about 6%. In MEN1 patients, it's a bit higher. At surgery, what we aim to do in the classic operation — which is what we would call a subtotal parathyroidectomy — is to identify all of the parathyroid glands. Which really means, most probably, four parathyroid glands. Because you don’t know who's got more than four, so you won’t go looking for the fifth gland unless you know it’s there. One therefore inspects all the parathyroid glands, and then you have to choose. First of all, you’ve got to do this operation without damaging the parathyroid glands — without compromising their blood supply. And then once you've done that, you look at the parathyroid glands and you think: right, which is the most normal-looking of these parathyroid glands? Once you've identified that gland, you leave it, and you remove the other three parathyroid glands. Now, if you're unlucky and all of the parathyroid glands are clearly diseased, then you have to remove three of the parathyroid glands and half — or a significant fragment — of the fourth parathyroid gland. And from a surgical point of view — I don’t know how many surgeons listen to this — the important thing is that if you're going to remove half of a parathyroid gland, or a fragment of a parathyroid gland, you always do that first. Because sometimes you will find that the act of removing half of that parathyroid gland obviously compromises the gland. So you don’t want to burn your bridge — you want to do that first. And then I always say to the team: don't even look at that parathyroid gland. It's got to survive now. So we don't go there again, and we remove the rest of the parathyroid glands. So that is the classic parathyroidectomy in MEN1 syndrome patients. Now, then there's the issue about whether you remove the thymus or don’t remove the thymus. The rationale for removing the thymus is to remove supernumerary parathyroid glands, or islands of parathyroid tissue. Now there's often a misunderstanding about why people do a thymectomy in MEN1 patients. It's often the doctors — young doctors — who don’t understand. We're not doing it because MEN1 patients may get a thymoma — because you can’t reliably remove a thymoma through a neck incision alone. And often you would know that the patient has a thymoma — or possibly know. That would require a different operation. So, in summary: the patient has three or three and a half parathyroid glands removed, with or without removal of the thymus. That's the classic operation performed in the UK in specialist centres. Now, there are other options that have been popularised — including doing a unilateral operation. So, in other words, you use imaging. You find which is the dominant parathyroid gland on one side of the neck. You go to that side of the neck, remove the clearly abnormal parathyroid gland, remove the second parathyroid gland on the same side, and possibly do a thymectomy — all on the same side. So you may ask: what's the rationale for that? Well, the rationale is this: that if you can do that, then when the patient has the inevitable recurrence, you'll be going to a virginal side of the neck. So in other words, you’ll never have to go back to the side you operated on previously. And what parathyroid surgeons don’t particularly like is having to reoperate in a scarred neck. That is a significant part of my practice in primary hyperparathyroidism for sporadic disease as well as MEN1. Because you go back — it’s often a patient’s had a parathyroid surgery, and the abnormal parathyroid gland has not been identified. So you have to go in and reintervene. These operations can be difficult because of the scarring from previous surgery. So that’s one of the reasons why people thought that, in MEN1, this might be an option — and it has been vaguely popularised in Sydney, in Australia, and San Francisco. They've published on this as a good technique. My personal experience is not great with it, because I think the recurrences have been much, much earlier than I would have liked. True — you go into a virginal neck. But still, it’s very difficult to say to a patient after 18 months, “Oh, I'm afraid that the calcium's high again.” It's not a nice conversation to have. Whereas, if they come back after 10, 12, 13 years, you say, “Look, you've had a good innings. You've had a good run. Now we have to think about the next step.” I don’t know if this is going to come across as a very sort of obtuse comment, but this sounds like such a kind of precise, complex piece of surgery. And I don’t know whether I have a whole newfound appreciation for the practice of surgery in and of itself, but I mean — there is so much at stake. And there must be so many different things to consider when you're in the operating theatre. And goodness knows there are a million and one different things going on. And, you know, you are wanting to perform the best operation possible but also having to think about all the potential repercussions that may come further down the line. I mean, it just sounds phenomenal in terms of the space you’re having to really consider — such an important piece of surgery, really. I just needed to kind of share that because I really am quite struck by the precision of it. Well, I think everyone’s job has its stresses and complexities. I think that this is just — this is just another operation. All surgeons have difficult operations. But the thing about — I would say if we have to be honest about this — the thing about this type of surgery is it's quite rarefied. And that’s the thing — it’s the understanding. The nuances of patients with syndromic primary hyperparathyroidism — because there are other syndromes as well where one gets hyperparathyroidism — understanding those small differences that can make a difference to the patient. And there’s another aspect to this, which is really important, I think. And that is the emotional aspect to this. And that is that when you operate on an MEN1 patient, you’re often not operating on a patient — you’re operating on a family. So you know that a bad outcome has major impact. Because if one family member has a bad outcome, then the subsequent family members are either reluctant to have surgery, or it creates a degree of anxiety for them. So getting it right the first time — or as right as you possibly can the first time — makes a big difference to you as a surgeon, but mainly to the patient and the subsequent relationship that you have with the family, with the patient, and the other family members. So yeah, it's not always easy. It’s not always easy. But it’s very enjoyable, that’s for sure. I love to hear that. It's very — I think — reassuring to know that the work itself is appreciated. And definitely, I mean, I haven't had parathyroid surgery myself, but I know from other MEN1 surgeries that, yeah, having that really strong relationship with the surgeon and the medical team is so, so important. And it made me want to ask, actually — when you see patients in clinic pre-op, is there any kind of advice or tips that you can give them in terms of being in the best shape possible for the surgery? I'm thinking about, you know, does fitness make a difference, does being well slept make a difference — those kinds of things that we tag as general health. Well, I think that MEN1 primary hyperparathyroid surgery — and patients in that respect — they’re not different, because we give the same advice. Namely, if you have primary hyperparathyroidism whilst you're waiting for your surgery, the best thing to do is stay well hydrated. Because if you become dehydrated, your calcium level goes up. And if your calcium level goes up, you can have some effects — for example, you can find that you're going to the toilet more, especially at night, because of what's called the diuretic effect of a high calcium. So if you've got too much calcium in your blood, and then you're passing it through your kidneys, you will pass more urine — especially when the calcium gets high, towards the sort of 2.9 levels. And the problem with that, of course, is if you're getting up at night — as many middle-aged men will tell you — if you're getting up at night, then you have disturbed sleep. If you have disturbed sleep, then you feel not quite so fresh during the day. So that's one thing that has to be done. You have to stay well hydrated — and ideally, not drink loads of water late at night, but just drink it during the day. Otherwise, you'll provoke the problem that we've just tried to avoid. That's one thing. And staying physically active is important for your bone health. But there's obviously a great drive — especially in patients of middle age — to try to keep their bone mass by doing weight-type training. Now this applies more to sporadic primary hyperparathyroidism than MEN1 syndrome patients, because most of the MEN1 patients we operate on — not all, but most — are young, are relatively young. So the peak incidence of primary hyperparathyroidism in the general public is in the 50s, whereas we know — as I said earlier — that primary hyperparathyroidism in an MEN1 syndrome context is present by the time the patient’s in their 20s, for sure. So it's a different sort of patient group. But the principles remain the same: to prevent end-organ damage as well as you can by staying hydrated, which not only avoids the big peaks in calcium levels, but also has other beneficial effects — not only the diuretic effect, but also the way that you feel. Because we know that if you have a very high calcium in the older age group, you can become a bit confused. And we see this in elderly patients who have very high calciums — again, not typical of MEN1, but the principles remain the same. And how about post-operation and in the recovery period? I know that parathyroid surgery — particularly in the last, well, 10–20 years — will have come on such a way. And sometimes I think it's done in a day and there's no need to stay overnight and this sort of thing. But you know, the body is still responding to a kind of trauma (again in inverted commas). Is there anything that you recommend patients are aware of in those few weeks post-surgery — either steering clear of, or things, you know, little habits that are going to help them get better? Yeah, I think that you've got to remember that after you've had a parathyroidectomy for primary hyperparathyroidism — in all contexts — there's a change in your bone metabolism. Mainly, the bones — if you like — they call back the calcium that they've been losing. So during that time, it's important that the patient has a normal vitamin D, whenever possible. And the reason is because vitamin D is fundamental in the absorption of calcium in the gut. So what you want to do is make sure that you just have a normal diet. You don’t necessarily have to take calcium supplements, although it’ll certainly do no harm — and to have a normal vitamin D so that you absorb that calcium, which then goes back into the bones, where it's supposed to live. So that's important. And then the other things really are just the management of the local effects of having an operation on the neck. Those instructions should be provided by the surgical team. And then just returning to normal life as soon as possible — I think that’s really important. I'm a great fan of convalescence, by the way. I think it's underrated. I think we have an obsession now of, you know — surgery, back to work. Well, actually, I agree with that from a national economic point of view — that’s great — but I also think that sometimes patients really need to get over the general anaesthetic, and the discomfort in the neck (which is usually not that bad, by the way), and actually the stress of having an operation — which we so often forget. Because what is another day at the office for me is a life event for the patient. And overcoming the surgery is not always easy for all patients. And one other thing we have not spoken about, by the way, is the issue about young patients and young women, and MEN1 syndrome-related hyperparathyroidism. Because you've got to remember there's an added factor — and that is whether they're pregnant or not, or whether they're planning a family or not. So all these things — all these things come into play. But in terms of answering your question about the recovery — not to go back too far off the line of questioning — it should basically be nothing particular other than good nutrition, vitamin D levels, good physical activity levels, and a gradual return to normal activities and work. Thank you. That’s really helpful to hear, and very tangible as well — which I know patients love. Because sometimes it can feel like everything’s hard to grasp. But I think having some really clear things to do is really helpful. And I’m glad that you mentioned the topic of pregnancy — it’s just reminded me that there are a number of young female listeners, probably around about my own age, in this audience and this MEN1 community. In terms of family and family planning, is there a rule of thumb that most MEN1 centres follow in terms of recommending surgery before pregnancy? And what happens, for example, if someone is already pregnant and they find out they have MEN1 or high calcium? What are the instances that you’ve seen in your experience? Yeah, well, this is a brilliant question, and it’s something which is of particular interest within my group. As you know, I work at the Hammersmith with my colleagues Mr di Marco and Neil Tolley, and we’ve discussed this at length. We’ve published on this as well — both in patients that have miscarriage and the possibility that they have undiagnosed hyperparathyroidism, and the problem of what to do with a woman with hyperparathyroidism who’s pregnant. Now MEN1 has got a peculiar position. Let’s start with the patient who is not an MEN1 patient. So in that situation, the patient is found to have hyperparathyroidism during pregnancy. It could be MEN1-related, but it most commonly won’t be. So that’s one scenario. The second scenario is the patient who is in her late 20s and wants to start a family. And she will say to her endocrinologist, “What do I do? Do I have my parathyroidectomy straight away, or do I have my pregnancy and then have the parathyroidectomy?” Now as a general rule, we prefer women not to have hyperparathyroidism during pregnancy. And the reason we don't want them to have hyperparathyroidism is because it’s associated with reduced birth weight of the fetus, a risk of preeclampsia (a condition where you end up having high blood pressure and some other bad effects) — so that’s something you really don’t want. Whether or not it leads to miscarriage is more contentious, but certainly those two things are important. And you have a higher rate of emesis — in other words, you’re more likely to feel sick during pregnancy if you have hyperparathyroidism — which in itself provides another problem. That is, you’re more likely to become dehydrated. And if you're more likely to become dehydrated, your calcium goes up further. So it's not ideal to have hyperparathyroidism during pregnancy. So if you're an MEN1 patient, there's the conversation to be had about when you intervene and when you have your family. And that's a conversation, actually, that the endocrinologists are probably having more of than us. Having said that, most of our clinics are joint clinics — which is the gold standard in endocrine surgery, I think. That you have a clinic where there’s a surgeon present and there's an endocrinologist present — because then the patient has the opportunity to speak to both at the same time. So timing of hyperparathyroid surgery in MEN1 has to take that into account. If the patient is pregnant — and it has happened, by the way — where you say to the patient, “You've got MEN1, your surgery is going to be in six months’ time, don’t get pregnant,” but they forget. And so the patient becomes pregnant. Then you’ve got to make a decision what to do. Okay, well, you asked for a rule of thumb. The answer is: every department will have its own ethos. But I would say — I’m going to take a chance and say — that most big centres would adopt a plan that’s not dissimilar to ours, which is: if the biochemistry is very, very mild — so in other words, the calcium’s 2.6, 2.7, something like that, very marginally raised — then you might say, let’s sit this out. Now, why is the level of calcium important?The level of calcium in the mother is important because we know that the fetus’s calcium will always be higher than the mother’s. Because the placenta produces something called PTHrP — now it's getting unnecessarily complicated — but basically it produces another form of PTH, which makes sure that the fetus always has a higher calcium than the mother. So it's like a parasite — your fetus is like a parasite. The mother will always give up her calcium to the fetus. But there’s a problem there — because if the mother’s calcium is too high, the fetus’s will be higher still. So if your mother’s calcium is 2.8, the fetus’s calcium might be 2.9, 2.95. And when the fetus is born, there’s a problem — because the fetus’s parathyroid glands will be normal. And therefore, if the calcium is high — say my calcium’s at 2.9 — my parathyroid hormone level would be very, very low. It would be suppressed. And the fetus is the same. So when the baby is born, they have no parathyroid function — and therefore their calcium crashes. And that’s called neonatal tetany. Now, if you know this is happening, it can be managed. In specialist centres, they make sure the fetus is given calcium — usually into their umbilical vein. But if you don’t know, and the baby has convulsions and tetany — then of course it becomes a panic, because you have to try and work out why that’s happening. So you see — in the pregnant woman, it’s complicated. So in summary — if I can try to summarise what I said — it’s: try to avoid being hypercalcaemic during the pregnancy. If it happens, then you have to have a very careful conversation with your clinician so you can decide what to do. And normally, if you’re going to have surgery, you'd have surgery in the second trimester — in other words, between the third and sixth month of your pregnancy — which is the safest time to intervene, as a general rule. And if you have to have surgery, that should be done in a specialist centre where they’re used to managing both hyperparathyroidism and pregnancy — which, I have to say, is like we have at the Hammersmith, because we have a complex pregnancy and neonatal unit at Queen Charlotte’s next door. Brilliant. That’s massively clear — to me anyway. And as I said before, I think MEN1 patients love anything we can get our hands around and hold very tightly in terms of information and advice, if you want to call it that. So thank you very much. I very sadly in a moment have to draw the episode to a close, but I wanted to ask you one final question before we finish, which is: if you could give any kind of piece of advice, or share anything with an MEN1 patient audience who has listened to this podcast so far and is still here — from your experience, your expertise, your knowledge of your profession and all the work you’ve done in this area — what is one thing that you would leave with people? Right, that’s an interesting question. First of all, I’d like to say that you’re very pessimistic to say “for those that are still here” — implies that you fear some of your listeners have left already. That’s not good! I think one of the things I’ve noticed about MEN1 patients — especially at the beginning of their journey — is that there’s a sort of feeling of: “How did this happen to me? Why did this happen to me?” Well, I would say that there’s nothing that anybody who has MEN1 has done to deserve this. That’s one side of it. But I think the most important thing is to realise that this is all pretty manageable. The pituitary disease, like the parathyroid disease and the pancreatic disease — it’s all manageable. And it has to be managed by a multidisciplinary team. I think that’s so, so important. Historically, the outcomes were probably not as good as they are now. Because now, everything is discussed in open forum — whether it’s your pancreatic disease (which I don’t do, but I sit in on the MDT). All these things are discussed. And having experts — so endocrinologists with an interest in pituitary disease and neuroendocrine pancreatic disease — is really important. And with the surgeons who cover the same disease. I think that’s got to be the best bit of advice you can have. And oh, second really good advice — but I think you’ve covered it already — and that is: ask all the questions. There is no silly question. Ask them. And if your surgeon gets angry with your questions — well, we’re all a bit stressed, and the clinics are busy and so on — but if your surgeon gets angry when you ask them, “What operation are you going to do for my parathyroid disease?” then you’re in the wrong place. Because this is a part of your life. And I think you want to be reassured that whoever’s dealing with you is comfortable with the problems that you may face with your disease — your parathyroid disease in the context of MEN1. Thank you very much, Professor Palazzo, for your time that you’ve given over today, and the depth of the information. I really think that we’ve stayed on track, but also gone down a few tiny little rabbit holes — and I think that’s actually what sometimes MEN1 listeners are looking for. For these questions to be asked and answered in a really different setting. And I’m very grateful that you’ve come on and, as I say, given us your time. So thank you — and hopefully we might have you back on again in the future. I would like to congratulate you for your work, and for the initiative of this — because I think that patient support is very important in this type of disease. So well done. Thank you very much.Thank you.