← Living Well with Multiple Sclerosis
Living Well with Multiple Sclerosis
Bonus from the archives: In Conversation with Caroline Clarke | S8 bonus
00:21:42
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- [00:01]
A
Hi, everyone. Jeff, Alex here, your host of the Living well with Ms. Podcast. To all our listeners, I hope you and your families are staying safe and healthy during this COVID 19 crisis. While social distancing and other restrictions may seem like a drag, in the long run, they will prove critical to stemming the tide of this epidemic and returning to a sense of normality. I have faith we'll come out of this stronger, smarter and a bit more enlightened as a result. In the meantime, we at Overcoming Ms. And the whole team behind this podcast are here for you to keep you informed and help you keep on track with your personal journey to a healthier you. Now on with the show. Today's episode is a personal and professional perspective on oms. For this episode, I'd like to welcome Caroline Clark, the Chief Executive of the Royal Free London NHS Foundation Trust. Caroline has been the Royal Free London NHS Foundation Trust's Chief finance officer since 2011, and in 2012, she was named Finance Director of the Year by the Healthcare Financial Management Association. She was appointed the Trust's Deputy chief executive in 2012 and chief executive in 2019. Caroline is a trustee of Overcoming Ms.
- [01:16]
B
So welcome, Caroline, to the podcast and I'd like to start out by asking you why, as someone who's heavily involved in the nhs, you chose to follow Ms. And really just about your Ms. Journey.
- [01:33]
C
Okay, so I was diagnosed with something called transverse myelitis in, I think probably 1997 when I was working at a hospital in the East End. And I can remember I fell off my motorbike and I remember thinking, oh, something's wrong with my leg. And I went to ae and of course my mates were the doctors and they said, oh, we probably need to just run a tests on you. And nobody was really explicit about what was going on. And it was kind of when I was given an MRI and they wanted to look at my head, when I thought I'd slipped a disc in my back, that I realized something was a bit strange. And then they sent me to a neurologist and the neurologist explained that I had a lesion, one lesion, and if it was only one, it was called transverse myelitis. And then I sort of read loads about it and you know that thing when you read, you read what you want to see. So I sort of read that there was a kind of conversion rate into ms, but that it was tiny, tiny, tiny. And I think I probably transposed the numbers, unfortunate because I'm an accountant. So, anyway, so then that was 2007 and I was quite poorly and I kind of lost. I couldn't walk for a while and it took me about a year to recover properly, but I got better and I carried on working. And then I think in about 2015, I remember the same creeping people call it the Ms. Hug, don't they? That thing you get around your stomach. And that happened. And I remember it was a Wednesday morning and I was working in my current organization, Aurora Free in North London, and I just thought, oh, God, I know what that feeling is. And I suddenly thought, I think I've got a horrible feeling. I think this might be Ms. So I hadn't thought about it. I'd had kind of, you know, six or seven pretty good years, and I just always thought I had this weird neurological thing. And it was called weird neurological thing. And then I went into work, I saw my medical director who referred me to a neurologist. And really, really quickly, unlike lots of people, I had a diagnosis and I had a bunch of lesions on my sort of neck, quite high up, and it really, really knocked my arms and hands out and I had the stuff. So it was all upper body and so I was able to walk. And then quite quickly, one of my colleagues said, you need to go and see Gavin Giannoni. Who is Giovannoni? I can never say his surname. Who's that? Bart. So quite quickly I got kind of medicated, but at the same time, one of my colleagues and I was quite open at work. I just thought, I've got to make a decision about whether I'm going to tell people or not. And I felt it was a bit like coming out. So I'm gay, I came out. Well, every day I have to come out to people because you sort of have to do the explanation about where your husband isn't and all that stuff. And so I sort of took a decision. It's a bit like that. So I kind of just. I'm going to come out to everybody. And one of my colleagues gave me the OMS book and just said, you need to read this. And she's a woman that has an underlying health condition herself, but knows Linda Bloom brilliantly. And so this connection happened and I read it and I've been like most people, I'd done the thing, I trawled the Internet, I'd gone through a period of eating organ meat. You know, what's that diet? It's the Walls diet.
- [04:59]
B
I've sort of done a bit of.
- [05:01]
C
This feels really peculiar and not quite right, although there's some of the science, you know, I kind of, you know, work in the health service and I'm quite interested in science, so I sort of quite like that. But then I, then I read, I read George's stuff and blew me away. And I was like, well, this just makes perfect sense. And it made perfect sense partly because I kind of, you know, my partner's an acupuncturist. I live as a relatively healthy diet. I'm 51 years old, so I'm kind of in middle age. And you sort of have a, there's a middle aged wake up call, isn't there? And then the science behind it and science behind the diet and the fact that there are these different facets of the OMS program really appealed to me. I'm not the most disciplined person in the world. So, you know, that's the thing I probably struggle with the most, is this compliance aspect. But no one's telling you to do it. You're doing it for you. That's the point. And so I started doing that and then I was really lucky to be introduced to Linda and Tony and the sort of OMS gang and just thought they were the most amazing people. I'm conscious that they'll now think I'm flattering them and I'm not. I just, they're amazing, you know, I think what they've done is brilliant. I think Linda's journey is inspirational and something about that really, really got me. But I kind of, I would, I was, you know, I'd made a decision to follow it because I felt like it would make me, make me stay strong and, well, and thus far it has.
- [06:37]
B
And what do colleagues in the NHS think about it? Do they think, oh, this is like complete alternative sort of new world stuff, or is it sort of generally respected? And you think, oh, actually you're doing, you know, the best you can.
- [06:56]
C
Well, you know, so it's really interesting, isn't it? The NHS is made up of really different people and doctors are. There's a broad church of people who are doctors. And most doctors, all doctors, want you to follow a healthy lifestyle. Right. So there are aspects of the OMS program which are just so uncontentious. And you know, who, you know, I don't see how anybody can really, you know, I suppose what, what am I trying to say? I don't really see how anybody could say anything negative about oms because I just think it's so good and so sensible, but where people are hold back a bit more or a bit more reticent is I think they just don't see that there's more science that's needed. And I suppose what I do urge the Ms. Community and the scientific Ms. Community to do more is do some more research on it, do some more research on the different facets, do some more research on the diet and. Because that would really help. And I think, but I think, you know, generally most of my colleagues just, this is what I do. It's not a, you know, and I don't always get it right but I'm, you know, they know that I practice mindfulness. I'm very open about that and in fact it's opened up some brilliant opportunities for me. So during the COVID crisis, which we're in now, we've put together a very big health and well being program for our staff because they're having to do things in their daily lives they don't normally do. It's much, much more stressful and they're working really hard. So we put in a bunch of psychological support programs and mindfulness programs and yoga and all this stuff and being able to talk about it from a position of knowledge and practice actually really helps. So I think there is, you know, it's opened up loads of avenues for me and I sort of really, I'm really glad that I'm doing it.
- [08:55]
B
And so you've also got a very high pressure and high profile job. Now. A lot of people with Ms. End up taking early retirement. Physically, they might not be able to and mentally sometimes. So most people will find that stressful situations probably exacerbate their symptoms. So how does having a high profile job, a high pressure job, affect your Ms. And how do you deal with that? And how would. Is there any tips for people to deal with pressures at work?
- [09:29]
C
Yeah, it's a good question. So it's the first thing I should say is my symptoms at the moment, touch wood, are relatively gentle. So I can't write. My hands are really affected, my arms in my upper body, but I can walk and run to a certain extent, not much, but a bit. And so I feel pretty physically able. So therefore you're constantly having to come out to people. It's that kind of hidden thing, isn't it, which lots of people would experience all the time. My symptoms get worse with stress for sure and my team all notice. So I have a thing when I fiddle with my hands because I can't feel them and I want to make sure they're still there and my team know that and it's like one of those signals and they kind of, if there's a big conversation and Caroline's fiddling with her hands, so I'm trying to learn to sit on my hands. And of course during the COVID epidemic pandemic there's all this stuff about touching your face. So I'm really trying not to be so moving around with my hands. So I'm not a particularly high stress individual. That's the first thing to say as well. Like I just have always been told relatively. I found it relatively easy to pull myself back from a situation, take a deep breath. And now having practiced mindfulness for a number of years, that's helped. And I'm quite disciplined about taking holidays and having weekends and having time out. That's really important. I have a 10 year old daughter who makes it all worthwhile and you know that stuff. And I have a lovely partner who's really supportive and so, you know, all those things make it easier to take time out. And as soon as you walk in the door, you have to stop worrying about work. I have to say I've been rubbish about recently, the last few weeks. I think it's kind of, I would say that I'm not living my usual life, but I will get back to it. And so I think, you know, managing stress in Ms. Is probably the most important thing that I can do. And the way I got into mindfulness was really helpful actually. I did some people kind of getting through apps or whatever, I did an eight week course and it was, that was probably the single biggest intervention I've made over the last 10 years. It's really made a difference because it means that I have a practice and that it's not, you know, I don't spend an hour every morning doing it. I practice throughout the day at different periods and it just really helps. And you know, in a really stressful meeting where, I don't know, we're discussing oxygen levels in the hospital and we haven't got enough oxygen, actually breathing and taking a step back and observing what's going on is really, really helpful technique. So of everything I've done actually, you know, along with a diet and exercise, mindfulness is really, really helpful practice.
- [12:39]
B
So actually if you, so if you're feeling at all stressed, you do a sort of like micro, micro session.
- [12:45]
C
Yeah, I do. In fact, sometimes I go to the toilet and do it. I just, you know, just. There's something about just getting away. I've even, you know, so little things in life. So someone bought me a Apple watch for my 50th and that's got a little breathing. It tells you to breathe. And even that's quite helpful. You know, it's like you can't. I think the thing you learn when you practice mindfulness is to be kind to yourself and give yourself a break. You need some discipline and some practice and you've got to keep doing it. It's like anything, isn't it? 10,000 hours of practice makes you better, but, you know, you can do it at weird times of the day and all that stuff. And the other thing that really helps, of course, is sleep. So I have really noticed my sleep patterns ebb and flow. So they really changed after I had Lemtrada, so that I don't know what happened there, but they kind of just did for them slightly and then they came back. And then recently I've been a bit agitated in sleep, which I think is quite entirely. I think that's a decent response to the COVID pandemic, you know, kind of. I'm not anxious, then. What am I? You know, But I. But I am so much better when I sleep. So really sleeping properly, not eating big meals at night, not drinking too much at night, all that stuff. Really sensible advice, things we learn in middle age with all that stuff. Annoyingly true.
- [14:07]
B
Yeah. There was something Craig Hassett said. He does a lot of the mindfulness stuff for omas. He said about that it's good to have a. Do a mindfulness session every day is great, but actually to throw in sort of mini mindfulness sessions as well and just say you can do a minute here and just to sort of reset yourself. It's a useful technique. And if you're just wandering somewhere, then you can do that mindfully. You can make a cup of coffee mindfully. All those things count.
- [14:38]
C
Yeah. Live your life mindfully. I think that's absolutely right. I mean, I would say I probably have 10 at least such mindful incidents in a day, but it just is how I am now. And the escaping to loo thing doesn't happen quite so often, but I do take time out and I do kind of go for little strolls around. So I work across three hospital sites in North London, you know, and there's, you know, it's perfectly easy to walk out of a hospital and walk around it or in Hampstead, to walk onto Hampstead Heath or, you know, find some space where there aren't other people and just breathe. That's quite. That's, you know, that's a thing everybody can do. They can get out, I think. Well, actually, that's not true. So it's quite interesting, isn't it? In these Covid times you realize not everybody has a balcony or an outside space. Not everybody has a garden. So some people do have to work harder than that.
- [15:35]
B
Yeah, no, I've realised we moved 16 years ago from central London to North Devon which. And this goes out around the world. So that's a very rural area. So go from very, very, very, very built up area and we had a shared front door so you know, I had to have no outside space, shed, front doors. It is very different. And now I have a garden and then I can actually stay in on my property and do some exercise and it is difficult, isn't it? I think different people but so is there people. So we'll come back to COVID 19 in a minute But I realize you're not a medical doctor but do you have any advice for people with ms? Because obviously you are very, very connected with the health service and obviously your neurologist is Gavin Giovannoni who's top specialist. So you do have a lot of exposure to this information and no Linda and Tony Bloom as well. So do you have any advice for people who have Ms. In general terms to start with generally?
- [16:51]
C
Well, I mean I suppose we, you know, you can only talk about the things that have helped you and the stuff you've read and I think rereading George's book actually helps me. I've probably read it about four or five times now so there's something for me around this because there's nuggets in there, aren't there? And so that's always if you know, if you can be bothered to read a book but you know, or just you know, having a look at the website for. You got it. You got to. I'm not a particular disciplined person so I'm constantly needing kind of sources of kind of re inspiration and things. So you know, if we're thinking about diet I'm always after kind of new things to cook and make and all that stuff and I, you know, like I hate oily fish, it's really disappointing but I hate sardines so you know, that's, you know. Where do you eat protein from? I tell you what, in the last few weeks I've eaten more lentils than you can shake stick at. I kind of just. But you know, so there's something for me around sort of reinspiring oneself. I think there's a real thing at the moment about. I know it's been really sunny but if people are in lockdown, they haven't been out. It's a real thing about vitamin D, isn't there? So making sure you keep all that up and keeping exercising if in lockdown, that's quite hard. I've personally found it really difficult to exercise recently because I've been so time pressured that even kind of I cycle everywhere and that's kind of how I get my base exercise. But I've sort of been promising myself to return to normal exercise. I have to say I had, I think I've had COVID 19. I had it quite early on and I was quite poorly for a couple of weeks and I haven't been for a run since because I haven't wanted to test my lungs and it's a nasty, nasty illness. And so I kind of. But I think you just, you need to, you know, the exercise we know that our muscles waste if we don't exercise right. So, you know, people who are, you know, listening to this, who are in completely different situation to me will know that more than I do. But you know, there's something about where you can take your moments to exercise in any way you can, I guess.
- [19:15]
B
Yeah, I mean on a personal basis I do, I found because I used to do lots of exercise. So I went from, ran a marathon that's probably getting on 10 years ago now. I read that about you rock climb, surf, mountain bike, snowboard, everything. And I never really doing a marathon I had to train for. But the other things, I didn't really train specifically. I just went out and did stuff and was always fit and active. And now if I don't do anything for a few weeks, my fitness levels drastically drop really quickly. And I don't know if that, I mean, is that what you're saying? Is that sort of an Ms. Specific thing that you think is.
- [20:02]
C
That's general. It's general, Jeff. I think it's, you know, if we don't. And so we see this in hospitals, right? So people say that kind of if someone comes into a hospital bed, you just want to get them up and about as quickly as possible. In fact, the worst thing you can do if you're ill is just like lie down in some senses. Obviously not for all illnesses, but particularly older people and frailer people. Once you start lying down, you lose muscle mass and it's much, much harder to get up. So I think that's for all of us. It's going to be particularly for people who've got less ability and have more impact of Ms.
- [20:43]
B
It does seem that actually A lot of the things that we're doing in OMS are becoming more mainstream anyway. Not for people with ms, they're so exercise. Yes. Eat healthily. Yes. They're now saying in the uk, they've just recently said, you need to take vitamin D because that might help you with COVID 19. And what they were saying generally about a year ago, they're saying everyone's probably deficient of vitamin D and particularly COVID 19. We think that might help. So a lot of the things that we're doing are starting to become mainstream. Not even people with Ms. They're just saying everyone needs to do this stuff.
- [21:18]
C
That's right, yeah.
- [21:20]
B
Scientists may be catching up.
- [21:22]
C
Yeah, well, I hope so, I hope so. That's what I meant when I said before. I really hope the research Ms. Community does more into particularly aspects of our program that haven't been so researched. So more on diet and low fat diet, I think would be really, really helpful.
- [21:40]
B
And so the other thing I want to ask about. So this recording is being done at the height of the COVID 19 pandemic, certainly in the UK. And if you're managing a healthcare trust, I just wanted to ask specifically, is there any advice for people with Ms. At this time with COVID 19?
- [22:02]
C
Yeah. So caveat everything by saying that I'm an economist and an accountant and I'm not medically qualified, so I can only talk about what I know and what I've read and what people have told me. So that's what I think. I've had the disease and I have antibodies to it because I've had a test. And although people tell me the tests aren't as accurate as they could be, but I like to think it's my immune system giving me some payback. So it's so good, it's attacking my myelin sheath and it's making antibodies and it's nasty. And it made my symptoms worse. So it made the neurological damage that I have and my ability to use my hands always gets worse when I have a cold or a fever. And it was exactly the same with COVID So that's one thing. I had it relatively mildly and it was unpleasant. So that's another thing to say. And of course, my hospitals are treating hundreds, possibly thousands of people now who are very, very ill and quite quickly get into very severe breathing difficulties. That didn't happen to me. So the things that I know are, of course, if you're immunosuppressed, it's a really horrible thing to get. And we're seeing more patients in our hospitals who have a compromised immune system. So for us that will be lots of people on medication, I guess, where the medication works in a way that suppresses your immune system. I've had Lemtrada and I know that I would not have, I didn't want to go near anybody with a cold after taking Lemtrada alemtuzumab in other countries. So same rules apply. As you just said Jeff, we're all being encouraged to take vitamin D and I don't know the science behind that, but I do understand the science behind the sunlight vitamin D connection. So if people are in lockdown and not outside as much, then it seems quite obvious to me that they should take vitamin D and I've upped my dose and in fact here in London we've had our first rainy day for about three weeks. It's quite weird. So lots more reasons to stay inside. I think the same issues around making sure you take exercise and making sure you keep fit and healthy. I mean it's kind of, you know, it's the same rules. The difficulty with COVID 19 is we don't really understand the disease. It seems to progress in a way that we're not familiar with and can attack people going to multi organ failure more quickly and in an unexpected way. So because it's quite a new disease, my medical colleagues are still trying to work out, you know, the best way of treating people. There are loads of clinical trials going on in the UK now we've got a vaccine trial that's just started trials in humans. So you know, one would hope within a year to 18 months there will be a vaccine but that's a year to 18 months away and that's an optimistic view. One would hope that the clinical trials actually treating the disease will result in a treatment relatively quickly. But again, clinical trials can take a long time because results need to come through and you need enough patients to have tested them in, you know, tested new drugs in to be sure that they're going to do the right thing. And of course testing people. In the UK we've been quite slow to test people, whereas in other countries actually, you know, testing out in the community is prevalent and we see that making a real difference to keeping the COVID numbers down. So I think for our Ms. Community and the OMS community, I say stick to the program, stick to the program. If your immune system is compromised, just take extra care. And in the UK in the next two weeks, we think the government will probably, we know the government's thinking about the policy of physical or social distancing. And we know that there'll be some more guidance coming out. And I think for our community, we just need to take. We just need to be super careful, take extra care. And there'll be people listening to this who are probably on the list of what they call shielded people in the uk, where people are, yes, I'm having fixed specialists, I'm on that list.
- [26:25]
B
My letter recently, I got my letter just last week, but we'd already decided to essentially shield anyway. So, you know, I'm. I do live in a rural area, so I do walk my dog, but I don't see anyone when I walk my dog, just go directly to fields and literally I don't have physical contact with anyone at all. Does that. So. And it does seem to be inconsistent. I mean, I got my letter somewhat unexpectedly because my Ms. Nurse didn't think I would. And I've had it, and I've had Lemchard as well. And I thought it might be because of that, but it just says the reason on it is because I have multiple sclerosis. So some people are getting the letters to say, and I mean this in the uk. Some people would be familiar in the UK with the shielding term. But essentially what they're saying is people who are sent these letters should stay in their own property and to the extent that they will actually even send you food deliveries.
- [27:31]
A
And you should stay.
- [27:32]
B
In your own property for 12 weeks. So do you think, does it make sense for people with Ms. To try to, whether they've had a letter or not to say they should? Does it make sense to isolate themselves as much as they practically can?
- [27:50]
C
Oh, I don't know. I think it's really difficult because I think the shields and guidance has been really inconsistent and it's followed different. Local authorities are doing it differently. The advice that I've had personally from clinicians has been, I'm okay. And I've asked a neurologist, an immunologist, and I asked about four different people because I was concerned. Remember I took Lemtrada, the last dose was four years ago, and my immune system and I get tested. You probably have the same thing, Jeff. You have kind of monthly blood and urine tests to check everything's okay. So I'm pretty confident about my immune system and I feel okay and I'm not taking any undue risks with my. In my job. So I'm. I'm trying to provide visible leadership to my teams over. Over the phone and over the iPad and then I do go and visit the hospitals and see people, but I'm appropriately, you know, two meters away. And where it's appropriate, I'll wear a mask if I'm in a patient area, so I can't. The shielding thing's really difficult, isn't it? I don't really, you know, I think if someone had sent me that letter, I would feel quite uncomfortable. But I'm at a different cycle to my treatment to you. And I've had some different clinical advice. And this is the nature of all these illnesses, isn't it? We don't know 100% what's going on, but if you feel your immune system is compromised in any way, then that's, you know, then I guess you follow the advice. And if I was living.
- [29:29]
B
So maybe sort of be careful but not be overly concerned.
- [29:33]
C
Well, I think if you're not, if you're in my position where I know I'm not immunocompromised, I know my immune system is okay, then I think I'm just like everybody else. So I think when I. And I don't. And I think I've had Covid and my partner's had Covid. I think I had it slightly. I was slightly more effective than she was. Or stroke, she was braver than I was. So balm. Okay. You know, so very difficult to give advice in these situations, isn't it? It's a new disease, so it's really difficult. And when you have new diseases, people are super cautious. And, you know, I think I would feel very differently if this was 2017 and I was like, you know, kind of months after my second lot of Lemtrada and possibly I might have to have a third, then I'd be thinking really differently to how I do now. You know, it's that thing.
- [30:25]
B
So best to speak to your neurologist about that, because I know they are delaying some treatment.
- [30:33]
C
Yeah, that's quite interesting, isn't it? I wonder if people listening to this. There may be people listening, thinking, I've had my treatment delayed because of the pandemic. I don't know of anybody. I don't think in my. I think in my organization, if you would. If you were due some treatment, you would still have it, but I don't know that. And of course, one of the things we're thinking about in English NHS is how you restart services in a way that protects people that haven't got Covid and how you test them and stuff. So it is likely that if you're waiting for treatment you're going to have to have a COVID test to make sure that you got it. And there's a whole bunch of things that we probably haven't done in the past that we will do in the future as a response to the disease and that will impact people waiting for treatment or in treatment. And I also expect that we'll be doing it slightly differently around the country because it's also new and it's, you know, things aren't so heavily protocolized yet, but I think they will.
- [31:32]
B
Gavin Giovannoni did actually say that the year between Lemtrada treatments or, you know, if you're having ocrelizumab, then you have these sort of treatment sort of schedules, they're not set in stone that you don't have to worry too much. And delaying it by several months, six months even, is not an issue really. It's, you know, it almost fits easily just to say, oh, it's yearly. That's sort of really, that's kind of random to how the earth spins around the sun. It's not actually medically a thing. Yeah, so, so he, he was very much saying, you know, don't worry about it. And actually personally. So my second round of Lemtrada, completely not in a serious way, we were going on holiday to Thailand. So they said, oh yeah, just delay it. We'll just let delay it two months. Yeah, it's family holiday. And they said it's fine, absolutely fine. So I don't think people need to be able from the advice from Gavin Girononi, certainly don't be overly concerned by delaying a round of treatment because yeah, it's fairly random in almost that it's exactly a year. It doesn't have to be exactly a year.
- [32:41]
C
I think I had 16 months between my two treatments for exactly that reason that summer got in the way. So although as I was saying to you, I was listening, I remember my second treatment and it was must been in June because it was. I was waiting for the European Union referendum results and the stuck at home post Lemtrada forced to listen to the radio. Strange days indeed. Although that seems like a terribly long time ago, doesn't it?
- [33:08]
B
Yes. Right, well, thank you very much for very informative chat and just really insight to as much as anything, having a very high pressure, high profile job and managing really well with oms. So yeah, I'd just like to thank you very much for being our guest on this podcast.
- [33:29]
C
Thank you for having me and thank you oms, for making a real difference to my life.
- [33:36]
A
With that. I would like to thank you all for listening to this episode of living well with Ms. Remember, there is a wealth of information@overcomingms.org including show notes and an archive of all Living well with Ms. Episodes. Once again, that's overcomingms.org there. You can also find OMS friendly recipes and exercise tips. Connect with other oms' in your local area through our OMS Circles program and learn about the latest research going on in the Ms. World generally and related to oms specifically. I encourage you to register on the site and stay informed about the latest news and updates. I also encourage you to subscribe to this podcast so you never miss an episode and please feel free to share it with others who might find it of value. Let us know what you think about the podcast by leaving a review. And if you have ideas for future episodes, we'd love to hear from you. So please contact us via our website, overcomingms.org thanks again for listening and for joining me on this journey to Overcoming Ms. And Living well with Multiple Sclerosis. I'm Geoffrey Alex and I'll see you next time.