Many modern consultation practices have lost the competency of human connection. Physical examination and patient observation techniques, is sadly becoming a lost art in all forms of health care. Well, Dr Nirala Jacobi wants to change all that by igniting a passion for the functional medicine examination techniques that have been passed down from the former vanguards of naturopathic and musculoskeletal therapists. Ahead of her keynote speaking engagement for the ATMS Functional GI Symposium in Sydney in September 2019, Nirala joins us to share an insight into some of the techniques she has learned across her two decades of practice from some of the best practitioners in functional medicine, including Prof Steven Sandberg-Lewis and Dr John Bastyr.
Covered in this episode
[00:52] Welcoming back Nirala Jacobi
[01:40] Orthodox vs. Functional Physical Examination
[05:09] Blood pressure cuff to aid mineral status assessment?
[07:43] Things we can learn from the art of observing our patients
[11:07] Fingernail signs
[14:10] Oral health, infections and digestive disorders
[19:30] Hiatal hernia and ileocecal valve manoeuvres
[25:43] Murphy's sign
[32:09] ATMS Functional GI Symposium in September 2019
[33:46] Online courses
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Dr. Nirala Jacobi who graduated from Bastyr University in 1998. She practiced as a primary care naturopathic physician in Montana for seven years before arriving in Australia. She's considered one of Australia's leading experts in the treatment of small intestinal bacterial overgrowth - SIBO, a common cause of IBS. She's the medical director of “SIBO Test,” an online testing service for practitioners and she's so passionate about educating patients that she founded The SIBO Doctor, an online professional education platform for functional digestive disorders. Welcome to FX Medicine, Nirala. How are you going?
Nirala: I'm going great. Thank you for inviting me again, Andrew.
Andrew: Thanks for joining us here. Now we're going to be talking today about functional GIT physical examination, but not just that, but what is the functional gut exam, or GIT physical exam? And how does it differ from an orthodox abdominal examination?
Nirala: Sure, and that's a great question. You know, when we examine patients, and let me backtrack a little because a lot of functional practitioners, a lot of naturopaths in Australia don't really examine their patients as much as I think they could, and there's a lot to be learned from physical exams. It used to be that you make your diagnosis on sort of a three-legged stool, you know? Like, what patients tell, like, the history, what patient tells you, the lab results, and also the physical exams. That was always the objective-finding in our SOAP notes.
So, this is, I think, sort of a lost art and not only for functional practitioners and naturopaths but also for GPs. There are so many people that come to see me that say, "Wow, I've never had that exam done," which is part of an orthodox abdominal exam, for example, like the gallbladder exam or Murphy's, for example. So, I think generally that with the ever-decreasing amount of time that people spend with patients, especially in the conventional medical model often at the expense of physical exams. And I find that they're really useful and just want to sort of revive the enthusiasm for physical exam skills.
So, an orthodox or, you know, sort of general conventional GIT exams includes looking in your mouth, maybe, to kind of assess the teeth, how well you can chew your food. Often that's neglected as well. But then we move basically to the abdomen, and it's inspection, auscultation, and palpation, and then deeper palpation. So, that's… basically takes about 30 seconds to do. But when we examine patients in more functional way, we look at the hair, the nails, the eyes, the tongue. That, already, can give you a huge amount of information on nutritional deficiencies.
And then we can move into particular reflex points to assess for low stomach acid, for example, or digestive difficulties. These are well-known reflex points. And also organ mobility. Sometimes, for example, I see patients that obviously have a lot of functional digestive difficulty and epigastric pain and bloating and sometimes when I just examine the costal margin, or the edge of the ribs and find a very, very tight diaphragm, that alone can cause a lot of their discomfort. So, knowing that would then mean that I'm not going to necessarily give them supplements, but really work physically on releasing that diaphragm just as an example.
But also using things like the blood pressure cuff or tissue mineral assessments is really helpful and looking at a particular muscle strength in different areas. I mean, there's just so much information that the body can give you if you really know where to look.
Nirala: It's a really easy, simple trick. And if we think about all the minerals that are involved in muscular contraction and relaxation, we have magnesium, we've got calcium, we have potassium, and even sodium. So, it's not specific for any one nutritional deficiency. But when people, you know, often when you consider that maybe their stomach acid is low and they can't absorb, naturally, a lot of minerals, even if you're supplementing a lot of minerals, and they still are cramping, a good test to do is basically, it's just placing a large blood pressure cuff around the calf, and seeing how far that patient can tolerate the pressure of that blood pressure cuff. A normal, no cramping calf should take about 220 millimetres of mercury.
Nirala: And so, that's pretty normal. It might be uncomfortable, but many people, you can kind of gauge how efficient they are by how quickly they say, "Oh, stop. I'm going to be cramping." So, I've had people as low as 80, and they're severely, you know, mineral deficient. So, it kind of helps to know the degree of mineral deficiency basically just as a screen. And so, if you are already supplementing and that patient is still deficient, you might want to look elsewhere as to why are they not absorbing these minerals, or why they're not utilising these minerals? So, it's helpful.
Andrew: Is that kind of like a forced claudication?
Nirala: In a way, it is, but it's not so much claudication in terms of vessels. It's really the muscle that we're actually contracting, right? That we're really compressing. Yeah.
Andrew: That's really interesting.
Nirala: And it really works. I mean, these are the little tricks that I've learned along the way. I mean, I've had my physical exam training 25 years ago or so now, so it's been a long time. But there are masters in functional GIT exams, and one of those masters is Dr Steven Sandberg-Lewis.
Nirala: Who actually came out to Australia, I know BioCeuticals had him for a SIBO talk. But he really is a master in functional assessment of the body. So, I think that really also revived my enjoyment of using simple techniques to give me a lot of information about a patient that don't necessarily require that you do a test.
Andrew: And he's a lovely man too.
Nirala: Yeah. Very lovely man.
Nirala: I mean, Murphy's sign is the basic assessment of gallbladder problems, right? Where you're actually compressing, or you're sort of allowing the patient to relax and then compress right below the right sternal margin or costal margin rather, and you're eliciting, you're looking for a sharp inhalation and eliciting a pain response that would indicate that this person's gallbladder is problematic. That's a really crude assessment of that. But even if we just start by the patient walking in your room and assessing their gait, I mean it really starts there. And seeing if they're shuffling, if they're coordinated.
Andrew: Doubled over, yeah.
Nirala: Yes. I mean, you know, in my line of work where I deal with a lot of digestive issues, constipation is a problem. We know Parkinson's, that very first symptom, is constipation, very often. So, you start to put these pictures together, and I just think that adding in physical examination skills can just kind of give you more of a 3D picture of that. So, that's just an example.
But for example, I also look at fingernails. So, if you, you know, we know about the spooning with iron deficiency, but ridging also can be connective tissue issues and basically protein deficiency and things like that. And I actually monitor nails, and they definitely improve when you target absorption of certain nutrients and improve mineral status.
Just as an example, we know that the tip the tongue or that the colour of the tongue can indicate a B12 deficiency. Those little things that can, you know, make it really simple for you without actually testing anything. That's always is what I'm kind of passionate about, is because I think functional medical practitioners and naturopaths are sometimes guilty of overtesting when sometimes physical exams can tell you what you need to know.
Andrew: You know what? I'm so glad that you're talking about this because I've said this before, I know. But there was, and I'll always remember this lady who basically saved my mind and perhaps my profession and that was Sister Gettys, who when I thought it was all too much, she said, "You can learn all the technical stuff in time, but right now I want you to observe your patients." And it was an amazingly important lesson, observing your patients. It's amazing how many people forget to observe.
Nirala: Exactly. Exactly. If, you know, like, you can check vagal tone, for example, just looking at the palatal rise in the back of the mouth, you can...just putting a tongue blade on your patient's tongue, you can observe their dental health. You can look for halitosis, you can look for all these different things.
Nirala: That give you clues about their digestive status. So, it's been really fun to get back into that and, you know, I mean, a lot of my practice is online, so I don't get to do it with everyone.
Nirala: But it is something that I'm also passionate about teaching practitioners to revive their skill and their tactile sense and touching their patients.
Nirala: Well, there's clubbing, right? There's all kinds of things. And I mean, those are really obvious, and I'm not even talking about those, Andrew. You know, I mean, those, we know, are specifically, you know, if you're looking at splinter hemorrhages, very much associated with particular rheumatic diseases. But that's actually, you already know that that person has rheumatic disease, you know, or pulmonary issues with clubbing.
But what we're talking about are the hidden things that where you don't really know what name to give a particular condition that this person walks in with. That's what functional medicine and natural medicine is really about. We're looking at how is this body handling whatever stressors or toxins, or infections without necessarily… I mean, we want to diagnose obviously, but it doesn't always have a name, right?
Nirala: So, it's not always cardiomyopathy, thank God. It's not always rheumatoid arthritis. It's sometimes a really, sort of, overloaded system that has multiple pathways that are compromised, and you're looking for the best way in. "How can I best help this patient and what nutrient or dietary adjustments should I make for that patient so their body can help themselves, or heal themselves." And that's really the heart of naturopathic medicine. But also, functional medicine looks at the function of the body, right? The different pathways. So, I think that's why it's so helpful because it can give you an idea of what to really prioritise too.
Andrew: Yep. Zinc. One of the easiest ways to assess zinc is said to be the white spots in the nails. I've never ever found any evidence to support that and yet, trialling some zinc has always gotten rid of those white spots. Help. Help.
Nirala: That's right. That's right. But I don't stop there. I'm like, "Okay. White spots. Okay. Is it just the dietary deficiency of zinc?
Andrew: Is it absorption? Is it, yeah. Yeah.
Nirala: Is it a malabsorption issue?" Right? You need zinc for the production of hydrochloric acid as well.
Nirala: So, is this sort of, you know, the plot thickens then when you have a zinc deficiency, sometimes it is just as easy as increasing zinc in their diet or supplementing for a period of time. But yeah, it's always about looking deeper into, "Why is this person presenting with these nutritional deficiencies that are not explained by the diet?"
Andrew: Such an important point. Thanks so much for reiterating that, because we often do. We often lead the way, forget the way if you like and just stop at that. "There we go, I have an answer, and that's it,." whereas what you're doing is you're saying no, it gives you an opportunity to ask the question, "Why did that happen in the first place?"
Nirala: Yeah. That's right. And that's, you know, one of, as you mentioned in the bio, my specialty is SIBO. And after almost 10 years of really specialising in SIBO and focusing on that, it's not really so much about the SIBO. The SIBO is an end result of something. It's really about finding out why this person presented with an overgrowth of bacteria, to begin with? So, that's a lot more rewarding for me at this stage than just treating SIBO. Treating SIBO is not difficult. It's about preventing relapse and understanding what caused that in the first place. Was it adhesions? So, an outflow problem? Was it some problem with motility in the upper gut? What is really going on with this person? And I think we need to be better clinicians really in that way, in that we ask the more difficult question of, "Why did this happen to this person?"
Andrew: Do you ever see with SIBO being a, I'm going to use the word dysbiotic, scenario if you like. Do you ever see examples higher up in the alimentary tract of disproportionate overgrowth of bacteria, like, for instance, with the tongue? We're not looking at things like, you know, black tongue or anything like a superinfection. But do you ever see nuances in their tongue? Like, for instance, IBS can cause dehydration. Do you ever use the tongue, you know, commonly?
Nirala: Not specifically foreseeable. You can't really tie that to any one sign. You know, because SIBO has what I would say four different categories of underlying causes, and all those will present differently physically, right?
So, sometimes, I mean, I do see quite a bit of geographic tongue in my dysbiotic patients. There is some research looking into the oral microbiome as a contributor to SIBO, especially those that are hypochlorohydric. So, there are connections between different biomes and/or malfunction there and the resulting SIBO, especially if there's poor oral hygiene or if there are infections in the mouth. That can, is actually being actively researched. And especially if you are on a proton pump inhibitor that's inhibiting the major bacteriocidal juice of the body, you know, that can happen, that can certainly result. But there isn't a specific sign, a physical sign, that correlates with SIBO as the only one.
Andrew: Got you.
Nirala: As the only physical sign. Yeah.
Andrew: And earlier on you mentioned dentition, and, you know, we're not just talking about being able to chew, but indeed there's a microbiome and microbiota which inhabits our mouth and our buccal area. So, do you ever see any, correlation is a bit too strong, but hints that something might be going wrong down below? You know, if I was going to say reflux, that's still, you know, quite lower down the oesophagus, but something along that sort of lines. Do you ever see hints and tips there?
Nirala: Absolutely. I, you know, whenever I have a patient in my office, I do look in their mouth, I look at the soft palate. I look at the teeth themselves. I look at if they still have old mercury fillings, I ask about root canals. I ask about these things because I have had patients and currently have patients who their digestive symptoms started after they had a root canal placed or they had a massive stress. They had a root canal maybe 20 years ago, then they underwent a massive stress that then started to sort of spread the infection, you know.
Nirala: And the way root canals, the way I understand it and I have some experience with that because I had a colleague who became very, very ill from multiple root canals and anaerobic infections that spreads through the maxilla. So, you know that's a real thing that happens. And with root canals, you can have a small infection that normally the body sequesters. It's pretty good at sequestering small amounts of infection, but when you have a massive stressor that acts as a trigger and allows now this infection, that had been previously walled off, to spread, you can all of a sudden become really ill, and it looks a lot like chronic Lyme infection, or mould, or all these types of illnesses where the body's immune system has been overwhelmed. And I have a patient right now who's tested positive for SIBO, and upon further investigation, she had two root canals that were massively infected.
So, you know, there's no... I'm not saying that the infection in the mouth, which is often anaerobic, can cause SIBO, that's not what I'm saying. But there's a lot of immunomodulation that doesn't occur when your body is busy with other infections. And mucosally, that's of course very important in the small intestine.
Nirala: That's quite possibly the most, my most favourite manoeuvre and the most revolutionary that I've experienced in my 20-plus years of practice. It really is, and it's not hyperbole. It's like one of those things that comes along, you never knew about it, and you do it, and all of a sudden, a patient that's had five years of epigastric pain sits up and says, "Oh my God. The pain is gone." It's that powerful.
So, if we look about... If you think about a hiatal hernia, oftentimes it's diagnosed via a gastroscopy or an endoscope, and oftentimes, actually, when they are too small to see which is... And then, in a nutshell, a hiatal hernia is that part of the stomach has squeezed through the hole in the diaphragm that allows the oesophagus to go through the diaphragm. And it can actually cause a tremendous amount of epigastric discomfort, anxiety, gastroparesis and a lot of digestive symptoms. And I really didn't know that much about it. I always thought, "Okay. Well, I only test it on people that have reflux." But it really has a place in a lot of the epigastric dyspepsia, for example, functional dyspepsia, I often check for haiatal hernia.
So, basically, it's a maneuver that aims to pull the stomach back through the hole in the diaphragm, but in such a way that actually repositions the stomach properly below the diaphragm. And it takes about five minutes to do. You also do some things on the spine, distraction of the scalenes for example, and compressing certain trigger points to allow this maneuver to settle. And it is really amazing. And he taught it at last year's Functional GI physical Exam Practicum which is a course that people can access on the sibodoctor.com where they can learn this maneuver because I wanted to make this available to as many practitioners as possible. It is part of a greater course that is taught by Dr Sandberg-Lewis, so you'll learn a lot of different things about functional GI exams. But this one for sure, for me, personally, was worth it just to have him fly out here just to teach us this one maneuver.
And the other one is the ileocecal valve maneuver. And it turns out the ileocecal valve is very often a problem for people with functional digestive disorders. Because of either they had an appendix removed, and there is adhesions and scar tissues, or maybe there is inflammation or just distal small intestine bacterial overgrowth, or dysbiosis in the large valve that all caused this area to be really sore. And what happens is, the ileocecal valve is a valve, just like other valves in the body. It can be stuck closed, it can be stuck open. And so, you can actually physically manipulate this valve, and you can teach your patient how to do this every day. And it can also be quite revolutionary really for these patients when they are out of pain, and there is an answer for their problem.
Andrew: Yeah. So, I'm just wondering about ileocecal valve pain? You know, and I'm wondering about red flags here, you know. For instance, an inexperienced practitioner, somebody who hasn't been taught this, how to do it properly, if they're going to do the hiatal hernia manoeuvre, which accesses the sternal notch where there's xiphoid process is. You know, one could assume that somebody silly might break that off and, I mean, that's happened in other things. I know that can take quite a lot of force, but there is that risk. With ileocecal valve manoeuvre, people would likewise have to be cautious that it's not a grumbling appendix or a bowel obstruction.
Nirala: Of course, yes.
Andrew: So, what other learning is important to go along with this to make sure that people are doing the right things?
Nirala: Well, it is a course for professionals, right? So, it assumes that there has been some professional training in the health sector, right? So, that's what we're assuming. We also get people ready with sort of an intro video or webinar where people kind of refresh their skills, but we're not promoting this for people that have never really been taught how to touch a patient.
Nirala: So, there is some understanding that the basics, I mean, if you've never taken the blood pressure of a patient, you probably, this course, is not for you.
Andrew: You shouldn't be, yeah. That's right.
Nirala: Yeah. This course is not for you.
Andrew: I want to always cover these red flags.
Andrew: Because despite FX Medicine being designed for practitioners, it's available on iTunes, available to all. And I want people to be doubly sure that they're doing the right thing and that they're being safe.
Nirala: Well, the ileocecal valve manoeuvre is a pretty safe manoeuvre, you know. You're not going to burst somebody's appendix because you'd have to peel them off the ceiling first because it's so painful, you know? You're not going to really do much harm. They'll tell you.
Andrew: I think they'd be telling you with the rebound pain, yeah. But, you know, even things like, you know a, let's say a nearly blocked ileocecal valve with a bolus of worms or something like that, that's happened.
Nirala: That's never happened.
Andrew: Ahh, okay.
Nirala: I've never seen it in my practice, and never say never, of course. But anytime you touch a patient, you know, you assume some sort of skill to understand what your hands are feeling and what you're actually looking for.
Nirala: So, you know, again, with the Murphy's... And, you know, I've actually mentored and taught a lot of practitioners about physical exam skills and, you know, mentored a lot of students. And by far the most prevailing finding I see, is that they just don't touch strong enough.
Nirala: So, I'm far less concerned about them doing damage by, you know, ramming their fist into somebody's abdomen, which is not going to happen. But more likely that they're just don't use enough pressure to really get the finding or to get an accurate understanding of what's happening. And really what you're doing with the Murphy's is you're really trying to elicit the pain or no pain. That's all it is. You know, in order for you to really palpate the liver border or you going to have to also do some percussion, you know, of the liver border that's a bit more accurate because you can miss the liver border with the Murphy's if that's all you're looking for.
Nirala: But, you know, those are the little things. And again, we're talking about the average functional practitioner, and naturopath, and sort of holistic practitioner, not an ER setting where you're going to have, you know, portal hypertension and all these sorts of things that are probably just...
Andrew: Triple As.
Nirala: Yeah. You just not going to... That's not what we're talking about.
Nirala: We're just encouraging people to not be afraid. If they're allowed to touch their patients with the license that they have, they should be able to practice these physics. Just even the skin, you know, you can... Just dryness of the skin, skin turgor to understand hydration status or understand essential fatty acid deficiencies, you know. I mean, it's so simple. You don't need a blood test for that.
Andrew: To me, it's part of the lost value of, as we mentioned right at the beginning, the observance of the patient and the whole examination skills that we should be doing.
Nirala: Mm-hmm. And you know, my mentor... Well, he wasn't really my mentor, but Dr. Bastyr is a very revered naturopath who's passed away now, was the founder obviously, well, he wasn't actually the founder it was Dr. Pizzorno plus others who founded Bastyr University. But he taught us, he said, "Always, always touch your patient, even if it's just a hand on the shoulder as you guide them out of your office. But always make that human connection." And I think a physical exam, even a small one, even if you're just looking, reaching across the desk and looking at their fingernails or looking at their skin. It's so simple, and it really humanises the experience, and it actually increases confidence in the practitioner from the patient.
Nirala: Yeah. And, you know, reflexes we think of just the hammer on the knee. That's not what I'm talking about. Although those are also good reflexes.
I'm talking more about points that have been discovered, in a way by, you know, it's like, these old chiropractors and osteopaths, you know, turn of the century. They had systems of assessing that used different organ reflexes, whether that was in different dermatomes or using, different organ reflexes is really what they looked at.
And one particular man was Dr Riddler. And Dr Riddler gave us the Riddler's hypochlorhydric or the Riddler's stomach acid point, or the stomach point, let's say. I use it a lot in my clinic. And it basically is on the left hand of the costal margin, so about an inch below the xiphoid over to the left and really palpating for tenderness in that area. And I tell you, it's so often accurate. Most of the people with reflux, all of them have that point, super, super tender. And people that are really hypochlorhydric also have that point often very tender. When I say hyperchlorhydric, this is not documented with a Heidelberg, but just improvement with either bitters or hydrochloric acid supplementation subsequent to that test, right?
Nirala: So, that particular point has been proven very useful for people to pinpoint if it's super tender compared to, let's say, the pancreatic reflex point. So, you would start with possibly bitters.
There is a fascinating test called the Lingual-Neural test that Dr Steven Sandberg-Lewis also talks about in his book, "Functional Gastroenterology," I think it's called.
Nirala: And basically, it's where, let's say, that Riddler's point is very tender on a patient and you put a substance in their mouth and wait about 30 seconds and that pain will be gone, right? So, these are the kinds of miraculous… we don't really fully understand, but he explains it that the lingual reflex is the quickest way to the brain. And so, it actually is very easily assessed whether or not this particular substance is going to be beneficial to this patient. So, I do it. I have a bottle of bitters in my office, and if that point is very tender, I put some bitters on that person's tongue, I wait 20, 30 seconds and almost always it will work if it's going to, if it's going to work, that pain will be gone or at least 90% better.
And so, you know, it's just one of those little tricks of the trade that just makes the experience a little bit more, like I said, have more confidence in what you're prescribing because you know that substance is going to work for that patient.
Nirala: So, that's an old, old point that has been revived by Doctor SSL as we affectionately call him. Or Dr. Steven Sandberg-Lewis. And there are others, the Sailor’s point and like... He really gives a lot of homage to a lot of these old chiropractors that have figured a lot of these reflexes out , that make our functional exam a lot easier.
Andrew: This is really interesting stuff, I've got to say, Nirala. You're going to be speaking about some of this at least, at the ATMS Functional GI Symposium in September 2019. What sort of other things that you're going to be covering there without giving too much away? I've got to ask though, are you going to be demonstrating any of these at the symposium?
Nirala: Yep. I'll be demonstrating some of them live, some of it will be video, some of it will just be taught. Like, the five skills or five physical GIT exam skills that I'll be covering is proper assessment of eyes, nails, and tongue. So, when I say eyes, it looks at sclera, pterygiums, that kind of things, what are associated with that. Also nails and some of the things we covered here, tongue and all that. And then also the hyperchlorhydria palpation techniques that are just sort of briefed over, but they're really having people experiment this on themselves.
I'll also talk about how easy is to assess the vagal tone, right? Everybody talks about brain.. gut-brain axis, and the vagus nerve being so very important in digestive function, which of course it is, and so sensitive and vulnerable to chronic infections and the function of the vagus nerve being very sensitive. And so, a quick and easy way to assess the vagal tone. And I'll talk about the Murphy's gallbladder point and then the mineral status. So, you'll get all of that, plus these other skills that I'll talk about in the symposium.
Andrew: And for practitioners that want to delve further and they want to get, you know, right into specialising in SIBO or looking after GI patients properly, you've developed a course, right? An online course?
Nirala: Yeah. So, you know, one of the things that I've been passionate about ever since really, I became a practitioner, is not just mentorship for students, but also teaching practitioners, right? So, especially when it came to SIBO because no one really knew what they were doing, myself included when I first started. And so, I really endeavoured to learn everything about it. And what's morphed out of that is that I love having a platform, The SIBO Doctor, that actually allows me to showcase different talents like Dr Steven Sandberg-Lewis and his Functional GIT Physical Exam Practicum that we spent two days with him here, and we turned that into a professional course, and I'll have another course upcoming, which is "Mastering Inflammatory Bowel Disease," with Dr Ilana Gourevitch, who is an incredible specialist in this field.
So, really allowing us to dive much deeper into these topics and become really, digestive experts, for those that really want to pursue that.
Andrew: That's awesome. So, you're really gathering, like, the best that the world has got to offer, and putting, you know, housing it in Australia. So, that's awesome.
Nirala: Well, it's like my wishlist, you know. It's people that I want to learn from.
Nirala: So, you know, it's wonderful to be able to showcase them for sure.
Andrew: Yeah. Well done. Can't wait. And I would urge every practitioner to attend the ATMS Symposium if any of your patients have a GI disorder. Which is only a few, of course.
Nirala: Only about 90% of them.
Andrew: Nirala Jacobi, thank you so much for taking us through just tidbit of what you'll be covering at the symposium later on. And again, thank you so much for what you've brought to so many, not just patients, but also other practitioners so that again, they can help their patients in turn. Well done to you.
Nirala: Thank you. It's always a pleasure talking to you, Andrew.
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.