 Questions? Yes, Robin. Cezette, thank you very much for having the courage and humility to share a failure in front of several thousand people. How does it feel now that you've done it? I was very nervous, but it had to be said, and for me it was really heartbreaking, but not for me, but for all the patients who need now again to have the pay for injections, which is very expensive also. I didn't mind to tell it, but it's very, very, very disappointing. The outside world would like to speak to us again, and then Francesco, and then down here. So a question for May-Wen, as to whether you included qualitative measures of patient perception within your study specifically for the simplifications conducted? No, we didn't do any qualitative study at this moment, but I think that perhaps is a way to go. Francesco. Francesco, and then some epicenter. So about the Legemanizes trial, did you control the temperature of the pack? I mean, did you measure that? Because I think it's quite striking the difference between your failure and the success of the previous one. No, it's true. I wonder whether everything was done, I mean, did they check the temperature of the other one? Do you check the temperature of this? Because I think it's pretty, since it's sensitive to the temperature, maybe it's good to know if the measure, the temperature was correct, I mean, or enough according to the previous research. Yeah, well, we have an infrared thermometer that we measured the temperature of the skin and of the heat pack before and after the treatment. And we had six different thermometers, not at the same time, but we have checked that it was exactly the same temperature. But also we found an average or an immediate temperature of the skin was around 39.6 degrees Celsius. And it was similar to the other study, which was having, in the study they had between 38.6 and 40.6. So it was exactly the same. So, yeah, even that could not, because that was our, my first thought, it's the temperature. Temperature is too low, around 40 degrees, but yeah. Hi, so that's the same question as well. Did you think that the intralesional concentration of parasites could be responsible? Do you think probably the parasite load per centimeter square of the lesion could be different from other studies? And so you probably aren't killing enough parasites. Or do you think that the immunological differences in the response to the parasites that you found, especially in the three patients who had spontaneous recovery, what do you think could be responsible? Do you think it's spontaneous or were there underlying immunological differences? Yeah. From the three patients who did cure, I think the spontaneous healing was there. They are, all the three are very different, but if the parasitic load around the lesion, if that could have been the cause, I don't think so. Because some patients, they had a parasitic load of only one in the field, and other had six, like we have a grading, which is what grade six. So I don't think that could be responsible, I am honestly speaking. Other questions? Thank you very much for your great presentations. I'm Jean-Bosco from Save the Children International. My question, I have a short question about hepatitis C. It looks like the number of patients with hepatitis C was growing higher. And I'm curious to know if you evaluated the association with other infections, mainly HIV and other STIs. I want to make a clarification. The number of patients coming to the clinic increasing, but it doesn't necessarily means the number of patients being infected and increased. I don't know if I answered your questions. We have a general population cohort, which are the patients who are mono-infected by hepatitis C. We also have HIV cohort. Those patients are co-infected by HIV and hepatitis C. Is there a prevalence of HIV and hepatitis C? I don't know the number in Cambodia among HIV-infected patients. But currently there's no very good estimation of the prevalence of hepatitis C in Cambodia. But we always see the estimation as 200,000. Patients are infected of hepatitis C. Currently we're doing a prevalence survey in Mongolsa District in Patongbon province in Cambodia. We want to know the prevalence from there and then to better make our strategy. Outside world. The outside world is very active this afternoon. First question for the Leishman-Isa study, Suzette. Given that you've been brave enough to share a study failure, what do you think are some of the key learning points that other MSF projects may want to consider so as not to repeat similar failures? So to avoid failure in methodology or in how things are thought about. And then across the board, one of our online audiences is asking, all of these presentations are really important and the findings are impactful. How does MSF perform, in your opinion, in the dissemination of such innovation research? Go ahead. Will the other MSF OCS or OCS should not make the same mistake? So I guess it's about do you have learning pointers on perhaps what were the problems within the study that led to failure and could perhaps give advice to other studies about. And then across the board, how do you feel MSF does, as an organisation, in disseminating the results of its innovation studies? Well, I think for what I've learned, it's really easy. This heat pack is not working in autopic settings. But what we could do is, if you are in a major setting, which I think is in the Middle East, where they do treat alasmania, I need to think about that. But I think we could do the same setup, but then really, really maybe more early follow-up of the patients and keep in mind that it can fail, because I think after two months we already suspended, but I think you always have to keep in mind that it can be possibly not working. Yeah, and for disseminating, I would like to... How do you want to take on with me? Yeah, I'll try a little bit to answer this question nicely. We don't do it well. One of the more influential papers that I read in MSF is actually Ben Ramalingam's paper from 2008 about complexity. And I think we are a complex entity with multiple sections, multiple projects. And what we don't have is both the mentality, nor the tools to kind of work through these. And these are transversal communication tools, but also the kind of mentality of sharing. And we have these forms, which are great, and I think these add to it, and we need much better tools within MSF. Even some simple things, right? So when you go do an implementation of focus in a project, where it gets maybe perhaps skeptical OC or desk, now it becomes convinced because they find that their clinicians and the returning volunteers like it a lot. Where we need to do is get that to all the other desks and OCs. And I think we are still struggling with figuring out how to overcome compartmentalization in MSF. And so, yeah, I don't think we do it as well as we need to. I don't think I can speak for MSF, but for our project. The goal is to have the simplification of care and to further use this simplified mode of care to benefit more patients in resource-limited countries. So I think as our goal is that, and we're disseminating our findings from the project, that means we're hoping to have more people benefit from it. And also, we're still on a way of simplification. So we are hoping, finally, we will find the best mode of care and then we will have the MOH takeover the mode of care and make it as a national program. So Cambodia is of course a kind of special project because the focus is really on research and the objective is that certain of our activities, findings, strategies would be replicated. So per definition, we are now starting a phase with a lot of communication externally, regionally, locally on the project, but again, that's not representative for the other projects we're doing in MSF. Other questions out there? One there and then one in the back. Hi, Beth Stringer, working the Manson unit. I just wanted to reassure that some of the greatest things that we've learned have come from failure, actually, and you just have to keep going. I think even one famous, sort of, I don't know if anyone in the room, but it's to do with DNA or some sort of, you know, experimental that starts with failure, you then learn your greatest achievement. So keep going. In the back and then we'll come back here. Sarah Wookie, doctor. I'm simply going to echo that. I wouldn't describe your trial as a failure. It was a well-conducted, well-organized trial that answered a very important clinical question and it means that patients in the future are not going to be subjected to treatment that's not going to work as a result of your trial. So I think this is a success. Right, thank you. You are? Right, I'm waiting for the mic to turn on. My name is David Bevers-Lewis. I'm an emergency physician working with MSF. Adi, a question for you. So a lot of early ultrasound studies look at training and feasibility and then the next level of study often goes to clinical efficacy and outcomes and proving that it's not just possible but useful, potentially cost effective. You mentioned quite a few different potential applications. What do you think are the low-hanging fruits and the most effective thing that this can be used for in our projects? All. The two that are probably both the low-hanging fruits that are kind of easy but also some things that are incredibly valuable is number one, extra pulmonary tuberculosis. So there's a couple of researchers in Southern Africa, Tom Heller and Sabine Billard who have been doing amazing work trying to find diagnosis of extra pulmonary tuberculosis in patients with HIV and I think we need to learn their lessons and adapt it or try and find if that can help us diagnose in patients that don't have HIV but also maybe similarly immunocompromised patients with malnutrition, other patients with HIV patients. This is an impossible diagnosis in our field and if you can use ultrasound to make any kind of improvement I think that would be huge. The other is cardiopulmonary ultrasound. So especially when you don't have X-rays frequently you have patients who have dyspnea or hypoxia in our ICUs and we're not really sure why especially if they have a positive rapid diagnostic test for malaria then they get put into the diagnosis of severe malaria when in fact they may also have additional like large consolidation from pneumonia or and just happen to be R-D-T positive or they have tuberculosis and pericardial effusion and pleural effusions or they have rheumatic heart disease and they're in heart failure and these are really hard to diagnose clinically and so I think using these two would probably be the ones that I would say we really need to push because I think those are the ones that myself but also many other field clinicians really struggle to make the proper diagnosis and help the patients. Other questions? I see one in the way back there and another one. So my name is Hasan Zahe. I work for MSF in Karachi. We have a very similar hepatitis C project as Cambodia. So what we have struggled with in this simplified model of healthcare is treatment failures. How do you manage treatment failures within your project and more importantly how do you inculcate them within this simplified model of healthcare which is based on a cascade of care? I understand the first part of the question so how we manage the treatment failures so fortunately today we're in a stage where we still have a second line ACT that works and fortunately there's also evidence that the ones resistant to mefloquine are usually most often not resistant to paparoquine. So for the time being we can still manage the second line treatment while the national program normally recommends quinine which we are not given to the patients simply because we know from experience that quinine is a drug that never is taken correctly by the patient assuming that it's already prescribed as a full treatment by the prescribers. Usually the prescription is already shortened or with insufficient doses to avoid the side effects and then the patient still takes less. I'm not sure I got I answered the second part of your question. Thank you. Thanks for the question. I heard a lot about the project in Pakistan as well. Luckily we don't have a lot of patients failing for the treatment. The success rate is quite high as 96%. But currently we don't have a solution yet for the field of patients because second line drugs do quite expensive and next week is the strategy planning week. I think our medicals and head of mission will have further discussion with the headquarter to see what we're going to do. All right. The clock on the wall is ticking down so I'm going to take our last question here. This is for Adi. I am from MSF in Barcelona. The question is do you think the focus could be feasible or useful to be used by nurses in primary health centers or is going too far in the task shifting? Is it nurses in family health centers? Yes. Maybe. My I think yes for everybody. This is really simple pattern recognition and but I'm not sure but I yes I would like to but I think we also have to be realistic that this is a little bit more advanced and a simple diagnostic for malaria and we need to be sure that we're providing safe diagnostics for our patients. I think myself even through this exercise I've realized where there are some limits and maybe in a few years when it becomes much more prevalent and there's experts or not even experts but really experience people in the fields who can supervise mid-level staff or additional staff whether it's nurses, nurses or whatever in our fields who can give them close supervision. That's what we've done at that point but we just don't have enough right now that I can blanketly say that it's completely safe everywhere. I'd like to thank all of our presenters for some very interesting presentations and thank all of you for sitting on your questions until the end and making only two declarative statements. Thank you very much.