Medical Cannabis: From Farm to Pharmacy (with Azhar Rana and Sandra Couto of IMC)

Medical Cannabis: From Farm to Pharmacy (with Azhar Rana and Sandra Couto of IMC)

Azhar Rana and Sandra Couto talk to GrowerIQ about getting medical cannabis from farm to pharmacy, IMC’s innovative research, and the challenges ahead.

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Transcript

Steve Looi 0:03
Hi, everybody. We’re here today with Dr Azhar Rana and Sandra Couto of Integrated Med Health Communications. And just to start off, let’s hear a little bit about yourselves and what integrated med health comm does.

Azhar Rana 0:17
Sandra, why don’t you start? Ladies first.

Sandra Couto 0:20
Wonderful. So hi, Steve. Thanks so much for having us. My name is Sandra Couto. I am a licensed pharmacist, and currently the head of medical and scientific affairs at IMC. IMC is a medical health education and communications agency. We work with clients all over the world all over the globe, pharmaceutical and cannabis as well. And I’ve been very interested in the medical cannabis arena, not only as a health care professional, but also as a Medical Cannabis Patient myself, I suffer from rheumatoid arthritis and have been using medical cannabis. So really excited to be a part of our discussion today. Thanks for having us. Excellent.

Azhar Rana 1:10
And my name is Azhar Rana. Thanks again, for having us as well. So, I’m the president at IMC North America. As Sandra mentioned, we’re a full-service medical communications agency. We have offices in Toronto and Boston for our North American affiliate and offices in Cairo, London, and Cambridge for our UK and global offices. Most of the work we do is, as Sandra mentioned, with pharmaceutical in the cannabis world, our role is to be the experts in communicating the science and the data that needs to go out to healthcare professionals, policy advisors, patients and other stakeholders within the environment.

Steve Looi 1:49
Gotcha. Gotcha. So let’s jump into this. So, the rates of prescriptions coming from doctors seem to not be where a lot of folks wanted it to be – especially, I guess, during the heyday of this whole industry when it was hyped up a lot. Can one of you tell me a little bit about why doctors are hesitant to prescribe?

Azhar Rana 2:15
Well, I could. Well, in the physician industry, if you will, there’s always been scepticism about medical cannabis and the value of medical cannabis. And I think a part of that is obviously driven by the lack of solid evidence that has been generated over years. And we’ve all known why. Cannabis hasn’t really been studied for many years, and now it’s starting to. So, I think for physicians, specifically, the challenge has been: how do you reconcile a product that was illegal? How do you start transferring your thought process to be prescribing for your patients? And the second is obviously the stigma associated with cannabis, right? It’s there, the people who have studied it and who understand it can see the therapeutic value for it. But the general average physician who hasn’t spent a lot of time with medical cannabis probably still sees it as something that people will smoke and use as a recreational drug rather than the medical treatment.

Sandra Couto 3:23
And if I could just add to that, in all fairness to the medical community who’s looking for scientific evidence, as with any new drug that comes on to the market, I think that they were hoping for and rightfully asking for some of this data to be available to them when they’re trying to prescribe and unfortunately, because of the way the industry has evolved, and also because cannabis itself is a generic plant and hasn’t been patented, the level of rigour and the clinical studies that are required for a molecule like that is not similar. We can’t apply the same model if you will, that in the pharmaceutical industry exists. And so there’s been a bit of a catch-up. So while physicians are asking for data that should be available, the industry, the cannabis industry is just catching up in terms of doing the clinical work in order to make the scientific evidence available for these prescribers and for patients and for payers as well. So we’re moving in the right direction, but we’re not there yet.

Steve Looi 4:32
Gotcha. And so communicating this information to doctors, among other stakeholders is something that IMC is involved with, right? And so you guys have an interesting viewpoint on what’s out there. Can you talk a little bit about the research that’s happening? And perhaps with your global view, tell us a little bit about which, which countries are doing are doing a lot of work here or maybe even the companies? Yeah, if you guys can comment on that. That’d be interesting.

Sandra Couto 5:00
Sure I can jump in, take that one. And then as we’re maybe you can comment on some of the work we’re doing globally. But in Canada, IMC has been supporting some great novel work in the collection of data from patients who are using medical cannabis, specifically with respect to validated strains of medical cannabis. So right now the industry, there are no standards for licensed producers when it comes to making their cannabis products, we know that there’s a lot of substitution that happens, we know that patients will often start with, let’s say, one cannabis product, find effectiveness. And then three months later, they order the same product, but they’re not necessarily getting the same efficacy or results that they had three months ago. And that’s because there are some substitutions that are happening when licensed producers are making their products. And so for the first time, we in Canada are actually studying the, what we’re calling validated strain. So licensed producers have rallied together and have committed to providing full transparency of their strains with respect to the cannabinoid profile, the terpene profile, and the DNA makeup of that plant. And so now for the first time, we can actually start collecting outcome data for patients that are taking these strains and measuring their effectiveness. And so IMC has been instrumental in supporting the study development from protocol, synthesis to data collection tools, working with academic, the academic site, as well as physicians across Ontario. Oh, through Canada, not Ontario. I was looking at a map of the globe and I said Ontario, sorry.

Azhar Rana 6:57
To your other question about what else is happening around the world? And where’s the data being generated? I think we’re all very proud of the fact that Canada is definitely at the top of that list of leading research within the space. It’s fantastic that it’s something that we’re investing in. Something that we’re looking to study and actually understand rather than, unfortunately, what we’re seeing south of the border where cannabis research or medical cannabis research is very stifled because of the Controlled Drug Substances Acts and the issues that they’re facing both at a federal and state level within the US. So Canada is one of them, which we’re doing great work in. Israel is another country that is very invested in understanding cannabinoids and terpenoids and making sure that patients who need the treatments are getting the right things in the right concentrations. Unsurprisingly, the Netherlands has been one of the pioneers of cannabis for four years. There’s a lot of research that happens both at a national as well as the local level within the Netherlands. There are European countries that are starting to pull research together. So we know that Germany is leading the charge in Europe; the UK is starting to come on board in allowing for some sort of studies on what happens specifically in the epilepsy space. And the one other on the list, which which is surprising for me, is the Czech Republic, they’re doing a lot of really great work at a number of centres within the Czech Republic that are dedicated to cannabinoid research. So yeah, fascinating stuff.

Steve Looi 8:40
Any particular studies that are that have come up that are interesting to you guys that are surprising?

Azhar Rana 8:47
Well, one thing that I would say is interesting is the one that we’re doing. Jokes apart, I think the study that we’re working on right now is really one of its kind. It’s a study where there are patients coming in, they’re getting validated products, we’re assessing the response to cannabinoids based on validated questionnaires on different disease states, and really understanding it from a patient perspective. What happens to you as an individual when you’re using medical cannabis, and with the validated strains that Sandra mentioned, we’re able to go back and then understand how those strains have affected different people. So I think this is one of the first ones that is that intensive in terms of the data that we’re we’re hoping to get out. Sandra, any other ones that you want to mention?

Sandra Couto 9:44
Not at this point. But I do want to say that what’s exciting is that we now have consensus and agreement from the licensed producers in Canada, which is really, really exciting. We didn’t have that in place before and so now we’re creating the structure if you will, or the framework for licensed producers to work within and to provide that transparency, which I think they didn’t have before. And so now, that’s really shaping the Canadian marketplace. We’re going to learn a lot from this particular study in terms of the importance of validation, as well as the importance of having transparency from seed to sale. We all talk about it. But now we actually have the data to showcase for it all the way to patient-reported outcomes. To your earlier question, Steve, about what physicians are asking for and that they don’t have available to them, we still will have some of that information that will certainly help them prescribe more confidently for their patients.

Azhar Rana 10:52
Yes, if I may just add one of the ways from just from a research perspective, there’s companies and partners that we’re working with who are doing bench and scientific research on the use of THC, CBD and other cannabinoids within the product. And those studies are going to be vital for decision making for physicians in the future as we get more and more options in terms of delivery methods for cannabinoids. So whether we’re looking at oils, whether we’re looking at sprays, or gels, or topicals, or whatever the formulations that are coming in, there’s a lot of innovation there. Those will be focused on product delivery. But one of the things that we’re seeing within the market is that there is still a lot of people who like their oils and like their flower. So for them, and for those people to have validation of what they’re doing – and for their physicians to have validation of their treatment plans – I think some of these real-world studies are going to be very important.

Steve Looi 11:55
Yeah, that’s excellent. And I want to touch on that in one sec. But one question I want to get in before that is for medical patients right now. And for doctors right now. If a patient is coming in, presenting with a certain indication, or the patient’s themselves are looking for strains, how are they going about choosing the right strain for them right now? Is that really possible? Or is that more of a trial and error thing right now?

Azhar Rana 12:30
This is a topic we’ve debated many times!

Sandra Couto 12:34
That’s a great question. And I think that there’s a lot of ways of answering your question, Steve. I think from a patient perspective, there is no one place for patients to go to. They will rely on their health care professionals. And if their health care professional is open to and comfortable with prescribing medical cannabis, then they can certainly have that discussion. We know, however, that there’s a number of them that aren’t, and so cannabis clinics have started to pop up, at least in Canada, and that they have been instrumental in helping patients get access, as well as information, about the strains that are available. And those are usually led by healthcare professionals. So, in terms of at least accessing the information, patients do have that option. They can obviously self-learn and self-educate. But when it comes to picking the strains, and matching it to their ailment and their symptoms, that’s a little bit of a trial and error. We know that there are variations between individuals when it comes to metabolizing cannabis. So a dose that works well for you may not work well for me, and vice versa. And so having, somebody say “well try this strain at this dose” – that may not be enough for patients. And so patients will often have to go through a number of different options or trials before they can actually get to the strain that works.

That’s why that study that we were talking about is going to be so critical for them because they will then be able to find that right strain, and know for certain when they buy that particular strain. Now with transparency, they know exactly what’s in the bottle. What they’re paying for will give them the effect that they’ve they’ve been experiencing. So, I think it’s a bit of a trial and error and also for physicians as well in terms of the robustness of the data. There is a lot of data that’s been generated over the last few years on medical cannabis, no discounting that. But in terms of the repository, where all that information resides, I think it’s a bit fragmented right now. And so trying to consolidate and have that available easily for physicians is something that’s sort of emerging. We have been working very closely with organizations educational organizations within Canada to put forward accredited programs for physicians to access and that continues. But in terms of a quick and easy fix, there isn’t anything like that right now. Azhar, add anything more?

Azhar Rana 15:15
Yeah, I think you’ve covered 90% of it, there’s a couple of large data collection tools that we know are in the markets that are collecting data from patients and individual patients. What we don’t have right now, I think, is a way to play through that data entirely. And to come up with all of the questions or the answers to the questions that we have. So I think there’s, as Sandra said, data that’s being collected. There are the trials that we’ve discussed, there are the apps and the programs that anybody can download and collect their information. How do we pull that together to make sure that we’re getting the information? We need to put both the stigma to rest, but also physicians and patients minds at rest. This is something valuable for them.

Steve Looi 16:01
That’s really interesting. So it sounds like we have the data out there. It’s just almost a matter of time. Really, before we go through and really mine and understand what those results mean, what that data means for patients. And it also sounded like there’s an element of personal medicine there. And when do you see – so I’m going to ask a few forecasting questions here. I have seen some companies out there that are doing genetic testing sort of the 23andme as relates to cannabinoids, and folks, so that’s really interesting. When do you foresee that intersection really being fruitful for people? Personalized medicine and the mainstream is starting to come online or being talked about way more? When do you see that intersecting with the understanding of cannabinoids really? And providing better outcomes for patients?

Azhar Rana 17:02
I think we’re that’s a great question. I think we’re on track with that right now with this program across Canada to have the validation of strains. What patients will get from that is they’ll have clarity on what is the cannabinoid profile, but also what is the terpene or terpenoid profile for the product that they’re taking. So what that’ll give patients the option and the ability to do is whether it’s through trial and error, or whether there are other future genetic tests coming or not. At least having that profile of your cannabis gives the patient the ability to choose exactly what works for them for patients. So like, I know, people who will use a certain strain if they’re feeling anxious, and they’ll use a certain strain if they when they need to sleep. And so being able to generate that information for yourself, by providing patients with that profile and the exact ingredients, if you will, of what your cannabis is. That, I think is the biggest step forward that we’re taking right now.

Steve Looi 18:06
Awesome. Yeah, so that’s really interesting. And so with the validated strains, I think that’s an excellent step. But for a lot of pharmaceutical products, when we’re talking about a molecule, quite often, it’s just one molecule. But in the plant, we have this entourage effect, where there’s a bunch of different molecules interacting, and we don’t completely understand what the interactions are or what interacts with what to give what effect. And in a plant, it’s almost a roll of the dice to see what comes out. And I understand people are getting consistency. But do you see an evolution in the sourcing of the molecules away from the plant? One analogy I often give is that we don’t for a headache, we don’t chew willow bark anymore because it has its inherent problems in the production, etc.

Sandra Couto 19:01
Oh, I do, I don’t know about you, Steve.

Steve Looi 19:05
Well, but wait, do you see that evolution coming or, even necessary for cannabis as a medicine?

Sandra Couto 19:16
Well, that’s a great question. And I think we shouldn’t forget that we do actually have cannabis products, synthetic cannabis products that are on the market that has been on the market for a very long time, that have an OCS and have been approved by Health Canada. So in terms of, of synthesizing those molecules, I think that there is a need and an interest and certainly a marketplace for that. So there are a number of licensed producers right now that are involved in developing synthetic cannabis-based products, that and they are putting those into clinical trials just like they would a pharmaceutical product. But I think we just need to be mindful of the end-user and what they’re using the cannabis products for. So we know that when patients inhale, for example, they will get the entourage effect from the terpenes and cannabinoids through the inhaled route. Whereas when you’re taking an oil-based product, you’re really just getting the pure THC, CBD or whatever the cannabinoid is in that oil. So it’s really going to be dependent on what patients choose and want to use the cannabis products for. I don’t think there’s a lack of opportunity or a need for these molecules, these synthetic derivatives. It’s just that the market is big enough to have them and it really is gonna depend on who’s buying them. And for what purpose.

Azhar Rana 20:52
We’re already seeing conflicting data coming out, right, so there are some studies. I read a paper last week, I think that said that terpenes don’t have an effect. And the use of terpenes will not add. There’s no such thing as an entourage effect. And the terpenes won’t do anything for a patient. It’s the THC and other cannabinoids and then a paper that you shared with us today that describes, the definite benefits of terpenoids. So we’re getting into the stage now where there’s going to be different types of molecules and formulations produced by some probably on one side of the fence, without having the entourage effect of terpenes. And then the other side effect, on the other side of the fence with terpenes. It’s going to be, as Sandra said, what the end-user needs it for. I’ll give you one analogy a child suffering with Lennox-Gastaut syndrome who has multiple seizures in a day, if they’re being controlled with THC, or a combination of THC and CBD for example, then for them, terpenes and the entourage effect will have little or no value. But for other people using cannabinoids – when you’re inhaling cannabinoids, as we talked about, where terpenes can have an effect or do have an effect subjectively, for those patients, people are going to be more likely to purchase that sort of a formulation. So the market has space for both.

Steve Looi 22:23
Smoking is probably one of the worst ways to get this medicine, these molecules into your body. I don’t know if there’s any other analogue out there where we get patients to smoke something to get it in their bodies know. How far away is the industry from having something that we recognize as a true prescription pharmaceutical, something that’s dental, that has a drug identification number, easily paid for by insurance etc, that we get from the pharmacy like a Lipitor or what have you.

Azhar Rana 22:54
Yeah, there’s a lot of products that are in development. So we know that there are already, as Sandra mentioned before, some synthetic cannabinoid molecules which are available as DIMed products, or prescription-only products. I think the future development of this or distribution methods of cannabis, whether it’s going to be through the lungs, we’ll move away eventually, from the smoking. I think we’ve already we’ve seen a lot of challenges, right? With the vape products, for example, and in all of the contaminants that were in vape products and people struggling with that. But I think the inhalation market, fortunately, is still going to be a big player within the cannabis space for many years. I don’t think those products are ever going to get in. As you said, there’s probably limited analogues of inhalation other than inhalers, but that’s a totally different space. But there are companies that are developing DIMM products as we speak, like some of our partners that we’re working with are developing topical products and oral products that will have a dent eventually will be pharmaceutical products that are prescribed, so timescale, maybe four years probably, that we’re away from.

Sandra Couto 24:11
And just to add to that, in fairness, I mean, the smokeable form of cannabis has been around and available for centuries. Well, I think that as we start to evolve the industry and the partners and the investment in true clinical development, we will see great products that will slowly replace the inhaled formats, but to others point, it does remain the biggest player in the market in terms of usage. We know that there are a lot more patients out there that are using the inhaled route simply because of the fast onset and until we can catch up with the clinical development and start making other products available in the same sort of ingredients but in different formats, whether they are through inhalers or through some other form that gives a quick onset of action. But we are getting there we just we have to give these companies time to do the clinical development work.

Steve Looi 25:15
Gotcha. So we talked a lot about the doctors earlier. But Sandra, when we talked earlier, we talked a little bit about pharmacists and how they’re not really being tapped that much for what they can provide patients. And so for any MMJ patients out there, I want to ask you, what are things that you can talk to your pharmacist about, in terms of treating yourself with medical marijuana?

Sandra Couto 25:44
Yeah, that’s a great question. And, and I’m a little biased here. But I do think that pharmacists are probably the best-positioned healthcare professionals out there right now to help support medical cannabis patients for a number of reasons. One is, they still remain the most trusted health care professional for patients to contact whether it’s through the retail setting or through, hospital affiliations. But pharmacists also have extensive training on drug interactions. And so quickly understanding how cannabis is metabolized. And then looking at your profile of medications, a pharmacist can really help you hone in on the dosings that you need that are appropriate. So if you’re taking certain types of medications that metabolize or affect the metabolism of cannabis, then you’re likely to see less of an effect. And so you’ll need to up your dose of cannabis, or vice versa, if something is inhibiting the metabolism of cannabis, you’ll have much more of that in your bloodstream. And so you may not want to start off with a very high dose. So from a drug interaction and also from a dosing perspective, pharmacists are very well versed in that domain.

Unfortunately, though, in terms of educating pharmacists and bringing them into the circle of care, we have seen a lot of fragmentation and variation across the country. So some chains of pharmacies will support their pharmacist and provide a lot of education. Others will not. The independent pharmacies will end up doing their own programs. It’s a bit of a mixed bag and we do end up leaving the patients alone and sort of unsupported. And they have to go either to those cannabis clinics or to a call centre, or somewhere where they’re not necessarily speaking to a representative or a healthcare professional that has full transparency of all the products that they’re on and their comorbidities. So I am still waiting for the day when we can actually bring medical cannabis into the pharmacy setting, where it rightfully should be, and part of the standard of care that pharmacists are providing to patients.

Steve Looi 28:03
Right and presumably, pharmacists are a group of stakeholders that IMC can or does work with. Is that right?

Azhar Rana 28:12
Yeah, we work with pharmacists quite a bit across different disease areas, and also across different types of projects and activities. So everything from training, communication, education, as well as getting advice and input from pharmacists through advisory boards. We have engaged with pharmacists quite a bit.

Steve Looi 28:35
Interesting. So Sandra, just a little bit more about that. I’m sure there’s more work that needs to be done. But do we fully understand or not fully understand we have a beginning on the understanding of what interactions are possible out there with these cannabinoids. I mean, what sounds like we don’t understand completely. The canon cannabinoids that we do know there’s a bunch of cannabinoids, we don’t know about. Where are we at with in terms of the interactions? like is this another grapefruit?

Sandra Couto 29:10
I think we’re peeling it. Yes, we are. There’s a lot to it. And I don’t know if we could use the analogy of peeling the grapefruit or the onion but certainly from the cannabis plant itself. We know there are hundreds of cannabinoids and terpenes and so we’ve only just started to scratch the surface with CBD and THC but there are lots of others and having a full repository of drug interactions. To my knowledge, I know that many pharmacy software programs have started to incorporate cannabis into their dispensing system. So there is a way of tracking but again until we have transparency of what patients are taking in their bottles and in their products at home. There’s really no way that we can start isolating, CBD A or G or all of the different cannabinoids and how they interact with the product. If we don’t know what’s in the bottle, we can’t measure it. And so we speak loosely around the class of CBD or the class of THC or the class of the terpenes. And that’s why we keep coming back to that study. But that study that we’re doing right now is very, important and will inform us on a lot of interesting areas that we can build on. So, to your point, I think documenting and lots of programs have been updated to include cannabis in terms of drug interactions. But we still are long ways away.

Steve Looi 30:41
Gotcha. So you mentioned some of the different cannabinoids out there. And you guys were consuming a lot of studies and understand or know what’s being researched out there. Do you guys have an idea of what – so CBD in the last year, maybe a bit more, has sort of become the new black? It’s in everything out there. Which cannabinoid do you think is the next CBD in terms of the research out there? And its efficacy and treating a myriad of things, if any?

Azhar Rana 31:17
Well, there’s been some data that’s talked about CBG and antibacterial properties. So there’s been some speculation, I think, in the literature about whether CBG can be used to treat the superbugs and the superinfections that we see in hospitals.

Steve Looi 31:35
Oh, interesting.

Azhar Rana 31:36
So that’s one I know of for sure. That’s being that’s being studied. I can’t really think of any other ones. Sandra any other ones that come to mind for you?

Sandra Couto 31:48
Well, I know a lot of them but I don’t know in terms of what they’re all being for. So I think we’re just mapping those out right now. The interesting thing is, in the study that’s currently being done to validate the various cannabinoids, they’ve picked the five most common ones. Now, I can’t remember which ones those are, I’d have to go back just quickly to the notes, but the top five have actually been identified to be recognized in the study.

Azhar Rana 32:17
So I think we’ve got THC, CBD, CBN, CBC, and yeah.

Steve Looi 32:25
Interesting. And does that include the acid forms or just those..?

Azhar Rana 32:31
Now you’re getting all pharmaceutical.

Steve Looi 32:37
We can leave that one. So a couple of quick questions just to wrap up here. Um, how has your guys’ business or your day to day how has it been affected by COVID? Oh, yeah.

Sandra Couto 32:56
Take that one.

Azhar Rana 32:57
I’ll take that one. So we’ve actually been shut down. Our offices have been shut down since March 16. Right, working at home now. So it’s been – what is that? Five months now, we’ve been at home. So from a business perspective, it’s been tough on the team, because everybody’s been isolated. With the work that we do, we’re very – it’s a very social sort of interaction. And there are clients, and you work with clients, and you work with the team internally as well. But our team is absolutely the best group of people you could ever imagine working with. They’ve adapted so fantastically to this adversity over the last few months. So people are good, we’re at home, we’re working and our business is actually pivoted quite a bit from the live interactions and the live engagements to everything virtual. So all of the conferences, all of the meetings and events, all of the scientific engagement, working with physicians and other healthcare professionals, we’ve moved everything online. So thank god – touch wood – our business hasn’t suffered. And we’re running strong to continue communicating science.

Sandra Couto 34:12
I can just add to that. We do have in house capabilities to do a lot of market research and insights. And so we have been working with pharmaceutical companies and licensed producers to help them address this whole pivot with virtual healthcare and virtually seeing your patients and what patients are going through because they’re virtually at home and can’t connect with their health care providers. So we’ve been doing a lot of work with our companies and our clients to really start to map that out and help them because care has to continue and research has to continue and products need to come to the market. And so if there are companies out there that are looking for that expertise. We certainly have that at our fingertips and in-house we can certainly support.

Steve Looi 35:07
Right. And I’m sure those of us in the industry cannot wait for this research to… to prove out and any delay would be not amazing. You guys mentioned the conferences and stuff. For the listeners out there are there any conferences or speaking engagements that we can look forward to seeing IMC at?

Azhar Rana 35:32
We’re working on a number of opportunities to speak on the cannabis space, we’re looking at a number of opportunities to speak in the US as well as Europe. So they’re small conferences, some of the bigger ones I think that we were used to, and we’re looking forward to being on pause, I think both funding perspective as well as just availability of people perspective. But there are some opportunities that are coming up in Europe in the US and happy to share those with you as soon as those get solidified.

Sandra Couto 36:03
We do post those on our website as well. So if the listeners out there want to visit us on our website, that would be a great place to start.

Steve Looi 36:15
And what is the website?

Azhar Rana 36:18
The website is IMC medcom dash NA .com.

Steve Looi 36:25
Okay, awesome. Well guys, thank you so much. The interview just flew by there. And I have a lot more questions for you. But we got to stop at some point. Thanks again, everybody. And yeah, I really appreciated the time spent.

Azhar Rana 36:40
Thank you very much for having us.

Sandra Couto 36:41
Thank you for the opportunity, Steve. Take care. Bye-bye.

Azhar Rana 36:47
Bye.

Steve Looi 36:49
Take it easy guys.



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