because I'm aware that Governor Sarah will be leaving and you will be, so to speak, taking the Olympic flag of the urban age over and hosting us next year. Perhaps you might want to make a few comments before you leave, and then I'll come to you. That's all right, thank you. Thank you. Well, we have heard in this two-day conference about the various challenges of governing the mega city of Mambé, Mumbai. As we look forward to the urban age South America conference in Sao Paulo, I would like to stress how critical it is for political leadership to address these concerns. In Sao Paulo, improving the governance structure would require three process of change that are very difficult, but not impossible to implement in the medium and long term. First, we need to create a single transport authority in metropolitan regions, which could consist of a council with representatives from states and cities. In Brazil, a change of this nature requires the need for a constitutional amendment, something that, in spite of the magnitude, could be achieved in the medium term. Today, each of the 39 cities of Sao Paulo metropolitan area has full autonomy to manage all aspects of local transportation, creating an irrationally inefficient system of transportation as far as its structure and function. Second, we need a national fiscal system reform. There is a federal fund in Brazil that transfers more than a fifth of the two most important federal taxes to the cities. But the formula of distribution not only ignores the territorial basis of where those taxes were levied, but takes as a constant any population higher than 160,000 inhabitants. That is, cities of 1 million or 11 million people receive the same amount that a city of 160,000 inhabitants. The available income tax revenue per capita in the larger cities are lower than in the smaller cities. There's a distortion taking account the different levels of expenditure they need. Third condition, there is also a third condition that strongly affects governance in a way that is very adverse to Brazilian larger cities, the electoral system. In Brazil, the representatives are elected proportionally by states and not by districts. For instance, in the state of Sao Paulo, we elect 70 federal representatives. Each candidate must campaign for votes in the whole state, among 27 million voters. I was representative two times, and I was voted in 640 cities out of a total of 656. But I have never been in 90% of those cities. In practice, this brings to an underrepresentation of metropolitan regions, because smaller cities tend to concentrate the vote in one candidate that will represent the region, the city. Whereas in metropolitan areas, electoral preferences are more pulverized, and votes tend to be dispersed among several candidates. For instance, although it is home to 50% of the voters of the state of Sao Paulo, the metropolitan area elects only about 25% of representatives. The same happens in other metropolitan regions of Brazil. This, of course, undermines the region's weight and influence in the distribution of state and federal resources. Well, we have a lot to discuss in Sao Paulo. Let me tell you that Sao Paulo is considered to be one of the most miscegenated cities in the world that gathers people from the whole world and from the whole Brazil. As we say, you know you are in Sao Paulo when you meet Japanese or Korean people speaking Portuguese with an Italian accent. This is our greatest wealth and one that we are very proud of. In this sense, we are very happy to welcome the urban age group in our city. I am sure the contribution to our policies will be very important. The comparative analysis between great urban conglomerates of the world, the problems they face and how they solve them, and also their enormous intellectual capital accumulated in this series of seminars make us very eager to be object of your attention. We hope to meet in Sao Paulo next year as our honored guests. Thank you.


Stephanie, thank you for inviting me again, for giving me a shorter slot for such an important topic, and a little late, and the slot before break. But I will take one minute to congratulate Stephanie and her colleagues for this symposium. And for 10 years of this, and 10 years of advocacy for women's health, particularly as it relates to cardiovascular disease, many people come to this conference and realize that this is just one aspect of what she has done. There's public education on the web. There's community outreach programs to help the underserved, particularly women. And then there's issues with advocacy. So 10 years of that, Stephanie, is wonderful. So now I only have... Now, I've got to cut the applause short, because now I only have 14 minutes, because I'm with the break. So I do think this is an interesting topic, and as Stephanie was introducing me, she said cardiologists enrolled with diabetes treatment, and I've really come to think of this different. Cardiologists should be involved with cardiovascular risk reduction. And so how you do that, let's call it whatever we want to call it. And there's this debate about diabetes, no diabetes, but what I'm going to try and convince you now is that this is an issue of cardiovascular disease, cardiovascular mortality, and these diabetic drugs are treating cardiovascular disease and not necessarily diabetes. So we'll go from there. So just sort of as an objective, we're really going to use this to help identify which medications we use to treat our patients who have cardiovascular disease. And this is really based on the data regarding cardiovascular safety and efficacy profile of the agents, as well combining that with the patient's individual cardiovascular history and their comorbid conditions. So I'm going to center this around a case, and we'll keep coming back to this. And this is Cynthia. Cynthia is a 56-year-old woman who presents for routine care. She has heart failure with reduced ejection fraction, an EF of 40%, as Jerry said, maybe mid-range, low, right at the top of that, right at the bottom thing. A strong family history of heart disease, but she herself does not have obstructive coronary artery disease. She was cath and had small vessel disease. She has a long-standing history of type 2 diabetes on the DP-P4 inhibitor to sacsagliptin and metformin. The medical history is here on the left, as we'd seen multiple comorbidities that we often find, hypertension, hyperlipidemia. And her medications here on the right include Lysinopril, Carvetalol, metformin, 1,000 milligrams twice daily, sacsagliptin, 2.5 milligrams daily that was recently started, maybe three months ago. Vynlaxifine and Atorvastatin. When you talk to her, she's doing well, other than occasionally describing disney on exertion, as well as pediladema. The exam is here. Her BMI is 29.9, blood pressure 142 over 85, heart rate of 60. 5, heart rate of 62. Exam is really unremarkable. A1C, 7.8%. Lipid panel is okay. Her electrolytes are reasonable. And her EGFR is 52. So some degree of kidney disease. So the question is, is you're busy in clinic? Given Cynthia's existing type 2 diabetes and a diagnosis of reduced left ventricular systolic function, what changes would you suggest making to her regimen? A1, let her go. Doing okay. We'll just go with that. 2, increase sexagliptin to 5 milligrams daily. A DPP4 inhibitor. 3, replace sexagliptin with Gliberide, esophaneurea. Replace sexagliptin with an SGLT2 inhibitor. Empagliflozin. Replace sexagliptin with laryngotide. Or add insulin now to her regimen because she has kidney disease. The list can be really long, right? So let's go through this just a little bit. I won't spend too much time on this. We know that the prevalence of type 2 diabetes continues to increase. Nearly 30 million Americans have diabetes of which about 7 million are undiagnosed despite our efforts at increasing awareness and to make the diagnosis. And this rate is going to increase in conjunction with the rates of obesity as well as the aging nature of our population. We also know that we've made substantial improvements in how we treat diabetes and that the burden of cardiovascular disease in general has reduced over the last two decades. But cardiovascular disease still remains the leading cause of death in patients with type 2 diabetes. It increases the risk of stroke, increases the risk of coronary heart disease, rates of heart failure. Jerry's lecture was wonderful. We know for a long time that diabetes amplifies the risk for heart failure, it's a risk of cardiovascular mortality, as well as increasing the risk of total mortality. Simply said, diabetes is associated with reduction in the life of a year's life. When that diagnosis is made, your life is shortened for both men as well as women. Now women, the conference is really focused on women. Women share I don't know, disproportionate burden. A special relationship would probably be. And not a good one with diabetes as far as the risk factor to diabetes plays for women. Prior to menopause, we've learned that generally coronary heart disease lags by about 10 years. There's this protection that women have before they hit menopause. But if you have type 2 diabetes, and a young woman like we're seeing more and more of, we realize that this protection is lost, that it's attenuated. When we look at studies and we look at relative risk, we see that women than in men. Several studies, this is from the Rancho Bernardo study where men had a two-fold increased risk for coronary heart disease while women had a three-and-a-half increased risk for coronary heart disease compared to their non-diabetic counterparts. When women do develop diabetes, when they do develop cardiovascular disease, their outcomes tend to be worse in those with diabetes, diabetic women compared to diabetic men counterparts. MI may occur earlier in women with diabetes than in men. And if when they have an MI, the mortality may be higher. Mechanism behind this are unclear. We're hoping that we're closing treatment gaps that have occurred. The institution of evidence-based medicine, but we still see that there's a residual risk. And in heart failure, it's an important complication associated with increased morbidity as well as mortality. And the Framingham Heart Study showed us that the relative risk associated with diabetes is higher in women compared to men. Now another thing and busy slide is just that we don't see diabetes in isolation, right? And particularly when people have cardiovascular disease, we realize that there's this multi-morbidity that's associated with diabetes. And this is what this slide is really trying to show. Here we see these dashed lines, and it has three comorbid conditions. Type II diabetes, MI, and stroke. And here on the bottom line are survival curves or estimated life of years of life lost for diabetes alone, stroke alone, or myocardone farsion. When we can see as these start to add up, you know, as we see our patient, Cynthia, that the risk increases, which makes sense, but by age 60, which should be right today, midlife, I guess we'd call it, that it's not midlife for someone who's had a stroke or MI, their life is shortened substantially. That a history of any of these two conditions is associated with 12 years of reduced life expectancy. The history of all three is associated with 15 years of reduced life expectancy. So let's go back to our case and go to how do we take care of our patient with diabetes. So A1C is important. A1C we can't ignore. Many of my cardiologists want to say let's forget about it, but it does it is important for micro vascular disease, retinopathy, nephropathy. And so these are the recommended goals that the ADA as well as the American Association of Endocrinologists propose. And we can see that these goals are individualized depending on comorbid conditions, duration of diabetes, how well people are tolerating medications without side effects. But in general a goal of seven has been recommended and people with advanced disease we may be less stringent. But I would imagine that most of us would consider treating Cynthia a little more aggressively at 7.8. She's doing well in general and hasn't had many complications. But we have a lot of choices now, right? Of diabetic drugs, tons of choices. 2p4 inhibitors, sulfonorrhea insulin, the whole work. So with so many drugs to choose from, how do we decide? When I like to spend the rest of the talk is really describing the evidence that we've entered a new era of diabetes management which shows safety and efficacy and cardiovascular impact well beyond an independent I'm going to say of lowering A1C. So let's come back to that in a minute. The ADA and the EACD suggested when we're looking for what medicines we're going to choose with Cynthia that we consider a variety of factors. Hypoglycemic risk. What is the risk of hypoglycemia? What are the implications of an episode in someone who's sick? Need for weight loss? Chronic kidney disease? Cost effectiveness? What can people afford? And then we have in blue here cardiovascular disease, heart failure and ASCVD. And really this portion of heart failure and ASCVD is the decision tree when you're trying to decide on what agent to treat someone with. Chronic kidney disease, I need to fix my slide, should be on it but should probably come into that group as well. And so previously to 2008 we had very little evidence to help us decide how to treat people but in 2008 I won't get into too much, the FDA said it's no longer adequate or appropriate to approve drugs just based on glycemic control that the medicines we're going to use to treat diabetes to lower A1C have to be safe in people who have risk. This can be a medicine just to lower A1C, they have to be safe. And so they require that all new agents undergo cardiovascular safety testing and a cardiovascular outcome trial. And so over the last 12 years we've had nearly 200 thousand participants participating in diabetes trials aimed at cardiovascular risk reduction. They're non-inferior studies, are they safe? And then if they're safe, test for superiority. Nothing to do with A1C efficacy, right? No A1C, no diabetes sort of an issue here. These are all cardiovascular outcome trials. And so I'm going to talk about these trials and sort of big sweeps, lots of data and we'll come back as it helps us treat Cynthia. And I'm going to start with the incretin memetics, so the DPP4 inhibitors and the GLP1 receptor agonist and then I'll end with the SGLT2 inhibitors and sort of sweep it big and try and go quickly. There are four trials with DPP4 inhibitors. Our patient was on Saxagliptin, so is that a good medicine or not? So when we look at the cardiovascular outcome trials that are here, compared to placebo, we can see in the four studies that have been done, each with an individual agent, when we compare it to placebo it was as good as placebo. So it could lower A1C and it didn't cause harm. So all the studies met primary end points showing no increased cardiovascular risk. So another agent we can use to treat people if we need it for glycemic control. But a bit of caution from the studies was that when you looked at the secondary outcome, so those outcomes are what we call major adverse cardiovascular events, cardiovascular mortality, non-fatal MI and stroke pretty much. One of them had hospitalization for unstable angina. A secondary endpoint at the point at the time which was kind of relegated to secondary but become more and more important as we think about it was heart failure. And we saw early on that within the DP4 class there was heterogeneity in heart failure. So the first study that looked at Saxagliptin, which Cynthia's on showed that the rates of heart failure were a little bit higher compared to placebo. The second study with Allagliptin in an exam and patients who had acute coronary syndrome also trended in that direction. So in that setting the FDA put a warning on all DP4 inhibitors that we have to be cautious and maybe avoided in people who have worsening heart failure even though that's probably unfair for the last two for citagliptin and linagliptin. So if I made that, if I had any financial stake I'd probably be mad about that. But that being said for Cynthia, Saxagliptin probably not the best choice. So probably not the best choice. So let's move forward to the GLP1 receptor agonist what do we have from these data. So we have some exciting and promising data and we'll go over how they fit into the guidelines. There have been six studies published today about GLP1 receptor agonist sort of grouped them with three on the left here leader with larygolotide somagolotide sustained six and dilagolotide rewind which have all shown benefits for reduction in the MACE cardiovascular outcome. And this is what's shown here. Dilagolotide is a little bit different. This rewind is a slightly different study because a lot of patients in this one didn't have established cardiovascular disease they were just high risk. So I think it was around 60%. And these two these are people who had most almost all of them had cardiovascular disease. Larygolotide also had a 22% reduction in cardiovascular mortality as well as a 15% reduction in all-cost death. Somagolotide when we looked at their secondary endpoints what really stood out with some effects it had on stroke for both of these agents. So here are the three that have shown benefit these three on the right have not shown they have shown that they are non-inferior to placebo and trends that are in the right direction not for lixicinotide but for Excel there were some trends that went in the right direction for long-acting xenotide or by durian. And then I'll just point out this last publication that was last year it was an oral GLP1 agonist so it was an oral somagolotide we know that the rest of them were all injectables this was an oral pill and so it compared to placebo in a smaller study and it was non-inferior to placebo it missed superiority testing so non-inferior but what we saw was that there was some interesting findings as far as reduction in cardiovascular death as well as all-cost death that once you don't meet and statistically if you don't meet that first threshold of superiority the rest is just hypothesis generating the study included about 3,300 people so it was half the size of some of the other ones so it's so questionable what that means but again for patients who don't want to take injectables it may be an option from the GLP1 receptor agonist I definitely won't go over this too much but these are just something to keep in mind when we're dosing these medicines and all the medicines have to do with the renal dosing and GLP1 receptor agonist particularly related to laryngotide as well as somaglotide and dilaglotide can be used in people who have more advanced kidney disease so this might be helpful for our patients with advanced CKD where we've been limited in the past so turning to the SGLT2 inhibitors lots of excitement with the SGLT2 inhibitors and deservedly so three studies have been published to date one's the EMPA reg outcome study one's the canvas study and the others declared CIMI58 I'll start with the first two because they were more similar people who mostly had cardiovascular disease and we can see that for the primary MACE outcome there was almost identical reduction in the hazard ratio compared to placebo in the impaglophosism there was a statistically significant and pretty marked reduction in cardiovascular mortality trended in the right direction with canvas but wasn't statistically significant but again looking good and then what was most remarkable was we found with heart failure hospitalization only about 10% of people had heart failure so this is really prevention of heart failure hospitalization and so we can see that there was about a third reduction in heart failure hospitalization and Jerry will know Jerry wrote a paper with me and I forgot many years ago about when we talked about diabetes and heart failure we always talked about harm we talked about TZDs causing volume retention and we talked about hypoglycemia and then all of a sudden the signal comes up well this isn't harm right this is benefit so it was a really different I mean that's really different than what we had talked about 10 years ago when the conferences first started the next study that we have here is Declarer 58 it's a dappaglophosin and this is slightly different because what they did was they rather than use a common endpoint that everyone else said they split their endpoint into two they said we're going to look at heart failure really closely so we're going to look at both MACE outcome and heart failure CV death heart failure hospitalization and it also included about 60% of people who did not have established cardiovascular disease so I was looking at the high risk group but didn't have an event yet and what they found was that for their MACE it was not statistically lower but for the composite of CV death and heart failure hospitalization there was this effect even in a lower risk population so lots of lots of excitement coming back to our woman with an EGFR a 52 I think I said can we use it? the answer is yes but we do have to be aware of renal dosing there's a slight discrepancy between what the ADA recommends and what the FDA recommends at this point as far as their labeling I listed the ADA and took out my FDA slide in general the ADA is pushing further down the spectrum of advanced chronic kidney disease particularly because these agents have shown to have renal protector effect I didn't show a study called Credence of a kidney disease looking at cannagal flows in reducing cardiovascular outcomes with an EGFR down to 30 as well as improving renal outcomes so this is again we need to be careful careful I don't know if we need to be careful so the glycemic effect is much lower it becomes less effective at lowering A when C down at this lower spectrum but it doesn't seem to be less effective at reducing cardiovascular disease this excitement has led to the question earlier that how are these things working which could be another good talk and the answer is we're not 100% certain but the idea that they can prevent heart failure and can work for prevention and then in the small sorts of people who have heart failure could these medicines not be diabetic medicines at all but could they just be cardiovascular medications with some glycemic effects and so this has led to this hypothesis looking at these medications in patients with heart failure in the absence of diabetes and there are several large outcomes studies that are going on I included a couple of functional studies here and we're going to get a lot of information but we were fortunate enough to hear about the first one at the end of last year and that was called DAPA heart failure which was a study with DAPA glyphosin and over 4,000 patients who had heart failure with reduced CF less than 40 randomized to DAPA glyphosin versus placebo on good medical therapy maybe some of them weren't on interest though but it was still good for the time it was started with a primary outcome again cardiovascular outcome of hospitalization for heart failure or death from cardiovascular cause followed for an average about 18 months and what was seen was that there was a 26% reduction in the primary outcome as well as a 17% reduction from death from any cause 60% of patients in the study did not have diabetes 40% did and there was no heterogeneity of effect really across any subgroup there was some signal that maybe was a little bit more beneficial in those who had a lower New York Heart Association class compared to a higher one but this was not statistically significant and I don't think that portrays very well but these are just the outcomes again just so you can see the event curves they begin to split early quite early in the study so the benefit was seen at 18 months without the primary outcome heart failure hospitalization seen here death from cardiovascular causes with the hazard ratio of 0.82 and death from any cause with the hazard ratio of 0.83 so a remarkable push forward of taking the medicine from diabetes and moving into the cardiovascular world as far as and seeing benefits that I think will be incorporated into the next algorithm of our algorithm as Jerry has at Cleveland of how we treat our patients I was reminded that if my kids saw this slide they would be mad at me too they would they'd say dad what are you doing but I just wanted to show that these are the 2020 guidelines just published last month at the standard secure ADA and we're going to come to this section here on the right ASVD in a better slide but what it shows is that first-line therapy still is metformin 70% of patients in all these cardiovascular studies were on metformin to begin with it still remains first-line agent even though the body evidence behind it is not super strong it's still there the next decision tree here in red is indicators of high risk or established ASVD chronic kidney disease or heart failure if no then you come here and we go to hypoglycemia weight loss cost if yes you come to this category which we'll come to but what's new in the guidelines and kind of slipped through people who don't read them obsessively or is that this is consider independently of baseline A1C or individualized A1C target that is different than any other guideline that had been published before where it was if needed therapy beyond metformin to get to glycemic control reach for these agents this says that we don't care about A1C right just treat and so this is it looking at it metformin and lifestyle if you have ASVD risk a GLP1 receptor agonist would prove and benefit so that means you have to know the slight differences in the study or an SGLT2 inhibitor with proven benefit if the EGFR is adequate and then if A1C above the target we have other options if heart failure or chronic kidney disease exists then we should there's preferential recommendation to an SGLT2 inhibitor as long as the EGFR is acceptable to use it so that's what I wanted to talk about these are some take home points just as far as the antireminder that the antidiabetes agents with proven cardiovascular benefits include the SGLT2 inhibitors empagliflozin cannagliflozin endapagliflozin so this is what we have so far there are more coming the FDA has approved these medications and you can look for a reduction of cardiovascular events treat diabetic kidney disease none of these indications by the FDA have anything to do with A1C like the cardiovascular indications and then GLP1 receptor agonist laryngotide has an FDA indication for reduction of adverse cardiovascular events in patients with cardiovascular disease I want to thank you for your attention and let's you get to your break


I was actually struck by both Orsi and Kira, you open with sort of more modern theories as a way of entree into earlier material. And I wonder just methodologically if you could talk about that more, how does that work for you? How do you avoid the pitfalls of anachronism and why use that technique to get us into these discussions in these earlier periods? Is this? Who goes first? I think I had various reasons to open my talk with this. First, I think I just so difficult to relate to anything medieval for us and I just wanted to make it relevant to us because we tend to think today that we read self have books a lot and it's something new and it's just kind of a modern phenomenon but I think that it's so interesting to see that medieval people have were concerned with very similar issues we are struggling today and they had very similar psychological issues and problems they wanted to deal with and I really wanted to make this to make it relevant or relatable to us. I have some of the same interest as well making it relevant to not being, you're being able to explore ideas that people are exploring now but I also have some reservations in using modern ideas the way I justify it for myself is that these two that I'm thinking of, conspicuous consumption and self-fashioning really resonate with ideas that were contemporary in the 16th century. Conspicuous consumption is reminiscent of magnificence which was known and discussed and used to justify the lavish expenditure of rulers it was seen as a duty even for rulers to spend in this way and then self-fashioning reminds me of something like Castiglione's spritzatura as well. So I come at these with some reservations as well but because I hear these important, I don't want to say echo but these resonances with ideas that were contemporary in the 16th century I think it's acceptable to bring them in especially if they help us understand either the social phenomena or the art in a new way or a deeper way. Thank you and Michelle I really am curious to hear about your broader project and how this study of the Jamalian's fits into what is your broader motivation for the study and part of what I'm thinking is that as a non-Islamic art specialist I feel like when you think of the medieval Mediterranean and cross connections with Western New York you think of Venice and that's very well studied and very well known. So is your project making the connections with France and central France actually more well known? Yes, thank you. Yeah, so centers like Venice, like Sicily have been really over-studied in terms of how they functioned as poles of commerce and trade in the medieval Mediterranean but what I'm interested in more is kind of the reception of Islamic art in Western Europe and what that meant for users and viewers of these Islamic models. So a prominent example is the pseudo Arabic like what I showed and what I'm interested in is this idea of harnessing the exotic and what that means for the social class of the people who are using these exotic models and if that means that by using pseudo Arabic or any kind of other Islamicate images you're kind of elevating yourself. You're situating yourself aspirationally to kind of emulate courtiers and nobles who could afford to for instance travel to that region and so I kind of see, this is why I call my talk enviable possessions, these are objects that you wanted to possess because it was a way for you to assert your social status. So yeah, yeah. Now do you guys, I have questions for each other? I mean especially, I think you're honestly in here your papers really did speak to each other but if you have questions for each other please feel free otherwise I'm gonna open it to the audience. I have a question to care about the members of the confraternity. Do you know anything about it? Who participated this and was it specific to certain social groups or nationalities or? So the Crucifiso was a devotional confraternity so it wasn't a national company and it wasn't a professional association so it's particular to the devotion to the crucifix. It was an incredibly elite society, all of the big names, the who's who of Roman society were members, the Colonna, the Carafa, the Farnese, Alessandro Farnese actually served as Cardinal Protector of the organization, Renuccio Farnese before him. So they're certainly among the most elite. That said, there's a membership list that survives from mid-century 1550 to 1557 and there are over 1,800 names in the culture pieces membership list including artists, artists that work for the company like Perino del Lago in their chapel. So although control was probably exercised by a rather elite group, the membership was diverse and certainly devotion to the crucifix attracted a diverse group as well. I'll say that the elite status has actually presented some problems in setting the confraternity or in people's responses to it. I think because the idea that it's such an elite group comes with it, the idea that these devotions aren't really heartfelt and my project aims to resist that. Thank you, thank you for these papers. Actually, I have a quick question for Kira and also one for Michelle. Kira, to what extent were these practices conceived of as an innovation, a revival, or the perpetuation of practices that had gone on uninterrupted? I mean, in what way were they placed in the context of invention or revival? And for Michelle, if I may, to what extent was this interest in Islamic chivalric practices and Islamic art? To what extent was it consciously thought of as related to Islam or to the Arabic-speaking world? And to what extent was it, and if you will, just sheer novelty? I'm trying to, I mean, obviously, I'm thinking of anachronistic practices too, like, I don't know, the 18th century interested in Chinese or the 1900 Viennese interest in English things. I mean, there we go, those are those. So Kira and Michelle. I'm trying to answer your question. I'm trying to think of the company's own words of the archival records that I've read, if there's any sense in those records or in the statute books of feeling one way or the other. And I can't think of any particular great examples. I will say that obviously nothing develops out of nothing and something like the Easter Sepulchre practice is an exaggeration of an existing medieval liturgical practice. So this practice of symbolically bearing the host on the altar had happened before, but usually in a small vessel. What is innovative with the company's practices is this incredible ephemeral architectural structure that is built for this ceremony. And I'll say that it also then leads into something like the better known, sometimes better known, 40 hours devotion that is institutionalized at the end of the 16th century by Clement VIII. There's some important differences when it happens, where it happens. And I would say also most importantly that in the Easter Sepulchre, the host is buried. In the 40 hours devotion, the host is exhibited. But these are certainly connected to each other. But I think that there's a sense, especially around the 1575 Jubilee that this is unprecedented and new. In many ways it was the 1575 Jubilee, for instance, attracted 400,000 people to Rome. So something different is happening, something grander, more conspicuous, if you will. So to respond to your question, is it novelty or is it conscious appropriation? I think it's a bit of both. I think there's definitely a novelty aspect that plays into kind of the harnessing of these motifs. But I also think that at this period, in the medieval Mediterranean is also fraught with a lot of military conflict, right? Because the Crusades are happening and there's a million Crusades that we can talk about. So there is this kind of antagonistic relationship that the Western European knights are facing with the Islamic world. And I think they're also living in that region at the time. And so I think this kind of appropriation cannot be nearly seen as just a coincidence. I think there's something a little bit more conscious that's going on there. Yeah. You had a question for Osolia, correct? That was a really fascinating paper and really interesting and quite convincing explanation for how these images are working. The question I have has to do with gender and the fact that you have in your painted in one image of a woman and the other images, men. And I'm curious if in the reconstruction, and perhaps you mentioned this and I missed it, but in the reconstruction that you're suggesting, is it possible that there would have been a female figure who would have been mirroring the female figure in the scene and kind of along the same lines? I was really struck by how the female figure in her destruction, the one element, at least one element that isn't the same as the mirror. And of course, women, I think perhaps in all medieval cultures, this certainly happened in Byzantium as well. Women are often accused of the various ways that their mind wanders. One of the ways their minds often wander is to their own sort of self-cultivation and their physical appearance rather than their spiritual formation and cultivation of the spiritual self. So I guess I'm curious in sort of multiple ways how the image might be gendered if that demands a different kind of reconstruction for the paired image. And I guess finally, and again, I'm sorry if you missed this, I'm sorry if you said this, I missed it, but might it be possible that that entire set of images would be gendered in terms of the person who used it or the setting in which it appeared? In particular, is it perhaps a private, I wasn't really clear on scale, but is it a private set of panels that could have been in a woman's private chambers or in some other environment in which her representation in a private setting would have been particularly relevant and sort of mirroring her own experience? So I think that anything might have been on the other lost half. I just don't have any way to prove it, but there are around 30 surviving images of this iconography and every single case you have two men under the crucifix. And even in the case, the earliest example is coming from the 14th century codex which was made for Benedictine female monastery. And even in that case, the two person is men. And so, but I'm not sure that it posed any problem for the viewer to imagine herself in that place, but yeah, it's cause because that white only man, I don't have any answer for that. And the size of these polyptych is kind of a medium size, I would say. So the panel itself is like that. So I think it's very much speaks for a private environment for use, but whether it was a domestic one or a site or tar or, I don't know, but yes, I think that the size itself is indicative of its function. Sorry, can I just piggyback on that and expand on it? Because I was very curious that you described the panel as unique. And then here you're saying there's 30 or 40 other images, but these other images in manuscript form? No, they are mostly frescoes from small village churches from Sweden and the French Alpine region and all around Europe, but they are very rare. Excuse me. Sorry, go ahead. Question. Oh! This is a second. I'm happy to defer. Okay, I'm on the same topic. The six scenes for the distractiveness, are they consistent in the 30 examples? They are mostly the same, yeah. There are instances, there are small of them, but they are always mostly the same, I would say. The reason I ask is the conspicuous absence in the painted one is that you have a view of the city and one of the scenes is clearly of the country, the trees and so forth. And so it occurs to me that the two things for your hypothetical reconstruction. One, you should ask whether the perspectival open wall on the left is mirrored on the right, which would not be stylistically unsuited to the period. And if so, is the scene, if you would imagine that, the scene on the outside of that side is of the countryside, which is the one missing from your repertoire. This just, I don't know whether that's the question about both, there should be two women or men and that seems irrelevant, I don't think we could know that. But if the repertoire is consistent, you might do better in a reconstruction not to rely on the print, but to use its references of a little more strongly. Thank you, thank you, that's very helpful. Thank you very much for these tremendous talks. I enjoyed them very much and I'm totally envious of each of your fields now, because you're all working on objects that are fabulously interesting and I wish I were doing that too. For Michelle, I kind of have an idea or a comment and I'm not sure if it translates into a question exactly. My area is mid-century American painting, but I'm very interested in color. And I'm noticing in the objects that you're looking at that aid their copper as opposed to the Islamic antecedent objects which seem more often to be brass and that the chromatic material, the colors that you see on the jameleons that you presented, which constitute the full set of objects I've seen that I know now, seem to emphasize a vertigree color which is very similar to the color that Kira is wearing in her sweater. Maybe a little bit darker, yeah, there you go. And what's interesting to me about that is in this period in the ancient world, colors often associated with geography. And I mean the most obvious example is lapis lazuli, ultramarine coming from Afghanistan and other colors as opposed to vertigree which is a very kind of locally producible color. And if you're making these jameleons out of copper, that's how you make vertigree, right? And if they're washing their hands or feet with any kind of water that's got an acid in it, like vinegar, if they're doing it to kind of key up the washing aspects, that copper's gonna turn that color. And so I'm wondering if there's not only a kind of referencing of the antecedent imagery but also a kind of play with color that's produced, that you can produce on the spot as opposed to buy, expensively from a remote location. And in fact you can see it sort of turn that color gradually and then you gotta clean it. But the enamel remains as a kind of reiteration of that color you're gonna get if you get that slightly acidic water in the basin. I think that might have a lot to do whether, however with like whether or not these are actually objects that get used or if they're kind of heraldic objects that represent cheaper versions you actually would use. I don't know if any of that is connects to what you've been thinking about in terms of these objects. No, definitely. And so for the color, the most often color that you do see on limo enamel in general, not only on the Jamalians, is this kind of like vertigrate, yeah. And that is the cheapest and the most commonly available color. And so the range of colors that you find on limo enamel ranges from green to being the cheapest, red is the most expensive. So if there's a lot of red on your enamel, that means it costs you a lot of money. But I did not think about kind of like the chemical reaction that Coburn might provoke. So thank you so much. My questions for Orshi and knowing nothing about that fascinating object. I wanted to know if a wandering mind is at all similar to a melancholy mind at the time and like seeing a depiction of a very fraught relationship between a figure's mental states and the sort of surrounding objects that couldn't help but think of like Durr's famous melancholy imprint. Are they like similar at all in terms of historical overlap or sort of mental state or are they totally different sorts of things? I'm not an expert of human theories. And so I would say that, as far as I understand, the wandering mind was a more universal human condition. To be melancholic you were more exposed, more prone to be melancholic if you had certain kinds of humors in your body. But the wandering mind happened to everybody. And that's where I would put the difference between the two of them. Orshi, my question is for you too and along the same lines. I was looking at the wandering mind and all the different, and looking at the different activities and where your mind can go.  Like is that at all depicted as one of the places where the wandering mind may go or shouldn't go? I think it's, the woman is kind of a subtle signifier for this problem I think. And that's, but there is no more explicit reference for sex, but obviously in contemporary literature it has been addressed as one of the problems which might distract you from looking at a passion. But. There is a bed in the manuscript that illustrates what you showed us. And I have, sorry, you're getting a lot of attention, but obviously it's the richest of your material. I just wanted a clarification, a question for clarification. In the panel with the woman, the lines, I can't quite tell, but they don't seem to be protruding directly from her head in the same way that I could see on the manuscript. They seem less organized, like they're attached to the shelf and the rod. Yeah, they are less organized than in the woodcut. And I cannot tell because it was the exterior. So it's more damaged and that's why the lines are not so well organized. But on the other hand, I think there is an interesting link between the woodcut and the panel because in two cases, the lines are exactly at the same spot, crossing the two fields. And I think it shows two certain kind of connection between the woodcut and the panel. And I wondered if there's one line that seems to go off to the right and if you thought that could potentially have a, do you think that's any kind of connection with another panel, which wouldn't make sense because then you'd have the other figure.  All of them are cut there. They are all running to the right. To my left, well, as I'm looking at it, they're all running to the window that's on the left. No. It's not important. Okay, okay. So which, are you talking about the panel? Yes. The panel, so runs to the head of the woman or from the head of the woman to the other side of the lost half. Actually, to the head, is it just that we're not seeing it? Yeah, it's difficult to see on the slides. Sorry. Question? We are at the end of the symposium. How are we doing on time? We're okay? Okay. Maybe we've run out of steam. So unless there are more questions, I think we're gonna wrap it up. And thank you to everybody who participated today and to everybody who came and listened. We're really grateful to have you here. So thank you and I'll see you all on April 15th.