Bonesupport Holding AB (publ)

and welcome to the bone support quarter three 2023 result call. My name is Emil Billbeck and sitting next to me is Håkan Johansson, our CFO. So we will use the next 25 minutes to guide you through the presentation of the third quarter results and then we will open up the line for questions and answers. So if we start by going to slide two and before I start the presentation. I would like to draw all of your attention to the disclaimers covering any forward-looking statements that we will make today. And then let's start the presentation and go to slide three. Thank you. So I would like to begin this presentation with some condensed highlights from the report that we released this morning. Overall, quarter three sales were 158 million SEK, which corresponds to a reported growth of 87% year over year. In constant exchange rate, the growth rate was 76%. The operating result before incentive program was 25 million SEK, which is a profit improvement versus the same period last year of 29 million. Reported EBIT was 15 million SEK, which marks our third consecutive quarter with positive operational result and the first quarter with positive operational cash flow. Let's speak a bit about the highlights of the quarter. And of course, the ongoing launch of CEREMENT-G in the US was one of them. We're noticing a strong U.S. approval traction and market penetration, bringing U.S. sales of CERAMON-G to 63 million SEC in the quarter. The use of local antibiotics play an important role in the global antibiotic stewardship program. And in the quarter, further confirming and validating data on CERAMON-G has been presented. In August, The Solario study included a final patient, which means that the study is expected to be closed in quarter three, 2024. Håkan and I will cover each of these topics in more detail during the presentation. So let's go into the details and go to slide four, please. So let's start out looking at the sales development. And as you see, this slide is one of the standard charts. displaying the top line trajectory for the business. And the graph shows last 12 months sales in Swedish currency, every quarter since quarter two, 2016, and split by segments. Quarter three displayed the biggest ever quarter over quarter growth. And of course, this was boosted by the 63 million SEC contribution from Sermont G in the U.S. In Europe and the rest of the world, the antibiotic eluting Ceramant, that is Ceramant G and V combined, grew with 38% in the quarter versus last year, with a noted market share gains on other therapy options, mainly autographed and traditional bone cement. So one year after launching Ceramant G in the US, The total global sales in LTM of antibiotic eluting sediment is close to two hundred and ninety million sick. It holds a share of the total sales in LTM of fifty five percent and is currently growing at two hundred and ten percent. But let's instead go into the details of the US and go to the next slide. So in the US, sales were 121 million SEC in the quarter, which corresponds to a reported growth of 115% year-over-year. At constant exchange rate, growth would have been 102%. Sequentially, growth was 17%, meaning the growth over the sales numbers reported in quarter two. We're starting to see some cannibalization between CEREMENT-G and CEREMENT-BVF in the US. But despite this, CEREMENT-BVF in the US grew slightly in the quarter versus the quarter three 2022. On the next slide, we will speak a bit more about the details on the CEREMENT-G law. So let's go there. So we have previously spoken about the market dynamics for the introduction of a breakthrough orthopedic device and the necessity to get GPO contracts sequentially followed by hospital system approvals and then to get moving on the promotion to surgeons and on clinic level. We early on displayed the number of hospital systems where ceremony got approval as we wanted to give a flavor of the rather fast approval pace. But now I would like to emphasize that a hospital is the facility where a patient is being treated and the hospital system is an administrative and logistic association or a contracted cluster of many hospitals. So a hospital system, which sometimes also is called integrated distribution network, has a group of member hospitals. There are about 420 hospital systems in the US, and the number of member hospitals varies greatly. As an example, there are more than 200 hospital systems that have only between one and five member hospitals. And the biggest hospital systems in the US have between 150 to 200 member hospitals. Since the launch of CEREMON-G, we have focused on the most important hospital systems. And in the quarter, we added about 22 hospital systems approval for CEREMON-G, leaving a total of 82 hospital system approvals. These 82 hospital system approvals provide us with a total listing access for CEREM-NG to over 1,000 hospitals. So we have really only scratched the surface, and we've only started our journey in terms of penetrating the full potential for CEREM-NG in the hospitals to which we now have access. Meanwhile, the pace of securing additional hospital system approvals is continuing. The metric of hospital system approvals was relevant in the very first quarters of the launch to demonstrate that the strong benefits of 7G also translated into positive approvals. We will not report all of these details going forward, but rather focus on sales, which we believe is a good reflection on how many products are actually being used in the market in each quarter. Part of the explanation for the strong market penetration so far is that we can show both superior clinical data and also relevant and positive health economic effect from a one-stage procedure, lower infection rate, and reduced amputation rate. This has paved the way for high success rate with private payers. And in the orthopedic clinics where early adopters have started to use Serum and G, we conclude a positive follow up on patients treated. The benefits noted and registered are matching what has previously been shown in clinical studies. The early adopters of 7G are also becoming ambassadors and sharing their successful patient cases with colleagues in the clinic, in the region and at congresses. As previously stated, we are currently putting the last pieces in place to be able to submit our label extension application on open trauma fractures to the FDA during the quarter. Now, let's turn to Europe and UROV on slide seven. So, for the quarter, we saw sales of 37 million SEC, corresponding to a reported growth of 31% year-over-year. and 26% growth at constant exchange rates. The third quarter is usually a bit slower in terms of overall surgical volumes in Europe. Staffing issues were expected to exaggerate and slow down the surgical rate even further during the vacation period. In addition, there was again a physician strike in the US, sorry, in the UK, of course. which is one of our largest market. Despite this, settlement sales developed very well with plus 26% in constant currency. And the year-to-date growth of also 26% in constant currency represent a development which is about five to six times higher than the year-to-date market growth for bone grafts, testifying to the strong and continuous market share gains Looking at some of the highlights, the schedule for conferences and congresses is completely back to normal after COVID. This is important for bone support as we are early on our journey and congresses are an important way for us to reach new surgeons. The most important European meeting is the European Bone and Joint Infection Society meeting was held a few weeks ago. The meeting attracted close to 650 participants, mostly orthopedic surgeons and infection disease specialists. Bonesport hosted a satellite symposium with a panel debate on the theme limb salvage. With a record 120 participants, it was the most visited symposium of the meeting. At the EPGIS, the European Bone and Joint Infection Society meeting, several new clinical findings were presented as posters and stage presentations. One of the more important ones were the findings from Bernadette Young et al. where 125 patients with a recurring infection originating mainly from failed prosthetic joint implantations or trauma were investigated at two centers in the UK. 72 patients had their initial surgery performed with CERAMON G or V. And patients were then followed up several years later where there were recurrence of infection and this is to our knowledge the largest study of microbiology of recurrent bone and joint infection reported to date. Culture-based diagnostics were used and the authors conclude that quote treatment of orthopedic infection with local antibiotics was not associated with emergence of antimicrobial resistance, end of quote. This, in adjunct to previous data, confirms and validates the benefit of local antibiotic elution as an important tool under the antibiotic stewardship program. The European Bone and Joint Infection Society is also the originator and the facilitator of the Solario trial, a final patient was included in August, which means that the study will close in quarter three next year. And with that, I will hand over to more of a deep dive of the numbers to Håkan.

Thank you, Emil. So, net sales improved from 84.6 to 158.2 million, equalling a growth of 87% or 76% in constant exchange rate. Emil has already spoken about the strong performance in the two segments and the major drivers behind the sales acceleration. Let me comment on the currency. Changes in currency, measured as year-to-date averages in 2023 versus 2022, had a positive impact of in total 9 million, of which 7.5 million relates to a stronger US dollar. The depreciation of the Swedish currency versus other currencies also drives expenses, as you will see on later slides. The contribution from the segment North America improved with 35.3 million and was reported to a regional contribution of 46.5 million. The improved contribution relates to increased sales after effect from increased costs. Sales and marketing expenses during the quarter amounted to 67.6 million compared with 37.7 million previous year, of which sales commission to distributors and fees amounted to 42.2 million compared with 21.1 million the same period last year. The increase of 8.8 million excluding sales commissions and fees was driven by currency effect of 1.5 million and the remainder from an increased activity level. As we have announced previously, the US booster positions are up and running, and there's a strong focus on medical education and increased market presence, also contributing to the cost in the quarter. The contribution was also charged by R&D costs related to clinical studies of 0.3 million in the quarter compared to 3.2 million previous year where previous year included 2.5 million related to ongoing projects. From the lower graph showing net sites as bars and gross margin as the orange marker, it can be noted that the gross margin is remaining strong and reported to 94.6%. In Europe and rest of the world, a contribution of 9.3 million was reported to be compared with 7.3 million previous year. The improved contribution relates to increased sales after effect from increased costs. Sales and marketing expenses increased with 5.6 million and was driven by field vacancies and an increase in sales representatives. From the lower graph, the orange mark and the orange marker, you can see an improved gross margin compared with the previous quarter this year, following an improved product mix, with a high sales ratio of antibiotic-eluting products in the quarter. Selling expenses increased with 14.7 million versus last year, of which 1.5 million relates to current effects and 2.5 million in non-recurring costs. As we mentioned before, the US booster is up and running, and we continue to see results on top line. In Europe, we have filled vacancies and increased our total Euro commercial organization to 31 people. The cost increase in the quarter relates to a ramp up in activity level at Congresses, medical education, and of course, the continued launch program for 7G in the US. As you can see, R&D remains largely in line with previous year and administration remaining on a stable level, excluding effects from the long-term incentive programs, equaling 11.9 million compared with 11.3 million previous year and 12.2 million in previous quarter. The operating profit was reported to 14.9 million compared with a loss of 13.9 million for the same period previous year. A 28.8 million improvement following a strong sales performance. The profit also includes expense provisions regarding long-term incentive programs amounting to an expense of 9.7 million this year compared with 9.5 million previous year. The total cost of 9.7 million in the period Only 0.2 million is cash flow impacting in the future. The operating profit improvement before the long-term incentive programs was 29 million, confirming a strong underlying positive trend. For the first time, a positive cash flow from operations was reported, reaching 21 million and yet another confirmation on the strong momentum in the business. And to round off, I would like to pay attention to two one-offs reported in the quarter, one related to deferred tax income and one relating to a self-correction of ECVAT. With the strong and positive underlying trend in the business and with prudent but realistic assessment of the future, a value has been assigned in the balance sheet attributable to the tax losses carried forward, as well as other temporary tax differences. A total deferred tax asset has been reported amounting to 230 million. 30 million posted directly as equity and 217 million as tax income. Selling expenses in the quarter included 2.5 million regarding a self-correction of ECBAT for earlier years. The background to this self-correction is complicated prerequisites relating to the production process and has been initiated by the company. The self-correction also led to interest expenses of 1.9 million and an exchange rate loss of 0.6 million in the period. And the net cash flow impact from this self-correction totaled 7.1 million. And with this, I hand over back to Emil.

Thank you, Håkan. So, we are, of course, pleased to present such strong quarterly results, and we believe that the results are more than confirming the high expectations on what sediment can do to drive improved patient outcome. The journey to reach the full potential for... Oh, okay. We're jumping a little bit back and forth. Okay. I was just saying that the journal has to reach full potential for Saramant within its current market. It's only in its infancy. In addition, there are more and further indications and geographies to eventually be explored. Almost every quarter, there are new data arriving, confirming the strong benefits of Saramant. This solid foundation of evidence has led to a fast-paced adaptation, especially in the US. In the US, the number of surgeries is fully back and even above pre-pandemic levels. In Europe, while not yet back on previous levels, we believe that the market dynamics will continue to develop positively. The European surgical backlog is at all-time high, and CYRAMED is in a good position to replace an outdated standard of care. Finally, we would like to inform you that we're planning to hold a capital market in late November in order to provide further details on the development of the settlement journey. And with that, we conclude our presentation and would like to open up for questions and answers.

If you wish to ask a question, please dial star five on your telephone keypad to enter the queue. If you wish to withdraw your question, please dial star five again on your telephone keypad. The next question comes from Eric Castle from Danske Bank. Please go ahead.

Hi. Good morning, Emil Håkan. Just first off to sort of get it out of the way, there was quite substantial downtick in BVF in Europe that's not seen in the 7G sales. Just wondering what's the reason behind that, sequentially that is.

Yeah, so I think we're all thrilled to see how strong CYRAMENT G and V is performing. And as we've anticipated, there has been a bit of cannibalization in Europe as the surgeons have a stronger preference for the antibiotic eluting product. If you look also at BVF, the numbers are quite small and could vary quarter from quarter, depending on if there are orders being placed from distributors or distributor markets. And in distributor markets, many times BVF is slightly bigger. So there's nothing else than those parameters that have influenced the result.

Okay, perfect. And then also on the US conversation, I mean you mentioned that you see conversation for BVF in the US, but are we seeing any substantial different pattern playing out in the US compared to the dynamics that we've seen in Europe going forward?

The biggest difference is the very strong acceptance and adaptation driven by the not only clinical data, but also the health economic data that we have. So if you look at the US sales in the quarter, CEREMON-G is now already bigger than CEREMON-BVF after one year only. And I think it shows how quickly the system responds. And with system, I mean when you have both the payer of the bill and the clinician, the surgeon, join forces and see that there's a modern treatment that can reduce the recurrence of infection and also have a material impact on the rate of amputations. So what we see in the U.S. is very similar to what we have seen in Europe, but just at a higher pace, at a faster pace.

Okay, okay, good. And I'm wondering on the sales commission levels, 35% in this quarter, when could we expect to see that start coming down, maybe approaching 30% or even lower?

You should start to see that coming down now and going forward. But at what pace, we don't want to speculate in. And here's the reason why. The sales of Sermon-G, I think, has exceeded most analysts' expectations and admittedly also ours. And that means that some of the independent distributors in the US have succeeded significantly. And there is a staircase model. So when they do really well, the commission increases slightly. But then every year they get a new quota. somehow neutralized at the end of the year. But over time, as we gain better and stronger economies of scale and size, the commission should be dropping over time. And then, of course, baked in that same line in the P&L is also GPO fees and freight. And here there are less economies of scale.

Okay, perfect. And then just the last one for me. Now that you have positive cash flow and also a pretty good cash position, what are you going to do with the cash flow now, from now on? Do you see any organic or inorganic opportunities to deploy that cash? Thank you.

Yeah, thank you, Erik. Yeah, I think if there is one thing with Sarment, it's definitely the opportunities that we see for the future. We're in a strong position. We like to be in a strong position. And I think we need to have more time to discuss what are the opportunities for the future. So a good opportunity would be at the Capital Markets Day, which we are in the planning of. So that's the next occasion where you can expect us to talk more about the future direction.

Okay, perfect. Looking forward to that. Thank you, guys.

Thank you, Erik.

The next question comes from Matthias Vadsten from SEB. Please go ahead.

Thank you for taking my questions. I have four. Take them one by one. First on Cerement G, if I may. You know, running the numbers, taking Q3 Cerement G sales in the US, it's running somewhere around 250 million annualized in sales. You know, this would imply sort of half of the market in Östermalit. so we all understand that much sales comes from trauma of course diabetic foot and so on so question is you know how much of a trigger is really the extended indication application you're you know are you having potential customers awaiting this approval or customers that want you know to have the n-tap for instance some thoughts here around the dynamics would be would be great

Okay. Yeah. So we start with that question. Yeah, indeed, Mattias. Thank you for the questions. And Salamangie is trending very nicely. We agree. Are there surgeons waiting and holding back using what they believe is best for the patient because of an extended indication? Not. That is not the case. The surgeons will, in every single case, look at what they believe is best for the patient. And we can conclude that in our visits in the US, which have been many during this year, we've been in direct contact with surgeons that have had positive experience from ceremony in treating bone infections. And they have also started to use it preventively. With clear instructions from our side that this is off label and not yet on the IFU, the surgeon make their discretionary decisions. So I can confirm that. To what extent that makes up sales, I don't dare to answer or speculate in.

I appreciate the flavor there. And to elaborate on Erik's question on Cermont BDF, I mean, it increases both Q1Q and year-over-year. Do you actually, do you see the CermetG launch actually helping you here as, you know, brand awareness has improved, increasing, you know, that it increased new customers for also the BVF part of the CermetG offering or the Cermet offering. That's the next one.

Yeah, thank you. That's a good question. I mean, we have access to meticulous data for both the US and European markets. So we can, of course, see much more granularity than what we're sharing with the market from a quarter to quarter perspective. And there is a sentence in the CEO comment in the report where I state that we're very pleased to see new customers coming on board, customers that attracted to Cerament through Cerament G and that have not used Cerament BVF before. When these customers come on board there is also an element of them starting to use not only Cerament G but also Cerament BVF. So you're absolutely correct in your conclusion that Cerament G has such newsworthiness that it attracts customers that also gives extra flavor and boost to sediment BVF.

Thanks for that and the next one is if you have an understanding of where the market is compared to pre-pandemic in both regions and for EMEA specifically if you feel you start to take market shares as a higher rate now compared to a year or two ago given you know the growth rate here looks quite impressive given the underlying surgery volume that you speak about. That's the third one.

I would say that US surgical volumes in general are above and beyond pre-pandemic levels. There's a strong financial incentive for the hospitals to clear the backlogs. I haven't seen a number update, but I saw a couple of research institutes predict that this year would be between 5 and 6% even above the pre-pandemic year 2019. That makes sense. When it comes to Europe, it's a little bit more difficult to make a solid conclusion. I think there are some markets that are back and even beyond pre-pandemic levels. while others are still struggling more with the staff shortage that was a consequence of the pandemic. So if I would take a guess, I would say that Europe as a cluster is probably still 45% behind pre-pandemic levels in total surgical volumes. At least the public data available on the backlog would testify to that. And your side question there is, are we taking market shares faster? Yes, we are. The pace of capturing market share has increased. And the simple explanation to that is some of you might have known us for a few years, but we are still a small player with a breakthrough technology that is transforming standard of care. And we need to have access to the hospitals. We need to have access to the congresses, which is a a great forum for us to meet new surgeons. And during the pandemic, we were a rather wing cut in our ability to promote the product. So as restrictions went away and we kept investing throughout the pandemic. So we came out of the post restrictions with hitting the ground running. So our market share gains have indeed picked up and accelerated.

I appreciate all the favour there. The last one should be quicker. To talk about your production setup a little bit and to the extent there is free capacity to increase production if you're confident there. Just the last one from me.

Let's say like this. I have the greatest confidence in my team, in my organisation. hardworking, very talented people that have made it possible, first of all, to carry out and satisfy the need on the product with the strong increase on sales that we see now. So I have equal same level of confidence in my team and the high quality suppliers that we're working with. Maybe suppliers is the wrong word even, it's more partners. We work very integrated and interactively with our partners and we are transparent with them to communicate also our plans for the future to make sure that they have the ability to raise capacity to satisfy our needs. On top of that, the team is working diligently to build even further safety stock so that we can be flexible to the fluctuations of the market. With all the knowledge I have today, Mattias, yes, I have full confidence. Thank you very much.

The next question comes from Christopher Liljeberg from Carnegie. Please go ahead.

Thank you. It's Christopher here. Four questions from me as well. The first one is if you could comment on the surprisingly limited increase of the working capital this quarter if there is anything special explaining that.

Well thank you Kristoffer and glad it's noted and again somehow a supporting factor has been quite some focused and accelerated efforts when it comes to collecting of payments in the US. In the background of the rapid sales growth we've seen, it's an area where we have had to extend efforts and so on to make sure that we keep our customer base also in line with our commercial conditions and so on. So that's a contributing factor.

Okay, so that's positive to hear. Saying that, do you expect working capital as a percentage of sales to come down here?

I think that somehow it's at least not to increase. It's an area somehow, as any other company with a high growth. So it's an area to really work on and focus on. And we have such a focus. So we expect that if not to come down, at least to maintain on a stable level.

Okay. But given that if you paid more focus on this, this quarter, I guess there's some exceptionally good level in, in, um, in the third quarter that we shouldn't see again in, in Q4, if you, yeah. Okay. That's good. Uh, then on the selling cost and, and R and D, um, in a very stable, uh, I would say quarter of a quarter, you see anything here that would accelerate these costs going into 2024?

Again, somehow in selling expenses, there is a bit of seasonality also in relation to where you have congresses, etc. And somehow in the beginning of the year, it is a high activity level in that aspect. So you will continue to see a certain volatility. But again, looking at the base platform in our commercial organization, etc., that will not have big variations over time.

And R&D costs, I think you talked about previously a little bit about CEREMENT, the potential to expand into new areas using that as a platform maybe. Does this mean we should see much higher on the cost coming years?

I think that again, as Emil mentioned, we are working towards a capital markets day end of November and that would be a good arena also to get the flavor of what to expect when it comes to R&D and R&D spend going forward.

Okay. Another thing, of the 1000 hospitals you mentioned where you have administrative approval, do How many of those hospitals are actually treating with CERAMENT?

Yes, I do. We were contemplating if we should speak about that number, but we decided that if it's inquired, of course, we will release it. And out of the more than 1000 hospitals, at least one fifth have bought at least one box of CERAMENT-G year to date. So we're releasing that number also to give a flavor of how early we are on this penetration journey. So 200 out of 1000 is of course not a big number and yet we see already rather big use of Saruman G. And given that you have approached the larger hospital systems, so if we just look

Of the 62 systems out of total number of systems in the US, I think that would represent some, I don't know, 20%. But I guess they are larger also, so it should be a larger percent, maybe 40% of of volumes where you have administrative approval, but if we also consider it's one fifth of those hospitals that are actually buying the product, so of the hospitals that are actually buying the product now, do you have some sort of figure for how much of volumes they represent maybe? Treatment volumes, I mean.

Yeah, yeah. As we mentioned, even before we launched Styrometry, but after we received the approval from FDA, we started immediately to work on the IDNs or the hospital systems and the GPOs. And we also in the beginning released a few names. We mentioned that we are fully approved by the Veterans Affairs, for example, Cleveland Clinics. and Baylor Scott and White, these are big hospital systems. So we have not been as active with the small hospital system. So you could clearly envision that the hospital system, the 82 that we have approved, represent some of the absolutely biggest ones where there are major university clinics connected where there are big bone infection units. We have, through collaboration partners in the US, very good data on which hospital zip code is treating the most bone infections, where are their most amputations and so on. Our sales effort in the US is probably a little bit more specific and targeted than what we are able to communicate at the quarterly core. But we're not going to try to provide a number of those hospital systems or hospitals that we have used, how much of the total treatment that represents. That would be too much of a guessing.

Okay. Another question I had, given what you said about new customers also using BVF, do you think it's possible to keep BVF sales at current levels going forward?

That is difficult to say. I find it difficult to give a guidance on that. We knew there would be cannibalization. And at the same time, we keep winning new accounts. So I think those two parameters stand against each other. I think we can look at Europe and give at least us some understanding on what long term will happen in the U.S. but the path there and the time and pace, it's too difficult to speculate on.

Okay, and final question. You talked about when it comes to selling commission that distributors were hitting sales targets and the staircase model. Does this mean as long as you have You know, a strong sales momentum, and particularly if sales price on the upside, that you would have a seasonal effect in Q4, where the selling commission as a percent of sales would always be lower than what you have seen for the first three quarters in the year.

We try to assess that when doing the SMART provisions with respect to quarter, etc. But there could be such a risk that there are additional SMART distributors that is hitting and running beyond their established quotas. But again, we are constantly evaluating this and making sure and working on establishing necessary provisions.

But if they hit the quota, the sales commission will be lower. Is that what you're saying? Or are they getting some extra bonus?

There is an inbuilt incentive in the commission structure. So if they are beating and running ahead of their quotas, there is an incentive to get a higher pay.

And if they hit their annual quota, the commission will be around 30%. Yeah.

OK, thanks.

Thank you.

The next question comes from Oscar Bergman from Red Eye. Please go ahead.

Hi, guys. It's Oscar here. Congratulations on a very strong report once again. I have a few questions. The first one is if you are starting to notice in competition and if they're taking any action against you in the US specifically.

Thank you. The strong success of Ceramid-G is definitely noted by everyone, I would say. If you're a company with traditional bone cement that is mixed label with antibiotics or into PMMA beads, I think Sermon G is now on the level that it should be recognized by others. We haven't seen any reactions or aggressive price dropping of bone cement. Bone cement is rather generic in the market, I would say, so it's already on a rather price depressed level. Then, as I mentioned a bit in the call also, we're also taking market share from Autograft and from Allograft. And here, of course, there's really no competitors that can react to the product. So, in short, I know I'm not answering your question maybe. We are definitely being recognized, but we don't see any counter activities in the market, which honestly is probably difficult when there's a breakthrough product, which is unique in its category.

Thanks. And just to continue there on Christopher's question about the hospitals. Could you say roughly, on average, how many ceremony procedures could be conducted at these hospitals on an annual basis with ceremony?

No, I could not, actually, because I don't know where to draw the line. Just as there are hospital systems with 200 member hospitals, there are hospital systems with one member hospital. John Hopkins, where we are approved, have an extended use of products for bone infection, while a smaller rural hospital has a different need. So I couldn't give an average and make it justice actually. Maybe if we have the opportunity at the Capital Markets Day, we can try to bring some clarity on what a really big hospital would have in use and what a really small hospital to be in use but that analysis have not been done in preparation for today.

All right and I guess my next two coming questions will possibly be more addressed at the capital market today but are you soon looking into other markets such as Japan and will you maybe provide more financial targets on profitability going forward?

We are actively looking encouraged by the strong success of CEREMENT, the technology and the platform. We're actively looking both at other indications where we believe the patients could benefit from CEREMENT and other geographies where we believe there are patients that still are treated with outdated standard of care. So you're correct. And in terms of modifying our guidance, it's also something we're looking into to see if we are ready to modify that and if we should continue to speak about top line or if we should also add something on the margin or profitability level, but we haven't arrived in a conclusion there yet.

Okay, all right. Just two or three more questions. I know there's a lot of focus now on the US market and despite UK hospital workers' strikes, you have seen a growth in the European market. But is there a risk that the US focus could result in the EU being left behind in some sense?

No, that would not be the case. We have a team in Europe which we have slightly expanded. It consists of 31 people and they are fully dedicated to their territory their surgeons, their clinics. We have an equally talented and skilled team in the US that are focusing on their surgeons. And there's a lot of exchange between these groups also in terms of clinical papers, promotion materials and so on. So our vision is not so much to drive business. Our mission is to go surgeon by surgeon, clinic by clinic and convert them so that their patients can get a better care. So I don't think so, actually.

Okay. And can you also just brief me on how the NTAP has impacted your sales and ceremony, both in Q3, of course, but ever since the launch of the product in the previous year?

So the NTAP, is an area where we don't have an exact knowledge because not all of the billing sheets are then transparent and shared with us. So I couldn't give you an exact number of what is the impact in quarter three. Admittedly, we were very pleased when we received such an NTAP of 4,920 US dollars. And seemingly, what I can share, at least from my experiences, having extensively traveled in the U.S. and interacted with surgeons, is that the NTAP has significantly less impact compared to what we thought, mainly due to the reason that the private payers, so the insurance companies of private payers and the patients, has such strong and immediate appreciation for the health economic benefits of Cerament so that the NTAP doesn't really come in play. As you know, the NTAP is for the Medicare patients, and it seems to be less share of Cerament G sales than what it represents in the population. Significantly less.

Just a final question before I can head back into the queue, but could you give me some more insights on how the booster program has gone forward ever since launch, if it's below or above your expectations and so on?

The booster program is meeting my very high expectations. We quickly realized that in order to get a drive, strong conversion, the surgeons have to feel well-educated. The nurses in the operating theater has to feel well-trained on the application. And we also needed a way, a channel to reach out with all the clinical evidence that we had. So we've strengthened our organization in the US. We're focusing more on medical training and medical education. And we see that also this is a great channel to have the surgeons understand the clinical benefit, but also the private payers to see the health economic effect. Now, how big of an effect it has had and how much is the effect of the sale on the ground or the ambassadors, I couldn't split that. I can say it's all of those different factors combined is giving a very nice and strong market penetration rate for Serum NG.

Okay. Well, thank you. That's all for me. So thank you very much, Emil, and looking forward to the Capital Market Day.

Thank you, Oskar.

There are no more questions at this time, so I hand the conference back to the speakers for any closing comments.

Yeah, so we're running a little bit short on time, of course. Thank you for all the questions. We're excited to deliver yet a strong quarterly report, and I would like to thank everyone for calling in today to taking the time and showing interest for our business. Thank you very much, and hopefully speak soon again.