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Okay. So this is about essential radiology for medical students and foundation doctors. The first part of this talk is going to be on the chest X ray. And if I um if I get us to do this again, I'll carry on by going through ct brains and abdominal X rays. Okay. So the learning objective is really primarily to demonstrate common and clinically important pathologies that you can see on a chest X ray or what every foundation doctor needs to know about the chest X ray. So foundation doctors in the UK are those doctors who have just qualified in the 1st and 2nd years? Okay. So this applies to medical students, foundation doctors because all the principles you learn in the last year at medical school translate into foundation years. Now the silhouette sign, what is the silhouette sign? Well, if you have structures of a different radiographic density that lie adjacent to one another, they can be easily seen separately. So in other words, one structure casts a silhouette against the other. When the earth spaces, a pacify the silhouette sign is lost between the lung and the adjacent structure. So in other words, if you can see the vessel and the heart, you can do so because the heart and the vessels have a different radiographic density to the lung that surrounds them. And if you then get consolidation and you can see in a bronchogram, the er bronchogram can be seen because you've got a negative density surrounded by something that is positive density. And that's the nature of the er bronchogram. So this is the er bronchogram and you can see that gas in the bronchial tree is able to be seen as a negative contrast because we've got consolidation in the surrounding lung. And one of the first things to go when you dealing with consolidation is the blood vessel. So all the blood vessels are now invisible. Whereas in the middle lobe here, you can see that the blood vessels are positive are positively seen. So the first thing that goes is the blood vessel because the blood vessel now has the same Rafic density as the lung that surrounds it. But because you've got air in the bronchial tree, you can see that as a negative contrast against this positive consolidation. And if you put the stethoscope on this patient's chest over the consolidation, you will see what you'll hear. What, sorry if you auscultate over the writer below been this patient. What will you here? Any thoughts Echols you might hear, crackles, anything else? Rails. All right. Rails. Yeah. Crackles. What about bronchial breathing radius? Bread sounds. Yeah. Bronchial breathing. So your breathing, bronchial breathing and Bronco grams, uh, require the Broncos to the consolidated lung to be patent. Okay. So both the, er, bronchogram and the, um, bronchial breathing require a patent bronchus and effectively bronchial breathing is just tricky. Well, breath sounds transmitted through hollow bronchus into a loudspeaker, which is the consolidated lung. Okay. So, it's, it's really, that's what it's all about. And so if you wanted to simulate bronchial breathing, you need to put your stethoscope over somebody else's trachea. Okay. So, um this is what the, what it looks like in real life. You've got the um skyscraper which has become invisible because you've got a mist descending over the skyscraper and as the mist descends over the skyscraper, that's really like a blood vessel that's been lost because of the mist and the skyscraper can be seen against the normal sky because it has a different color density. So that's if you like the blood vessel, that's the lung. This is the consolidation which obscures the blood vessel. Okay. So that's, that's what it looks like in real life. Now, I'm going to um post to you a link which I hope you can get in the chat. Can you get that chat chat link? Is everyone able to see that? Yes. Okay. So I'm going to show you a left April pneumothorax, okay? And the left April pneumothorax can be seen just here. You see the lung edge and you can see that this, even if you can't see the lung edge, why am I convinced that this is a pneumothorax? There's the lung edge. If I, if I couldn't see the lung edge, because sometimes you can't see the lung edge, why am I convinced that that's a pneumothorax. The long marking some extra, completely correct? You've got absence of lung marking. So if we press this little blue tab and press on the lung edge, it shows you where the lung edges. Can you all get that? And there's the absent lung markings. So the diagnosis here is the left side of, you know, atarax, all happy with that is everyone able to, to scroll through the um or get this on pack spin. These things called packs been here. Yeah, great stuff. Ok. So let's go back to the power point presentation. So a pneumothorax is where you get air in the pool space. It can be due to blunt or penetrating trauma which causes damage to the visceral and or parietal pleura. Don't forget that you can get cystic lung disease or emphysema that can predispose to pneumothorax and ventilation, positive pressure, ventilation can lead to pneumothorax. So here is the pneumothorax. In a different patient, you can see the lung edge and you can see absence of lung markings in this area. It just so happens that the pneumothorax has got bigger during exploration. But the reason why we do an exploratory film is to make sure that we've got a difference in density between the pneumothorax and the lung, which is greater and the lung density becomes greater on expiration. Okay. Sometimes the pneumothorax can lead to surgical emphysema and the surgical emphysema is going to happen. If there's a tear in the parietal pleura, an air in the pleural space escaped out and into the subcutaneous tissues. There's a left april noon, forex can't see it very well until you Zuma and you can see the lung edge here. No, this is a patient who has an erect chest x rays. The patient is standing or sitting in the erect position and the pneumothorax is always going to collect at the apex. But if you then have a patient in a supine position, what happens is that the pneumothorax is going to collect in this position because it's the least dependent portion of the chest as opposed to the erect position where this is the least dependent portion of the chest. So in a super patient, it's going to collect about here and indirect patient, it's going to collect here. So the patient had a pacemaker and the pacemaker insertion has inadvertently caused pneumothorax and they've got a luggage just here and absolute long markings here. But it's more challenging to see it in a Supine patient. And so when you look at this Supine scout film from a CT scan, you can see that the right costophrenic sulcus is deep and we've got this lucency overlying the liver and this is a super pneumothorax. And so what we look for in a super impatient is the so called deep sulcus sign. So this the costophrenic circus is deep on the right compared to the left. And then we've got this lucency that lies over the river. If we do a ct scan of this patient, you can see the deep sulcus sign here compared to the one on the left. And the patient has got this very large pneumothorax with surgical emphysema. And here is the intercostal drain going in. But the pneumothorax collects mainly at the base of the hemi thorax because of the patient's supine nature. So here is another uh schematic diagram of that same patient. There's the pneumothorax, most of it collects at the base because of course, it lies higher than the apex on this particular patient because they're in a supine position. And you've got the deeper costophrenic sulcus on the right hand side. In a different patient. We've got boutique customer XL cus here deep sulcus here and there's your basil pneumothorax. Patient has got a nasogastric tube in situ in the right position. We've got an et tube in trickier. It could do with being pulled back about a centimeter or so. It's a bit too low in position, should really be 2.5 centimeters away from the carina. But if you can see a lucency here, this lucency is caused by a basil pneumothorax in a suit line patient. Okay. So what do I mean by tension pneumothorax? Anyone tell me what attention pneumothorax is? There's a pneumothorax with the media's general shift because uh it certainly does cause the mediastinal shift. But what what what actually does attention pneumothorax mean to a clinician and to the patient. Well, immediate intervention is needed because patient is going to go into uh that is absolutely fatum. That is absolutely correct. So if you don't relieve the tension, pneumothorax, urgently, the patient will go on and die. And the reason why the patient dies is that if you think about a normal person, when you breathe in and breathe out, you are creating a positive pressure and a negative pressure in the forex. And during the negative pressure in the thorax, you are allowing venous blood to return to the heart because blood flows from high pressure to lay pressure. So if all of a sudden you then take away that negative pressure and convert it into very, very high pressure in the thorax, your venous blood is not going to get back to the right side of the heart. Okay. So the intrathoracic pressure is so big that it won't allow venous blood to return to the heart. And if you can't get blood back to the heart, you're not going to be able to pump blood out of the heart. And therefore you get circulatory collapse and therefore you get a situation in which the patient has a cardiac arrest. So um tension pneumothorax is such an important diagnosis to make that you have to make it pretty quickly in order to avoid this scenario where you get circulatory collapse and you should really be able to recognize this clinically. Okay. So clinical diagnosis is is very important and you should be able to make the diagnosis before you need to do a chest X ray. Okay. But if you do do a chest X ray, the sign you're looking for is flattening and diversion of the diaphragm. So that's like flipping the diaphragm downward. So instead of being convex upwards, it's convex downwards. So there is the diaphragm that's convex backwards. And this is a diaphragm that is convex downwards because the pressure inside that hemi thorax is so great, it's now overcoming the pressure in the abdomen. And so you're getting this IV version and depression of the diaphragm is everyone clear on that. Okay. I can see a thumbs up. So that, that's good. Okay. Here's another example. So this patient had a scout from a CT scan. There's the et tube, you've got an intercostal tube on the right intertubing on the left and they've been involved in very severe road traffic accident. And you can see that there is depression and the version of that left Henry die from. And that's a tension hemopneumothorax. I know it's a hemopneumothorax because although this is a pneumothorax, it's grayer from the density on the other side. And therefore, because it's a super inpatient, there must be blood layering along the back of the Henry thorax in addition to the gas. So this is a tension hemopneumothorax. His question is it always the case that um the affected side is always lowered, that from the other side is always elevated. Uh So yeah, so um this is elevated probably because the patient is breathing in at the time. Uh Sorry, I beg your pardon, breathing out. Um But, but then when you got so much mediastinal shift, it is going to contract the volume of that lung. Okay. And so when you contract your lung volume again, that tends to make them uh the diaphragm become elevated because you're losing volume. But the uh the actual tension is on this side and it's moving everything over to the right and it's pushing the diet from down. And you can imagine the pressure inside that hemi thorax is so great now that the venous return is going to be impaired and that's why they get circulatory collapse. So this is just another example of attention hemothorax as the left Henry diaphragm and the right Amitiza frame is so far off the film that we've got no visibility of that diaphragm. Okay. Here's another example of a tension pneumothorax this time on C T and I'm going to stop that there because it's a fast moving movie. I'm gonna go anteriorly there's the heart, there's the lung on the right, there's the pneumothorax on the left and it's depressed, the diaphragm, there's the stomach, there's the diaphragm and there's the pneumothorax, there's the left upper lobe, there's the left lower lobe, got a massive pneumothorax with complete depression of that left Henry diaphragm. And that's because the pneumothorax is under tension and also the patient's got contusions in the lung, contusions in the lung. But primarily we've got attention in the thorax which needs treating pretty quickly. Okay. And in fact, that was treated uh fairly, fairly quickly. Okay. So I'm going to go back to that. Um Let's go to the second one. This is a pneumomediastinum. So it's the second one on that link. Are you all able to open that link case too all able to open it? You're able to see that pack spin link. Yes, I'm just going to post it again in case somebody has arrived late. So have a look at that packs been link. And this is case number two medical student, finals, case number two pneumomediastinum. So let's click on this blue tab chest X ray of a patient with spontaneous chest pain. The parietal pleura of the mediastinum is stripped away from the heart border and the appearances of those of a pneumomediastinum. Can you all see that there? And so a pneumomediastinum is, well, you've got gas in the mediastinal space and what it does, it strips the parietal pleura off the mediastinum. And this can be seen in patients who are asthmatic or patient who have ruptured their esophagus. Okay. And the most important diagnosis to exclude is the patient who have ruptured their esophagus and you get gas in the mediastinum. And so the best way of uh excluding a ruptured esophagus is to do what we call a contrast swallow of the esophagus or to do a CT scan. And it's, it's called a pneumomediastinum. Now, it's very, very subtle and I would not expect medical students or foundation doctors ever to pick this up. But I'm just telling you about this condition because radiologists do need to pick this up. One of the over signs of pneumomediastinum is what's called a continuous diaphragm sign. And that's where the gas not only tracks up into the neck and subcutaneous tissues, but it also goes underneath the heart and makes the diaphragm look continuous like Bassett, so called continuous star from sign. Okay. I'm going to go on to the next one which is um number three. So this is a patient who has got right lower lobe consolidation. Okay. How do I know it's in the right lower lobe? Anyone? So opacity and the right, meaning this business and the obesity. So we've got an opacity in the right lower zone which die from is invisible, the right or the left, the right diaphragm, the left, the right diaphragm has become invisible because as the X ray beam hits the dome of the diaphragm. You've got consolidated lung just above it, touching the diaphragm and therefore the consolidated lung that's touching the diaphragm makes the diaphragm invisible. By virtue of the silhouette sign. Can you see the right heart border? Yes or no. Yes, yes. Therefore, the middle lobe was not involved. Therefore, it must be the lower lobe. So this patient has got right lower lobe pneumonia, okay, right lower lobe pneumonia. And on the lateral film, you can see that the left hemidiaphragm is nicely shown. There's stomach bubble here, it stops at the heart, but I can't see the right Emmy diaphragm because we've got consolidation in the right lower lobe. There's the oblique fissure, there's the horizontal fissure and the middle lobe is clear but the right lower lobe is consolidated. And here is the ct that goes with that patient and we can see lots of consolidation in that right lower lobe and that's obscuring the diaphragm. Now sometimes you can get a lower lobe consolidation but can you see the diaphragm? The can you will see the diaphragm partially, partially. Yeah, but it's completely gone here, isn't it? Yeah. Now, why is that? Well, it's an interesting question. And if I then do a electoral view of the second patient, I can see that the consolidation isn't quite as widespread as it is on this film. Okay. Well, this film consolidations really quite widespread. Whereas on here, consolidation is just confined here. Now, if the X ray beam hits this part of the diaphragm, you're going to see the diaphragm on the, on the film. Okay. And so what I've done is I've done a little schematic diagram and that diagram is like that. So in this patient, I can see the diaphragm because the X ray B hits the dome of the diaphragm where there's aerated lung on it and the consolidation is either behind or in front of that point. Whereas in this patient, the consolidation is so extensive that the X ray beam is touching the diaphragm above which you've got consolidation. Do you all kind of understand that? Okay. So let's go to the power point presentation. So, pneumonia, this is right lower lobe consolidation. This is what's happening. You've got obliteration of the diaphragm at that point. And so you missed the diaphragm on the pa film. And because of this point here being aerated, you can see the diaphragm even though it's right lower lobe consolidation. So you don't always lose the right lower lobe, sorry, you don't always lose the diaphragm with right lower lobe consolidation. And this is the reason why okay middle lobe consolidation, I can see the right hemidiaphragm. But what if I lost here? Big globe, right heart border, right heart is absolutely the right heart border is gone. And that's because anatomically the middle lobe is right up against the right heart border. Okay. And so as the X ray beam touches the diaphragm. I can oops, I can see the diaphragm because it's got aerated lung above it. And then the right heart border is caused by this consolidation which is superimposed over the heart and this is a middle aged consolidation. A lingula consolidation is the same thing. So you lose the left heart border just here because the lingula, her segment of the left upper lobe has got consolidation inside. Okay Just here. This is a young male with a dry cough, dyspnea and fever. And we've got ground glass change in a peri holla distribution. We've got no pleural effusions. So, what diagnosis does that suggest? Pneumonia? Yeah, it isn't very. Which type would it be wider? Uh It could be a viral pneumonia. Anything else in particular young male, dry cough, distant fever? What what also Enza Yeah, it could be that. What else might you consider immunocompromised patient? Immunocompromised PCP, PCP. Absolutely. PCP. It's now called P J P P JPs. So Pneumocystis, Jiroveci pneumonia or P J P. This is a different patient and basically you get lots of ground glass change and ground glass change is where we've got uh increased density but without losing the blood vessels. Whereas consolidation, you lose the blood vessels eventually that might become consolidation. That's ground glass change. And this was the patient's chest X ray. So we got to patient's with P J P. This patient here has got perry highlight, ground glass change and got some air bronchogram of consolidation. We've got a nasogastric tube in situ in the stomach, but right, internal jugular line in situ in the right internal jugular vein and then the S V C and then we've got a track. Yeah, we've got an et tube, endotracheal tube in situ tube and going back, this is the CT scan of that same patient that was Pneumocystis Jiroveci pneumonia. Now COVID 19 pneumonia tends to give you very, very peripheral consolidation just like this. Okay, quite, quite different. Whereas PCP gives you perry hill a consolidation, this gives you very peripheral consolidation. And of course, we've got serotype uh methods and uh PCR methods of making the diagnosis of COVID pneumonia hum binary TB. This is just an example of TB. And you can't really make the diagnosis just on the X ray alone. You need other uh information such as the patient's alcohol uh status. There may be a miller compromised, there may be homeless, there may be living in a home with somebody who's got open TV. And you tend to get very nodular irregular um consolidation in uh different anatomical places. And then if you get miliary TB, miliary TB is where you get lots of tiny nodules throughout both lungs. And this patient's got miliary TB. Now, how does the TB get into the lung? Mr cause miliary shadowing. Does anyone know uh a reassortment? Yes, Hemet. Oh Gin is spread. So it spreads via the bloodstream. So the the tuberculous infection is involving the, the bronch I and that then invades the blood vessels and get hematogenous spread. And they tend to be no more for three millimeters in size, multiple hematology, Innis uh uh granulomas up off miliary TB. Okay. So, back to the presentation, um this was the PCP. It just happened to be during a COVID outbreak and everyone thought initially this was COVID, but it did actually turn out to be PCP. And if you scroll through the cases like this, can you all see that? Are you all able to scroll through the case? Yes. Yeah. Great stuff. OK. So this is PCP Perry Hilar Earth by shattering. Okay. So, excuse me. Yeah, of course. Um When we have a preview AP chest X ray was clear sign of PCP or BJP. Does the patient need to go for a CT chest? Can we manage them with just a one film alone? That's a really, really good question because if you think the patient is immunocompromised, they've got a dry cough and a fever and dyspnea and you see this appearance, you don't need to do a CT because the diagnosis is PCP. PCP, you don't get plural effusions and you don't get lymphadenopathy. And so all of those features would be in keeping with PCP if you're not sure and the patient was not immunocompromised. You may need to do further investigations, you may need to do CT and if you're convinced the patient has clinically got PCP, but the chest X ray is normal, you would then go ahead and do a CT scan because CT is much more sensitive than a chest X ray in the detection of PCP. Is that ok? Ok. Thank you. Thank you. Okay. Um Okay. So the next case is heart failure. So let's have a look at the heart failure that is batwing pulmonary edema. Okay. And we've got bilateral pleural effusions, got batwing pulmonary edema. So this looks a little bit like PCP, but it isn't PCP because the patient's got bilateral pleural effusions and the history says sudden onset of breathlessness, whereas PCP, it would be more gradual. Okay. So this is heart failure and when the heart failure is partially treated, what happens is the patient has an improvement in the Harry highlight batwing pulmonary edema. But can you all see the curly be lines here? So what are curly be lines? Anyone? Yeah. So yeah. So we've got curly be lions, pulmonary, a deeper uh interstitial pulmonary edema. And that's where you get fluid in the spaces between the secondary pulmonary lobules right. Now. This requires a return to anatomy, right? So the lung is composed of secondary pulmonary lobules. So there's a secondary pulmonary lobule, there's the Broncos, there's the pulmonary artery adjacent to it. And then we've got the pulmonary vein and the lymphatics that run in the space between the secondary pulmonary lobules okay. Now, when you get pulmonary venous hypertension, the fluid from the vein oozes out into the space between the secondary pulmonary lobules. And when you got engorgement of these spaces, if you look at them and on, you'll see these curly be lines. So curly be lines here. Okay. Another example, curly be lines all along here at right angles to the chest wall, curly be lines, bit of alveolar uh pulmonary edema. Nice example of curly be lines. And if I just turn that diagram at 90 degrees, when we get engorgement of the scepter, so it's the gap between the secondary pulmonary lobules when they are aligned one on top of the other like a ladder, these like steps of a ladder, curly be lines and it means you've got pulmonary venous hypertension or in other words, interstitial pulmonary edema and it's the prelude to getting alveolar pulmonary edema. So the next step is for the interstitial pulmonary edema to become al viola pulmonary edema. And so here we've got Batwing alveolar pulmonary edema, I'll feel a pulmonary edema. And we can say now, bronchogram and this is a more advanced case of pulmonary edema than interstitial pulmonary edema. And these patient's are very, very breathless and this is treated with 100% oxygen and diuretic has another example of batwing pulmonary edema. Again, Perry Harlot Earth by shadowing and the circumstantial evidence that this patient has got cardiac disease is the pacemaker. Okay. What's wrong with this one. Well, the patient's got batwing pulmonary edema, they've got a left pleural effusion and they've got a misplaced nasogastric tube. Can you see that misplaced nasogastric tube? So that needs to be pulled out. The patient needs diuretics, 100% oxygen and the N G tube needs to be recited. So it's in the correct position. So if we come out of that, uh and then go into four A. So case for a, you can see the curly be lines. So there's the curly be lines. What do you think of the et tube position? Anyone? It's almost on the right bronchus. Yes. So it needs to be withdrawal about. Yeah. So if we click on the hyperlinks, you can see the curly be lines, you can see the curly beeline zoomed up E T T too low. Okay. So let's go back to that E T tube too low. And then let's have a look at the secretary Pulmonary lobules. That's the diagram. And we've got the Broncos Pulmonary Artery. Why have I colored that blue? It's not oxygenated, correct? And then we've got oxygenated blood in the pulmonary veins. So when you get pulmonary venous hypertension, as you do with left ventricular failure, the fluid from the veins uses out into the septum and produces these curly be lines. And the other cause of curly be lines is lymphatic obstruction because the other thing that runs in the septum is the lymphatic. Okay. Now, the other thing about anatomy of the lung gets wherever you see a bronchus, you will always see a pulmonary vein. That's what curly be lines look like on CT thickening of the interlobular sector due to fluid. And here is the reason why you get fluid oozing out of the pulmonary veins. And this is what it looks like on an axle ct. The other thing to note is that if you ever get a lamella effusion, that's where you've got fluid between the visceral pleura and the lung. So, pleural effusion usually is between the visceral and parietal pleura. But if you get the fluid between the visceral pleura and the lung, you've then got an area of fluid which is vertical and can you see the curve debris lands here and when you see that that's very powerful radiological sign of heart failure. And I'm going to show you one more example of pulmonary edema. Uh This time, it's a younger patient who has no history of heart disease, but they have either had a head injury or a subarachnoid hemorrhage. And this particular patient has had a subarachnoid hemorrhage and you can see the peri hilar er space shadowing, which is the pulmonary edema and you can see a little bronchogram running through it, but this patient has got no history of cardiac disease at all. And when you look at the brain scan, you can see blood in the fourth ventricle and then blood in the basil systems and early hydrocephalus because they've got subarachnoid hemorrhage and that's called neurogenic pulmonary edema. Nobody really truly knows what causes the pulmonary edema, but it's related to some sort of neurological catastrophic insult and, and this really uh produces the pulmonary edema. Now, the pulmonary edema is treated in exactly the same way with 100% oxygen and diuretics. And clearly another treatment is required for the subarachnoid hemorrhage. It may be that the patient needs a shunt if the patient's got hydrocephalus and they may need a bolt to measure the intracranial pressure. Okay. But that that comes under the uh the guidance of a neurosurgeon. But when, when these patient's present with head injury or a devastating neurological illness, they can, they can actually present with pulmonary edema. Okay. I'm going to finish that. I'm very happy to take any questions. Um Do you like the fact that you can scroll through the images? Yeah. And any questions on anything of taught you this morning, everyone happy, slightly complicated to understand the lateral view of the chest X ray compared to the AP view. Okay. So let's let's go back to the lateral view. Uh Let's have a little look at that. Uh huh okay. So the lateral view here is the horizontal fissure. This is the bleak fissure, this is the heart, the aorta is seen here. Okay. There's the thrust ick spine, the left hemidiaphragm normally stops where the heart is because of course, the heart is on the left hand side, it sits on the hemi diaphragm. The density of the heart is the same as the density in the diaphragm. And so you lose the diaphragm with the heart, heart sits on it. And in this particular case, we've lost the right hemidiaphragm because the right hemidiaphragm is obscured by the consolidation in the right lower lobe because it has the same radiographic density. Now, when we look at the lateral view of uh this particular patient, um this one here, let me just get it. It's uh in this case. Um Oh yeah, you okay. So and let's put this one up here. You can see the left hemi die from finishes with the heart is and the right hemidiaphragm can be seen where the heart is because of course, it's on the right, not the left, but we lose the hemi diaphragm posteriorly because we've got consolidation of putting the post cereal left handed are front, but we don't lose it on the AP view or the pa view because all you need is the incident beam too, strike the touching point of the right a middle from on the R rated longer bucket. Okay. And it it's demonstrated quite nicely in this, in this particular film here. So we don't lose the diaphragm because the incident beam is a booting, the point at which you've got normal lung, aerated lung and then diaphragm which is here. Okay. Now, when we've got consolidation at that touching point, that's where you lose the diet from. Does that, does that make sense? Yes. A little bit, a little bit. Don't, don't worry, it's quite complicated, but don't worry about it at all. I've gone into some great death. Somebody's asked as an F one, what is absolutely necessary to pick up on a chest X ray? Well, I think a pneumothorax, pneumonia, a large lung tumor. Okay. Gas under the diaphragm of a new more person name. And I would say that's probably about it. Now. I have got um, an equal number of cases that I could go through with you on a later occasion. Okay. I can't do it all in the allotted time, but I can go over the rest of what you need to know, um, on another occasion if you want that. Is that something that you all want this way? Okay. That's fine. So I hope you found that useful. Very happy to answer any more questions. Uh, if there are no more questions, uh, all I can say is I hope you keep nice and safe wherever you are in the world, especially in Ukraine. If anyone is in Turkey or Syria, keep safe, it's been a terrible earthquake and I just hope that everyone is very, very safe. Thanks for your attention. Uh Any questions, please get back to the moderator who can contact me and I'll be very happy to answer them. Uh until next time I will go through the rest of this presentation, but do have a look at the link that I've given you to have a look at all the other cases. Is that okay? Thank you. My pleasure, Cheerio. Bye bye, bye bye. Thank you.