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Okay, here we go. Uh, just let me get this out of the way, okay? Okay. Hello? Hi. Um, uh, doctor John Bogle, Um, intensive care, recently retired intensive care consultant in the NHS and Denise test. And today I want to talk to you about, um, necrotizing soft tissue infections also used to be called necrotizing fasciitis, but that's a term that's too specific. So today we use the term necrotizing soft tissue infections. And the reason I want to talk to you about these is that in my 41 year career, I was lucky or unlucky enough to see, uh, several, uh, several cases. And it's one of those, um, uh, one of those, um, diseases that are often not recognized because they're rare. So I'm going to start off with giving you a couple of, uh, three clinical cases that really marked me in my career. So I'll start with Mr Charlie McDonald's f. R. C s. He was my first boss when I was doing my surgical house jobs. And when I turned up, I was in Scotland and I was doing an award round, started my attachment and surgery, and, um, I saw a routine case of appendicectomy, uh, done by a locum surgeon. And the next morning, Mr McDonald came in a very experienced and admired a consultant surgeon. And we walked into this room of what I thought was a routine postop case, and he took one sniff and said, Get theaters ready. I had no idea what he's talking about. Well, he was right, because we went inside and we saw what I thought was normal tissue, which looked not quite like this. This is not the real person, but it was not particularly outstanding for for unexperienced eyes. Let's put it that way. But that was anything but the case when we opened this person up and we found something that looked very much like this. Except I remember the procedure went from the man's knees up to his nipples. But it was horrible, and what was ironic was about a week later, I was doing a ward round and again I walked in with a sister this time and I took a same sniff, and again it was another case of necrotizing fasciitis, and that's what we used to call it or necrotizing soft tissue infection. Very dramatic and I thought I'll never forget this. The second case was a Mr See. He was a gentleman who was coming in, uh, at night or in the evening for a routine redo of an anal fissure. And the team that was anesthetizing him was being overseen by myself. And I was about to say goodnight to them because that was not a kind of case that I thought I'd have to be present for. It wasn't a major case, and I walked into the anaesthetic room with the person still awake, and I took one sniff. And again, this is like 40 years later, almost 40 years later. And I remember that odor. And I said, Get the consultant surgeon to come in. He came in from home, and this is what we found because of that smell. It just rang a bell. And this man had what they call 40 years gangrene, which is a taste of necrotizing soft tissue infection. And he was also he had a colostomy and he had a major procedure from the lower part of his thighs all the way up to his nipples because it was all dead tissue. Sadly, he passed away and the last case, at least the last case I'll talk about today was a bit of a, uh, an interesting case. It was concerned a lady who was a female, uh, researcher at Imperial who was a specialist inside a kinds and she was a VIP. And so what happened was that she came in 42 years old. Cancer researcher, meeting specialist inside of crime research. Ironically, previously healthy, she had a two day history of having lent on her elbow when she was playing with her little child, and she had a bit, which he thought was a liquid non bursitis. So had a bit of a bit of a rub on the on the elbow, and it was swollen and painful but not very swollen. Not very painful. She took a few non Steroidals, and soon afterwards her arm and forearm swell became red and tender. But again, it wasn't dramatic. It was just a little bit swelling, a little bit red, a little bit tender. But what did strike her was that she had a lot of upper abdominal pain, diarrhea, nausea and vomiting. So if he eventually had to end up going to the excellent emergency department of our hospital, mainly because of abdominal symptoms. And when she was there, they found she had a low BP, noticed the low diastolic pressure that we talked about last time. Fast heart rate, high temperature and everything else was within normal range. They gave her fluids because of her low BP, and they suspected infection. So they gave her a book spectrum antibiotic. That was a beta lactam terazosin. People selling in Taszar backed, um with Amikacin to cover possible gram negative or staff. They then added clindamycin and nor adrenaline to try and improve her BP. They contacted the surgeon who was on call, and he said, Well, we'll see her later in the day and this was early in the morning, so they were going to wait at least 12 hours before they even assessed her fully. Then I was contacted, and I totally disagreed. I said, No, this is a surgical emergency. And so I had a heck of a time trying to convince the surgical team, and I guess, went over their head and contacted various consultant surgeons. She was then transferred to the intensive care unit where he was a very, very sick woman undergoing what we thought was a so called cytokine storm. Despite appearing relatively well, she was even cracking jokes. We immediately organized a multidisciplinary care plan that we were going to execute emergently. In fact, the surgeon insisted on seeing a CT, which is a little bit, um, controversial. And I remember personally taking her down and literally taking a routine patient for an elective CT out of the scan to stick my patient in. In other words, this was a very a very serious emergency. So how sick was she? Well, she was in septic shock. Severe metabolic acidosis, ARDS. All the figures are they're really severe kidney injury D I C inflammatory markers and circulatory failure. And basically, I put that up to say she was a really, really, really high risk of dying. Um, everything was everything was shutting down on her. Her CT, by the way, showed this ARDS what looked like a septic abdomen with a lot of third spacing and a very distended gallbladder. It was the size of a full plus. He had an inflamed arm. So where was the source? Was the arm Was it the abdomen, and we didn't know that if the source was not found and controlled, he was a very, very high risk of dying. He was already at a very high risk of dying, but it almost certainly was going to end up a poor result If we didn't find something quickly, based on a suspicion that you might have toxic shock syndrome from her arm, we started her also on linezolid an IV IG intravenous immunoglobulin, which we added to her previous regime. And this is what her abdomen CT looked like just to prove that we weren't making this up. There was a distended, distended, very thin walled gallbladder which looked like it was very septic and a lot of third spacing. So a massive amount of edema. So we schedule her for surgery emergently. And the problem was this. I was very suspicious, based on what I had seen in the past, that this could end up like this or like this with a four quarter amputation. And I told her husband about this when I had to see him. So what Surgical exploration showed. Very swollen, but nah, necrotic soft tissues. A gynecological procedure procedure exam was unremarkable in case she had a tampon induced toxic toxic shock system. Uh, syndrome. We, uh, took We had a motorcyclist ready to take the sample taken from surgery to another hospital where they had the on call. Microbiologist. Ready? And the microscopy showed you had grand positive. Cocky. And so the presumed diagnosis was cellulitis with a toxin secreted. Um, uh, microorganism either a group A strep or staph, but there was no necrotic tissue, but there was a very, very sick woman with what looked like a toxin, uh, toxic shock syndrome. But it could still be the abdomen. We weren't sure. So what was the final outcome? Microbiology called to confirm this was indeed a group a strep streptococcus. So the antibiotics were. Then we call deescalated. We focused them to penicillin and clindamycin. The patient was actually did very well. After our emergent care. She was extubated and discharged to the ward three days later, which is an Incredibles outcome. Given that we thought she was going to die. And 10 days later she went home. And in fact, I know for a fact that she was able to celebrate Christmas soon after the words with her husband and her two young kids. And I think most people recognize that the fact that we recognize this urgently and really expedited care made all the difference in a very sick woman. So what's the path of physiology of criticizing soft tissue infections? Well, let's go look at some of the anatomy of the skin and the soft tissues. So here you have the anatomy. You have the skin, which is consist of epidermis and dermis, and the symptoms of infections you may get would be things like every syphilis or impetigo. If it goes below the skin into the subcutaneous tissues, then you can have you have the super superficial fascia. You have fat nerves, blood vessels and the deep fascia between the superficial and the deep fascia. You have the fat nerves and blood vessels, and there you can have cellulitis or we used to call necrotizing fasciitis and further further, deep or deeper, you have muscle. And what would be my hope? Necrosis. So there's basically considered to path a physiological mechanisms. Either you have a defined portal of entry, so you have a brief in the skin that the post surgery post trauma could be a an injection, even any sort of breach in your skin or your mucosal barrier will cause the the entry or ingress of organisms or spores, and they will cause damage to your blood supply and release of extra toxins. And basically, you're starting from above and digging your way down to damage deeper tissues. And you'll get necrosis of multiple layers as you get vascular occlusion from and you'll cause ischemia. And they can also cause things like, uh rarely. But depending on the organism, toxic shock. The organisms involved tend to be gram positive and gram negative and and Arabs and the course tends to be slower because, uh, they have to work synergistically to cause all the local inflammation. And because of that, because of the slow onset, people often or doctors often don't recognize, um, what's going on. And that's slow onset in a lack of urgent care often leads to a high mortality. The other type of pathology is what we call the non. It's called um Type two words, no defined portal of entry. And that means that, uh, that means that usually have a mono microbial, uh, organism. Usually it's a streptococcus group A strep pyogenes or a staphylococcus aureus. In this case, you could have something minor, like a bruise muscle or a hematoma. Um, this is probably what happened to the first lady. If you probably lean and got a small hematoma deep deep in the tissues and do two seating from the bloodstream, they will, um, cause an infection. And there you can get, um, toxin secretion. And these are not synergistic. Unlike the other type that is due to a brief in the skin. And this comes on very rapidly. And about 50% of cases, um, you will get, uh, release of various toxins, super antigens and various toxic proteins. And this comes on very rapidly. Now, the thing that's important to recognize and this is one of the main problems with this is that they're very rare. These these necrotizing soft tissue infections And because they're so rare, many doctors have never come across them. Or if they do, they don't recognize them. So to give you an idea of the incidents and this is the Netherlands, but it'll be the same in most other countries. A myocardial and fortune you'll see per 100,000 people in a year about 1000 200,300 necrotizing soft tissue infections about one. So you can't have seen a myocardial unfortunate about 1000 times more common than seeing a non, uh, necrotizing soft tissue infection. Hence, if you don't see them you don't recognize. And that leads to death. And they are deadly if you were to see how deadly they are, if you take 100 people roughly speaking, about 40 or more percent will die from your non your necrotizing soft tissue infection. So it's really very serious. How about the diagnosis? Well, the key thing is you have to have a high index of suspicion. You can't just it's not going to be clear cut. Most of the classic signs and symptoms are not present at half the time, at least, so you've got to really have a high index of suspicion. You got to be very, very, um, skeptical. And really ask yourself, Could this be, uh, because if it is, you've got a lot of work to do and very quickly. Clinical findings? Well, these are the classic clinical findings, so risk factors you want to know. Age, diabetes, obesity, nonsteroidals perhaps, um, several studies have strongly suggested that be the case. Early physical findings. Everyone talks about pain out of proportion. Erythema not always tachycardia fever again. Less than 50% of cases. So you've got to be very, very, uh, suspicious. Late physical findings. Um, foul odor is often mentioned disorder pus. When you eventually open the person up gangrene, frank gangrene, but shock and organ failure. And if you see someone sepsis and you see them with a swollen ish arm, you might have to think three times. Could this be a necrotizing, uh, soft tissue infection? Uh, as as a new diagnosis, so classic classic symptoms and signs. This is the one everybody talks about is pain that's way out of proportion to what looks like a relatively minor physical injury. So pain, pain, pain, pain and pain. And the other thing you want to remember And this is the one I definitely remembered, uh, in two of the cases, the first two cases I mentioned is the UN for unforgettable aroma. It's repulsive, and it's Feeded. And once you smell it, as my surgical mentor has told me in the first day, I was there he said. Once you smell that, you will never forget it. And boy, was he right. But you got to be aware of pitfalls because those are classic symptoms and signs. But they're often absent fever. There's absent. Cutaneous manifestations are absent. Often you may mistakenly attribute pain to, say, an injury or post operative procedure. They're non specific imaging often and you can often mistaken systemic manifest taking other causes of, say, nausea, Rodney and diarrhea. And the classic presentation only occurs about half of patience. As I said. So you got to be very, very, uh, skeptical What you see. So how about treatment? Well, the key thing is early aggressive surgery, none of this keyhole stuff. None of those small incisions you've got to go in. And if you do find necrotic tissue, you've got to keep you gotta keep aggressively debriding until you get clean tissue. That means that can be very, very extensive. Often the initial surgical procedure seems to be, uh, you know, you think you can get away with not doing much, But in fact, um, you may have to go in and very extensively operate, for example, you may have to do a colostomy to keep a perineal wound clean. Surgeons often don't like to do that if they don't have to. But you have. You have to insist, and you have to go back the next day and debride again. And you have to keep going back every couple of days until the tissue is clean. So it's gonna be early. You can't wait. You can't say we'll see them in the evening. You've got to get it. It's a it's a surgical emergency and you got to be aggressive with your surgery. What happens if you don't? If you don't if you're not, uh, if you don't, uh, if you do delay surgery, what if you are not a rapid in your diagnosis and your treatment? Well, this is one study. Many, many studies very similar results. Your mortality. You'll survive or you won't depending on how soon you are treated. And many studies have shown that a delay of Beyonce six hours or more will have a major impact on patient mortality. Is this is an absolute surgical, uh, emergency, but you got to recognize it for for the to get the machine working and early surgery will save lives, so if one person would die is in despite of surgery. If you delay surgery, say 24 hours, another nine will die, and it does not just be expedited. Mr. Surgery doesn't just have to be emergency surgery. It has to be aggressive surgery. Why? Because if you don't adequately debride the wound initially, you'll you'll increase the risk of death. You've got to have a very wide re century. So you want to get some blood order because you're gonna be incising until you start bleeding. An aggressive surgery is the key to survival. And it's gonna be early and aggressive because antibiotics, which often surgeons or, you know, other medics will say, Oh, just give him antibiotics. But they can't penetrate thrombose necrotic tissue. They won't get into the areas that they have to get into. So the only way to get get rid of that is to to, uh, incise it and debride it. There are also there are relatively few inflammatory cells that, with your body's own defense mechanisms having trouble getting in. Also, about half of the cases will have toxin producing bacteria. And if they do, uh, you got to get rid of those bacteria by debriding. And this is just a histological sample showing in a case of of necrotizing soft tissue infection. If you know how to look at these, there's a relative absence of acute inflammatory cells in this area of necrosis. So you've got to get rid of that dead tissue. What about a driven treatments? Well, of course, you do want to use antibiotics, but you want to just You don't want to just rely on antibiotics, so they're just an adjunct to surgery. That's a key thing to remember. They're there to assist in surgery. They're not to replace surgery. You want to cover them with broad spectrum antibiotics that will cover gram positive, gram negative and Arabs and MRSA. Um, depending on your local environment if you like. Um, until you get your gram stains back or your cultures back, you want to cover everything, and then once you get your cultures back, then you can do it. We do with the third lady. You can then focus in on what you have grown. You want to use antibiotics that are. They're going to suppress toxins. So some of the antibiotics we use don't just kill the bacteria. They also stop the production of toxins, and one of them is clindamycin. It has what they call it doesn't have what they call an eagle effect. An eagle effect is certain bacteria will, um will grow. And once they get to a certain size, once they get to a certain size, they they stop growing. And a lot of the beta lactamase The penicillin, like antibiotics, work on the membrane of reproducing bacteria. So they stopped reproducing because there's no more food because they've outstripped their food supply. If you like, then the antibiotics won't work. Well, clindamycin does, because it doesn't show that what they call the Eagle effect and the other one is linezolid. Now up to up to 15% of streptococcal infections in the U. S. Strep group A strep and up to 95% China. So it depends on the country will be resistant to clindamycin so often we replace. Or we may replace or use linezolid, which covers everything clindamycin covers. Um, and there's much less resistance, and it also is toxin suppress and remember, because thrombosis, that's what you say in these cases because of thrombosis, you're going to get poor penetration of antibiotics so they will not work alone. You got to combine them with surgery. So how do we classify these necrotizing soft tissue infections? Well, we call. These are just artificial classifications. There's type one, and they tend to be polymicrobial. So there'll be gram positives, gram negatives and Arabs and Arabs, and they tend to work synergistically. They don't produce the toxins so much as they work together, causing slow but rather irrevocable damage. The well, they say the most common probably about 50 50 in fact, depends for some reason. Um, the type two, which I'll talk about in a second, is increasing in in, uh, in frequency these days. So you're gonna get either 50 50 type one or type two. It often occurs after we said earlier, a break in the skin or mucosal membranes. So after, say, surgery. So someone who's got we talked earlier about the second case he had, uh, an anal fissure repair or a hemorrhoid repair something very minor. Any break in the skin can cause that, and it it's it's basically burrowing its way in from the superficial layers down to the deep layers and later into the muscle, and everything occurs more slowly compared to the group A strip or clostridia. But it's still highly lethal. And so this is a kind of typical surgical procedure that following the surgical procedure patient may not be right. You got to have a very strong and, you know, they're they're in pain. You wonder why they didn't such pain. And you're not They just don't look right. You've got to always think, Could this be, uh, necrotizing soft tissue infection? They may not look all that ill, in fact, and this was the case of the first man I told you about his case. He had a, uh, the most benign procedure possible. An anal fissure. And, uh, and he he wasn't looking particularly ill, and he just had a bit of a little bit of pain from his procedure and went back for a relook. And he was desperately ill. They had when they opened him up and we insisted that he did because I told you, we I sniffed something and I thought, this doesn't smell right. And the consultant came in. We spent the night with this gentleman. He had a colostomy to keep his perineum clean, and he spent weeks in intensive care and sadly, he didn't survive. But, uh, here you can see some of the causes of this 40 years getting green and peri anal fistula fistula to me, an anal fissure. That's what he had to die from an anal fissure. It's terrible. So that's mister See, just to remember to recall the second case we talked about and the second type of necrotizing soft tissue infection, with or without toxic shock syndrome. So in the second type, you don't have a bridge of the skin. Remember, this is often causing. It's a muscle sprain or small muscle hematoma. It'll be seated by, uh, small bacteria in the blood stream, and sometimes it's often group a streptococcus or staphylococcus aureus. And both of these can produce in about 50% of cases specific, uh, toxic antigens, um, toxins. And so they cause, uh, not just the necrotizing soft tissue infection, which is severe but also the release of cytokines. They cause, uh, sort of full body inflammation called the Toxic Shock syndrome. And these are often caused by Group A streptococcus. What we call gas flight heating bacteria. Some people call it and and staphylococcus or areas they produced virulence factors and on the case, it's often things like M protein's, which inhibit complement super antigen, which trigger T cells, which cause a massive release of cytokines. Only certain individuals are susceptible because the vast majority of people have antibodies to these. But about 15% of people don't, and they're the ones who tend to get this. And there's a specific antigen, and I put in just to to to refresh your memory or to to bring this to your attention. There's Staph Aureus produces something called the Panton Valentine Lucas Sidon, which is often causes, uh, pneumonias. And if you see that, you'll get necrotic lesions in your lungs. Remember the doctor? A see? That's what she had. She had a cellulitis, but it was a toxin secreted cellulitis, a group a strep and she almost died. What about other treatments? Well, obviously you want to get these patient's into the intensive care unit for massive support because they're going to need it and you want to give intravenous immunoglobulin. It's a little bit controversial, but the vast majority of people today I think we'll use this because it tends to neutralize, um, the various toxins and the super antigens that these microorganisms can secrete. Some people talk about hyperbaric oxygen, but there's not. There's no real evidence for this, and it delays definitive treatment. So today it's not advanced. But most importantly, if you see someone who's deteriorating after surgery, you want to go back for further debridement because they may still have the microorganisms that are that are reproducing and and still secreting toxins and causing further necrosis. So if in doubt, you go back to theater and you read a bribe them. What about differential diagnosis? Oh, this is the big one. Cellulitis. People think cellulitis. No, no problem. Um, necrotizing fasciitis, we used to call it. That's the one you want to go to surgery for. Well, it's really not easy to distinguish between the two. If you have someone who's toxic with cellulitis. Someone who's got, say, heart failure with sworn legs turns a bit red. Uh, and they don't look particularly toxic. I think you could then treat them as cellulitis. Not too much. Uh, you know too much danger. On the other hand, if you have someone who has, uh, what looks like cellulitis, but they look toxic. They look like they're going to sepsis. You want to definitely distinguish that from necrotizing soft tissue infections because they said in this many articles, it's very difficult, if not impossible, to differentiate cellulitis from necrotizing soft tissue infections. And if you doubt if you have any doubt you've got to get in the surgery and explore, it's the only way you can distinguish it, too. And it's a true surgical emergency requiring aggressive debridement, as we said, and with the toxic shock cases, the mortality can go from 40 to 80% and this is very important. So it comes it comes on with. So it comes on so fast that once you see it once, you'll never forget it. And the problem is, it hasn't achieved the same level of awareness amongst healthcare professionals. So a lot of doctors just don't recognize it. As I say. I'm not trying to boast, but because of my almost accidental, um, discovery of this thanks to my, uh, doctor, Mr McDonald, who showed me this the very first one of the first days. I was a surgical house officer. It was very, very much on my radar screen, but people around me when the when that third case came in, people didn't even recognize this and they were just going to sit on her for a weekend. And, uh so it's really important to to be aware of this. Yeah, so early management to summarize this if you like. If you suspect non, uh, necrotizing soft tissue infection, you want to start immediate antibiotics broad spectrum plus clindamycin or loanees lid. If you suspect gas, and I would say, Just get in there with that you might want you might want to use IV IG if they look particularly septic and urgent surgical debridement, and then you want to follow that with ICU admission and treat organ failure. Don't forget the tetanus toxoid support and then POSTOP management. You definitely want to have a second look the next day, Um, and you want to reassess the antibiotics spectrum on cultures. So to recap, soft tissue necrosis is deadly. You have to diagnose it by having a high index of suspicion to treat you want source control. You want early aggressive emergent surgery. It's a surgical emergency, and antibiotics that include toxin suppression and I v i g and then intensive care. Remember, there's not a moment to lose. Every minute counts. It's a surgical emergency, so that's familiar. All I have to say about that, and I hope you don't see too many cases, but at least you'll be prepared for that. If you do see them. If they're any questions, I'll be happy to answer them for you. He really tried to, um, Dr Vogel, thank you for that fascinating and really important lecture with so many take home message is that I'm sure let an impression on the students. Um so be great. If anyone has any questions, you can either put them in the chat or you could a new it yourself because we're a very small group. Uh, And ask Dr Vogel, uh, and you can share even more of his, uh uh, expertise. Um, so wait for people to come forward. It was, uh, quite, uh, quite fascinating, really. And very topical as well. Yeah, This is a group A strep. Yeah. I think you might have stunned people into, uh I think some of the images were really hard hitting there. And yeah, intriguing cases. Absolutely. I agree. That sums it up. You're lucky. I had had about 10 slides of I called my chamber of horrors. Of all the things you could see, I thought I'd leave that out because I thought I didn't wanna It was going to advance the, uh, your knowledge in the case, but it really is quite dramatic when you see it. Absolutely shocking. Yeah, I'll put just because no questions. Yeah, I think I'll put the link for the feedback form also in the chat. Uh, just in case. I don't know. Um it seems that we've got through things you know fairly quickly today, but, uh, nevertheless, should we continue for a bit longer just to see if there are any questions that pop up in people's minds? Or maybe any other cases that you want to, uh, share whatever you think it's already. Well, there's no questions. That's fine. Okay, Well, you are. We are winding down. I suppose it's, uh maybe the holidays so we can let school finish early today. At least this lecture We've got one more session later. We've got a well being session and I'll put the link that's open to everyone I'll put the link for that in the chat. We've got a team from Brighton. We're doing a special well, being session pass, which were really looking forward to it might be helpful for all of us. Really is a is a question, I believe. Yes, sir. Uh, is it possible that for the fasciitis to grow towards the paces them or is it just towards the limbs of the trunk? Specifically, it's situated, or, um, so I I didn't get the the very first part of that question. Is it possible that the fasciitis could, uh, go, uh, like, reach towards the face and the neck is on the neck and head area as well? It can start there. Yeah. I mean, it could be something very banal. I mean, someone even with nasal packing can get, uh, introduction of, uh, for example, staphylococcus or any of the any of the microorganisms that can cause this. Yeah. In fact, it tends to be certain again. It's not. It's a rule of thumb. Certain infections tend to occur in certain areas, so the type to the sort of mono microbial you know, strep or staph tend to be in the limbs. Uh, the trunk and the face and head and neck tend to be type one, so that could be multi, you know, polymicrobial. But they can definitely spread. That's the point. If you have something that looks circumscribed and you incise it, you're just going to basically remove that small area. You may find that as you keep incising further and further along, you're gonna see it spreads all the way up. So the gentleman, the very, very first case I saw it was it was post appendicectomy. So it's a very small incision at McBurney's point. Um, the lower right, uh, fossa. And when we took the patient to theater, I mean, literally, I'm not making this up. He was from from his kneecaps to his nipples, he was totally flayed his testicles. I remember very well. His testicles were, you know, white testicles are hanging out there. It was just unbelievable. So you've, you know, you've really can spread like wildfire. It's very, uh, it's very important to very, very widely excise. Everything that doesn't look alive. Is it also possible that, uh, a bite from another person or a dog bite can also cause us a fashion STIs. Yeah, of course. Anything they can reach the skin or mucosal membrane can introduce bacteria. And that would tend to be a type one. Uh, I mean, it doesn't really matter. The classification doesn't really matter. What's important is you got to think about it. That's the point. If you think about it and you even consider it, then you've got to do it. You got to get everything ready urgently. You can't sit back and say, Well, we'll see how it goes and you know, to tomorrow or the day after the third case that what the doctor I was telling you about, what was so striking about that case was everybody was very laid back about it. And I'm not trying to boast again, but because I have seen these cases before, I you know, I recognize this could be something very, very serious. And I literally had to move heaven and earth to get everybody to get their skates on to get moving. Can appendicitis lead to Yeah, absolutely. The answer is yes. Taiwo, do you want to read that question? Uh, just because we're recording it because it can. Can appendicitis lead to Yeah, can appendicitis lead to, uh, necrotizing self tissue infection? The answer is yes. In fact, the very first case I saw was the, uh was secondary appendicitis. Don't forget what I said to you. These cases are relatively rare. The incidents for 100,000 people per year is something like one or so. And so you know, it's you're not going to see them very often. So that's why you've got to think about it. Most people don't, and that's the problem. And when they finally do think about it, it's often too late. The mortality can be, you know, 80% or more. So it's It's basically, you know, think about it. Thank you very much for that. And, uh, for the questions, um, if ever none further can I really encourage people, uh, to fill in the feedback? We are absolutely dependent on that. To continue the medical school, I'm going to put my, uh, contact number because I'm not going to be able to post this certificate on this chat right now. So I'm going to put my contact number in the chat, and you can What's athlete for your certificate? And I'll send it across to you. So sorry about that extra hurdle. But on this occasion, I'm not able to post the certificate in the chat, okay? And it's a it's Doctor Sharon here. Just so you know who's speaking, Um, and any comments that you'd like to put in the chat, it's always, uh, you know, good to see what the feedback is. Also, just some narrative, you know, feedbacks and comments, because we get some, uh, get some feedback, of course, on the link, and that's very important. But it's nice to hear also your more personal comments, and I will stop recording now.