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Mm. Fake. That's us. No, There we go. We're live. Hi and welcome, everyone. Welcome to what is the character journal club? Before I introduce our wonderful speaker today and highlighting what will be discussing today, I wanted to take the chance to welcome you to attend in today. Um, and I want to welcome to this journal couple that is really accessible to all. Whether you're a researcher, whether you're cardiophysiologist, whether you're a student, whether your cardiologist, as long as you have an interest in today's talk, you're welcome. Um, and I'm sure it'll be fantastic talk. The goal of this journal club really is a fantastic opportunity to share expert knowledge online. Make it accessible to everyone. So wherever you're at and driving interest in science, with the final goal being allowing us to all to work that bit closer with the ultimate aim of improving the health care service we'd deliver and provide to our patients. So how can you enjoy tonight? Well, whilst you won't be able to join in with your video audio, what you can do is pop in some questions that Curtis has kindly offered, um, to tech at the end of today's session. So if you pop them into the Q and A section, so it should be a little we chat box that you might see on your screen. So if you have any questions, you wanna talk, pop them in and I'll address the curtains then, or if they come towards the end, we'll address them then. Um, so tonight, Curtis is going to be talking at first. Like, who is Curtis? Well, Curtis is a PhD student at the Children's Health and Exercise Research Center at the University of Exercise Exeter. And that is really the only dedicated research center for pediatric extra sized physiology in the UK. Stumbling over my words tonight, Um, and Curtis is a really good expert in the space. He's published quite a fantastic, systematic reviews and med analysis recently. The methodologies really robust for anyone who's a little bit geeky and limb like me. So I was very much impressed. Um, and really, the floor is yours, Curtis. Um, so I'm going to transition to you because I'm not going to steal your funding. Cheers. Thanks. Thanks for the kind introduction. Hello, everyone. Um, we'll share my screen and, uh, let's get started. Thanks. Thanks for joining in tonight. Uh, here we go. Say, Gavin, just let me know if you can see my screen. Okay? Please. Okay. Brilliant. Okay. Well, welcome, everybody. Um, so today we're going to be talking about a review paper I wrote probably last year in the peak coverted. Um, and the title of it is the role of cardiopulmonary exercise testing and predicting mortality and morbidity and people with congenital heart disease. But what that boils down to, really is the title of this talk today, which is, should we care about fitness in our congenital heart disease patients? Or simply is fitness important? But first, who are my Gavin's introduced me. I'm PhD student at the Children's Health and Exercise Research Center. I'm in my third year. Um, and my pH is all about cardiorespiratory fitness and the other people with congenital heart disease. Um, that's me there on the right. And that's my supervisor, Professor Craig Williams. And my background is, uh, MSE and pediatric exercise, physiology and health. And I've I've worked in kind of the NHS in in primary care since 2014, doing a raft of different jobs. Um, and when I'm not doing research. I'm normally doing stupid things under water. This is me here in the inside of a German World War One battleship. Um, so that's a little bit about me. I'm a part of a big team, though, Um, and I should really give a lot of credit to everyone in this picture here. So this is a big collaboration between Extra and Bristol Hospital, and we have the broad, um, research interest of physical activity, exercise fitness in congenital heart. Um, but we also work a lot with athletic populations. So, um, when we see training adaptations, can we differentiate between pathology or normal physiological adaptations? Um, so that aims. Today. We're going to look at the background, the methods and the results of this review, but we're going to come across to kind of themes. One is fitness in general, heart disease is important, but also, the evidence based the quality. What? What's the quality of the evidence base? So for those who might be unsure, um what what? I'm defining congenital heart disease as, um, I'm talking about structural abnormality of the heart or vessels leading to or from it. Plumbing, plumbing defects. Um, there's a congenital heart disease is very common, essentially 1% of all life births. Um, and that's approximately 18 Children a day, Uh, 6.5 1000 in one year in the UK and do to improve medical care. Survival is substantially increasing, and now it's reported that 97% of Children born with congenital heart disease will reach adulthood. And while this is fantastic, we now have a growing population which need lifelong monitoring and care. So I should also introduce what type it is. It's essentially an exercise test cardiopulmonary exercise test where it can be done on a bike or a treadmill. Um, and we get to measure lots of things such as pulmonary gas exchange, BP, heart rate and rhythm, oxygen saturations and how much work they can accomplish, and then a clinical setting or research setting. We can also tap on lots of other extras such as echocardiography near infrared spectroscopy if we're looking at the muscle. Um, but what I'm interested in really is what we see here in this nine panel plot. This plethora of gas exchange variables which we know are very important. But what I think we can really condense all those nine panels down to is we can look at peak values such as peak heart rates, thresholds, slopes and reserves. Um, so let's get into to why we bother to do this review because it did take a long time. So first we did a Cochrane Review looking at physical activity interventions for people with congenital heart disease. And Gavin presented this in his first journal club, and he he presented it a lot better than I can see. It was a bit jealous, but he did a fantastic job. But the background on on this is we did looked at all different types of physical activity interventions and congenital heart disease. Um, exercise, training, physical activity promotion and inspiratory muscle training. And what we found were the peak exercise oxygen consumption. It does improve by about three meals per kilo in people who have done exercise training, but roughly about two meals per kilo per minute of oxygen consumption. Uh, when we look at all the different types of physical activity interventions, and so we were a bit stumped here because this wasn't statistically significant. This is 21.89. It's less than a metabolic equivalent task, which is 3.5 mils per kilo per minute. So when we did, our grade analysis, which essentially is the is the recommendations, um, to to lay people and to policymakers, we we have to say that physical activity and exercise interventions may increase fitness slightly, but it's not clinically important. And this picture here is of Rod Taylor, professor of tailor at Glasgow University. And he's done more. Cochran reviews, um, than I've had hot dinners. And, uh, he he was saying that in heart failure, we need one metabolic equivalent to ask for it to be prognostic. Um, but we're unsure what that value is in congenital heart disease. So hence does this to meals, a kilo per minute of fitness increase. Will that lead to improve patient outcome in the long term? So rationale for the review Growing congenital heart disease, population cardio respiratory fitness has been associated with clinical adverse events. And, um, we're unsure on the Cochran review findings. What do they mean for patients? Prognosis. And so we we developed our research question, Um, and we do this using the pickups framework. So we look at the population and we said anyone with congenital heart disease Um, we were interested, and we'll include them within our review. We have our index prognostic factor and this What is any type of parameter that we can obtain from cardiopulmonary exercise test, either on a bike or a treadmill? But they must have included, uh, gas exchange measurements, comparative prognostic factors. These are essentially co various things that, um, any kind of demographic or clinical parameter that could've explained the outcome such as an obesity or BP or severity of the congenital heart disease, has we We want to extract that information we want to see is fitness important even when we take into account all these different factors the outcome we we were interested in a composite outcome of major adverse cardiovascular events. So hard clinical outcomes, um, all cause death transplantation, my cardio infarction, stroke, unscheduled sized cardiac hospital hospitalization, timing. We were interested in routine care, um, and setting obviously all clinical in the hospital. And we published this protocol here, and we followed the the most rigorous guidelines of the time published by Richard Riley, who's, uh, statistical editor for the British Medical Journal. So we followed his recommendations. And we This is a charms checklist. This is all the information we extracted from studies, and I'm not going to bore you with it because it's quite a comprehensive list. Um, and then we also had to do a risk of bias assessment. So for every single study we included, we looked, say, a domain of study participation, and we had to check that all of these were met and then we could judge them as a high risk, moderate risk or low risk of bias in several domains. Um, and then we can see, um, what the quality of the evidence is like across the board. And this is really, really important, because Doug Altman said Good reporting is not an optional extra. It's an essential component of research. So before we get into the results, I'm going to take you on a whistle stop tour of a typical study. We see um, looking at fitness and outcome in our in general patients, and I have not picked on this journal this article for any other reason. That it's quite a typical representation is published in a very good journal medicine, science and sport, and exercise. Um, and they were interested in auction uptake efficiency slope and the V E V CO2 slope. And it's predictive ability, which is very cool. And they performed a typical analysis where they performed a rock curve where they looked at, for example, the V CO2 slope. What's the point of that? That it offers the most sensitivity and specificity. They performed a capital in my A plot. So for the VCR to slope less than 37 more than 37 they do a log rank test, and they say, Oh, it's statistically significant. People who, um, have a VCR to slow up higher than that point are more likely to die. Um, and then they run a Univera ball cox, Um, regression analysis, Which gives you a number on that. And they say, um, your for for V V C to slow your 10 fold. More likely to have the two year cardiac morbidity if your slope is over that. Okay, so what? What were the results of our of our review? Well, you can see here. We identified a lot of studies through our searches, and it left us a bit like Macaulay Culkin. They're absolutely scared because we had to go through 5000 abstracts and we had to read 212 papers. So there's a lot of work to be done, and we managed to whittle those down to 48 studies that we included. 34 of them were able to be pulled into a meta analysis because they presented survival analysis statistics. 14, uh, were included, but they didn't provide provide those statistics. We analyze them in different ways. So the headline results really were 48 studies, roughly 18,000 people in the meta analysis and only 1% was pediatric data. Um, most popular index prognostic factor was peak oxygen consumption. And we had four types of congenital heart disease that was most widely reported. And they were fontan circulation's, where venous return to plump straight into the pulmonary arteries. So 11 pump, essentially one ventricle. Um, we had, uh, was that transposition of the great arteries and this was the old type. We didn't have any arterial switches. They were all the old sending mustard ones that aren't done anymore. And we had tetralogy a fellow, and the fourth group was a combination of all different types of congenital heart disease is, uh so bicuspid aortic valves, atrial septal defects, tetralogy of fallot all pulled in together. So let's let's go through. So peak oxygen consumption. For those who are unaware, if we do an exercise test, the amount of oxygen you breathe increases up to a point where it plateaus or you get a peak. And, uh, this is kind of the gold standard measure of fitness. Um, and it is a product of card cardiac output and the arteriovenous oxygen difference. So essentially, how much blood, oxygenated blood your body can pump and how much it can extract. And it's normally typically presented in liters a minute as it is here, or because this is biased by size, they tend to divide by body mass to give a size independent approach. But more on that another day, Um, or percent predicted, achieved okay, so they could say you reach 70% of your your value for someone of your age, stature, height, whatever weight and what we found were for PPO to So this is, um, the meta analysis that we performed or a section of it Um and we pulled hazard ratios. Okay, So hazard ratio one means you're at no greater risk than anyone else. Anything to the left of this red line is good. It's protective. So fontan patients, um, who had their PPO to assess that 10 studies reported that, um had a hazard ratio of 0.82 so roughly and 18% reduction in risk if you had a higher V 02. And this is pretty similar across the board, we got 20.82 point 84 for transposition of great arteries, 840.88 for the mixed group. And you can see these are all statistically significant because these confidence intervals do not cross this line so very good. Um, and this included these 10 studies. Some of these studies may have included as meals per kilo per minute or percent predicted. But even if we dial down into just per unit increase of meals per kilo per minute, we can still see that across all of these studies. The majority of them show statistically significant and and clinically significant results we have. So if we go back to our peak are thresholds are slopes. This is a threshold. So, uh, an aerobic threshold or gas exchange threshold where we see an inflection of V CO2 over V 02. So a transition point where we go from an aerobic two or more anaerobic state again, we can We can report this differently. And this is our We have a lot less here, as you can tell, a lot less studies, only five reporting survival. And it's kind of a mixed bag. Nothing significant on the on the thresholds. And then we have slopes. This is the V V. CO2 slope. This essentially looks at how efficient you are extracting carbon dioxide. So this on the Y axis here we have ventilation on the X axis. Here we have a carbon dioxide expired and we can see it's very linear up until the break point. This is sometimes called V T two or the respiratory compensation point, but the steepness of this slope varies depending on someone's health, so we can see a normal slope. Here is quite it's about 45 degree angle. But then, if someone has dilated cardiomyopathy, we see a much steeper, more abrupt slope, and we can measure this just by planting a linear aggression through this And for this one individual, This is actually, um, athlete. They have a VCR to slope of 36. So for every one unit increment of carbon dioxide, their ventilation has to increase by 36. Tha ventilate out that much carbon dioxide. And this is actually seems to be quite prognostic of outcome across a range of congenital heart disease types here. So 0.9, so 6% reduction across the board there. Um and this was the main meta analysis we included within the study. And, um, the the reason I've broken it up is because that looks quite daunting. Um, but one other thing I want to show you is heart rate reserve. So this is the difference between your resting heart rate and your peak heart rate. And this looks like a very important metric within our congenital heart disease populations. So we as we talked about we we've got essentially, fitness is important. Um, but is it important when we take into account all the other things that we can take account of? Such as, um um So what we did, we performed a head to head meta analysis. Okay? I've never done one of these before, so it was a bit bit interesting. Um, so what? On the primary, you know, very analysis you saw on the previous slide. It included 80 congenital heart disease CPAP combinations. Um, in the secondary analysis includes only 37 because fewer studies performed multi various analyses. So we pulled only studies that reported the multi various association. So once they controlled for those comparative prognostic factors on the left panel here we have our, you know, various associations on on the right. We have our multi variable associations. And what I'm just going to do is talk through one particular slide, one particular one So we can see here fontan. So, people with fontan p 025 studies, we see a hazard ratio 250.7. Oh. However, only three studies included, um uh, this in their multi variable model, and it became non statistically significant and the hazard ratio increase towards that line. So it goes from 30.72 point 78. So this is kind of what we would expect if you take into account uh, Fontaine's peripheral vascular resistance. Uh, type of operation. We'd expect fitness to become less important. And that's what we saw in this particular case. However, anything you can see here in blue was still statistically significant and clinically significant, Um, after multi variable analysis. And so that is actually really reassuring that fitness is very important for these people, even after adjusting for all these different confounder. Uh, so moving on. So risk of bias across the board was pretty poor. So around 60 out of all the studies included. So the 50 old studies included, uh the majority of them were either a high risk of bias or a moderate risk of bias. And that was pretty similar in the meta analysis that, um around 70% were of a moderate risk of bias For studies to be considered low risk of bias. They must have presented a detailed description of their cohort registered what they were going to do and why they were going to do it. Um, there was no evidence of selection bias, appropriate statistics, well described protocols, etcetera, etcetera, and very few studies did that. Well, so some additional findings some people may find interesting, um, the majority is kind of a split between cycle and treadmill is a pretty fair split. Um, some people actually failed to report if the exercise test was done on a bike or on a treadmill. Um, the protocols used across the board where the kind of the Bruce Protocol, if they were doing it on a treadmill or a step or a ramp, they're doing it on a bike. Um, and the majority of studies used respiratory exchange ratio. So the ratio between oxygen carbon dioxide to validate a maximum effort, which probably isn't the best way to go. But it's enshrined pretty heavily in the literature, and we see a few studies explored the actual statistical assumptions or explored if any of these trends were non linear. So should we care about fitness in our congenital heart disease patients? Let's go back right to the beginning and and I think yes, yes, yes. We is definitely important for our congenital heart disease patients, even after adjusting for known, um, factors like echocardiography. MRI. So conclusions from this talk. So what are the clinical implications? So fitness, measured by see, appears to be associated with cardio vascular events later on in life. And although data are limited, no study reported, Um, an event during the CPAP. Um, so But due to the moderate quality of evidence, um, and the lack of pediatric data is probably insufficient evidence sort of definitively determine the prognostic influence of cold respiratory fitness. There's a lot more work to be done to tease out what's really driving the fitness effect. Is that the way were express expressing the fitness variable as such, um or is it the way that people are doing their statistical analysis? Um also so adequately powered studies should follow using contemporary prognostic factors guidelines. And we came up with some some guidelines if people are going to do this kind of research in the future, So, um, firstly, all studies should report if there were any adverse events during CPAP. Okay, we need to know is this is this safe? Because no one seems to report it. Um, following the prognostic factors prognostic reporting framework such as remark progress, tripod um, future research aimed to prognostically register, avoid summary statistics computer from dichotomous CPAP data. So where we've got a nice continuous variable, such as pique view to don't break it up into 50% more or less than keep it as a continuous variable to keep all that rich information in there before running a cox regression. Um, to estimate the independent of fitness, we should control for common kind of vary it such as age, oxygen, saturations minimum. Um, okay, so and just some kind of after thoughts, um, in in how people like to do, uh, prognosis research across the board. So there are 408 prognostic models that you could use to give someone with COPD. They're they're prognosis. And there's 363 models for cardiovascular disease. Someone's risk of it. So almost one for every day of the year. You could use a different prediction equation in clinic every day of the year. And what people are saying is you know, very few of these models have been validated in new data. Models are easy to create. Um, we're probably no intention of actually using them. So really, if people are wanting to do this research, go to this website Prognosis Research. Okay, I've got no involvement with them whatsoever, but they are just a really good free resource on how to how to do this kind of research. we've got this text book here. I think it's a bit pricey, but it's very good. But also, all of this is also published. So look for the progress. Um, work if you if you're going to be doing this as part of a S t. P. A. Master's a PhD because this will save you a lot of head scratching. Um, so 22, quote drug Altman, we need less research, better research and research done for the right reasons. Um, I'd like to say thank you very much for giving up your time on this, Uh, whatever. Afternoon is, um So thank you very much for joining. And I hope you enjoyed the talk. Thank you very much about Curtis. Um, if you wanna stop sharing your slides. Wonderful. Great. Um, so if anybody does have any questions, we got one fired in there. Please do send them into a little chat. Uh, I'll direct them, if appropriate to Curtis and And we do have one in Curtis. Um, it's a lot of it's specific. Uh, feel free. If it's a little bit outside the scope, feel free to do for someone else. Um, let me have a little red from How do you think we could try something? Okay. From the view At some point of the junior doc, Doctor and NHS, how do you think we could best implement this data into an evidence based practice if you have any ideas, for example, is there an idea to suggest that low to moderate, vigorous physical activity after an acute hospitalization, uh, may improve morbidity and mortality or even symptoms? But I guess in terms of purpose of today's talk, it's not really that cute hospitalization. It's more in terms of general with, uh, with a pediatric in general heart disease. And I think you probably Yeah, I will not put words in your mouth because I've got an idea as to where you might go with that question. Okay, Uh, so any data to suggest low or moderate MBP a after hospitalization, improve morbidity mortality symptoms. So really good question. Um, really Good question. So, yeah, I think there is, uh, So, for example, when I was saying about can we improve fitness in this population? We most certainly can improve fitness if we improve it in heart failure. By one metabolic task, we reduce their mortality rate by about 20%. That, um How about acute after acute hospitalization? I think just for some people it's going to be difficult to walk to the kitchen, isn't it? So it's getting them to just do, uh, individualized progression of what they can manage. Um, but you know, yeah. Gavin, Um what? What? What were you going to say? I was thinking, that is a difficult one to go down the line because it's going to be very specific to that situation. So I think that's too difficult to answer on here. But I think in terms of from a stand in terms of the best evidence based practice in terms of ideas for exercise recommendations is that great tool kit available from your research group That's online, which people can consult. Oh, yes, yeah, heart research UK. Um, that's, uh, specifically for congenital heart disease. But there's two kits for for parents who have kids with congenital heart disease. There are stool kits for young Children, adolescents, young adults, Um, and it's a big document with that kind of age appropriate. It's got loads of advice on physical activity, exercise advice, and there's even one that they can give to their school teacher. So, um, you know whether the kid is, um inclined to to sit at the side. If they want to do that, they can give a note to the P teacher from this tool kit, and the TPP teacher goes, Oh, no, you're having us on. You can join in on this or actually, maybe we should restrict you from from this certain exercise. So you go and go and have a look on the heart research UK tool kits. They're they're really good. And I guess the question from me you're not there is, um I can't forgive me up around two something, but that ultimate that recommendations from, you know, the but recommendations in terms of that step by step process. What? It would be good to get your thoughts on that There. What, you think? Yeah. No, I think the buds criteria. So, for for people who are unaware, um, so they're also been embedded into the European Society of Cardiology. Um, guidelines now, um, for physical activity prescription for people with congenital heart disease. So it's a five step process to take a history, um, physical assessment. They have an echo. They have, uh, an exercise test that all feeds into a hideous kind of flow chart. But it's really simple because it's, um you just go through. Do they have five echo parameters? Do they have this, uh, yes. Know, go down. And then it will whittle down to what kind of exercise they're they're safe to do. And I think that's really important, because you might have someone with a severe congenital heart defect who is. Actually, their function is really good. So it's where, as you might have someone with a kind of a mild moderate congenital heart disease, where the old guidelines would say, Yeah, go and do what you want. And these restrictions actually take the individual, take their function into consideration, and then we'll give them the appropriate guidelines. So, yeah, I can I can share those kind of documents with you. I'm sure you've got them. If you want to send them out. If anyone's interested, yeah, you might be able to I know I can upload slides I might be able to direct, put it in some way. That way, you might be able to share post, but yeah, they're all open access. If you just type into Google E S C sports cardiology guidelines, they're all they're cool. Um, I guess one of the points that you to use that from the data is there is seriously limited amount of data in pediatrics. Why do you have any speculative reasons as to why that might be No. Um, so my my initial thought would be, um, physical size of the child, um, or comfort levels of clinicians physiologists in in being happy to supervise the child exercise. Um, also, you know, you need to be of a physical mental maturity to understand, you know, the coordination of running on a treadmill or the coordination of cycling on the bike. But certainly, I think in our lab, we've had them from kind of six up to 2. 18. and as long as they fit on the bike, you might have to do a bit more Familiarization with the younger ones. Um, but six is definitely on the lower end, but from 8, 10 upwards, we should really be capturing, I think, um, and it's just my opinion, but I think we should be doing kind of adolescent. See pets because I think it gives a lot of comfort not only the child, that they're safe to do exercise, but also to their parents. And I thought if that was the only positive outcome of the CT pet of just giving them confidence that they can go out and do exercise, then it would be a worthwhile task. Um, but we also get loads of clinical information. That's really cool. Also, Yeah, Yeah, very much echo that thought process as well, because it just gives that reassurance to everybody. Um, the confidence that often is the barrier. Um, I guess one of the other things, I think, in terms of health related quality of life is that something that you, you guys are currently looking at as well or in the future, Or so we We've looked at health related quality of life for sure in the Cochrane Review. And so there's lots of different questionnaires that becomes a bit of a mess in terms of analyzing it properly. But, um, essentially, health related quality of life does not change after exercise interventions, But what I think is that health related quality of life is not measuring the right thing. So we might be seeing things that these questionnaires are measuring, if that makes sense. So I've spoken to people who have gone through exercise interventions or have undergone this kind of thing, and they've all said, you know, their confidence to do it improves. But maybe their their their overall health related quality of life doesn't, um, and also this, uh, in the literature. A lot of it is, uh, the outcome. Assessors, aware of the of the allocation of the participants in the evidence based a high risk of bias just because of the way the tools work. Um, in terms of health related quality of life in See pet, I haven't done anything on that, but on the exercise intervention stuff, I have yet cool. Um uh huh. Yeah. No, that's great. Um, fantastic talk. It was really good to have you on. I know that if there's any other questions they're doing fire them in, I do know we have, uh, fill fill on here as well. Um, and he owns metal. And he wanted to say quick Hello to everyone who's joining in today. So fill the floor. Is yours there. If you want to go live with the audio. Thank you so much. Gavin and Curtis, thank you for giving us just a few minutes to talk about what we're doing. Uh, metal as well. I really appreciate it. And, um uh, and it's a real honor to kind of be here alongside both of these wonderful human beings, as we're kind of leaning into making healthcare training accessible for everyone. And I just wanted to share a little bit about why we're here on this platform. What we're doing and what are kind of goal and vision is and it really is this. It's really about making healthcare training accessible for everyone. And why does that matter? Um, well, we need to train 18 million more healthcare professionals by 2030. It's a number that comes from the World Health Organization, and it's been turned the workforce crisis in healthcare. But healthcare training is expensive than 15 years to train a fully trained doctor similar for lots of other healthcare professionals and up to $700,000 and coupled with what the Lancet describe as severe institutional shortages in our healthcare training capacity, we have a bit of a toxic combination so we need to train millions more healthcare professionals, but we don't really have the resources to train those people. And unfortunately where the need is at its greatest resources are at their least So there are 11 countries on the continent of Africa that do not have a single medical school and over 20 countries which only have one medical school. And there are five times fewer medical schools per capita on the continent of Africa compared to Europe and the USA. So we have a little bit of a we have a little bit of a global problem, but it's not a far away problem. It's a problem that happens across the world. And whilst we know there is a problem in low income countries where perhaps resources are stretched in the UK and in the US, in Australia we face very similar problem. And in the last six weeks we've seen headlines on the BBC News talking about the NHS facing it's worse staffing crisis in its history, and when you look at some of the numbers behind that, actually you can begin to see how, how much of a problem we have here in the UK as as well. And this is a paper from the Association for Surgeons in Training talking about surgical training and talks about the cost of surgical training to the individual health care professional. It's up to 71,000 lbs out of pocket cost to the individual, and the range typically is between 20 and 26,000 lbs. And a lot of that is spent on courses in conferences and travel. And coupled with the real term earning of healthcare professionals decreasing by at least 10% over the last 15 years, we have reduced buying part of our salaries. When we're paying out of pocket expenses for training, it really does pose a problem. This is a tweet from an individual talking about how that's really impacted them as a widening participation doctor. Money is and always has been tight, and study budget covers one big course or maybe two or three small ones. But to meet my training requirements, the wealthy can easily treat the application as a paid kickbox exercise with little development. So it really affects in individuals as doctors and more importantly, it affects patient's, and that's why we really want to make accessible healthcare training available. And that's why we love working with amazing healthcare professionals like Gavin and Curtis as they are doing just that, making freely available healthcare education to, um to lots of us. And that's really important. We need to make healthcare training more accessible. But we also need to do that scale as well. How are we doing that? Well, you're on metal tonight. We have an approach of working alongside other amazing healthcare organizations. We've done that because we know that healthcare organizations face a problem. We know that organizing, teaching and training can be administratively heavy. We know that often healthcare professionals are doing this teaching and training above and beyond everything else that you need to do in your healthcare careers. I'm a doctor by training. I've been here, I've done it. I felt it. And we also looked at how healthcare organizations were setting up teaching and training. We saw organizations setting up a registration formal, an event right, or Google forms bouncing people to zoom call pitting a pdf um uh, schedule recording the some call. But they only have a gigabyte of storage on the some accounts for downloading it. And then re uploading it to YouTube or Facebook or video, and then also in the live event, kicking in a Google form to collect feedback and then manually making certificates on a Microsoft word document, saying as a Pdf and emailing it out. And then for the on demand content sticking into Google Form link and the whole process starts again. And there's no real guarantee that the person ever watched the video and we just thought, Oh my goodness, what are we doing? Um, if we can possibly solve some really small pains for amazing healthcare professionals and healthcare organizations, we hopefully can save them a lot of time that can be reinvested into more awesome teaching and training, but also, if we do that on a platform where were wearing are teaching and training, we open up the possibility for more people to be able to join our teaching and training sessions, and we lifted the limit. So Zoom has a often a limit of 100 or 300 depending on your license. It's expensive. We wanted to blow that out of the water. If we need to train 18 million more healthcare professionals, more than 100 people need to be able to join our teaching sessions live. And so we increased our limited 10,000. And not only that, but we've made it freely accessible. So if you're running a free and open access, um, event for healthcare professionals, you can actually use our software free and open access. And we think that's really important. We only ever introduced a charge when someone is charging for their event. And we also did something really interesting, really inspired by the word you see on screen from Doctor Tedros from the wh oh, he needs no introduction, but he said this a tech conference a few years ago, he said, Ask yourself every day if your technology works to help the poorest in the world and to reduce in equalities and that's something that we're really passionate about, how do we make healthcare training more accessible? So even for events that are running paid for tickets, we provide a special ticket type called fair medical education, which we don't charge for, and we encourage the organizations not to charge for as well. It allows them to automatically offer free or no cost tickets. Two colleagues in lower middle income countries. We do all of the administration for them so they don't need to do any verification checks. They can just say we want to do this. We believe in this and we make it happen and we automated for the health care professional on the ground. And that means that, um, colleagues who are who have been attending our courses or conferences or events over the last two years when we return to face to face. If we offer a hybrid option, offer fair medical education, we can continue to welcome those people to are teaching and training. And it's something we're really passionate about. The other thing that we do and I'm I'm not going to take too much longer because I know it's a quarter past six and probably dinners on the stove or we've got a we've got. We've got to feed ourselves or see the family. I'm almost done. The last thing we're really passionate about it on demand and it's something that we've kind of seen become really important, live and virtually are awesome. They increase accessibility. That means that people can join from anywhere, but they're not a magic bullet, and actually if you live in an area which has low Internet, and that's not just low income countries, if you live in Northern Ireland like me, actually Internet is sometimes a problem. And so being able to watch at a time and Internet connection that suits you is really important. And that's why we made it automatically available for the organization to produce their events available on demand afterwards. No downloading, no real uploading, one click available. And that's the result. In 18 months, 1300 amazing healthcare organizations have delivered over 5000 courses, two colleagues in 171 countries. And the awesome thing is, those organizations come from 20 countries. There's 20 countries worth of healthcare organizations teaching and training colleagues in 171 together. When we work together, we can really move the needle. Does it work? We really believe that it does. This is a paper in surgical endoscopy where David not from the David Not Foundation, also from Imperial College London, actually took metal, compared a basic surgical skills course which was being delivered face to face with a virtual equivalent which was delivered over five 100 surgeons, and they find that the outcomes were exactly the same. There was no statistical difference between those who were attending online and those who are attending face to face. And what they actually said was online teaching of surgical skills, practical things for early years. Training is actually an appropriate alternative to face to face teaching and in the full discussion. And they were here surgical endoscopy in the discussion, they actually talk about how this has the potential to scale up the amount of teaching and training that we can provide around the world. It does require us to think creatively and to do things differently, but it has really power and potential, and this is the sort of potential that it had. So they taught over 500 surgeons in 20 countries in a single course. Practical skills. Uh, this is someone who's learned awesome stuff in a webinar. She actually tweeted about how she attended a webinar run by Amazing organization called Learn with Nurses, and she spotted signs of cardiovascular disease in a patient which had been missed for a long time. And she referred them to any a lovely comparison as an individual story and one last story and then I'm done. Um, in April of this year, we saw the real impact of this type of virtual education. As you can see on the right hand side, we actually verify people before you can chat in the chat box. And we do that because it means the organizations can make their events truly accessible. You can have people join. You can make it freely accessible. Advertise. It will make your event open arms and people welcome. But it also keeps your events safe. Means that you know that people are joining as healthcare professionals and occasionally, once or twice a week, we get people who can't verify myself and we help them. We have a manual process to help, but in one day we had between 50 and 100 people reach out to say, Hey, for whatever reason, I can't verify myself and so on. Our support team actually reached out to these people and asked, Is there anything we can help with? Is there any reason why you can't verify yourself? And they said, Well, actually, I've had to leave everything. I don't have access to my institutional emails. I don't have access to a letter from my dean to say that I'm a medical student or their student to access your platform. Why? Because I'm a student in Ukraine and actually I had to leave everything, and I haven't had the opportunity to do those things. Thanks very much fair play. I think we would agree that that was absolutely right priority. But what happened was there was an organization called the Crisis Rescue Foundation. He had recruited 250 healthcare professionals from around the UK to teach 2000 Ukraine Ukrainian medical students seven times a day every single day for two months, not as some sort of imperialistic or the UK is going to teach Ukraine, but instead so that the medical professors and lectures on the ground who are trained healthcare professionals could be freed up instead of providing face to face medical education, to provide face to face patient care and to bolster their resources. And the effect of that was pretty dramatic. This is a quote from a professor in, uh, people who said, Thank you for everything you're doing for Cipro and for people who are trapped in this situation. When we work together, when we work flexibly. The healthcare community has real power, and that's one thing that we're really passionate about. We need to train 18 million more healthcare professionals by 2030. We believe that it's only by working together in one single community that we can really make this happen. I hope you've really enjoyed your event this evening. If you want to get involved, if you wanna host an event org slash host, you find this event metal door slash events. If you want to attend an event, if you just want to catch up on demand metal, org slash on demand and it would be our honor to help and support you. Thanks for having me, Gavin and Curtis. And, um, I hope everyone has had a really awesome session. And I hope you really enjoy your breakfast, lunch or dinner wherever you're based. Thank you. Thanks for joining in. Um, that was a great whistles starter, and I think everyone listening into that can probably understand why I'm using metal and not any other platform for this, because it's pretty darn good and you guys are very, very supportive in terms of helping out with lots of questions. So that's all for tonight. We don't have any more time for questions. There is one I just seen popped in. And I think that will be really That's quite a specific question. I think that's probably the easiest for Curtis to deal over email, because then you'll be able to walk you through it step by step. And I'm seeing an organ by Curtis. So that means yes. Um, but thank you very much for tonight. Enjoy the rest of the evening. Well, I say evening, like food. Feel a little bit to wherever you are. That could be breakfast right now. See? Yeah. Thanks. Thanks a lot. Thanks, everyone by