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Okay, right. Hi, everyone. I'm just gonna give us another five minutes for everyone about that. And yes, I'm going to give us another five minutes for everyone to join, and then we'll go ahead and stop. Yeah. Yeah. Okay. So we'll go ahead and start. So thank you all for joining us today. And welcome back to you. Another session on the mind of sleep. Urology weaponize. So today's topic is going to be covering hematuria and all it's details. Um, and, uh, I'll go ahead and just switched over to the next slide before we start. Yes. So I'm just gonna give a quick message out to our sponsors who we partnered with that COPD. And they're basically providing us with hundreds of COPD credits. Webinars. So they haven't awesome application, which you confined on android and your apple foods. Um, with called dragon drop feature for your continued professional development. And it's mainly designed for people who are very the registered that GMC with the NMC or any other health care professional. Really? Eh? So we've got quite a good discount from them, so I have sent off. You can get their application for any 8 lbs for the whole year. So if you're interested in that, please go ahead and use the QR code on the slides. And then I'll go ahead and hand over to Ahmed. Who's gonna be presenting today? I get the evening. Everyone. My name is a model. I can't. I'm one of the urology trainees in West six currently working in harm. Share holds little foundation Trust on Thank you. Thank you for inviting me to get this stone tonight. Um, I hope that you are able to hear me loud and clear. Everyone all through, please feel free to ask. I believe there is a chat function that you can ask questions and bacteria will hopefully help us get these questions through. So we're going to use some questions through the presentation to just try to make it more interactive. So please do open on the website at Minniti meter dot com so that you can answer the questions or through the slides. So, without delay, what is the material? So, you know, basically, it's blood in the urine on According to the American Urology Association, in any three or more blood cells in the high powered field of my cross convicted valuation should be considered the him a cheerio. On that what we call, is it a microscopic hematuria? However, there is always across the material, which is the other end. Which means that, you know, patient is basically seeing blood in the year. And so by self explanatory, more or less so just to give you an overview. It's a very common in the urology to see cross the material on. It presents more than 20% off the patients coming for evaluation. Looking at microscopic hematuria, even healthy adults can have it. So a lot studies has been done to evaluate that on some of them found as low as 2.4. But some of them found up to 30% of the healthy people can have microscopic hematuria. So not every microscopic hematuria means disease. And that's why it needs sometimes to be investigated, taking into consideration the risks that the patient have. Okay, so what I'm going to do today to make it a bit more fun, because I know listening eight PM is not a lot of fun, Teo. Someone talking about just material, so I'm gonna try to make it an interactive and make you think of it by making it is scenario on then taking this scenario and just go through with their on into which I hope that you will be able to see how we diagnosed. UTI is managing Materia, another cancer at the end of the seminar. So our presentation is Mr Adamson, who is a 60 year old mechanical engineer who presented to his GP complaining of visible blood in his urine. Over the past two days, he has been passing urine more frequently than usual over the same period of time. On it stinks when he bounced urine, he also had similar blood in the urine previously about four weeks ago. Sorry, this like I just got stuck there. Yeah, so it's that so He had a similar presentation with just blood. But few weeks ago on at that time he didn't have any other trouble passing urine. He had a urine dipstick done by his GP, which was positive for nitrate leukocytes and did blood cells. He takes a number of medications, but the alarming medication is warfarin for his atrial fibrilation. So his urine dipstick is positive for nitrite supersize 100 lot cells do you think this is significant on? Why do you think this is significant? Do you think the GP needs to do any furniture? Best on what further tests are they? What they're going to show on what treatment would be necessary. So, um, if you all can open mental neat mental dot com and put the codes just the top on. Tell us. What do you think? Can you blame the material on the combination of UTI on warfarin therapy? Do you think the cause of the material is just the infection? What seems to be, like an infection and warfarin therapy or not? So I'm going to give you a minute or two just to open the outside. As this is the first question on, I hope some answers will come through anybody. Okay? It seems like what happened. A bit of an issue with managing editor of the moment. I'll pass this question. And if you also tried to Logan into the mental dot com on, we'll try it with the next question again. So he's a very yeah, that's fine. Okay. And can you hold me to switch to the next flight, please? Okay. Okay. So the dose stick results are, As we've said, the presence of nitrate on the depth steaks means that there is an infection. So, yes, the MSU is significant. So there is a UTI. Significant numbers of leukocytes and Brussels can also be seen. An infection on the GP should send an m s you to confirm the diagnosis on a suspected of sensitivities. So the GPS job is to confirm that there is an infection. It can start treatment right away, but before that, he needs to have a nemesis. You sentence because the MSU shows is the type of bacteria that is there and what type of antibiotics it would be sensitive for. So we need to have that before starting the patients on antibiotics. Because if you start them on antibiotics before doing bad, then we won't have the sensitivities that we need to treat the patient appropriately if he doesn't respond to the primary antibiotic that we've given. So ms you meet midstream urine on. It's usually carried as microscopy, culture and sensitivity. It takes about 48 hours, and that's what I've said. Why I said that the patient can be started on antibiotics so that his symptoms obviously improves. We don't have to wait for this. However, this is very important in case that the bacteria that the patient has is resistant on so that we can have some targeted treatment for the patient. So always make sure to actually send a mess. You for any patient that you suspect an infection and has you're in depth, stay so positive nitride and leukocytes. And sometimes there is reports cells can indicate on infection. So usually a bacteria count of more than 100,000 indicates an infection on small number. If there is on the small number of white blood cells with the presence of bacteria, especially if there is if you feel cells as well in the microscopy than that, most probably the contamination rather than an infection. Usually we treat infections with a short course of antibiotics on females can be as low as three days, so 3 to 5 days with antibiotics a chance trimethoprim, Keflex and night referring Toyne, a patient that has pile of Fridays with Lauren pain or fever with probably need a nap mission with IV antibiotics on. Sometimes we need to make imaging if the patient doesn't improve with the antibiotics to make sure that the patient doesn't have an obstruction or pie in the throes is which means pass collecting into the collecting system that might need training. So that was our question before. Can you blame the hematuria and the combination of the UTI and warfarin treatment? That's the patient need further investigation? So too important questions. The patient had a UTI, which was proven by his steps. Stick with the nitrated. Besides, and it's symptoms. However, he had a hematuria on. Let's remember that he had an episode of the material previously without any other symptoms. So can we just say that it's because he's taking this blood thinner on just because he's having infections? That's because of his hematuria and just ignore it, Or does he need further investigations? Okay, so again, let's try to answer this question on menti. So he go to www dot Manti dot com. I try to use the codes and let's see if it works this time. Okay, so I'm going some messages that it's working now. Um uh, there we go. Okay. Good. I'll give you one or two more minutes to see. What do you think Okay, That's very kind of close. It's almost 50%. So Okay, so it's and 40 to 4 years we can just plain the warfarin and the UTI. I want 23. So, you know, we need further investigations. Okay, so, um, numbers are increasing, so let's just give it you seconds. Okay? 43 to 25. So the fact that the patients is on the blood thinner doesn't mean that we can actually say that this blood thinner is called it causing the material the blood in the urine. So think of it as a normal physiology. So why would anyone have blood in the urine if they're not having an in the line problem? Even if they're on blood thinners with someone bleed out of their skin? Just because they're taking blood thinner, they shouldn't injection sides it promotes is something different, But yeah, if someone is taking blood thinner, it can make the bleeding west. But it shouldn't cause bleeding on its own. So Hematuria's cannot be blamed on the warfarin or any other blood thinner. If the patient has material on, he's on the blood thinner, he still need to be investigated. Just like any other person. So that's very important. To know on this is a very clear message. He needs further investigations. Okay? Yes. UTI can be partially claimed for hematuria in young females with an infection. Yes, but on other people, it's needs to be investigated. Okay. So make sure it I'll each time you see how much a hematuria patient that you do refer him to a urologist for investigation. Okay, Make sure that your conscious about a mature yet because it can be an alarming symptoms, especially if it's across the material on. We're going to talk and details about when aunt how to refer the patients with material and we'll urologist. So one more point to say all males with a UTI needs further investigations, not for females on. That's just because females have a tendency, unfortunately to have infections do too short urethra on other physiological factors. And I'm not a nickel factors that cause them more infections. However, in males, they shouldn't have an infection on if they do have an infection, then there is an underlying cause that needs treatment. Okay, I'll go to next slide. So does he needs to be referred to a urologist on should distributor the urgent? What do you think the urologist will do for this patient? On what investigation does the GP needs to do on would be helpful for the urologist. So a lot of important question that comes to it. Everyone's mind. So if you're sitting in a GP practice or UC were related with cross the material, you're going to get asked Total. So what's next? You want to refer me on it? How urgent till I see my GP or my urologist on What does do you think the urologist will do? On what? That shall I take with me to the urologist? So these are very important questions. So again, we'll use men to me to hear Teo have a question. Right? So we're going to stop with the count down so everyone get ready to answer the question. Oh, okay. You try and click enter on your side. Yeah, I'm trying, but it's not working. Okay, there we go. So would you consider this as an urgent to ferret urologists? Okay, that's great. So most of you would consider it as an urgent referral. That's a very good s. Oh, yes. It is definitely an urgency. Ferrell's across you materia, especially if the patient doesn't have the symptoms of infection. Like our patients who had two episodes, one with infection and one with our is a very important indicator for possibility off having bladder cancer. So this patient definitely needs more. Investigating aren't need an urgency federal. So I need milk patient aged over 45 with physical material. We need you any side. So we've asked, what should the GI be due? So the GP needs to do you knees and dance, because when the patient creatures us reaches the urologist, well, most probably need a CT urogram, which requires an uptodate give me function a full blood count. Obviously someone is having any material and he's bleeding. We need to make sure that the mobile been is okay. If we suspect an infection, we need to see the inflammatory market such as the world but cells. So that's also give us an indication a PS PSA test would be very useful because he material sometimes can indicate prostate cancer as well. But just to make sure he is a is only done if we do not expect on infection, because if there is an infection. PS PSA is going to be high as a urologist. What we will do is we will arrange this patient to have a camera inspection of his bladder, which we called flexible cystoscopy. So for a female will go through the opening down below for mail will go through the ureter for the Penis on go all the way into the bladder. They can look inside and make sure whether there is any abnormalities inside of the bladder. Mucosa, a CT urogram or ultrasound will be done according to the risk of the patients, so upper tract imaging to make sure that this material is not coming out of the kidney. So as you know, it's just one track, so blood out of the urethra can be coming from anywhere in the urine tract. So we still need also to rule out problems within the kidney. So urine cytology. I'm not going to talk about it much because there is a lot of debate regarding it in in literature. However, with high grades or high risk cancer patient, it might be useful sometimes to do it, but it's not mandatory to do it. For every a material patients. Okay, so what about asymptomatic patient aged under 45 with microscopic hematuria? These do not need to be referred. So two urology So young people with my cross scopic in a tree and not gross hematuria microscopic. Okay, they do not need to be referred. So you need to check the g of our BP on drool out. And if you're allergic or cause of their hematuria because the probability of him have having a cancer in the urine tract is extremely rare. Um so all patient with cross the material will need a cystoscopy another tract imaging. As we've said so, the only people that we might exclude is a young female with this with the UTI that has resolved on infection. But we need to make sure that she never had any other episode of the material which didn't have an infection on different Reekers then Yes, absolutely. Really fair. So or patient aged over 45 should have a cystoscopy in of attract imaging. As we've said, patient aged over 45 we're across the material are at high risk, and the CT urogram, rather than an ultrasound, should be done. So cross the material for patients over 45 with your CT urogram gross hematuria Patients under 45. We don't know sound to rule out upper tract pathologies. So these are the national guidelines in regards to have to refer the patients into the urologist. So if your GI be in practice or your GP trainee, do I need to do for this patient as a two week rule, or do I need to refer him urgently or not? So these are the cervix. Planetary nice guidelines. I'd mix it with a bit of files guidance as well, which is the British Association of Urology. Clinton certain surgeon. So if there is a dysuria with explained microscopic hematuria for patients a 60 or above, then two weeks referral with meat, which may, which means anergic tree fell, I should be made. So the cereal with microscopic hematuria, but the patient is over 60 obviously cross symmetry a visible and then explained without an infection or or it possessed after infection. For patient 45 above again, that's an urgency. Pharaoh resistant infections or recurrent urine tract infection in patients age 60 and above, needs to be referred this well to rule out cancer, but these are not urgent referral. These can be a regular referred more or less so any cross the material for a patient or 45. Basically, it's the urgent referral on this cereal, with microscopic hematuria for patients age 60 and above. Microscopic Hematuria doesn't require an urgent referral, but it does require a referral for the urologist. So just to explain previously, um, any pain list is it with maturity of any age was actually referred as a two week referral, however, due to the fact that microscopic hematuria has been found to be very much know, indicating a a significant pathology in a lot of patients. So we were basically over investigations patients that are less than 45 years old. So the's are not urgent anymore. And that's why they stopped just referring them as urgent referral. So we refer patients over 45 now ours on a two week wait referral, which is basically the urgency Pharaoh. Okay, so you can see here some scans showing patients presented with cross the material. So for the two upper scans, what do you think the cause is? So if you just go back, give them a second to take a look at the scans. Okay, so the are the two scans on the upper bed. So I think What are the causes of the him? A trea? Why these patients present with the materials. Okay, let's go to the next live and see what do they think, right? Okay, right. So still in this is the right answer. So the most if you have found the stones, which is quite impressive, so that's very good. So, yes, there are stones. If you look at the picture to the left, there is a You're a trick stone. Just a the upper birds. Uh, let me see if I can have a marker. So yes, Laser pointer. Oh, sorry. Can we go back once lied trying to get the pointer. It's not working greatly. Sorry. Okay, So I hope that the pointer is working now. Okay, So this is where I'm pointing on the left image. Last the stone and the left upper ureter there, Um, again here, if you can see on the there is a kidney stone that on the right image there. So it's just a kidney stone. So next question on the lower scans. What do you think? Because of the hip material is to we'll go to the next life now. Okay. Um, sorry a lot. Don't meant emitter is a bug. A meter, to be honest. So, ms, each time it creek sec area, can you try to click, enter each Dhammika get it just goes into the next slide? Yeah. I'm going to give this a shot just to seconds. Okay, that we go. Okay, great. Okay, that's great. So 41 person's found that it's cancer, and that's the true answer. So, uh, I'll try to go back into that slide on. I hope that point it will work quicker this time. Okay, So if you look at the scan to the left, past the left kidney, and you can see all of this is actually cancer, so it's necrotic, and it looks really ugly. So dance what we call in every doctor. I agree, Doc. Really? So that's the cancer. What? We'll hear there is just a small mass on the CT scan. To the right. You can see that there is a small mass just right here in the kidney. So that's the mask on both of these patients have actually presented with cross immature yet. So as you can see, multiple causes infection, kidney cancer, bladder cancer on. Don't forget that Batman get a lot of material due to trauma. So that's a very also important cause of hematuria, which is trauma. Okay, so trying to get to next life so mental neater, causes a lot of trouble. To be honest on. I'm going to call it from now on. Buggy meter. Can we just go to the next line? Okay, great. So our patients, Mr Adamson, let's go back to him. This nice gentleman. We've given him a course of five days of antibiotics, of people. Axon. It's symptoms improved on his GP has done the right thing by defending him to us under the two week rule. His symptoms are much improved on. As we said, his flow is is still a bit low, but that's not something that is very significant for his age. A urine test at the clinic nationals only blood, but no one I tried know Lucas eyes. We do a cystoscopy on. We find throws. Three small papillary bladder tumors. If you look at the image below, that's a typical appearance off a blood ability tumor? Can we do a CT urogram? As he's more than 45 on, it shows upper normal tract. Okay, so next slides. So, um, you've heard me talking about urgent referral on two weeks referral. I would like to make sure that you know, What is that? Two week two Feral. So how good. Clean doing the street. These patients refer them to this room on what sort of patients are usually referred to us as a urologist under this room. That's really important things to know. So my next question is going to be young men to meter is how quickly do we need to treat patients referred under this rule. So it's a two week rule. I'm sure you've all heard of it. I want to know that. You truly know. What does it mean? Okay, I'm just trying to get to the next slide. Okay, let's hope this works. Yeah, go back, Go back. You know, we're just trying to seconds. Okay, I guess before she's on, But let's see. Well, this know we'll see him. Spain. Attention. At least you train click entrance. See about works? No, I wish we used to holds. Okay. Sorry about other technical issues, guys. It's my first time to try this mental meter. And it didn't work on my computer's a career. Helped me at the final moments. Bye. Presenting from his computer. So Okay, it doesn't want to back. Come on. And you try and I was a career. Just if you press one press and then press enter from your side seems to be recurrent issue concern there. No. Yeah. All right, well, give us more, more sharp. And if not, then we might have to just go on with this question, Unfortunately, Yeah. Okay. It's not liking. Sorry. Anyway, I hope that you all new? No, the two weeks you're pharaoh mean that patients need to be treated with an 62 days on not 14 days. So the two weeks really means that the patient needs to be seen within 14 days. Needs to be investigated within 31 days on They must be treated within 62 days. So although it's called two weeks, if Errol, it means that Bishop patient needs to be seen with in this period of time and not treated without a period of time because that's quite unrealistic. So 62 days okay, I would go to the next lower. I'd So what? We've asked what patients are usually refer to urology. End of this rule on, as we've said, patient's age, 45 above with visible hematuria. So Christmas Tree A. Patients are above 45 any patient age over 60 with microscopic hematuria. Any man with a raised PS A or abnormal feeling. Prostates. So it's suspecting prostate cancer. Any man with a testicular mass or possible penile cancer on any patient that was found to have a kidney region. So all of these are you due for them to this room? So it's basically a cancer referral way to make sure patients just have a priority. Ask cancer patients are treatment is very sensitive, time sensitive. So we this rule was made to make sure that these patients get priority to be seen as soon as possible on to be treated within the time limits on a very important question that I want you to think off. So we're going to over what we're going to over the space. That's treatment is a T u R P T, which means trying to reach for resection of bladder tumor. How far do you think we can wait to do this procedure? Can we wait for the 4 62 days or not? Say, I'll let you think about until we complete on would come to the answer later on. So why did Why did we repeat as urologist the urine dipstick on Why is the persistence of blood is important? Please go to next lives. Okay, so we repeated this test to make sure of a UTI has results, as we cannot do a cystoscopy, even the flexible cystoscopy, which is done in the local anesthetic if there's an infection, because if we do, the patients might have might get your sepsis, which is a brace of your infection on in contradiction to simple UTI is your sepsis can be a killer on. It can progress very quickly. So your sepsis is one of the most dangerous substance that can happen on. They need to be treated fairly. A fairly aunt Yeah, quizzically. So the absence of nitrite and do besides said just that the antibiotics treatments been successful, as we've said on the presence of unexplained the blood cells in a patient over 60 requires investigation. So even if we didn't even if Mister Adolescent didn't have the cross the material episode before the resistant of this blood in the urine still requires a referral. So we've done the cystoscopy. It showed three brother tumors. What would you tell the patients? What do you think is the appropriate thing to tell him When you're doing the flexi and you're done, you want to sit with him in a quiet place? What you're going to say, What would you do about these tumors on When would you do it? That's my question previously, So we'll come chance of this shortly. What complication do you think would come out of our treatments on? Is it important to do up attract imaging? I believe we've answered this already on Are the tumors like it to be life threatening? So these aren't very important questions that all of us get and asked about every time we do a hematuria clinic on the answers are in the next lines. So, as I said, we're going to do a transurethral resection of bladder tumor, which means a camera that goes through the urethra into the bladder on with a heated loop by electricity. We do resect these masses so it can be done in the general or responding anesthetic. Hey needs to stop his blood thinners before the procedure as we're going to basically be taking a layer art of the bladder and it's going to bleed, so we don't want it to bleed more with the blood thinner. So this procedure needs to be done within 31 days, and if you think of it, it's not. Why is that is because it's diagnosis. Take So Cystoscopy is a diagnostic as well as it can be. You're upsetting procedure, so it has to be done within 31 days and not 62 days because it's not just there are pretty thick. So we diagnosed the cancer by scraping these off and sending them to the pathology. Loved to have a look under the microscope until us. What sort of cancer are they, or if they are actually benign or inflammatory or cancer? Search Cystoscopy's a diagnostic procedure, so 31 days is mandatory for us to do the cystoscopy within that lot time limit. So what are the possible complication of this procedure? believing off course as we're taking a layer as well as I've said before. Urine tract infection happens and 50 in one and 52 1 in 100. So it's not real common, but it still can happen. Brother preparation is rare, so it's about one in 1000 hours, and it's it's not very. It's not really common to happen. But if it happens, is serious complication. If it happens, so what we do. How do we treat BP a shin? If it's Richard Pretty Tonia, then we'll just put a catheter for a prolonged period off about 5 to 7 days. However, if an interpreter only a large perforation happened, then we'll have to do on all conservatory to actually repair the bladder. So these patients that have multiple bladder masters or small mass is inside of the bladder. After the resection, we do put on interval cycle treatment on intervals. I could chemotherapy treatment such as Mitomycin or Doctor be seen on the aim off this chemotherapeutic agent inside the bladder is to actually prevent the recruits of these tumors, so blood tumors, unfortunately, are behind. The truth is that if one happens, it will probably happen again, so it depends on the grade on the stage of the tumor, whether it's going to happen again or not. But there is, unfortunately, are high probability that it will actually do happen again. So my two, my sin, is a way a treatment that can help prevent this from happening in the future. Again, there is a stronger treatment called BCG. I'm not going to talk about it much. It prevents recurrence and progression as well. So bladder cancer can progress in great as well as stage, say, BCG can sometimes help. So why we are, even if we diagnose of the other two, we still need to do on upper tract imaging. So doing a cystoscopy for a patient who presented with across the material. If we do find the bladder tumor, it doesn't mean that we do not need to do an upper tract imaging because about 5% off people who have blood that masses will actually have also kidney masses, saying it more appropriately. It's really a pelvis masses, so their masters in the ureter or in the real pelvis or the political issues system of the kidney, so transitional carcinoma once it happens somewhere in the urinary tract. All the, you know, really tracked or the transitional cell in the urine tract can be prone to have cancer. So it's important to still do a CT scan even if we diagnosis of the cancer. For hematuria patient, it doesn't mean that we we found it that said, no, we still need to do it. Uh, most of these tumors are diagnosed early, so 70% out of peace are actually small to mother are off a low grade and low stage on, so most of these are treated with on the re current. Cystoscopy's on to your beauty's on some off the maker. Some of them don't. As we've said, intravesical therapy can be helpful to prevent the recurrence and progression. About 60 to 70% are diagnosed early on as a t a r T one, which only requires to stop frequency starts, copies or cystoscopy survey on Intrasite the treatment, while on the 20 to 30% are diagnosed honesty too, which would require more severe treatments, a chance radical cystectomy or radiotherapy with chemotherapy and said Yeah, so most of these are superficial can be treated with only two. You are BT on surveillance later on. So I hope that you've learned some off today a stoke about how to manage uti investigating you Hematuria's on the management of superficial liver cancer. Um, I would like to say again on a patient over 45 point across the material, please. Yeah, Ginger tea fair and to a urologist. So this is the most important thing to really understand from the lecture crossing material is a very important in sign of cancer, So please be aware of it. And patients that you can you see with cross to materia, Be sure to assist him. Well, do the blood test that we've talked about before referring them to the urologist on be assure them that it will be taken. Care off on if you have any questions, please let me know. Okay. Thank you very much dot That was a great presentation. Despite all the technical issues. Um, does anyone have any questions? They'd like to pop in the chat box and I'll relieve them. Teo, I just now just having a look. It walks. You okay? Sorry. I'm just gonna need the most for a second here. Um, right So there's a question here. What would you do for hematuria caused by trauma of anything? Okay, Um, actually caused by trauma. Is it very significant? Think to look at I've not talked about because it would require me an hour on its own. But any patients that present with cross hematuria after trauma will need a CT urogram. So we will need to do it on urgency to, you know, crime to see on grade the injury. So most of these will depend on what sort of trauma they got. So if it's a law in trauma, it's stronger going into the line. Then we would expect a kidney injury. If it's an acceleration deceleration, it can be the kidney or the ureter on if it's trauma to the abdomen and then we would suspect leather injury. If it's a pelvic fracture or trauma to the perineum, then we would expect a ureteral injury, so it will depend on the scenario. But the most important thing is to start with a CT urogram for patients with Crossing Materia that we suspect did knee or other injury ureteral injury. We usually do a retrograde ureterograms for bladder injuries. We do Sister Grams. So each sort of trauma would require a bit off a different sort of management and investigations. But yes, gross hematuria with chrome and these investigations. Okay, so I hope that answers your question and yeah, and we just have another question from a Dell. Why did we use Catholics in front of biotics? Well, we've just used it according to the sensitivities of the patients. So he had previous duty ice which showed that he sensitive to keep relaxing while he was having some resistant to the other antibiotics. And it doesn't have to be careful accent per se with a UTI on. I would always advice to go into the micro guide of your trust and used the antibiotics, especially doing antibiotics up front. Go to the micro guide, go to urinate tract infection and see what your trust advice. Each trust has its own really guidance in regards to want to politics to start with with the UTI on, of course, cystitis. We're talking different treatment from part of the frying test. So yet for this specific case, we've just follows sent the previous sensitivities of the patients. Okay, perfect. And I think we have more time for one more question. So we have a certain question from Sarah with the age rules. Also apply Teo ambulance staff to with a male and a 45 with nuclear infection. Be advice to contact the GP, or would you recommend convinced TV? So it's it's sorry, can you repeat with the start of the question? So with the age rules also apply to you ambulance staff, too? What do you mean by our billing staff's? Sorry, could you props elaborate on that? Sara Sara Lee. I'll just give her a second to type and can. Well, I think the question wasswa the mail under 45 with no clear infection. B advice to contact the GP or would you recommend convict you as a gross hematuria? Definitely contact the G B. If it is a microscopic amount, assure you we would usually advise them also to just contact the GP to repeat the urine test in another time. So sometimes what we care about in microscopic hematuria that it's persistent materia. So if someone has only microscopic hematuria or once okay but doesn't mean anything, it can be really anything like dehydration. Sports sometimes can cause microscopic hematuria and the younger person. But if it's a persistent A material and yes, by all means, you need to contact your GP so that you can get a referral to the nephrologist rather than the urologist to get more investigations. If it's a gross, um, a tear than yes, you would be actually referred to a urologist. I hope that answers the question easy. Okay, thank you very much that that was a really good presentation on by Hope It was useful to all of you. And we apologize, obviously, for the technical issues and, uh, to our next laid. Obviously, we really appreciate your feedback. So we will be willing to accept any constructive criticism. Feel free, Teo. So I was afraid the whole, you know, all the way through that my daughter would just bumping into that door and I will be on YouTube, right? So feel free to use the QR code on the slide on diet. Also popped the link in the chat box for the feedback form so that you guys can give us a few back and get your certificates. If you have any other questions, feel free to send us an email address. That's just there. And be sure to join us next time on the clock retention. So thank you very much, everyone. And have a good night. Everyone, have a good night.