Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello. Um Good evening everyone. Uh I'm sorry about the delay. Uh My name is Rosa, er, I'm the one of the I MG um colleagues. I've got Aisha here with me who will be er, presenting our neurology series today. Um Please save all the questions till the end so she can er answer your questions better. Um And I will let her start. Um So hi, everyone. Uh I'm Aisha, I'm currently in Fy two in the Royal in Liverpool. Um So I'm gonna be talking through this Neurology powerpoint. Um and we'll go through a few different topics and how to kind of approach them um on your on call or during work. So, the first topic um I'm gonna go through is, is ti A and stroke. Um This is an important topic. It's a leading cause of disability and the second cause of death worldwide. It's often an emergency situation when you are cause to see someone with a possible stroke. Um and timing is really, really important. So, um just to start with the definition. So stroke is a clinical syndrome. It's characterized by rapidly developing signs of focal or global disturbance of cerebral functions and stroke, it lasts in um these disturbances last longer than 24 hours or they lead to death. Um And we have two major categories in stroke. We have ischemic and hemorrhagic tia. A. Um On the other hand, is a transient neurological dysfunction, which again is caused by focal brain, spinal cord or retinal ischemia. But there is no evidence of acute infarction. And the key thing to differentiate is that in tia a, uh the symptoms last for less than 24 hours. Um and they manifest as a sudden onset of focal neurological deficits. Um and in stroke and taa, the signs and symptoms are dependent on the location of the stroke. So, the Bamford or Oxford classification is quite useful. Um and it splits stroke into uh total anterior circulation, stroke, uh partial anterior circulation stroke, lacunar stroke, or posterior circulation stroke. And if you have a look at that and you recognize kind of the symptoms in each, you can have a rough idea when you're seeing the patient of what kind of stroke uh or where the disturbance is um in the brain. So, um to go through each type of stroke, the vast majority of strokes are ischemic strokes and it accounts for around 85% of all the cases. And we can use the to classification to kind of subdivide uh ischemic strokes into different categories. So we have large a uh artery atherosclerosis. We have small vessel disease uh cardioembolic stroke, uh stroke of a determined cause and then we have stroke of undetermined cause or a cryptogenic stroke. Um On the other hand, hemorrhagic stroke occurs in only 15% of cases usually. And it is due to a focal collection of blood from within the brain parenchyma or the ventricular system, uh or bleeding into the subarachnoid space. And then we can further divide hemorrhagic stroke into intracerebral or subarachnoid. Um And the symptoms in the hemorrhagic stroke are usually caused by the bleeding and the pressure exerted on the tissues in the brain as a result of a bleed. Um, so risk factors for stroke. So when you see a patient with a possible stroke and you are trying to assess their risk factors, you're thinking about um they're nonmodifiable risk factors and they're modifiable. So, nonmodifiable their age, male sex, uh the presence of any genetic disorders, a history of ti a or stroke or coexisting cardiovascular disease. Um, some modifiable risk factors. So these, you might think about when you're um kind of uh thinking about stroke prevention. Um, so smoking, sedentary lifestyle, hypertension, diabetes, hypercholesteremia and high alcohol intake. Um are all things to consider when you're seeing possible stroke. Um So we're gonna go through the scenarios. So how, how you can commonly be asked to see a patient with a possible stroke or how kind of nurse or someone else in the hospital will describe how the patient is presenting to you. So they can say um Mister Smith seems more confused than usual. He's slumping to the left side. Can you urgently come and review him? And that might be the only kind of information you get? Or uh my patient is complaining of a dull, heavy feeling in an arm or a leg or on one side of their body. Um Another thing to remember our fast symptoms is speech is one of them. So if they say someone's speech now sounds slurred, or someone presents in the ed with a new um difficulty in speaking. Um You, you think about stroke. So how, how would you approach? So there's a couple of things you can do before you get to the patient. Because again, with stroke, the most important thing is, is our timing. So if you're on the other side of the hospital and a nurse has bleeped you and asked you to see a patient with a possible stroke or one of these symptoms, you can ask her to do a couple of things before you get there. So usually you'll start with your basic observations. You can ask them to do an E CG and you can ask them to gather equipment, um gather equipment to take bloods to gain IV access. Uh You can get a tendon hammer. So anything that you think will help you when you get to the patient. Um and again, with a stroke patient, you might not be able to get the best history. But again, some important things to consider that can help you differentiate what's causing the stroke is the onset of the symptoms. Um So sudden or a gradual onset, the duration and the presence of a headache. Um any vision changes, any limb weakness and any unwitnessed trauma or falls is quite an important one to consider. So with stroke, um while you try and get the best history, you can, I think examination is key. So we use uh doctor ABCD E. So that's our danger response. Um airway breathing, circulation, disability, and exposure. And if you approach all cases using this system, you, you're unlikely to miss anything. So you're gonna do a full respiratory cardiovascular and neurological examination. And the key thing to assess in stroke is our G CS, our eyes and our vision. We do a full cranial nerve examination, looking at the upper and lower limbs and you can do a cerebellar examination. So what would put you towards a stroke is the presence of any fast symptoms? A a decreased G CS, new confusion and most of weakness. So I think this is a classic one where you think a patient will have um new left sided um weakness in their arms or their legs, hypertonia, hyperreflexia and a positive babinski sign. So these will all have you thinking, OK, this could be a possible stroke. How would we initiate management? Um So the first thing to do is you're, you've ensured there's no airway compromise, there's no breathing difficulties. You want to have senior support with you, you're gonna gain IV access. So get a cannula in and then collect your full bloods, including full blood count, electrolytes, C RP LFT S and AC profile. Um, you review any medications and because of the possibility of a hemorrhagic stroke, we wanna stop any anticoagulants. Um, we wanna make sure the BP is under control as much as we can. And even while you're then going to order scans or look at other, uh look at the pathway in your, in your hospital, you ask someone to do regular neuros. So management in stroke, usually we, the first thing we need to do before we manage it, um is make sure that there is no intracranial bleed and that's how we do that is we get an urgent CT head. So once we have our CT head, we now know that it's a hemorrhagic, uh a hemorrhagic stroke is excluded. Um, we give, you can give a loading dose of aspirin. So 300 mg and then depending on the window of the symptoms. So within 4.5 hours, there is consideration of thrombolysis within six hours. They uh they can be considered for a thrombectomy and then these patients have to be followed up. So if the symptoms do resolve, then you need follow up in Ati a or a stroke clinic. If a bleed is seen on the imaging, a subarachnoid or an intracerebral bleed. Then you would uh refer to the neurosurgeons for further management. Um And these CT images just show a left middle cerebral artery occlusion. So you can see the area of infarction here. Um And then on the other image images, we see a right frontal parietal hemorrhage. So you can see the bleed here. So investigations. So our CT head is our first in investigations, but there's a couple of further investigations we can do um to. So especially in ischemic stroke, the ischemic changes might not show up on a CT head straight away. So it doesn't mean that they haven't had a stroke. Uh but MRI is much better for soft tissue imaging. So further investigations can include an M ria CT angio across a Doppler. And then outpatient management could include a 24 72 hour E CG um A cardiac echo, a lipid profile and HBA1C. So looking at all the risk factors again and following these up secondary prevention of a stroke. So if a patient does not have atrial fibrillation, we the the usual first line is antiplatelet monotherapy and that uh antiplatelet of choice is clopidogrel 75 mg daily. They'll usually be um se on a statin and it's important to inform the D VLA and make them aware about driving precautions and advise lifestyle changes for prevention of further stroke or TI. So that's stroke and again, if you have any questions, just put them in or put them in at the end and I'll go through all of them again. Um But the second one is, is seizure and I think seizures can be quite scary. I know for myself it was um I was very nervous if I was ever asked to see a patient who had a possible seizure. So what are seizures? How do we define them? So they're clinical manifestations of abnormal excessive or synchronous neuro neuronal activity in the brain. So essentially excessive neuronal activity and they can cause changes in behavior, memory or feelings. Um With these, we have to consider our differential diagnosis. So, syncope or disassociative attacks are quite common and they can be confused for a seizure. We have three general categories. So you can have a focal seizure, a generalized seizure or um an unknown seizure. And in general as well, we think about is the seizure provoked or unprovoked. Yeah. Thank you. Yeah. So causes of seizures. Um That's always important to consider. I think in even in when you're initially seeing someone, um it's it's hypoglycemia and it's to take a blood sugar and make sure that that's not the cause. Um when you take your bloods, you're thinking about sodium disturbances um and sodium levels, other electrolyte disturbances, alcohol and drugs. So oftentimes we can see a patient with a someone will describe it as a seizure and it could be an alcohol, withdrawal related seizure or a seizure caused by drugs, um head injury. So, posttraumatic seizures, uh seizures caused by an underlying infection such as encephalitis. Um of course, we have the big one which is epilepsy and we have uh syncope as another cause of seizure. So a few different ways again, that you can ask to be a, a patient where you think this could possibly be a seizure is they will describe it as this patient is jerking in her bed. Could you review her urgently? Um Or my patient has had a sudden collapse with rhythmic movements of their arms and legs. Um A sign of an absent seizure could be that a patient has been staring into space or has been unresponsive for a couple of minutes. So um I think with seizures, the thing that we have to focus on as well is ensuring that their airway is secure. So if you have someone try and have a nurse or someone in the room with you at the time, so you can both manage it together. So you wanna start a timer because the timing of the seizure is quite important in management, ensure they're in a safe position. Um make sure that their airways secure. If you have any doubts about an airway, you can use an airway adjunct um and continuous observations start the patient on uh oxygen and then begin your initial survey. So again, Dr ABCD E um and then you wanna ensure that there is a cannula in or some form of IV access and we wanna send off our initial bloods again, checking the blood glucose, our electrolytes and then we check FBC SLF TSC RP, all of these to investigate the possible underlying cause. Um always consider a toxicology, screening seizures. Again, alcohol and drugs are quite common cause and you wanna make sure that you know how to access your local protocol for seizure management or benzodiazepines. Ok. So you have the patient in your safe position and you and you're secure their airway. When, when do you start thinking about, I need to intervene and um start medically managing the seizure. So if a seizure is lasting longer than U a usual duration in a known epileptic, if a seizure has lasted more than five minutes, we say more than five minutes. But I would say at about two minutes is when most people will start thinking about um uh drug management or if they have more than one consecutive seizure without recovery in between, then we wanna start thinking about what medications do we give. And the first line is um IV LORazepam, 4 mg. If we can't gain IV access or uh don't have access to LORazepam, then we can give pr diazePAM. But again, LORazepam is the first line. So if you've given these interventions, you've given uh 4 mg of lozepam and the patient is still seizing. Um we at this point a senior should be there and be supporting you. But we wanna give a further dose of a benzodiazepine. And then we start thinking about considering a loading dose of a non benzodiazepine. And this as we're doing all of this, we're thinking about we're addressing the underlying cause. So at more than 20 minutes, um the kind we start thinking about giving a nonbenzodiazepine. So these include phenytoin valproate or levetiracetam or Keppra. Um And we, we've given a loading dose of those and at this point, maybe anesthetics is involved, we start thinking about intubation, securing their airway, transferring them to the itu and caring up monitoring. So, seizures are dependent on the timing on consecutive seizures um and how the patient is recovering in between. So um repeat your ABCD E again and there will always be new findings on each assessment. And if the patient is recovered, um their G CS has recovered, you wanna take a full history and the important things to take in a history of a seizure is how are the patient feeling before? Do they remember the events before? Do they remember the events after? Was there an aura or migraine? Um if there are known epileptic, did it feel like um they're normal seizures? Did they, did they know it was coming? Was it a witness seizure? Um if they had any other symptoms, um a headache, if they had limb weakness, if they had any other thing that could point you towards a tiaa stroke, um, chest pain or palpitations, um, any use of alcohol and drugs. And again, if they are known to have a seizure disorder, how compliant are they with their medications? It's important to note in the history. You wanna review what medications that they're taking at the moment, um, especially if they're on, uh, antiepileptic medications and consider dose adjustments or if you need to discuss, um, the doses that they're on with um neurology department or um anything else like that. And then you need to get an E CG and we would consider act head and a lumbar puncture, I think especially in posttraumatic seizures. Um, we need to consider act head. If you're suspecting a bleed, you need to consider act head and lumbar puncture will be done after. Um, so the next topic I'm gonna go through is is back pain. Um So back pain is, is very common. Um, and it's usually nonspecific. So it can be, it can be a bit difficult to, um I think, differentiate between when we need to be concerned and when it's, it's a normal back pain. So it's commonly used strain of the lumbar muscles or impingement of, of the nerves and um, back pain can be be referred pain from other conditions. So, pancreatitis is a classic one where you have pain, radiating epigastric pain, radiating to the back. It can be renal colic. Um, it can be a more serious condition such as an aortic dissection where you, they have a tearing pain radiating in the back. So we need to differentiate is the pain back pain or is could it be a referred pain from a different cause? And again, the main aim um of assessing back pain is to, to exclude those serious conditions. Um but other things we need to think about is pain control and physical disability and psychosocial impact. So, uh physiotherapy is the patient safe to go home. Do they have um help at home? So it can be quite debilitating. So all of these are things to consider. So, so what are the kind of emergencies where we would then start having to consider urgent in interventions? So we have infections such as discitis and epidural abscesses. So these you would think about in patients with risk factors. So possibly um immunocompromised patients, patients with diabetes, patients who are known um intravenous drug users, um patients who have a history of um in the history that give you signs of uh infections such as fevers being generally unwell patients with a septic picture. Um malignancy. And I think a big one is metastatic cord compression or called equina. It's always important to rule out when you're seeing a patient with back pain suggests disease of the bone and fractures. So a few different ways again that you someone um can present with back pain. So patients have had a fall and is now complaining of severe back pain and their mobility is significantly reduced or they're unable to walk or as previously, um they could walk un assisted. You could be asked to see a patient who is suffering from lower back pain and new weakness in both of their legs. Or you could be asked to see a patient who has complaining of back pain as also spike to temperature looks unwell. So just a couple of different scenarios. So initially, what when I'm looking at these, a few different things would come to mind. So if, if a patient had a fall was complaining of back pain and now isn't able to walk. The first thing that would come to my head would be a fracture. If um I was asked to see a patient who was suffering from new weakness in both their legs and a back pain or bilateral lower limb pain, that's new. I would uh think I have to rule out an M sec or a patient who's complaining of back pain and has also has a septic or infective picture. Um I would start thinking about a discitis or an abscess. Mhm. Mhm. So again, going back um to our history. So with the back pain, we're gonna use Socrates. Um again, the site onset character radiation um associated symptoms, the timing or the duration, exacerbating factors or um um exacerbating factors and anything else. So, red flags um in, in our back pain would be a change in the nature or the severity of a chronic pain. So patients can often come, especially elderly patients with quite a long history of chronic back pain. Um, where you want to be cautious is if they say now it's a different kind of pain. Um, there could be a neuropathic shooting pain. Um, whereas previously used to be quite a dull achy pain, it could be that the pain has changed significantly changed in severity and that's why they've now presented. Um or that's why you're asked to see them. So, again, age is a big one. So in patients, less than 20 so Children, um or young patients shouldn't really have back pain and it would be an immediate or a plague if um a younger patient came in with severe back pain, um or more than 50 because again, high risk of comorbidities, high risk of malignancy, um osteoporosis and higher likelihood of fractures when we have mood or sensory changes. Um It's a red flag if we have a change in our bowel or bladder functions or any urinary incontinence where previously there wasn't any um any numbness in that, in, in the genital area um is, is one to think about. So again, we have trauma, um we have bony tenderness and infection. All of these are red flags of back pain. So, um how, how would you examine a patient with back pain again, ABCD, e um use a systemic uh approach. We'll do a full neurological examination. You wanna assess the, the patient's gait. I think it's especially important in back pain and how has it altered their mobility? Assess the range of movement, um passive and active and how, how this affects the back pain. Um Assess for spinal tenderness by palpating each spinous process. You wanna have a feel of their paraspinal muscles for any tenderness. When we're thinking about a Cordona or a metastatic cord compression, I think pr is, is important. Um So we wanna assess their rectal tone and their perineal sensation. So we wanna do a pinprick sensation and APR exam. Um When we again, are thinking about M sec, we consider a preimpose for bladder scan and we wanna see if there is um any signs of urinary retention. So I think around 100 and 50 mils is, is um the volume. If, if they're retaining that after they've gone and um passed urine, then it's a, it's a red flag for a metastatic cord compression and then there's maneuvers such as the straight like test. So that can help you to differentiate. Is the pain mechanical or is it a neurogenic pain? Ok. Oh A, I'm just moving on to the next side. So, investigations in back pain, again, you'll take your routine bloods. But I think what's important to think about is your inflammatory markers to rule out any kind of infection and a bone profile. So this will include your A LP, um your calcium profile, um your Vitamin D especially in elderly patients. Um If you are suspecting a fracture, especially in um an elderly patient or a younger patient that's coming after a trauma, you can use a lumbar spine X ray and it can help to give you an idea. But ct spine will let you get a better look if there's any wedge fractures. Um If there is any nerve damage, if there is any change in the height of the vertebra, um if we were thinking about a soft tissue cause such as a malignancy or to assess for a metastatic cord compression, then you would go to an MRI spine. And I think if you're thinking about myeloma or if there's any suspicious signs for myeloma, you would consider a protein electrophoresis. So, um what, how, how do we manage back pain? So if, if we have ruled out all of the red flags and it's a patient that you're thinking it's a nonspecific back pain, um It's, it can be, we can manage it with low dose, uh preferably non opioid analgesia targeted exercises. They can often be referred to some kind of physiotherapy clinic. Um But when we have, I think it's important to know the management of especially uh metastatic cord compression. So I want to think about getting a senior involved, getting an urgent MRI spine. Usually, if there is a confirmed M SCC, um the patient will be admitted and you want to commence them on steroids and that will usually be dexamethasone um with a PPI for Gastric protection. And in, in most hospitals which has there's an M SCC coordinator um that you can contact and, and they will help you kind of further manage the patient. But definitive management will include uh neurosurgery. Um and it can also involve radiotherapy. Ok. Yeah. Um So another topic that we're covering again, a very common neurological topic is is uh headaches. So, headaches again, like back pain, very, very common. Majority of the time are not life threatening. Um And in our common headaches are we have tension headaches and migraine, but it is important to be able to recognize when a headache is a, is a sign of something more serious. So go through a few different things. So, uh headaches can be primary. So migraines, tension, headaches, cluster headaches, um or they can be secondary and they can be due to a few different um other things. So, infection, a space occupying lesion, raised intracranial pressure, a subarachnoid hemorrhage, um GCA sinus, venous thrombosis trauma or medication overuse. And I think these all have things that about the patient or in their investigations that we can think about. So, again, with um an infection as a cause of headache. Is there any other symptoms um such as uh such as neck stiffness, such as fevers, spikes such as nausea and vomiting where space occupying lesion is there new neurology with raised intracranial pressure again, is the, is the timing is important? Is it worse in the morning? Um I think subarachnoid hemorrhage is the big one to rule out when it comes to sudden headaches. Um And again, is there any comorbidities, do they have hypertension? Is it a severe high intensity pain? Uh giant cell arteritis. So, if a patient has a bitemporal headache, if they have anemia, if they have scalp tenderness, uh a sinus venous thrombosis, is there any vision changes? Um, trauma and head injury and medication, overuse headaches and again, for trauma, you can always access the nice guidelines for your CT head and that can kind of help you along the management of a suspected head injury. Yeah. Um So how, how could you be asked to see a patient with headaches? So if a patient was complaining of um a new headache and neck stiffness, um would you, could you see her initially, you would think about, is this a possible meningitis or an infection? Um, if a patient presented, if you were working in the emergency department and they've come in with a sudden severe headache and they're found to be hypertensive. Um the first differential would be a subarachnoid hemorrhage and if a patient presents with a progressive severe headache and it's on both sides of her head and she is a younger patient, she has a higher BM I, you could um think about idiopathic intracranial hypertension. So again, even when you're first asked to see the patient without taking your history and examination, you'll have a few differentials in your mind just based off um the patient characteristics and their, their complaints. So again, um what you go through your Socrates for pain and the um to take history of the pain and all the details of it and what are our red flags? So again, a sudden onset and a high intensity headache, um, age if they're less than 10 or over 50 if there is any other neurological changes, um if the pa the headache has been progressive in severity, so if it started off quite mild, um and in the course of a few days, it's now become unbearable, then it's, it's a red flag and you wanna think about further investigations, um, medications if the patient is pregnant, um and pain that is, has certain characteristics. So it's worse in the morning or positional changes. And that can um point towards a raised intracranial pressure. Um So how would you examine the patient? You're gonna do your observations again, your ABCD E um then you'll do a full neurological examination. Um And you want to include your King and Rozanski signs. Um, but key findings in, in when you're examining a patient with head injury is any, any signs of trauma, any bruising or swelling, any battle signs. Um If their pupils are unequal, if their pupils are sluggish or in their reactivity. You wanna start um think about a more serious cause if there is any associated focal neurological deficits or any limb weakness, um any abnormal sensation, if they have um neck stiffness or neck pain, any ophthalmoplegia and any papilledema. So I think a fundoscopy is quite important also to include um when you're assessing a patient with headache. Ok. How, how would we manage a patient with headache? Um So you're gonna start with your routine investigations. So E CG bloods again, including an F CCR P LFT S your re and electrolytes and an E sr um CT head is often the most accessible thing for kind of excluding uh a bleed, a subarachnoid hemorrhage, a space occupying lesion, um a possible stroke um with CT um again, we can't say everything. So for further investigation of any suspected soft tissue cause we go to an MRI head. Um And often the patients um for example, with a suspected infection or a suspected Subba hemorrhage will then have a lumbar puncture some um after being admitted. Um And it's important to remember when you're suspecting a patient with possible um meningitis or uh encephalitis, we don't wanna delay kind of initiating antibiotics or antivirals in a suspected infection. Um And just, and remember that when you get your CT head, if there's any signs of an intracranial bleed, then you want to have neurosurgical involvement. Um So to kind of summarize um I think it's important to have a systemic systematic approach to all the scenarios. So again, using your ABCD, e using your Socrates when you're taking your history, um and that way you won't miss anything. Um It's important to remember with these kind of neurological scenarios. The most important thing is timely recognition um of these serious conditions and initiating management as soon as you can. Um again, your aim is to exclude more serious conditions and be able to differentiate between common things like uh chronic back pain or migraines with more serious conditions. And in those trusts will have local pro uh protocols. So for example, it's seizures, there will be a protocol um or with uh possible uh head injuries. So it, it's good to know the protocols and how, how you can access them in your own call in your everyday job. Um just for any support that you need. So I think that's the end of the presentation, but I forgot any questions. Thank you, Aisha. That was really good. Um We'll just give people some time to um type the questions because that does sometimes take a bit of time if anyone's got any questions or to um unmute themselves and, and actually just say it that will also be fine. OK. Um OK. So we have a question from doctor a addie. He said, how would ischemic uh CVA management alter if the patient has bar aneurysms and a polycystic kidney disease? Um plus or minus a history of subarachnoid hemorrhage. So, if you're suspecting an ischemic stroke in a patient who was possible risk factors, um, for, or a possible history of a subarachnoid hemorrhage. That's a question. Yeah, I think that's what he's asking. Yeah. Uh, ok. So, I think, um, ischemic stroke, you're going to manage it the same because again, um, you would give your, uh, if the patient is on any kind of, you're gonna review their medications. Um, but you need to manage the ischemia because there's infarction of brain tissue. So, again, you would give your aspirin, um, 200 mg you could involve. Um, but if, if there's no, if there's no bleed in the, in the presentation and you've excluded that, then I think you would follow the normal pathway for an ischemic stroke. It wouldn't alter the immediate management. No, it wouldn't. It's a b very aneurysm. It hasn't ruptured. So it's still an ischemic CVA. So that's what you're going to treat. Um, you will, you can definitely involve, um, especially if they've had a history of erythroid hemorrhage involved in neurosurgeons. But since there's nothing, now, there's nothing stopping you from, um, I'm treating it as ischemic. Yeah. Um, and then nine has a question. So if a patient within 4.5 hours onset of symptoms, um, a shall we prescribe aspirin 300 mg asap after a bleed is excluded or aspirin 300 mg, then thrombolysis or no aspirin but only thrombolysis to be given. So you, you would give your aspirin, um, if they present it immediately and you're suspecting a stroke regardless of the further management. Um, you will give them aspirin a after the uh, bleed is excluded and then follow the appropriate pathway. Yeah. Uh sometimes even the patients will come in with an ambulance via ambulance having had a stroke and they would be given, um, um, aspirin even before you've seen them in Ed. Um, and it's, yeah, it's, uh, obviously the best case scenario is getting the CT head first because once you come in with a patient, you want to make sure that it is not hemorrhagic. Um, but I guess because of the low probability of it being that a lot of patients are given aspirin even before they come in, but you want to give it when, when you are here. Have you got any other questions? I just give you a few minutes. Mhm. Mhm. Yeah. Yeah. Ok. I'm assuming that's probably it. Um, that's fine. If we don't have any more questions, then we'll, um, end it here. So good. Yeah. Yeah. Well, thanks everyone for listening, attending. Thank you.