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Yeah, this is snakes. Can you start? Hello, everyone. Can everyone hear me? If if you can hear me, can you just comment in the chat box so that just to make sure that you guys can clearly hear me and it's the slights visible to everyone? Mhm. Yeah. Taking the start now, Can everyone see the slides now? Thank you. Thank you for letting us know. Um, Good evening, everyone. Sorry for the technical delay. Um, we have got Doctor Jaggedy Srinivasan today. One of the post foundation doctors in Wigan in February will be talking to us about oncological emergencies. Part one. There are many, many oncological emergencies. Um, however, we're just covering a few today, and then there'll be the rest of it will be covered in other sessions before we, uh, yeah, I think we don't have to delay anymore. Decade is you can take the stage. Thank you. Uh, thank you so much. Diarrhea. Thank you so much for the introduction. Uh, yeah, as you mentioned earlier, I'm going to speak about Oncological emergency. And, uh, obviously, there's a lot of oncological emergency. And we can, uh, do that everything in one presentations. So we have decided to do it in probably two or three parts. But today I'll probably focus on the main few important condition that you can see, uh, in an oncological patient's, um so throughout the presentation today, I'll probably I'll probably make it like an interactive session so that everyone could take part, and then we can We can have, like, a sort of brief discussion and share your thoughts as well. So I'll mainly focus on the chat box If you can have a look at the chat box, uh, and then just come in and, you know, pose any doubts that you have, and so that we can answer all this throughout the presentation. So before I start a brief definition about oncological emergency, probably many would have known this. So oncological. Emergency is an acute, potentially morbid or life threatening condition, directly or indirectly related to patient's tumor or it's treatment. So anyone, um, with a background of cancer or tumor, Um, so they can come in with some emergency situation either related to their cancer itself or the treatment they are receiving. So without further delay, I'm just gonna start only on a case discussion today So, Case number one today, Um, we have a 54 years old lady who came in with feeling generally unwell, fever and lethargy. So just say, if you get this referral from an A any, um so without knowing any background, you've been referred 54 years old, generally feeling unwell, fever and lethargy. What is the next further question? Would everyone asked if you could just post in the comment box? Oh, guys, anyone out there just want to share your thoughts? What? What? We like to ask for a further question, a 54 years old lady came in with generally unwell fever pathology. What do you think? The next appropriate question we can ask so that we can rule out, uh, the causes and come into a diagnosis. Uh, yeah, I can see that. I'll do a general assessment. Better to be to the assessment. And if she's stable, I would gather information. Uh, yeah, that's right. Exactly. That that's the right appropriate management. I mean, appropriate steps to do so. Let's say the the patient is stable now so you could get more history from her and you speak to her and she says the symptoms started about three days ago. She has a cough, sore throat and then fever, not reliving with paracetamol. She is known to have hypertension, diabetes and reason diagnosis of breast cancer. And she takes, uh, Ramipril and amlodipine, probably for hypertension, metformin for diabetes. And what is the next relevant question? Do you want to ask her with a background of breast cancer? Yes. Duration of complaint. That's right. So she said about three days of symptoms. Um, so that's probably the duration of complaints. But you know that she has hypertension, diabetes, and reason diagnosis of breast cancer. So you guys want to ask anything else about her breast cancer there? Anyone would just want to post in the chat box. That's fine. So uh huh, press cancer diagnosis, stage treatment. Yeah, that's that's That's good. That's good. That's what we're supposed to ask. That's right. So we know that you know when we're dealing with some oncological emergency. So anyone who comes with a cancer, the next question is exactly like, when was it diagnosed what stage it is, and in particularly what treatment is she on? Because you know that the treatment has a lot of implications on the condition she present now. And the next important question is to ask, When was the last time if she would have received any sort of chemo or radiotherapy. So this lady had a third cycle of chemo last week. So you know that she had a chemo one week ago and now she's coming with unwell fever and lethargy with a bit on and off cough. So on examination, what do you guys want to have a look like? Uh, what's the important examination do you guys want to do on her? I know. Previously, someone told a two e assessment. Um, yeah, that's that's an ideal approach when you see someone in a, any usually do should do an a two e assessment before you could come into the diagnosis. But let's see, when you see someone in an A and A what is the first examination step? Will you start with So So let's say this patient is here. Um, so the first thing you will do, obviously you'll get a vital sign. You just want to see how stable is she. So she's stable enough to give you history so you know that she's stable to to answer you, but let's move on to the vital sign and see. So the pulse is 1 to 8. The respiratory rate is 22 as P 02 is 96% temperature, 38.8. BP under four by 68. Right. Just is clear. I got the answer for you guys anyway. Yeah, having cough, I will focus on respiratory examination as a start, then general and breast looking for Resh. Yeah, that's right. Yeah. So, um, just like a systemic approach. I would say that doing an A to ease is quite good enough because I know that she has some respiratory complaint. So obviously you wouldn't want to miss a respiratory examination, but equally doing other examination as well as important, because sometimes you might have missed something, so But obviously, the main priorities are respiratory because she's having some respiratory symptoms. So what do you guys think about a vital sign Now, uh, with regards to a pulse, blood pressure, temperature saturation and respiratory rate. You guys think it's normal or anything? That's alarming. Yeah. Thinking of subsidies having Yeah, that's right. Yeah, you're right. So we know that the pulse is a bit high. She's taking cardi. She's having a temperature 38.8. A BP is pre normal, but I just met. Just think about it. She's known to have hypertension, so that's probably a bit low for someone at hypertension. But again, that's within the normal range. Uh, but yeah, someone with taking cardi temperature of 38.8. You should always think about sepsis. That's a very good thought there. And so the next move on from there onwards, Obviously, we're going to do a systemic examination on her, and I've given the answer. The chest is clear. Heart sounds normal. Abdomen is soft, nontender and, uh, so given here. So you guys think that she's having a Subsys Now? What do you think? The next important investigation you want to do with someone with sepsis? Anyone heard about a term related with sepsis? Like, what do you have to do with someone who's suspected sepsis? The culture elected? Yeah, Yeah, yeah. You're right. Yes. Decomp. Yeah. Yes. Sub 66. That's right. 766. So anyone, um, in the UK, uh, or anyone you cluck the patient in a and e. And if you suspect the patient of sub 66 and obviously you have to do the, uh, sepsis, six investigation and management. So which includes Take three and give three. So you obviously would like to give antibiotics fluids, and you want to take the Lactaid blood culture and we'll talk about it. The latest slides about Subsys six, but that's the right approach. Subsys six. And so I see you're gonna do You're in deep and urine MSU. That's a part of your sepsis. Six as well. Blood's full blood count lft you nsn CRP. This is probably like a routine blood to do and obviously, with an infection if you're suspecting and CRP will help you with that as well. Blood cultures. So part of your sepsis. Six. As well, E. C. G. You know that she's technique. Ardeche. Um, well, Ucg might might be normal in this case, but it's it's good to do because she's obviously she's presented with tachycardia. You don't want to miss anything else that's worrying. Chest X ray pretty valid because she has respiratory symptoms. Even though your chest examination is normal, you might have missed something, so it's it's good to do a chest X ray, and I liked it so that that again, that's part of your Subsist IX as well. So that's your Subsys six. Know your Subsys six. So So we usually say Take three gift three. So you give oxygen fluids, antibiotics and take cultures measure elected and urine output. So the ideal thing about Subsys is it's, I mean, when you diagnose someone at sepsis, giving the patient with antibiotics as soon as possible is important. So usually in our trust, we try to give antibiotics. Within one hour. The patient presents to an A and evident Subsys because there's been a lot of study saying that the outcome is much better with those patient with subsidies who received antibiotics within one hour. Then later, they even recovered with better prognosis. So let's move on to the investigation. So we have her hemoglobin 105. Platelet is 1 20 White cell is 2.1. Neutrophil is 0.3. Lymphocyte is 0.9 crps 128. Lft and U. N s are normal. Before I move on to the checks X ray. Can anyone just sort of interpret the blood resolves And what do you guys think going on with her now? Yeah. Sepsis. Six. Yeah, that's right. Correct. You all right, And, uh, now focusing. You know that she's on sepsis now? Yeah. We all agree that she's in Subsys. Um, so if you got a routine blood test now, could anyone just briefly interpret and see what's wrong with a blood test? And what do you guys think now? No white salaries. They're sort of confirm sepsis. Yeah, so that's right. So if you can see, uh, hemoglobin is 100 and five. Um, so I would say that's like borderline low as well. A platelet is 1 20. So she has trauma cytopenia. She's anemia. Um, her white cell is 2.1. So when someone with low hemoglobin, low platelet, low white cell like, what do you think this is like what? What is the term of this three? Anyone? Yeah, that's right. I can see someone answering pancytopenia. Yeah. So, yeah, she's She's having pancytopenia, which usually seen with someone after the chemotherapy. So there's usually patient's of the chemotherapy can present with pancytopenia, but this usually resolves after a few weeks to months. But what's more alarming is obviously the low white cell with a temperature. Turkey cardi. And what do you guys think about a neutrophil count? 0.3. Are you guys happy with the neutrophil Count Neutropenic? Yeah, that's right. So So neutrophil count is 0.3. We all know that anyone with a background of chemotherapy comes with a low neutrophil. Obviously, um, we are worried about neutropenic sepsis, So I'm sure everyone agrees that she's having neutropenic sepsis and your usual neutrophil count of less than one. It's called neutropenia, and less than 0.5 is actually a severe neutropenia. And I'm sure everyone agrees that the CRP is raised as well 128. So a brief recap. A middle aged girl with a middle aged patient with a background of breast cancer, uh, who had chemotherapy a week ago, came with neutropenic sepsis, and, uh, but next she has some respiratory symptoms, but nothing concerning from her examination. So we we ordered for a few routine investigation, so we got the blood results. And now let's move on to a chest X ray. If anyone can just interpret the chest X ray and see what's what do you think going on with her? I'm not sure if this will be Nutropin exceptions following. Yeah, that's right. Yeah. So we know that because the neutrophil count is low, she's in a sepsis. And so someone would post chemotherapy, obviously that at a very high risk of getting a neutropenic sepsis. So it's fair enough to say that she's having neutropenic sepsis. So we did all the routine investigation. We're not too sure where the source of infection, though. So we have done her chest X ray now because she's been complaining of cough for the past three days. So what do you guys think about the chest X three? Anyone want to comment on the chest X ray? Okay, so, um, for me, I think the chest x ray looks clear. Like, can't see. Yeah, that's right. So I can't see any consolidation as well, so it's quite quite clear. So obviously we requested for an E c G as well. So got an e c g for you guys. So what do you guys think about the e c G. Now? Anyone who want to volunteer on commenting about the e c g. Okay, that's fine. so looking at the e c g. I think it's just a Sinus tachycardia. Um, so it's probably due to the sepsis and with the high temperature any patient can actually present with tachycardia. So the E. C. G confirms it was just a Sinus tachycardia, So move on to the management. So I hope everyone is convinced that she's having neutropenic sepsis, um, with a low neutrophil count. So managing a patient of neutropenic sepsis is very important because it's a part of an oncological emergency. So the most important step with someone with neutropenic sepsis is giving them the IV antibiotics. So I hope, like every trust has his own policy. So I'm just going to talk about the management from Wigan Trust where I work so we now would trust. What's important is that giving the antibiotics within one hour, as I told earlier, within one hour, the patient presents to an A and E if you suspect the patient is having a neutropenic sepsis without waiting for the blood investigations or blood cultures or the infective markers is fair enough to give the antibiotics as soon as you have a clinical suspicion. So the choice of antibiotics. Um, in my trust is obviously meropenem. Uh, so we give 1 g stand and then usually we give about 7 to 10 days. Um, depending on the trust guideline as well. The patient has some penicillin allergy, uh, just rash. So some usually patient will say they are allergic to a lot of medication. So when you take a history which you take a detailed history to us, what type of allergic they have, So sometimes they might have just a mild abdominal discomfort of slight diarrhea, or it might not be related with that medication at all, and they they would have been labeled as an allergy. So just make sure be careful about about the allergic history and if you suspect it's not very significant, and obviously you can you can give them metal panel. But if you're in a doubt obviously discussed with your seniors or or the consultant, if the patient has severe allergy and your second line will be, take a planning, uh, ciprofloxacin and also gentamicin. So that's again, depending on your trust as well. Inform acute oncology team. So any patient who presents with oncological emergency you should always do a referral to an acute oncology team. So acute oncology team is there in every trust. They usually works during office hours, like even though if if you see this patient at night, if you put in a acute oncological referral, they will pick up this patient the next day of words. So it's important to refer to that your oncology team. But make sure that treatment, like the antibiotics, is started before the review by them. So neutrophil count less than one you admit and more than one oral antibiotics. So this again a bit debatable because even though patient has a neutrophil count of more than one. But if you think that they are not fit to be discharged now, obviously it's fair enough to keep them in patient because bear in mind that this patient has a background of cancer, the after chemotherapy they might have a bit of difficulty in eating. They might have a bit of sickness warm eating. So if you feel that you're not happy to discharge them, you can always admit them a day or two to wait for your consultant. Review Phil Gas Stream. Um, if you guys are aware it's a granulocyte stimulating factor. So usually, um, it's given for someone with severe neutropenia. Neutropenia count neutrophil count of less than 0.5. But this usually will be discussed with the acute oncology team. So if you if you plug this patient at nine, you don't necessarily need to start them on filled gas stream. Obviously, the basic investigation, like antibiotics and fluids our started. But for this you can always wait for the acute oncology team and then get their opinion. So brief discussion about neutropenic sepsis. Uh, so, as I said, it's a potentially life threatening complication of systemic anticancer therapy, particularly chemotherapy, so should be suspected in a patient presents within 28 days of systemic anticancer. So, like I said, anyone who had chemotherapy always ask them, When was the last cycle you had it? Because that will give you a very important clue. A significant cause of cancer treatment related mortality is between 2 to 21% in adults, so that's quite high, though, so that's that's why it's important if you suspect the patient as neutropenic subsidies. Just give the antibiotics without further delaying it so early. Recognize Asian as management is essential as early sign can be septal and patient can Dettori it rapidly. Yeah, so patient at risk would be those within 20 days of chemotherapy. Malignant hematology Patient's have high risk of coming with Nutropin exceptions. Previous chemotherapy, previous neutropenic sepsis. So you know that sometimes if they're on third cycle, then you can just dig up a bit of history to see how they responded to the 1st and 2nd chemotherapy. Sometimes they might have neutropenic subsidies in the 1st and 2nd cycle. Then you know that. Okay, she's probably having a similar thing now in the blink a data and line. So always someone with, like, a line or catheter, it always carries a risk of infection and substance. Elderly patient, co morbidity, advanced cancer common, even even a patient with uncontrolled diabetes, they actually are a very high risk of getting worse. Subsys, pelvic, spinal radiotherapy and poor general health. So early signs and symptoms so patient report generally unwell. Flu like symptoms. That's probably our patient. Earlier, she just report a bit of like cough and flu like symptoms, which seems to be mild, but she's actually having neutropenic sepsis, and if this not being picked up early. They can obviously Dettori it and going to worsening sepsis. And that's when you can see they can have a colon. Call me peripheries, Wrestlers, hyper hypothermia, hypertensive and tachycardia. So the main important takeoff point is the Dettori ation can be very rapid. So always, always have a strong, suspicious mind. Like you see, they will often look well, a little orientated. Feel warm perfused, maybe slightly tachycardic or slight. I pay attention. And, uh, if it's if you missed it, then probably they can go into worsening sepsis, a complication of neutropenic sepsis. Um, so delirium quite quite obvious. They're like, especially elderly patient. When they have any sort of infection, they can go into delirium and careful opathy organ failure coagulopathy so coagulopathy organ failure. They probably can go into D i. C. And then obviously ultimately that that's what we want to avoid here. Okay, guys, So I'll move on to the second case now. I hope it was clear. And if you have any questions and probably I'll answer it towards the end of the session. So, second case, we got a 75 years old gentleman presented with worsening back pain for two weeks. Um, So what What do you guys? What do you want to ask for this patient? 75 years old, Two weeks on back pain. What do you guys want to ask? Further history. Yeah, and sorry. I was just happen to read the commands in the chat box. Her entry looks okay. Can't see any consolidation or mass can see Claustrophobic. And on the no metastases, probably chest X. We're not the mess. Yeah, you're right. Like, yeah, Chest X ray was clear. Yeah, no mats. Probably chest. Actually, not the best modality. Yeah. So I would say if the chest X ray is clear. And, uh, if if your clinical suspicion of metastases is lower, then probably you might not need to proceed with a CT scan as such, so that chest X ray should be sufficient. Enough soccer. It's Yeah. Yeah. So Critz. So that's, um, probably the next good thing to ask for the three sockets. So let's move on to the further issues. So low back pain radiating to lake weakness in low early continuous pain for two weeks. So severe, unable to sleep, not resolving, with algae, etc. Opening bowel and bladder normally no incontinent past medical history of rheumatoid diabetes, hypertension and CKD prostate cancer. So I hope everyone remember that I told earlier, If anyone with cancer, the next question will be what is the trick many's on? And when was the last treatment he received? So yeah, before that medication is allergic to penicillin. Very, very important. And like I said, when you ask someone with allergy, always remember to ask, What are they allergic? They have, like what reaction they develop after taking the medication. It's very important to make a clinical judgment. There is currently on insulin ramipril amlodipine completed chemo and radiotherapy awaiting follow up with oncological team. Right. So what do you guys think? Like what's back on your mind? Like, what do you think this patient is having 75 years old back pain for two weeks. It looks like a very severe back pain. Just a back background of prostate cancer Completed chemo, radiotherapy, waiting, follow up in oncological team. So, Kurt, red flags called icona Fine bone mats. Okay. Metastasis. Yeah. Yep, yep, yep. Yep. So always anyone with cancer comes with the back pain. Always, always. It can be as simple as mechanical back pain or some you know, um, or a muscular skeletal injury or just a sprain. But always think of the worst one so that you don't miss anything that's concerning so metastases. He has obviously have to think about that. But before that, let's see what's the examination like? So new Score temperature. 37.4 Saturation 97. Heart rate is 78. BP is fine. Respiratory rate is fine. Heart sounds normal. Chest is normal. Abdomen soft nontender urological examination. Let's come to the important bit of the examination. Spinal tenderness. Low early, reduced own power. Four out of five bilaterally. Sensation in tech reflects is normal. Unable to assess gain, Finding it difficult to stand due to pain. Rectal tone normal Right before we move on, what do you guys think about the neurological examination? Do you think it's normal or anything that's worrying you? Right so you can see he has some spinal tenderness. Okay, well, the power is four out of five Relief stone. Um, so obviously there's some neurological changes there. That's a bit concerning now. That's what we like to do. The next step. So routine. Blitz, obviously that's that's the important thing. Let's go step by step. Routine blitz. So have we see you? Any CRP lft? Well, just just to see if there's any sort of infection that you're worried. But But, yeah, we assume it to be normal. Yeah, it's normal in this case, Chest X ray of back. Well, we usually start with a chest X ray because obviously, if it's a fracture or anything that's bony related, you can actually visualize in the chest X ray. I mean, my bad. Sorry, it's not a chest X ray. I mean, X ray of the back. And, uh, obviously, the more precise one MRI scan. Um, that's a better morality. So let's assume that's the MRI of the patient. Uh, what do you guys think about the bit with the arrow there, if you can see the white arrow. So what do you think about that condition? Anyone? So if you could see the arrow and if you can see that that bit bright, um, bright side, I mean, obviously the one I'm sure you can visualize the bone. So just to the right of the bone, that's actually the spinal cord and the arrow that's focusing is actually something. It's probably a tumor that's compressing the nerve. So that tumor probably compressing the nerve, causing the pain and some weakness in the limbs. So what do you guys think this condition is? Uh, yeah, I can see bone Mets causing Yeah, yeah, that's right. So it's probably a spinal cord compression. So? So this condition is obviously an oncological emergency, according US Met aesthetic spinal cord compression. It's very, very important, uh, someone who comes in with a back pain and limb weakness. So it's very important to refer to an msec coordinator to get advice. So again, I'm just speaking behalf of my trust. Like what? We usually follow here, but I'm sure it's pretty standardized across the UK Anyone, uh, suspected msec will will have msec coordinated Elias with steroids. So as soon as you suspect msec, even though it's not confirmed, you can always start the patient on dexamethasone, uh, 60 mg once daily as I mean 60 mg ones as an initial dose, and that subsequently 8 mg BD always remember to give a patient with PPI cover like omeprazole because you know that steroids can always cause a bit of irritation in your, uh, gastritis and cause ulcers. Always remember that. Give PPI cover with any form of steroids. Flatbed risk Lock Road Immobilized Patient's very important. Um, because you know that you don't want the tumor to compress further and cause complete compression to the spinal cord. So make sure that lying flat. If it aggravates the pain significantly, make sure the patient's comfortable elevating the hate and, uh, make sure give the patient some painkillers because they can have really a lot of pain with the spinal cord. Compression admission. Obviously, these patient's need to be admitted to medical unit and, uh, so remember, every patient who comes with a spinal cord compression will need a full neurological examination documented daily, so any doctor will see this patient every day. You have to document the neurological examination just to see if there is any sort of extension, worsening or improvement, so you need to document it on day to day progress. Note. Contact the Spinal and Oncological team. Um, some patient will be will be sent for a surgery, and some patient will need radiotherapy, depending on the spinal team and oncology team. So here in Wigan We usually applies with the spinal team itself and our own oncology team to see whether this patient suitable for surgery or whether it can be sent for radiotherapy is pretty much reversible condition. But you have to make sure you picked it up early. So important. Elias in both the team update plans to what? Miscommunication, Physio and occupational. Try be obviously to regain the strength and and the strength, as well as the uh of the lower limb. Obviously, you need physio and occupational therapy as well. So metastatic spinal cord compression. So any patient with cancer. Obviously, there are high risk of spreading to other parts, which we call as metastases. So spinal medicines can be very, very painful, and if it's not treated, it can lead to spinal cord compression. So it's rare. But it can lead to spinal cord damage and permanent paralysis. So this is important when you see someone with a spinal cord compression. Obviously, you have to make sure you make the decision as soon as possible and start the patient on steroids as soon as possible, because the treatment, while patient's still walking, essential to prevent neurological damage, achieve the best outcome. Red flag sign So early warning sign in someone with spinal cord compression referred back pain. Usually it's a multi segmental of banned like escalating pain, poorly responsive to energetic, very difficult to control the pain. They cannot sleep. They probably can't do any day to day activities at all. The pain is so severe, different characters side to previous symptoms. So they might just say that this is a terrible pain they have experienced in their life. So, yeah, funny feeling. Odd sensation, heavy lakes. Everything related to core compression, like weakness, lying flat increases pain because of the tumor. Compresses further into the into the court's. So you feel more pain when you lie flat. And obviously, Sylvia Pain. Like I said, Gait disturbance under steadiness, usually due to the weakness sleep. Grassley affected. Yeah, so that's all guys for today. So if you can see oncological emergency, there's a lot of oncological emergency we can talk about. And I've spoken about two important oncological emergency that you will usually see in your day to day practice. I just don't want to overload be a lot of cases, but probably that you might feel a bit sleepy at this time. So if you can see we've talked about neutropenic, sepsis, spinal cord compression, but patient's can come with variety of emergency. It can be a metabolic neurological, cardiovascular hematological infections so they can have as simple as hyper calcemia and as severe as D. I see. So I'll talk about the ecological emergency upcoming part, too. I'll probably select some other, uh, important emergencies that we can see. And until, thank you so much. And that's my reference from Do you guys have any questions? Feel free to just post in the chat box, and I I'm happy to answer it. Wonderful. Good. Uh, will you wait for NBC? No, you shouldn't wait for the f b c. Like I said, if you suspect the patient having neutropenic sepsis. So the ideal time rule is to give the antibiotics within an hour. So sometimes your full blood count might take depending on how fast or how busy is the lab. So might takes time. If you suspect Do give the antibiotics as soon as possible. Do not wait for the full blood count. Yeah, you just treat all reason. Chemo patient. If you If you have a high clinical suspicion of neutropenic sepsis. Just treat them without waiting for the blood test. Mhm. Um, yeah, sec. According I think the VA has answered that question. Yeah, so every hospitalist msec coordinator. They are part of the oncological team. And, uh, they were lies with the hospital and the oncological team. Yeah, that's right. Any more questions, guys? Did I miss anything? Yeah. If there's no more question, can we end the session? The right. Ok, thank you, everyone for attending the the attending today. So please fill up the feedback form. I think one of my colleagues has put in a link in the chat box. If you can just click the link and fill up the feedback form and do let us know your opinion and what can be improved in the upcoming presentation. And what do you guys want to gain from this presentation? And then we can probably cater towards your your request. Is that OK, Livia? Are you happy to end the session today? All right. Thank you. Everyone have a good evening. When is the next presentation? So our presentation is every Wednesday. Uh, 6. 30 usually starts around 6. 30. So if you If you just follow, it's going to be every Wednesday. So it's gonna be next Wednesday now? Yeah, every Wednesday, 6. 37. Yeah. Yeah. Just follow the Facebook page, and then we'll keep you updated. Thank you, everyone. Bye. Have a good evening. Mhm D level.