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Prehospital POCUS Survey UK - British Mountain Medicine Society Journal Club meeting #2

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Summary

This session of the British Mountain Medicine Society Journal Club delves into the application of ultrasound in medical field scenarios and wilderness expedition medicine. Led by Chris Grieco, a radiology registrar with experience in wilderness medicine, and Sid Nayak, a third-year medical student at the University of Cambridge with training in teaching ultrasound, the session dives into the paper, "National Survey of Pre-Hospital Ultrasound usage in the UK: Use, Governance, and Perception." While discussing the historical perspective and capabilities of ultrasound technology, they examine its evolution from large, complex machines to pocket-size devices such as the Butterfly probe. The educators also investigate current governance, the benefits and barriers regarding its implementation, and common uses in pre-hospital care. This session is highly relevant for medical professionals interested in emergency and expedition medicine, or those who wish to understand the evolving role of point-of-care ultrasound.
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Description

The following journal article will be summarised & critically appraised:

Naeem, S., Edmunds, C., Hirst, T., Williams, J., Alzarrad, A., Ronaldson, J. & Barrat, J. 2022. A National Survey of Prehospital Care Services of United Kingdom for Use, Governance & Perception of Prehospital Point of Care Ultrasound. POCUS J. 7 (2), pp. 232-238.

See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9983728/

Please take the time to read it prior to the meeting to facilitate joint dissection & digestion of the literature & shared learning.

Learning objectives

1. To understand the history, fundamentals, and development of ultrasound in medicine, specifically point of care ultrasounds (POCUS). 2. To learn about the specific uses and benefits of POCUS in pre-hospital and emergency medicine contexts, including its usefulness in diagnosing various pathologies. 3. To understand the current governance and guidelines established by the Royal College of Radiologists for the use of POCUS and the issues that can arise with untrained usage. 4. To review and analyze the results of the National Survey of Prehospital Care Services in the UK with a focus on POCUS use, governance, and perception. 5. To discuss the limitations, barriers of implementation, and potential future improvements in the field of POCUS as it relates to prehospital care services.
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Computer generated transcript

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

All right, we are live. So introductions. This is the um second edition of the British Mountain Medicine Society Journal Club. Um My name is Chris Grieco. I'm ast one radiology registrar based in Cambridge. Um but on, on, on the side as well, I've done a fair amount of wilderness um and expedition medicine particularly um focused around sort of um trail running events um with companies like trailed and things like that. So I'm very, very interested in the world of imaging but also how it um correlates prehospice as well. Um And we're bringing you a paper this evening that looks into um the use of ultrasound, um particularly pocus, which is point of care ultrasound um in the um hem service. So without further ado, I'd like to introduce Sid Sid. An Nayak is a third year medical student at the University of Cambridge. And he's also qualified and fulfilled a kind of training qualification in teaching ultrasound for first year medical students where they are now teaching every first year medical student ultrasound during their anatomy demonstrations, which is a really cool innovative step in the training curriculum and is where I met Sid was doing these supervisions, anatomy supervisions for the Cambridge medical students using ultrasound. So, over to you said hi. Thanks for asking. Uh, so can you see my screen? Um, just double checking. Yeah. If you, if you click the present now button they'll arrow up and that should, uh, is that? Mhm. Allow you to present the screen. But I think he, she spoon. Um, yup. Can you see it now? Ok. Oh, it's a, a technical, I don't know what is it called? Um Had another shot. Mhm You managed to before, didn't you? Yeah, I think it was um let me see if I can do it for you and I can be the slide transition person if needed. Um Just bear with us. Mm sid. What's the error on your end? It just as a technical error is a thing. OK. Fine. I'm gonna just put it into Google slides and we'll go from there. Yeah. In fact, I've got them here. OK. No se or yeah. All right. I will let you um introduce the paper. Yep. So the paper we're looking at is a national survey of Prehospital Care service services in the UK. And basically they're looking at use governance perception of prehospital ultrasounds of focus. And um so to start off with the introduction. Um and yeah, I think um we'll change slide. Um So what is ultrasound? Um So uh well, sound refers to a type of wave composed of vibrations these vibrations can pass through air, liquid and solid and particles vibrate at a certain frequency and amplitude and these govern pitch and loudness respectively. So, human range of hearing is between 20 hz and 20 ki er to get an idea one Herz refers to a single particle vibrating once per second on the wave. Um ultrasound refers to frequencies or pictures that are above 20 kilohertz um as shown in the diagram here. So the sound is made by a piezoelectric crystal which changes shape when an electric current is passed through a um a concept called the piezoelectric effect. If an alternating current um is passed through the crystal, uh the crystal is constantly changing shape or vibrating, generating the sound. Uh This high frequency sound has been harnessed for medical imaging uh as sound waves travel through tissues. And because of the physical nature of ultrasound, it's reflected at boundaries between tissues of different densities such as the boundary of the liver and right kidney, which are both uniformed with different densities. These reflected waves travel back to the transducer or crystal. And by the same effect um that causes a change in shape of the crystal and that is converted to an electrical signal that can be detected. And we know basically the time delay between when these sound waves are produced and when we get them back, and we can use the speed of sound to work out tissue dimensions and the internal tissue structure as well. Uh which is useful diagnostically. Furthermore, when sound waves bounce off a moving object, they change frequency, the waves get squashed together depending on the velocity of the object. And this is called the Doppler effect. Um The Doppler effect harnesses this to measure blood flows, which is useful in many cases such as in detecting preeclampsia in pregnant women when there's abnormal blood flow through the art or spiral arteries flowing to the placenta. So to um move on to the history of uh point of care, ultrasound, um the science of sound dates back to er Pythagoras in the sixth century who wrote on the mathematical properties of stringed instruments and then a lot of the discoveries are now more recent. So ultrasound was discovered uh when they, when spa Dzi er discovered echolocation in bats er in 1794. And then later, ultrasound and sound waves generally proposed to be harnessed for submarine detection in the first world war. Um it only really entered the medical sphere when doctor Carl Du um in Austria applied ultrasound to study the brain and he was the first to publish work on its use in medicine. His sort of early apparatus as shown here. Um A lot of rapid developments have happened since then. Um improvements in processing power development of Doppler ultrasound to see blood flows, improved resolution 3D imaging and more. And during these developments, there was widespread adoption in hospitals in the 19 eighties with more and more uses for this modality. Now, in terms of technology, ultrasound has reached a point where they can be called handheld. So originally D six apparatus is really clunky and large. You can see here that uh they've sort of become more and more compressed. And now we've got handheld devices like these butterfly probes, um which a picture of which are shown here. Um And basically how these work, they're really cool. They all they need are a network connection and a plug in device such as a phone or an ipad. And you can get real time quality images of almost any part of the body. Of course, the resolution and clarity of the images in update from the butterfly probe are only really good enough for maybe rapid diagnosis of major more anatomically obvious conditions such as maybe gallstones or which can be quite bright on ultrasound if they contain calcium, but it might struggle with like smaller tumors. But so like the resolutions of the sort of larger hospital ultrasounds are still much better, but the technology is improving and it won't be long before they're of comparable quality. And this is all highly relevant to the point of care. Ultrasound as portable and lighter machines are more practical to bring out with you into the field and um used to make diagnoses outside the hospital. So to uh go to the capabilities of current uh portable ultrasound machines, uh include cartoons of some uh organs that ultrasound can be used to visualize for diagnosis to give a few examples. Cardiac ultrasound can be used uh to diagnose cardiac tamponade uh fluid um in build up of blood in the pericardial sac pericardial effusion. Um It can be used for to diagnose polycystic kidney disease tumors. As mentioned, kidney and bladder stones, uterine fibroids. But a more niche example um would be like a muscle tendon rupture which um is sort of what I've been working on this year for my year three project. Um So ultrasound can be used to look at nerves uh such as the median nerve. So just to summarize ultrasound is extremely rapid, versatile and highly diagnostically useful uh for diagnosing a range of pathologies uh especially in trained hands. And the technology has reached a point where they can be used in remote emergency situations at a large scale due to their portability and the decrease in costs. So, the current governance of point of care ultrasound um since ultrasound is being implemented more and more, uh non radiologists are using it more especially independent of the radiology department in the case of pocus. So the Royal College of Radiologists have created guidelines so that they can be safely performed. There are um many issues if ultrasound machines are in untrained hands including infection, in the case of poor hygiene, um misdiagnosis, delayed treatment um and also in the case of medical records and storing images safely. So the guidelines which they've proposed fall into six main categories, um capable capabilities and maintenance of the ultrasound machine, clinical training required um to gain the skills, maintaining these skills, regular audits, to ensure quality, record keeping and guidelines for image storage and data protection capabilities of the machine. So to move on to the paper, um this study is a national service, a survey to basically look at this out of hospital use, um governance and perception and see how um it like varies across the UK. So the study aims to um so the aims of the study are to assess um point of care, ultrasound, uh to assess governance of prehospital focus, to understand perception about its benefits and barriers of implementation. So the uh so four groups were assessed uh the UK helicopter emergency services, the helicopter emergency service clinicians. So they get the individual scale national ambulance services and community emergency medicine services. Um So the study design um they first performed a research group with uh Prehospice clinicians um with a specific interest in focus across the UK. So the focus group that they formed um was used to determine a method to better understand the use of focus in pre hospital settings. So, um they wanted to understand like all of this at the individual clinician level, but also service level. Um And so, uh so key areas of questions were identified such as barriers and benefits to use training requirement and implementation. So they uh developed four questionnaires using like it scales an example of which shown on the bottom, right? Um And they had also had the yes, no answers and ranking questions. Uh They had eight questions. Um Each targets for questionnaires are shown on the slide, helicopter emergency services, ambulance and community emergency services as mentioned. Um So to move on to results they found so the basic response rate that they got from the organizations was quite good for UK UK helicopter emergency services. 90% and they had about six from the ambulance and community emergency services. And they looked at a mixture of doctors such as consultants and registrars and also allied health professionals such as paramedics and they also had one specialist nurse as well. Um So governance of focus generally focus have been well implemented for community emergency services and helicopter emergency services. But the in the ambulance service, only half uh use ultrasound routinely and also helicopter emergency services. And ambulance services are mostly like mostly competent, trained in the use of ultrasound. While only a third of the community emergency services, the basic competencies, all three organizations assessed generally had an inadequate um image archive um and procedure for image reviewing uh to reassess diagnoses, assess accurate diagnoses. And they've also found uh like common uses. Uh They also assess common uses of focus which include echocardiography and life support. Uh lung, ultrasound and vascular access focus was generally considered to be useful. But the extent of um usefulness was variable. Uh Respondents mentioned that the main barriers for implementation and focus were uh lack of training standards, uh lack of governance, difficulty in performing focus or delaying patient management. Uh I think uh change of slide. Um Yeah, so you can uh see the results there with um what proportions of organizations use uh like ultrasound for different uh in different cases and what sort of the biograph to show like what proportions um state of what barriers for use of ultrasound. So to move on to the conclusions, um focus um uh focus governance in terms of focus governance use is common. But the formal image review and story of scans and clinical records is uncommon. Uh The Royal College of Radiologists has guidelines for use of for the governance that is that emphasizes written guidance for ultrasound examinations, appropriate training and accreditation of clinicians of providing the right training and quality assurance of practice. Um archiving images and including images and medical records. Overall, there seems to be a lack of focus governance as a great proportion of the services survey don't meet the stated guidelines at the beginning. Um And focus is used to diagnose cardiac pathologies, lung pathologies or vascular access and fast uh fast being a sort of rapid scanning protocol of like major areas like the pericardium, the hepato renal pouch. So just to see major areas where blood can accumulate in emergency situations, uh benefits of focus have not been formally assessed and it is a bit unclear if it delays medical interventions um such as CPR, but most clinicians do judge it to be useful for patient management. The major barrier appears to be um training and equipment. This is currently being counteracted by national specialty uh colleges by incorporating focus into the curriculum. So now we move on to the critical appraisal if you want to take a request. Yes, I'll just unmute myself. Thank you for introducing that. I said, I think it is. Yeah, a really interesting paper to see the lay of the land of pocus use in the UK and it's fairly recent as well. Um I try not to make it too much of a complementary appraisal, but I do think it's a, a really good paper and um really interesting one. So first off, we looked at the aims, were they clearly stated? Um I see, I think there's the old slides. Uh Let me see if I can get these ones. Uh apologies. Yeah. OK. Just one moment. Yeah, that's it. Sorry about this. OK. OK. Say, yeah, we first looked at whether the aims and objectives of the paper were clearly stated. They, we came to the conclusion that yes, indeed they were um they talked about the governance quite clearly talking about the RCR six criteria. Um talked about perceptions and barriers to implementation of pocus which um we may come on to a little bit more. Um Some of the other points, the groups were clearly stated in terms of who was involved in um giving the survey responses. So we, we thought this was a a yes in terms of the study design, was it suitable for the objectives? We weren't quite 100% sure whether it was optimal. Um What I did really appreciate is that they managed to keep it to only eight questions. I know um that probably was a massive plus point for getting adequate responses. Um methods and outcomes were all of the appropriate methods and outcomes considered. So we thought overall, yes, there, um there it was a, a good study design, but there were some limitations um particularly obviously the ease of, of doing, of filling out. This survey was um is a massive factor in the percentage response rate that you can get and being realistic, you'll never really get 100% response rate. So I think um in terms of the design, they, they did try and optimize and um I think that did show that the it was very well responded to um the responses themselves. So uh were the results presented clearly objectively and with sufficient detail? Um We thought yes, the um the it was clear which of the perspectives were displayed. So whether it was a hems clinician or an ambulance staff member, um we didn't however um get a complete breakdown of kind of individual, they, they could have used anecdotes from, from some of the responses from the free text sections to illustrate some of these points a bit clearer. Um which is difficult when you're trying to display quantitative data. Um but can, can really help in terms of conveying the message that um people actually performing the point of care, ultrasound problems that they might be having, having. Um So the conclusions we generally agreed that they were justified to conclude um that po is poorly governed and they clearly relayed this back to the six factors that were included within the Royal College of Radiologists um Governance Statement. It did go into a bit more detail in, in which specific areas of the governance uh that was lacking. So, for example, um we kind of looked into whether there was a standardized training pathway for focus users and it doesn't seem that um everyone who responded to the survey has, has been through sort of a, a distinctive training program. Um They did mention a few kind of specific named courses that were available that seemed to have pretty good governance. Um But I think there's a lot to consider about an individual's confidence and competence following a course and you can't paint everyone with the same brushes attended the same course, which this wasn't really kind of touched on in terms of the, the survey um in terms of um the usefulness options. Yeah, we thought they could have been a bit a bit clearer with their like a scale labels because terms like somewhat don't, don't really convey sort of actually what, what the severe respondent felt. All right. So future directions in terms of this checklist item, so any necessary changes be implemented in practice, this was really good. We thought cos actually they elus um some positives that come from using pocus. And what was really interesting is that often in prehospital medicine, the key step is to get the patient to hospital. Um So it was an interesting discussion that they had as to whether adding pocus necessarily added clinical benefit um or whether it just added a time delay in certain circumstances where maybe the the person using it wasn't um confident or, or well trained and that might end up causing a harm to the patient outcome given that it delayed. Um The yeah delivery of the patient to the hospital in some instances. Um The real key future direction here was about improving training opportunities. Um It seems like with the increasing ubiquity of handheld ultrasound devices starting ultrasound training early is gonna be really important. And I'm certainly aware of people that have been on wilderness um medicine and uh various expeditions and have had a point of care, ultrasound within their pack, but for whatever reason, not, not been in the situation to use it or not felt confident to use it. And I feel that this survey kind of did echo the um those anecdotes that I've, I've heard from other people that maybe this is an underutilized tool due to a clear lack of training and possibly a lack of training opportunities as well. Right? Say those are our references. We'll without further ado just open the floor to uh to any questions. So, Ala or M I is it Mark who's watching along as well? Do you have any, any questions about this paper and about focus in general? So I think my question to both of you guys would be based on reading this paper. Um And your kind of personal experiences of, of using point of care, ultrasound. Um What do you think the kind of implications are for our prehospital practice as wilderness medicine doctors? Because I accept that, you know, it is a type of prehospital emergency medicine that we practice, but it is in quite a different environment often to the environment that y you know, a hems clinician will be used to working in. Um So I suppose what, what do you think are the implications for our practice? Um And do you think any of the um perceived barriers would be more notable in the environments that we might find ourselves working in so high altitude or poor environments or you know, potentially jungle, desert, et cetera, et cetera? Yeah, that's a really good question. I think there's a lot to that and I think you have to just think about the technical capabilities of these different probes, right? So you've got um you need charging facilities for most of them. Um And uh you know, you need a, a smartphone or ipad device usually to um in order to use a display. And I think in austere environments, most people do have the capability to do that. But say you're going on a, a long, a long um duration expedition or say you're, yeah, as, as I think you were either for several months in the Antarctic, was it um you, you're going to be rationing the use of electricity and your portable battery supply. So there are a lot of um technical barriers to having these at hand, easy to use when you're in those austere environments. Um And I think the reality of these becoming more and more ubiquitous. Um I think it's gonna take a long time to be honest and there's certainly utility there. But I think it, it really needs to start earlier in terms of when people are learning and training to use these things. Um And I hope as well that with the rapid increase and improvement in the technology which we have seen over the last five or so years that and with smartphones being so much more capable as well. Um I think, yeah, there's, there's a reason to be optimistic and to think that this is a trajectory that um we'll we'll see increase in terms of the, uh, the use and, um, utility of prehospital ultrasound. Um, but really when you're planning a trip, it's all about weight and it'll be interesting to hear from your point of view on. Are you going to pack one of these, um, and what situations might be useful in? Oh, that's a really good question. So we, we did actually have one, with us in Antarctica last season and the season before actually, um we had a, a handheld device. Um but actually, we didn't have cause to use. It is the honest answer. Um Because most of the problems that we were seeing didn't require use of um point of care, ultrasound. Um I can think of a couple of instances where perhaps it would be useful. So we um when we're working for Antarctic logistics and expeditions, we are essentially working in a very tiny field hospital um which is pretty well equipped, but we don't have any um imaging capabilities down there. So, um if for example, we were to have a client or a staff member with a suspected fracture. Um And one have the appropriate training, then potentially, I suppose you could use ultrasonography or point of care, ultrasound um to help diagnose fracture. Um Again, kind of trauma patient, if you were concerned that they might have a pneumothorax, then correct me if I'm wrong boys. But I believe that your positive predictive value um when looking at lung sliding is something in the region of 90 to 99%. Does that sound about right to you guys in terms of diagnosing pneumothoraces? Yeah, what is in the right hands then it influence can be quite easily identified. But I think as you kind of allude to dependent and this is a difficulty with ultrasound compared to other imaging modalities, the acquisition of images is is so operator dependent um that without really, really good training and people being confident to then you know, apply the really good core foundational knowledge that they've developed to these new unique situations. Then I can understand why there would be apprehension and to use it even when you might be in a situation where you could one point that came up from what I've seen kind of as a relevant point in practice, if we just go back to the six points of governance, is this record keeping and image storage. So most pocus use pre hospitals, they don't save any pictures or um write any reports to it. I think that can be quite an onerous task if you've not had any um any training um to yeah to, to report your images as well. So I think how we bridge that gap is is something that I'm not quite sure is is realistic in the prehospital environment. Um And even in emergency departments where larger port port machines are becoming more commonplace, um they don't often sync up with the PAC systems um and clinicians using them in those settings won't have had the prerequisite training to report images that they save. Um So it's, it's being used more as a, a kind of a s kind of said uh big and obvious. Um Can we spot big and obvious things such as um yeah, pneumothorax or a large cardiac tamponade. Um Thanks. Yeah, there's a focused assessment of soy and trauma to see, look for fluid and bleeding. Um But people are not certainly not applying their kind of best practice, image acquisition and then reporting practices afterwards. Um because it, it delays and is not practical in the situations that we're talking about. Yeah, I completely agree with that statement. And I think um uh you know, clearly the, the findings of the study suggest that governance is, is a a significant barrier to, to poker use. And um I would say certainly in a, in an expedition environment where often notes are not electronically kept. Um You know, that certainly isn't a problem. Um When I work down south in Antarctica, we do have electronic notes um but certainly kind of the the storage of images um would be more tricky um with my other hat on as a a hems clinician. Um The service I work for II think has a a good governance structure in terms of pocus. Um We use the, the butterfly um and we each have our own logins and we save images to our logins and then we're required to upload them to our electronic um patient notes um and are encouraged to write uh our kind of findings down. Um And then our cases will be discussed in our weekly um death and disability meetings. Um So I think actually government structure for that service is, is pretty good. Um But then if you're working in an austere environment, you know, you are reliant on um your own clinical skills, you might not have somebody um who can review images for you or more expert opinion to hand. Um So I think then that becomes more of a problem in the, the austere environments that we find ourselves working in. Mm I'm quite surprised to hear that that is something that's been done in hes actually having images saved and uploaded. I think that's good. But I'm surprised you have the time and the c still curious how, what the time sequence does the machine automatically record it or would you have to manually? Yeah. So we um we have, when we, when we are actually scanning, we are recording the images as we scan. Um And then the notes are written normally as you finish the case you hand over the patient in the hospital and then we er endeavor to type up our written notes um as quickly as possible after the handover and upload the images from the er ipads or iphones that we carry on our person. Um So it does happen relatively quickly and any um case of interest would be discussed um at our weekly meeting. So, you know, the the kind of polytrauma patients would normally um be discussed on a kind of weekly, weekly basis. And um we have a top cover consultant um kind of on call when we're on shift, who we could potentially ask to review images. Um or certainly they would then lead the subsequent um D and D meetings and would be able to comment on the images acquired at the time. So it does work relatively well, I think in our service. Um And we're very fortunate for all that I think um from, from looking back at the paper, 17 out of the 19 hem service that were surveyed are using pocus. So I'd be curious um that, that, that I think is fantastic that, you know, it is that widely used, which is really good, but I'm, I'm curious what the standard kind of training pathways have been for you ala. Um and for other hems people sort of getting to grips with pocus. Yeah, sure. I mean, I can only speak for myself but um as an emergency medicine trainee in the UK or certainly when I was originally a core trainee, um we were required to do a level one ultrasound course. So that was our kind of formal training um as co trainees. And then we are required by our college, the Royal College of Emergency Medicine to then formulate an ultrasound log book. Um So you again, you kind of acquire images, you save them. Um You're encouraged to reflect on the cases. Um And then eventually the log book is reviewed and you are then assessed, undertaking a set number of scans um in kind of each of the scanning domains that we um are trained to undertake. So, for us, that would be um echo and life support. Um lung ultrasound uh fast um and normally um vascular access as well and scanning of aortas. Ok. So those, yeah, clearly the sounds like people who have responded to the survey have had a similar sort of um exposure to what they are comfortable with scanning um based on, on the R chem training pathway. Yeah. Sure. Exactly. Um And I think from a, from a wilderness point of view, potentially useful um I guess lung sliding particularly um in the case of trauma. Although fast again, it's, that's a, you know, it's a rule in test, isn't it not a rule out test? So I'm not sure how helpful that would be in a, in an austere environment. Um So, yeah, yeah. And from a from a radiology perspective, that's the these are, yeah, the cardiac and and lung ultrasound is not routinely taught. We're very much um yeah, focused around diagnostic abdominal, predominantly abdominal ultrasound. Um along with yeah, more kind of routine things like deep vein thrombosis and um superficial lumps and bumps and things like that. So it's interesting to see the different domains that prehospitally are deemed most important and it does make sense that those differ. Um Interestingly, II think Chris probably in a um in a traditional prehospital environment, I totally accept that the way that perhaps I'm taught is is of more benefit. But I think in an austere environment and a, a an expert addition world potentially the way that you are taught is more beneficial. You know, it'd be great to be able to have somebody who can confirm that, you know, the, the flank called the loin pain is actually a renal calculus rather than, you know, where consolidation in a lower lobe of the lung. So, um you know, II can see that somebody like yourself would be invaluable in, you know, Antarctica for several months at a time. Yeah. So I think uh unless we have any more questions from um from anyone viewing, I think, Mark, have you got any, any questions for her to call you out from the crowd? But if not, we will um we'll wrap up there. Um And I just wanna say a massive thank you to Ala and Sid for um being involved in organizing this and particularly SID for er all the work he's put into to getting this presentation ready. Um So I think the, the next episode of the Journal Club, the date is yet to be published and launched. But if you are interested, then you'll hear about it on BM MS social media or the email newsletter. Um and a, I'm sure you may have some more to say about that in, in the following weeks and months. Yep. Sure. So again, thanks both you Chris and er, SID for your help today. It was um really interesting from my point of view. Um Yeah, and by all means, get in touch if you're interested in presenting, er, for the next edition of the Journal Club. Thanks very much. All right, we will.