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Primary Care Updates 2024: Neonates– Outcomes of Prematurity



In the on-demand teaching session titled "Outcomes of Prematurity", consultant neonatologist, Andrew, discussed various aspects related to premature babies. Starting from defining prematurity, he outlined different types of birth weights and the concepts of corrected gestation and small for gestational age. He also highlighted the structure of neonatal units in the UK, including the three standard types of units, and stressed the importance of delivering extreme preterm babies in an appropriate unit for better outcomes. He discussed the legal limit of viability and some factors that can affect a preterm baby's prognosis. The talk had a Q&A session at the end for further clarification. This teaching session is particularly useful for medical practitioners aiming to improve their knowledge on this topic.
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About the MedAll Primary Care CPD Programme

We are passionate about making medical education free and more accessible. In light of the increasing financial pressures faced by healthcare professionals, including the rising cost of living and strained practice finances, we felt compelled to do something. It's why we have introduced a no-cost CPD programme for doctors, nurses and other healthcare professionals working in primary care. We recognise that the high expense of traditional CPD update courses is a significant barrier, and by collaborating as an entire primary care community we hope we can offer a practical, accessible alternative.

About our speaker: Dr Andrew Elliot-Smith

Dr Andrew Elliot-Smith is a Consultant Neonatologist and an Honorary Clinical Lecturer at Queen Mary University of London.

Who Should Join?

✅ GPs

✅ Primary care and practice nurses

✅ Practice pharmacists

✅ Other allied healthcare professionals in primary care

Note: this event is not formally accredited by an external organisation for CPD points. The current guidance for GP CPD is that it is appropriate that the credits you self-allocate should equal however many hours you spent on learning activities, as long as they are demonstrated by a reflective note on lessons learned and any changes made or planned (if applicable).

Learning objectives

1. Understand the definition and categories of preterm birth, and the different types of neonatal units and their roles in the care of premature babies. 2. Gain knowledge on the risk factors impacting the prognosis of premature babies. 3. Learn about importance of considering the gestational age of an adult patient when treating them. 4. Recognize the immediate and long-term complications associated with prematurity and how to manage these in a primary care setting. 5. Reflect on the implications of prematurity into adulthood and strategies for preventive care.
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Computer generated transcript

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

Good evening and welcome to our medical primary care event tonight. We have two back to back. Uh This one is, er, called outcomes of prematurity. Um And then we're gonna have another one in half an hour time on a different event link, you'll find the event link in the chat. I'm not gonna talk for long. All I'm gonna say is pop your questions in the chat. If Andrew can get through them at the end of his talk, he will, if not, these will be converted into a thread and Andrew has said he will type in the answers then. Ok. So, uh and we'll communicate the thread link to you as well. So without any further, Ado Andrew, it's open to you. Thank you very much, Steve. Um So, hello, everyone. Um My name's, er, Andrew, I'm a consultant neonatologist, um based out of the Evelia at Saint Thomas's Hospital in London. Um, and this evening, as I said, we're gonna do two topics and the first one we're gonna kick off with is about outcomes of prematurity. Um Here's a very heavy slide with the learning outcomes that um we formalize for the session, but essentially aim to just give you a bit of a, a feeling of what prematurity is about. Some of the stuff that we do on the neonatal unit. And I've tried all that kind of as like a discharge summit translator and the things that you're going to be reading about, about the baby as we discharge home and then near the end of the session, think about some of the longer term complications you might be managing patients in the community with. And then also very interestingly thinking about the impact of prematurity into adulthood and things you can do as a general practitioner. So some of this might be a bit basic. Um But hopefully you'll take something away from the session this evening just to, to start, I just wanted to put these questions out there for you to reflect on. Um And then that relates to how often when you're taking a child health history, when you've got a kid in front of you, how often you ask the family, what gestation the child was born at? And conversely when you've got an adult patient in front of you, how often do you genuinely consider what gestation that adult was born at? And I hazard that probably the second one. It's not so often, but hopefully by the end of the session, I can convince you that it's probably worth thinking a little bit more about when you're seeing your adult patients as well. So just in terms quite medical school kind of level stuff, but just so we're all singing off the same hymn sheet at the start of the session. So, prematurity, I'm talking about any baby born before 37 weeks gestation. So that's up to 36 plus six weeks, that occurs around one in 13 pregnancies in the UK. Now, um we term extreme prematurity is those born before 28 weeks of gestation. Um and that only occurs in around 6% of preterm birth. So the vast majority of preterm infants are in kind of the late prematurity category, kind of from 35 to 37 weeks. Um It's a small minority that are born before 28. There's some terms related to weight. So we've got low birth weight less than 2.5 kg, very low birth weight, less than 1.5 kg and extremely low birth weight less than a kilo. Now, these are relatively old terms, babies come a lot smaller than that these days. Um It's not uncommon to have babies born around 500 g and the smallest baby I've personally looked after weighed only 413 g at birth. So we probably need a new term nowadays, but they are the kind of standard definitions that are used and there's also this term small for gestational age. I'm sure you've heard of which is just a cut off of any baby, less than 10th centile for weight for their gestation. And just to just highlight that, you know, the term SG A, you'll know the term IUGR intrauterine growth restriction. You sometimes see people use those interchangeably, but it's just a flag that SG A is not the same as IUGR and small for gestation age, any baby under 10 centile gestation. IU R is when there's been growth restriction, that fetus has not grown as well as expected in the in UTR environment. So you could have a baby that was always destined to be a very big baby. Both parents are large, that was always going to be a baby born on the 75th centile, they might be IU gr they might not have grown as well as they could have but still be born on the 25th centile equally. You could have a small vest age baby, but they're always destined to be small for gestational age. Both parents are small and they've always had small kids. So they've grown beautifully in neutral, but they are still asg a baby. So they often do co occur, but they are slightly different terms. I'm sure you're aware about the term corrected gestation. Um That is just correcting the baby's age um for the prematurity. So for a seven day old baby, born at 24 you had a week. So that'll be 25 weeks, gestation for an older baby. Maybe they, they were born at 24 weeks and they're now 12 months old chronologically but corrected, we would refer to those as an eight month old, corrected gestational age. And that's relevant for two main things. One in terms of their growth assessment. So whenever you're plotting the weight and head circumference and length for a preterm baby, we correct for their gestational age up until two years of age. And similarly, for developmental milestones, we allow them the corrected age to meet the milestones that we expect of them though. It's not relevant for immunizations. So we still vaccinate our babies at two months of chronological age. We don't wait until that two months, post term. So we give a fair number of immunizations on the neonatal unit just for a bit of knowledge. Really, I'm not sure how much of this is widely known, but just the structure of neonatal units, which has relevance to the care of preterm babies in a number of ways. But neonatal units in the UK work in networks which are termed operational delivery networks. And there's three kind of standard types of unit. Level, one special care units, they look after the biggest and later gestation infants, level two units, local neonatal, let's look after babies from around 27 weeks and over 800 g and term babies, they might need a short period of intensive care, but less than 48 hours of ventilation or inotropes and then level three units, neonatal intensive care units, look after all babies. So from whatever gestation and however sick, the term baby might be. And the relevance for that is is that we know the outcomes are better if an extreme preterm baby is born in an appropriate unit. So if a baby, if mum comes in threatened preterm labor less than 27 weeks gestation, we know the outcomes for that baby will be better if they are delivered in a neonatal intensive care unit rather than have to be transferred postnatally, other units um provide extra services. So Evelia where I work, we also do neonatal surgery, we also a cardiac center. So we have babies with congenital heart disease deliver with us as well. If a baby does end up somewhere that they need care elsewhere, then there are specialist neonatal transfer teams that move them. There is a small picture of me when I did my stint with the London Neonatal transport team. So basically in neonatal intensive care on wheels and we'll go pick the baby up and transfer them to a high level unit and also take them back once they're better, which is also obviously an important part of the process. And there's just a further info link there for you to read a bit more about that if you wish. So, prematurity, how low do we go? So the it was not so long ago where you wouldn't really get many babies below 24 weeks um being resuscitated. But nowadays, um in select cases, we would resuscitate babies from 22 plus zero weeks, gestation. It's very much dependent on risk factors. And some of those I'll come to and also in an in depth discussion with the parents, it's obviously not a easy conversation to have, but we make sure parents are all aware of the outcome data, which I'm going to be presenting to you this evening. Um And we would offer, if the circumstances were advantageous that we would offer some life support to the baby to see how they responded and see if we can admit them to the neonatal unit once you get up to 24 weeks and above that is legally the legal limit of viability. Um You would generally find most babies would have an attempt at resuscitation from 24 weeks onwards. And I say resuscitation and kind of inverted here. A lot of babies don't need resuscitation. They need what we term a kind of supported transition. Most will come out, they'll cry, the heart will be beating and we just really need to support them into ex life in terms of resuscitation. When we think of resuscitation, we think of chest compressions and adrenaline and emergency drugs. We would generally not go to that extreme at the limits of viability. If they were not responding to airway measures and kind of more basic support, then we would deem that actually in the balance of that baby's best interest that it would not be in their best interest to pursue heroic intensive care. So it's more a kind of philosophy of supported transition. And many I was talking about, you know, being in a baby with optimal risk factors in terms of which would most likely benefit. And there's lots of things that impact that baby's prognosis. Some of those are listed here. So it depends on the mum's health as well if mum is profoundly septic and really unwell, and that can obviously have an impact on the baby, the size of the baby and whether the baby has any known congenital anomalies um for complex reasons, baby girls do better than baby boys. And that's very clear across the data. Um and it's not entirely clear at this stage why um singleton pregnancies do better than multiple multiple pregnancies. The babies always behave like a a younger gestational age. Um if they've been able to optimize with steroids and magnesium sulfate as well as as I was alluding to on the previous slide, er depending on where they actually are. So um in extreme preterm, ideally delivers in a nicu environment that the link here about the BAP guideline is quite an in depth guideline. But for those of you with a particular interest, it's an interesting thing to read just a little trivia point for those with the interest. Um Neonatology is a relatively young specialty. Um ironically and it kind of really all kicked off from JFK and JFK S. Um child was born premature, only around 34 weeks gestation, but had quite severe lung disease and passed away. It was really with the president's child dying a lot of interest and funding went into neonatal care. So you really see a huge rise in neonatal care kind of from the mid to late sixties after that event. Now, this probably I could stop the talk after this slide because this is a lovely infographic from back home, which is the British Association of Perinatal Medicine, which basically summarizes the key outcome statistics um for the lower gestations um from 22 to 26 weeks gestation, I'll just zoom in a little bit for him. So this is a really helpful graphic and we can use this in our counseling to parents as well and it it displays the information and I think quite a nice accessible format, but these are the kind of headline statistics that we have for extreme preterm infants. So really at the real limits of viability 22 weeks, gestation of the babies that we actively aim to stabilize. So some of these conversations, obviously, the parents will decide that they would not be for um for resuscitation and that's completely understandable. Um And, and we would support that family and support that baby to, to what we term comfort care, to keep the baby be comfortable after birth and allow nature to take its course. But of those babies that we do actively um support. At 22 weeks, gestation, only three out of 10 of those babies will survive. And at 23 weeks, four in 10 will survive. And then up to 24 the odds start to go in their favor. And around six in 10 of those babies will survive the pie charts to the right of that. Then show that of those babies that survive how many of them will have a severe disability. Um And severe disabilities will be classed as things like being um having severe cerebral palsy and being wheelchair dependent, having um being blind or having a significant hearing impairment. Um and there's obviously a spectrum of disability below that. Um So as you can see, it's, it's over a 50% chance that the baby will die despite our best efforts at 2223 weeks. But as I said, after 24 the majority of those babies will survive and actually only a minority will have severe disability as they grow up. Um As you might imagine the numbers get better, the later in gestation that you go. So really by the time you're getting up to 2728 weeks, gestation, the vast majority of those babies will survive, it gets kind of less than 5% will pass away at 28 weeks gestation. And again, it's a minority of those that have a real significant disability of the survivors. So that's kind of a snapshot overview and we'll, we'll go into a little bit more detail into different uh outcome measures. Um As we progress through the talk, um per natal optimization, I've already alluded to some of these things, I'm just gonna twist it around so it's slightly easy to read. Um But these are the things that we can do to try and improve the outcomes for babies before and immediately after they're born. Now, some of this relates to our obstetric colleagues in maternity care. Um and these are all the kind of risk factors that we know of in relation to increasing the risk of preterm birth. I'm not going to to read um this list out for you, but you can prove it um at your leisure. And as I said, a lot of this is kind of maternity level care. So us as neonatologists are often not really involved in managing these risk factors. What we can influence and encourage is uh the things lowered down on this list. So, trying to encourage women to deliver in the appropriate place, making sure that they have steroids and magnesium sulfate. So, steroids are critical for um reducing the risks of um respiratory distress syndrome and chronic lung disease, magnesium sulfate given to mum, as we know reduces the rates of cerebral palsy. And if there's um infection, then treating the mum is beneficial to the baby after they're born, delayed cord clamping is beneficial. Maintaining normothermia is critical and it's been shown that um if a baby is admitted to the neonatal intensive care unit, hypothermic, that is an independent risk factor for mortality. So, making sure babies are warm after birth is critical and also encouraging maternal breast milk. Just another little trivia point. I'm sure you're all familiar with the Cochrane Review um organization and their logo. That logo is a little um fox plot graph of the the meta analysis, the systemic um systemat review that was done into antenatal steroids for um chronic lung disease, respiratory distress syndrome prematurity. So, um neonatology is at the heart of the, the Cochrane logo, which is quite nice and a good little pub quiz question. So just of some of the the conditions and controversies and things um that we deal with on the neonatal unit. I'm gonna whizz through these because this is the kind of main focus of the talk but respiratory distress syndrome, that's the lung disease that preterm babies get. There's a big drive to minimize the ventilation that we give them. Um we can give surfactant without intubating them these days and we try and give as gentle ventilation as possible. Some units use prophylactic steroids, um some need steroids to extubate them to reduce the inflammation. And we also give caffeine to reduce apneas, chronic lung disease of prematurity C LD. Um That's kind of the clinical term. The pathological term is bronchopulmonary dysplasia. So, dysplastic uh lung tissue and the simplest definition of that is a baby still needing respiratory support at 36 weeks, gestation. And we know that those babies are at increased risk of complications and infections as they get older. Um Having CD can increase the risk of pulmonary hypertension, which can be very serious. But even babies with CD and even those that go home on home oxygen, the vast majority are off by 12 months of age P DS, paining ductus arteriosis get a lot of attention, but it's a hugely controversial area and the management varies widely depending on which country you are and even depending on what unit you're in. Um So there's still a lot of controversy around there. But if they are going to be treated, we generally use paracetamol or Ibuprofen. And some babies undergo kind of surgical or transcatheter management for them. Some people, babies will be very sick when they're born and be hypotensive and need inotropic support, necrotizing enterocolitis. I'm sure you've heard of can be a devastating disease. Um affects around 5% of pre babies under 32 weeks and unfortunately has quite a high mortality and can also lead to lots of other complications such as short syndrome and liver disease. And some units use probiotics to prevent that. So you might see some babies that have been given probiotics. Babies obviously can have jaundice and we have one conjugated, conjugated and babies with gut problems often develop conjugated jaundice as well. Lingu or hernias are not uncommon in the preterm population, we often like to close them just prior to, they go home. So, um, get them into the as big and as stable as we can and then quickly do it. It's almost kind of a day case procedure before they go home. Establishing feeds is obviously a key thing and some, depending on where you are, they have good neonatal outreach teams that can support NG feeds in the community. Um And you might be familiar with that where you work and there's a few other kind of complications um that we regularly manage, which are listed there. A big thing that obviously has impact longer term is preterm brain injury and there's a few specific types. So we have intraventricular hemorrhage where there's bleeding into the ventricular spaces and that goes from grade one and two, which don't generally cause longer term problems um to grade three and four when actually the bleeding is extending into the brain parenchyma. Um And that's what we term a hemorrhagic parenchymal infarction. So there's involvement of the parenchyma and that is far more linked with adverse neurodevelopmental outcomes. You can also if they've, even if the blood is contained to the ventricle and that can actually stop the reabsorption of the CSF and can lead to a situation of posthemorrhagic ventricular dilatation PH VD and some of those babies need to have um shunts inserted by the neurosurgical team and a horrible condition is periventricular accumulation in particular cystic periventricular leucomalacia, which is pictured in that bottom, right ultrasound scan there where there's kind of degradation and decay of the parenchyma based on kind of a period of poor perfusion. It usually occurs 2 to 3 weeks after the insult. And obviously, it is a devastating thing if we see it, but that will typically affect the babies that have been critically unwell with hemodynamic instability. Another key thing is retinopathy of prematurity. So, this is caused by abnormal development of the retinal vessels and we routinely screen for it in babies less than 32 weeks and less than 1.5 kg. Um And we can treat it with intravitreal injections or laser therapy. And another trivia point is uh rop is the cause of Stevie Wonder's um sight impairment. So, longer term complications, some of those I've already mentioned um and there's various things you might be asked to kind of prescribe and um put on repeat prescriptions in the community. Um Vitamins are very common. The exact formulations depend on, on where you work. Um Some babies need to go home on specialized formulas, some will go home on reflux medications and and some will be on other supplements, but less commonly in these days, I find obviously, neurodisability is one of the key things that we worry about and um it's proportional to the gestational age and birth weight. Um and the presence of one of those specific preterm brain injuries that I talked about and this is one of, um, a more recent study of the percentages of, um, babies based on the gestational age with moderate to severe impairment. Um, just a flag that the, the top of this scale is 70% not 100% because it, it looks worse than it is. Um, but it's kind of similar, um, it, it's slightly worse rates than in the bap and Infographic, which I showed, but that was just focused on severe disability. Um, in this one, it's moderate and severe as well. But you can see that at 2223 weeks, you've kind of got a 5050 chance to have a moderate to severe impairment. And as you get bigger and older in gestation, the likelihood of having that decreases, we also see that these babies can often have kind of er feeding and weaning issues related to oral aversion. Um And our therapy colleagues are very crucial in managing these babies. This is a slide that hasn't come out very well. I appreciate. Um but it, it kind of drills down into a few more specifics. The reference for this article is at the end of the talk. So I'm not gonna dwell on it because I can barely read it. So I'm sure you can't either, but you'll be, you'll have access to the slides and the references and you can perhaps have a look at that in your own time. Um we also know that um prematurity increases the rates of autistic spectrum disorder and ADHD um and to a reasonably high level, so generally around three times the rates for the general population. And again, as you might expect the likelihood of that is dependent on the gestation. Um So there's a kind of relatively recent study that looked at a big cohort of babies and it breaks it down the frequency of their diagnosis dependent on the gestation. But generally speaking, it is a multitude higher than standard term babies as a factor of those. It's probably not surprising that preterm babies can struggle at school compared to their term born peers. And this was a study that looked at the proportion of preterm babies that had special educational needs statements. So formal statements of educational need and as you can see the lowering gestation that you go, the more likely it was that a baby would have a sin in place. The there's a good resource for teachers that came out in Nottingham uni the link of which is there. So if you do know a teacher, it's probably worth forwarding that on to them. But it talks about prematurity and things they can do as teachers to support preterm infants in their classrooms. What I think is interesting just to flag you see that pick up at the end, it's kind of like AJ shaped curve. So the babies that are born and post term are also at risk of complications. Um So they have, there's a proven kind of the optimal time of delivery is around 40 weeks. But I think this is one of the most fascinating slides I've ever seen. And really a sign that we really need to tackle poverty and child health, poverty and the links with that with outcomes is that it really isn't just down to the prematurity. So this was a Scottish study that looked at all, all babies born and mapped their gestation to their, their Scottish index of multiple deprivation um based on their postcodes. Uh uh uh and, and the like. So quintile one indicates the most deprived. And so that's the top dark line and quintile five is the least deprived. So the richest kids is the bottom gray line. And essentially what that shows I draw a line across it. So essentially baby is born at 2526 weeks. Gestation from the richest areas had the same likelihood of a difficulty as a baby born at term from the poorest areas, which I think goes a long way to show that it, it's there's a lot that poverty has to answer for. Um And really the the gestation gestational age impact of communication, language difficulties and that is really not the whole story. So um that's again, the link is in the references at the end, but um a very interesting study so shows there's a lot more we can do to improve our health outcomes of our babies. So just to finish off um just a few slides on the impact into adulthood. Um So this is where I think we it has been kind of underestimated and perhaps neglected um up until now, but we know that preterm babies throughout their life have an increased risk of mortality compared to adults who were born at term. And in part, this is relatively new data because you think as I said at the start, neonatology really only picked up in the late sixties. So babies born at those extreme preterm ages in the sixties, seventies are only now reaching middle age. So we've not really had the chance to assess the impact of prematurity on adults before now. But certainly, the data that's coming out does show that complications persist into adulthood. Um We can break that down by systems, we know in particular they have an increased rates of hypertension and often quite early onset hypertension. The feeling that might be related to the development of nephrons in in the preterm kidney and that predisposing to early onset hypertension. Um It does have an impact on ischemic heart disease and heart failure, but less less convincing than hypertension. We also know that probably related to um the way that they've grown and the management of their lipids in the early preterm period, they can have increased rates of diabetes, both type one and type two rates of lipid disorders. So high cholesterol and triglycerides and the like a and also increased rates of C KD, in particular for Children that had had an acute kidney injury in the neonatal period. Um respiratory, perhaps unsurprisingly, um, babies with chronic lung disease have reduced lung function. Um and across preterm babies, um in adulthood, they have increased bronchodilator use, um increased rates of infections and increased rates of sleep disordered breathing, a neurodisability I've kind of already described but going on into adulthood that it can impact the rates of epilepsy as well as hearing impairment and mental health. And there are again, increased rates of depression, anxiety and psychosis and a Swedish study. As stated, there showed around kind of 2 to 3 times the rates of medication prescriptions for mental health disorders in a preterm population. And again, this is a, a link here to a, an interesting review article that kind of o gives an overview of that in a little bit more detail. It's not all doom and gloom though when you go down into the statistics, it can seem a bit depressing. But when you look at preterm babies quality of life, they're all reported very highly. And parents report good high quality of life for their Children who were born at extreme prematurity. And overall for all he's born less than 28 weeks, gestation, kind of one in five of them will have no major comorbidities going into adulthood. Many preterm babies achieve great things So Laura Trott is a multi gold medal winner, Albert Einstein was born preterm and recently brought the English cricketer made the news and was famously born preterm as well. Um in terms of follow up, I'm very wary of the time. We generally look after our babies up until around two years of age and then refer them on if needed. Um generally to community pediatricians if they need ongoing developmental support. And again, here's a link to a review article all about preterm follow up. So just to summarize things you can do, obviously, we know that preterm babies are at increased risk of complications. So the kind of routine health promotion is all very important and if not more important for this population, early intervention is really key, the earlier we can intervene for babies with problems the better. So you know, really if you have concerns, there's no shame refer them back, they're probably still under some pediatricians care, but if they have been discharged, have a low threshold to get them back in the pediatric services. I make use of the MDT kind of therapy team ST PTO T, they're real experts in managing these babies and we should make the most of that in the middle. There is about supporting parents and that's really key their engagement in health care and health promotion is paramount and it goes wider than just the healthcare appointments and that, but as that poverty graph showed, ensuring that the baby is growing up in the most enriched environment is possible. So supporting parents to access all the benefits and things that they are eligible for is really part of that holistic care. And as I kind of alluded to at the start, it's important that you as people that look after adult patients as well, really do acknowledge the impact of prematurity for their whole life. And when you're dealing with adults, it might not be a silly question to ask if they were born preterm, especially if they're presenting with things perhaps sooner than you would expect. So, you know, a young person with hypertension or kidney disease, it may well be related to their prematurity. So hopefully that's something that will be beneficial to you in your practice. Thanks very much. That was very much a whistle stop tour. There was as I thought half an hour would be enough just to give the highlights. But as I was putting it together, I realized there was so much I could talk about, but I've whizzed through it, but you'll have the slide, you'll have the recording. Here's a link to all the kind of key studies and things that I referenced. And I would be more than happy to answer the questions that have come in, but we'll have to do that after the next talk. Yeah. What we'll do everyone. Um If you write your question in here, I'll make sure that they have been marked with a little question mark that says added to Q and A. This will then start a thread and we'll make sure that you get notified about that thread. OK? So that you can go back, Andrew has said that he'll go back in and he will answer those questions for you. And I'll make sure whoever's asked that question gets notified by us directly that there is an answer there. OK? I've popped in the neonates the crying baby event link into the chat. So if you want to carry on and listen to Andrew for another half an hour, join us in there, Andrew. If you want, you are more than welcome to leave now and click on that and I'll see you in there in a second. Thanks very much. Thank you. So everyone, if you have any further questions, please pop them in the chat and I'll make sure that Andrew gets them, your feedback form will be in your inbox and once completed, then your attendance certificate will be on your medal account. And if you can join us on this event, we'd love to see you. Ok? Thank you very much for coming and hopefully we'll see you again soon. Take care. Bye bye.