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All right. Um, hello everyone. I'm Jason. Um, all go in there. Um, what I've put on the, on the presentation. Um, can I just, um, make sure that people can hear me if they can put something in the chat? It's my first time doing this. So, um, I'm anticipating quite a few hiccups along the way, but hopefully not too many. Uh, I know it's due to start in at seven o'clock, but I think we'll just wait for a few minutes. Um, so that people can join or when people do remember that they did sign up for it. Thanks to you. All right, I think I'm gonna start otherwise it would be very unfair for those who did show up on time. So let me just get my slice ready. So, yeah, thanks everyone for coming online. Um, it's your Thursday evening. So, um, I hope not to take up too much time of yours. Um, so I'm Jason, one of the, uh, foundation year one doctors um, in Gloucestershire and I'm quite interested in ent, that's why I'm speaking to you about this. Um, so we'll be going through hearing loss and audiogram interpretation today. Um and from the survey results, um it looks like ENT is not a very well covered um topic in a lot of medical schools. And I remember in my medical school we had very little ent exposure as well. So, and um I think I practically lent all of my ENT on passed and ques meed. Um So I just hope to go through some of the points that I have helped that I've found helpful in my ent placement and what I've picked up in my ent electives and hopefully to provide you guys really with a, with a set of tools um to go through a ent history and to be able to interpret um very common ent examinations and investigations to reach a, a right diagnosis. Sorry, moving on to the topics covered. So firstly, I would like to go through a little bit about the basic anatomy and physiology of hearing. So I bring you guys um back to sort of first year and second year physiology lectures just to um, so bear in mind where the problem would be um in different presentations. And I've always, I've always found it useful um to have that in mind when I'm able to link anatomy to um the, the pathology. And next, we'll go through very common differentials and how do we actually assess them as if it's as if we're in a ent um hot clinic. So we'll go through um history and examinations and how do we interpret those? And lastly, um, we'll go through the pure tone audio audiogram, which is the most common audiogram that you'll find in exams and, um, in, in acies, uh, or whatever that's called. Now, um, that really shows my age in terms of when I've trained. All right. Is there any questions from anyone? If not? I think we should just begin. Sorry. II have to jump back and forth because the chat disappears. Um When I, when I present. All right. So starting with the basic anatomy of hearing, um the ears are divided into three main parts. Um So the outer year, the middle year and the inner year, um the outer ear contains what we can see from the outside, which is a, which is also called the pinna, um including all of the external acoustic meatus um and ends in the ear at the eardrum or the tympanic membrane. Um The middle year consists of the tympanic man brain and the set of bones which we collectively called um ossicles. Um and ends where the sta the stae foot plate meets uh the, the oval window here in the, in the year. And basically the inner ear contains all of the sort of um sensory organs um that transmit, that converts uh connecting energy from sound waves to electrical impulses that our brain perceives. So, moving on to um a a close examination of the middle year and the inner ear. So, we've got the tympanic membrane here, which is the start of the middle year. And we've got this set of bones that I have mentioned is called the ossicles, which is made out of three main bones. We've got the malleus, uh the Incas in the middle and we've got the stapes. And for those who have already been taught how to do an endoscopy, you will probably remember one of the landmarks that we look for is the hand of the mellas, which is here, which is attached to the tympanic membrane. So the sound would be hitting the tympanic membrane cause it cause it to, to vibrate. And that vibration is amplified through this chain of bones. Um and ultimately reaching the sta piece uh which is also the smallest bone in your body and the stapes, it's attached to the oval window, that's, that's here. And then we've got the inner ear which is made after cochlear, which is responsible for hearing. I've got the um three sort of semicircular canals that's responsible for, for balance. Um So I think it, I thought it would be useful to go through the chain of transmission uh within the sound. And just as I've asked you guys to answer in the quiz um in the registration. Um So when the sound waves goes through the tympanic membrane through the ossicles and hitting the over window, which is sort of the opening of one of the openings in the cochlear it causes vibration of this liquid called perilymph um that's contained within the cochlear in a sense vibration all the way down throughout the cochlear causing the membranes within the cochlear to vibrate as well. And the round window here which is the other opening of the cochlea is able to expand and this allows um the wave of fluid the the motion of the waves to occur within such a tiny structure. And so how does all of that get converted to a electrical signal? It's down to the hair cells um within the cochlear itself. So if we cut the cochlear into a cross section, you'll find three main compartments that are separated by different membranes. So we've got the sla vestibuli Skela media and Skela tympani and within scala media, it contains this structure called the organ of corti, which is the um sort of the sensory organ that converts the kinetic energy from the sound waves to electrical signals. So, if you look closer um at the hairstyle, which is, which makes up the organ of co co it's got a very funny looking structure which is very specialized. Um So this whole thing, I hope you guys can see my cursor, um it's called the hair cell. And what's sticking on top of that. Um It's called the sterilia. It's a bit like the cilia that you find in um the gut mucosa. And what's on top of these sterilia are these mechanically gated ion channels that allows potassium to come in. So when the sterilia moves as a result of the sound waves, um these mechanically gated um ion channels actually opens when the sero cilia moves. And that causes an influx of potassium from the perilymph into the hair cells and ultimately causing a release of neurotransmitters. Um when the cells is depolarized or the inhibition of, of neurotransmitters being released when the cells is hyperpolarising, and that ultimately changes the uh kinetic energy into um electrical signal that our brain can interpret. And I hope by going through um the anatomy of the year, um I really hope to made you guys appreciate how delicate the structures are within the years and therefore how easily damaged. Um they could be um by noise pollutions or um autotoxic drugs. So, moving on to um assessing common differentials of hearing loss. Um Actually, before we do that, um if you guys have any questions, um please just pop them and chat and I'm more than happy to answer all of those questions and I hope to finish this talk in um about half an hour's time. So we have some time to um go through uh the questions, right? So in this part, we'll basic, we'll, we'll go through the history and um the common examination that we do when a patient comes into a clinic presenting with, with hearing loss. So how to take a hearing loss history. Um One of my good friend gives me a really, gave me a really good tip doing my osk. Um He said, it's always very important to understand the context and chronology of the patient's presentation to get a really good idea of what the patient has been through themselves before coming to seek medical attention. So it's basically like taking, for example, AAA pain history using your Socrates. So asking very um useful questions such as when did a hearing loss start? How long has that been going on for? Has that gotten better or worse? And um it's also important to get a bit of a history on what was the patient doing when the hearing loss started? Was the patient um experiencing, did they wake up with a hearing loss or did they unfortunately hit their head over something that they fell down? Um a mountain which is actually a case that I saw which resulted in a fracture within a temporal bone, cutting straight into the cochlear, which ultimately resulted in sort of irreversible hearing loss. Unfortunately, um for pediatric history or elderly patients, foreign bodies, um it could be a cause of hearing loss. Um Any habits of um evacuating ear wax, uh could be a very common cause of hearing loss, any recent air travel or diving which could point towards barrel trauma um that results in a in a perforation of the tympanic membrane, any recent infections, um which we'll talk about later and any occupational exposure to excessive noise. Do they work as a mechanic somewhere? Um, and just like in, in a very common pain history associated symptoms, very useful for us to, um, get an idea of which diagnosis would be more, um, possible. So, things to ask includes when they have this hearing loss, have they noticed any discharge? Um, how does it look like? What sort of discharge is, is it, is it clear, is it, um bloody or is it um sort of quite murky and foul smelling? Which points to a particular diagnosis? Has there been any pain? Um I told you and tinnitus, which is very common associated symptom with hearing loss, any vertical or naus nauseousness which can point to um sort of further involvement of the semicircular canals and some important reflex to notice in a hearing loss history, um which is quite important to bear in mind, any history. Um So any recent trauma which will then require sort of urgent surgical intervention and since meningitis could present as hearing loss, so any systemic symptoms that might suggest meningitis such as feeling generally unwell fatigued, um having a fever, headache, uh photophobia, neck stiffness and any facial weakness, which can point towards a um sort of neurological cause of hearing loss or um sort of surrounding nerve involvement. And last but not least, um a good medication history and surgical history will be very beneficial uh in this context. So any recent antibiotics, any loop diuretics, uh which can contribute to hearing loss and any recent ear surgery, which could um warrant quite urgent attention as well. So in terms of examination, um a few bits that you want to cover. So a for general ear examination, looking at the outer ear, uh if there's any uh sort of obvious deformities, um a cranial nerve exam will be very helpful to discern if there's any other um um potential sort of involvement of other cranial nerves and especially with the facial nerve, the seventh nerve because it sits quite closely to the vestibulocochlear nerve in the brainstem. And it'll be useful to test their um hearing grossly. So how, how well they can hear whispers um by masking the other ear and the r and really the notorious Rennie and Webers test that we'll go through in, in just a moment and oscopy, uh which is quite useful to um discern if there's any pathologies within the external acoustic meatus or the tympanic membrane itself. Um which I've always found is, is quite a difficult skill and um no sort of ear canals look the same. Some can be quite um sort of want bendy, which is quite tricky. So, um I've always found Rennie's and Webers quite confusing when I was first taught this. But what I've realized over the years is that it's actually a really, really simple test and I hope this presentation will be able to clear any sort of misunderstanding or confusion that you might have with Rennie and Webers. So, traditionally, um, we performed the Rennie's test first and then the Weber's test and, um, I'll just go through how you exac how do you perform these tests? Um, exactly. Um, so ideally you'll want to get a tuning fork of 512 Hertz. And I remember in my medical school they used to try to confuse us by placing a few different tuning forks, um especially the 128 Hertz and the 512 Hertz in the same box. Um And how I've always remembered it was that comparing to a longer 128 Hertz tuning fork, it's probably less painful to, to insert the, the shorter tuning fork into your ear. So that's why that's, that's um the one to use in Re and Webers. And the reason why we're so particular with the 512 Hertz tuning fork is because of the acoustic decay of the tuning fork given high frequency. Um The decay time is very, very, very long. Um So it's very helpful for us to check the air conduction ability of the patient. So what you would do is to ring the tuning fork um on your elbow or you try to pinch the ends of the tuning fork together, you place the end of the tuning fork at the patient's Mastoid process on one side and you ask the patient to let you know when they can no longer hear the vibration or the sound coming from tuning folk at the back of their head. And once that they, they tell you, um, they can no longer hear from the back of the head, bring the tuning fork right next to their ears and ask them if they can hear the ringing that's transmitting from the tuning fork to the ear. And if they are able to, to do that and tell you that they can hear the tuning fork when you bring the tuning fork back to their ear. Um That will suggest that the air conduction is better than the burn conduction. Um which in technical sense is a positive Rennie's test. OK. Um So you do that for one year and then you move on to the other year. OK. Um I'm aware that this is probably a bit confusing. Does anyone have any questions about, about this? Ok. So if there's a, if there's no question, I would move on or if, um, if you guys have any parts that you're confused, I'm happy to talk over again at the end of the talk. OK. Um So that's Renny's test. It helps us to do discern um, if air conduction is better than, than bone conduction. And um, and yes in Webers test, it's a bit more straightforward. Um So you still use the five and 12 Hertz tuning fork and you ring it and you place in the middle of the patient's forehead and you ask the patient which ear they can hear the ringing better. And if they say the right ear is better, then you would describe this test as the Weber test, then electrolyse this to the right. Um However, if the Weber's test is on the same is, is the same on both sides, then you just say um there's no electoral in Weber's test. And at this point, you might be wondering if the Renny's test can tell us whether um the air conduction is better or the burn conduction is better. Why do we do a Weber's test? Because actually in, in the Renny's test, we're able to discern the two main categories of hearing loss is a conductive, which means there's a blockage among the um transmission of sound somewhere from the outer year all the way to the end of middle year or is it, or is it a nerve problem? Is it a cochlear failure or is it a um sort of cranial nerve aches, vestibular cochlear nerve problem? But in the context where there's actually a sensory neural hearing loss, for example, in the left ear, the, the RS test for that ear would be that the bone conduction would be better than the air conduction because the nerves are just, it's just not working. Um And it would be a false negative Rennie's test because the bone conduction is actually transmitted through the Goodyear um which is the right ear. Um So then you need Weber's test to figure out whether it was a true conductive hearing loss or is it a, is it a actually a sensory neural hearing loss? There was a long string of argument to follow, say. Um So I hope that was clear. Um I think it will be clearer if we're able to go through some of the um cases later. Yeah. So that's basically the rationale between the Rennie's and Weber test. So just to go through things again. So Rennie and Webers tests help you to discern whether the patient is experiencing conductive hearing loss or sensory neural hearing loss. Is it nerve failure or sound transmission failure? And uh a sound transmission failure means the nerves in that you're experiencing hearing loss is still working perfectly. It's just that the sound is not able to get to the cochlear. Um So the Rennie's test help us to identify um which ear has better um air conduction, which is the normal way of hearing and it will help us to identify if the, if the ear has any conductive hearing loss. But in the case of sensory neural hearing loss, you will have a false positive, false negative um Rennie's test because the nerve is just not working. So there wouldn't, there wouldn't be any perception of sound when you bring the tuning fok to the ear. So that's why the Weber's tests come in. So if we move on to the next slide. Um I've really just put it in because I just thought um the diagram is really trippy um with the eyes. Um So when the weather's test come in, if the patient has sensory neural hearing loss, their bone conduction would be um that on, on this year as well. S but when you do the Webers test, it will electrolytes to the good ear the year that is working. So it'll help us differentiate um whether that's a true conductive hearing loss or a sensory neuro hearing loss and counterintuitively, I think that's why re and we is so confusing, a conductive hearing loss in a Weber's test um actually sounds louder in the bad ear where conductive hearing loss is happening. Um So, in this case, in a conductive hearing loss here, the bad year would have a negative re where the bone conduction is better than the air conduction because the transmission of sound is bad but counterintuitively, the Weber's test sounds louder in the bad ear. And there are a few theories behind that. Um One of the more convincing one that I've read is that let's say you have got um a tumor or like a, like a cholecyst steatoma growing in the um ear canal. It creates this, this sort of echo chamber when Weber's test is performed and therefore reinforcing that noise transmitting to the cochlear. So, yeah, so, so that's Rennie's and Weber's test um which is really helpful in discerning conductive versus sensory neural hearing loss. OK. Um I'll go through any questions um of R some of us at the end, I hope that was clear enough. So, moving on to audiogram interpretation, um I think really the key is to understand the layout of um audiograms. So on the Y axis, the vertical axis, we've got um hearing levels uh measured in decibels, which means how much, how loud the sound needs to be for the patient to perceive that sound and down on the ax horizontal axis, you've got uh frequency and I think it's quite important to sort of learn the keys er of, of audiogram. So for air conduction, um it's, it's dots and crosses. So um I've, I've always struggled to remember it. Uh So to me, the right is always a dot or circle because there's more curves in R and X is always left because L is more sort of angular. I think that's, that might be helpful to remember. So that represents the air conduction of the right and left ear which will be plotted there and the bone conduction is always plotted um by er things like that shapes like brackets. So just to start off with an example, so we've got dots and crosses here, which means um it's a diagram showing us air conduction of the left and right here. And um I've made this audiogram um which is supposed to represent normal hearing. So across all frequencies. Um The the patient is able to hear um within sort of um 2525 decibels. So from 0 to to 25 will be considered as normal. And how these tests have actually conducted is the patient will be wearing earphones in a very quiet room and the audiologist will be playing sounds of different frequencies and we will ask the patient to press the button when they are able to first perceive that sound, which give us these markings. Um So that's how it, it's, it's sort of a subjective reporting from, from the patient, but that's one of the best tests that we can we have. So moving on to another sort of audio gram, er we've got dots and cross this again. So those are your um air conduction and we've got a funny looking bracket here which represents bone conduction. So here we can see the, the right air conduction is significantly worse than all of the other markers here, which suggests there's a moderate hearing loss in the air conduction um of, of this patient. So what what this really means um or represents is that there's a air bone gap which is suggestive of what we call conductive hearing loss. Ok. So it's a bit like a visual representation of the Rennie's and Webers where um the patients would always report the bone conduction sounds better. And then when it's through their um ears, the transmission of sound is not getting to their cochlear. That's why they are reporting. Um they will need a higher amplitude um a higher energy um to hear through air conduction. So that's AAA very classic looking conductive hearing loss audiogram. So I hope that's helpful. So, just a bit of recap um the horizontal axis er represents the Hertz uh the, the, the frequency of the sound um and the vertigo axis represents the um the de sort of how loud sound is in, in decibels, um which is how loud the patient, uh how loud it needs to be for the patient to hear it. And the dots and crosses uh the right ear is always a dot or circle. Um The left ear, air conduction is always across and for bone conduction, it's always some sort of um bracket looking thing. And yeah, I guess it makes sense. It looks like the right ear and the left ear. Ok. So moving on from audiogram, um I thought it would be useful to go through some cases before. Um we, we finish. So let's start with um this word II can never pronounce, I'm gonna try. Um So pre Biss is a very fancy word for age related hearing loss. Um And it's, it's always thought to be um due to cochlear hair, cell degeneration, um and the loss of auditory nerve fibers in cranial nerve eight, the vascular cochlear nerve. And as you can see, er in this very nice um electral electro microscopy diagram er of or image these hair cells are so delicate. You can imagine how easily they could be damaged with very loud high energy noises. So given the n the etiology of of this disease, it's a type of sensory neural hearing loss and going back to the history taking, how do we actually get reach this diagnosis? Um So these patients often present um older and often 60 years old is a cut off. It's often a bilateral progressive hearing loss. So it doesn't really get better with time if anything gets worse. And it's often bilateral because the amount of noise damage is the same um across both years, usually across time. And um one of the more interesting um thing you can ask the patient or their family members because that's often who, who first notice when they're turning on the TV, or, or, or um radio a bit louder is that they have really sort of, it's really challenging for these patients to hear you when they're in a very noisy environment, like in, in, in a coffee shop or, or in a, in a tube station. And it's actually one of the more prominent signs for age related hearing loss and it is often associated with tinnitus. So, ringing in the ears and risk factors to explore with the patient includes occupational exposure like we've talked about in the beginning of the talk and any recent or past medical history of autotoxic medications. So, moving on to another type, um, of hearing loss that comes to the clinic quite often. It's, um SS NHL. So it's sudden sensory neural hearing loss. There's a big debate on what actually causes it. Uh, some people theorize that it's um, a bit like Ati A where there's a transient sort of embolic or, or um blockage of the terminal arteries that supplies the, the cochlear nerve resulting in nerve failure. And some theorize that it might be due to viral infections like mumps or it could be an autoimmune process. Um uh a little bit like optic neuritis and MS. So, in terms of the context and chronology of patients who present with sudden sensory neural hearing loss, as the name suggests, it's a, it's a very sudden and often unilateral hearing loss. So often patient presents after they wake up and noticing that that death in, in one year, most common age group is between the 4050 year olds and it may be associated with tinnitus. And it's quite important to get this diagnosed very early on um with an audiogram. So we use the dr of three to diagnose uh er this hearing loss where the hearing loss has to be of greater than 30 decibels in three consecutive frequencies. And given, given the name of this disease, the onset has to be within three days. And the reason why I've put a Cochrane Cochrane Review um logo here is because it, it recommends to commence these patients on high dose steroid like 60 mg. Um However, when I looked into the Cochrane review done in 2013, he only had three randomized controlled trials and only one showed statistically significant um benefit in providing steroids. So the evidence are actually a bit mixed for this disease. But the recommendation is to give um these patients high dose steroids. Um and I'm guessing that it relates to the autoimmune um process um in this, in this disease. So, moving on to two sort of um tumor related cause of hearing loss that I thought um can be quite confusing for some people. So we've got Cholly choleste toma here on your left. I've got acoustic neuroma on your right. Um They're both sort of, they're both uh abnormal growths, but they result in very different um pathways resulting in the hearing loss. So, ca talking about cholesteatoma first, it is a um uncontrolled growth of squamous cell epithelium starting really in the um external acoustic meatus that erodes through the middle ear and to the mastoid air cells in the temporal bone. Um And because of this erosion and invasion into the middle ear, patients often presents with chronic or recurrent middle ear infection. A lot of pain and discharge and and the discharge is often uh kind of uh sort of mm foul smelling as I've written here and it is often a unilateral disease. So, patient will be um describing a unilateral progressive hearing loss. Um What's really useful in in these patients is to um take a look into the um ear canal using endoscopy to look for any signs of, of chol cholesteatoma. And on the other hand, we've got acoustic neuroma here um which is a tumor that arise from the myelin sheath of the, of the sn cells in, in Creon nerve, eight, the vest of the cochlear nerve in this region of the brain stem. Um It's called the cerebellopontine angle. So that's the um pons and that's where it connects to the brain stem there. Um The best imaging modality for suspected acoustic neuroma is actually MRI. So this is at one image um where the the fats actually light up. So the common sign is is called the ice cream cone sign. I'm not sure if you guys can appreciate that, but it's often round on the top and sort of triangular at the end. And given the proximity of cr of eight to crinan of seven, we look for any sort of um signs of systemic involvement. So it might be associated with uh facial weakness or or numbness. Um when it also uh affects the trigeminal nerve patients often present with headache as this is a tumor that's growing in their head. And given the cerebellar involvement, patient can often present with aia or imbalance in their walking as well. So it's often unilateral progressive hearing loss as well. And just on a slight note, patients that present with bilateral progressive hearing loss, that's, that's found to be acoustic neuroma is very suggestive of uh neurofibromatosis to NF two, which is a hereditary condition. So those are the two um sort of tumor related uh causes of hearing loss. And next, we have autos sclerosis, which is a very interesting disease. So you probably remember this diagram is the middle year and uh your inner year where the stapes here connects to the oval window. O sclerosis um is a disease of abnormal bone growth of the sties foot plate causing fixation onto the oval window and, and it ultimately results in inability for the um sta to transmit sound uh from the over window into the cochlear anymore. So it's a type of conductive hearing loss. It's it is preventing the transmission of sound and it's often a a progressive unilateral to bilateral hearing loss over many, many years. And in terms of epidemiological data, um female are, are twice more likely to um experience or sclerosis than men. And there have been anecdotal evidence or, or, or reports that these um hearing loss worsens during pregnancy um due to hormonal involvement. And it's often a question that you can ask if you're suspecting als sclerosis. Um if a young patient presents with these symptoms, um if they've had previous pregnancy and if they have um noticed hearing worsening during their pregnancy and given the nature of this this disease. Um It's, there's often AAA relatively strong family history. One of the associated symptoms could be vertical in atherosclerosis and what they actually do to fix otosclerosis is actually quite clever. They use lasers to burn off. Um these articular points in of the, of the sta piece here where the sta connected anchors and around the oval window uh using laser and then they um put in an artificial prosthesis that replaces, um, the, the sta piece to continue to transmit sound to the over window. Um, and patients often report hearing instantly, becoming better after surgery. So quite, quite a really good surgery. So, last but not least, um, some of the medications, infections that can contribute to, to hearing loss. So some of the ones that I've come across so far in my very short f one career is actually loop diuretic when I was on cardiology, um, aminoglycoside and marker like er antibiotics. So your Gentamicin, Amikacin, your Erythromycins platinum based, uh, cytotoxic chemo agents like CISplatin antimalarials, um, drugs as well. And really for, um, medical students that are in their final years or going to FBF one very soon. Um, autotoxic is a horrible side effect of these medications, but it's not really a strong contraindication for these medications. If they are in heart failure, then they need to be offloaded was to give the flusemide. But, um, as incoming doctors, it's quite useful to think about how do we actually reduce the risk of autotoxicity in these patients. So for example, um flusemide, the higher the higher the dose, the more likely they will be experiencing autotoxicity. And you can think about a continuous infusion um using IV er instead of boluses, which is actually better in preventing autotoxicity and for things like antibiotics, um monitoring gent levels er is quite important uh and that other implication as well like renal impairment, infective causes um to contribute to hearing loss as well. So, acute otitis media and acute otitis externa uh labyrinthitis, which is a result of uh viral infections normally associated with um vertigo as well and meningitis as we've talked about. Yeah. So that's the end of my talk. These are my references all usually for my, all the beautiful drawings that I have reference to hear. So not too bad with the time actually. All right. So I hope I've not bored you guys. Um Does anyone have any questions at all? Ok. Um I thought it might be fun to do a little quiz if you guys don't mind. So if you guys can use your phone to scan the QR code or if you go to Ment meter ment.com, good in the chat and the login code should be 6532 215. I really hope this works. Um So we'll see. Yeah. Yeah. How would I know? Good. Let's see if the code works. 6532. I'm sorry. Ok. Give me one second. Yes. Yes. Ok. Mhm. So. Right. Yeah. All right. I'm not really sure if that would work unfortunately. Yeah. All right. Then since I don't think the quiz is working, um, I think that's, that will be the end of my talk. Um Thanks everyone for your attention and if there's anyone that has any questions, I'm happy to answer at the end. Um, if you guys can fill out a feedback form for me, that would be greatly appreciated. Um It's a link down below and, and yeah, I hope I've not confused you more and before the talk. Mm. Oh, yeah, I see. Ok. Yeah, they, I'll try to quiz next time. Ok. And yeah, if you fill out the feedback form and have any more questions, feel free to log off and have a good Thursday evening. Thank you guys for attending. I mean, just stay on to eight just in case if there's any last minute questions.