66. FIS highlights 2 - Neurosurgical infections, parasitology reg, anti-fungals, NITCAR

Join Jame, Callum and Pals for a discussion on some highlights from FIS 2023: https://microbiologysociety.org/event/full-events-listing/federation-of-infection-societies-fis-conference.html

Mentioned in episode:
ESCMID brain abscess guidelines: https://www.sciencedirect.com/science/article/pii/S1198743X23003993#
ORAL study protocol: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-021-05783-8

ACBLM/ALM: https://www.acb.org.uk/

Pathology networks: https://www.england.nhs.uk/pathology-networks/

UCLH/HTD: https://www.uclh.nhs.uk/our-services/find-service/tropical-and-infectious-diseases
uclh.parasitologyspr@nhs.net

Review article on anti-fungal resistance and global health: https://www.nature.com/articles/s41579-022-00720-1

NITCAR website: https://nitcollaborative.org.uk/wp/

Transcript

0:00

Hi everyone, welcome to the Idiot's Podcast, that's Infectious Disease Insight of two specialists. I'm James, that's Callum, and we're going to tell you everything you need to know about infectious disease. Soon may the editing come to discontinue the tase, oh son, one day when the CRP's done we'll take our leave and go. Hello and welcome back to Fizz, part two. It was great to be able to attend Fizz this year and meet some loyal listeners. James and I were very fortunate to be able to present about this podcast and the journey that we've gone through so far in producing it. A disclaimer is that in that presentation, all the jokes were James. I thought I'd take a moment to interview myself before we get started about one of the sessions that we didn't manage to catch any of the attendees at during Fizz, but I really wanted to share some interesting learning points. The BAA clinical grand round, which is on the Tuesday morning. Having been to a few infection conferences now, I have to say that the clinical grand rounds are always one of my favourites. There's many key learning points for all professions and all grades. I really enjoyed the case based discussion and also Seeing experts put on the spot and having to come up with differentials. Often when we are presented with cases and we know what the diagnosis is already, it's very easy to see how people got there. But the clinical ground round is great because you, you see real time how these experts decision making and problem solving happens. The panel consisted of Harriet Hughes from Wales, Rebecca Sullen from Edinburgh, Kate Templeton from Edinburgh, and Lee Stewart from Glasgow. There were four clinical conundra presented, and to give the game away completely, I, at this point will say spoilers, if you're going to go back and watch the recording of the session, then do so now. So the four cases, the first was a patient's, Who presented with new onset confusion and the diagnosis in the end was meningovascular syphilis. Now, I think in all of the four cases, this is the one that for me made the most sense in terms of the presentation and, and the description of vasculitis, but the learning point that I took from this case was that they added in steroids as the patient was not improving. And this had seemed to have quite a good clinical effect that was later on down the line after they had the antimicrobial management for for syphilis and there was a debate on the panel about the relative merits of keftraxone which was used in this case versus things like benzyl penicillin and I think it went to show the importance of MDT input in management in patients who are complicated as that's how they came to the decision to add steroids which wouldn't be done routinely. The second case was a patient who presented with multiple skin lesions and was young had sort of facial involvement. And the eventual diagnosis was Sweet Syndrome, which I have to say wasn't at all when I was thinking about it, watching the case in my, in my list, which is a inflammatory skin disorder, which I would suggest you look up further because this isn't an infection podcast. But I think the important points there for me were to highlight. As always, as infection specialists, we need to consider the non infective etiologies and our differentials. And also, in this case, the, the key diagnostic test was a skin biopsy and getting, was it, tissue is king? I think one of my consultants has told me before. So always pushing to make sure that you get tissue diagnostics can be really helpful. The third case was a patient who had travelled to Bangladesh and been involved in some building work or proximal to some building work and returned with a respiratory illness and had been quite unwell. And the eventual diagnosis was a histoplasmosis. And again, that, that, the, my learning point from that was that in this case, the B2D glucan test was done and that was strongly positive. And I think that we've always a bit reluctant with these sort of fungal markers because they are very nonspecific. But in this case, it was really useful to push the team towards making that diagnosis. But the discussion was really rich with, with a really wide range of differentials and actually confirming the diagnosis of histoplasmosis. Plasma was quite challenging not least because it is, a lab hazard organism, so you have to be very careful with it. And then the final case was, a patient who had had a transplant, I think liver transplant, and following this had become unwell, had some rejection, lots of steroids. And went on to develop a clinical syndrome which was undiagnosed and developed small bowel obstruction. Which led to theatre and eventually, strongyloidosis was the diagnosis made. Now, this is a really interesting case because when they delve through the travel history and they're presenting it, this isn't really an enemy's differential because there wasn't a travel history that would fit. And then when they went back to the donor, they had found that they had positive serology, but they, again, didn't really have a travel history in keeping. And I think what I took from this was that when you're getting into these really difficult to diagnose, difficult to treat cases, we often think about our epidemiology and travel history and, and, and put risks into brackets. And here, I guess when you get into this rare state, Maybe you have to say okay. Well, maybe there isn't a set travel history, but We're going to still consider things that are travel related. But when when and where you do that is is not straightforward So again, and I think all of these cases really the the key point was they were really difficult diagnostics they involved MDT and even the the most capable infection specialist can't work single handedly and you really rely on your, your colleagues and other professions to, to give advice. And so, yeah, that was, that was some learning points I took from the clinical grand round. and I'll now hand you over to our interviewees to find out some more highlights from PHIS 2023. Hello, we're back at PHIS live 2023. And, we're joined by, I don't know where I was going to say that, we're not, we just edit out. Maybe I better take over. We're live at Fizz 2023 with Naomi Gadsby. Naomi, welcome to the show. Hello. Welcome. How is your Fizz going? Have you got any sort of highlights so far? Key learning points? neurosurgical infection, well neurological neurosurgical infection session this morning. Any highlights you'd like to make? Guidance? Yeah. That was excellent. Really enjoyed that. Yeah. I was there as well. Jayme and I have divided and conquered the conference. There was a lot of insights. What were your sort of, do you have any key learning points from those talks? I think it was interesting about, so I'm interested in molecular diagnostics and what that adds or doesn't add. And I think there is probably limited value in doing 16S on pus and to, to gather more anaerobes, a whole long list of anaerobes that you probably know is going to be there and you're going to cover. And that was quite interesting in terms of, like, whether actually we need better culture methods, and actually, the molecular may or may not add very much to what you're actually going to do in protein to ZB antibiotic cover, apart from, you know, looking for nucardia and other things, and actually whether probably a targeted panel might be better than doing 16S, maybe. That's one of the things I was thinking about, but on pus and brain abscess. But yeah, so that was quite interesting. Yeah, it was really interesting. And they were, one of their key points was if you've got an oral cavity pathogen, then you're likely to have polymicrobial infection, including anaerobes, and to cover it. So I guess that's what you're... Which makes complete sense, whether you detect it by, you know, molecular methods or by culture, or you don't, you're always going to cover for anaerobes. Yeah. And that's certainly our practice, and it, you know, it was kind of backed up with the studies, but... Yeah, I thought it was good. It was also really good to get the insight, because sometimes you read a guideline and you look at the recommendations that they make and you don't quite understand how they got there, even when it's explained. So, they were giving a bit of an explanation about their lack of recommendation on oral oral trans... oral transition around the, like, lack of evidence there around, which is interesting in the context of the push that we're seeing to move to more oral transitions earlier. To say that there's not enough evidence, which doesn't mean it doesn't work. It's just, we don't know. So I wasn't really sure what to do with that, but it's an interesting question, certainly. Because we kind of think that the push to IVOS is a more modern phenomenon, but obviously. The 2000 Bush Journal that is actually, well, this is a thing, and actually when it, when Yakub looks at the evidence, there's not a lot there at that time to support that. And not a lot since, in fairness enough, so that's the idea of the trial that he's... Really putting together. So, so that's kind of interesting in a, has slightly more historical context that Yeah. We're all asking the same questions over definitely, yeah. Go back far enough in the literature and you'll probably find the paper that's been made again. Yeah. And you, you chaired a session at, at for several? Yes. I, yeah, yeah. I've got one today, but I'm so I'm a consultant clinical scientist, and I'm the meeting secretary for the Association of Clinical Biochemistry and Laboratory Medicine. Which, as of next year, will be changing its name to the Association for Laboratory Medicine, which is SNAPIA. A reflective of the fact that our membership is clinical scientists, and predominantly who work across laboratory medicine disciplines. So, obviously, I'm a microbiologist, and a lot of people in the society also are not all biochemists. So we were partnering with Fizz. We put on a couple of sessions. The beauty of being invited to put sessions on is that you get to pick the people and the topics you really want to hear from and hear about. So we had a session yesterday on a difficult, well, management of tricky infections in haematology, oncology, transplant population. And I wanted to split it between fungal, viral and bacterial and pick speakers who would approach it from a very kind of diagnostic perspective. So I think it's nice to bring that element to Fizz. We have a lot around. Management, prevention, treatment, but actually diagnosis is really, really key and I think it's great to have a platform to have up to date kind of updates on where we're currently at in terms of the state of diagnostics. Yeah, that, that fungal diagnostic session was excellent. It was really nice. So Reena's a fantastic speaker. We send a lot of our stuff to Manchester. She's given me advice on cases before and it's just great to have her presence and her overall summary, you know, some, If you get a chance to look, listen back, because that was a recorded session, some really excellent slides there, the heat maps on the new antifungals, and what's what with all these unpronounceable names of antifungals. Yeah, but that was really excellent. And we had Louie Sweeney from, from Manchester. Obviously they deal, they've got a higher gram negative resistance rate than we do up in Edinburgh. And keen to sort of see how they're managing to treat those. And again, she's had a great slide on the most up to date, you know, the gram negative antibiotics and what covers what. Yeah. Interlactamase or resistance mechanism or not. And that was quite, that was quite nice to hear from. And the other thing we've got, we've got a session today, well actually yesterday we had another session on pathology networks, so I think as microbiologists we tend to maybe steer clear of some of the strategic direction and travel of what microbiology services and diagnostic kind of services are doing, and nationally things are different to Scotland and England and Wales. And I think it's good to be aware of some sessions. We had a, NHS England Divine Assange came to speak about pathology networks and consolidation of laboratory services and how things are going in England. And somebody from, we had Susan Lovegrave from, from the Black Country Pathology Services to sort of give us an on the ground assessment of how that has worked or not worked and the challenges around that with microbiology. Yeah. And I think it's one of those things that policy is set. You know, central, from central government, and then actually how it plays out on the ground. And we're obviously, it's the sort of thing that, as microbiologists, we should be involved in those discussions and try and shape some of that change. Because, you know, change is going to happen, and it's better to try and understand how to get involved in that. So if there's any trainees who go, who's, you know, have trusts or health boards that are going through kind of pathology consolidation. And any sort of those changes are perhaps good to get involved so you have an understanding of how things might, how you can influence some of that change. And how would, how would one get involved if they wanted to? So the, each sort of trust or pathology network has a, has a kind of steering group or a team. And often there's always a, you know, clinical lead for that who will be microbiologist or as well as the kind of senior laboratory management. So it's kind of understanding what's going on in your local kind of trust or hospital and asking to join those meetings and just trying to find out a bit more about that, I think. That sounds like a really interesting opportunity. And you've got one more session this afternoon as well. You've been very busy. I know. I was just asked to chair this while this is organised by the BIA, on ophthalmic infections. But yeah, we've got some really great speakers. Some really interesting challenges around just getting antibiotics at the right site of infection, and really rare, diagnosing and treating quite rare complications that end up in somebody's eye. Yeah, there's a whole raft of interest there, I think. Well thanks very much for your time out of your very busy schedule this conference to come and talk to us about some things and I hope that people can maybe try and pick up on that opportunity that you've suggested about pathology networks, which certainly would be an aid, definitely. Thanks very much, guys. Thank you. I'm here with Lara Payne. Lara, thanks for coming on the show. How's your fist been? Yeah, it's been, it's been really exciting. So, you've got a really interesting presentation that's happening later today, is that right? So, my last job, my rotation, I was the UCLH Parasitology Registrar which is the one parasitology reg. For the country, which is, is quite exciting and it's quite niche. And I'm presenting on Occus Mulis. So we've seen a really dramatic increase in eis, which it, it's called alveolar Osis because of how the, the cyst form. So the two types of Akin osis are cystic kinosis, so that's aoc, Occus Granulosis or alveolar Kinosis. Which is Echinococcus multilocularis and it's, it's to do with the definitive host. With the Cystic Echinococcus you get endemic causes in the UK with sheep and foxes. Whereas with E. multilocularis these are always... All imported cases, basically. And where are they coming from? So, yeah, we're seeing quite a lot of cases from Eastern Europe. And these are migrants coming from areas like Latvia and Lithuania. So rural agricultural kind of parts of Eastern Europe. Exactly, rural agricultural parts of Eastern Europe. And then also we've got quite a population of travellers. So these are people who spend the summers in the south of France or chalets in Switzerland. And they're their time there, they, these are small little hotspots of eis and it can cause really quite devastating disease because the, the cysts metastasize the brain, the lungs, the liver. Yeah. And in contrast to EEG granulosis, which is forms these discreet cysts and then more of a, a mass effect, what EIS does is ITR destroys the structures. So you get invasion of the liver. Mm-Hmm. Invasion of the, the brain. And often the definitive treatment is, is things like a liver transplant. So in the, in the lung, what can you do? So if you get it early enough, you can do like hepatectomies. So hepatic resections. buT because of the way that invades the vascular structures and the, the biliary tree emotylocularis is quite challenging for hepatectomies and often. If it's very advanced, then they might need to consider taking out the whole liver. And I think one of the interesting things that we found with our patient cohort is that people are really being diagnosed very late on in their disease. So stage three and four. And at that point sometimes there is no option for definitive management. If it's spread to multiple areas, it's almost like an incurable cancer. And then people are just on long term suppression therapy for life. And what do you use for suppression? So we use albendazole. Okay. So at least it's a easy to tolerate drug, but it doesn't cure it. It just stops. It stops progression. Exactly. And, and actually easy to tolerate for some people, but not all. So we've seen a lot of side effects, especially people if they've been on a bell and dissolved for 10, 20 years. And there is something as well about alveolar echinococcus and that people get more side effects. We've seen people get pancytopenic um, Also, it has full alopecia transomitis is caused by the alveolar organococcus. It's something to do with how the the disease as well affects, affects the body and causes more side effects for alveolar organic kinkosis with the albendazole. I see. And in those cases, we've had to have people on. On things like long term Ambizomes. So yeah, we've had to... Oh, so Ambizoma has some kind of effect, yeah? Yeah, and these are like really small case reports from Germany where there's a high error of it. People have been used as a second or third lead angel and they use things like Ambizome, and then I think also some anti malarials as well have effect. But yeah, really small numbers. Even with our, our cohort of patients with alveolar chanukah cosis. We, we see, we're seeing I think this year we've diagnosed 13 patients already. Oh yeah. In 2011 there was just two patients diagnosed, but we're steadily seeing more patients diagnosed with this disease. And do you think that's because you're better at diagnosing it, or do you think that the prevalence is actually increasing? I think we're probably, with the prevalence, I think it's a bit of both. I think we, we are better at diagnosing it. But unfortunately, there is a significant lag period between people presenting to healthcare facilities and being diagnosed. I think the longest in our cohort was 144 months. From first presentation to a hospital and before diagnosis. And so that's, I think what I'm really trying to raise awareness is that we need to get on the top of these diagnoses earlier because it is a very treatable condition when it's caught early. Yeah but not later on. Exactly. Cool. Is that the talk then? Yeah. Good. Don't need to go. But I will. Definitely. And if somebody has a query case or they want to discuss it, what options are available to them? Yeah, yeah. So UCLA has a Parasitology Registrar which was me but I've handed over the torch now to Erin who's the new Parasitology Registrar and, and the number for that is available. I'm sure probably you have it on your hospital systems. Or there's the general email. So uclh. parasitologyspr at nhs. net. So if you have any queries, especially regarding query hidatid or if something comes up on a radiology report or specifically alveolar echinococcus, we want to know about all these really early on and that we do. serology for this, which is a blot. And then we also do the the general ELISA as well. And you do that at UCLH? Yes, the parasitology reference lab, which is at UCLH. Perfect. Lara, thanks for coming on the show. Oh, and we have an MDT. Every week. I'm sorry, you can't say that now, I've, I've, I've, I've, I've come to the end. I'm here with Twitter superstar and occasional ID physician, Neil Stone. Neil, thanks for coming on the show. Thanks for having me. Just given a presentation on the, in the AMR. session this morning. What were you talking about? So I was talking about the rise of antifungal resistance and I called it the path of yeast resistance. Catchy title in there. No that's good, that's good stuff. And I think we all know about antimicrobial resistance but we always think about antibacterial resistance and that's had loads of focus but antifungal resistance tends to be forgotten and I think that's a big mistake and that's what I was talking about because And I have a serious problem with antifungal resistance as well. Yeah, I mean, not least because we've, you think we don't have many antibacterials, just wait until you see how few antifungals we've got. And most of them have, you know, very similar spectra, you know, thinking of the echidna candens and therefore run resistance mechanism takes them all out. Exactly. And that was one of the focuses of my talk, actually, that we only really actually have three classes of antifungal. and clinical use, certainly for severe fungal infections. Yeah. And some of the mechanisms are very similar. So it doesn't take a huge stretch to imagine that just one or two resistance mechanisms puts you in serious trouble. Yeah, and then you're done. And for all you know, the patient won't tolerate whatever that other class that's been left is. Yeah, absolutely. And I think part of the opening part of my talk was just decades of neglect really in antifungal drug development means we're really suffering from that now that we've got so few and inevitably antifungal resistance is going to creep up on us. That's exactly what's happened. So treatment options are just getting more and more difficult. So did you chat about the new stuff, the your razor fungus, your iverex, the fungi aperture, this is in that. I did. Yeah. That was really in the context of talking about. Candida auris. So you won't be surprised that Candida auris featured quite prominently in the talk. So this is our, it's been called the first fungal superbug. Multi drug resistant yeast, which often has multiple resistance mechanisms, with some of them even being untreatable. There's a strain in New York at the moment which is pan resistant. Really? Jesus. So we are desperate for new drugs. And as you said, there are new drugs coming through now. Finally, which is new rare for antifungals and they've got completely unpronounceable names and you can always tell a mycologist because we can actually say very quickly things like fosmanogepics and ibraxofangirp because we've been practicing saying it for ages. Well, I think that's how you actually get entrance to the, you know, the society of medical mycology. If you can say that, you know, quickly, they just let you in. Exactly, but yeah, they are promising. So certainly, so Phos Manigepix is interesting because it's a completely new mechanism of action. And how does it work again? So it's called something called a GWT anchor protein inhibitor and just putting that in simple terms which is how I like to think of things. These are anchor proteins which basically are like scaffolding in the fungal cell wall. You disrupt that process, the fungal cell wall becomes floppy and wobbly and eventually dies, putting it in very simple terms. But that's completely unique and nothing like anything we've got so far, which is important. Yeah. So the other, the other one, so Ebrexifunga for example, that's pretty much an oral Echinocandon. Yeah, it just has a very slightly different mechanism, which ernt its yeah, so ernt the suffix erp, instead of the standard Echinocandon suffix. That's right, it's known as, it's a class called a triterpenoid, so erp, that's where it comes from. Slightly different, but it's very similar to the Echinocandon, so. Kind of think of, of it as an oral Echinacandon. That's how it was introduced to me as well. We used to try and get it over from America on special licence and all that sort of stuff. And, you know, I'm unfamiliar, I don't know if they've got their licence in the UK yet. They don't, so I know for example in the US it's got FDA approval for vulval vaginal candidiasis and you can buy it there. easily, but at quite high cost but it's not licensed yet in the UK and it usually involves filling out a huge number of forms at five to five on a Friday to get it for a patient, which is usually unsuccessful. But I think it will come to us eventually. It seems strange that you can get it for vulval vaginal candidiasis, but what we want it for is invasive fungal disease, you know? Absolutely. I think that's a good point, actually. And the reason for that is because it's easier to do the studies involve vaginal candidiasis because it's common. And patients aren't very sick, and it can be done in outpatients. That's why with antibacterials, you'll notice they always get licensed first for skin and soft tissue infection. Yep, yeah, yeah. Because there's so much cellulitis, they're pretty stable and easy to recruit. So that tends to be the entry point. But yeah, of course, we are much more interested in it. Well, I'm not belittling vulvar, vaginal candidiasis, which is a huge problem. But in our hospital practice, yes, invasive fungal infection is what we're concerned about more. Yeah, yeah. So anything else in your talk that you want to mention here? I think that was really the, the, the gist of it is what, not only the problems we face, but what we can do about it. I think beyond new antifungal drugs, they're all well and good, but we know from the bacterial world that we just blow them up pretty quickly as it develops. So we need to prevent this happening again. You know, a raised antifungal stewardship, which is exactly the same as antibacterial stewardship, but just as important to prevent the emergence of resistance. Neil Stone, thanks for coming on the show. Thanks very much for having me. So hello, it's Callum here, live at Fizz 2023, and I've just ascended a really interesting session, and I've got the pleasure of interviewing our hosts. The session was on the NITCAR, and I'll hand over to introduce yourself to the listeners. So hi, I'm Katie, I'm the NICAR trainee chair. I'm Jonathan, I'm the communications lead for NICAR. My name's Ashley and I'm the vice chair for NICAR. And Andrew Kirby, consultant chair. Thanks everyone. So maybe I can ask first with the, the question that I know the answer to, but I'm not sure all our listeners would know, which is, what is NICAR? NICAR is the National Infection Team's collaborative for audit and research and we focus on collaborative research. Yeah, so the idea of NITCAR is essentially to to have a UK wide collaboration Projects that generally trainees or, or the healthcare infection specialists will bring forward. They come usually kind of with, with the idea initially. We, and we help them to kind of build, build a more detailed protocol around how they can transform their. ideas to, to national projects and, and hopefully utilizing the networks that we have with, with different infection specialists across the country to get kind of some maybe more robust data from, from multi centers. Yeah, and, and that kind of adds to the, to the whole pool of data that they would otherwise be able to access. So NCCAR can help with planning the project, with data collection or data analysis, all the way through to publication. And we have monthly meetings on Teams as well, which all the project leads are invited to. So it provides that area for communication. sort of touch base. Yeah. And I think all trainees across the country have to do an audit projects and service evaluations. And so the idea is that instead of those people doing local projects that everyone contributes to a collective project and get something a bit from, as Jonathan said, a more robust set of data that can be used. One of our key focuses and as well is not just including the infection trainees, but including clinical scientists. infection prevention nurses and pharmacists as well. Definitely. We're a big fan of every career out there. So we want as many people from as many different aspects in healthcare to get involved. Brilliant. Thanks, everybody. I'm having just attended the session. I can say that there was some really exciting projects that have been done or ongoing. What? What sort of things would you what? The sort of upcoming projects that you'd like to share with our listeners? What can we look forward to coming out soon? Hopefully, well, sir, I'm currently working with Dan Newport, who's a doctor at Birmingham, I think, at the moment, NHS Trust. And we're doing a project called Salvage, which is about investigating how many hospitals have guidance available on line infections and looking at line locks as well, because we know that we tend to advise them from a microbiology point of view, but perhaps in the wider hospital, people maybe don't encounter them as much. So we're looking into whether they have guidance available. whether guidance is followed. what the microbiology team would recommend in the situation of a line, a line infection, and whether that guidance was followed appropriately, or whether there was a reason that it was perhaps changed. So it'll be interesting to see how the different hospitals deal with line infections. Currently open for local recruitment at the moment, but we're looking to become looking to open to national recruitment in January. So that'll be interesting to see what's going on in the different hospitals. Yeah, it's a big problem, line infections, so I'm glad that you're looking, looking at that one. The other studies that are looking at starting to recruit in the new year are JointCase, which is a study working alongside Orthopaedics to look at the air quality in theatre. They're hoping to start recruiting in January. So, there's more information on our website but it looks like a really... Another really important study coming up and there is the DI Blood UK study, which is a exploratory survey. It's run by Vanessa Anton Debaske down at St. George's, and that's a 17 point exploratory survey looking at how labs in the UK process blood culture samples at the moment with a real focus to see if. UK labs are prepared for rapid diagnostics in the future. Thanks. So lots of really exciting work going on. So how, how can trainees or other professional groups that you mentioned there, that are based in the UK, how can they get involved in NICAR? What would you, what would you suggest they do? So I'd suggest at whatever stage you're up to with any ideas that you have, you get in touch with, with KnitCart. yoU can get in touch via our email at chair at knitcollaborative. org. uk. And we do have a website, which I'm sure you'll find with a bit of Googling. So... At whatever stage the idea is at and, and, and kind of whatever support you have currently for the I for the project idea. And then please get in touch and we can, we can work through it with you. And then we can, you know, if we, if we need additional kind of specialist advice, we can always use our networks to access that ourselves. And then kind of can. Contain that idea into, to, to a functioning project. And for those trainees who don't want to lead a project nationally, which is understandable, there's keep an eye on our newsletter, which comes out through the BIA or on our website, there's a list of projects that are ongoing or coming up. And those projects are always looking for, trainees to take part in those audit service valuations or research projects. So keep an eye on those and get in touch with the, the project leads on those and hopefully they'll be able to include you in those. And to try and persuade people, if you're interested in getting involved in a project that is already in existence, I think most projects do offer authorship. For the lead trainee, correct me if I'm wrong, Andrew. So, yeah, projects look to offer authorship where they can do. So, look at the deal that's being offered in that project. The project protocol should describe what criteria need to be met from a trainee to get authorship, or to be acknowledged on a publication downstream. Yeah, and I think I'd emphasize and try and emphasize the point that if Nick Harkin kind of have as much or as little involvement as as the kind of lead really want Want us to have and we can help with that kind of dissemination of well established ideas and projects or we can really help with that development. So I, I think if it depends really on the people approaching us what kind of they want from, from what we can provide. And also I'd say that each year NICAR looks to bring in new people to the committee. So if you're interested in a committee role, whether that be meeting secretary, IT support, chairs, consulting then get in touch because we, we do want to get representation from around the country to get involved with the, the committee. from everyone in healthcare as well. No matter what your job is, we're really big fans. Well, we're big fans of clinical scientists and other healthcare groups on the Infection podcast. Yeah, it's podcast, I couldn't have named the podcast wrong. It's embarrassing. So thanks very much for your time to sort of jump on you at the end of the session there. I'm sure our listeners will be really interested. whether they're UK based and maybe they can get involved or maybe they're based in a different part of the world and they can maybe learn something from Nick Carr and, and have something similar there. And what I'll do is I'll put the link and the email in the, in the podcast notes so you can have a look there and please do get in touch because Nick Carr doing really important work and, and helping people do audits that are, are going to have a big impact. So thanks everyone. Thank you. Thank you. Thank you for listening to the idiots podcast. We are supported by the British Infection Association. But they do not have creative control over the episode content, so please don't blame them if we get something wrong. Questions, comments, suggestions? Why don't you send them in to idiotspodcasting at gmail. com. Have a five star review in your pocket? Calum and I would love to have it. Please drop it in your podcast player of choice. We tweet at idiots underscore pod, and if you want to donate to support the show, there's a link to do so in the description. But until next time, I'm Jane. I'm Callum. See you now. Now that the episode's done, we hope you learned and had lots of fun, so go forth and treat people with some of what you now know.