#8 Collapses

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All you need to do to sign up is go to pacesahead.com and I advertise for these two sponsors because I genuinely believe that combined they essentially guarantee you'll get that all important parts in Paces. So use the discount code Pre Paces 15 at quesimade.com and sign up today. Welcome along to this episode of the Pre Paces podcast. I'm your host Dr Sam Williams and this week we welcome Dr Ashley Nisbit, consultant cardiologist to the show where we discuss the topic of collapses and we discussed the key features to focus on when you're taking history from these patients. I do have a slight disclaimer to mention in this episode which is that just before we recorded our regular feature quiz the consultant there was a slight microphone glitch it switched to recording from my laptop rather than my podcasting mic so I just thought I'd give you a little heads up about that in case you're wondering why it sounded slightly different. Anyway I know lots of you must be working so hard towards your exams so here at the show we really do wish you all the best for your preparation your vision and your exam itself when that time finally arrives. Please do subscribe to the show or whatever podcasting app you use to make sure you don't miss an episode and without further ado on with the show. Welcome to the Pre Paces podcast the only podcast that prepares you as well for Paces as a loaded dose of amiodarine prepares you for a lifetime of defective thyroid function. Today's episode we're covering a topic that is certain to get your heart racing and it's a favorite in both station five and the history taking station and that is a patient presenting with a collapse. Joining us is truly the Queen B of Syncopy it's Dr Ashley Nisbit. Consultant cardiologist and electrophysiologist at the Bristol Heart Institute. She is also an honorary senior lecturer at the University of Bristol and is also the cardiology training program director in the seventeenery. Not only that but she also regularly examines on Paces so we are extremely grateful that she's managed to carve out some time in her busy schedule to appear on the podcast so thank you so much for joining us Ashley. No problem. And I know for a fact this has come up in multiple different forms in Paces in the past so why is there such a favourite for the examiners to include in Paces? Syncopy is a very common presentation and I think that it's an important thing to examine because it really demonstrates your ability to take a good clear history so much of what you get in terms of diagnostic indicators in the patient with Syncopy comes from the history that you take. And that is essentially why it appears in Paces quite often. And not only that but quiz the consultant is returning that's right. Our consultant take on a quick fire quiz on a specialist subject of their own choosing with the caveat being that it can't be related to medicine so Ashley what have you named as your specialist subject and why? Well I am an 80s child and therefore I've chosen 80s pop. And can I say it was an absolute joy to do the research for this quiz so that's going to be coming up a little bit later in the episode but we're starting off with a deep dive into collapses. So if we start off I think it would be fair to say that this would probably be most likely to come up in either the station five so the brief clinical consultations or in the longer form history taking station so station two. And in the station two you've obviously got more time so you're going to be expected to be more comprehensive in that history and the station five it's going to be much more focused with also including relevant aspects of examination. So we're going to be covering both aspects of that and obviously the comprehensive history is going to include a lot more detail so you're going to be taking elements of that history into a shorter focused history for your station five so it's all going to be relevant. If we first start thinking about someone who presents with a synchipal episode Ashley what are the typical features of a patient who suffers a synchipal episode? So what you want to find out from the patient is what exactly the mean by a faint or a blackout or a funny turn and the history well it comes from the patient also should potentially come from witnesses. The key features in the patient presenting with synchipy rather than seizures which is obviously an important differential would be that the transient loss of consciousness happens very suddenly so they have a rapid onset of symptoms usually of quite short duration but also importantly they often have a very rapid recovery afterwards. They may or may not be amnesic after the episode and it is essentially a syndrome of transient global cerebral hypo perfusion so a sudden abrupt drop in blood pressure which reduces the circulation to the brain. It's very important to be alert to other potential causes of transient loss of consciousness that are not synchipy per se and so what we have to do is recognize those red flags so that we know who we need to investigate further as an inpatient investigate urgently or who are safe to discharge without any further investigation and really the key to this is a very detailed history. So when you're taking a history from a patient then you want to make sure that you do so in a structured way something that you'd be very familiar with from all medical training and finding out about what's happened not only during the episode of synchipy which they may or may not be able to tell you but how they felt before and then what happened after. So there we have it the structure in any sort of loss of consciousness type station should be a history before the episode during the episode and after the episode and I guess something which is less relevant in pace particularly but in is very relevant in our own clinical practices patients who have a transient loss of consciousness from something which is potentially an acute an acutely unwell illness so something like severe sepsis acute coronary syndrome, hypothermia or hemorrhage or something like an illtidisection or a PE. Now that clearly isn't going to be as realistic in pace because those patients are still going to be in real life they're going to be very sick but those are still things to consider in paces but it's somewhat contrived to think that a patient would be sat in front of you stable talking about having an illtidisection but those are just things to consider. So although I will say just as an aside and this is something that we quite often see when patients come in with syncopate I honestly don't think I've ever seen an acute coronary syndrome present with syncopate so I think that that is something that you know unless there is a very clear history of an illtidisection associated with it I think very rarely is a collapse due to a non-ST elevation in my own acute coronary syndrome so that's just a sort of less of a point for paces more of a point for actual practical clinical medicine when you're seeing patients coming in through the ED I think it's very unusual. Okay thank you for that and how can we categorize syncopate when it isn't related to those acute presentations? So the key thing with syncopate is to understand whether the mechanism is newly mediated so neurocardiogenic syncopate which otherwise is known as simple vis-vegal syncopate or feinting or whether it is due to orthostatic hypotension which again has a similar mechanism to the neurocardiogenic syncopate but predominantly the issue is a drop in blood pressure rather than necessarily any bradycardia or cardinonhybitri effect and the key thing is to hunydd yn myn he்ud efolgihau'r nostaryd, fel ni new ein ni viadau sy'n fennegraflios, Hysfâda fben hardoedd cafŵu gerdau sydd â edryff knowssa bod fwrd gwahanol ffordd o edryff gwasарol yn y galluol killers, ac eisiauwl yn jakimill, ffeth rydym yn dimoddellu ynwaedeth i'r gyda IMercydd ' o hystechrau mentor eu ar Batau microscop בחedio zombies y cwell i miçãoidoel fy rhoi amion nie disprenetus Ieith o'r gweithio yn fod ym yn ffyd. Mae'r gweithio yn ffyd. Ys gwaithio yn ffyd. Mae'r gwaithio yn ffyd. Mae'r gwaithio yn hwnnwch yn ffyd. a fîr o train hyだ ми a y stedrill goriant ond og phall er o sé cynnofallu a sembryd calam i booking i sirl ja nhw fîr econom i bilw yn erros i yn pob으 ar oryddiad yr quiser ceis degy ridde wrth gyda queue ac oediddol hakkineg entering Chyifi gan bob hwn chyr app i'r hynny i'r hynny. Mae'r hynny i'r hynny. Mae'r hynny ymdraiddol am gyda i fod ymdraiddol am gyda i'r hynny. Ymdraiddol am gyda i'r hynny. Mae'r hynny. A wneud ar ymdraiddol am gyda i'r hynny. Mae'r hynny. Bwisioedd ydyr. [Ball] 她 o gwase yna. cover. Ond wneud llawer yn ddye 말씀드�iaethu o Quite Shallas a br fasten. Mae ei bod yn fy n Mythナ am paler Syleriwyllfa sy ad eion m�yd fixing ti. Mae'nny golaw mae'r conti'r pwel sylwedd y byddau le 😀 recognised Declaration of the Staracol & Nature AT machine. Mae'r yda dmar hinterf ord yn goolach neu dod ychland y disefyniaethol? Ond fan diachio'r cyfrifondod datblygu erodradu meddeír peoniad hyn, ac ryd wneud ikher oFree This Is Is N représentueffan? Ty rhwbeth yn gwleim i ostatig odmethatius, it's making again that way. If she has a HIV but for example, I would think SUBSCRIBE on Contest services, to join us! But within that voice if there is a population of Schluss and conductor they want more enough to ensure that there are people around those who visit the city and submit smaller things in the room than those in themselves or red flags. But the sudden onset with no pro-dome and no precipitant and without going too far into the investigation or examination if you examine the patient you find that they have got signs of structural heart disease such as a murmur or if they have an abnormal ACG to start with again those in themselves are indicators that you need to be considering admitting them for further investigation. Perfect. So all of those obviously applicable in our clinical practice as well as in paces and you've mentioned a couple of things there when if you have more time for example in the history taking you've got more time to go into the structure of a full past medical history and a full family history which where you can take a long history but even more important just to demonstrate that you've got an awareness of that even in the shorter other things to potentially ask about thinking less about cardiac synchopean more like vasovable orthostatic hypertension would be hyperattention itself and treatment for that because patients can quite often be overtreated. Yeah definitely so if you've got time to take a full history what you want to be establishing of things like the drug history so what medication is the patient on has anything recently been changed particularly other things to note are what their comorbidities are, what other past medical history do they have? Things like Parkinson's disease can cause quite a lot of postural instability and autonomic dysfunction which in itself can cause orthostatic hypotension and synchopean that setting and I've already mentioned the presence of known structural heart disease so someone who's had an echo you know five years ago showing a degree of aortic stenosis but hasn't been followed up and they now come in with synchopean you need to be wondering whether that is in fact the reason the other key things in the history are they suddenly breathless, if they had any hemoptysis because comorbidism is another very important cause of synchopean that's life threatening that has to be considered I've mentioned briefly taking a family history so if there is a family history of structural heart disease or an arrhythmia syndrome such as hypertrophic cardiomyopathy arrhythmogenic cardiomyopathy or prigada syndrome these are worrying features in someone presenting suddenly with synchopei and also you need to know a bit about what the patient does in their normal daily life their social history is important particularly when it comes down to what their job is if for example their groupers or if people need to drive for their work because that may be relevant to their their livelihoods going forward and you have a duty to make sure that you inform them of the appropriate DVLA guidelines with regard to synchopei when you see patient with that history and just going back to the family history one of the things which I know has sort of come up before is they may not necessarily know the diagnosis but they'll say oh my first cousin had a collapse and now has a device in so something like it's not vague there's no there's no a diagnosis there but it's still important to ask about other events similar to this in the family because obviously with things like congenital syndromes there's a degree of heritability there and coming on to driving we're going to talk a little bit about that later but I would say it's almost a whole another episode in itself that we would need to dedicate to that we may well end up doing that so after you've taken a full and complete thorough, fluent and systematic history at least in the station five you're going to be coming on to a very focused examination and you've got such a small amount of time a minute maybe a minute and a half to demonstrate that you know the pertinent parts of examination in a patient with a transit loss of consciousness so actually what would you suggest that the candidate start with in this very short period of time that they have to examine these patients so in station five particularly you'll be asked to take a history and do a relevant clinical examination based on the history that you've heard and so if you have a patient with a transient loss of consciousness depending on what the told you you'll either be examining the neurological system or the cardiovascular system and if it sounds like it's a cardiac history then you want to be examining for cardiovascular disease briefly looking at the hands looking for cyanosis feeling the pulse checking for any murmurs when you listen to the pre-chordium predominantly looking for signs of aortic stenosis or for example hypertrophic cardiomyopathy if it sounds more like the history consistent with the seizure then I guess you'd be looking at neurological examination and where that is concerned checking for for example signs of movement disorder as well such as Parkinson's disease might be relevant if there's for example orthostatic symptoms predominantly but I think that you often find that there's nothing abnormal at all in examination of patients with synchope and you may be shown an ACG which is also something that could come into that station and so I think you just have to think about what you might ask for and you might well be expected to see I would like to see the patient's ECG and one of the things in a station 5 particularly related to the examination is they often use actors for this station so although obviously paces is about examining patients with clinical signs and detecting them station 5 is one of the ones where they may not give a patient with signs so it's obvious that you have to demonstrate that you know which signs to detect more often than not in my experience anyway they didn't have any signs and it's just demonstrating that you know which systems you need to examine especially in an orthostatic type history or a vasavagal type history where they would have a completely normal examination so we've talked a little bit about the history of examination so let's move on to when you come to your presentation of the case and talk about the investigations and management of these patients [Music] so the presentation is going to vary widely depending on the exact clinical history which has been elicited but using the elements of each type of history we've discussed hopefully you'll have collected enough information to give a diagnosis which is divided into one of the categories which we've spoken about so far actually what investigations would you suggest that the candidates start off in their presentation to the examiners? So if we ask you what you're going to do to investigate this patient mesynchepy then you are going to tell us that you're going to want to check some routine observations particularly you're going to check a pulse you're going to check their blood pressure and particularly important is to check both lying and standing blood pressure to see if there's evidence of postural hypotension you're going to ask for a finger prick glucose test see if hypoglycemia could have been the mechanism you would also clearly want to do a 12 lead ECG and on that ECG you're looking for particular signs that could indicate underlying structural heart disease such as left and tricular heart disease a hi perchfei o'r anaxis, sifth, ac yn cydindicatio ortygstynosus, o hi partofi carmylopu. Byw'r oesio o'r rydm yn ddairdyn sydd, ac yn bradig hordea, y prezans arabns yn y ffintricularach, ac yn cydindicatio a'r ten dyn sy'n ddyn sy'n gweithio. Ym yn ddyn sy'n yw'r cydindicatio a'r cydindicatio, pethau'r petor profohietum oedem sut y gansydd i fod yn duchen才raodd a cyst i rhau, ordd yn jaen chanel o anynyb'm b faint hynost式 o trwy fawr bod yn c cosmetics ei ni singlesa caton ametances i'r ll darkon. Mae'r arsiau yn gwaith par o gladdwur. Mae sy'n cesio 'ng mor hyb. Wasot rhunaith02 minna could效arron Po ond fra Ch Yaரio cruisingis. fo'r alteranie-rian crín iddalenio lefydermaiff new Liberal chapter o rydynya'r dr精 drwych i ym sofa fe d i? G citizenseraan rhyng熟io gifthara â'r ein Imi Yo, a dat Dusu am yr a'r Tro Richardson a eu Llywydd misfirellelwylhydd- fo sabd o ag忙andaeth rydy'm i dewl zero fe groithio y fynd perfixio si drwy yna syl чwch chi sy'n tahain bod mae. bwrdd diwyr, gwasanaethau wrth dag modeli rhoi hwypaaraeth yma cefodaeth gen�a. I'n linguistic humaniaid cael hynna,honeu mo i'r test o pan amgynd Wyrfoedd it'swch notch yn yUREALLY troll mae'r erbynu 'eosol i yneulol bod yn pr языw pŵeio'r Tyrannion "ŵw'r p происходитol ' mich' a foze dom a'r tr cactus "Ai ddwy roedd ymwy dranion ' włahiys? I canal gan hyn ar eraor "I'n ffarkt, so 'I' don't think it adds much to your diagnosis "Unless there is a clear history of chest pain that sounds like my cardial ischemia "in the preceding history, so no, I don't think it's necessary to check it up on it." Fair enough. And when we come to imaging our patient, I mean, everyone gets a chestache to open and they come into hospital but that's not a good enough reason to a pace's examiner. So I always just said, 'Oh, to check for infection because that's a potential cause' even if there aren't particularly any infective symptoms, it's still possible to have an occult neuronea, which is the reason why someone's collapsed. And then thinking about structural heart disease, an echocardiogram would probably be the investigation of choice. Yeah, I think so. I mean, you sometimes get a clue from a chest x-ray that there's something abnormal going on with the heart. Rarely, you might see a widening of the media sign in which in itself might indicate in the orthodysection, but you probably would have other features in the history that were indicative of that rather than it all hanging on the chest x-ray. You might see in somebody with an underlying cardiomyopathy who could potentially have had an arrhythmia, you might notice cardiomagally on the chest x-ray. So yeah, there are lots of reasons why a chest x-ray might be helpful, but it's probably not the primary investigation, I think, probably the ECG is and looking for structural heart disease and certainly an echocardiogram. But most people can't get that in the emergency department or in the acute receiving units when you see the patient. So, you know, you have to have an index of clinical suspicion and be good at using your stethoscope to detect murmurs. Yeah, because also I think you can get pulled up in places for over-investigating as well. So it should only really be done if you genuinely think that there is a suspicion of doing that. Because the risk then is that you admit someone for an examination or an investigation which actually they don't require and that's a waste of NHS resources. So, yeah, definitely. I think on that subject, I think that when it comes to monitoring for arrhythmia and patients with synchopie also, I think you have to be careful of your modality that you choose to do that. What you're looking for with ambielatric ECG monitoring is symptom rhythm correlation. And in somebody who has one synchopolepsida year, your likelihood of positive yield from a 24-hour ECG is really quite minimal. And so if you do have a high index of suspicion that this is not newly mediated or ways of agol synchopine, you think it could be an arrhythmia, then you should consider more extended amulatory monitoring. But probably an implantable recorder is a better means of actually obtaining that symptom rhythm correlation should and event happen again in the future. And then that can be diagnostic and then you can make your management decision based on that. So that's covered the cardiac rhythm related collapse which you might be presented with. In terms of the newly mediated or the orthostatic, the management is largely based around educating the patient and allowing them to take measures to try and prevent this happening again. Yeah, absolutely. So if you make a diagnosis of vasomegal and you really mediated synchopole particularly in young patients with otherwise structurally normal hearts and normal ECGs, the key to the management of this is patient education. Because although there are drug options that can reduce the frequency of events, the vast majority of benefit comes from the avoidance of the precipitance and the triggers for the event and also recognising that the symptoms are going to come on and getting in a situation where you can sit or lie down to prevent injury predominantly. Vasevago think it can be really life affecting for people, especially if it happens very frequently. It can be really quite debilitating and quite anxiety provoking for patients. So it is really useful for them to have some way of sort of taking control of it and managing things themselves. The key pieces of advice that we give to patients are to ensure that they are drinking enough food. So that means at least two litres of water a day, but probably more than that in order to maintain good hydration. Also to have a high sodium diet. So not just adding a bit of salt to your food, this is actually using a high sodium diet. So salty snacks, the whole shebang, they can have everything. Because in fact what that does is it helps to keep your blood volume within your blood vessels rather than pulling in the soft tissues and the ankles. And those things can really make a difference to some patients. Other things that actually have been shown to help are strategies called bolus water drinking. That may not be something that anyone's heard of recently, but this is something that has been shown to be quite effective. So there are some patients in whom they feel worse first thing in the morning because they've lay in bed all night. They're blood vessels are relaxed, they then stand up and then get in a hot shower. And so they raise their delight even more. They get more venous pulling in the ankles and then they feel dreadful for the rest of the day. Or people who have particularly bad orthostatic symptoms. Having a huge, you know, a large glass of cold water before standing up, before getting out of bed might actually help to reduce those symptoms. And the mechanism by which this works is not entirely clear, it could be related to a bit of vasoconstriction in the splanchnic vessels and the abdomen, which then maintains circulation to the brain. So those things can be quite helpful. If it's very severe, wearing compression garments can help. Now, you know, flight socks up to your knees work to some extent. But actually the things that really work are the ones that you wear that go right up to your waist. And most young women who have a vagal synchipiduno want to wear those things because they're ugly. But those are definitely the sorts of strategies that we can use to help patients to manage their symptoms. But the key is really recognizing those circumstances where it's likely to happen and just trying to avoid them. Don't let yourself get too hot. Don't stand up in, you know, carriages of hot, stuffy trains. If you feel that you're getting dizzy or you're going to faint, try and sit down or lie down because then you might not injure yourself if you do pass out briefly. Perfect. So that takes us pretty much to the end of the aspects on management. And all I'd say is one of the main things that will come in terms of examiner questions or one of the most important aspects of managing these patients is driving restrictions. Now with this particular presentation, it is very tricky because there are a great diversity in the guidelines themselves. And actually a sort of semi-cop out would just be, I would look at the DVLA websites on the driving restrictions and I would make my decision on that. I don't think it would be unreasonable to do that. And I think as long as the examiner has appreciated that, I think that would be okay, especially if it's somewhat of a equivocal history where maybe the diagnosis isn't clear. Yeah, absolutely. I think that's right. And actually the DVLA guidelines do change from time to time. And I think that's the appropriate answer to that question. I think that it's better, even in clinic, you know, when I'm not sure I will check it and I will check it. am y meddwl am yna i'n gael bod yna ei a'r gael ei ac yn yna. Mae'n gael ei'r gael ei ac yn yna. Swy'n gallu'r gael gael, mae'n gael ei fyddiaeth yma. Mae'r gael ei fyddiaeth yma'r gael yma yn ddim yn ddawn i'r gael ei ac yn yna. Mae'n gael ei fyddiaeth yma yn ddawn i'n gael ei fyddiaeth yma. Mae'r gael ei fyddiaeth yma yn ddawn. Mae'r gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Mae'n gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Mae'n gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Mae'r gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Mae'n gael ei fyddiaeth yma. Mae'r gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Mae'r gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma yn gael ei fyddiaeth yma. Iom yng Nghymru Ond tryn nhwi'n m making honas. Could it be my son of the 80s, my dad large concerns ofleydo and trying to improve power часов humour through the career and that will be perfect and it's never a route for a sponsored project. So I have chosen 80s pop music because I am a child of the 80s And I am quite proud of my record at pop quizzes of the pre-paces podcast is limited and I can't afford to pay off every music producer in Hollywood. So it is mainly on songs, lyrics and other things related to 80s music. What's your area of specialism even within 80s pop? Do you have a specific band that you're a particular fan of or were you a musician yourself? So I wouldn't consider myself to be a musician although I did sing which is a bit of a secret and now I've just talked to one of them. I was in lots of different choirs and groups and was a huge fan of musical theatre and was in the University of Gilbert and Solomon Society. So yeah, I'm a closet and drum enthusiast. But when it comes to 80s pop I just loved it. I've got very clever to taste some music. I was a huge fan of Michael Jackson. I was a huge fan of Wem. But I also liked a bit of the sort of soft-drocks stuff as well. Perfect. Well, you may well find out that some of your special interests come up in this quiz. So before we go ahead, this is how we play. There are 10 questions in total. If you want to immediately without taking the multiple choice options, you get two points. But if you're not sure, you can take the multiple choice options and that gets you one point. So 20 points to play for and you can ask for the multiple choice options if you're not sure. And I have to say I had a real blast researching to this quiz. It was fantastic. You probably weren't born when the songs were 8. I'm a child of the 90s. I don't but hey, I can still appreciate some good 80s pop. So 10 quick five questions on 1980s music. Are you ready? I'm ready. In the song, don't stop believing by journey. The city boy and the small town girl catch the midnight train. But where was it going? Anywhere. Anywhere is correct for two points. Who in 1986 said that we could call him out? Paul Simon. Another two points in the bag. Question number three. What is the name of the Whitney Houston song featuring the lyrics? There's a boy I know he's the one I dream of. Oh God. You may have to do it with a multiple choice option. Okay, we can do the multiple choice options. So is it A, I will always love you. Is it B, how will I know? Is it C, I want to dance with somebody or is it D, the greatest love of all? That is correct for one point. Question number four. Which film Colin song was parodied in a categories advert in 2007 by depicting a gorilla performing of the track in the air tonight? Two points. Question number five. In the chorus of the song, never too much by Luther Vandros. He names two things which he says and never too much. Name either one. I think any of the multiple choice in that one. Okay, that's okay. So is it A, a thousand kisses from you. B, a million months in your heart. C, a hundred nights spent with you. Or D, a thousand hugs on the stairs. And that's in kisses from you. That is correct. Which song by Frankie Ghost of Hollywood was covered by Gabrielle Applin in 2012 and reached number one in the UK after featuring in the Christmas John Lewis advert in the same year? The parod love. That is correct. The two points. Question number seven. Michael Jackson's 1983 single Beat It is one of the best setting singles of all time. But which iconic lead guitarist recorded the guitar solo for the track? Oh, was it Slash? It wasn't Slash. I'm afraid I can't give you the multiple choice options either. It was Eddie Van Halen from Van Halen. Question number eight. Which Norwegian band sang Take On Me in 1984? A-ha indeed. Is correct for two points. Question number nine. Which Leonard Cohen song has been covered by Jeff Buckley, John Kale, Rufus Wenwright and Alexandra Burke? How long do you get? And that's correct for another two points. Last question. Question number ten. Which 80s pop princess sang girls just want to have fun? Single. That is a single law. And that is a respectable 16 point. That is certainly a respectable score on Quistett Consultant. And have I ever told you Mike, my joke about the lot Smithy wrote us on? No. Well, just as well because it's got a really a key change at the end. So I think that brings us to the end of this episode on Collapses and 80s pop music. And that only leads us to paying huge thanks to Dr Ashley Nisbit for joining us to cover this critical important paces topic. Thank you, Sam, for having me. I'm enjoying doing it. If you have enjoyed this episode and you liked the podcast, please do like, comment and subscribe to the show wherever you get your podcasts. Don't forget you can get in touch via all the social media channels on Twitter and Instagram. It's @prepacespodcast and if you want to get in touch on email, it's [email protected]. So thank you so much for listening. I'm going to go and rehydrate myself and we hope to see you next time on the prepacespodcasts. [Music]