WEBVTT 00:00:08.070 --> 00:00:10.689 Hey, welcome to another episode of our podcast, 00:00:10.910 --> 00:00:13.550 The Canadian Breakpoint. So as everybody knows, 00:00:13.589 --> 00:00:16.410 we're live here today at the AMR Symposium in 00:00:16.410 --> 00:00:20.350 Toronto. We've had some great talks on AMR, antibiotic 00:00:20.350 --> 00:00:23.429 stewardship, diagnostic stewardship, and really 00:00:23.429 --> 00:00:27.500 lots going on in the area. And so today I have 00:00:27.500 --> 00:00:29.480 a very special guest with me and I will have 00:00:29.480 --> 00:00:33.920 you do your introduction and we are going to 00:00:33.920 --> 00:00:37.429 talk more about AMR. Well, thank you for having 00:00:37.429 --> 00:00:40.890 me. I'm excited to be here. So my name is Dr. 00:00:41.009 --> 00:00:43.170 Kanchana Maruchanga. I'm an infectious disease 00:00:43.170 --> 00:00:45.609 physician and work in the public health realm. 00:00:45.969 --> 00:00:47.829 So I currently work at the Public Health Agency 00:00:47.829 --> 00:00:50.950 of Canada and specifically in our AMR task force. 00:00:51.490 --> 00:00:53.390 So I am the director of stewardship, but also 00:00:53.390 --> 00:00:56.270 the medical advisor for the task force. And I 00:00:56.270 --> 00:00:58.590 do part -time clinical work at the Ottawa Hospital. 00:00:58.869 --> 00:01:02.109 Okay. So lots going on. Yeah. And so what brought 00:01:02.109 --> 00:01:04.500 you to the symposium this year? So this is my 00:01:04.500 --> 00:01:08.060 second time attending this symposium, and it's 00:01:08.060 --> 00:01:10.579 mainly related to some of our work. It was to 00:01:10.579 --> 00:01:12.500 provide an update in terms of what the Government 00:01:12.500 --> 00:01:15.340 of Canada is doing when it comes to AMR, which 00:01:15.340 --> 00:01:18.000 is a priority for us, but also to give an update 00:01:18.000 --> 00:01:20.760 on one really special project that we're working 00:01:20.760 --> 00:01:23.079 on that we've launched with some of our partners, 00:01:23.159 --> 00:01:25.599 which I'll talk about. So that's really the main 00:01:25.599 --> 00:01:27.879 reason I'm here. Awesome. So yeah, why don't 00:01:27.879 --> 00:01:30.579 we dive into some of the work that you guys have 00:01:30.579 --> 00:01:33.120 been doing? Obviously, I think the goal being... 00:01:33.200 --> 00:01:38.000 for everyone is to really fight the AMR increases 00:01:38.000 --> 00:01:40.900 that we've seen and kind of work together with 00:01:40.900 --> 00:01:43.680 collaborative partners to do this. So what has 00:01:43.680 --> 00:01:45.920 been kind of the experience or what's been going 00:01:45.920 --> 00:01:50.040 on over the last year? Yeah. So, I mean, AMR 00:01:50.040 --> 00:01:52.260 is so dynamic, right? And the landscape continuously 00:01:52.260 --> 00:01:54.959 changes. And I've been in this field for the 00:01:54.959 --> 00:01:57.579 past decade or so from the government side. And 00:01:57.579 --> 00:02:01.579 as was discussed at my... presentation, but also 00:02:01.579 --> 00:02:04.900 from the government end, we did develop a pan 00:02:04.900 --> 00:02:08.620 -Canadian action plan. So WHO has their own global 00:02:08.620 --> 00:02:10.979 action plan, and most countries now are developing 00:02:10.979 --> 00:02:13.099 their own national action plan. So this was Canada's 00:02:13.099 --> 00:02:16.439 effort to coordinate efforts, both nationally 00:02:16.439 --> 00:02:19.259 and with provinces and territories. So the PCAP, 00:02:19.319 --> 00:02:21.379 as we affectionately call it, was put out in 00:02:21.379 --> 00:02:26.060 June 2023. So currently we're in a phase of really 00:02:26.060 --> 00:02:29.259 looking at gaps and strengthening governance 00:02:29.259 --> 00:02:32.039 in terms of within, as you know, Canada is a 00:02:32.039 --> 00:02:34.039 federated system. So healthcare delivery is done 00:02:34.039 --> 00:02:36.699 at the provincial level. So at the national federal 00:02:36.699 --> 00:02:39.449 level, it's always a... tough position, but really 00:02:39.449 --> 00:02:41.650 our goal, our work is to really bring people 00:02:41.650 --> 00:02:44.430 together and say that this is a priority and 00:02:44.430 --> 00:02:47.370 we need to continue to fight that fight. And 00:02:47.370 --> 00:02:49.569 within that PCAP, we have five major pillars 00:02:49.569 --> 00:02:52.129 which fall within AMR. So we have surveillance, 00:02:52.349 --> 00:02:54.530 which is really keeping a pulse on what's happening 00:02:54.530 --> 00:02:57.870 on a domestic as well as global level. We have 00:02:57.870 --> 00:02:59.810 research and innovation, which it comes to when 00:02:59.810 --> 00:03:02.849 it comes to delivery of new therapeutics, antimicrobials, 00:03:02.909 --> 00:03:05.889 vaccines, diagnostics, which was discussed even 00:03:05.889 --> 00:03:08.360 at the meeting here. We have infection prevention 00:03:08.360 --> 00:03:11.020 control. We have leadership, which is the governance 00:03:11.020 --> 00:03:12.819 aspect, and then stewardship, which is really 00:03:12.819 --> 00:03:16.300 the focus of the symposium this year. And so 00:03:16.300 --> 00:03:19.419 there's multiple different projects happening 00:03:19.419 --> 00:03:22.439 on that, both at the federal level. We have 13 00:03:22.439 --> 00:03:24.199 different federal departments that are involved 00:03:24.199 --> 00:03:26.780 because PCAP is really, it's not just human, 00:03:26.819 --> 00:03:30.080 it's a one health focus. So it's human, animals, 00:03:30.159 --> 00:03:34.009 and the environment, and it's interesting. And 00:03:34.009 --> 00:03:35.710 there's a lot of work happening on the human 00:03:35.710 --> 00:03:38.389 and animal front. Environment is coming along. 00:03:38.590 --> 00:03:40.930 It's an area that's still, you know, very much 00:03:40.930 --> 00:03:45.090 research in the research involvement. And so 00:03:45.090 --> 00:03:48.069 there's, you know, there's progress reports that 00:03:48.069 --> 00:03:50.289 are published every year. There was a progress 00:03:50.289 --> 00:03:52.229 report last year. This year's report is imminently 00:03:52.229 --> 00:03:54.810 going to be published. And some of the highlights 00:03:54.810 --> 00:03:57.789 include, so this year we published the Canadian 00:03:57.789 --> 00:04:01.050 priority. pathogen list, which is the MR pathogens. 00:04:01.210 --> 00:04:04.229 There was a list published in 2015. So it took 00:04:04.229 --> 00:04:08.409 us about 10 years to update this one. And it 00:04:08.409 --> 00:04:12.560 was done. with external and internal consultations. 00:04:12.560 --> 00:04:15.460 And so that was released in earlier this year, 00:04:15.520 --> 00:04:18.259 and it was also published in a scientific journal. 00:04:18.500 --> 00:04:21.319 And really that's to help us with guidance, not 00:04:21.319 --> 00:04:23.819 just guidance, but surveillance and to really 00:04:23.819 --> 00:04:26.899 identify some of the, what are the priority pathogens. 00:04:27.300 --> 00:04:31.329 There's also the... One Health research strategy 00:04:31.329 --> 00:04:33.949 that was discussed last year here at this symposium. 00:04:34.009 --> 00:04:35.889 And then they did a survey over the last year. 00:04:36.089 --> 00:04:38.730 And now from that survey, they're putting a list 00:04:38.730 --> 00:04:42.069 together of the sort of the priority areas of 00:04:42.069 --> 00:04:44.269 research when it comes to One Health and AMR. 00:04:44.389 --> 00:04:47.069 And that's coming out in the next few weeks. 00:04:47.069 --> 00:04:49.230 I've had a few people come up to me asking, do 00:04:49.230 --> 00:04:51.879 I have any further insight? Yeah. And then the 00:04:51.879 --> 00:04:54.319 other aspect is stewardship. And one of the major 00:04:54.319 --> 00:04:57.100 aspects of stewardship was development of guidelines. 00:04:57.439 --> 00:05:00.019 So both for animal, and I can speak to the human 00:05:00.019 --> 00:05:04.019 side. So one area was to have part of that availability 00:05:04.019 --> 00:05:06.279 of information, education for prescribers, was 00:05:06.279 --> 00:05:09.300 to have national guidance. We don't have national 00:05:09.300 --> 00:05:12.019 guidance, right? A lot of the times, even as 00:05:12.019 --> 00:05:14.339 a clinician, we go to IDSA or we go to other 00:05:14.339 --> 00:05:18.259 global... resources and so this was a first of 00:05:18.259 --> 00:05:22.279 its kind noting that a lot of regions and provinces 00:05:22.279 --> 00:05:25.160 have have their own guidance so this is more 00:05:25.160 --> 00:05:28.720 at a high level national level for regions to 00:05:28.720 --> 00:05:31.120 adapt as needed or for areas that don't have 00:05:31.120 --> 00:05:34.660 guidance in areas for prescribers frontline family 00:05:34.660 --> 00:05:37.779 doctors, nurse practitioners, pharmacists, and 00:05:37.779 --> 00:05:40.220 really targeting the current focus is primary 00:05:40.220 --> 00:05:43.560 care. So primary care syndromes. And this is 00:05:43.560 --> 00:05:45.720 the initial launch, which is really focused on 00:05:45.720 --> 00:05:47.579 the respiratory syndromes given the season we're 00:05:47.579 --> 00:05:51.279 in. And so we worked with our partners, AMI Canada. 00:05:51.759 --> 00:05:54.040 who spearheaded developing the guidance. And 00:05:54.040 --> 00:05:57.279 then Firstline, the company that has helped implement 00:05:57.279 --> 00:06:00.040 and disseminate it. And we're really excited. 00:06:00.439 --> 00:06:03.139 We're now working on promoting it so that people 00:06:03.139 --> 00:06:06.439 get to know what it is. There were QR codes in 00:06:06.439 --> 00:06:08.839 our presentation that people use it. And I know 00:06:08.839 --> 00:06:11.319 Ami and Firstline are working on other venues 00:06:11.319 --> 00:06:14.720 to really get the word out. And it's, yeah, it's 00:06:14.720 --> 00:06:16.439 really exciting. That's awesome. And then in 00:06:16.439 --> 00:06:18.279 terms of the guidelines, just because I'm interested, 00:06:18.500 --> 00:06:20.980 because I'm a pediatric infectious disease physician, 00:06:21.069 --> 00:06:23.769 and you probably realize that there's very limited 00:06:23.769 --> 00:06:26.629 guidelines and consensus. I mean, we have Canadian 00:06:26.629 --> 00:06:28.870 Pediatric Society, which I serve on the committee 00:06:28.870 --> 00:06:30.790 too, and we always have consensus guidelines. 00:06:30.990 --> 00:06:33.329 But it's kind of nice to have something more 00:06:33.329 --> 00:06:36.850 national or at least, you know, framework for 00:06:36.850 --> 00:06:39.889 it. So are these going to be more aligned with 00:06:39.889 --> 00:06:42.870 clinical syndromes and antibiotic durations, 00:06:42.870 --> 00:06:46.829 that type of thing? Or is it... more from like 00:06:46.829 --> 00:06:49.810 a different angle with like um lab and diagnostic 00:06:49.810 --> 00:06:52.889 stages it's more clinical syndromes and and really 00:06:52.889 --> 00:06:55.790 treatment focused there is a bit of a diagnostics 00:06:55.790 --> 00:06:59.449 and laboratory or primary pathogens of concern 00:06:59.449 --> 00:07:02.529 so for example the respiratory guidelines we've 00:07:02.529 --> 00:07:05.420 released focus on both adults and pediatrics. 00:07:05.560 --> 00:07:08.839 And so community -acquired pneumonia, pharyngitis, 00:07:09.180 --> 00:07:12.360 sinusitis, so the syndromes of interest. And 00:07:12.360 --> 00:07:14.819 then we're going to continue to work on others 00:07:14.819 --> 00:07:17.879 like UTI, skin and soft tissue infections. And 00:07:17.879 --> 00:07:21.319 so really the focus is once you have a patient 00:07:21.319 --> 00:07:23.680 and you think that that is what you've diagnosed, 00:07:23.860 --> 00:07:26.620 here's your guidelines in terms of treatment 00:07:26.620 --> 00:07:30.120 and duration and if an antibiotic is not needed. 00:07:30.439 --> 00:07:33.600 Right. And that's also in there. And we've connected 00:07:33.600 --> 00:07:35.920 to other groups like Choosing Wisely Canada. 00:07:36.060 --> 00:07:38.339 So they have their viral prescription pad. So 00:07:38.339 --> 00:07:40.399 it's all available on that app so that clinicians 00:07:40.399 --> 00:07:44.339 can easily access it. Also NACI guidelines for 00:07:44.339 --> 00:07:47.379 vaccines. So for chronic pneumonia, for strep 00:07:47.379 --> 00:07:49.899 pneumonia, what are the guidelines? And I know 00:07:49.899 --> 00:07:52.699 it's varied across the provinces, but it's there 00:07:52.699 --> 00:07:56.040 for clinicians to access in terms of sort of 00:07:56.040 --> 00:07:59.300 hopefully a one -stop shop. Because it's overwhelming. 00:07:59.720 --> 00:08:03.000 There's so many resources out there. So the goal 00:08:03.000 --> 00:08:06.279 is to have everything sort of there at your fingertip 00:08:06.279 --> 00:08:10.089 to be able to. to access to at the bedside. Awesome. 00:08:10.209 --> 00:08:13.350 Yeah. So it's really centralized and, and kind 00:08:13.350 --> 00:08:15.430 of creates that consistency. I think that's the 00:08:15.430 --> 00:08:17.970 other thing, even with, I always see like if 00:08:17.970 --> 00:08:20.550 there's a bunch of ID docs in the room, sometimes 00:08:20.550 --> 00:08:22.930 the consensus could be so different. So this 00:08:22.930 --> 00:08:26.209 is helpful because you can centralize these and, 00:08:26.230 --> 00:08:29.569 and really have like a focus there. And obviously 00:08:29.569 --> 00:08:31.350 everything's case by case and guidelines are 00:08:31.350 --> 00:08:33.669 guidelines, but I think it's good framework for 00:08:33.669 --> 00:08:36.970 especially community care physicians who don't 00:08:37.000 --> 00:08:40.299 have accessibility or don't have day -to -day 00:08:40.299 --> 00:08:42.100 follow -up with their patients. I think inpatient 00:08:42.100 --> 00:08:43.980 medicine can sometimes be a little bit easier 00:08:43.980 --> 00:08:46.360 in that sense because you can have your day -to 00:08:46.360 --> 00:08:47.960 -day follow -up with that patient and round, 00:08:48.139 --> 00:08:50.220 but community physicians, I think, would benefit 00:08:50.220 --> 00:08:53.919 from this infrastructure. Yeah, 100%. And, you 00:08:53.919 --> 00:08:57.399 know, Deb and the other panelists can really 00:08:57.399 --> 00:09:00.679 speak to the amount of work and effort. And as 00:09:00.679 --> 00:09:03.159 you mentioned, you have... 10 ID physicians in 00:09:03.159 --> 00:09:04.720 the room and sometimes we have 11 different opinions, 00:09:04.879 --> 00:09:08.559 right? So really getting down to those recommendations, 00:09:08.919 --> 00:09:11.980 there was a lot of work put in and really keeping 00:09:11.980 --> 00:09:14.320 into not just the evidence, but I think Dana 00:09:14.320 --> 00:09:16.850 described this really well. treatment is not 00:09:16.850 --> 00:09:19.610 just the evidence it's directed by patients. 00:09:19.629 --> 00:09:23.190 So keeping in mind the patient population and 00:09:23.190 --> 00:09:25.690 all the factors that come into that. And there's 00:09:25.690 --> 00:09:27.850 other tools in there in terms of like allergies, 00:09:27.850 --> 00:09:30.570 like pen allergy and how to work, navigate that. 00:09:30.669 --> 00:09:33.149 Cause that's always a challenge. And the goal 00:09:33.149 --> 00:09:36.710 is it was following the WHO aware antibiotic 00:09:36.710 --> 00:09:40.590 head book. So ideally. it's not to prescribe 00:09:40.590 --> 00:09:42.950 if when not needed, but when you do prescribe 00:09:42.950 --> 00:09:46.909 to find the most narrowest, most effectively 00:09:46.909 --> 00:09:49.809 side effect, shortest duration that's out there 00:09:49.809 --> 00:09:53.159 in terms of. therapy based on evidence great 00:09:53.159 --> 00:09:55.960 yeah super exciting and you mentioned um obviously 00:09:55.960 --> 00:09:58.620 amy and first line are kind of working in that 00:09:58.620 --> 00:10:02.200 so kind of what's the best resource tool that 00:10:02.200 --> 00:10:05.220 our listeners should be looking out for when 00:10:05.220 --> 00:10:07.580 when you're getting all these updates and where 00:10:07.580 --> 00:10:10.659 can they go and where can they yeah um so i mean 00:10:10.659 --> 00:10:13.080 it's available for free you can go to your if 00:10:13.080 --> 00:10:14.919 you have a iPhone, you can go to your app store. 00:10:15.379 --> 00:10:18.600 Android, I'm sure, has a similar feature. And 00:10:18.600 --> 00:10:20.700 you can download Firstline. Now, Firstline's 00:10:20.700 --> 00:10:23.600 been around. They have guidelines across Canada 00:10:23.600 --> 00:10:27.960 for institutions, for other global entities. 00:10:28.399 --> 00:10:30.919 But you can specifically look for the Canadian 00:10:30.919 --> 00:10:33.080 Antibiotic Treatment Guidance. That's the... 00:10:34.279 --> 00:10:36.899 canadian specific and it's available for free 00:10:36.899 --> 00:10:39.840 for for clinicians and you can sign up for push 00:10:39.840 --> 00:10:42.980 notifications so that as we update things you'll 00:10:42.980 --> 00:10:44.980 get a notification saying that this has been 00:10:44.980 --> 00:10:48.919 updated and that's great yeah perfect so obviously 00:10:48.919 --> 00:10:50.759 you guys have been working on a lot and so i 00:10:50.759 --> 00:10:52.659 feel a little bit bad asking like what's the 00:10:52.659 --> 00:10:54.419 future because it seems like there's a lot going 00:10:54.419 --> 00:10:57.019 on but i'm sure my listeners are thinking okay 00:10:57.019 --> 00:10:59.159 what's next you know so it's always exciting 00:10:59.159 --> 00:11:03.080 yeah you guys have a lot of momentum going and 00:11:03.080 --> 00:11:04.940 and there's a lot of work going on I mean even 00:11:04.940 --> 00:11:07.460 from I was at last year's symposium and I think 00:11:07.460 --> 00:11:10.139 you guys have done fantastic even just in a short 00:11:10.139 --> 00:11:12.700 period of time so obviously it's commendable 00:11:12.700 --> 00:11:15.159 but what is the future and what are some of the 00:11:15.159 --> 00:11:16.500 other future initiatives that you're looking 00:11:16.500 --> 00:11:19.909 at yeah in terms of the I mean as I said, AMR 00:11:19.909 --> 00:11:21.950 is a priority for the government. And it's an 00:11:21.950 --> 00:11:23.830 area that we're going to continue to work in. 00:11:23.929 --> 00:11:26.990 Now, funding and budgets get very complicated 00:11:26.990 --> 00:11:29.950 over time. But in terms of the guideline project, 00:11:30.090 --> 00:11:33.429 the goal is to complete the syndromes that I've 00:11:33.429 --> 00:11:35.649 discussed so that there is a comprehensive list 00:11:35.649 --> 00:11:41.190 of syndromes for clinicians to access. And we're 00:11:41.190 --> 00:11:44.009 in discussion with AMI and Firstline about ongoing 00:11:44.009 --> 00:11:46.830 maintenance and perhaps addition of future guidance. 00:11:47.110 --> 00:11:49.929 A lot of that is still being discussed based 00:11:49.929 --> 00:11:53.309 on available budgets and such. But that is the 00:11:53.309 --> 00:11:56.490 hope that it continues to be a flagship resource 00:11:56.490 --> 00:12:00.690 for clinicians across Canada. In terms of other 00:12:00.690 --> 00:12:03.429 areas, as I mentioned, surveillance is another 00:12:03.429 --> 00:12:05.610 area that I'm very involved with in terms of. 00:12:06.169 --> 00:12:09.529 targeting up -and -coming concerns. So we know 00:12:09.529 --> 00:12:12.610 based on the most recent data, we have Canada 00:12:12.610 --> 00:12:15.309 Oris, that's a new kid on the block that was 00:12:15.309 --> 00:12:17.889 mentioned. So that's an area where we're trying 00:12:17.889 --> 00:12:21.370 to focus carbapenemase -resistant or carbapenemase 00:12:21.370 --> 00:12:23.490 -producing organisms, which are more in the healthcare 00:12:23.490 --> 00:12:26.789 setting. But we do have programs funded through 00:12:26.789 --> 00:12:29.649 BHEC like CNAS that do collect that data. But 00:12:29.649 --> 00:12:32.350 the other focus is equity is a big piece that 00:12:32.350 --> 00:12:34.929 was included both in the priority pathogen piece, 00:12:35.009 --> 00:12:37.830 but it's also an area of interest specifically 00:12:37.830 --> 00:12:40.850 for the government because we know that AMR impacts 00:12:40.850 --> 00:12:45.899 different populations. And so that's an area 00:12:45.899 --> 00:12:47.200 that we struggle with in terms of collecting 00:12:47.200 --> 00:12:50.200 data, because we know when we look at like Staph 00:12:50.200 --> 00:12:54.159 aureus, MRSA or other STIs, different populations 00:12:54.159 --> 00:12:56.019 are impacted differently when it comes to Indigenous 00:12:56.019 --> 00:13:01.120 populations or GPMSM. So trying to collect that 00:13:01.120 --> 00:13:03.120 information is always a bit of struggle. So that's 00:13:03.120 --> 00:13:06.659 an area we're trying to look into so that we 00:13:06.659 --> 00:13:09.919 can provide the necessary response and guidance 00:13:09.919 --> 00:13:11.740 that's culturally appropriate or appropriate 00:13:11.740 --> 00:13:15.539 to that. particular group and continuing to work 00:13:15.539 --> 00:13:20.299 on governance and strengthening the the AMR response 00:13:20.299 --> 00:13:22.639 now across Canada that's awesome yeah no it's 00:13:22.639 --> 00:13:24.460 really great because I think you're bringing 00:13:24.460 --> 00:13:26.419 up a really good point in terms of, you know, 00:13:26.440 --> 00:13:29.100 it's even though it is a national and Canadian 00:13:29.100 --> 00:13:32.000 plan, I think it's really nice to look at the 00:13:32.000 --> 00:13:34.500 regional differences that there are certain areas 00:13:34.500 --> 00:13:38.580 that are requiring enhanced kind of need in, 00:13:38.580 --> 00:13:41.120 for example, like I practice in Saskatchewan. 00:13:41.220 --> 00:13:45.100 So our sexually transmitted infections or MRSA 00:13:45.100 --> 00:13:48.840 risk factors and population are really high compared 00:13:48.840 --> 00:13:52.279 to some of even, you know, really close provinces. 00:13:53.100 --> 00:13:55.019 And so I think it's really important because 00:13:55.019 --> 00:13:57.299 it isn't like, it's not one answer for everyone. 00:13:58.019 --> 00:13:59.559 And so it's really good that you guys are looking 00:13:59.559 --> 00:14:01.700 at all the regional references and, and really 00:14:01.700 --> 00:14:04.620 excited that, you know, having the support because 00:14:04.620 --> 00:14:08.200 I think as a clinician. practicing it's super 00:14:08.200 --> 00:14:11.519 nice to know that there's like you know a national 00:14:11.519 --> 00:14:15.039 guidance on this and I think that sometimes is 00:14:15.039 --> 00:14:17.580 frightening as especially as we're like seeing 00:14:17.580 --> 00:14:19.700 all the global threats with AMR we're seeing 00:14:19.700 --> 00:14:23.340 all the resistance that's developing the carbon 00:14:23.340 --> 00:14:26.179 penemase resistance and then not only that with 00:14:26.179 --> 00:14:29.019 immigration and travel there's obviously emerging 00:14:29.019 --> 00:14:31.940 infectious diseases as well and so and we we 00:14:31.940 --> 00:14:33.980 kind of talk about all this on the podcast and 00:14:33.980 --> 00:14:36.110 it's it's frightening I mean it makes for good 00:14:36.110 --> 00:14:39.370 conversation, but it's very scary. So thank you 00:14:39.370 --> 00:14:41.750 so much for all your work and your effort. And 00:14:41.750 --> 00:14:44.970 we look forward to seeing what's up and coming. 00:14:44.990 --> 00:14:47.090 Thank you so much. Awesome. Thanks for being 00:14:47.090 --> 00:14:48.350 our guest. Thanks.