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one as on. Yeah, And I'm Holly rich. Cinnamon. Have to Doctor Manchester Real Infirmary. Eso This is thief Third under crying session that I've done with you on this time, we're gonna look at type one diabetes going to give you a bit of a global overview of diabetes eighties. Um, at the beginning, start off with because I know we've got some earlier students on the corners. Well, eh? So just to make sure that everyone is kind of up to speed, um, with what we're talking about, when we say diabetes on, then I'm going to talk about how insulin therapy works as well. Diabetes is a huge topic, so I'm going to cover it again on Wednesday. And that time I'm going to focus more on type two. I may just a type two, how we assess the monitor and some of the common complications that'll that ethics can experience. And so start off with a bit of a refresher quiz. See what the answers in the chat with which is these is an over watching definition of diabetes mellitus. So we do have a couple of sees in the chapped Doctor Ali. Okay. Um, I can tell you it's not. See so glycemia dysfunction is correct. Classy make refers to the amount off sugar and blood eso glycemia dysfunction is a very good district description of diabetes This, uh, by and large when we say diabetes mellitus, it's not usually auto immune because most patients with diabetes mellitus has got Type two um, which is not an autoimmune condition, but type one is on. I think it was a big meeting because I did say that this is going to be about Type one diabetes. That's probably why you went to see on something be a complication of a least significant systemic morbidity. That's not right either. So obesity is a significant risk factor for Type two diabetes. You wouldn't normally describe it as a complication because there are cute genetic risk factors for Type two diabetes, um, and other risk factors like a genetic necessity. And but it is correct that it has system a significant systemic morbidity. I think generally people are going for D, which is the correct answer. Eso diabetes mellitus as a whole, both types one and two is a metabolic condition that leads to life long time logic levels well done. Who's purpose of that and just looking quickly at point A. Anyone who is here for my diabetes insipidus lecture should recognize A as the definition for diabetes. Insipidus. If you won't have that lecture, um, just be aware. Diabetes mellitus and diabetes insipidus are entirely unrelated conditions. You've got similar names, but then nothing to do with each other. Good. Someone's put it all in capitals in the child, so nothing to do it each other Diabetes insipidus is caused by not enough anti diuretic alone or by the kidneys failing to respond to it. Great, that's good. A good first answer. Just oh three question Quest to start off with, which is not correct regarding the public health impact of diabetes mellitus to have a couple of being and C's Yeah, good. I'm impressed by the amount of people who were saying they on be is the correct answer because it's actually 10% of the NHS budget, which I think is incredible when you consider how much money the NHS spends on, if feels s so you can see from my side what a massive impact diabetes has on the health and on the health of the population. It's only going to get worse. I've been extra you decades. So there's five million people in the UK at the moment who have got diabetes. 10% of the electric budget is spent on managing diabetes. So if we start getting it right, then we'd have to spend a lot less on treating those complications. Um, all of the others that correct on it's time to diabetes that has a strong genetic link. Know type one, um, point day about the complications is what we're going to cover next, Uh, on Wednesday. Uh, no question. Which is not correct regarding glycemia control. This is not correct. So you have quite a lot of these in the chat, Really? And everyone remembers those diagrams from the first couple years of school. Great to be is the correct answer. We're gonna really quickly recap physiology in a minute. So just for those who haven't covered it yet, just remember, there are two types of cells in the pancreas that's do things to control blood sugar levels. Alpha cells release the hormone called glucagon on beater cells release a hormone called insulin of the reason that be is incorrect is that it's insulin that promotes uptake of glucose by body cells. Because insulin is always working to you decrease the amount of sugar in the blood, whereas glucagon is always working to increase it out of sugar in the blood. So here's a recap of glycemia control. So you eat chocolate bar goes into stomach, you start to absorb it, which means that your blood sugar levels shoot up. That's activate the beater cells, which are in the islets of longer hands inside the pancreas, and they secrete insulin eventually works, but I all of those things listed there it makes the body cells tank up. Blue goes to remove it from the blood. It stops the liver from releasing any more blue goes into the blood. It makes the liver take up blue goes and store it as glycogen. That's good. Like a genesis on. It stops the breakdown of release of Fats Teo. Bring the blood sugar down but normalizes on D. And then the reverse happens when you've got a low blood sugar, which is usually due to starvation or too much insulin on. That's when the alpha cells are activated in the islets of lung hands, they secrete glucagon, which essentially just does the reverse of everything listed in that box above. So it causes release of glycogen from the liver like a journal isis. Now all these weird sounds similar. Not the same thing releases fatty acids from adipose tissue causes conversion of proteins and fats into glucose in the liver, which is gluconeogenesis and the new blood sugar goes back up. So the process is that working all of the time to keep your blood sugar at the study level? What kind of steady level would you expect in a healthy person for that blood sugar? Does anyone have a A range? So what's a normal blood sugar for a healthy person? Yeah, lovely. Some very nice Rangers. Bye, love. And so you're right. You're redefine, right? Just different places. But as long as it's roughly somewhere 4 to 8, that would be. That would be good for a healthy person. It's usually 4 to 6 before a meal, and then it can go up for a little bit afterwards before the engine, it brings it down. I mean, it's important to note, but you will hear much sugar being described as be and I'll probably do it a lot because we always describe it as a BM. That's a really outdated term. Actually refers to the German company Boehringer Mannheim that used to make the testing strips just the little bits of paper that we used to test blood sugar. But it has no clinical meaning. It's all but you will hear blood sugar being referred to as being at all of the time. Okay, so just take a look at the top half of that diagram. That's how insulin should work. And then the next line. This is what happens in type one diabetes. So you eat the snack, your blood sugar goes up, then do two on auto immune. Process your beat. The cells have been destroyed. They can no longer secrete insulin to your blood. Sugar stays very high, and that's what needs to chronic hyperglycemia in type one diabetic expressed. That's all you need to know about the pathology. So just for any of the earlier years, you just want to remember fee crucial things. Type one is lack of insulin do to the audio mean destruction, and you get chronic hypoglycemia. Type two is when your body sale. Body cells failed to respond as well to insulin s. So you've got lots of glucose in your blood. You got lots of insulin in your blood as well. But the body cells can no longer react to the glucose and the insulin and the way that they used to, um, usually due to chronic exposure to high blood sugar levels. That's why you tend to get it in a beast. Patients, um, but both type one and type two You end up with patients with chronic hyperglycemia, so their blood sugar levels are always high until treated on, and that's why they tend to get the same complications for the timeline. But when you understand this, this explains why type one is exclusively treated with insulin. There's no need for any of the other fancy drugs that you use with type two, so so type. What? All you do is replace the missing insulin, Titus Coolaid's of working treatments. Um, for anyone who wants to get the extra mile, uh, then just have a read through this box and or you can ignore it, cause it is a bit of extraneous, actually details. So what causes the symptoms and type one diabetes. You've got too much glucose. It's forced through the kidneys filtration system, and it pulls water after it by osmotic diuresis because water tends to follow the large molecules. So then you get high volumes of sugar in urine. So polyuria lots of urine like a Syria is urine with glucose in. And you're dehydrated because you most lots of the walk body water because you're dehydrated. I don't get thirsty, which is politics. Yet on the weight off is because your body cells would love to be able to use all this fluid goes that's floating around in the blood stream. But they can't because there's no any insulin for them to take this. If it goes into the body cells, um, which they have to burn fat and muscle instead. That's why diabetics will lose weight. Um, okay, good. So how can you diagnose type one diabetes? These are the general rules. There's lots of I/O to it, but I think this is what you have to know. Um, so if you've got someone who presents your diabetes symptoms so politics here, which is excess thirst, call a urea weight loss. All you need is one of the following blood results. You don't tend to use the finger prick blood glucose test. You tend to use the more accurate venous blood test. You take a whole bottle blood and send off to the lab. Um, just gets more accurate, but he can use anything. Three tests, a random test. So at any time of the day, if their blood sugar is above 11.1 on you got symptoms, then the and then that's that's diagnostic of diabetes. Um, it may be type two diabetes as well, but with considering, um, you know, kind of younger patients here without the risk factors for type two, um, fasting plasma glucose is they have to fast for a certain amount time. A car from how long? Actually think it might be over night. So you take this first thing in the morning on then if their blood glucose level is over seven and that's diagnostic on, then the oral glucose tolerance test is what shown here in the orange bottle. You ask them to fast for several hours, then drink the bottle full of glucose and then you take a blood sugar level two hours later when in a normal person, the insulin would have already acted and the blood sugar level would have gone back to normal if two hours after the old glucose tolerance test of the much sugar is above 11.1, that is also diagnostic. It gets a bit trickier with patients who are asymptomatic if you just take a blood check for another reason, maybe to turn up today and and you take a blood sugar for completeness. Um, and if you get deranged results in a symptomatic people that you would ask him to come back another day, not saying day on to do the same test again. Oh, I'm sorry. Or do any of the other tests listed above on As long as they've got to do a range but results, then that's another thing that could need you to the diagnosis. So here's a case study will be following this 12 year old girl whole way through. She's based on a real patient I saw in a in a couple months, Um, 12 year old girl with no medical history presents to an eight with abdominal pain, vomiting and lethargy. In the last three months, months from a on his notice. 3 kg of weight loss, along with increased thirst, increased urination on examination. She's drowsy, appears dehydrated. And you noticed a fruity smell to her breath. She's talking Codec. And to kick Nick with normal oxygen SATs, BP on DNA. Oh, fever. Which investigations do you request for people? Like hopefully we don't go for sorry. Kittens? Yeah, Ketone is very good. Full set of bloods. Yeah. You just don't ever think this This girl is quite well. So blood sugar would be number one the second she walks through the door. Anyone with tummy pain and vomiting get the blood sugar? Uh, then people saying for blood count yes, that's correct. And ketone again are essential. So people are coming to the diagnosis of DKA, which is correct. I'm gonna talk through DKA now. Um, so just have a look at this girl's investigations. Her blood sugar is very, very, very high. Her blood ketone a very high. Um, King joins a remark of DKA, which is a complication of diabetes. We're going to get to on. She is acidotic pH is below the normal range. Um on. She's also leaking glucose into her urine, and she's leaking Keto dye into the urine. It's This is a really classic picture of the eye, a better ketoacidosis. So I just I got to ketoacidosis. Um, it's a diabetic emergency. Um, Andi, because so many Children are just running around with type one time type one diabetes and might not realise about it. 23% of those Children only realized that they have diabetes when they get this very serious complication. Diabetic ketoacidosis, um, and the rest of picked up by by screening and by going to the GP with weight loss and things. Um, so yeah, respected it for DKA is not knowing you have diabetes on then, in people who do know they have diabetes, you can also be prone to decay if you come currently got an infection. If you're not taking your insulin because that makes your glucose shooter or during a heart attack, um, you can get decay in type two, but it's very rare. I wouldn't I would for yourselves. I would just think DKA is type one diabetes. Um, very serious. 1% of patients die. I used to be a person only a few years ago. That's come out recently. I think cause of DKA is uncontrolled Hyperglycemia. So you get, um so it's so sorry. You get a high blood sugar levels that your body is unable to use that Rico's. So instead of using glucose, it has to use fat instead. Seaga Unrestrained breakdown of fat, Which sets off a complex chain of reactions which I don't really want to go into. Uh, from the breakdown of fat, you end up with ketone bodies. Ketone bodies can be used in normal metabolism, and they are a source of energy. They can be really useful because they can cross the blood brain barrier s oh, yeah, they could be. They could be used as part of cells. Normal sample is, um, but when they start to build up uncontrollably like they do during fat break breakdown in DKA, um, they cause acidosis. Um, which ricket? Because kee times are acidotic. Um and that is what causes the allergy in people with decay. It is a medical emergency, which is characterized by high blood sugar, high key tones on a sec dot stick. Would I get the picture of nail polish remover on just to remind me if you have a case study that you're reading with a person who presents with fruit east mowing breath on, then it's DKA because, um, key tones that the primary ketone that is in the body is acetone, which is the simplest, smallest ketone. Molecule on acetone is one of the active ingredients in nail polish and that you can breathe. You can get rid of acetone with respiration. Eso patients will be breathing out this this free t smell that smells like now, um, so in DKA and things that are going to kill you, Uh, dehydration acidosis, Onda, potassium in balance. So the main thing that you do, first of all to treat them is replace the fluid she needs, Give them intensive resuscitation. Um, following on from that, you give them the insulin infusion, which brings down the amount of fluid goes in the blood, um, and gets the cells to start taking up and using glucose instead of producing key tones. Um, so first thing for its second thing insulin the whole time this is going on, it's quite a precarious balance off of the amount glucose. And have ketose be mapped. Ask him in the blood. She need to make sure that you're monitoring them really closely on you. Would never be managing this by yourself and kind of f one F two s, t one. Probably a pencil reginal. You would always want to get a senior involved. Um, because it is a very serious, um, serious presentation. Um, there are hospital policies on exactly which bags of fluids to prescribe in DKA and when. But it's very depending on which hospital urine. And I'm just going to explain about potassium enough. But embolden that the reason that potassium is important hidden DKA is because your body is excreting all of these key tones, which means that it excretes a water alongside it. An it excretes a low potassium along side the water's You've got massive excretion of all this stuff, which is important. Potassium and water. Um, so the amount of potassium that you have in the body is very low. Um, but to counter act that potassium migrates from the cells to the blood stream, so potassium might be really low, but he won't be able to detect that on blood tests. It will actually be normal or high. Um, if you measure potassium. So if you've got someone with a slight hyperkalemic a in DKA and don't worry about it because they're actually passing will be low. Um, insulin really quickly drives potassium out of blood and into cells. Eso When you start treating these patients with insulin, you're gonna find that they're slight hypergly near very rapidly drops Teo a profound hypocalcemia. Um, and this can This can kill people. Um, So that's why you have to measure zero potassium really frequently throughout DKA. Because if they're taxing, drops really rapidly than that can lead to life threatening cardiac A with muse. So then this 12 year old girl is treated with fluids, insulin and intravenous potassium replacement, and that's the mainstay of treatment for DKA. It looks like she's getting better over the next 12 hours. He saw her out. Her observations get better, blood sugar drops and ketone has dropped. I haven't put it here, but he'd be looking very closely at her pH as well, her arterial gauge to see that she's not no longer acidotic. So it looks like she's getting a lot better. Um, are you happy with this? Is it time to go home. Hopefully not. Um so at this point, you've got a young girl who had no prior medical history. Um, who has presented with DKA. So this is a go type one diabetes. On going back to the previous diagnostic criteria, she easily needs those. Aside from the fact that she's currently in DKA, she is a symptomatic patient on a random blood glucose was 20 something where she would, um, be able to diagnose if the round of applause likely places over 11. So this little girl can be diagnosed by yourselves in any with type one diabetes. Um, at this point, you would get the pediatric steam involved on pediatrics would come down on. They would probably admit her for a least 234 days, because what's really important in the next few days is that she gets education. Um, she's been diagnosed with a lifelong condition where she will need multiple daily injections of insulin, and she'll need to always be aware of hands a recognized life in conflict complications like another DKA, or like a low blood sugar, which can also be life threatening. So she'll have to measure her blood sugars. At least four times a day, Um, and her parents or herself will have to be taught how to inject the insurance. All of that takes days. It's not quick. Thing is, so that's the hospital with this. Even once you sorted them out. Um, that was quite stressful for the for the little girl that this case is based on because she had to go onto a ward and actually thought she was going to die with all of this decade. It was going on, and she actually and then she had to stay. And then it was craving so she could really have receptors are from her parents, and she have to stay in and learn all of these horrible new things about have to take blood sugar readings that pattern minister into. It's a shame that Okay, so types of insulin regimes that you can start a patient on with newly diagnosed type one on this this two or three regimes the usual one that you would start someone on is called basal bolus. On. This is referring to the type seven Jalyn that you're giving the patient and when you're giving it to them, um, I always find this really confusing at med school? Um, if anyone is finding it confusing, I can repeat it again. And I got to go because, um, it does actually make sense when you look at the graphs. So initial ins come in long acting, medium acting, short acting and rapid acting. Um, and you can also mix them together. And that's called, um, extension. Um, the primary regime that you would put someone on is where they have a basal dose of a long acting insulin, which is usually given once or twice a day. Um, generally, it's it's, ah, once nightly dose for a newly diagnosed patient on. Then, with every meal time, their glucose levels will shoot up, so they need their insulin levels to shoot up well, she'll give them a short or rapid acting dose at every meal time. You can see that brunch at breakfast lunch on, but I would call it T time, breakfast, lunch and tea time. She's going to take enough insulin to cover the amount of glucose that she's getting at that meal. Um, it varies with diabetics as to how they measure how much short acting insulin to take. You may have heard of carb counting. That's where you take your meal and you work out how many grams of carbohydrates in it that you then take a certain amount of units of short acting insulin per gram of carbohydrate. Other people look at there, and I think this one's easier. You can look at your premeal blood sugar, and you'll say, if it is less than eight, I'll give four units if it's between eight and 10 on if six units or whatever. That dose is very hugely, because people have different amounts at well, people way different amounts. And people have different levels off of intervention resistance. So so these regimes can be applied to both type ones and type two's on with the type two's. They will need such massive amounts of insulin because their bodies are resistant to it anyway. Um, okay, no titers will be on insulin because this's insulin is much further down the line for Type two's. After they tried lots of other medicines, his first line for type ones. This is a different type of regime, so you'll see a basal bolus. You'll also see mixed or by phasic regimes on D on with this. It's fewer injections on. It's the same type of insulin that you take each time. So I think this diagram is a little bit more confusing. She's actually the person in this diagram. Only had two insulin injections. She had one at breakfast, and she had one at her evening meal. But both of those injections had a mixed prep aeration and containing both short acting insulin on dinnter media acting insulin. So the short acting insulin covers her for breakfast, and in the intermediate acting insulin covers off the next 12 hours. Um, it will peak roughly during the midday meal, so she doesn't need to take any short acting insulin during the midday meal on. By the time the evening meal, higher insulin levels something that quite low again. So she takes another mixed dose. Short acting covers the evening mail on the intermediate covers her overnight, and still, it's time for her morning dose. Is there's a different times. Eventually therapy, Um, then in terms of recognizing insulin drugs, Um, I don't think it's quite important. Teo roughly know what you're looking for when you see an insulin prescription, because insulin would just be prescribed a Z 10 units. Long acting insulin. It will always use the brand name and different runs. Make the engine it differently, so they're not interchangeable. You can take someone who's on tresiba, which is a long acting insulin, and switch it for 11 years. They always have to have the same ones. The hospital should have all of the different brands. Stock on insulin is also usually made from pig insulin or cow ensure. And so it You just need to bear in mind that sometimes a religious element to consider for groups who would be comfortable using pig or cow products. Um, I've got a load off insulin names. They're they're randomly sorted. Just have a look at some of those. You probably will recognize this, um, and others. You can work out what type of insulin they are. Um, see if you can put two or three of those insulins in a while, five of those columns I'll just give you a minute to see what you can do on. But since it in the shaft you want to on, then I'll give you a few tricks to work out which one's belong in which Colin, Because there are usually rules to do with the naming. Okay, good. I think people are generally looking at the names of them and kind of working out from that, which is good. Um, so these are correct ounces. Um, Tresiba, Lantus and Levemir are very commonly used long acting ones. I don't if there's a good way to remember that, I guess the Lantus and Levemir both begin with l. Same as long acting, Um, ones that are intermedia. So sorry. Long acting would usually be a once daily dose into media. Acting would usually be a twice daily dose. Um, for the purposes of med school, I would say you could love a long acting and intermediate acting into one group, and you can love short acting and rapid acting into one group. I think it's only really endocrinologists that that would take it much further than that. So Lantus and Levemir just seen but a long acting ones with I end usually intermediate acting so human and I as opposed to human s, which is short acting on insurance. Heart is intermediate. That's rapid is confusingly short acting, not rapid acting on then, um, Nova Rapid and Apidra which is kind of a nanogram of rapid rapid on, then, just to be aware, if you see once that I've got numbers on so 25 slash 75 30 slash 70 they tend to be mixed insulins with the numbers referring to what percentage of the insulin is long acting and what percentage of the insulin is short acting. So if you see those on a drug charge, then should be able t o. I'm kind of work out. What purpose? That playing, For example, if you could pick up on errors if you saw that never happened, was being prescribed once a day at night time. That would be ridiculous, because, um, Nova Rapid needs to be given at mealtimes because it's rapid acting. And where is he long acting insulin like to receive? It would be fine to give a night because it would. It would act over the next 24 hours. There are different ways of administering insulin. I've never seen anyone used your engine vial. We don't use it in the chest. Um, they use more commonly abroad in places where people have to get insurance s so that never quite popular in America because on day are cheaper on. Insurers won't pay for insulin pens like the one showed on the right on, so syringes are cheaper. You draw up the dose yourself, which means that it's more prone for you to make mistakes. Um, patients who use syringes. I think it's 10 times more likely to get hypoglycemic events on it's more painful depends on more accurate what you do. She turn the dial on the right hand side of the pen. Um, Andi. It has little numbers, and then you take up to eight units or having much, and then you just inject yourself. That they're prefilled contract is, um, the only really advantage to the syringe other than cost, um, is that some people self mix their own insulins. They they draw up a little bit of long acting, and then they drop a little bit of rapid acting, and then they mix it together in the syringe, and then they can administer that themselves. So it's fewer injections than using a long acting and a rapid acting pen. People sometimes perfect out for kids, it gets one fewer injections, Um, and then this is new technology. So instead of a pump or so instead of a syringe or a pen, some people use insulin pumps. It's a little tube that goes into the subcutaneous tissue, and you have to change the tomb every few days on. It's constantly delivering a rate of background insulin, and you can change that rate using the buttons on the device. And they're useful for patients with recurrent hypoglycemia years. But they're really expensive. Some people buy them themselves on the NHS. They'll only be funded if you meet really strict criteria, like if you have, if you're taking your insulin as you are supposed to. But still getting recurrent hypos than any chest will find one of these for you. Um, there's been really interesting. Recent developments with people who have have hacked the code for these insulin pumps on day have used smart technology to link it to a continuous glucose monitoring machine, so separate leads the pump. You can have have a little monitor that can give you up to date glucose readings. On day, someone put together a load of code to get those two machines to talk to each other so your glucose monitor work. If the will give you a glucose reading on, then. Based on that, the pump will adjust how much insulin it's given to the patient, and that is essentially building your own pancreas. It was all very kind of, uh, like a nefesh a while. There was nowhere that was willing to take the risk of it all going wrong on be a patient, leaving everything up to the automated technology and not realizing that their blood sugars were going absolutely after control on the patient's built these for themselves, and they used to go two sessions when they would be taught how to put the pieces of technology together on Dakoda was widely available on the Internet on. This was kind of going against what a lot of kind of big farmer wanted to happen because Big Pharma were happier with people using um, using the syringes and pencils prescribed and on a lot of endocrinologists preferred that people used it as prescribed, and we're safely checking your own blood sugar levels on. But within the last few months, there's been updates that Ms build your own pancreas technology is is starting to be licensed. Um, as long as she takes your blood sugars every now and against that, it's working. Okay, Um, so he prescribed the patient. Some regular insulin give her some Levemir to take a night, and that dose could be calculated using the patient's weight and using a load of algorithms. Um, Andi, she's decided to do carb counting so she'll take rapid acting insulin at one unit per 10 g of carbohydrates and all insulin is given subcutaneously. When you prescribed, make sure you prescribed in units patients have died When? When doctors have prescribed. For example, if you want to prescribe 10 units and you write 10 you that you can look a lot like a zero on, then the patient can be given 100 units instead of 10. Um, or you can look like 10. So if they prescribed three, are you meaning international units? Then I guess you could give 310 units. You question whether someone should should notice that that's a really high dose before giving it. But patients have tried, some actually prescribed using the full terminology, um, she'll be given education. Such a Z how to measure blankly goes herself, which will be at least four times a day before every meal and before bedtime. And she'll be given advice on diet on D helps control glucose and how to recognize diabetic emergencies. Um, yeah. When you when you prescribed insulin for a newly diagnosed type one diabetic. A rule of thumb is that about 40% of the total daily insulin should be long acting, and the remaining 60% will be rapid acting. Okay, well, we thought that was the end of the case, But then six weeks later, I own made this better. This didn't actually happen in your life. But six weeks later, she presents today any with shakiness, weakness and blurred vision. She has come straight from her school Sports day. On examination, she is very sweaty and tachycardia. That sugar is 2.6. So this is a hypoglycemia. We said before that blood sugars, sugar to be between four and eight. Diabetics have a bit more leeway that the lower limit is very strict. Hypoglycemia is a blood sugar off less than four. Um, And again, this could be life threatening. So been kind of things that cause it. Our patients taking too much insulin, um, or fasting and continuing to take your insulin anyway. Well, alcohol Or if they exercise and then use a lot of the bunch, um, it can present with increased heart rate, dizziness, irritability, lethargy, sweating on the ones in red are symptoms are really severe. A life threatening hyperglycemia. Um, for those who want to know, some people can develop reduced hypo awareness over time. Uh, this is usually the more hypos you have, the less the wettest you have off them. Um, this could be really dangerous because ideally, if someone's entering a medical emergency, you want to know about it? Um, on also, these people with reduced hypos can be going about their daily lives and then all of a sudden, completely crash become super and well, people with reduced hypo, and it's not allowed to drive in case they have a severe hypo on the motorway on Do think they're restricted from, um, certain, um dangerous jobs as well. Um, shaking us witnessed blurred vision. Sports day. So she's been exercising. That sounds like it's probably the because of this, um, and sweating and tachycardia. So this classic hypoglycemia. Um, So this is how we treat her. If she can still swallow Um, And then you get you get fast glucose improvement by using or glucose. Um, I used to get confused with between, like, glucagon glucagon release quicker tablets. It's kind of a little is a lovely it's It's just different ways of administering it. So whatever you go on the ward, you can give to a patient with the Hypo fruit juices really good. Often, we just they give them some orange juice, depending on how low the blood sugar is on. We can just give you that chocolate and biscuits and very fatty, which delay stomach emptying. So it there's no great if they're there, anything you've got that he can use. Chocolate misc It's but they don't even have that higher sugar content. And and then obviously don't start giving insulin Tia patients, even if they do an insulin dose. If they're in a little hypo, Um, and then once their blood sugars over for give them a lot on acting carbohydrates, so give him some toast. Give them a normal meal. If they do that, um, and then your second option. Sometimes these pains, but people are have got ridges consciousness. Sometimes they're not safe to swallow you can give Intramascular Glucagon, um, talked about things gone earlier. It's a hormone that's made endogenous Lee in the body on it encourages thie body to release all of it's going go stores into the blood. You can give that intra muscular it's fast acting. Or you could give them a drip off intravenous Glencoe's, which is the same thing as intravenous dextrose. By the way, dextrose and glucose for the sake, off IV fluids are exactly the same thing, then it. So that's it, for they haven't impact swallow or, if they are not improving after usually three sets off or Ultram mint. So three sets of Glucotrol. Then try giving click on or intravenously goes, um, on call for senior helpers. Well, if if they look right there on deteriorating and we had a patient have a high both on my ward about 34 days ago on, but every single ward should have a high poking it, which is this's kit on the bottom, right in the orange on it should have a glucagon injection, and it see consults someone out like that if they're having a high plank. Unfortunately, some of the lesser keyboards tend to not stock these. Um, I want to pay for these. Eso took it longer. It's You are on a ward to be contracted. You've got a high pick. It, uh, patient's blood sugar and creators. This is the case conclusion. You give a glucose tablets, orange juice keep going to close observation on then. Usually, the diabetic nurse will just come and review the interim regime. It would usually be up to the doctors, and they the nurse says that the patient should just reduce the rapid acting insulin on days when she's playing sport. Because it seems like her, um, in generation was working fine up until sports day on. Also, take more, uh, frequent blood sugar readings, Um, on days when there might be issues. So the end of the case, Um, I will. Dohn a five question quiz. Um, about what we've covered it on do then they'll be tired. A little bit of time for questions. Every run again. Sorry. Question one. Which of these patients could be diagnosed with type one diabetes? So we've got a couple of days in the chat. Yeah, wonderful kind of these cases it quite long, So I want to give you enough time to read it. Um, the correct answer is day, and I will just go through. Why so for a she has got symptoms that you would expect a random glucose to be over 11 in order to diagnose so that those symptoms obviously still need investigating, but that that test is not diagnostic unless it's over. 11. 12 year old here is asymptomatic, with a runs and plasma glucose of 16. Again, you would expect you would bring out patient back the next day on Do Another glucose test because if they're asymptomatic and they need to deranged blood results, seeing sounds a lot more like a time. Two. Diabetic. He's got risk factors in that he's slightly older, not your usual type. Two diabetic gauge but slightly older. He's South Asian, which is a respect for type two. He's overweight with the beast on HBA one C, which is a measure off approximately. How how your blood sugar has been over the last few months, um, is high. We don't use HBA one C for diagnosing type one because there are so many of the factors which can affect it, such as any disease that affect your hemoglobin levels. Um, but we can use it for diagnosing type two in time. Well, in both times, it can be used to monitor how well the trick has been controlled over the last few months. But it's only used to diagnose type two, and in perfect the part D is correct, because she's got two separate readings which are within the diabetic range. So you need symptoms plus one of the following, um, blood results, um, or asymptomatic and to derangement. Results were good. Uh huh. A posse question to an 18 year old girl presents with her third episode of DKA in the last six months, which is not a possible risk factor over current E k, the nice ones of intricate. So I didn't go through all of this these these days, Mainly thing I see is the correct answer, and body image concerns is a risk factor. I'm surprised no one except that it is a risk factor. Maybe you're already know this on do with people who are trying to lose weight. They often going to take their insulin because if you don't take insulin than your body can't absorb, absorb the glucose. Therefore, you can't gain weight that you end up with lots of complex occasions because you all of the glucose stays in your blood stream so you can't get things like a recurrent DKA. The body and concerns is a risk factor. Infection contributing K and pregnancy contribute DKA A family history of type two Diabetes is nothing to do DKA, but it puts you at greater risk of type two diabetes. Question three. Which of these signs is prognostically poor in a patient with DKA? I almost didn't put this morning, so I thought it was a bit mean. Um, I don't think it would be acceptable for an exact question, but we'll see how you do. So of course, if you ate a couple of CDs in the chat. All right. Well done, Jay. Uh, the current tense it is B. So a lot of people think. Okay, I understand that hyperkalemic is usually a big warning sign, but it is kind of expected in DKA. And you would expect that it would drop us. Do you should give the insulin. Um, so monitor it. I'm not saying it's fine, but you would expect that that comes down, um, and put you in for the pH of 7.32. Usually you could only diagnosed DKA if the PH is less than 7.3. So even though it's outside the range, it's not even really probably D decade up, um, blood glucose 28.2. It's pretty awful, but it's quite normal for DKA. Um, the BP of 88 51 is what I'm worried about because what generally kills be plenty. K is dehydration. So that is a sign that they are severely dehydrated because they lost so much urine. Um, yeah. So life threatening issues, dehydration mainly, and then acidosis. And when I put potassium in balance, I mean hypokalemia question for which type eventually maybe would best suit a newly diagnosed type one diabetic who wants to take the same type of insulin for each dose as otherwise. He thinks he might mix the medicines up. Think ever we've had everybody on. So no. Okay, um, so depending on how you're gonna read the question, multiple of these could apply. It's not a because basil voters regime via pen is where you take a long acting insulin and then you take a long acting insulin at night or in the morning, and then you take short or rapid at every meal time so he could mix those up in bay. Um, yeah s over my a syringe. He would need to take long acting, um, unsure it acting. He could take together maybe once a day, but he would also need to take short acting every single meal time. Because that's how basal bolus works with by phasic regime. At two meal times in the day, he can take a long acting and a short acting together. And you can get that in a mixed insulin pen. So the correct answer is, See, So he could take a mixed regime by a pen s so he could take something like Nova mix twice a day on that would suit him very well with insulin. Pump is the same type of insulin, but it's 3000 quid. So for a newly diagnosed, he was only quite area is that he doesn't want to mix the medicines up. Um, and he's not having any other criteria like recurrent hypos. That would mean he needs insulin pump, and by phase it raising would be more sensible for this time. Final question, which is not a common sign of hypoglycemia. So you got a lot of these? Great. I haven't used the word cause more yet, but cause more breathing is deep, rapid breathing, and it's commonly associated with DKA. Where is only other signs of hypoglycemia? Um, so that was the end of teaching for today. I am teaching. You're gonna Wednesday and going to do warn diabetes. I'm gonna dio overview of management for type two Diabetes was talking about the knowledge when drugs, uh, common complications, all of the microvascular microvascular. I've started writing an underground quiz about the previous few lectures that I've given A because I would be teaching you after that until the end of May, because I've got a place right exam coming up. And so I thought that you might want to do a quest in the meantime, to recap some of that into crying stuff. Um, if you if you can please for that feedback, because it is really useful to reach for it and just to get numbers of how many people have come, I I did get some feedback last time and people want a lecture on reading EKGs, blood tests and your analysis eso if we've got time to do that next month, and I could definitely squeeze that in a less than one. Just beforehand. Yeah, thanks very much. Super long trip questions to have think it's summer, Doctor Lee. Yes, we do have a couple of questions in the chat, so, um, it is asking how frequently do need to measure serum potassium? It doesn't say so in the guidelines. If it's within rate, I I don't know what the actual rule is. You would be doing regular BMS and ketone Zaun these patients. If the potassium is out of range, then you would certainly be measuring it much more frequently. I would say as a kind of ballpark guess you maybe be measuring every two or three hours with the acute presentation on, then check it. Maybe every saying I was until you're 24 hours and so about think so much. Um, Seder's asking what are the criteria is for introducing short acting insulin. Uh, so I've got the Internet regimes here because someone wanted me to go through by phasic again. Um, short acting and rapid acting insulins. They're the only well, it they're different in that short acting lasts slightly longer on, but they're both taken at mealtime with rapid. You take it while you eat. I'm with short acting. It takes a little bit of time to build up. You usually take a half and hour beforehand for the purposes of almost anyone. Apart from endocrinologists Thumb, consider short acting rapid acting to be the same kind of thing for just to show you those graphs again. So basal bolus. You've always got your basil going, and that would be from water or two daily doses. On your bolus is a short acting or rapid acting at every meal time on. And then someone wanted by phasic again. So there's only two doses being given. That is the breakfast dose, which is mixed. So both those is a mixed, short, acting longer thing said breakfast dose on evening male dose? Uh, yeah, perfect. That makes perfect sense. State. I'm going to a need you, So if you can ask your question, please, Thank you dot So just basically the question was, uh when would you introduce the short acting? So you did explain it to people that were taken before food. But when? When? When We will introduce it, for example, for the shot for the two diabetes. You won't give it because you started Leah. Other forms, um, with metformin are likely that it's stuff like that. But for the short acting, when is the time where you will introduce it? Uh, is there a specific bacteria? Thank you. Yes. Great question. Um, so when I think you're referring was type two. Um So when tight one, they're always gonna be on insulin that matter what with type two diabetics, they were. The issue isn't that they don't have enough insulin on the issue is that their body cells are failing to respond to the insulin. Say there are other drugs that get used first. Like metformin like sulfonylurea is on. We're going to go through those next week on those generally work to you, help the body cells become more amenable to insulin and in other ways. But in patients who have got such poor diabetic control on the way that you would tell if they've got awful diabetic control is by looking at the HBA one C s. So it should be below, uh, 48 ideally, but I've seen patients with HBA. One C is like 100 twenties, Just horrendous. I seem in control with those patients. If you can't sort it out by music, your other medicines that you would use insulin. What? You've exhausted all the other options in type two. Think you're much even though if they are on the combination off the There are, um, medications you think you would, you would keep them on. There are other medicines as well. You patients could be on lots of diabetic medicines at once. Um, there's a list that you would go through with Type two's on Insulin tends to kick in once all of the other medicines have failed. Thank you. Sorry. The reason you can treat talk to an insulin is because you get from such massive doses of insulin barmal that my body would actually be producing. Thank you so much, Doctor Holly. We've got questioned by our Leah and she's asking, what is the best insulin regime, and how can we treat which one would be the best one for the patient? Uh, first line is this one basal bolus, um, on D That's good, because, um, they can vary in ugly crazy and take it each meal, for one thing. So you could say I'm having a tiny breakfast so we'll just have a tiny amount over Rapid, or I'm gonna massively splurge out and go to a restaurant for my tee time on. You can have a big dose of overlap. It was that's first line. Some patients just prefer this, this one the by phasic regime, Um, because it's fewer injections or because it's less different types of insulin to worry about. But considering you wouldn't really be able to go and have, um, a tiny breakfast or a massive tee time if you were on this regime because if you're trying to take less insulin for your breakfast, then you'd also be taking less long actings. He wouldn't have much cover throughout the day, and the heart really various much so those have been to normal types of regime. And then, on top of that, you've got insulin pumps, a swell which are wonderful but expensive, Um, so they don't tend to be used first line. Thank you so much. Doctor Ali Down is asking why was the abdominal pain in the first case of the young girl with DKA on what caused the abdominal pain. That that is a good question on. I think it is quite poorly understood. I I didn't understand that. I still don't buy news. Always go to us. That's why when I looked up for today that there is reduced gastric motility in DKA on Do You can just get all sorts of gastric pathology in DKA. But it's a complicated set, of course, is on. It's not when I say it's not fully understood. I mean partly by May. And also I don't think all of the courses have been explained to her. If you Google wise their abdominal pain and DKA there's like contradicting articles on it. So no one's got a I set Answer that you would expect it to road learn for medical school. I'm glad I listen, I have a session. Thank you so much, Doctor Lee. Um hum more question before we do, give it a rat. Um, same is asking. What is the diagnostic laboratory test to distinguish between time be sixties type one and type two s o. They, uh, I'll get back to the tests can, uh, diagnosis s so it would be similar in type two. Yes, it's so exciting. You would also expect diabetes symptoms, and you would expect at the randomly goes over 11, not the fasting of seven or the or glucose tolerance test over 11. You can also look at HBA one C and type two, which you can't do in Type one on. There's a pre diabetic range, which is 42 to 48 for HBA, one C and a diabetic range, which is 48 over. I'm other than that. It tends to be clinical history. So with your younger patients who are not overweight to don't have all these risk factors when you got a 10 year old kid who comes in and that's going to be type one or if you've got someone with a strong family history of Type two diabetes on. But they are overweight and they're over usually 30 or 40 well, usually over 50 on DC a family history lifestyle, then that is usually like the clinical difference between type one type two super Thank you so much. Doctor Holly, is that any other questions that you almost to ask. Feel free to meet yourself. Have you gone to the session after this? No, we don't actually have another session. We do have another session at five o'clock with Dr Pull Brennan, and he's gonna go with a case base of the tallest team. I'm afraid to take questions. If anyone has any, uh, please fill out for you. Yeah. So we don't have what questions Have a dose for insulin. It's all based on weight. Um, so for the very first dose, you got the calculation for it. Written somewhere. Um, we go to this calculation. So a new patient will need approximately north 0.5 units of insulin per kilo per day per kilo of the body weight if they are a patient who is under 25 kg. Say, for little kids, although need nor 0.7 units per kilo per day if over 25 kg. So that gives you the total amount of actually maybe, But you just you look all this up when you're prescribing it on. Then once you've got the total amount that you need, 40% of fact should come from long acting insulin to work out How much Levemir to give them on. Then the rest will come from from Nova Rapid. If they're doing something like carb counting, then obviously they will take however much they need based on how much they eat. Um, but approximately 60% of that should come from, um, counting a board of the overactive I need. There are also guidelines with things like the patients of a certain weights, whether it would be one unit, her 10 g or whether it be half a unit took two units per 10 g of carbohydrate. They're just tables that you can find and they'll be in your hospital policies. So I think it's so much Doctor Lee down. I'm gonna meet you. So if you can ask your question, please. Yeah. Hi, Doctor. It was with the abdominal pain in the patient with DKA a day. First I was thinking in my head all. Could it be pancreatitis that's causing the diabetes on? I wondered, Is that a realistic differential, or is it more the case that DKA would occur? Um, significant time after acute pancreatitis. So scared. You're right. You've got similar symptoms in that you've got to be pain on vomiting, pancreatitis can usually rule in or out with a blood test, depending on which hospital you're in, that they will use, like, pays or amylase on be sent off on your falls. Blood results, Vance, you send off a seizure, patient arrives. So if you come back with a severely elevated, like pays or amylase that, yeah, you start thinking Oh, my God, Is this pancreatitis? On top of everything else, but with the high blood sugars and high key tones that is on the acidosis, you have to have really severe pancreatitis to guess a DNR with it on. Do you Wouldn't expect to be key ptotic all hypoglycemic either. Um, so yeah, it just clinically it could be either when they come in. Um, but from looking at the sugars which you get straight away, then you get much more inclined to think DKA on your treatment for pancreatitis. It's fluids, which is the very first thing that you're going to give this decade nation. Anyway, she might as well start off with a lot of fluids on on. Then they'll need insulin anyway, because their hyperglycemia, uh, so you're not going to have done any harm if you treat DK and that makes you find out that they've got pancreatitis. You didn't give it to hold the treatment they need. Anyway, I think he's ever took the Harley. Same. I'm going to meet you so you can ask your question, please. Okay. Thank you, Doctor, please. My question makes apart from the used off insulin to regulate type one diabetes. Can we use any other medication or therapeutic in apart from day, they use off usually into really type one diabetes. Um, no. Good question. But with type one diabetes or you need is insulin. You're missing insulin, so you need to replace it. There are complications that type one diabetics and type two diabetics gets They get kidney complications, and I complications. And and once it's a cardiac Asians. So when? Those ago. And let's say you're diabetic. Patient has a heart attack, then you obviously start treating him for that. And they might not think I've never had that heart attack if they didn't have diabetes. Um, but, uh, but for the actual blood sugar management, you give insulin on the only other drug that you would give a type one diabetic is glucagon If they are having hypos. You need to drugs. Is that fluid out quest? Can I ask you? Okay, my full, My food. A question X. You know, most facilities when a patient's is six and you go see he diagnose off having diabetes, they are not able to distinguish whether this is type one diabetes or type two diabetes. And since no Molly type one diabetes is related by the use off initially. So what about if that person goes to their facilities, diagnose off his diagnose off having diabetes? But But it was type one diabetes, but they gave her think you've been cut off of it, That, um, one that I'm sorry, actually, back you. So is it? If you're not sure if they've got type one or type two, how do you know how to treat? Yes, yes. How do you treat you Should you should become a current very quickly, because with type one, they're still responsive to insulin, so you can give him quite small dose of insulin on a will respond to it. Wears with type two. If you give them a few units, is probably not going to do anything because they have all their own insulin, which has been trying to do at the whole time. Anyway, um, it's does not, Doesn't never really a case where you can't work out which, which type of diabetes someone has got. Because, um, a large part of it is the age of which they present on then yet is that the insulin responsiveness is well, so if you've got someone who I guess he your know entirely sure, they've just come in with hyperglycemia on. Maybe they're 30 years old and this is a new presentation on. Then you would start treating the retention and fluids if if they need it, if they're fluid depleted, um, on die that that if those levels should go straight down, if they are type one. If they're very overweight, then you can give them metformin, which can help control glucose levels on metformin is the first line treatment for Type two diabetics. But you also give it's type one diabetics. You have a BM i over 25. Um, so in that way, the treatments do overlap. If they were not responsive to insulin on the head of the risk factors for type two, and yet you would start thinking about metformin and the other type two diabetic treatments. Yeah. Thank you, Doctor. We gave him. Actually, we don't have a three more questions in the child's class. Okay, Those Sangsad is asking what the contraindications for delivering insulin prior IV countries faces. So, um so for the most patients in, like, the community begin urination by a, um, sucker by pen. With syringe, you can give insulin IV and hospital, but it can cause complications at the cannula site because the high glucose, very insulin by IV route, um, contraindications for every inch in my IV rate. I mean, we don't normally, um, if someone's really hypoglycemic in there very sacred it and you would give insulin. I can't really think what The contraindications. I might be wrong that But, um, isn't that's bringing to mind? Sorry, it Maybe if you look it up on some white come up best a three. Finding your doctor about the next one. What is the management for people who can't take insulin? Treat a religious reasons on. Well, there's this and pork insulin on this bovine issue, and so usually some contain one or the other. There is synthetic insulin as well. I don't how it's made. Um, Andi, um they talk to go to a specialist. I'm going to be prescribed that that there's dissension available. There's no from a pig or from a cow. Um, I haven't seen it before about things so much around knees asking. Aren't diabetic drugs of choice in case of patients were CKD which therapy is the best alternative? Eso I can't remember off the top of my head. I s o on Wednesday, I'm going to be going through a type two diabetes medications. So if it I want, anyone can have insulin, CKD or not. For type two, you could give metformin on be a first line and then following on from that You for multiple of the diabetic drugs, some of which about two CKD, some of which aren't. And I can't remember which ones which. But I will tell you that Wednesday, I promise, having this much, um, you're staying in the syringe, I imagine. Just based on the size of the the needle, they go into the same place. Um, pens are flying a short tip. From what I've seen, maybe and maybe the tip of the pen actually stops you from going too far. Where, as with the syringes, literally just the needles that you could accidentally go too far. Um, I need to do that. What are the key? Nurse and considerations. Patients taking insulin for Ted. Um, so, uh, there are you? Yes, engine, especially the type one diabetics. Um, it is not time critical in the sense of some mentions, like Parkinson's and athletic medicines, but it's essential the patient receives it. Um, so insulin is prescribed on a separate drug chart to make sure that it could never be overlooked. Um, on blood, sugars need to be taken really frequently, eh? So sometimes in a least risky patients, we would take it twice a day. We can do it up to four hour later. If patients have got variable blood sugars, Um, or if there's a live in a few topside, that we take it much more frequently. Um, on when you consider things like surgery or any time when a patient has to be mailed by mouth, then you need to be simply careful about your patients who are on insulin, because if they're not taking if it and if it or anything but I still taking insulin. Then there a risk of a high? Um so if a nurse is aware that there's a patient who isn't eating as much, then it's well worth asking whether their insulin dose should be adjusted. Sometimes when we have patients who come on, um, with a really stable insulin prescription at home but who have had high pose before with the benefited hospital, then we will just reduce their insulin dose perspective, lady, because we know that no one likes hospital food. They probably won't be eating as much, or they will be feeling poorly, and we're eating as much so it will reduce the eventually bases in order to, um, yet reduce the risk of hypos. You're as a nurse. Well, as as an inpatient clinician. It doesn't matter so much if your patients go hyperglycemia. It's not ideal, but, you know, blood sugars have kind of 16 20. There no unexpected impatience, and you could bring those down with overactive it. But you would fire rather have that than have a patient who is frequently getting high posed out 2.5 or whatever, because that's very rapidly. That's a very rapid problem on, But it's what which is difficult to spot early on, one which can kill the patient. Where is the B m of twenties? Know? Kind of thanks so much. Um, I'm I'm just asking. How do you decide to change the dose of the incident? You base it on blood sugars. Um, so I start this in this case, study was still on the screen, and I started it. Based on your generic starting insulin does. She will have lots of follow up with the community diabetic team who will measure her glucose levels on. But there's no always a formula as the how much to change it. But let's say that she is getting nocturnal hypoglycemia, which is quite a common problem. So at nighttime, Herbert sugars are dropping too low, which implies that she's probably taking too much Levemir. Um, so you could reduce the Levemir. But then let's say that she starts getting high blood sugars just after breakfast, and you could increase the morning over rapid dose. It's You have to look at the blood sugars over the day. There's some amazing technology, uh, say basics biggie. But a lot of the endocrinologists have got these APS on their phones, and they've got a list of all of their diabetes patients, and they've got the ones with continuous glucose monitoring they can see and graph of 24 hours and how the patient's blood sugar changes over time. And there is some problems which are really difficult to detect. Like if someone's having nocturnal hypoglycemia has How am I even going to realize that because no one takes blood sugar at night? But with the advent of of continuous glucose monitoring in the last few years, it's been much more possible for people to see exactly when the problem times a day are. And if that's nighttime warning little whenever you can change the insulin dose that corresponds to that time, too, in order to, uh, Teo negate that and you can just take it up a bit, take you down a bit to get a blocked having a house they need. I think it's so much. Doctor Holly. One last question before we do actually give her a wrap. Thanks. So it's asking sometimes for some patient. Their body develops insulin resistance during the course of the treatment. So what are the alternatives for those patients on dot How is the treatment continued? Yeah, so that's kind of becoming a bit more like Type two diabetes. Yeah, bit Type one diabetes. Nobody's coming conventional resistant on. But if it's becoming insulin resistant and you can start them on the kind of treatments that you would consider for Type two, diabetics are the ones to teo. Increase their responsiveness to insulin. And these are all ones that I'm going to go over on Wednesday. Uh, metformin, and one's further down the line, DPP four's and, uh, still ti's. So yet that those are possibilities that you could start. He can always increase insulin doses. So this little girl who we didn't case study should start on quite a low insulin dose. And then maybe she gets older. She becomes less responsive to do it. I just been up, up, up. Hey, can always refer to a sore more senior in this. Uh, there's the kind of patients that would be seeing frequently and diabetic Clinic to review that HBO What sees on see if they've had poor good glycemia control on what needs to be adjusted, so but thank you so much. Think it's up the holidays for the remarkable and interactive session on medical management of diabetes. I think when it comes down to endocrinology, it can get a little bit tricky to graft at times. But thanks year has actually really made it clear, along with the whole, like, new technology side. Well, well, if I need to make it if I need to make it easier or harder than, um, you know, house pay for a whole group of first six. Yes, that's totally fine. Thank you for giving up your time to pride us with this session today of your tree. Really great. Prefer it on? We have actually enjoyed the session. Um, so on next session will be at five o'clock today with Dr Pool Brennan on. He will be going over like I said, hematology case based studies. So what I'll do is I'll send the feedback from once again for those I haven't actually received him. I'll keep the chart on for a couple of minutes on. I will see you are five. Cook today. Take half. Thank you so much of funny. Thank you. I