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Do you want me to wait a few minutes or we just start if you're happy? Fine. Yeah. Um, hello. My name is a and I'm a final year Scotland student. So I did my finals in June last year. Um, so I've just kind of made a bit of a presentation about some of the main gi conditions and I've got some questions. Um, I haven't done any liver because I feel like that's quite a big separate topic. Um, but I've kind of done a mix of other things and then I've sort of done like comparisons between different things that you might get confused between and kind of how to spot, um, different ones and what you're looking for in the questions. Um, I think just as a general tip for finals before we start, um, I found them, I found it really hard but then I passed fine. So I think don't panic. Um, a lot of the stuff you can work out from the questions. So I know that Edinburgh students have a lot more physiology teaching. So if you don't know the answer straight away, don't panic, just think, think through your kind of physiology and then you can try and at least eliminate some of the answers that way. Um, and you'll, you'll be fine. Um, so we'll start with IBS versus IBD. I know that you're all going to be studying a lot and a lot of it's probably stuff you already know. Um, but I think just going through some of the main things you're looking out for in questions is useful just as a kind of refresher. So, um most of a lot of the stuff I've taken, I've kind of used some of the um acronyms and things from zero to finals, um which I think is a very useful tool. And then I've used looked at some of the nice guidelines and things as well. So one of the acronyms for IBS on Zero to finals is to literally use the IBS. So you're looking for intestinal discomfort, bowel habit, abnormalities and stool abnormalities and you need to have had these for at least six months. Um And then you also need to make sure that you rule out other things first. So just because you think it could be IBS in a question if they haven't ruled out like Celiac disease IBD, even though you don't think that's likely you need to still choose the answers that would rule those things out. Um And then if they, if they say that they've already done that, then your treatment for IBS is just going to be lifestyle advice um, they don't of, like, in real life, I don't think they wouldn't normally treat the symptoms as in it's more kind of lifestyle and then it's just if it's really persistent then you would maybe give them loperamide or laxatives to try and treat whatever s symptoms they have. Um, I think it's just you, like, you kind of, you start with what you think it is and then rule out other things first, You would go for lifestyle advice first. But if they've already tried that, then you might give them some medications to treat the symptoms. Um, so IBD. So the zero to finals one for, uh, Crohn's is Nests. Um II don't know that I found that acronym that useful, but if it helps you to, to remember things with, um, acronyms, then obviously that's, that's one that you can use. So there's no bladder mucus in Crohn's and remember it's a whole gi tract that's affected and you could have skipped lesions. So just remembering that, that means that you wouldn't be able to do a surgery to remove the affected part because there could be kind of multiple parts throughout the tract. Um, terminal ileum is most affected. So that would be something to look for in a question, transmural. So it goes through the entire wall of the bowel. Um, smoking is a risk factor. So, um, that would be a key difference between Crohn's and colitis. So, smoking is a risk factor. For Crohn's, but it is protective for colitis. And then in Crohn's, you get strictures and fissures as well. Um I think it, it is worth kind of just remembering the, the main management for IBD is that you need to induce remission. Um usually with steroids and then once that's, once they're into remission, then you need to maintain the remission. And for Crohn's, you would normally use azaTHIOprine or a mercaptopurine. Um And then if those things haven't worked, remember that there's other like you can use biologics or you could use methotrexate. Um The pneumonic for colitis is close up. So this one is a continuous um lesion of inflammation usually starts at the rectum and kind of works up from there. Um It's only superficial smoking is protective, you do excrete blood and mucus. And then for this one, you would normally use aminosalicylates and remember that it's associated with PSC as well. Um And then for colitis, it's like another step that so you need to first work out whether it's mild or moderate or severe, I think in questions, they normally make it fairly obvious. So if they're having like multiple epi episodes of bloody stools a day, they're hemodynamically unstable. Um then you kind of know it's severe and they're more likely to need IV steroids. If it's uh mild to moderate, you can usually use oral or electile steroids um and mesalazine to induce remission. Um And then once, so if you've kind of worked to have its mild or moderate or severe then to maintain the remission, it would still be topical or oral aminosalicylate. So, like mesalazine for um, yeah, mild to moderate and then for severe it would be oral azine or oral mercaptopurine. Um So I've got a question here. So, um, five year old woman, seven month history of crampy abdo pain, diarrhea, passing watery stools and some mucus. Um, her symptoms improve with opening her bowels and passing flatus. There's no rectal bleeding or black tarry stools, abdo exam, unremarkable, no significant family history. When she's asked, she mentions that diarrhea is the most bothering bothersome symptom and she would like some help. That's her blood. So, and what is the next step in her management? Um I think Adam has got a pole. So I will let people answer and then maybe he can let me know what the, because I can't see the poll, I'll share the poll in a few seconds because previous times would have been on the poll goes right in front of the slides and you can't actually read the question for yourself anymore. So I'll give it a little bit of time, just run, it comes up. Um So you'd probably long enough. Um I'll start sharing the book. I can monitor the responses as well. So I'll let you know when most people have done. Have we had any answers? Yeah, we're about halfway. Ok. We're sitting at 16 or so. A few people, uh, I'll give it another 2030 seconds and I'll close up. Ok. And that's probably in so the majority of people, er, voted for e, uh, 61% of people was a bit. Second, most popular answer was c ok. Um, yes. So he is the answer. So this was just to kind of highlight what I was saying. So, although this kind of looks like it's most likely to be IBS because she's not really had any other um tests. We need to make sure that her, that she's not um Celiac first before we kind of do anything else. Um I've got a second question here. So a 32 year old exacerbation of um she's got 6 to 8 bloody stools per day for three days. She's got mild fever, tachycardia. Um Other odds are normal and she's got these inflammatory markers. So she was admitted with um and a remission was achieved with steroid therapy. It's her second admission with the last being six months ago and when she presented with similar symptoms, um an examination, well, yeah, similar symptoms and examination and investigation findings. So, on discharge, what medication would we like to trial? Similarly? I'll let them up and it's Paul go up about halfway again. The answers are an anonymous people. I can't see who's doing them. All right now, stop it there unless anyone has any last minute answers. Great. Uh So the most popular answer was C and second one was B Yeah. Um OK. So her colitis, so as we see, yeah, that we can kind of work out that this is gonna be severe. So she's having 6 to 8 stools per day for three days and then she's also got some systemic features as well. Um So the, it's just, it's just remembering what treatments you use for what. So for severe colitis to maintain remission would be oral azaTHIOprine. Um the amino soit are usually used for the mild to moderate and is more likely to be topical um to maintain if you were trying to maintain remission. Um So there's just a little slide about kind of the main things that we've kind of talked about. So having an idea of what the main features of Crohn's and Colitis are. So you can differentiate between the two. Remember the second line treatments I did find in the MLA that there was quite a few questions where you would know the treatment and then they would say, oh, they're allergic to this or they've tried that before and then you needed to know what the second line was. Um So I think for some of the common things, just remember that you need to bear in mind what the top two treatments would be. Um Or if somebody's allergic to a drug, what the, what the alternative would be. Um, remember to exclude other causes for IBS um more than two exacerbations of IBD in a year um would be severe. So we need more treatment. Watch out for a teratogenic drug. So if they're on methotrexate, just remember that you need to think about what other consequences that might have and then don't forget about celiac disease. So, remembering anti TTG and anti EA are the two ones that you can use. Remember they need to be eating gluten for six weeks beforehand before you do any tests. And then if the question mentions dermatitis, herpetiformis, anemia, that you're not really sure where the anemia is coming from. Um venous atrophy and crypt hyperplasia are all kind of like buzzwords for celiac disease. So moving on to an upper gi bleed. So the most common causes of upper gi bleeds are peptic ulcers, mono, vice tears, var or cancers. Um They do like asking about scores. So I always got confused between these two scores. I don't really know a good way to remember it, but the Glasgow Blacker one is the one you use at initial presentation and that's to kind of figure out what the risk of having an upper gi bleed is. Um part of that includes having high urea. Um I don't know if that's, that's helpful just if they mention that, then that might be more likely the score that they're wanting. Um And then the Rockall score is the one that you would use after endoscopy and that's to assess the risk of rebleed and mortality. The main management for upper gi bleeds is gonna be doing your at e remember you need to do endoscopy within 24 hours. Terlipressin and antibiotics would only be for variceal bleed. Um And you need to remember to give them before endoscopy. Um and you can give a beta blocker for a variceal bleed after endoscopy. Um you also need to give PPS um for variceal bleeds after band ligation. So toilet press antibiotics, beta blocker after and a PPI before or after, sorry for a variceal bleed. And if it's a non viral bleed, you, I got myself confused here. If it was a nonvariceal bleed, you would only give the PPI after endoscopy. So this is, I find this very confusing because they, I think in past me especially they like to ask questions and then they'll give you, I've got an example. Actually, they give kind of give you like answers that kind of all look like they would be right. And they're always, and they're all kind of like part of the management, but it's just trying to work out what you need to what stage of the management you're at and what you need to prescribe at that point. So I've got a question here. Um 63 year old man with a longstanding history of alcohol, alcoholism is currently recovering post procedure on the GI ward. He was admitted to the Ed yesterday after um repeated episodes of vomiting. He vomited approximately one cup of blood and had severe epigastric pain. He'd already undergone endoscopic variceal bleed, ligation, um, with, and he'd had, he's already had his pre procedure prophylaxis. He's not got any allergies or medical history. So, what are we going to prescribe now? So, it's a variceal bleed and he's already had the procedure and he's already had his pre procedure prophylaxis. I'll give you a minute to read it. Uh I'll start sharing the book. Uh Someone has put in a chat for a way to remember. GB Glasgow Black Fir has got a bleed and, or for rock fall. We, oh, that's, that's useful. Thank you. It's fine. You've done your exam though. So you don't need it. Still waiting on some response. It is very split at the moment. I'll give it a little bit longer. It's quite a somewhat even at the moment. All right, let up on there. So it's quite close. Uh Most popular answer with 36% is C and the close two behind it with 21 both is B and E. So it was, it was a bit more even. Um So the answer is propranolol. So I think this is just an example of you need to kind of pick up through the question, work out what, what they've already done. So, you know, it's a variceal bleed and you know that for that, for the prep procedure of prophylaxis, he should have had terlipressin omeprazole and prophylactic antibiotics already. Um And then, so we can kind of narrow it down to what we're gonna do afterwards, which would be to give a beta blocker. And I think it's just that propranolol is the one that you would use. Um Yeah, I don't really like these questions where you have to work out so many different things before you get, come to the answer. Um for upper gi bleeds, just some kind of general things to bear in mind. So remember to look for risk factors for ulcers. So if they're mentioning any nsaids in the question or H pylori, just kind of remember that those kind of things are things that you would need to look out for. Um And remember that to have a look at their medications. So if they're on any anticoagulation, then they're gonna be more at risk of bleeding and that might need to get stopped. Um I think it's always useful to remember, you need to look at the obs. So don't just kind of ignore the obs and they might not specifically tell you that they're hemodynamically unstable, but if they've got a low BP tachycardia or kind of other signs of shock like confusion, then that's gonna be a bit more serious and um that would indicate that they're hemodynamically unstable. Um And then just remembering when to use the scores, um I don't think that they would want you to really know the specific details of what is in each score. But I think kind of knowing vaguely when to use it and what the, what the numbers mean um can be useful. So we're on to cholecystitis versus cholangitis. Um So these are another two that I always got confused by. Um, so acute cholecystitis is inflammation in the gallbladder caused by a blocked duct. This is the one that um if they mention Murphy sign or they mention palpate in the gallbladder and they take a big breath and they're, and you kind of feel the gallbladder and they, they're in pain. That's cholecystitis. Um For this one, you would do an ABDO ultrasound first and you would be looking for a thickened gallbladder wall, any stones or sludge and then any fluid around the gallbladder. Um, because you can kind of get, um, like pass around the gallbladder, basically. Um, then if you can't see anything on the ultrasound, but you still think it's called cystitis, you might do an M RCP. So the management, um, again is the kind of details that they seem to like you to remember. So if it's within 72 hours of symptoms, then you can just take the gallbladder out. But if it's gone beyond that, you need to leave it for 6 to 8 weeks for it to kind of all settle down. Um, and then you would probably do an elective, um, totally forgotten the word for removing your gallbladder, but you would remove it electively 6 to 8 week later. Um, cholecystectomy. Yes, thank you. Um, and then you could also do ERCP to remove stones if that's what had been causing it. Um, so I think just in the question, try and work out when the symptoms started and then work out whether you would be wanting to take it out immediately or do it later. And actually, I think that was something that came up in one of our oy as well that you kind of knew that the gallbladder needed removed. But it was trying to work out when it started to, whether you were going to say to the patient that we're going to remove it right now or whether we're going to do it electively later. Um Acute cholangitis is inflammation of the bile ducts. So this can also be caused by obstruction, but it can also be caused by infection. So for example, if you've had E RCP, um and that's introduced E Coli cloudar into this one is where you would look for Charcot's triad. So, right, upper quadrant pain fever and jaundice are your three things. Um I think in the, in the um when you do the exam, you can like highlight things in the question. So I found that quite useful for things like this where you might not automatically see the connection. But if you've kind of highlighted some of the symptoms, then you, it might, it might help you kind of remember that there's things like this that would point towards cholangitis or cholecystitis. Um, management would be that you need to remove the stone. So you would, you would also make them nail by mouth, give them IV fluids, check their blood cultures. You would give them antibiotics if we think it's an infection or, well, it's going to be an infection. Yeah. And then if it's stones that are causing it or obstruction, then we need to remove them. Um, if that's all not really worked, then the next step would be to do PTC, which is where you kind of stick a drain in, through outside and, um, kind of open up the ducks that way. Um So we've got another question here. So this is a 52 year old man who presents to the ed with acute abdo pain feeling unwell. Normally th well, enjoys long distance. Running past medical history includes a broken finger, um, gallstones that he's never been troubled by on examination. He has got icteric sc sclera heart rate of 106 BP 125. Over 85 temperature is 38.1. This marked rebound tenderness and guarding in the right upper quadrant, bowel sounds are quiet. What's the most likely diagnosis? Give you a few minutes to read the question. Uh, she, it, I'll stop this one shortly. It's gonna a definitive answer, you know? Ok. And so major answer is d 80% Yeah. Um Yeah. So this is just an example of trying to spot Charcots triad in a word question. Um And then that helps you point towards cholangitis. Um Another one so 45 year old woman presenting to the ed intense pain, right? Upper quadrant pain, pyrexic tachycardic, tachypneic. What is she most likely to be suffering from? I'll just pull this one up as a short question. Yes. Mhm mhm. A bit more of a split this time we'll get another 10 seconds. Uh So most popular answer is b uh closely followed by a um Yeah, so, so I guess the answer is be here. Um So we can figure out that it's gonna be one or the other because, and it's not going to be like bilary colic or something because she's systemically unwell. So she's got some kind of infection. Um I think in this case, like she's not got, they've not mentioned any jaundice, um, which would be more suggestive of cholangitis. Um I think, yeah, I mean, even being able to narrow it down to a couple of answers and then trying to work out what the most likely one is um, is useful. So well done people. Um I've got a slide on PBC versus PSC. So primary biliary colitis is autoimmune attacks the small bile in bile ducts in the liver and this one causes obstructive jaundice and liver disease. Um This one is, I think to work out the difference between these two is kind of working out what the typical patient looks like because they quite like to describe them in questions and then work out if you kind of know what that's associated with. So, a typical patient for PBC is white women, 40 to 60 years old. Um and they would have abnormal LFT, they might also mention autoantibodies. Um So, ama is the only one that's diagnostic and then A N A is only in 30% of people with PBC. Um Then they'd also raised I GM. Um and the treatment for this would be ursodeoxycholic acid. So from zero to finals, I think the useful way to remember this is the um rule. So I GM AMA and then middle aged females. Um PSE is the one that's more associated with ulcerative colitis. Um And that's intrahepatic and extrahepatic bile ducts and it, they get inflamed and form strictures. And your typical patient in this case would be a male, 30 to 40 years old, possibly with ulcerative colitis or a family history. Um They'd also have raised ALK fos um in this case, autoantibodies are not helpful for diagnosis, but they might have piana A N A or anti sma. Um Just if they mention that in the question, it's not, although it's not diagnostic, it might help you kind of veer towards PSE M RCP is um the diag that's how you diagnose this. Um But you might also want to do a colonoscopy to check for you see, because there's a, a close connection between the two conditions. Um there and then for this one, there's not really any specific treatment. You might give them a cholestyramine for pus. Um you could do ercp restrictors and replace the fat soluble vitamins, but it's more of a um kind of managing the symptoms rather than treating it. Um I think worst case scenario, we might be able to give them a liver transplant. Um The other. So apart from you see, the other thing this is closely connected to is cholangiocarcinoma. Um So I think those kind of three links appear quite often in questions. Um So it's just kind of like helping you refresh your memory on that. Um So I've got a 45 year old woman who's got eight months of fatigue and pru this despite scratching, she's got no relief and there's no rash. She also has hashimoto's thyroiditis, which is treated and her grandmother had, she has never drank alcohol and on examination, she's got Xantho asthma around her eyes. So this is her bloods and then what test is most specific for the likely diagnosis? Oh. Someone's asked if you can click the hide button on your because it's covered if I just move it. Is that, does that help? Yeah, it's, it's not covered anymore. Hold up. Yeah, it was a very popular request. Well, uh I'll give it a few more seconds just so people can read that question. Uh because it's a bit more wording. Uh We'll pull up. Ok. Start it up. Mm. Good. We'll give this just a wee bit longer. Most people have anti. Mhm. Ok. Uh, most popular answer about 90% is b good, well done. Um, so yeah. Yeah, I think it's, you, you kind of just look at the typical type of patient. Um, so it's a middle aged woman. She's also got another autoimmune condition. I think the grandmother with UC is just kind of in there to throw you off. Um But we know that the most diagnosis, diagnostic test would be ama um A NAN A. So C would be another one, but we said that that's less specific for um PVC. Um And then I think these are my last slides. So acute versus chronic pancreatitis. Um So it's kind of just trying to know what the difference differences are between the two and what you're kind of looking for. So for acute pancreatitis, remember you're looking at rapid onset, remember that normal function should return afterwards. So it should kind of resolve completely. Um If they've got epigastric pain radiating to the back, systemically unwell and if they're vomiting, those are all kind of signs that you would um expect in pancreatitis. Um I think it's really important in pancreatitis to remember to look at the bloods. So, so, Amylase is one of the ones that you look out for um and you're looking for it to be three times the upper limit of normal for acute pancreatitis. Um I've never actually seen the use like a in real life. Um I know that when you're studying, it's like, oh, this one is more sensitive and more specific. So I think it probably is worth remembering for exams, but in real life, they seem to always just use a um then the scoring for this would be the Glasgow score. Um And you're looking at the severity of pancreatitis, it only goes from 0 to 3. So three is going to be severe and zero would be less severe. Um And then the management for pancreat acute pancreatitis is just supportive. So kind of giving them fluids. Um It's kind of, yeah, it's looking after them on the ward and it should improve within 3 to 7 days. Chronic pancreatitis is mainly caused by gallstones, alcohol or post ercp and they would have chronic epigastric pain. And then you'd also have signs that the pancreas wasn't working anymore. So just remembering what your pancreas does, um you'd have loss of extra cr and endocrine function. Um and then you could also get kind of damage and strictures um management for this is that you need to stop drinking, stop smoking. You might be able to give them some analgesia. Remember you need to replace any enzymes they're losing if they've become diabetic because the endocrine function is gone. You would need to give them insulin. Um, you might do surgery but it kind of depends on severity and whether that's possible. Um, you might do ERCP to try and open up some of the strictures. Um, yeah, I think for chronic it's kind of if there's especially looking at the pancre pancreas function. Um, so if you've noticed that they've kind of got this chronic pain and then other things are going as well, then it's more likely to be chronic pancreatitis. Um I always forgot about pancreatitis and exams. So just remember that epigastric pain can also be that and it's not, um it's not just anything to do with the stomach, stomach pain. Um, 61 year old man is admitted to hospital with severe abdo pain. It's typically worse after eating a meal. He admits to regularly drinking at least 25 units of alcohol per week for the last 30 years. And he's recently been diagnosed with type two diabetes. Uh abdominal CT shows calcification of his pancreas, given the likely diagnosis which of the following tests can be used to assess this organ's exocrine function. Yes. Uh Bull, I'll give it a wee bit longer. It's quite a split decision here. Mhm. Mhm. Or seconds, right. Uh So most popular decision was b followed by E Yeah. Um Yeah, so this, I mean, this is just kind of a bit of a specific one. So we're looking for the extra cr function and apparently you would find that through fecal lot of stays, um, you could probably narrow it down. So I guess a is more like, like that's not really going to be to do with the pancreas. That would be if you're looking for I BDC and E are kind of more useful in chronic pancreatitis. Uh, sorry, acute pancreatitis. Um, and we know that this is chronic pancreatitis. Um, so I guess even if you can just try and eliminate some of the answers, if you don't know. Um but apparently for or exocrine function, it would be fecal at last days. Um And then we've got a 67 year old man who presents to GP with pale oily stools for the last few weeks. There's no pain during or after defecation and the patient feels well at rest. He's previously been diagnosed with chronic pancreatitis. Um and has been referred has after being referred to the endocrine um for chronic post prandial pain, which he still suffers from. He drank 20 units of alcohol a day for the past 40 years and continues to do so alongside chro chronic pancreatitis, he's been diagnosed with type two diabetes and hypertension for which he takes amLODIPine and Metformin. What is the most appropriate management? Ok. I'll start the pool also, if um you would prefer, I just started to pull immediately. Let me know that I did find previously. It does go right in front of when you trying to read, give me 10 more seconds. Oh, sorry. Ok. So most popular answer is d yeah. So the, so we know he's got chronic pancreatitis. The main issue at the moment is having pale and oily stools which suggests he's not, um, it's not his pancreatic enzymes aren't working. Um, so that, yeah, that was a fairly straightforward question. Um, so kind of finally just remember if you've got any potentially surgical patients. So if you think that they're going to need surgery, remember that they need to be nil by mouth, they would get an NG tube and IV fluids for the drip and suck thing. Um I think sometimes, yeah, they kind of you read the question, you think they're asking what the, the sort of definitive management is, but just look at the wording and make sure they're not just saying immediate management and it would actually be that they need to be nil by mouth immediately. Um, remember to look for Charcot's triad, um, watch out for sepsis. So if they're coming in and they're acutely unwell, um, don't, don't again, don't get caught up with what's the sort of definitive management for what's wrong going to be? Uh, remember that you need to do a set to six steps before you would do any surgery. Um I think it is useful to look at the different antibodies and just know what they're associated with. Um, because I think it's really helpful if they mention, mention them in a question and you immediately know what that would be connected with for pancreatitis. Um with amylase. Just remember, you're not just kind of looking for a random rise for acute pancreatitis. It should be three times the normal limit. So it's worth trying to work that out. Um And then remember it's not specific to pancreatitis. Um It can also arise in things like small bowel obstruction. So just because they mention Amylas doesn't mean it's definitely going to be pancreatitis. Um I hope that's been useful. Um I didn't include any like malignancy things because I thought a lot of the time it's quite obvious it's a malignancy and the management. It's kind of similar. Um Is there any questions that I can try and answer? Yeah. There, there's one came up in the chart just now. If you're able to, if you stop training, you should be able to see it. Uh I'm gonna post in a feedback for like for people to use. If you could please fill it in, uh You'll need people to fill it in for you next year. Please bear that in, in the pain. Um So this question in the chat about how, what I did to study for the MLA and in hindsight, what I would have done differently. Um I think so, I think for me, I kind of needed to learn. I couldn't just do past med or just do questions to learn. I sort of had to learn it all. My, like, learn the content first. Um I found that sort of writing notes helps. So, um, so I've kind of had been writing notes for like, throughout the year. But then as I got closer to exams, I just like condensed them. So I just made, like, I made a lot of cards that I didn't actually use. But I found that actually just writing the cards was really helpful and I think as well with passed, I found that actually doing questions in like picking the specific topic I was trying to work on helped because I think it can be a bit overwhelming if you just, if you've been studying something and then you just put on passed and do all the topics and then you feel that it can, it can feel a bit hard because sometimes what you have just been learning. Um I think as what I think, what I'm trying to say is if you are focusing on a specific topic and you've been learning that, then I think it's worth trying to do some questions on that topic to sort of consolidate it. Um And then obviously, I mean, you, when you do the exam, you will need to do all the topics. Um even, or the other option would be when you look at the, what the two papers consist of, like you could practice, you can, you could set up your pass med so that you practice a similar kind of topics that are going to be in the first exam together and then the second lot together. So you're kind of used to used to those kind of questions and what you're looking for. Um, I don't know if that's helpful at all. I did a lot of talking to myself as I was learning, made, a lot of flashcards. Um, zero final flashcards are really helpful just to kind of remember, like to sort of do some quick learning. Um I don't, I didn't find ques meed as useful. I think the ResMed questions are probably not as accurate to what the MLA will be like. Um As pass me is. Yeah, hopefully that's been helpful. I think you'll have a few minutes now before the next session starts. No, thank you very much. Um Feel free to keep posting questions just now. We're just waiting on the next person turning up. I