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Hi, everyone. Can someone just say yes in the chat? So I know my microphone's working. I'm having some issues with my cameras. That's gonna have to be off for this evening. So I apologize for that. Great. Um, so my name is Olivia. I'm gonna be teaching rheumatology for final years this evening. Um, focus on some key topics. I won't be able to cover everything in rheumatology, and I'll kind of explain what I will and won't covering things that you have to look up in your own time. Also, just an apology that this was supposed to be carried out last week on the 29th of December, but I was ill, so I've had to reschedule it for tonight. So thanks for joining tonight. Um, just to shout out to Wesley and so they sponsor all of our webinars. Uh, they help you transition through your foundation programs and beyond helping you with your career finances and well being. So if you wanted to scan the QR code to find out more, you'll find more information there. Um, so I'm gonna mainly focus on connective tissue diseases, so I'll cover in detail SLE anti phospholipids syndrome. systemic sclerosis, polymyositis dermatomyositis insurance syndrome. And I'll do SBS on those and maybe some of the other topics I don't cover as well things that I won't have time to cover just because rheumatology is such a big topic, So I won't be able to cover the the different types of arthritis a story attic, reactive and rheumatoid. Um, won't be able to cover ankles and spondylitis, polymyalgia rhuematica, gout or pseudo gout or vasculitis. If I do have time in this series, I will try and put on a topic on vasculitis because that is a big topic, as is connective tissue diseases. Um, so focusing on SLE before so it stands for systemic Lupus erythematosus, and I'll go through how it presents. It's a multi system presentation with non specific symptoms. Patient's might present with fatigue, weight loss, aching of joints or muscles. Fever. Um, they might have skin changes. So the classic is a first er sensitive mala rash, which is kind of described as butterfly shaped and exam questions, and that gets worse with sunlight. Patient's might have lymphadenopathy splenomegaly shortness of breath, pleuritic chest pain ulcers. Um, Raynaud's phenomenon is a common thing to see in sle patients' or possibly alopecia sor hair loss, and it does affect multiple organs and multiple systems. So any kind of vague symptoms that patients present with this kind of needs to be in the back of your mind. It has a relapsing and remitting course of their symptoms, will get worse and better and hopefully respond to the treatment which I'll go over and investigations that you want to do. So you want to do auto antibodies is the kind of main one for diagnosis, and I'll go over then. But other things simple blood test like full blood count, kidney function, liver function, complement and low complement is seen in SLE, and that also relates to disease activities. If patient has lower compliment than it means, the disease is more active so that can be monitored throughout treatment and CRP and esr, too. Uh, it's kind of, um, test inflammation immunoglobulins your analysis and seen as any protein in the urine because that's a complication of S. L. A. And a real renal biopsy can be used as well in patients with renal um, involvement in SL A. So the auto antibodies that you need to be testing for is A N A. It's kind of nonspecific or two antibodies, and it'll be positive in 85% of SLE patient antidouble stranded DNA antibody. So this is quite specific to SL a not seen any other autoimmune conditions, and that will be positive in 70% of SLE patients' also anti phospholipid antibodies. There's a close relationship between SL A, an anti phospholipids syndrome, so testing for anti phospholipid antibodies to see if the patient might have both both syndromes. Diagnosis is done mainly through the slip criteria, which I'll go over on the next slide. And it's basically combining clinical findings with immunological findings. Complications. So, um, cardiovascular and cardiovascular disease and infection and the leading causes of death in S. L. A. And that's, you know, they've kind of got immune suppression, and all the inflammation in the cardiovascular system leads leads to those complications. There might be anemic, which will be symptomatic from, and then they can get things like pericarditis, pleurisy, interstitial lung disease or fibrosis within the lungs. Nephritis, um, can get neuro psychiatric problems. In SLE, you might see things like optic neuritis, transverse myelitis or even psychosis. Uh, managed mainly in secondary care by rheumatology, but patient's would be on NSAIDs, steroids and acute flares. Hydroxychloroquine is first line one in patient's that they should be using some cream on a daily basis. And those patients with severe or kind of resistant s l A will be given things like methotrexate. There is a thigh, a prin tacrolimus etcetera. Um, so just going through the criteria for diagnosis. Um, so for criteria in turtle are needed, one of one of them has to be clinical, and at least one has to be immunological. Um, all the patient has to have a biopsy proven Lupus nephritis. Um, so the clinical criteria so acute cutaneous Lupus. That can be things like the mala rash or bullous Lupus. Um, chronic cutaneous Lupus is merely discoid Lupus, non scarring, alopecia, oral or nasal ulcers. Joint disease. So that's, um, sign of itis. Inflammation of more two or more joints. Um, serious itis that includes pleurisy, pericarditis. Um, any renal complications. So protein, urea or any red blood cell casts within the urine. That's why I need to be in the urine dip. Um, and they're checking the use and ease and also the urine albumin creatinine ratio. Um, any neurological complications, like the ones that I mentioned on the previous slide transverse, my lightest optic neuritis, And then the blood. The blood test that you'd see on kind of routine blood. So hemolytic anemia, leukopenia, lymphopenia and thrombocytopenia. And these have all got to be all the other causes have got to be excluded. So without another cause. And they have those on their bloods Immunological. I mean, immunological criteria, which is mainly the antibodies that are discussed before. So a and a antidouble stranded DNA, a anti Smith antibody anti phospho antibody body, uh, low complement or a direct Coombs test in the absence of hemolytic anemia. And you. So you just need one clinical one immunological. And then obviously for criterion, Turtle. So you need another two, whether that's clinical or immunology. And this is just kind of a nice diagram that shows all the different kind of complications and presentations and symptoms that patient's with SLE might present with, um so affecting the lungs. Pleural effusion, pleural information, pleurisy. And with that, they'll get symptoms such as cough, shortness of breath, more kind of vague general symptoms, weight loss, fatigue. Fever more susceptible to infection. Arthritis, emotional lability, hematological disorders. Neuro disorders can affect the hearts of pericarditis, vasculitis, inflammation of the blood vessels in terms of the kidneys and the can get Lupus nephritis. And like I said, you can have that proven on biopsy protein, urea, hematuria and then skin changes. So everything is just rash when exposed to sunlight And this butterfly mala rash, um, that you can see in the top picture on the right and on the bottom. That's just a picture of patient's hands with Raynaud's moving on to anti Phospholipids syndrome. Um, so this is an autoimmune disorder predisposing to both arterial and venous thrombosis. Um, so how? My patient's present recurrent vte. So blood clots, recurrent miscarriage. They might have levied a reticularis, which is kind of a list like rash over their skin. And like I said, it's got a link with SLE, so a patient might have SLAA. And if they present, if you've got no ness, Elaine have recurrent miscarriages. They probably have antiphospholipid syndrome to investigate this. You want to ruin auto antibodies, which I'll come onto and consider the same SLE investigations that we covered before um, the antibodies associated with anti phospholipids syndrome. Uh, Lupus, anticoagulant, anti, uh, anticardiolipin antibody. An antibody to to like a protein one antibody. And for the diagnosis, it's quite similar to the SLE diagnosis that you need one or more vascular thrombosis events. O V T. A. Acutely, um, ischemia stroke like the arterial or venous thrombosis, and one or more pregnancy morbidity. So in an explained introduction, death, preterm birth or three consecutive spontaneous miscarriages, Um, the lab criteria is Lupus anticoagulant on two occasions, 12 weeks over 12 weeks apart. Anticardiolipin antibody or anti beated two glycoprotein, one antibody. And again, they all need to be taken on 22 occasions. Positive on two occasions, 12 weeks apart, and you need one clinical on one lab criterion to get yourself a diagnosis for anti Phospholipids syndrome. Generally, how patient's are managed is warfarin. There's more evidence that warfarin is more effective against preventing arterial thrombosis. Compared to dewaxer, warfarin is the preferred preventative treatment for V T A um, but if a patient's pregnant, obviously they can't have warfarin, so the patient would be started on either alert molecular weight, heparin or aspirin, or a combination of the birth. But they would be managed by a consultant obstetrician with the rheumatology team if they did get pregnant with Antiphospholipid syndrome. And again, just a simple diagram that shows things that you need to be looking out for in the complications, which I've pretty much covered there. And the picture on the right is a typical example of la vida reticularis, which is this, uh, lace like purple rash. Um, next, I'm gonna discuss systemic sclerosis. Sometimes you see systemic sclerosis, sclerosis and scleroderma used interchangeably. Um, and it's got two types. Um, and it's generally an autoimmune inflammatory condition. And it causes systemic inflammation due to interstitial and perivascular collagen deposition, and that that that collagen deposition leads to fibrosis and sclerosis, and the normal tissue is then replaced with this thick, dense connective tissue, causing that fibrosis. And it can affect it pretty much anywhere. So from the skin, blood vessels and internal organs. So there's two types. There's limited, cutaneous and diffuse cutaneous limited. Cutaneous used to be called CREss in Crest syndrome, and that would stand for C for calcinosis iss Raynaud's phenomenon Asafa Jal, dysmotility, sclerodactyly and Telangiectasia and and they get very late organ internal organ involvement compared to diffuse cutaneous, which is two thirds of the patient's with systemic sclerosis. Um, they have early internal organ involvement, and they get diffuse skin thickening with complications like digital ulceration. Um, because the organs are affected and get renal failure. Cardiac failure, pulmonary hypertension, um, an interstitial lung disease and respiratory failure secondary to interstitial lung disease. The fibrosis. There is the most common cause of death in these patient's, um, investigations that you'd want to do so again. Simple blood tests for blood count crp esr using these LFTs, um, antibodies, which I'll come onto. You'd want to be imaging the joints. If patient's are coming in with joint aches pains, you might see calcinosis there, so it's important to image the joint chest X rays and those presenting. You know, these patient's will present with shortness of breath and persistent infection. So you want to be doing chest X rays. See if you see any fibrotic changes. Endoscopy for those that present with esophageal dysmotility probably present with reflux and that will get them an endoscopy echocardiogram for cardiac failure Pulmonary function test again for I L. D and nail fold capillary oscopy and with the nail fold capillary oscopy, you might see microhemorrhages a vascular areas or abnormal capillaries. Um, the antibodies. So the anticentromere antibody is associated with the limited cutaneous or crest syndrome Systemic sclerosis, whereas diffuse cutaneous, um, systemic scholars. This is associated with anti SCL 70. And if you've got that, you're an increased I l d risk. And there's also anti RNA polymerase three antibody. And with that you're an increased renal risk. So RNA for renal risk SCL for lung I l d risk is how I typically remember it. I don't think you'll need to memorize the criteria to diagnose this, but it's a kind of diagnostic criteria created by the American College of Rheumatology and includes clinical features, antibodies and nail fold capillary oscopy management. So it's mainly especially supportive treatment. So treating the symptoms, you might want to give things like antacids or PPI s for esophageal dysmotility. Um, Metoclopramide is a pro kinetic, um drug, which can help with the esophageal dysmotility nifedipine is given for ray nodes, Um, advising things like stop smoking gentle skin stretching because you get the, you know, diffuse thickening of the skin. So they want to be using emollients and gentle skin stretching as well as physiotherapy. Um, for the more severe, diffuse, cutaneous patient's. They might be started on steroids, immuno suppressants and also is inhibitors if they have renal involvement. Um, here are just some pictures that I show the different symptoms. So the picture on the top left of the right, the top left hand side. Sorry that shows patient's that have got thickened skin, and it's causing the fingers to kind of curl up. And it really limits the movement and obviously limits the quality of life as well. They are unable to use their hands when the skin gets so thickened. The two pictures of the mouth is called My Crust Oh Mia and patient's get a small mouth because of the diffuse thickening around the mouth, and this can make it difficult to eat. And again if people can't eat, affecting the quality of life will affect the moods. That's mood is always an important one to be asking in history, taking picture of rain nodes on the bottom left calcinosis. So you see those small calcium deposits in that person's film and the chest X ray demonstrates what I l d or fibrosis might look like on a chest X ray and moving on to polymyositis. This I am so polymyositis is inflammation of striated muscle patient's present with muscle pain and weakness. And it's typically proximal muscle weakness and bilateral patient's are fatigued and the peak ages between 50 and 60 and it's more commonly seen in women. It mostly affects the shoulder and pelvic girdle investigations that you want to do. So you want to do the kind of, um, enzymes related to muscles, so muscle derived enzymes Sorry. So C K A S t A L T L D H might be wanting to do pulmonary function tests on patient's because they're presenting with fatigue and it can affect their pulmonary muscles. And MRI MRI can show kind of inflammation, which causes a Dema, which you see on the MRI scan. The antibodies associated with polymyositis so kind of non specifically a n A and then most specifically is anti Joe one antibodies, and that's associated with polymyositis. To get the diagnosis of polymyositis, it's presentation along with the blood test of the CK positive autoantibodies you might want to do E M G to exclude things like motor neuron disease and a muscle biopsy is kind of a definitive diagnosis. And with that, you'll see n demise your infiltrates, and that's infiltrates within the muscle. Fascicle management is with steroids, immunosuppressants IV, immunoglobulins or biologics. Mhm. The matter myositis so similar to polymyositis, but it's got skin involvement. Um, the typical kind of pathognomonic skin involvement that you see is something called Got Trans Lesion's. Which of these scaly erythematous patches on patient's knuckles, elbows and knees. They also might get a photosensitive rash and can get what they call a heliotrope rash, which is around the eyes associate with this periorbital edema. And these patient's can also get subcutaneous calcinosis that we saw in the Crest syndrome. Investigations are very similar to polymyositis you want to be doing C K A S T a L T L D H pulmonary function test MRI again. You'd still see that edema there on muscle muscle biopsy, you'd see perivascular infiltrates, which just infiltrates around the muscle bundles. You want to be doing antibodies, and dermatomyositis is strongly associated with malignancy. And so most commonly gastric stomach and bowel cancer. Um, the antibodies associated with it, uh, anteed me to and again non specifically a n A. And see these patient's don't matter. My scientist patient's can generally be diagnosed with positive antibodies, a good history, a good history and the pathognomonic skin changes. So if they've got got Trans, perhaps you ALS got Trine Lesion's with proximal muscle weakness and positive antibodies, then that will probably get them the diagnosis. They might not have to have a muscle biopsy with the polymerase itis, just the general proximal muscle weakness. Without the skin involvement, it can be a bit vague, and I can always get to a diagnosis. So the patient's with polymyositis often need a muscle biopsy compared to the ones with Dermatomyositis diagnosis. Big one to assess for the underlying malignancy and again very similar to steroids, immuno suppressants, immunoglobulins and biologics. Um, so these are the kind of things that you'll see so that again, the calcinosis in that patient's thumb the got trans popular is in the top, right? So this the scaly, erythema tous rough patches on patient's knuckles there, and the heliotrope rash that you can see around that person's eyes. They're all the got trans populace and the heliotrope rash pathognomic of Dermatomyositis. There's also the shawl sign, which you can see in the diagram, which is an erythema tous rash kind of over the patient's neck and on the upper back and upper chest. That's also associated with Chatham Irisitis Um, and last of all Shroh Gren syndrome. Um, I'm sure we've all heard of this. Represents with dry mucosa, saliva gland, swelling, fatigue. So dry eyes, dry mouth, etcetera. Um, antibodies associated with stroke and syndrome is anti Rome antilock, rheumatoid factor and again, non specifically A and a, um, things you want to be doing you want to be. Also do another blood test checking the thyroid, mainly the ruling. Other things out. Sherman's tear tests, which is putting some paper towards the eye. And if it doesn't collect any tears, it's a lie. Very gland ultrasound. If they're obviously presenting with saliva glands swelling, and you might biopsy that as well, and the diagnosis is made on clinical findings and antibodies. Management's just symptomatic of providing them with lubricant for their eyes and the mouth. Um, immune modulators might be needed, and stroke and syndrome is associated with lymphoma. And so I need to be screening for that. Okay, Now gonna go of the questions? Uh, just some SBA kind of exam style questions. I'll kind of be focusing on the things that I've covered. But there might be one or two questions on some rheumatological conditions that I've not tested on just to prompt you and remind you to have a look at that in your own time, if you can. And the QR code in the bottom right hand corner there is just for feedback. So if you could give us some feedback on the presentation, how it was delivered and the questions etcetera and what you thought about any changes, So question one. Oh, sorry. Let me just go back. Question one. Mary Jane Jones is a 40 year old lady. She has a long standing history of acid reflux but is now describing a difficulty swallowing foods. She has a background of rain nodes and hypertension. Bloods taken by the G P says that she's got a positive A and a positive anti SCL 70 antibody anti RNA polymerase three antibody positive. And on the on examination, you see this small mouth she's got fibrotic Velcro like crackles in the bottom of her lungs and the skin tightening over her fingers. Okay, I'm just going to get the polyp for that. So I think the polls are just in the chat box there. If people can start putting their answers in, I'll just give it a minute or two to get the answers to come through. Yeah, so most people have got that right down to systemic sclerosis there. So, um, this patient probably has diffuse cutaneous systemic sclerosis. They've got lung involvement, and they've got skin involvement as well. Um, so a 38 year old lady who's 12 weeks pregnant attends the OBS and dining outpatients for investigation of recurrent miscarriage. She's gravida four para 20. Her previous three pregnancies ended in miscarriage between 16 and 20 weeks gestation on exam. She has a uterine fund asses felt at the pubic symphysis in keeping with gestation and a fetal heartbeat is heard using a Doppler pale purple rashes noticed over her legs and forearms. And you can see, um, that's the rash that they see in clinic there. Which investigation is most diagnostic If anticardiolipin antibody be antidouble stranded DNA titer see anchor D anti RNA polymerase e anti you one ribonucleoprotein. So the polls in the chart, and I'll just give you a minute or two to answer that question. Okay, great. So, yeah, some results are coming through there. So most people got that right. So the answer is air anticardiolipin antibody. So this patient already has one feature of possible anti phospholipids syndrome with having the recurrent miscarriages. So a positive anti phospho lipid antibody that this appointment and then repeated in 12 weeks time would confirm the diagnosis because that would be one clinical and one lab criterion. The antidouble stranded DNA may be positive because there might be an association with SLE and anti phospholipids syndrome. But there's not enough evidence there for the S L. A diagnostic criteria for this to be a diagnostic test, you need to do other multiple tests alongside it. To be diagnostic anchor would not be a diagnostic test in itself. Um, anti RNA polymerase three. So diffuse systemic sclerosis, which this person doesn't have, um, an anti U one r MPs for a mixed connective tissue disease. And again, this patient doesn't have any of those features. Okay, so Mary is a 68 year old she presents with a two month history of shoulder and hip weakness. She's now having difficulty climbing the stairs and dressing her upper half. On further questioning, she reports unintentional to stone weight loss in around four months on exam, she has a dry, mild erythema tous rash around both eyes with some peri orbital puffiness. She's put this all down to stress following the recent bereavement of her husband. G P Bloods are positive for A and a anti me to antibody. She's got racy care, raised a S T. And she got microcytic anemia and a positive raised C e A. So what's the most likely diagnosis? Okay, Yep. Um, so most people again, I've got that right. The answer is bowel cancer with paraneoplastic dermatomyositis. Um, so it kind of gives you that it's dermatomyositis. She's got anti me to antibody. Um, she's got skin involvement as well as the proximal muscle weakness. The thing that gives it away that it's bowel cancer is that she's got microcytic anemia with a positive raised C E and C E is associated with, um, bowel cancer. Um, this is also testing your knowledge of tumor markers. So for liver cancer you'd want to protest in AFP. Pancreatic cancer. See in 19 9 Obviously bowel cancer. See, uh, ovarian cancer. B C. A. 125. Uh huh. One minute and I'll just go back. Sorry. There we go. Um, so Sarah's age 52 has come to the GP with painful shoulder's feeling exhausted after little exertion, she denies weight loss, joint swelling and visual changes. His sister and mother both have rheumatoid arthritis. On examination, there's an erythematous rash around both eyes in the base of her neck. She has multiple scaly papules at present, over the extended services of both hands. Muscle strength is four out of five proximately and five out of five distally. She put some muscle tenderness when assessing her shoulder extension. There is no joint swelling or deformity. Which investigation is most diagnostic? E s are anti Joe one antibody seek a muscle biopsy or rheumatoid factor. Okay, so the answer for this one is D muscle biopsy of all these tests and muscle biopsy is the one that would give you the definitive diagnosis. This patient's got dermatomyositis, and we can tell that by her proximal muscle weakness, but she's also got the pathognomonic path. Economic got trans popular is the multiple, scaly papules at present of the proximal of the sorry extensive services of both of her hands. That's the got got trans populous that that's getting at. And also the erythematous rash around. Both of her eyes has the Helier truck brush and at the base of the neck, the shawl sign. Um, so this patient has dermatomyositis, um, And of all these, a muscle biopsy would give you the definitive, definitive diagnosis. E s l be raised in most patient's with the connective tissue disease. Anti Joe is associated polymyositis rather than dermatomyositis. It's anti me, too. That's associated with dermatomyositis. CK would be raised in both patient's with polymyositis and dermatomyositis. So wouldn't be diagnostic like to be elevated, but not diagnostic and rheumatoid factor again. Unlikely to be diagnostic? Um, it's the muscle biopsy that's going to give you the diagnosis here. And with that, you'll see the perivascular infiltrates. Oops. Sorry. Let me just go back. Sorry. Um, so 38 year old Annie has presented to a knee with a dull central chest. Pain radiates through to her back. It is worse when she takes a deep breath in, and when she lays flat, it was relieved on sitting forward on further systemic inquiry. She reports weight loss and aching joints in her hands and her wrist. She's got no past medical history and takes no regular medication. She's on exam. She's got heart sounds. One to what? A pericardial rub. Abdur soft nontender. She's got her erythematous rash covering both of her cheeks and over the bridge of her nose. She got to oral ulcers, five millimeters in diameter and a temp of 38 e. C. G shows. Widespread saddle shaped ST elevation admission. Blood sugar, uh, Normocytic anemia, low lymphocytes, low platelets. Troponin of 3 40 on admission. And when that's repeated in three hours, it's 340 to her chest. X ray looks normal. What Asian is most likely to be? Diagnostic of her underlying condition. A anti double stranded D N A B, Angkor see echo d anti histone antibody or E peri cardio synthesis. Okay, so the answer for this is the antidouble stranded DNA antibody, and this is testing your knowledge of the slick criteria. Um, the slick criteria, if you remember, is the one where you need one for criteria for for criteria in turtle one clinical, one lab. And if we give her the antidouble stranded DNA, that will also add to slit criteria. Diagnosis of S L. A. She's presented with pericarditis, whether underlying kind of cause of that will likely be her S l A. And so 70 year old Frank is an inpatient on a qwerty ward. He's got a past medical history of hypertension, God, rheumatoid arthritis and anxiety. His drugs that he's on at the moment is amlodipine search lane, methotrexate and folic acid. He's been reviewed by the F one overnight due to new confusion, agitation and a low grade fever of 37 9. An infection screen was sent. His urine is positive for E. Coli sensitive to Keflex in purpose Ilin, tazobactam, trimethoprim and Nitrofuran To him, your micro guide of your hospital suggests that nitrofurantoin or trimethoprim for seven days in males UTI which antibiotic must be avoided in this patient? Yep. So the answer for that is see trimethoprim. And this obviously isn't highlight. This obviously isn't about connective tissue diseases, but it's just to highlight this patient has rheumatoid arthritis, a condition that you need kind of need to read about in your own time before your finals, and it's treated with methotrexate. But a lot of patient's with rheumatological conditions will be on methotrexate. And it is a drug to be aware about what prescribing antibiotics. And we can't give patient's with methotrexate trimethoprim because they both, uh, folic folic antagonists and can lead to bone marrow suppression. Um, so this patient would would be treated with nitrofurantoin for his UTI. This is the last question. So Mable, aged 82 presents her GP complaining of a source scalp and migraine. She believes her skin is starting to thin at the temples due to steroid use for her polymyalgia rhuematica, and this is what's causing the pain when brushing her hair. She's currently on a steroid weaning regime and asks if her 5 mg once daily prednisolone, can be stopped. What is the most important treatment for Mabel today is stop the prednisolone 5 mg at the patient's request. Stop the prednisolone, but tell her she must start on alendronic acid to protect her bones. 30 mg prednisolone for five days in a range of review to see if her pain has settled 60 mg prednisolone and send it to hospital or urgently check her esr and ask her to double her prednisolone dose whilst awaiting results. Just yeah, two minutes to answer that. Okay, so the answer for this question is did give her 60 mg of prednisolone and send her to hospital. So it's not testing of any of the connective tissue disorders that I've been over today, but it's a polymyalgia rhuematica and G C A is conditions that you need to read about for your finals. Um, so she has a history of PMR, so she's at risk of getting a giant cell arthritis giant cell arthritis typically presents with this history of pain at the temples when old ladies are brushing their hair and she already has the risk factor of having PMR. So, uh, she's at risk of getting G see a um G C. A. Should be treated with urgent high dose steroids to 60 mg, and she should be sent to hospital. Um, patient's that are not the given steroids straight away at risk of kind of permanent vision loss. And so, even if you're urgently checking her esr in GP land and asking her to double her steroids. Dublin. Her steroids to 10 mg won't be enough. She is high then that she needs 60 mg and waiting the results that will be at least 24 hours before you can get those results back if you're in GP, and so she needs to be sent to hospital for the management of this condition. Okay, so that's kind of all I'm gonna be able to have time to cover today. Like I said, if I do have time, I'll try and put a topic of session on vasculitis because that's a big topic within rheumatology that will come up in finals. But if you can have a read of the other conditions that part at the start. So the arthritis reactive rheumatoid, Um uh, G c A P M r and closing spondylitis. Um, if you can have a look at those things in your own time, prepare yourself for your finals. That would be really good for you guys. Um, again, if you can scan the QR code and you feeling the feedback what you enjoyed what could have been done better, that would be really useful going forward. Um and our next session is next week on the 10th of January, and that will be on hematology. So, um, the events already been uploaded to make sure you sign up to that to get all the updates and join us for that session. All right. Thank you.