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Hi guys. Um, I'm Rimsha. I'm one of the f one doctors. Um, I'm currently at Barts and I'm on Hemonc. Um, we've also got Kirsten in the chart. You probably heard us talking. Um, he's kindly sort of just helping keep an eye on the chat and things like that and she's also sort of in charge of the whole series. Um, so welcome to the talk on oncology. Um, it's aimed at final years, but of course, welcome if you know, if there's any younger years here too. Um, just a warning that I do have quite a lot of slides to get through. Um, so probably we'll be talking quite a lot and it might be a bit didactic but feel free to just message in the chat or, um, tell me to slow down. Um, and we'll go from there really. And I also just wanted to say sorry. Um, so I've made the slides but they've been checked over by my, um, oncology reg who's um, Doctor Sophia Kit. She couldn't come to the talk today, but just to sort of shout out and thank you to her and then, yeah, we can get started um, I hope everyone can sort of see and hear me. Ok. But, yeah, let me know if any issues because it says that my wifi is a little bit bad. But, yeah, so if we get started, um, so just a quick summary of everything that we'll sort of be going through today. Um, so oncology is, uh, I think, I mean, so I went to UCL and Oncology for us was only a one week placement. So sort of felt like it wasn't a huge part of the curriculum, but I think in general it just includes a lot of general medicine which can kind of crop up across all of your specialties. So I think it's actually super important and especially in your sys, you can get some of the, um, oncological emergencies. So that's sort of the main thing I'm going to be talking about today. There are six that I'll be going through in a bit of detail. Um, we'll then spend of times be the commonest cancers. So things like bowel cancer, prostate, et cetera. Um, we'll briefly touch on some of the sort of cancer, therapies, radiotherapy, chemo, et cetera. Um, and then palliative care will be the sort of the second half of this talk, um, with a sort of very brief touch on ethics and law and then we'll just, um, get some feedback at the end if that's ok. Um So we'll get started with an SBA, I'm going to try and create a pole, but I've never used metal before. So let's see how it goes. Um But if we just talk through the question first, so we've got a 28 year old um, inpatient. I haven't given you a gender but let's just say it's male. Um So he's on chemotherapy. He's got a new diagnosis of acute myeloid leukemia and he's had a severe sore throat that started this morning. Um so you go to examine him. He doesn't have any shortness of breath, no cough, no chest pain or any other infective symptoms. Um, but he has been taking paracetamol for his headaches. So, um, you go and look at his bloods, you see that his hemoglobin is 86. His platelets are 89 and his neutrophils are naught 0.7. Um, you get the nurses to check his abs, his abs are all stable, including his temperature. So, what is the most appropriate next step in management? Um, you've got a few different options there while you read through them. Try and make this pull. Mhm. Can you guys see that? I hope so. So, I'll just give you a couple of seconds to fill that out and then we can go through it. Got a couple of responses so far. Ok, cool. So we'll go through it. Um, I don't think I can show you everyone's answers but I can stop the poll. Um, anyway, so, um, most of you picked b for this one. So IV antibiotics and the rest of you were sort of torn between, um, options D and E so either oral antibiotics or blood cultures. Um And I guess the most important thing to think about in this scenario is what are we worried about in terms of diagnosis? Um And it's a bit of a vague question because I've told you that all of his obs are stable, which isn't particularly helpful. Um But the correct answer here is blood cultures. Um So, and I'll explain why. So, um the main sort of diagnosis we're thinking about here is neutropenic sepsis and we'll go through it in more detail. But essentially, you can see that in terms of his bloods, he's pancytopenic. So he's got a low hemoglobin, low platelets, low neutrophils as well. And um we want neutrophils to be ideally above 1.5 to 2. So his are actually really quite low and understandably low because he's having chemotherapy at the moment. And chemotherapy makes, you know, most people um neutropenic if not pancytopenic. Now, I think the the sort of tricky thing in this scenario is that actually his temperature was stable and we often think that we need a high temperature or fever to diagnose neutropenic sepsis. But in reality, a lot of patients because they're so immunosuppressed in the first place may actually not spike a fever. And on top of that, he's been taking paracetamol for his headaches, which can mask a fever. Um, so you'll learn that if, if you're ever on, on, on an oncology job or just sort of, generally you'll see that people who are on chemotherapy doctors are often quite, um resistant to prescribing them paracetamol because of the fact that it can mask fevers. And then you, you're sort of, you know, you're never sure whether they're actually septic or not. Um, and, and the main thing again to talk about here is, are we going to first give him antibiotics or are we going to first take blood cultures? And if you think about your sort of septic screen, both of these things are equally important. We want to do both. Um, you know, at the end of the day, but it's always important to do blood cultures before you give the IV antibiotics. Um, because otherwise if you've given the antibiotics, your blood cultures won't be accurate. You may not actually grow something. Um, but the caveat to that, um, is obviously if, for whatever reason, you know, you can't get any blood or they've got terrible veins. Um, if there's a huge delay in getting blood cultures, then we just give them the IV antibiotics. Um, and the sort of the, the time period for that, which we call the fever to needle time is one hour. So from when they spike or from when you think that they've got sepsis, you should get IV antibiotics and within an hour So, if you haven't got blood cultures in that sort of golden hour period, then you just, um, give them the antibiotics. Now, a lot of you were torn between, um, if we did give antibiotics, would they be IV, or would they be oral and what? We'll, we'll go through neutropenic sepsis in a second. But the main antibiotic that we give is tazocin, um, also known as Pillin tazobactam. Um, and actually that's not available orally, it's only available IV. So if you've got an outpatient or someone comes into the GP with this presentation, you would send them to A&E to get IVS um oral won't, won't do it and will be insufficient. So, so, yeah. And um I don't think anyone picked, I mean, uh sorry, a few of you did pick a um it will be important to optimize his analgesia, but in this case, it's not the first thing you would do. Um And A and C would both sort of just be dangerous and inappropriate. So we'll just talk a little bit more now about neutropenic sepsis. Um This is sort of my bread and butter. I literally am dealing with this all day long. So, um and if you get an oncology job, you will be. So, neutropenic sepsis is commonest in the sort of initial week to 14 days post chemotherapy. So once you give someone chemotherapy, it then takes a little bit of time for their neutrophils to actually um drop and that's called an a day. So the lowest point um and the diagnostic criteria is usually a temperature more than 38 and a neutrophil count of less than naught 0.5. Um It varies between center. So some people will use naught 0.5 some will use one. It's not really that important as long if they're neutropenic, they're neutropenic. So, um so yeah. And um although it's usually commonest, you know, in the first two weeks of chemo, if anyone's within six weeks of chemo, then we should definitely be suspecting it um in terms of the pathology. So, actually, in the majority of cases, it's really frustrating because we never find out what their source of infection is. We do the whole septic screen, blood cultures, urine cultures, et cetera, but we never sort of come to a, to a diagnosis of, of where their infection was. It's, it's very, very nonspecific. Um But in the, in the 50% where we do find a source, it's usually the bacterial um etiology or some kind of focal infection like a pneumonia or an abscess. Um et cetera. Um So in terms of signs and symptoms, uh like I said earlier, it's very nonspecific. So you may not necessarily get any localizing signs. They may not have a cough or um you know, crackles on their chest and things like that. So what's really important is that you do examine them thoroughly and examine all of their systems. Um, but of course, as with normal sepsis, not just neutropenic sepsis, you've got all of your, um, obs that might sort of go off and become unstable. So, tachycardia tachypnea, um hypertension as well. Um, in terms of investigations, it's no different to your normal sepsis. You want, you want the six in and six out, you want your blood cultures, um, four antibiotics, um, urine as well. Chest X ray isn't always required. But if you're worried about a respiratory source of infection, then um definitely we would get that. And when you are um getting IV access, it's always important to do a VBG as well just to check the lactate because if it's high, then you're worried about sort of sending them to itu earlier on. Um So that's that. Um I'm sure I don't need to go through the sepsis six again. But if you get neutropenic sepsis in an Aus, then just work through it in an A to e approach. Um And, you know, mention all of those management steps that we've just talked about. Um I've discussed fever to needle time being less than one hour. And like I said, our main antibiotic is prazin tazobactam. Um It's a penicillin, however, so um obviously just check your patients not got an allergy. If they do, then we usually give for meropenem instead. Um If it's a mild allergy. Um But that's sort of beyond um the, the, this talk um and then obviously we escalate if they still haven't gotten better and you will see some patients who are on something called Filgrastim, um which is the brand name, but essentially it's G CSF um which are basically subcutaneous injections, we can give to patients to boost their neutrophil count. So, if you've got a patient who's on chemotherapy and is and is likely to become neutropenic, then we often give them these injections just to help their counts, um recover a little bit quicker and, and you know, make, make their sepsis a bit better, I guess, or prevent it in the first place. Um And then just sort of treat your patient as a whole. They made a whole host of other things like fluids, antiemetics, um et cetera, so, or transfusions for our pancytopenic patient. So we'll go on to another SBA, I'll make the poll again in a second. Um But now we've got a 64 year old woman. She comes into EED, she's complaining of a two day history of shortness of breath. Um When you look at her, her face and her upper extremities are very puffy. She's got these um really bad 10 out of 10 headaches that are worse in the morning and she's also had some visual disturbances. So again, you examine her, you notice she's got distended veins on her face, her neck and her chest. What's the most likely etiology? We've got a few options there. I'm just gonna create the pole again, people to work it fine. So, um let's go through it. Um So the majority of you have gone for answer option C which is lung cancer with a couple of you going for um spinal cord compression B. Um So well done to those of you who said lung cancer that is um the most likely etiology. Um I'll go through all the answer options in a second, But it's important for me to say that. So the diagnosis we're thinking of here is superior vena cava obstruction, also known as S VC. Um and all of the answer options that I've listed here could potentially cause SVCO. But the key thing is to look at the wording of the question. So they've asked you for what the most likely etiology is and in the majority of patients, it's, it's caused by a lung cancer. And commonly, it's a small cell lung cancer um located in the sort of right upper part of your chest. Um And then following on from that, the second most likely diagnosis is lymphomas. Um So if we just go through the answer. Um So yeah, so like I said, small cell lung cancer is the commonest cause. Um your right upper lobe is where the, if, if you've got a cancer in your right upper lobe, that's where it will become problematic because essentially what happens is that your cancer will either cause external compression of your supera vena cava, or actually infiltrate the superior Vena ava. Um basically causing it to block off, which means that blood from your upper extremities, from your neck, your face, your arms can't return back to the heart through the um supra a cava. And therefore you get this build up of fluid, build up of congestion, a lot of edema. Um You'll see people's veins looking very swollen all over their, um or very distended all over their bodies as well. Um And it's very scary. Um We had a lady with this just last week and um they're so um distressed and just so dyspneic, it can actually be really scary. Um So it's really important to recognize. Um And yeah, like I said, other cancers include lymphomas. Um and aortic aneurysms are super, are a super rare cause of SVCO although they can actually um cause it in some cases, but I've never seen it. Um And oh, so ignore me. So spinal cord compression or vagal art artery rupture, they wouldn't actually cause um SPC because they're not impacting the super vena cava at all. Um And a more would, would present with more sort of neurological symptoms and weakness and um and things like that. So I hope that makes sense, just message in the chart if you've got any questions. Um But just to talk a little bit more about SPC. Um common things to remember is lymphomas and lung cancers. Some other rarer things you can get, um, in people with sort of thyroid issues or iodine deficiency. If you've got, if they've got massive goiters in their mediastinum, then that could also cause compression of your SVC, um, and cause similar symptoms. Um, and also very rarely if you've got a, if you've got a patient with a thrombophilia or, um, or, you know, something else that's causing a big clot in the SVC, then that can also cause um, obstruction. The key thing to remember for your SBA S is, is these symptoms of facial puffiness, breathlessness, um distended veins. Um And then we'll talk about Pemberton sign in a second. Um But the other thing is because of all of the congestion, people can get really, really bad headaches and that might be the main thing that they come in with. Um, and also a hoarse um voice with sort of pancoast tumors and, and, and all of that. Um The key sort of, if you, if you've got a SBA, which talks about investigating um superior obstruction, then the main thing they'll talk about is mediastinal widening seen on a, either a chest X ray or a ct thorax. Um And the, the sort of um thing to remember, I guess special test is Pemberton's test. So it's where you basically ask your patients to elevate their arms to the side of their head like that. Um And you'll see that it causes their face to become very red um, and also worsens their shortness of breath, which isn't obviously a nice thing to do. But, um, if it's positive, then it's a very sensitive sign of it being SVCO um, main thing with management to remember is dexamethasone. So, steroids um, treat this very quickly. Um They, they're sort of a temporary symptomatic measure. Um So we give 8 mg BD um important to remember that it's IV not oral. Um And then if that's um if you're worried about their airway, which can often become compromised, then obviously escalate up to an anesthetist. Um And like I said, dexamethasone just sort of temporarily treats the, the symptoms that people are getting. And if we want to treat this more definitively going forward, then, then the management is usually chemotherapy radiotherapy or stents to actually open the um superior a backup or treat the malignancy to, to prevent it causing the obstruction. Um Just checking the chart. If we've got any questions, I can't see anything but I don't know if that's just because you guys actually don't have any questions. So just let me know if um I'm missing something. Um And then a bit of a break from SBA, let's just also talk about metastatic spinal cord compression, which is probably one of the commonest um oncological emergencies that you'll see. Um And you should suspect this in anyone who's got a known cancer and comes in with uh back pain, even if it's very mild back pain, then it's something to always be worried about because there's such a spectrum of, um, you know how much the spinal cord is compressed, how much back pain they have, et cetera. So, um, yeah, main symptom is back pain, but other things can include neurological signs, so, weakness, um, sensory disturbances in their limbs, most commonly the lower limbs, um, important to always ask about bowel or bladder dysfunction. So, have they been able to open their bowel and bladder? Do they feel like they're retaining? Um, do they still have sensation when they're opening their bowels? You know, all those sort of quarter quina questions as well that, that you always ask for. Um, and then back pain, obviously, any back pain is worrying. But, um, we tend to get particularly worried with all the sort of red flags. So thoracic back pain, back pain in an unusual location, um, et cetera. And again, it comes up often in BS. But the main investigation you want, if you're suspecting, um, spinal cord compression is a full spine MRI and it should be done in less than 24 hours. And the reason why we, um, image the full spine is because although they may just be symptomatic at one point, actually, a third of people will have mets throughout their spinal cord or in various different places. Um, so that's that. And then the management is also, um, dexamethasone. People tend to vary in whether they want to give it oral or IV. Um we kind of do a mix on the wards. It's usually a consultant or a registrar decision anyway. Um But remember your PPI cover with your high dose steroids. And then um the other thing, the other good thing saying osk in particular is that you want to maintain spinal precautions. So, um you basically want to tell your patient to keep their spine flat, they shouldn't be wandering around too much. And ideally, we put them in a brace and you maintain these spinal precautions until neurosurgery, you all of their imaging and basically tell you whether the spine is stable or unstable. And so whether they can mobilize or um whether they should remain immobilized. Um And the two most important people to refer to in this scenario are neurosurgery and clinical oncology. So, neurosurgeons will tell you whether they want to operate on the spine. Very rare. Um And then clinical oncology will tell you whether um they would like to treat it with radiotherapy, which is usually what happens to most patients. So I've got another SBA. Um So again, 37 year old female, she's got a history of A L and also just to say this is probably the hardest um SBA of the whole talk. So don't worry if you're a bit confused, I made it a bit vague on purpose, but she's got A L and she was discharged home three days ago following her first cycle of chemo. Um, she then comes into her GP, she's had a lot of nausea and diarrhea. Um, bowels open seven times a day already. She doesn't have any shortness of breath, no cough, no back pain. Um, but she hasn't opened her bladder in the last 24 hours. So, um, the GP goes and checks her discharge letter, um, and realizes she wasn't prescribed any supportive medication before they started her chemotherapy. Um, she's a bit tachycardic, her blood. So you got her, you get her full blood count, that's all normal. Um, no anemia or anything like that. Her e are not back yet. So a bit suspicious. Um C RP is normal and what's the most likely diagnosis? I'll make a poll patch walk. Yes, fine. So I'm just gonna move on in the interests of time. Um But well done. The majority of you actually got the right answer which is um tumor lysis syndrome. A few of you um, have gone for spinal cord compression or infective gastroenteritis. Um, totally understandable. The gastroenteritis. She's got a lot of symptoms of it, vomiting, diarrhea. Um And then with the sort of spin cold compression, I guess, um, she hasn't got any back pain, which is why it's unlikely to be spinal cord compression and the nausea, the vomiting, the diarrhea wouldn't really fit with that. The key thing I was trying to get at this question is her knees are still pending Um And with tumor lysis syndrome, we'll talk about it in a second, but people's ene is basically get very deranged and they get very high levels of potassium phosphate urate. Um So we're worried about that because we haven't got that back. And then the other thing is she wasn't prescribed any supportive medication before chemotherapy. So by that I was trying to get out allopurinol or rasburicase. So, patients who are at higher risk of tumor lysis syndrome, who've got cancers. Um A a and patients who are higher risk are usually patients with sort of hematological malignant or cancers that have a rapid turnover of cells. Um So if you're at high risk of that, then they usually put on prophylactic um allopurinol or prophylactic rasburicase um to stop it from happening and she wasn't on anything which is why she's at um high risk of TL S basically, and that's what I was trying to get at. Um So yeah, key bloods to remember a raised potassium phosphate urate low calcium. We'll talk about why. Um Like I said, your, your leukemias and lymphomas are very high risk cancers. Um And it, so the other key thing to remember in this question is she's in, she's just finished her first cycle of chemo. Um And it's common TLS is commonest um after the first cycle of chemotherapy um when the cancers, you know, previously not been touched before. Um And again, patients present with all these vague symptoms of electrolyte abnormalities, basically. So, um, a ks abdominal pain, weakness, et cetera. Um And in terms of management, we'll talk about that in the next slide actually. Um But yeah, she, she wasn't on any prophylactic meds. So, tumor lysis syndrome, essentially, what happens is when you've got, um, when you've got a cancer that's being treated with chemotherapy, essentially, you're destroying those cancer cells. And when you've got a cancer that has already been dividing very rapidly, and you've therefore got loads of cancerous cells. When you kill them, all the intracellular contents are released very rapidly. And these contents basically include urate potassium phosphate. Um and so those shoot up in tumor lysis syndrome and your LDH will also be raised. Um The weird thing is your calcium goes low. And the reason for that is when all the phosphate is released from the the cancer cells, they, that binds to loads of calcium in the body and, and forms of calcium phosphate crystals, which can also go and deposit in various places. And that then causes your calcium in the blood to appear low. Um But actually, it's just all bound to the phosphate. Um, commonest in the first sort of 72 hours of starting chemo lymphoma is the commonest cause. And the important investigations to do. Are you using, we want a bone profile as well to include calcium and phosphate and an ECG um in light of the possible hyperkalemia. Um because that would be another thing to, to manage. Um The main treatment is hydration. So we give these patients loads and loads of fluid. Um and it's usually sort of 64 hourly bags and they just have fluid running for, for hours really. Um And to prevent it, always important to give allopurinol um or rasburicase beforehand, obviously treat hyperkalemia if that's an issue. Um And in very severe cases, if patients have got an AK that's not improving with um hydration, then they will need um haemodialysis as well. And I always found at med school. Um It just a little bit confusing about what the difference between allopurinol and rasburicase. So I've included a quick diagram here. Um just to show you it's from pulse notes to show you where the two different drugs um act. So allopurinol actually stops uric acid from being formed in the first place because it blocks this um enzyme. Whereas rasburicase works on uric acid that's already been formed. It just prevents it from becoming more soluble in the blood and therefore, you know, going and affecting all of your organs and whatnot. Um See you. Um And then the other, the other emergency to talk about is malignant bowel obstruction. I won't go on about this for too long because we'll talk about it in our gastro talk as well. Um The commonest uh malignancies are colorectal and gyne cancers because of location really. Um And also sometimes lymphomas that involve the, um, abdomen or, you know, the spleen or the liver. For example, um, your important investigations initially is abdominal X ray, um, where you'll get your distended bowel loops. Um, and then a CT Abdo as well. And then in terms of management, it's your usual bowel obstruction management. So, um, n patients nil by mouth, um, we insert an NG tube, um, with the sort of usual drip and suck management and then a lot of patients will need surgery. Um, either and, and that's usually just a temporary surgery to sort of treat the bowel obstruction, um, rather than getting rid of the whole, you know, cancer and doing a curative operation there. And then, um, and sometimes we can use stents, um, in the long term, obviously, putting patients on, um, appropriate chemo will reduce the cancer and therefore reduce the obstruction. Um, and the key thing to remember is never give bowel stimulants. So things like senna, um, metoclopramide, et cetera when you've got bowel obstruction because you will just cause the bowel to perforate. Um, yeah, so we've got another SBA. Um, so now we've got a 67 year old male. He comes into A&E, he's got a five day history of very crampy abdominal pain. Um, he's also got severe pain in his thighs. Um, in addition to this, he says he's been super thirsty and he's having to empty his bladder very often. So you do some bloods. Um, and you get the following. So his hemoglobin is OK. His white cell count is normal. Um a little bit of a low EGFR or very low EGFR rather. Um I'll let you form your own opinions of what you think about the calcium. Um But potassium and sodium are normal. So what's the most appropriate management? And I'll make another poll? No. Cool. So, um let's go through it. Sorry, I'm rushing all of this. Just got quite a lot of slides to get through. Um But like I said, let me know if you've got any questions. So, um the majority of you have gone for answer option A which is um the 500 mil bag of Saline and a few others who've gone for either um prednisoLONE or um pedate which is a bisphosphonate. Um So again, well done to all of you who put answer option A. So the main issue here is he's got a very raised calcium. So he's got hypercalcemia. His calcium is 3.1. Um very common in malignancies for several different reasons that I'll talk about. Um But essentially all of the answer options here are management options for hypercalcemia. The reason why a is the most correct um answer um is because it's, it's, it's essentially the first thing that we do. So when you've got hypercalcemia, we try and just treat it with giving patients lots of fluids first to dilute the hypercalcemia essentially. So you would try fluids and if fluids aren't working after, um, you know, four or 4 to 6 hours, then we can move on to some of these other therapies like bisphosphonates. And the next most commonest step would usually be a bisphosphonate. Um, or in severe cases, if you're still not managing to fix the calcium, then we move on to things like pred, um, thiazides or furosemide as well. But the key thing here is, um, we fluid resuscitate patients to, to treat the hypercalcemia. Um, and then, ah, yes, the other thing I remembered is so bisphosphonates, like I said, we, we usually try them after fluids, um, or alongside fluids. But, um, they're contraindicated in patients who have renal impairment and we can see that our EGFR here is 15. Um, so just something to be wary of. And, um, pharmacists are great to speak to about, about this kind of stuff when you're prescribing. Um, and then, like I said, everything else is for all the other therapies we trial only if, uh, fluid hydration hasn't worked. So, um, hypercalcemia, um, you don't really need to know the normal range, I don't think. Um, but 2.2 to 2.6 I thought this sort of, um, this thing that they teach you all the time at med school. I actually think it's really helpful to remember the symptoms. So, um, bones gross psychiatric overturns. So, with bones, it's essentially bone pain. Um, stones refers to sort of kidney stones, stones in the ureters, things like that. Crohn's is Crohn's just refers to abdominal pain or just generally sort of pain in the bones or anywhere really. Um And then I think, um Crohn's is the sort of polyuria polydipsia. Um, the almost sort of diabetic sounding symptoms and then mood disturbances are super common as well. Um And the key thing to remember is with hypercalcemia a bit like neutropenic sepsis and tumor lysis syndrome. It just presents super super non specifically. Um But your calcium will always, you know, give away the answer and on an ecg um just remember that high calcium causes a short qt interval. Whereas if you've got super low calcium that will cause a long qt interval um as well. Um and something to always do and then in terms of the causes. So just generally, um not, not specific to oncology, but just generally in medicine, the two commonest causes of hypercalcemia are either hyperparathyroidism, um or malignancy and malignancy can be either due to um a cancer producing parathyroid hormone um or in cancers like myeloma that you get sort of local breakdown of bones which causes calcium to be released into the blood. Um or very rarely, you can get some sort of very rare tumors that produce Vitamin D again causing hypercalcemia and we've talked about the management. The only thing we didn't talk about is something called calcitonin, which if you remember it's something that your body, um, your thyroid gland naturally produces in order to reduce your calcium levels. Um, and we can give that to patients. I think it's a synthetic form of it. Um, but the problem with it is that it works very quickly, but then it's got a very short term effect and you'll see their calcium rise again. Whereas bisphosphonates take a few days to work and they won't work very quickly. But then once they've worked, they will maintain a uh um no, no calcemic range fine. Um So next SBA um which of the following is most associated with raised levels of ca 125, put a pole in. Yes, you guys are very quick at responding, which is great um Fine. Um So most of you have responded um and most of you have gone for option C which is ovarian cancer. And then a few of you thinking breast cancer, um it's fine. So the those of you who put um ovarian cancer, you're right. So, um so again that you have to look at the wording of the question. So I think it's super, super rare, but breast cancer and in some cases, colorectal cancer can cause a Raia 125. but it's very rare if you see a Raia 125. The main thing that we're worrying about is ovarian cancer and specifically epithelial ovarian cancers. So, just a quick note on tumor markers, um like I said C 15 is for ovarian malignancies, cea, which is car something embryonic antigen. And that's for colorectal cancer. Um not used to diagnose it but just to sort of monitor cancer after treatment. Um The one to remember for breast cancer is ca 15 3, but we don't really use tumor markers in um breast cancer because they've just, they've never been proven to be sort of sensitive or specific enough. Um So for liver cancer, for hepatocellular carcinoma, a FP, which is alpha fetoprotein is the one to remember. A FP is also sometimes raised in germ cell tumors and testicular cancers. So just be aware of that and then um pancreatic cancer often crops up in SBS as well. Ca 19 9 is the one to remember for that. And unfortunately, you just have to learn those. There's no kind of quick way of um remembering them. Um I've got a few slides um going through some of the commonest cancers that pop up in BA S and are good to know about. I'm not going to go through them all in detail just and we've only got about 18 minutes left. Um But I'll just point out some key things with each of them. So with esophageal cancer, um the key thing to remember is all of your risk factors in particular um Barrett's disease. Um and smoking. And the other thing to remember is your alarm symptoms, which can be a sign of esophageal cancer or gastric cancer. And your alarm symptoms are um, it's testing me now as well but things like anemia, um loss of appetite, loss of weight, um recent onset progressive symptoms as the ri think and then um melena or hematemesis for the m um any of those super worried about gi malignancies, um the two week weight pathway. So anyone who's more than 55 with dysphagia, um straight two week wait for esophageal cancer. Um And OG DS are the, the commonest way in which we diagnose these. Um moving on to lung cancer. Again, look out for your risk factors, obviously, smoking. Um But thing like things like asbestos are important in mesothelioma. Um Obviously the symptoms of things like chronic cough, weight loss, your usual red flags. Um And often in FDA S, they'll ask you what the sort of or they'll say you've got a nonsmoker, 40 year old woman who's now got lung cancer. What's the most likely sort of histological diagnosis going to be? And it's always adenocarcinomas um in, in nonsmokers, not always, but majority of cases. Um And then your usual sort of lung investigations, chest x ray bronchoscopies, CT staging, et cetera. Um And then finally, breast cancer. So, um with breast cancer, I think the most important things to know um is how they present and the two week wait pathways. Um So in terms of presentation, just, you know, any breast lump thickening, um or lumps and bumps in the axilla as well. Um, changes to the so nipple discharge retraction and just any skin changes. So that typical, um, sort of orange peel appearance that, that you'll hear about and see as well. Um And then for your two week waits, um, there's different criteria based on whether you're more than 30 or more than 50 worth just going through at some point and learning and then the screening program. So obviously, we've got a national screening program for breast cancer. It used to be for ages 50 to 70 but they've now extended it for um 49 to 73. And basically women have a three yearly mammogram um or are invited to one rather. And um yeah, and then in terms of investigations, so you've got your triple assessment um clinics. Um you've got, if so, depending on their age, if they're less than 40 some people use 35 as a cut off, they'll get an ultrasound. Um And because of their breast tissues, I think a little bit more dense. And so it's difficult to fully assess it on a mammogram and an ultrasound is better in those cases. Um Whereas if you're more than 40 then you'll go for a mammogram. Um And yeah, just to be aware that treatment for breast cancer is often very specific to receptors. So you'll hear about drugs like Herceptin, um which have really revolutionized the management of breast cancer and then a few other important ones. So, colorectal cancer. Um, I think again, the most important thing to remember is your two week weight criteria. Um, different criteria depending on whether you're 6050 or 40. Um, but regardless, um, if I, anyone's presenting with signs and symptoms of, um, gi malignancy, then you'll do a fit test. Um, previously known as the FOB test which basically, um, detects hemoglobin in, in the stool, um, and colonoscopies as well. Um And then just remember there are some random sort of genetic causes, things like um familial adenomatous polyposis, which is FAP and then H PCC, which is also often called lynch syndrome. Um And sometimes in B you'll see this funny organism. So, streptococcus bovis, um which if people have that, then again, you should be suspicious of colorectal cancer. Um Not going to really talk about prostate, I think um it's one of the sort of specialties and you'll probably hear about it in your urology talk. Um The key thing to remember is raised psa malignant feeling prostate on apr exam. And your top investigation is a multiparametric MRI of your prostate, um liver cancers, uh loads of risk factors, hepatitis C or any sort of chronic hepatitis, um and cirrhosis of the liver as well. And it's often um with things like, uh you know, fatty liver or alcoholic induced cirrhosis. Um liver cancer is essentially the last step that you get in in the sort of journey of liver failure. Um And, but actually, interestingly, most liver cancers are um mets to the liver rather than a primary liver cancer. Primary liver cancers are actually quite rare in the sort of grand scheme of cancers. Um And then we've kind of talked about gastric cancer a little bit very similar symptoms to esophageal. Um, the sort of SBA thing to remember is these signet ring cells, um which they'll talk about sort of popping up on histology. Essentially, they look a bit like a signet ring. And the reason why they look like that is for whatever reason, the the cytoplasm in the cells, um and the vacuole become very enlarged and basically squish the nucleus to the corner of the cell. Um And that's why it looks a bit like a signet ring. But yeah, you do a gastroscopy and obviously do you would eventually do a CT or an MRI to do to fully stage the patient as well. Um I think I'm gonna skip over ovarian endometrial renal and bladder. But um this talk will be uploaded onto youtube. So, um definitely worth just going through the sort of presentations and investigations um in your own time and then just moving on to cancer treatment. So, um I think I always found this really confusing because you just, you know, you just hear about a load of chemotherapies, which don't really mean anything to you. But I think what's more important is just knowing about the, um, the knowing sort of basic principles behind cancer treatment. So there's three main things to think about. We give treatment either as neoadjuvant treatment, as adjuvant treatment, um, or treatment only. So neoadjuvant is when you give them something so chemotherapy before the surgery, um, to reduce the tumor size. So that essentially makes surgery easier. You have less to resect. Um, adjuvant treatment is when we give them something after surgery. Um, and it's usually to prevent that cancer from, uh, from coming back. And really, once you've sort of removed the main bulk of it by surgery, you would give them chemotherapy or something to eliminate all other cancers that are kind of roaming around everywhere. Um, and then sometimes we'll do treatment only which is where you just do something to eliminate the tumor. So, you know, surgically resect, um, a breast cancer, for example, and the three main therapies for you guys to know about is chemotherapy radiotherapy and, um, up and sort of, you know, the new thing everyone talks about is immunotherapy. Um, so with chemo, um, essentially we just give them medications, loads of different sort of cytotoxic drugs which will either make the tumor smaller, get rid of it completely or stop it from coming back. Those are the kind of three main three main reasons why we would use it. Um, interestingly, it's, um, I, so obviously on the wards, I mainly see IV chemo being given but actually it does exist as oral tablets as well, which I didn't really know before starting my hemo job, um, which is quite cool. Um, and then side effects are important to know about. So, pancytopenia, low hemoglobin, low platelets, low white blood cells, um, bad, basically. Um, and then loads of sort of other things which are good to know about. Um, just to sort of recognize them in SBS, um, radiotherapy loads of different ways of delivering it. And before you give someone radiotherapy, we usually have to do very sort of careful scans of the um mapping scans um to, to know how to target the radiotherapy to wherever the cancer is, um there's several different types. So external beams, beam, radiotherapy where we um just sort of externally um give the patient beams of radiation, internal brachytherapy where you can kind of install um radiotherapy emitting things in the body so that you more closely target the tumor. Um So, yeah, and then the side effects of radiotherapy are similar to chemo, but a little bit different. They're more specific to where you've actually given the radiotherapy. So if someone's got a lung cancer and they've got radiotherapy to the chest wall, then they might get a lot of sore skin on the chest or hair loss. Um If you've got radiotherapy given to the abdomen and you may have nausea, vomiting, diarrhea, um et cetera. And obviously just generally, um people can be very very fatigued. And in the long run, radiotherapy can actually lead to secondary cancers as well. Um Which is unfortunate really, but we, I have seen it happen. Um So that's that. And then immunotherapy has really sort of revolutionized the management of, of mostly renal cancer and um melanomas. Um but people have started to have started to use it for things like gi cancers as well. So it's um super exciting and someone school once told me that the way to remember the side effects of immunotherapy is all the itis um reactions. So, colitis thyroiditis, um anything with itis on the end really um can be a side effect of immunotherapy and often patients will get these sort of flu like symptoms, just feel a bit sort of cris and unwell um as well. Um And basically, with immunotherapy, we're just giving patients a load of drugs to boost their own body's natural um immune system and defense system to destroy the cancer cells. Um which is quite cool. So, yeah, and then next SBA um which of the following uh chemotherapies is most associated with lung fibrosis just gonna make a pull fine, fine, great. So most of you have replied, um so 60% of people have gone for Bleomycin and then there's sort of an equal spread amongst all the other answers. Um which is totally fair enough. I think side effects of chemotherapy are really difficult to remember. And also, um I think just as sort of general advice. I think it's probably not the most important thing for you guys to remember for SBS. But as you do questions, you'll recognize some of the important side effects to know about. And in this case, you'll now know and learn that um, the majority of you are, right? So, Bleomycin is a very common cause of um, pulmonary fibrosis. Um And then I've just listed a few sort of reactions here that I think are helpful to know about. Um And these are the sort of main ones that I learned at med school. So, um for Bleomycin, it's, it's lung fibrosis and it's a dose related effect. So the more you give the worse fibrosis um with your vinblastin, vincristin et cetera, peripheral neuropathy is the main thing. Um to sort of remember, um we've got a really interesting patient on the wards at the moment who's got peripheral neuropathy induced from um vinCRIStine. And actually, um he had it from a previous cycle of chemotherapy has now come back for a second cycle, but it's, it's just not gotten any better. So actually, these side effects affect people for a really long time and it's definitely something to watch out for and, and know about um cyclophosphamide um bladder issues. So, hemorrhagic cystitis, um CISplatin often cropped up in SBS is either a low magnesium or again, peripheral neuropathy and then um for your cardiac issues. So, um cardiomyopathy, heart failure DOXOrubicin is a really common cause of that as is um Herceptin. So the drug um often used to treat breast cancers. Um So that's that. Um it would be really helpful if you guys could just a quick break before you move on to palliative care. We're running a bit behind, sorry. Um But if you could just scan this QR code um for a bit of feedback and then I'll, you can sort of fill that out as I move on to palliative care stuff, I'll give you guys a couple of seconds just to scan that in and you do get a certificate of attendance for um for filling it out, which is great for your CV. So yeah, so fine. Oh, so I'll, I'll pop this back up at the end as well in case some of you haven't managed to get it now. But yeah, I'd be super grateful for any feedback and it's really useful for our portfolios as well. Um So thank you for that. Um I'm just gonna move on to palliative care. Now, we're gonna have to rush through this. Um But I did want to spend longer on oncology anyway. Um So palliative care. So what is palliative care? Um Again, you don't need to memorize this definition by any means, but it's important to just have a vague under, you know, a way of explaining it to patients because often you will be explaining it and people are really worried about, oh, you know, you're about to start my family member in palliative care. What does that mean? Are you giving up on them things like that? So, it's really important just to have your own way of explaining it. And I think the key thing is is that um it's an approach that we use in medicine to improve the quality of life of patients as well as their families. Um, it's usually patients who are um having problems and are approaching the um sort of end of life um or have life threatening illnesses. And the main aim of palliative care is to basically relieve their suffering in many different ways. So it may be relieving their pain. Um It may be relieving other sort of, you know, physical symptoms like secretions um and also just treating them very holistically. So looking at things like psychosocial issues, any spiritual requirements that they may need, um et cetera. And although this is an oncology talk, um just remember that it's really, it's for patients with any long term conditions. So people with advanced C KD heart failure, any chronic condition like, you know, MS um et cetera. So yeah, and then end of life care, I always really, um I used to find the term just really confusing and I think to date, um it's, it's still sort of difficult to know when you're definitely putting a patient or labeling a patient as, as receiving end of life care, but in terms of numbers, it's really anyone who, who's likely to die within the next 12 months. Um, and that can, you know, see it's quite a long time so it could be anyone from, it could be someone from, it could be anywhere between someone who's literally has hours or days to live versus someone who has months and you just don't know how the disease will progress with things like heart failure. Um So, so yeah, and then there's just a few different sort of scenarios where you might put someone, uh you might label someone as having end of life care over here. Cool. So this is a really important slide. So um common symptoms at the end of life. Um it's important that you remember these four symptoms, co um everyone, you'll be seeing patients eventually when, when you're in f one who are suffering from these things and if, if someone's at the end of life and is having a lot of pain, um you should still ask about all of these other symptoms as well. So agitation is very common. Um Pain, excessive secretions. Um and that can be sort of respiratory, mainly respiratory secretions, but also things like nasal secretions and then nausea and vomiting can be super common as well. Um So yeah, then II won't, I won't read through all of this. Um It's a bit depressing as well, but um signs and symptoms of dying is again, super varied. Um, but key things to know is, um, people who are very bed bound, requiring a lot of care. Um, people who've become very drowsy, um, unarousable, just sleeping pretty much all day long. Um, you know, things like not eating food or fluids, not mobilizing, not swallowing any medication and also changes in breathing, um, towards the end of life can be, um, you know, you know, again, a massive sign of someone, um, not doing very well. Um And the key thing you might hear of in sort of SBA S or you might even see on the wards is something called, um, chain Stokes breathing, which is essentially where people have these periods of not breathing at all. And then suddenly they'll start to take very deep and frequent breaths and it can be really sort of distressing to watch. Um So, yeah, and just generally feeling very cool peripherally mottling of the skin, et cetera. Um So to just talk about pain, um, this is your sort of Bible of pain. So it's wh o pain ladder. Um And you've got the, um, sort of three different steps. Um And really, um, you kind of have to assess how bad your patient's pain is. So, if they're in a lot of pain, it's very severe, then you might just start them on strong opioids and then work your way down. Um, for example, in someone who's POSTOP. Um, but if you've got someone who's got much milder pain. Then obviously, you can start with paracetamol and work your way up. Um But the key, key thing to remember is that um for mild pain, we'll give paracetamol. Um remember to reduce the dose if your patient's got renal, sorry hepatic impairment um or is less than 50 kg. Um And then we escalate up to weaker opioids. So things like codeine, dihydrocodeine um but important to remember that um a lot of people don't actually metabolize codeine, so it may not work for them. So in which case, you'll need to escalate on to, to morphine. Um And then obviously, in patients who've got a lot of pain, we'll give them things like Oramorph um morphine or in renal impairment. Um we tend to not give morphine and if it's just mild renal impairment, then we'll give them oxyCODONE. Um But in more sort of severe cases of renal impairment that we can consider things like fentaNYL or a fentaNYL as well. Um But that will never be you prescribing it, um nausea and vomiting. Um So a key thing to know is that we have a lot of different antiemetics, which is great because you can try a lot of different things with patients. But um they all have very different mechanisms of action and are all all sort of work well, for different causes of nausea. Um So the key thing to remember is Ondansetron is really good for chemo related nausea. Um and all of our chemo patients um are generally put on Ondansetron. Um, cyclizine is good if someone's got vestibular causes or vertigo or ent issues really. Um But, um, what I learned when I, only, when I became an F one, I didn't, I don't think I really knew this as a um med student. Cos at med school, we were told to just sort of prescribe cyclizine for everyone. Is that actually IV cyclizine um is not very liked in young women because it can cause this sort of high feeling and can be quite addictive. So avoid IV cyclizine. Um but the other routes, so things like oral are OK. Um And then Ondansetron can sometimes cause constipation. So just to be aware of that, um so metoclopramide and Domperidone, they're both dopamine receptor antagonists. Um And, but the, the thing that differentiates them is that with metoclopramide, um it does pass the blood brain barrier. So in patients with Parkinson's disease, who've already not got any dopaminergic neurons, you don't want to give them metoclopramide because you will just worsen their symptoms. Um And also it's prokinetic. So you don't want to give it in bowel obstruction. Um Whereas Domperidone again, you don't want to give it in bowel obstruction because it's prokinetic. But um you can give it to people with Parkinson. Uh sorry, with Domperidone, you can give it to patients with Parkinson's disease because it doesn't cross the blood brain barrier so it won't affect their, um, the very few dopaminergic neurons that they've, they've got left. Um So, yeah, that, that's the main thing to know. I always found this very confusing though. Um, and then we've got another SB I'm worried that it's eight o'clock so, um feel free to nip off um if you need to, but I'll just sort of power on. Um, so 80 year old woman with metastatic ovarian cancer and heart failure, she's got severe abdominal pain. She takes modified release, morphine, sulfate tablets. Um This has recently been up titrated. So she's on 30 mgs twice daily. Um You also need to prescribe her an appropriate P RN to have for any additional breakthrough um pain she's having. So what are you going to prescribe, making a poll? Uh Cool. So, um most of you have gone for a, which is 10 mg of immediate release or a Morse. Um Again, I'll just explain it in the interest of time. That is the right answer. Um So essentially, um when patients are in a lot of pain, they'll be on regular morphine, which is your modified release morphine. And then on the P RN side of the drug chart, they will also be prescribed um additional Oramorph which is immediate acting morphine um to have for if they've got any extra pain, basically. So the way we calculate this is you need to work out how much modified release morphine she's getting in a day, which is 30 mg BD. So that's 60 mgs total in a day um, of her regular morphine and then to work out how much, um prn you're going to give her. It's always 1/6 of that total daily dose. So it's 1/6 of 60 mgs, um which is 10 mgs of morphine. Um And the important thing to remember and how they sort of trick you out in, in SB is um the way they actually administer that morphine. So we've got two answers here that had 10 mg of, of morphine, ones immediate release and one's modified release, you want to make sure that you're always giving them immediate release. Um Oramorph for the breakthrough pain, it can also be given sort of subcut im IV if you've got a patient who can't swallow, but in the majority of cases, it will just be given as Oramorph but not as a modified release form. Um And then just another point to remember is um obviously Ibuprofen wouldn't be a correct answer here, but on top of it, just not being an adequate um prn it's also contraindicated in heart failure. So just something to watch out in exams and just remember to always calculate the total dose. So 30 mg, BD, total of 60 mg. Um So for opioid prescribing, um so remember, opioids are only for very severe pain. If you've got someone who's never been on any opiates before, then we usually just start them um, on 2.5 or five mgs four hourly. Um, and then we'll monitor them on just PRN S for a few days and see how much they're actually using. Um And once we know that, you know, for example, your patient's having 20 mgs or a morphine a day, you can then um convert that into a regular uh modified release dose. Um We've talked about how to work out the Pr Ns and then just in terms of symptoms, uh sorry, just in terms of options, um like I said, morphines are go to, but if they've got renal mild renal impairment, then we'll use oxyCODONE and then there's a couple of other options for more severe renal impairment. So, fentaNYL um et cetera and then with opioids, um your side effects. Um So remember things like constipation, nausea and vomiting. If they've overdosed, they may get very drowsy, very confused. Um So in all of these cases, it's very important to always co prescribe an antiemetic and a laxative as PRN. Um and then some, some doctors, although I've never really seen it also like prescribing naloxone P RN in maybe, perhaps for elderly patients that you're worried may um be very sort of sensitive to these low doses of more and more. So just in case um they get any respiratory depression, you can reverse that with naloxone as well. So this is a um drawing just from my sort of med school notes about the different um conversions of sort of codeine to morphine, et cetera. Again, I won't go through it now. Um I guess the main one to know is if you're going from oral morphine to subcut morphine, then you always um divide by two. But again, we'll upload these slides. So, um, it, this is definitely something that's good to memorize um for your exams. Fine, a bit of a longer question. I think this might be the last SBA. Um But again, we've got an 82 year old man. He's got metastatic prostate cancer. The pain team have come to review him. Um He's had increasingly severe generalized pain, it's particularly noticeable in his back. Um But he's run out of all of his pain meds. So now he needs a new prescription. So you go and check his previous prescription and you find that he's been using about 5 to 6 doses of his Oramorph per day. Um That's been effective but it wears off after two hours. So he keeps asking for more um each of those doses. So each of those 5 to 6 doses he's having is 5 mg. Um You need to convert into a sort of longer acting analgesia regime, which of the following is the most appropriate prescription. Again, I'll just do a pole fast ba guys, it cool. So we've got nine responses. Um Sorry if you still working it out, I'm just gonna quickly move on in terms of time. Um So well done to um those of you who put on option A. Um So in terms of working this out, so what we need to start by doing is we've got two things we need to figure out. We need to figure out how much modified release morphine he's going to need and modified release. Morphine is always prescribed BD just to remember as a rule. And we also need to work out how much um immediate release or a morph he's going to need. So first we need to work out how much morphine he's currently consuming. So he's having about 5 to 6 doses of 5 mg. So he's having roughly 25 to 30 mg of Oramorph um per day. So, and then what, what I would do here is essentially you're gonna have to pick whether you're giving him 25 daily or 30 daily. But because he's got increasingly severe generalized pain, sounds a little bit uncontrolled at the moment. I would go with the higher number. Um So I would go with the 30 mg. So he's having 30 mg already and to give that to him as a regular prescription to give it BD, you would just divide it in half. So 30 mg total is 15 mg. Modified release. Morphine, sulfate BD. I hope that makes sense. Just pop a message in the chat if you've got any questions. Um But once you've worked out that he's having that, that's his modified release. You then need to work out how much P RN meds you're gonna give him. So remember our rule, it was 1/6 of your total daily dose. Our total daily dose here is 30 mg and 1/6 of 30 mg is 5 mg. Um So we're gonna give him 5 mg of Oramorph um for breakthrough pain and usually that's given four hourly. Um So that's why that's the correct answer. Um With an option B the only wrong thing about it really is that 10 mg. Um you wouldn't, you know, you wouldn't give any more than a six of their total daily dose. Um What does BD stand for? Sorry, BD stands for twice daily. I don't know what the Latin abbreviation of it is, but um OD is once daily. BD is twice daily. Um T DS is three times daily and Q DS is four times daily. Sorry, lots of abbreviations in medicine. Um Yep, that's that. Um So that, so that's why I answer option B is wrong. Um The fentaNYL. So at a um 12.5 mcg patch of fentaNYL is equivalent to 45 mgs of oral morphine. Now, you don't need to remember that. But the point I'm trying to make is that um that's too much morphine. We only want him to have 30 per day. He's having that would be 45 MGS per day. Um And in our 82 year old patient again, that could cause a lot of toxicities and, and you could run into trouble basically. Um And then with the last option, which was traMADol. Um So 100 mgs of traMADol is roughly equal to 15 mgs of morphine. And if you're giving that qds, you'd basically be giving him 60 mgs of morphine, which is double um what we want to give him. And I guess just a side note to that is that traMADol um is a weak opioid. He's already on stronger opioids. We don't want to, I mean, the dose is too high anyway, but we wouldn't want to go from a strong opioid to a weak opioid when he's having increasing um pain uncontrolled on strong opioids in the first place. Ok. I hope that makes sense. Um But yeah, just pop a message. If not, I was I was wrong. This might be the last SBA I think. Um but um so 56 year old man, um he's got a background of pancreatic malignancy. He's approaching the end of life. Um G CS is seven so very low. Um When you see him on the ward round, his family expressed concerns of significant respiratory secretions which are seemingly very difficult to clear and you can also hear them at the bedsides, you can hear this sort of gurgling um in his throat. Family are obviously very distressed by this. What medication may be prescribed to relieve his symptoms and you've got a few different answer options there and I'm just making a poll. No. Great. Um Sorry for rushing you guys. I'm just very um mindful of the time and I'm sure a lot of you are hungry and want your dinner. Um But um so basically the key thing here is recognizing what the issue is. It's kind of in the, in the question stem, but the main issue here is respiratory secretions, which is obviously one of our four big things at the end of life um alongside agitation, pain, um and nausea and vomiting. So we're worried about his respiratory secretions. Um The family are worried about it. Um And we need to give something for it. Um And I guess the key thing here is obviously the question is asking you what medication may need to be given. Um And yes, we do tend to usually give something in this scenario or prescribe it as a PRN. Anyway. Um It's important to just um highlight that um I was always taught at med school that actually families get um very worried about this because they can hear all these noises at the bedside. And um the first time I heard it on the wards, I thought it was very distressing as well. But to patients actually, most of the time they're asymptomatic and it doesn't really bother them. Um And it's just a bit difficult at the end of life because their swallow is obviously weaker. So they're not clearing these respiratory secretions as well as a sort of normal person would. Um, so whether or not we treat it with medications is really a down to, you know, the doctor's decision, but if it's bothering the family, then always worth um, giving something because it's not gonna cause any harm. Um So most of you have gone through either A or D either GNI bromide or Hyos Butyl bromide, um which uh both of them are the correct drugs, but the key thing here is the dosing. Um So the correct answer here is actually um Glycopro bromide. Um And I've been a bit mean here. Um I feel like I didn't really learn the doses until sort of week before my osk. Um But you may be asked to prescribe all these anticipatory medications for patients in your osk. So worth just knowing um one drug and one dose for each of those four end of life symptoms. So just learn that for respiratory secretions, Glycron and bromide. Um 200 mcg, four hourly subcutaneous um is the, is the dose to give. Uh and, and the drug to give as well. Hyoscine is right, but it's the wrong dose here. Um So the 10 mg tds is usually the dose we give for um bowel colic. So, Buscopan, um and also I've said this patient's GCS is seven. So he's realistically not going to be taking anything um orally and the 10 M GTD S is an oral dose. Um And in this scenario, um you know, we would give him something subcut, not oral. Um And if you were to give Hyoscine, which is a correct drug, it would be 20 mgs four hourly. Um See you uh good. So a quick note on um, syringe drivers, we've only got two or three sides left. Um So syringe drivers are again something you might be asked to prescribe um in your oy and if you do an oncology job, um or Gerry's job job, then it will become a very common part of your sort of day to day basis. Um So, Syringe drivers are prescribed if patients are unable to take oral meds. Um and the way we sort of explain to patients why they need one is that a syringe driver will deliver a steady stream of medication through a small plastic tube under the skin. So, rather than needing to constantly give them, you know, a four hourly tablet or four hourly intramuscular injection, a syringe driver just over a 24 hour period, slowly infuses the medication to give a constant background rate of whatever, whether it's analgesia or um you know, something to, to, to, to get rid of their respiratory secretions or agitation, et cetera. And I used to remember it as the four A so um stuff to reduce their anxiety, um analgesia anti and anti emetics as well. So, um things we can put into a syringe driver. Um, again, I won't go through this for too long. But, um, y you know, you, you sort of know the sort of drugs that we can give, um, things to remember is that syringe drivers go under the infusions, part of the drug chart. Um, and then I know this might be hard to imagine without a drug chart in front of you. But in the infusion section, in the left hand side, you've usually got, uh you usually have to write the name of the fluid. And in that section, you just write um made up to 24 mils um with either water for injection or sodium chloride, um run via subcase infused four hours at a rate of one mil per hour. Um And then when and then on the right hand side, you'll have the column where you can add all your various different drugs to that um water or sodium chloride. Um And then you'd, you know, you'd put whatever, like morphine hyos cyclizine, whatever and per syringe driver. Um you can have a maximum of four drugs, but you have to check because some drugs interact with each other. Um And the BNF is great for this. There's a whole section on prescribing in palliative care which I'd really recommend reading. Um I think it's super helpful and um you don't need to read all of it, but definitely skimming sort of important parts. Um I got a question. Why are syringe drivers not used as much, um, elsewhere? That's a good question. Um, to be honest, I think it's just a, um, I think it's a few different things. I think it's a resource, um, problem. So, Syringe drivers are probably quite expensive. They're difficult to set up. Um, and not everyone needs sort of something to be constantly run over 24 hours, like in most patients who are admitted to hospital, like, you know, on the gastro ward or whatever can just have normal meds orally or IV, given by the nurses every whatever, four hours, six hourly and syringe drivers are just for people at the end of life who really can't tolerate any, um, oral meds. And it would be mean, um, especially if someone's, you know, on an end of life pathway for months, it would be mean to constantly be giving them I MS or constantly have a cannula in, um, which you have to, you have to change a cannula every 3 to 4 days. So it's fine if the patients just come into hospital for, you know, a four day admission. Having some, I don't know, like antibiotics for sepsis, it's fine for them to have a cannula. But if you've got an end of life patient, you don't want to be, you know, reciting a cannula, putting needles into them, causing them a lot of pain where so with syringe drivers, you can just put it in, once run things every 24 hours. Um, and you can ensure that they're comfortable, um, with this sort of constant background rate and it, I think it's even more important when, if patients are very unconscious and unable to express their sort of pain or agitation or whatever to you. Um, at least by giving something over constantly as a background, over 24 hours, you can make sure that they're, you know, comfortable and not in distress. Um, I hope that answers your question. It's very vague. I know, but it's a really good question. Um Yeah, and then, um, ethics and law. So I'm, oh, sorry. Um I'm not really gonna go over ethics and law topics because I think, um, like you guys can definitely go through them in your own time and maybe we'll try and fit an ethics and law, um, topic talking if you think it's helpful. Um, but, um, essentially I've just listed some key things that I think are important for you guys to read up about. So capacity, advanced statements and advanced decisions to refuse treatment. Um All of your different people who advocate for patients, your L PS deputies of court, um I MCAS and then for os in particular, um, certifying death and having DNA CPR discussions with patients. Um, so sorry, I don't have time to go through them, but I've listed them here as, as the things that I think are, you know, definitely important to look through um before finals. Um So just a summary of everything. So, um we've talked about the uh main oncological emergencies. Um Obviously, I think they're all super important, but the key ones to know about are your neutropenic sepsis. Um Because just because of, you know, you have to act very quick and you have to give them antibiotics under an, in under an hour. Um And then you, um you know, for those, for those emergencies, you do your A to e assessment. Um And then yeah, just don't forget the key things to sort of treat people with sota in, for sepsis, fluids for hypercalcemia drip and suck for um your bowel obstruction, um, fluids for tumor lysis syndrome, et cetera. Um for the, for your specific cancers, um It can feel really overwhelming. There's so many of them, um especially if you've only got a very short oncology placement like I did. Um But again, remember your key sort of SBA things, your key, key tumor markers know your two week weight pathways, especially for like the key cancers, like lung cancer, breast cancer, et cetera. Um And yeah, don't really, don't, don't worry too much about learning. Don't learn the therapies, don't, you know, try and memorize chemotherapies or anything like that. Um Just know a few of their side effects and toxicities and then with palliative care, I know we didn't go through it for very long. Um A key thing to know is those four common symptoms at the end of life, how we, how we manage them. Um And just remembering that at the end of the day, um the priority for our end of life, palliative patients is making sure they're comfortable um with whatever symptoms they may be having. Um I don't have any references other than just thank you to Sophia, who's my reg who just looked through all my slides for me. Um And I've just got the feedback again, please, please do fill it out. It's super helpful for us. Um I'm organizing the medicine lecture series for all these final year lectures that you're having. So, um we've got a load of talks coming up. But if there's anything additional that you guys feel like you haven't been taught on very much or you're just a little bit rusty on, then again, just put it in the feedback and we'll do our best to organize any extra talks. Um The next talk is a surgical one actually about upper gi um on the 26th of October. And then we've just got our email on there as well if you've got any questions. Um Doctor Ahmed's just put in the chat, please do mention the quick review resources for medical ethics. I'm so sorry. I have no idea what you're talking about. Um I don't know if you want to just unmute or just pop in the chat. Um What you're talking about sorry. Um But in the meantime, thank you so much guys for attending. I'm sorry, you ran over. Um There was a lot to get through. Um But I hope that helped. Um And I would love for all the feedback if possible. Uh And if anyone's got any idea of what that quick review resources for medical ethics is, then feel free to share and I'll leave the QR code up there. I've sent the QR code in the chat as well. So the OK. Um So someone's asked, um can patients be put on both allopurinol and rasburicase for TLS prevention? Um Given that they have different mechanisms? Great question. Um No patients aren't put on um or at least where I'm working on hemonc um patients aren't put on both allopurinol and rasburicase. It will usually be either or and our gold standard is usually allopurinol. Um Rasburicase is only used really if um patients have an allergy to allopurinol, which is surprisingly quite common. Um But the reason why we don't use both together is because they basically counteract each other, I think. Um And so yeah, there would be no point of giving them together. We, we only use one and allopurinol is common and yeah, feel free to ask any other questions if you've got any. Um Even just generally if you've got anything. Yes. Thank you guys. Um OK, cool. Um Thank you so much for attending guys. Um Like I said, if you're still here. Please do fill out the feedback form. It's really helpful for us um and see you at the next talk hopefully. Bye.