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All right. I think I'm alive now. Hi, everyone. Uh Thank you all for joining us today. Uh We will just be waiting for another five minutes to let everyone join in and we'll start the session soon after that. Mhm. Ok. Thank you. I think it's good for us to start. Um So we have the breast session today. Thank you all for joining us today. We'll be conducting the breast session today. We have he and Megan from Newcastle helping out with this session today. If you have any questions, feel free to put them in the chart and we will get to them as soon as possible. We could also ask the two of questions at the end of the session if you'd like. Um am I right to start? Yeah, you're good to start. Perfect. Ok. So, so we're talking about breast surgery today. So we'll be covering some benign breast conditions. Um some malignant ones talking a bit about how to conduct um a breast examination and a triple assessment as well. And then going on to some surgical and nonsurgical treatment for these conditions. Ok. So um I'll just talk a bit about the breast anatomy. Um because I think it's easy to understand the breast um conditions if you understand a bit about the anatomy. Um So far, it's divided into two parts. Um the circular body, which is the largest part and also the axillary tail which runs towards the axilla. So it's really important that in the breast exam, um you check all the way to the axilla as some malignancies and some lumps can present here as well. Um The majority of the breast is made of adipose tissue. Um And milk is produced in the lobules. As you can see in the diagram, I'm not sure if you can see my mouth, but um in the bottom right corner, um and these lead into the ducts which open out into the nipple. Um uh the nipple is also surrounded by sebaceous glands which secrete secrete an oily substance, um which helps the baby latch um during feeding as well. Um Each lobule lobule also consists of many alveoli which drain into a single lap for ad. So let's easy to see if you have a look at the diaphragm. Um It basically just lots of things drain and open out um into the nipple. Um In females, the breast also contains the mammary glands um which is one of the structures involved in lactation. So, the first condition uh we're gonna talk about is this one. So, um if you want to have a little think about what this can be um you can put it in the chat if you want as well and it only affects a male. Does this condition? Um I've just realized I can't actually see the chat. So just have a think about what you think it might be. Ok. So this shows uh gynecomastia um which is basically enlargement of the glandular breast tissue uh in males. And this is mostly caused by an imbalance between different hormones. So, a rise in estrogen, the female hormone and decrease in androgens, which is testosterone. Um also an increase in prolactin um can cause gynecomastia. Uh um and dopamine has an inhibitory effect on prolactin and I'll go on to talk quite a bit about the causes later. Um But uh antipsychotic medication can be a cause of gynecomastia and this is because it blocks the dopamine production um which leads to the prolactin rising which causes the enlargement. Um ok. So, these are just some causes um of the different hormone imbalances. So, raised estrogen. Um there's different causes listed there. So, test testicular cancer is one. So la cell tumors um and in men, uh LH hormone is produced from the anterior pituitary which causes the Lasix cells to of the testes to produce testosterone. Um So, yeah, we've also got other uh tumors there and other conditions there. And um so it can be things like hypothalamus or pituitary conditions in your primary conditions or which can cause then testosterone deficiency most of some genetic conditions there like F syndrome. Um and as I said, different drugs and medications can also um cause the enlargement of the breast. So, uh I mentioned antipsychotics, there's also digoxin opiates, um marijuana, alcohol and steroids as well. Um So some examination and investigation findings that you're fine with this condition is some firm tissue behind the areola, which is the growth of this tissue. Um And this can help distinguish the condition from pseudogynecomastia as you wouldn't find that firm tissue in pseudogynecomastia. Um if malignancy is suspected, then a triple assessment is required. Um And also an key investigation is to check the LH levels and testosterone levels. Um This will help to determine whether it's an estrogen problem or antigen or what hormone imbalance is causing the condition. So the management um is obviously to reverse the underlying course. So it depends on what the investigations find out. So you can use things like tamoxifen, which is uh reduces the effect of estrogen on breast. If there's raised estrogen levels, also, surgeries can be used, but that's more the later stages. Um when or if medical treatment has failed. Ok. So I'm gonna go and talk about some inflammatory breast diseases. So I've got some pictures here and I've just realized one of the pictures on the top list have got the I left the arrow on it. So you'll know what that one is. But uh does anybody you can have a think about if you know what the other conditions are. So I'll just leave that on for a few seconds. If you want, just put it in the chart, I'll be able to read it out to the computer. Oh, perfect. Thank you. Um, ok, so I'll go through a few of them now. Um, so top, the top, middle one is mastitis, which is quite a common one. the top, right, we've got duct SIA and then fat necrosis the bottom, right. Um It just shows on the ultrasound what it would look like. Um And then we've also got a breakfast as well. So I'll just talk about those in a bit more detail. So the first one is mastitis, um which is, you can tell with the itis ending it's inflammation of the breast tissue and it's commonly uh it's a common complication of breastfeeding. Um And the inflammation is caused by an obstruction in the duct, um which leads to the accumulation of milk, which can make it quite painful. Um And if the infection is caused by bacteria, um it's mostly caused by staph aureus and it enters the nipple and travels up through the through the uh breast of the. So, presentation is usually unilateral pain in the breast, although it can sometimes be bilateral, but it's mostly unilateral, you also see erythema. So a redness over the infected area in a wall like with most infections. Um Sometimes you also see significant discharge or a fever as well. Ok. So the management, so first line is to continue breastfeeding um and expressing milk and breast massaging um which will help alleviate the accumulation of milk, which will help alleviate the symptoms. You can also use more conservative management like heat packs, warm showers and some simple pain medication. Um And if the conservative management isn't effective, then flucloxacillin can be used and Erythromycin, if there's a penicillin allergy. Um now, due to the uh obstruction in the doctor, it can lead to a breast abscess, um which may lead some surgical incision and drainage if this does progress to an abscess. So we're gonna go on to talk about the breast status now, um which is caused by a bacterial infection uh and is filled with the pus, which contains white blood cells and white products. So it can be a lactational abscess associated with breastfeeding. So, that's what mastitis can lead to or nonlactational. So, common causes is staph aureus, which is the most cause the common cause. Uh streptococcal enterococcal species and also some anaerobic bacteria too, but staph aureus is the most common cause. Um and then this can present with a swollen flex, uh fluctuant tender lump within the breast. Uh So it's able to move fluid around. Um So infection without an abscess, you wouldn't be able to move fluid around within the lump. That's how you can tell if there was an abscess present. And you also might get some systemic features of an infection like a fever or muscle aches. Um This is treated, uh you might need a referral to the surgical team for the incision and drainage antibiotics as well. Um and aureus, the streptococcal and enter uh coccal uh bacteria are gram positive which means that penicillins are quite effective against them. So, flu fluoxil is the most commonly used one. However, if it's an anaerobic bacteria which is causing the abscess, um then penicillins don't cover these. So, carboxy or metroNIDAZOLE is a com a common antibiotic used to cover these anaerobic um bacterias. Um and again, continue breastfeeding or express the breast milk if it's too painful. So the next one we're gonna talk about are cysts. So they're benign fluid filled lumps. And the most uh they are the most common cause of breast lump and it's an epithelial line, fluid filled cavity. Um and it forms when they become the lobules become distended due to a blockage. So they are commonly uh occur in peri perimenopausal perimenopausal period. Um and they do require a further investigation to exclude cancer triple assessment. Um And if patients do present with symptoms, that operation can help resolve these, um It's an examination, it's a smooth well circumcised mobile lump, which can fluctuate in size of the menstrual cycle. And this is, these are usually telltale symptoms that the breast lump is benign. Um if it's smooth and mobile and it's got clear defined borders. That's usually how you can tell it's unlikely to be a malignancy. Um, or on a mammogram, you'll see a halo shape. Um And it's definitively diagnosed using an ultrasound. So I've just popped a picture on the right as well. Um, and breasts are uh linked slightly to an increased chance of breast cancer. Um So mammary duct ectasia. So it's a benign condition involving a dilation of the large ducts. Um and inflammation of the ducts can lead to discharge from the nipple. So, again, this occurs in perimenopausal women. Um and smoking is a significant risk factor for this condition. So, the main uh presentation is discharge which can be white gray or green, uh pain, nipple retraction and a lump. Um So this does mimic breast cancer as that nipple retraction, inversion is um some symptoms that you might experience with malignancy. However, pain you don't likely to experience. So, diagnose clinically uh I uh using imaging or definitively using histology. Um So it's fine needle aspiration or core biopsy. Um You might also use a ductography which is contrast injected and mammograms used to mammograms, used to help visualize the duct scan as well. Um Also examining cells in the nipple discharge um or a ductoscopy which is passing a tiny camera through the duct. So, management usually resolves without treatment and it's not associated with an increased risk of cancer. Um So conservative management is usually recommended. Um such as reassurance and symptomatic symptomatic management. However, if the symptoms are quite uh pronounced and affect like activities of daily living, then you can use surgical excision, um which is involves removing the whole milk duct. Ok. So, fat necrosis. So, um this is benign, uh and it's commonly triggered by trauma. So it's caused by local degeneration, scarring of the fat tissue. So that's what causes the lump. Um It can also be triggered by radiotherapy and surgery as it was um as well as the trauma. So, again, similar to the other benign conditions um fixed. Um however, you will see it can be regular and you can see some skin or inversion. Um which is why you would need an ultrasound or mammogram to exclude breast cancer. Um Again, this is treat to conservative conservatively. Uh with analgesia and surgical incision is only used to treat the symptoms. Ok. So I'll go on to talk about some benign breast tumors. Now, so the first one is fibroadenoma. Uh So this is a common benign tumor and it's caused by the proliferation of the stromal or epithelial breast tissue. Uh This more commonly infects younger woman um because it responds to estrogen and progesterone. So that's why it regress the amount regresses after menopause. So, with lots of the benign breast tumors, you'll see pain, uh smooth round, well defined borders. Um and it's also f mobile. So that's how you can help differentiate them from the malignant tumors, um, they're noncancerous. And again, these are not associated with an increased risk of breast cancer. Um And it will only need possible an incision if they're more than three centimeters in diameter and patient preference. So that can be um the way they look or symptomatic reasons. Next is adenomas which are benign glandular tumors. Again, these are mobile, uh nontender and palpable and they're usually not associated with skin or nipple changes. Um These are more nodular in appearance. So that's like an easy m malignancy. Um So it's important to get that triple assessment done. Um And it said their histopathological analysis will help differentiate these tumors from malignancy. Ok. So next is an intraductal papilloma, uh which is more of a water lesion which grows in the duct and it's proliferation of epithelial cells. Um Although this condition is benign, it's associated with some atypical hyperplasia or breast cancer. Um So, although this condition is benign, it can go on to lead to um malignancy um especially if they are multi doctor. Um and it's commonly, they're commonly found in the south areolar region, most commonly affect one between 35 and 55. Um This is often asymptomatic or clear or blood uh blood stain, nipple discharge, tenderness or palpable lump, but some women may not have any of these symptoms or a selection of them. So, again, diagnosis is they can um mimic breast cancer, triple assessment or ductography, which is the insert in the camera through the duct. Um So, biopsies are used and complete surgical excision. Um And then this tissue is examined to see if there's any evidence of hyperplasia which can uh lead on to malignancy. Ok. So the next condition is a lipoma. Um And uh as the name suggests, the lump of the adipose, the fat tissue in the breast, um they can occur in other places. Uh other than the breast, they are just to be talking about more in the breast. Um These have a low malignant potential as well. So they're not linked to an increased chance of breast cancer for an examination. These are more soft and painless and mobile and they shouldn't be associated with skin changes. Um Management is conservative as they are benign. Um and a and that don't cause a hyperplasia um of the cells. Um So, surgical removal is only really used as they significantly enlarged if it's causing a lot of symptoms for the person or for aesthetic reasons. Um Let you got the phyo tumor which are really rare. Um And they're tumors of the connective tissues of the stroma and the epithelial. Um most common between the ages of 4050 these are large fast growing tumors. Um and these can be benign, borderline malignant and the malignant tumors can metastasize. Um therefore, due to the nature of these tumors, surgical exit excision is required and a wide excision is used um to make sure that as much of it is removed to decrease the chance of it turning malignant or, and maybe metastasizing. Um and these can reoccur um and chemotherapy in malignant or metastatic tumors is also used alongside this uh surgical excision. Ok. So I'm gonna pause over to hurry now, the guy. So can you guys see the screen now? Yeah, we can. Cool. So, yeah, hi and Harry and I'm also a third year medical student in Newcastle. Uh thanks Meg for that lovely talk. So I'm gonna talk today about the breast examination, the triple assessment of the the breast, which meg mentioned a lot of the conditions which needed to actually diagnose them and then also touch on a couple common breast presentations and er conditions. So with the breast examination, there's four steps and it says here introduction inspection, palpation, then completing. So the introduction, it's just your standard stuff, introducing yourself, wash your hands, explain to the patient what it involves. But the difference with a breast exam is cos it's more of a sensitive or intimate examination. You really wanna ensure you've got a chaperone present er kind of for your s like safety and also the patients as well. And then you're gonna ask the patient to remove their clothing, to expose the chest from above the waist. And then it's also good practice to offer a blanket to the patient to cover themselves when they're not being examined. And also you're in a position of 45 degrees. And the next you're gonna start with a uh a general inspection from the end of the bed just looking for any obvious changes. And you wanna ask the patient to put their hands by their side and look for any obvious scars or masses, any skin changes. So, erythema puckering or poda orange, I think is how you pronounce it, which is this thing in the top, right? And these are more suggestive of a malignant er condition and then also look for any nipple changes. So, discharge or inversion and there's there's inversion there, which can be again, suggestive of a tumor underneath which is actually causing that inversion. And then to accentuate any asymmetry, you want to ask the patient to place both hands by and the head like that and then repeat the inspection and then also ask the patient to place the hands on the hips and do the same again and again, that's just to look for any asymmetry. Then with palpation, you wanna ask the patient to place both the hands and the head and you wanna start with the side which isn't being affected first and then leaving any painful areas till the end. And then the technique for this is you're gonna use a flat hand and press the breast against the underlying chest wall, rolling the underlying soft tissues. So you don't wanna be kind of poking it just with your fingers and you need to, as meg said, examine every single area of the breast. So all four quadrants and the auxiliary tail of Spence um and both the axillar as well. And then, whilst you're doing this, it's also good to assess for fixation, which is more suggestive of a malignant tumor. So what you do if you identify a lump, you ask the patient to push their hand out and then you wanna push against that and ask them to resist. And then you can feel if it's fixated to the pectoralis major muscle underneath. And then also it's important to make sure you assess for any signs of potential metastasis. So palpate the spine for tenderness, palpate the abdomen for hepatomegaly and then percuss and auscultate the lungs for any masses and then feel around the lymph nodes as well. And then to complete the examination, obviously, thank them, ask them to redress. And then that that's when you get on with the remaining components of the triple assessment. So the triple assessment is a hospital based clinic that allows for the early detection of breast cancer. And patients can be referred by their GP if there's been any suspicious findings or if they've got any worries or concerns. And there's three components, history and examination, imaging and histology. And then you combine all that information together to make a diagnosis. So to start with a history of eye examination, a breast surgeon or specialist will do a detailed history er and the examination like I touched on before. Um and it's just a usual er medical history but important to gain er what risk factors are present. So such as estrogen exposure or family history, er to get an idea of an increased risk. Then imaging, there's two options or three MRI s also an idea. But mammography and ultrasound are the most commonly used. So, mammography is this thing on the, on the right here and it involves compression views of the breast. So this is an X ray machine. Um and the woman places the breast in between the two plates and then an X ray is taken from two views. So oblique and craniocaudal. And that allows for the detection of any mass lesions or microcalcifications. Then ultrasound is also used but it's used in women who are younger. So less than 35 and also in men cos they've got an increased density of breast tissue. So the imaging findings are better for ultrasound and then histology, which is the last component of the assessment. A biopsy is needed of any suspicious matter or lesion to to confirm the diagnosis. And the most common method is a core biopsy. Er It provides full histology as opposed to just cytology, which is what you get in a fine needle aspiration. And this means you look at the entire block of tissue as opposed to just a single cell type. And that's important cos it means you can differentiate between invasive and carcinoma in situ, which I'll touch on later. And it also provides information about tumor grading and staging. It's also got higher sensitivity and specialty for detecting breast cancer, um fine needle aspiration. However, um can be quite useful if a woman's got cystic disease, so they'll build up of fluid in there. And the er this can be aspirated using fine needle aspiration to relieve any symptoms and then obviously also check for cytology. So the next learning outcome is just to look at common breast presentations and some of the differentials of these in the management. So, galactorrhea, er this is the production of milky discharge, not associated with pregnancy or lactation. So, breastfeeding is in galactorrhea, it's like it's physiological, er and this ex occurs almost exclusively in females, most commonly adults. However, it can occur in males. Um and it's associated with gynecomastia and also in male infants as well due to um placental transfusion, not really too sure. And it's important for understanding the management of galactorrhea to understand the physiology behind lactation itself. So, lactation is primarily primarily regulated by prolactin, which is secreted by the anterior pituitary gland. And this is regulated by dopamine, which is released by the hypothalamus. And then estrogen and trh also act to stimulate the release of prolactin. So, it's a kind of a balancing act between these hormones. And then this can allow gala to be split up into hyperprolactinemic or nor prolactine, whether the prolactin level is high or, or normal. And the hyperprolactinemic galactorrhea is much more common and the most common causes are idiopathic, which is 40% of cases, pituitary adenoma, which is a benign tumor of the pituitary gland, which is just producing prolactin and then stimulating um er breast milk to be produced drug induced. So, antipsychotics and SSRI s can be linked to this, er, neurological causes, er, varicellas zoster virus and um spinal cord injury can lead to this cos it er, inhibits dopamine production, which means that that's gonna then inhibit the inhibition of prolactin hyperthyroidism and also damage to the pituitary or other causes. And then normoprolactinemic galaxy, which is less common. It's typically idiopathic and the diagnosis is only made once all other causes be been excluded. In terms of the management with normoprolactinemic galactorrhea, you can just reassure them and observe them. It doesn't really have any significant consequences. Um but er, for hypoprolactinemic calica, it involves identifying and treating the underlying cause based on whichever cause it is. And dopamine agonists can be used to treat the symptoms cos they're gonna inhibit prolactin release and then hence um milk production. So, bromocriptine or carboline and then for those with pituitary adenomas, uh prolactinoma transphenoidal surgery can be used, mastalgia. This is breast pain. It's a very common presenting complaint in women. Um And often women apparently are quite worried and they'll present with mastalgia, worried about it being a malignancy. However, the incidence of a malignancy with presenting complaint of mastalgia is quite low. So that's reassuring. Um, and it can also occur like, er, gaur in men with gynecomastia. So, the most common form of mastalgia is cyclical pain. Er, this is pain associated with the menstrual cycle. It usually affects both breasts and starts a few days before, uh, the beginning of menstruation stops at the end and it's caused by er, hormonal changes. And you've also got noncyclical cyclical pain, which is about a third of mastalgia and this can be caused by certain medications. So, SSRI s antipsychotics and also pregnancy and infection. So like meg mentioned er mastitis, then you've also got extra mammary, extra mammary pain, which is pain, not in the actual breast tissue itself, but kind of referred to chest wall pain or, or shoulder pain. And the management is the principles are under the underlying course, should be investigated and managed appropriately. But with cyclical er mastalgia, in most cases, the pain is idiopathic and it's usually supportive management. So, wearing a supportive bra, er nsaids like Ibuprofen, paracetamol, avoiding caffeine apparently can help and applying heat to the area. Then if these first line options are unsuccessful, specialist referral may be needed. So, er specialists can initiate treatments like danazol and, and tamoxifen. And the last presentation is breast lumps. So there's many causes, many are benign like meg mentioned. Er, and obviously the most significant differential is gonna be breast cancer. So any breast lump needs a thorough assessment by the triple assessment to exclude the breast cancer. And there's ways of telling a difference between uh a malignant lump and a benign lump via er, palpation. So, the features of a malignant lump er would be hard, consistency, usually painless, like I mentioned before, the edges are regular and there's fixation to the skin or chest wall. So when you push against it, it might be stuck against the pectoralis muscle. It can also cause dimpling of the skin and, and skin changes, er P poda orange and there may be unilateral blood, nipple discharge, whereas benign, it can be the opposite. So it's smooth, rubbery, soft and painful, which is kind of counterintuitive well defined. It's mobile and skin changes and dimpling are, are unlikely. So I'm just gonna touch on a few breast conditions now. So, breast cancer, it's divided into two classifications, classifications based on if they've spread beyond the local tissue. So you've got invasive or noninvasive breast cancer, which is also called called carcinoma in situ. And then there's quite a lot of subdifferentiation. So I've tried to kind of make it as concise as I could. So we're gonna start off with noninvasive carcino and stitching. So, breast carcinoma in situ neoplasms, like the name suggests that have not spread into the surrounding breast tissue and they represent a precursor to invasive breast cancer. They're typically asymptomatic. So you're often gonna identify them solely on imaging from routine breast screening. And there's two main types, ductal and lobular. So we're gonna start talking about l ductal here. So this arises from the epithelial cells lining in the ducts. As the name suggests, it's the most common type of noninvasive breast malignancy. And yeah, like I said before, it's usually asymptomatic. So there is combined in the uh in the ducts and it's often detected during mammogram screening, et screening. And 90% of these have suspicious microcalcifications when I viewed a mammography and the management which I'm gonna go into more detail after is from surgical excision. So, breast conserving surgery or mastectomy. Now, lobular carcinoma in situ, this is much rarer than ductal and it rises from the epithelial cells inside the lobules. Uh So just before the ducks and again, it's usually asymptomatic and it's more often bilateral as opposed to just being found in one breast. So, unlike ductal carcinoma in situ, it's not associated with microcalcifications and it's usually diagnosed as an incidental finding and the management is dependent on the extent of the disease. It's usually treated with monitoring if it's low grade. Um However, bilateral prophylactic mas mastectomy can be indicated if they possess both the BRCA one or B BRCA two genes. So, talking about invasive breast cancer. Now, these are tumor cells which have invaded the ba basement membrane and these can be classified into invasive ductal carcinoma, invasive lobular carcinoma and other subtypes and like we talked about before they can present you symptomatically asymptomatically. And there might also be clinical features such as breast lump asymmetry or swelling, er skin changes like po Duran er or nipple traction. So, invasive ductal carcinoma, this is the most common type of invasive cancer, breast cancer. It originates in the epithelial cells from the breast ducts and this is more common in older women. And the gold standard is triple assessment of the breasts, microscopically, it's composed of nests and cores of tumor cells with associated gland formation. And this can be seen on mammograms, invasive lobular carcinoma. On the other hand, um can't be s is not always visible on mammograms because it's microscopically, it's characterized by diffuse pattern of spread which makes it harder to see and it's a lot er rarer than invasive ductal carcinoma. And like the name suggests it originates in the epithelial cells from the lobules. So, the non surgical treatment of breast cancers. So, there's three kind of domains, endocrine chemotherapy and radiotherapy endocrine treatment. The aim is to reduce estrogen activity to reduce tumor growth, but this is only if estrogen is an estrogen receptor associated tumor, which some aren't and for premenopausal women, er tamoxifen is indicated. However, for postmenopausal women aromatase inhibitors such as anos anastrazole recommended and chemotherapy. These are, this is used in one of three scenarios. So, neoadjuvant adjuvant or treatment of metastatic or recurrent breast cancer. So, neoadjuvant therapy is where the goal is to shrink the tumor before surgery. And this will allow breast conserving surgery to take place, which I'll explain after. And then adjuvant therapy is given after to reduce recurrence. And then radiotherapy is recommended to patients you've had breast conserving surgery to reduce the risk of recurrence. So my voice is going a bit now and the surgical treatment. So like I mentioned, breast conserving surgery, this is only suitable, suitable for patients with localized disease. And the principles are a wide local incision um with wide margins to prevent the cancer coming back. And it's about balancing kind of oncological. Er it's not gonna recur but with also aesthetic um of the breast as well. And this can be considered when the size of the breast cancer is small relative to the breast size. Um However, if the breast is quite small and the tumor is small, it might not be um possible the breast, the ratio is what's important the mastectomy. Uh this involves removing the entire breast and this is used where there is a high risk of recurrence and there's multiple tumors or the size of the tumor is quite large compared to the breast. And then there's a potential for immediate or delayed breast reconstruction. The plastic surgeons might get involved then axiliary surgery and this can be split up into sentinel lymph node, biopsy and axillary node clearance. And this is used when the cancer has metastasized the lymph nodes. So with sentinel lymph node biopsy, the first place, the uh lymph drains is the sentinel lymph node. And this can be identified with um gamma emitting isotopes um prior to surgery and then this lymph node is then removed. However, it is often the case that all the lymph nodes need to be removed. Um So this is auxiliary node clearance. Er So thank you very much. Um That's the end of the presentation. If you have any questions, just put them in the chat. Just thank you, Harry and Megan for that job. I think you both did an amazing job today. Uh We'd also like to thank our sponsors and for helping us make this possible. And we also like to thank you all for joining us today. I really hope that you all enjoyed the session. I will be sending the feedback form in the chart for you guys. So once you guys fill in this feedback form, we will, you will receive all your certificates and you will get discount codes for both the Mr CS and teach me surgery as well. Uh We will be putting out the recording and the slide decks for the session as well. Shortly after this gets over. And uh next week we have neurosurgery sessions on the 24th and the 25th, which is the Wednesday and Thursday. So if that's something you guys are interested in, please feel free to join us. And yeah, that's about it. If you have any questions, feel free to put them in the chart as well.