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All right. So, hello everybody. Um, we're back here again for our rheumatology session. It is quite a pack evening because our session tonight will be followed by, um, Nikita session on orthopedics. So we'll try to keep it as short and nice as possible. It might take a bit longer than, um, the hour with two of the specialties combined, both through mythology and orthopedics. But hopefully it is gonna be a, a night that's back with knowledge and back with very, very useful sort of resources, tips and tricks for finals. Now, I think we would, um, we could give people another sort of minute or so in order for them to join and then we can get started again just because it is quite a, um, quite a pack evening with, um, loads to cover. And, um, we don't want you, we don't wanna keep you here for too long. So we'll be starting in like roughly a minute and a half, I would say. So, maybe four minutes past seven would be a good compromise time for us to, to get started. Ok. Ok. So I think it's about time to get started. So, hello, everybody. Again, my name is Kathleen K, one of the final year medical students and also one of the peers are leads for the Belfast trust. And you're gonna hear a bit more from us in the days to come about, sort of the Belfast trust a and everything. So, um, keep an eye out on your emails. Now, with regards to tonight's topic, we'll be so of starting off, as I was saying earlier on to cover um rheumatology, bits and pieces about the rheumatic conditions, autoimmune conditions, bits and pieces about how to investigate them and sort of the most likely things um to be coming into an OSC and then Nikita is gonna be following up with sort of more muscles and bones um in orthopedics again, any questions, any issues, sort of unmute message, do whatever you feel like doing at any time, there's gonna be feedback forms coming. And if you're feeling in the feedback form towards the end of the um of the evening, you're gonna be getting the um the slides as um as well. So in terms of rheumatology, we'll be having a look over a good couple of me, uh rheumatological conditions um starting with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis lupus because we cannot do rheumatology sessions without having a quick chat about lupus and how to investigate and how to identify in M CQ questions and also in real life. But um we all know that the purpose of these lectures is preparing you for exams. Sjogren's syndrome, which again is one that sometimes pops up on past med and in um exams. So we like to be sort of aware of that. And also we'll be briefly touching on fibromyalgia, which is um, a very, very important condition that you're gonna see a lot of whenever you're gonna be doing your GP placements and in community now, very briefly touching on to the history um, of an inflammatory arthritis versus a noninflammatory wear and tear arthritis. And these are the couple of points that except for taking the pain history for any patient who presents with joint pain. You would have to include if you were to think, hmm, this might be an inflammatory cause. So morning stiffness will last more than 30 minutes in inflammatory arthritis. People will usually come in and say, oh, it takes me about 2 to 3 hours to get myself started. And once I get myself started, things are improving throughout the day compared to the wear and tear arthritis, the osteoarthritis, which is gonna be as the name implies, associated with the wearing and tearing of the joints. So, pain will be worse at the end of the day. Um, um due to sort of um the physical burden that it was placed on the joints, inflammatory arthritis will come with systemic symptoms. So they are gonna feel tired, they're gonna lose weight, they might have a temperature, they might have sort of other systemic manifestations that we're gonna see in a bit. Then um it may have an acute or subacute presentation. It usually grows on people rather than presenting acutely and the pain will be improving, improving with movement. So be very, very aware of these sort of pointers in a gestations, especially if the patient is sort of a youngish or middle aged female or male who's presenting with sort of more hard to pinpoint veins and hard to pinpoint symptoms. So, starting off with rheumatoid arthritis, it is a chronic symmetrical polyarthropathy with systemic involvement. What that means is it's gonna be presenting symmetrically. So, if there's only one hot red swollen joint, well, it's most likely to be something else other than rheumatoid arthritis. And it's a polyarthropathy. So it usually involves multiple joints, not only one, it's usually present in those joints highlighted there on um the diagram and it notoriously spares the D IP the distal in the in the distal interphalangeal joint, which is usually associated more with psoriatic arthritis or osteoarthritis. So, patients usually have sort of this proximal arthritis rather than the distal one. It's more sort of prevalent in females as with the majority of um rheumatological and autoimmune conditions. And the peak incidence is sort of in the young to middle age people. It is associated with HLA Dr four. That's just one point to remember in case there are some more cheeky mcq S that want you to know a bit more about the pathophysiology and the clinical features to keep an eye on for exam questions. And for OS, these are pain and stiffness for more than 30 minutes, particularly in the morning. And the majority of patients that I've met with rheumatoid arthritis really present with these sort of very, very bad pains and very bad stiffness in the morning that eases off. Um, throughout the day, it usually affects the peripheral joints and the D IP joints, as I was saying, are gonna be spared and it's usually progressive over weeks or months. It doesn't come on all of a sudden. And these are the other extra articular manifestations that you'd need to be aware of. I'll let you all to sort of dwell on into the diagram a bit more in your own time. However, it's really important to be aware of the lung manifestations. The pulmonary fibrosis usually associated with rheumatoid arthritis, which is also made worse by the methotrexate treatment. As we'll discuss in a second. There may be gastrointestinal symptoms. There may be neurological symptoms as well as well as um the disease affecting the kidneys. And as with any sort of autoinflammatory autoimmune condition, malignancy, particularly blood malignancies are much more common in these patients because their body is living in a constant state of inflammation and their immune system will be overactive compared to a normal person. Now, on examination again, the lovely hand examination that you may or may not get in your osc will involve um sort of the classical description of the rheumatoid arthritis hand, which luckily now with the development of biologics, it is not seen in patients anymore. So patients will present with absolutely normal looking hands and that's what we're aiming for um with treatment for all patients. This is a latest stage picture, picture, whatever they get the B Bonnie deformity of the thumb. So their thumb is gonna be in my head, at least curved backwards. Um And they won't be able to do their buttons. Um There's gonna be the ulnar deviation of the metacarpal pharyngeal joint. So you can clearly see how their um fingers are moving towards sort of their pinky finger while the ulna will lie. And there's that swan neck deformity of um the fingers, then we've got rheumatoid nodules which are very important to palpate for in um A and you can just feel for them over sort of the joints and over the elbows, they are very, very tender, they are quite hard, um, they're not sort of soft in texture and they are really, really tender for the patients. And lastly, in terms of investigations as with any autoinflammatory condition, the ESR and the CRP will be raised and the antibodies are really important. And that's a very big red flag for the MCU S. We've got rheumatoid factor, which is very specific and we also have the anti CCP, which is even better Nowadays, the first line investigation will be anti CP. It's both sensitive and very, very specific to the disease. We sometimes may want to check on A N A just to have it and to see, to monitor its increase or decrease with disease activity. And then we've got um sort of um the classical x-ray findings that I've got highlighted over there for you. You're gonna see this per articular osteopenia, the soft tissues will be swollen. So the hands will look puffy on x-ray and there will be a loss of joint space and some marginal erosions. However, that osteopenia and the erosions which seem like an aggressive condition will not be present in osteoarthritis. So you can clearly tell the difference in x-ray just based on these two particular findings and usually rheumatologists, it love doing ultrasounds just to see what uh what lies inside the joint, what um degree of inflammation there is. And they might put a Doppler um a Doppler sort of feature on the ultrasound to see how well vascularized the area is because if there is inflammation, there's gonna be a lot of vascularization as well. Now, in terms of the management, one important point to realize and again, not sure how often it comes up in MC Qs, but I know for sure it could be a very, very good OSK station or a very, very good sort of osk pointer would be the disease activity score, which is um do 28 which measures the number of swollen tender joints and also, uh, checks the patient's E sr in terms of the symptomatic relief. We do like to use nonsteroidal paracetamol doesn't touch their pain. So we do like to rush into nonsteroidals with PPI protection. Of course. And afterwards we jump very, very quickly to dmards, which are the disease, modifying anti rheumatic drugs. Usually they start with methotrexate, um, which has loads of side effects. Uh The main ones to remember are the deranged left. These, they need liver function tests every two months. They will also um need the chest X ray at the start to check for any kind of tuberculosis or signs of TB but also to assess for any sort of pulmonary fibrosis. And to have a clear picture to compare with, it may cause neutropenia, it suppresses the immune system and it's absolutely teratogenic. You know, the story with um ladies and gentlemen as well. Although the new guidelines say men are not um sort of affected anymore, but ladies need to be off the methotrexate at least three months before they are starting to conceive just because methotrexate is a folic acid inhibitor. And hence, the baby may be born with severe neural tube defects. Then in terms of sulfaSALAzine, which is another even milder beard. It causes infertility particularly in men. However, it's not gonna be teratogenic and it may cause um hemolysis in people with uh with um G six PD, leflunomide, hydroxychloroquine. Again, great drugs a bit milder than methotrexate and can also be used in pregnancy. Then as a short term um treatment, they may use corticosteroids. But we don't like patients being on corticosteroids for too long. And lastly, we've got the option of biologics as well, which come in at that sort of later stage. Important points to remember for us kids would be counseling on methotrexate is quite a high topic. So make sure to sort of have a look at that and know your red flags for methotrexate. They need to be on good contraception. They need to be aware that it's teratogenic and they should not get pregnant on that or try to start a family on that. And they should also be aware that any sore throat, any cough or cold they should present to the doctor because their white cell are uh count is gonna be low. Now, very quickly moving on, on to psoriatic arthritis, which is the one associated with psoriasis. It's an asymmetrical oligoarthritis. So unlike um rheumatoid, which was polyarthritis and it was symmetrical. This one is exactly the opposite. It may, it may cause one swollen, tender, ugly, nasty joint, it usually affects, as we were saying earlier, the distal um pharyngeal joints. So the furthermost joints and if you've been um reading through zero to finals, they do like to mention arthritis mils, which is that very, very bad version of psoriatic arthritis, wherever the bone basically gets eaten up. It's a very, very rare complication, but it is one of the fun ones to remember. Now, in terms of on examination, it's always important to look for the psoriatic features. So the psoriatic plaques, the nail pitting, the sub angle, um hyperkeratosis and deep onycholysis. All of those are gonna be pointing you towards. Oh, patient has psoriasis. Oh, they've also got a swollen joint. It might be psoriatic arthritis. Then it also presents with anusitis, which is a very, very nasty condition, which is quite sort of um, paop pneumonic for psoriatic arthritis. And that's gonna be associated with achilles, tendonitis and plantar fasciitis. Very, very sore conditions that are gonna be leading to. They, they are represented by um, a um inflammation of the tendons and they've also get, they're also getting dactylitis whenever their finger becomes a sausage finger, it's an inflammation of the whole finger and it is horrifically tender and very, very, um unpleasant for the patient. In terms of investigations. Again, the x-rays are gonna be the the best ones to look at for any kind of deformity. Usually they get this pathic penicillin, cuff deformity, um, which I've highlighted over there. But again, we usually don't see that anymore because patients are well treated with almost the same drugs as in um, the rheumatoid arthritis. Then in terms of the management, we use nonsteroidal, we use sulfaSALAzine, methotrexate and cycloSPORINE as well as anti TNF biologics. Now quickly running through reactive arthritis, which is as the name is a reactive type of arthritis. And it doesn't happen right away after an infection. Don't let your cells be fooled by. They've had a gastroenteritis two days ago and now they've had a hot swollen joint that's probably gonna be a septic arthritis if anything or some sort of gout, reactive arthritis usually presents sort of two weeks after infection and it is the one that usually presents in MC QS. That is somebody who's got sort of um a dodgy sexual history or they've had a nasty tummy bug a couple of weeks ago who is now presenting with um a swollen joint. It is again associated with streptococcal infections. S TI S and um gastrointestinal infections. The most common S ti causing this is chlamydia. Um You also can get it from salmonella shigella compacter and it is gonna be presenting with asymmetric arthritis usually affects one or very few joints. Dactylitis. It will have sort of conjunctivi conjunctivitis or uveitis. Um There may be a rash and they are gonna have tis and I'm sure you're aware of that. Pneumonic can't be, can't see, can't climb a tree, which is associated with Reiter's syndrome, reactive arthritis. So they will get their eye complications. There are urethritis as well as um sort of um problems with their joints. So they cannot climb a tree and the management for this will majority of times be symptomatic and it's really, really important to try to ascertain the cause. So do S ti swabs and do a antistreptolysin o titer for streptococcus and very similar to reactive but not similar at the same time, is gonna be enteropathic arthritis, which is usually present in patients with um IVD. It is once again an asymmetric mono oligoarthritis. So very few joints involved and it's predominantly present in the large joints of the lower limbs. It often occurs around the same time. The bowel has um a flare and the important aspects to look out for over here are gonna be things like pyoderma gangrenosum, which is a common sign that um is present on um patients with IBD, there's oral ulceration, there's uveitis again and erythema nodosum, those are things that you would need to sort of associate in your head with the idea of IBD because they're quite commonly mentioned in um questions. Then we've got ankylosing spondylitis, which is as the name implies, a spondylosis. So it will be affecting the axial skeleton, the back particularly. And this is one of those ones that's more common in men than it is in women in terms of the blood. It's very, very important to check their E SR and C RP. And they're also gonna have a raised HLA B 27. So HLA B 27 will be raised in almost 90% of the cases. And I should have said that reactive arthritis and um um enteropathic arthritis are also associated with the HLA B 27 cluster of genes. In terms of their examination, they will have a question mark, posture, their, their neck will be hyperextended and they will have very severe kyphosis of their thoracic spine. They will get this far spinal muscle wasting because they are trying to protect the area. So they are not using it and they will have costovertebral joint involvement with very bad sort of reduction in chest in in Spanish expansion and issues with their anterior chest. The best, the most important thing to remember for ankylosing spondylitis will be doing the ser test. So 10 centimeters above the pubic or the posterior superior like spine, five centimeters below within the midline. And you want um to have sort of an ex um an elongation of um that by at least 20 centimeters. And again, it is one that you might be asked to perform in a nosy. We have notoriously had two back examinations in um two years for so quite important one to, to remember in terms of the x-ray findings. Again, a very common m secure question would be about what you can see on the X in a person with ans spondylitis. And that would be um sort of eroded and sclerotic sacroiliac joints. It usually presents with sacroilitis. So if you're ever asked the best investigation for a diagnosis, a diagnosis of BB will be an X ray of the pelvis, whatever you expect to see sacroilitis. There is vertebral body squaring. There is gonna be these um sort of syndesmophytes which are just sort of overgrowths of, of bone towards the outside. And they may get in sort of later stages of disease, joint fusion and um issues like that in terms of the management, early diagnosis will be crucial. It's really, really important to advise them to exercise, get the physiotherapist involved very, very quickly. There are inflammatory episodes for which we can use nonsteroidals and for um the peripheral arthritis, um it is gonna be sort of again reso resolved with nonsteroidals or local steroid injections in terms of the complications. It is a disease that affects the spine. So there may be neurological compress for compression as well as a higher risk of fracture. Now, um another very, very important condition to be aware of and again, whenever you see a very weird looking unsecure, try to think lupus because it can present as a million things. It is a systemic and inflammatory multisystem disorder that affects women much, much more than men. It's got a higher prevalence in the Afro Carribean community, which again should be a red flag for your uncus and the peak age of onset is in between 2040 years and they get relapsing, remitting episodes. They may have periods when they're absolutely fine and periods whenever they are relapsing in terms of the investigations, they are gonna have an anemia of chronic disease a normocytic anemia that's just gonna be revealing how sort of stressed their body is. They will have low C three and C four levels. The complement is gonna be consumed in this um condition. And again, if you ever asked, cause I remember a couple of MC QS about that, um the level of complement is gonna be associated with the activity of the disease. So it gets consumed during active disease and replenished during um nonactive disease. It's got raise DSR and normal C RP. Again, another really, really important point. And um don't forget that with every appointment for every patient with lupus, you need to check their urine for protein, particularly because Lupus nephritis is a very, very common complication. Unfortunately, and these are the implications of lupus. So there are plenty as you probably know, it is a disease that attacks the antinuclear antibodies. So any cell that has a nucleus in our body can be affected by Lupus. They will have issues with their eyes, they will have problems with their lungs, they will have kidney disease which is really, really important to monitor for again, with every single um appointment for Lupus people, they do urine analysis on them. Um It's usually associated with antiphospholipid syndrome and it's also associated with the butterfly malar rash on the face. It may cause um joint pain. Um and it may also cause osteoporosis in terms of the investigations really common M CQ. Question about the A N A and also the DST DNA, apparently A N A is raised in like majority of like not majority of the population, but a very good amount of healthy population. So it's not necessarily specific. However, it is gonna be um very, very important and it was our first um antibody against Lupus. But then we've discovered the double stranded DNA, the DS DNA, which is much more specific for lupus. And then we've got sort of other couples of antibodies, anti and antila, which are more pre in Sjogren's syndrome, rheumatoid factor, antiphospholipid antibodies as well as sort of raised immunoglobulins. They may all be present in Lupus. However, A N A and DS DNA are the main ones to remember. And this is just um tiny sort of mention that I've made because I was finding it so, so hard to remember the medications that were induced in Lupus. And I know there are a couple of M CQ um on that on uh fed as well. This is sort of the least basically any sort of very, very nasty drug that you've learned about can cause drug induced lupus. Um So um things like phenytoin hydrALAZINE, which is used for heart failure, but it's like fourth line in heart failure isona, it, that's probably the most sort of um high yield for MS. And what they do is they cause these antihistamines antibodies. If you remember the histone proteins were the ones that DNA is coiling around in the nucleus and um the disease will be remitting if the drug is stopped. So there's gonna be no A N A or double stranded DNA, but we're gonna be finding these antihistone antibodies. Now, quickly going over Sjogren's syndrome, uh which I was just mentioning earlier on, it is gonna be um that disease which affects the exocrine glands. There's primary Sjogren's and secondary Sjogren's which is usually associated with rheumatoid arthritis, lupus or systemic sclerosis. And the classical features will be decreased ear production, dry eyes. They are gonna get this keratoconjunctivitis, sicca decreased salivation, dry mouth and dental caries. Apparently it is very, very bad for their dentures and the majority of them have an incredible amount of dental work before they get diagnosed just because of their dry mouth. And for this, don't forget streamer's test, which is whenever they put some filter paper under the lower lid and it should be sort of uh more than five millimeters in five minutes. The autoantibodies which are positive for Sjogren's are gonna be anti raw and antila and the management is just symptomatic relief trying to replenish their fluids with artificial tears, encouraging good fluid intake. And sometimes if it's very, very severe immunosuppressants may be working. And then I was mentioning that we should have a chat about fibromyalgia, which is a um pain condition. People present with normal vital signs and they will have no evidence of any active or chronic sinusitis joint effusions or deformity. They've got normal muscle strength, but they are just in severe severe pain. A lot of risk factors come to play into the development of fibromyalgia. Things like a low household income, lack of education, being female again, um family history of fibromyalgia, as well as trauma. It's believed to be one of the more functional sort of neurofunctional neuropsychiatric conditions. However, it is real pain and I want to emphasize that these patients are in actual proper pain. However, we were not yet able to sort of get to the bottom of what causes their pain. And the clinical presentations will be um of pain that's worse with stress, cold weather and activity. They will have morning stiffness, but it's gonna be sort of a weird stiffness, usually less than an hour. So more than osteoarthritis. But yeah, just um, a weird cut off there and they are gonna have poor, poor sleep and sort of the sleep is gonna be accentuating all of their symptoms and it's just gonna be making all of the matters worse. They usually have associated anxiety or depression. So it's really important to sort of investigate them for that and treat them for those. And it's a very, very vague condition with headache, urinary frequency, vague abdominal symptoms. So again, I don't know how likely it is to be coming up in your osk case, but just, you know, in case you're getting ready for a difficult consultation, sy this could be a very, very good one. Then we've got antiphospholipid syndrome, which is um, something that I'm just gonna tell, I'm just gonna say young female recurrent misc miscarriages. It is a prothrombotic state whenever um sort of they've got antiphospholipid syndrome, uh uh whenever they've got the lupus anticoagulant that just um causes them to have to over coagulate basically. And um it's really, really important to be aware of the fact that we give them low dose aspirin or Warfarin. Again, the guide guidelines differ from one trust to the other. But again, it is a prothrombotic um condition. So, um good anti thromboembolytic um measures are very, very important. And when you're gonna be covering obs and Gyn in fourth year or for the fourth year year, you've probably learned about it in obs and Gyn about sort of what we do in pregnancy because obviously, Warfarin is teratogenic. Then we've got PMR polymyalgia, Aromatica, which is an inflammatory condition. And the main sort of stay about polymyalgia. Aromatica is sort of somebody who's 55 or 60 who's presenting with shoulder pain and um hip pain. It is not gonna be associated with weakness, but it's just gonna be severe, severe pain. It's always, I mean, not always, but it's always in MCQ, it's always important for them to uh to, to screen them for giant cell arthritis because the association in between them is huge and it's different to fibromyalgia because the E SR is gonna be very, very high, there's less joints affected and they've got proper long-lasting stiff stiffness. And as a sort of important differential for PMR would be myeloma so important to exclude sort of weight loss, night sweats and all of those B symptoms then very, very quickly going over the vasculitis. Now, I know I've personally spend loads and loads of time myself, sort of trying to memorize the vasculitis, but I would say the main one to remember would be HSP also try to remember Kawasaki disease and giant cell arthritis, which is very, very important and I'll have a slight um sort of discussing those in a second. Now, in terms of the anca associated vasculitis is you may be aware that Bianca is now called MPO and Cianci is pr three and we have these three which are um Char Strauss syndrome or Eosinophilic Crans with polyangiitis when you hear eosinophils think about asthma. So these are patients with severe uncontrolled asthma that usually happens in adulthood. And it's quite weird for asthma to present in adulthood. So they usually do sort of an autoimmune screen and they find out that they fought high mpo and they diagnose them with a vasculitis. We've got granu granulomatosis with polyangiitis anymore, which is gonna be the one that presents with saddle shaped nose, sinusitis, epistaxis and issues around the nose. It's also triggered by intranasal drug use. So, snorting cocaine may predispose patients to to this So if any patient has a risk factor of cocaine abuse, it might be that nurse that they thought and then we've got the microscopic polyangiitis which is multiple mini clots that form all over the place and it can cause quite bad. Um sort of and um and infarcts and these are the stems of questions and associated conditions, the very important bits and pieces to remember from tonight cause I know we've rattled through everything. Um But just the thing, key points that I want you to take away is that in dermatology, clinical manifestations can overlap and be very, very nonspecific if they are anca positive in the question and if they are HEP B positive as well, that's gonna be polyarthritis nodosa. Again, another one that I've learned of fos me and I was like, I have no idea why this is happening but Hep B that's polyarthritis nodosa. They've got ent issues sort of um as we were saying that saddle shaped nose and pr three, that's gonna be Chronos with polyangiitis that affects asthma and eosinophils. That's gonna be the eosinophilic uh polyangiitic rash, abdo pain, glomerulonephritis and pain in their joints. That's gonna be HSP uh which is an iga vasculitis and the strawberry tongue and the high fever is Kawasaki disease, which is gonna be a large vessel vasculitis. If they've got I sr s called tenderness, headaches and they're older, that particular sort of headache when combing their hair, that's gonna be giant cell arthritis. And if they've got unequal BP in their arms, that's gonna be Takayasu arthritis, which is a very, very severe aneurysm of arthritis. So that is us. I think I did take a tiny bit longer than I was hoping for. But if you've got any questions again, I am aware that we've just rattled through all of those topics, but you're gonna be getting the slides and hopefully they are gonna be a views whenever you're trying to revise. I try to make them as vaccin as possible just for you to be able to open them, scan through them and be very, very confident in your M CQ and a answers. That's my phone number there. If you wanna message me on whatsapp, that's my email there. If you wanna be sort of more formal and um email me and then attach to the slides, you're gonna find a couple of MC QS that I'm afraid you may not have um too much time to go through today, but they are sort of quite variable there for multiple resources. Um And I think that is me. I let's um Nikita take the floor now and again, any questions you can just message me here on Zoom and I'll pop the feedback form in um the link as well. All right. So I'll let Nikita take the floor. Ok. Um So I will just try and share my screen now. Um ok. Um So Hi, everybody. My name is Nikita. I'm another one of the final year medical students and I'm gonna be covering orthopedics today. Um, so similar to Katinka, I've got quite a bit to rattle through, so I'll go as quick as possible, but you'll get the slides in the end. And so hopefully you can refer back to them, um, whenever you're revising if you find them helpful. Um, so let me know if you've got any questions during the talk, if you want to pop them into the chat, and then I've also got a couple of M CQ scattered throughout. So if you wouldn't mind like popping your answers into the chat and we can talk through them. Um So I am hoping you can see that. Yeah, we can. Fantastic. Ok, so I'm gonna be covering orthopedics. Um like I said, orthopedics, there's quite a bit to go through, but I like it and then it's quite succinct in a lot of the management and diagnosis for a lot of the varied conditions are very similar. So it's quite easy to um generalize things. So this is the basic sort of um lesson plan that we're gonna be going through today starting off with bone diseases. So, osteoarthritis, so very similar to the rheumatoid arthritis that Katina um covered in rheumatology. This is probably your bread and butter by now. Um So it's that sort of wear and tear arthritis that you see in the older population um, they mainly present with joint pain that gets worse as the day goes on. Um, and stiffness, it also gets worse as the day goes on. Um, in the morning they'll have usually a little bit of morning stiffness lasting under 30 minutes. Um, and it tends to affect hips and knees and that base of the thumb as well, quite commonly. Um, the X ray changes are quite sort of classic in textbook. Um You should be able to maybe recognize those on an on sort of imaging. So there is that pneumonic loss and I'll show you one of um the example x-rays in the next slide. Um You got Bouchard and Heberden's nodes in the hands. So I like to remember because B comes before H and the uh pip comes before the D so Bouchard and Heberden's nodes, um which are just sort of swelling of those joints there, scarring of the thumb and a loss of range of motion as well. Um You don't need any scans to diagnose it. It's a clinical diagnosis based on sort of those criteria there. Um And management is just helping the patient with symptoms, physio, weight loss and making sure they've got comfy shoes and pain relief. So, um here's some very common hand changes you might see in osteoarthritis. So those nodes again, the squaring of the thumb that you can see. Um and just general swelling of the joints, they just don't look very healthy Um And on the right is an X ray which shows your lots of joint space osteophytes, which is just chunks of bones coming off the ends of the joint. Um and sclerosis and cysts as well. Moving on to osteoporosis. Um osteoporosis, basically, when you've got a loss in bone density, so you've essentially got less bone, but the bone itself is healthy, you've got these gaps and pores in the bones essentially. Um So a dexa scan will basically give you what's called at score. And that T score tells you how many standard deviations below average is your bone density. If you were 2.5 standard deviations below, you can be diagnosed with osteoporosis essentially and started on management. Um A note here is that estrogen is protective against osteoporosis and post menopausal women are very prone to it as long as if you're on long term steroid treatment. Um So those are sort of red flags for osteoporosis. Um Management is um exercise, weight control, calcium, Vitamin D supplements and then bisphosphonates are a really popular drug in orthopedics. Um What these do is enhance the activity of cells that make bone and reduce the activity of cells that resorb bone. So, the osteoblasts and clasts respectively. Um and you can also do HRT if it's a younger woman. Um ok, osteomalacia, the typical presentation of this will be a patient with sort of like a virus deformity of their legs, which is like that sort of bow leg as you can see in the image there. Um, and then they will also tend to have like a sort of waddling gait. So this is basically when there is defective bone mineralization and the bones are actually soft. Um, and it's caused by in and Vitamin D so it'll usually be, the presentation will be a man who's, um, maybe sort of, um, a widower and he's just eating like soup and toast for every meal and he's not getting enough vitamins. And so he's presented with this. Um that was a question we had, I think in our finals. Um And then the management is just supplementing that Vitamin D Um Paget's disease is another sort of important one. So this is when those osteoblasts and clasts are just working totally out of sync and there's disordered bone turnover. So you've got areas with very high density and some areas with very low density of bone. So this just leads to structural inequalities and you're just more prone to fractures. Um So the um presentation will really just be pain deformity and things like that. I also wanted to mention here, if they show you an x-ray of a skull, it probably will be Paget's disease because you can get this like cotton wool appearance of the skull. Um So that should be a bit of a giveaway in question. And another way is um high A LP, that's really the only um marker that's raised in Paget's disease. So a high AP um on an LFT um and also, again, use um bisphosphonates to manage that. Um This is uh maybe a little bit more than you need to know. But I've put in red, the two that I think are interesting and also may be important to know. So in osteoporosis, like I said, the bone itself is healthy and so all those markers are normal, you just got less bone, more porous. And then like I said, with pagets, everything will be normal except that ap will be quite raised. Um Wondering if you guys want to pop in the chat. Maybe what answer you think um s would be? Thank you very much, Ben. Um Yes, osteomalacia. Exactly. Yeah. So he's got the waddling gait, which is sort of a real telltale telltale sign, bone pain, tenderness and proximal myopathy. Um Osteomyelitis then um is inflammation of your bone and bone marrow caused by a bacteria. So this can either be spread um from the blood. So if the infection started somewhere else carried by the blood to um the bone, um or it can be sort of if you've had an open fracture, an open wound or like an ulcer on your foot. If you're a diabetic, it can be direct contamination as well, usually caused by staph aureus. And because it's such a deep seated infection, um You need to do a six week course of um IV flucloxacillin to treat it. Um, and the investigation of choice is MRI. And so moving on to pediatric orthopedics, um, this is just a little table here that shows you what age groups you'll tend to see what presentations in. Um, that I think it is quite handy to look at. So, um, you can take a look at that. Um, so D DH, um, so the hip is really just a ball and socket joint fairly easy to picture. Um What happens in D DH is your ball isn't very well sort of settled into the socket and it can very easily slip in and out. Um There are some very typical risk factors. So a female child if they're breach if they're large for dates, um and if there's family history of it, um there are some tests that you can do to diagnose it. I don't think you'd need to know how to do these up until your pediatric placement next year, but they're Ortho uh sorry, Orlan and Barlows. Um You can ultrasound these kits up to 4 to 6 months. And after that, you need to do an X ray because the ultrasound won't pick it up. Um And the management is really just harnessing them to make sure the joint stays in place and then they all tend to grow out of it. Um Septic arthritis then um which isn't just seen in pediatrics. So, again, similar to osteomyelitis, very deep seated infection. Um, and it can again be spread by, um, sort of blood. So if the infection is coming from elsewhere, um, or it can be a direct spread as well. Um, if there has been sort of an open wound, um, so that's just a little like sort of summary of what bugs would cause it in particular age groups. Um, this is like quite an emergency and when you're gonna be worried about this is if you see a really red swollen joint and if you see that it's septic arthritis until proven otherwise. So immediately you want to check for your trust like hot joint policy, get cultures and start IV antibiotics, which you'll probably be on for six weeks similar to osteomyelitis, transient sinusitis is again, um sort of a very common presentation of a limp in a kid. It's also called irritable hip. The sort of Hallmark question for this will be a kid that's had a recent sort of upper respiratory tract infection and suddenly their hip or knee is sore and they're limping. Um It's self limiting will go away on its own. But if the kid has a fever, you need to rule out septic arthritis, like we just talked about um Perthes disease then is basically when there is a lack of blood flow to the um head of your femur. Um And so you get osteonecrosis where the bone is essentially dying off. Um It's not as serious as it would be in an adult because um kids bones regenerate very, very easily. Um But essentially, it'll be um a kid presenting with hip or groin pain and a limp, um more males than females and in about a 3 to 12 year old. And so as you can see here, it's on the patient's um left um leg. And as you can see, the head of the femur is quite flat and compressed. Um and then, yeah, it's mainly surgical sort of um management is definitive. So this is then what we call SUFI or slipped upper femoral epiphysis. Um So this is basically when um the head of the or sorry, the neck of the femur um slips up and down on the growth plate. Um And so the typical question will be um a fairly obese 12 to 15 year old boy that's presented with a new lip, uh sorry, a new limp and their um leg will be externally rotated. Um But obesity is the main risk factor really. So as you can see here, the, the neck of the femur is sort of slipped out of place of the joint. So the growth plate is intact, but the um neck has sort of moved out of place. Um And then what you need to do is really go in and just pin it together so that it stays in place and you might then go and pin the other one as well just for good measure. Um osteogenesis, imperfecta, very rare, um genetic mutation that causes um sort of defect in collagen um formation. Um But basically, it's called brittle bone disease. And it basically, these kids have bones that is really, really prone to fractures. They have a reduced life expectancy as well. Um But the telltale sign and the question will be a kid who has blue sclera. So the the whites of their eyes will be blue and recurrent fractures. Um And the management is bisphosphonates, Vitamin D and physio. Um This is a three part and I think this might take a little bit of time to do so I might just leave you with that and maybe you can attempt it um later whenever you're really looking at the slides. Um but yeah, moving on to the knee. Um So starting with osteochondritis dissecans. Um This is basically when you've got um sort of the bone that's underneath your cartilage dyes you to a lack of blood flow and then it can sort of a small chunk of the bone in the corner can break off and this causes pain and reduced range of movement, usually due to repetitive sort of stress or trauma and you'll see it in like a sporty young adult. Um And the presentation is the same as everything else which is just pain and swelling um and reduced sort of range of motion. Um chondromalacia patella. So underneath your patella, you've got um sort of a padding of cartilage. Um, and when there's basically overuse of that joint, the cartilage can sort of break down. And as you can see, then it's just bone rubbing on bone in the knee there. Um, again seen in sporty young adults, it's called runner's knee. Um, and one of the sort of key things so that it's worse on the stairs if you can imagine as that knee is trying to bend, um, it's just bone, rubbing on bone so that can be really sore. Um Oscar bladder disease, uh This is basically where wherever your um patellar tendon inserts um in your tibia, it's called the tibial tuberosity. Whenever you've got pain and swelling and sometimes a lump there again, due to overuse, um that causes um sort of quite a bit of pain and swelling. Um again, seen in young athletes. Um and you can just sort of see there the t curiosity um moving on then to patellar tendonitis again, an overuse injury, again, presents with pain and swelling. This one's called jumper's knee. Um So this is when there is um repeated stress on that patellar tendon. So the same one that's um inserting at your tibial tuberosity. Whenever there's overuse of that, it can weaken and then eventually tear. Um And like I said, the same presentation, um the meniscus tear. So, um your men are essentially just two sort of c shaped cartilages um that sit in your knee and they help your um, thigh bone to sort of glide against your shin bone. Um, and sort of they act as shock absorption as well. Um So whenever there's like a twisting or rotating injury, it will usually be if someone's playing soccer and their, they've sort of, their leg is twisted on itself, um, there'll be a rapid onset swelling and you usually hear a pop when it happens. Um, MRI is the way to diagnose this. So, x rays are for your bones and they don't really show soft tissue injury. So when you want to see soft tissue and Mris or go to or an ultrasound, maybe at a push, um again, like for everything else, pain, swelling and stiffness, um you can do the mcmurray's test if you've heard that on your knee exam that you might be doing. Um And then the management is rest ice and nsaids really. Um So then your collateral ligaments are um more pieces of sort of um soft tissue. So they sit um on the sides of your knees, you've got a median one and a lateral one and they sort of prevent your knees or sorry, your shin from moving side to side with respect to your um thigh. So whenever there is a force pushing your knees sideways, you can um break the contralateral um lateral ligament. Again, the investigation is an MRI and the management is ice pain or sorry, ice bracing and then physiotherapy. Um So the M CL will be damaged when there's a blow to the outside of the knee. And the LCL will be damaged when there's a blow to the inside of the knee. Your ACL is yet another piece of ligament. Um So this is one of the most common injuries. So your ACL and PCL are two ligaments that sit crisscross basically um behind your patella and they stop your um lower leg from moving forward and backwards with respect to your thigh. Um Whenever there is a mechanism of injury, usually involving sport yet again, um which when you're like stopping or starting like suddenly or if you suddenly change direction, um it can basically cause your ACL to break because it's quite a weak um ligament. Um Again, pain, swelling, loss of your range of motion. Um and MRI S, you should diagnose it and you can do your anterior jaw test on um knee exam, which again, you probably are familiar with. Um and a very similar management again. Um But surgery is quite commonly done here. Um And then your Baker cyst um is a fluid filled sac that sits in the back of your knee. Um It can get infected, you can do an ultrasound to see what it looks like. And if you're worried about it getting infected, we'll probably aspirate it and give um um antibiotics um or a steroid injection. If it's very inflamed again, we'll skip through that just as I am aware that we might be in a bit of a time crunch. Um ok. So moving on to back then. Um So um just back pain, it can be sort of um various causes, muscular joint dysfunction, et cetera. Um Usually we're happy to let back pain be without any red flags for about 4 to 6 weeks before we refer for imaging and the imaging of choice would be X ray to begin with. Um and basic analgesia you move up like the wo pain ladder essentially. Um So starting with Coquina, which is a, a very important surgical emergency that you should be aware of. So you've got like a leash of nerve sitting at the bottom of your spine after your sort of vertebral canal finishes. Um, whenever these get compressed, it's a surgical emergency. Um, the symptoms that a patient will experience is back pain, saddle anesthesia and loss of control of their bowel and bladder. Um If ever you're suspecting this, um, the patient needs to get a urgent MRI and they need to be admitted to hospital for emergency surgery. Um, spinal stenosis then, um, so this is basically when part of your spinal canal is narrowed, which will obviously cause compression on your spinal cord, which is running through it. Um This can cause claudication, which is sort of that. Um Sorry, um Which claudication, which is sort of that um, um, feeling of pain in your calves when you're walking. Um You've probably heard of sort of claudication in relation to um heart failure. This is claudication in relation to a nerve cause. Um again, an MRI scan to diagnose it, um it is a little bit less severe than claudina and that exercise and weight loss are usually fairly ok ways to um sort of manage it. Um sciatica, then your sciatic nerve comes from the L4 to S3 nerve roots. When these are compressed, your sciatic nerve is irritated and it causes unilateral like really sharp, neuropathic pain going from your back all the way down to your legs. Um If there's bilateral sciatica, that's a red flag cause that could mean that it might be called equina. And so, um really, you just need to admit the patient if that's happening. Um OK. Um disc prolapse, um and spondylolisthesis, these are both um fairly similar. So, in disc prolapse, um you basically got these like cushions sitting between each of your vertebrae. Um And whenever those cushions start to bulge, um it causes pressure on your spinal cord. Um it's also called her uh disc herniation or flip disc. Um and again, causing pain, irritation and numbness. Um, spondylisthesis is when one of your vertebrae, vertebrae will slip forward in relation to the rest of the spine. Usually happens in your lumbar spine. It presents with pain. Tumors can be primary or they can be um met from um particularly um breast or um prostate cancer. And then ankylosing spondylitis. I will um not touch on too much because Katina has covered it in rheumatology. Um But it's basically just loss of flexibility of your spine. Um OK. Do you guys want to give this one a go? Yes, thank you, Sarah. Excellent. Um Yes, an MRI um hours. So, as soon as possible really um And what we're concerned about here is um called Yeah. OK. Um So um there is not too much left to go, do not worry. Um But so dermatomes are next. Um So this is sort of a crossover between Ortho and neurology. I thought these were fairly important to know, um for a couple of reasons, sometimes they will give you a question where they give you a presentation where a patient's got sort of a loss of sensation in a certain area and they want you to identify what no root is causing it or also in your um sensory exams of your upper and lower limbs. Um I think it's quite slick when you sort of are touching on the exact right dermatomes because the examiner knows that, you know what you're talking about. Um I wouldn't even go through all of them. I think just even knowing the upper and lower limb ones is quite helpful. Um So I'll just leave that there. Um Similarly with myotomes. Um I sort of put in bold, a few of the ones that I remembered myself. Um remember to be quite easy So like C four shoulder shrugs. Um, C eight is thumb extension with finger flexion. So it's like you're making the thumbs up. Um, C seven is like making a seven with your arm. So you straighten out your, um, sort of elbow and flex your wrist. Um, things like that I found was quite helpful to know, um, reflexes again, um, come up exams, uh, quite often, to be honest. Um, so is this like rule that I sort of found was quite easy to help me learn what um nerve root was causing, what reflex? So, walking from the body, top or sorry, bottom to top. Um 12 are in your ankle. 34, are your knee? Um 56 are in your bicep and then 78 are your tricep. Um So it's just quite an easy way to remember what nerve root was causing what reflex. Um Do you guys wanna, I might actually skip this one? Um So this basically I'll just talk through. So, um she's got pins and needles in her right hand. Um And she's got um I'm gonna say, yeah, so, and they're asking you basically what um nerve root causes the triceps reflex. So, like we saw here, the triceps re reflex is C seven and C eight. And well, it is sort of just knowing that the radial nerve causes it, which um I was just an extra fact. Um These are some common presentations that you can sort of maybe go through in your own time. Um These would be common questions that would show that would show up um moving on to the elbow and the hand. So, um epicondylitis, this is basically whenever you've got, um So you've got flexor and extensor tendons that insert in either side of your elbow, flexor tendons will insert in the medial side and the extensor tendons will insert in the lateral side. Um And whenever those are overused or there's an injury, it'll cause pain in that medial or lateral epicondyle. Um And they're called or golfer and tennis elbow, um respectively. Um Alacron bursitis then very similar to your um baker cyst in that there is a pouch of fluid of synovial fluid sitting sort of right in your elbow. Um And whenever that gets inflamed or infected because of say rheumatoid arthritis or friction or trauma, um that can be, you know, swollen, warm and tender if you're worried about infection, antibiotics, otherwise rest ice and compression carpal tunnel syndrome. Again, very, very common presentation in GP and common exam question. You've got sort of a passage of um a certain number of structures that pass um through your wrist really, um which is called the carpal tunnel. The roof of it is the flexorum. If you remember from anatomy, um The most important structure going through there really is a median nerve. So when that becomes tight, that passageway, your median nerve will get compressed and, um, if you remember the distribution, um, which is the first sort of 3.5 fingers, you'll get numbness, um, tingling, pain pins and needles there. Um, the falls and Tinel test on your wrist exam, um, are helpful in diagnosing it and it's just rest and splinting it for management. Um, cubital tunnel, almost the exact same. It's just up in the elbow instead and it's the ulnar nerve instead. And so if you know anything about the ulnar nerve, it's causing um sort of pain numbness, tingling in the last 1.5, sorry in your medial 1.5 fingers and the sort of um medial aspect of your forearm. Um OK. Decors teno synovitis. Um this is usually um presenting in a student or it'll be someone that sort of uses um or like types a lot. Um It's pain in the radial side of the wrist. It's a repetitive strain injury and you get sort of inflammation um in the tendencies of your APL and B which cause abduction of the thumb and wrist. Um, trigger finger is basically whenever you've got these flexor tendons, you can probably feel them in your own hand. They run in tendon sheaths um down the palmar aspect of your hand. And whenever there's inflammation here, the flexor tendon will struggle to glide along the sheath and it can cause your finger to be quite stiff and sometimes it can even fix. Uh flexion of the finger, um, seen in like middle age diabetic women usually. Um, and then rest analgesia and splinting are great. Um, good sort of management options. You put contracture, it's probably something that you talk about in like your abdomen cardio exams and things. Um, but basically what it is is you've got, um, sort of a soft tissue which is fascia on the palmar aspect of your hand and whenever this becomes thickened, um the fingers can be tightened again into a flex position. So it's a very similar presentation to trigger finger, but a different physiology. Um and you can sometimes palpate to sort of thickened, um and like hard knot, nodular fascia in the hand. And yeah, they can be fixed and you can go and release this um surgically, which is really the only option for management. And then a ganglion cyst is a sack of fluid which sits basically usually in the dorsum of the hand, very, very um innocent and benign and you can um excise it if it is bothering the patient shoulder, then um adhesive capsulitis really common presentation in GP. Um So it's also called frozen shoulder. So similar to the hip, your shoulder is a ball and socket joint, which is covered by um, a joint capsule which is all this connective tissue when that gets inflamed, tight fibros. Um The joint doesn't move as seamlessly, um self-limiting. It'll usually only last a couple of years. Um And there isn't too much you can do, um, for it really other than, um, physiotherapy, um, and rheumatoid, um, sorry, not rheumatoid diabetes is a big risk factor for it. Um, rotator cuff tear. So, if you guys remember from like first your anatomy, your rotator cuff for the four muscles that sort of sit near your scapula in the back. Um, so be it due to an injury or due to sort of degenerative conditions. Um, the tendons of these muscles can get damaged or they can even rip, um causing a tear and to get shoulder pain weakness. And MRI is really good at diagnosing it and then similar to everything else. Rest, analgesia and physiotherapy are the ways to sort of treat it. Um dislocations. So again, like I said, ball and socket joint, um very easy for the shoulder joint in particular to slip in and out of place. So if your head of humerus moves anteriorly, that's the most common way it'll dislocate. Um and then it can also be posterior, but that's usually related to either a seizure related injury or an electric shock related injury. Um, a complication that can happen here is um damage to your axillary nerve. And if you remember anything about the axillary nerve, it ca um it gives sort of motor supply to your deltoid and sort of um what else you terry minor, sorry. And then um sensory um distributions to your sort of regimental badge area um, and then foot and ankle, you'll be glad to know this is the last joint. Um, ok. So plantar fascia is similar to fascia and you've got plantar fascia um, in the sole of your foot. Um, so this is basically when it's inflamed, it is seen very often in people that walk a lot or run. Um, it will cause sort of quite a severe pain in the, um, calcaneus or the sort of heel bone, um gradual onset. And again, there's not a whole lot that you can do about it other than um rest ice painkillers. And physio um gout is sort of um a bit more rheumatology maybe, but it's basically um a crystal arthropathy. So you get your uric acid crystals deposit in a particular joint, that particular joint just happens to be the base of your big toe usually. Um So it's an acutely f swollen, painful joint. Um You aspirate it as soon as you can. And the typical thing that you'll see is needle shaped crystals that are negatively birefringent of polarized light. So, n for needle and for negative is how I remembered it. Um And colchicine is the way that you treat it and then allopurinol for p prophylaxis after you've had one flare. Um So your achilles tendon then is a tendon which um sits in the back of your heel. Um It connects your um flater flex muscles, so your gastrone and soleus, um it connects them to the heel. Um So what can cause um problems with your achilles tendon is sports rheumatoid arthritis, diabetes. Um So basically it helps the um, foot to plan or flex. Um, when it is quite damaged, it can even rupture. So whether this is a sudden onset injury or due to degenerative changes, um it'll cause a sudden onset pain and you'll probably hear a snap um and use an ultrasound to diagnose it And yeah, you can do surgical management but immobilization ice elevation in the meantime, um this was a question that was just asking about um what you do for um achilles tendon tendinopathy. Um and it was an ultrasound. Um So this is like the last two or three slides. Um So bone cancers um can come up quite often in questions. So, um a sarcoma really is any tumor that originates um in the muscles, bones or any other connective tissue osteosarcoma is the most common and it also happens to be a malignant form of cancer. Um And so I sort of put here just like one key point that I remember about each of the type of cancers just because they're like buzzwords for questions. Um So it's, this one's got a bimodal age distribution. So you've got a peak of incidents in adolescence and then a peak in older adulthood. Um Chondrosarcoma then um originates from the cartilage and then ewing sarcoma usually affects kids. So, if you have a tumor a bone tumor in a kid, it will either be osteo or Ewing sarcoma. Um And Ewing sarcoma has um onion skin appearance on histology, which I remember because onions you, I don't know, um presentation is usually um sort of a bone swelling or a soft tissue lump. Um and kids will complain of like just bone pain. Um You wanna start off with an X ray if it's bony or ultrasound, if it's soft tissue, like I said, x-rays can't pick up soft tissue injury, you'll probably move on to a CT or MRI after that. Um And then surgical resection is the gold standard compartment syndrome is another one of the emergencies I wanted to touch on really quick. Um So the other emergency we talked about obviously was called quina. This is the other one. It happens after a fracture or a thrush injury. So basically all the um sort of all the structures in each of your limbs are organized into compartments. So each compartment will have a series of muscles, tendons, ligaments, um blood vessels, nerves. So whenever pressure within a certain compartment is elevated, the blood flow cuts off to it. Um because of all the pressure um and this can cause necrosis of all the structures within it. And so this is a surgical emergency and what you wanna do is immediately get the patient to surgery for an emergency, fasciotomy to relieve the pressure. Um And then the presentation is those five peas, which you've probably heard of um also associated with peripheral vascular disease. Um This is a list of stations that I have come up with that. I think um would be good to be familiar with. Um oy wise. So, drug counseling on methotrexate and bisphosphonates, I think could definitely show up there's plenty to talk about. So, like the osteonecrosis of the jaw and the esophagitis with your bisphosphonates. Um and then with methotrexate, just the immunosuppression and um with it being neogenic compartment syndrome called equina X ray interpretation could show up, I think um definitely osteoarthritis or bone cancers, um fractures, maybe not so much, maybe that's a bit more fourth year, um a history for osteo or rheumatoid arthritis, maybe having to differentiate between the two with, you know, the morning, um stiffness and then does exercise make it better or worse? That sort of question, um a back pain history and, you know, making sure you rule out each of the um e of the red flags, um counseling on a common condition and then examining really any joint um ts your finals don't get too bogged down with everything. And as long as you know, the basics, you'll be absolutely fine. Um I used almost exclusively plus textbook for like my fifth year finals and I did, OK, um get through as many questions as possible as well. Zero to finals, really helpful all the way towards the end. Um youtube videos for, if there's like a concept of the basics of which you're not too sort of um confident with a talking me. Um And that is me all finished. Um Please feel free to email me um with any questions about um, today's presentation or anything else, sort of, um, just finals wise, um if anyone's got any questions, um but thank you all so much for listening and um, if you wouldn't mind filling out that feedback form, that would be fantastic. Um But yeah, thank you all very much and I'll stick on if anyone's got any questions for a couple of minutes.