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Hello, everyone. My name's Masuma. My name is Judy and welcome to our teaching session on endocrine and metabolic diseases. We're part of a teaching group called The Teaching Frontiers. And before we tell you a bit more about us, we're gonna give it a few more minutes and let some more people join. Mhm. No. Mhm. Ok. We'll get started now. So, welcome to our teaching session on endocrine and metabolic diseases. We are part of a group called the Teaching Frontiers, which is made up of a huge array of different grades of doctors working in the NHS. And we aim to provide high yield teaching suited for final year exams. So make sure you keep a look out for all of our future sessions because they're targeted to what the MLA expects of you. Yeah, brilliant. So, as Assum said today, we'll be covering endocrine and metabolic disease. Um You might be asking how does, how does this fit into kind of the UK MA curriculum? Well, actually there's quite a big kind of significant section within the UK MA curriculum, um centered around endocrine and metabolic diseases. Um, so you can see both the presentations and the conditions they expect you to, to know about and expected, um, expect you to kind of be ok with being tested about as well. Um, we won't cover everything on this. There's quite kind of a few conditions on here, but we've picked the ones that we feel are most high yield, um, mainly kind of diabetes, cushing's thyroid and parathyroid disorders, things like that. Um, the conditions we feel come up the most particularly in oss and an M CQ. Um and the ones we feel that kind of you benefit most from, from covering today. Ok. So I'll get started with Addison's disease. Um Just as a quick side note, if any of you have any questions, please feel free to leave them in the chat and we can address them at the end. So, Addison's disease is a form of adrenal insufficiency. The most common cause being an autoimmune destruction of the adrenal cortex. The reason why it has the symptoms that it does is because it leads to a deficiency in two hormones, notably cortisol and aldosterone. So, in order to understand the symptoms of adrenal insufficiency, it's important to understand what the hormones do. Cortisol is really important in metabolism. It's increased in times of stress and immune response. And aldosterone is important in maintaining the biochemistry makeup of your blood. So it controls the sodium, the potassium and consequently has an impact on your BP. So, as you can appreciate, there are two very important hormones and they're produced by the adrenal gland. Therefore, any form of destruction to the adrenal gland leads to a subsequent destruction of these hormones being produced. In terms of adrenal insufficiency. The important thing to be able to recognize for an exam viewpoint is whether it's primary, secondary or tertiary uh insufficiency with regards to primary, that's the most common, that's when the adrenal gland itself is affected and there's a direct destruction, secondary, it's higher up in the chain. So as you can see in the diagram in the bottom, right, that's when there's a lack of ACTH being produced. And ACTH is a hormone that's produced by the pituitary gland. Therefore, damage to the pituitary means less ACTH means less action from the adrenal gland. And that can be because of tumors. It can be because of any surgery to the pituitary or radiotherapy in the past. And then we've got tertiary, which is the highest point at the level of the hypothalamus. So that's when the hormone that triggers this axis, the C Rh isn't being produced. And that normally happens if someone has been taking steroids for a long period of time and it causes the body's ability to produce its own steroids to be decreased subsequently. Yeah. Ok. So moving on to the signs and symptoms of it, as we mentioned earlier, all the signs and symptoms are related to the function of the hormones. So, because aldosterone is so important in controlling um your body's potassium and sodium levels. It can now subsequently lead to a drop in BP and cause postural hypotension as well as salt cravings. The most common presentation that you'll see when you begin work as doctors for patients that are especially coming in adrenal crisis will be nausea, vomiting and abdominal pain. And that's where it becomes very important to know the patient's background history in terms of Aussies, that's also key symptoms to look out for, especially if they are carrying one of the cards, which we'll show you later on. Ok. So in terms of actually investigating um whether someone has Addison's disease and being able to differentiate between primary and secondary adrenal insufficiency, you perform something called the short syn actin test. So in this test, you a as you can see in the diagram as well, you'll be giving baseline cortisol and what you'd be expecting is the cortisol should be rising. If there is no rise in the level of cortisol, after you have given a synthetic version of the ACTH, the hormone that triggers cortisol rise, then you know that there's primary adrenal insufficiency. You can also test for specific adrenal antibodies, which are listed below. But there are also ways of being able to differentiate whether it's primary or secondary adrenal insufficiency. So you can measure the ACTH hormone directly. So in primary adrenal insufficiency, you'd find that the ACTH is high because the pituitary is producing lots of ACTH without the negative feedback. Whereas in secondary adrenal failure, the ACTH level would be low. There's also some place for CT S and MRI s of the adrenal gland, especially if you're suspecting um some sort of adrenal mass or malignancy that's causing suppression. Ok. So now moving on to management, as I briefly mentioned earlier for Aussies and being able to recognize patients with first presentation of Addison's or in an acute adrenal crisis. It's important to look out for the steroid emergency cards that you can see on the right hand side. So patients will be asked to carry these cards in their wallet. And it's really important to check for it in a medical setting, especially if a patient presents with very nonspecific symptoms and, but they're still very acutely unwell and you can't figure out why. Now, in terms of Addison's management on a day to day basis, you have to replace the hormones that aren't produced. So there's place for Glucocorticoid replacement and mineralocorticoid. The predniSONE is used to replace cortisol, which the adrenals aren't able to produce as well. And the flu or cortisone replaces the aldosterone, it's really important to make sure that your patients are well educated on this and know about sick day rules, which basically would involve doubling the um cortisol that they're using in order