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Hello, everyone. Welcome to the second session of the undergraduate surgical teaching series, which covers surgical topics at the level expected of clinical year students. The topic for this session is urology. We would really appreciate if you could fill out the feedback form, which you can find in the chat. Upon completion of the feedback form, you will receive a certificate of attendance. Um, and we also have breakout rooms. After the 1st 30 minutes of the talk, Do make sure to join those as it's a great way to consolidate your information as well. Ask any questions that you might have were extremely fortunate to have. Mr James Blackmar, who's an ecard. Spreads clinical lecturer in neurology at the University of Edinburgh, an honorary S. T. Seven in the east of Scotland. After graduating from the University of Edinburgh in 2010, he completed Academy Foundation years, of course surgical training in southeast of Scotland. Before undertaking the early years of urology specialty training in the west of Scotland. He completed a PhD at the Institute of Genetics and Cancer at the University of Edinburgh, using human samples and human derived organoid to investigate gene environment interactions between vitamin D and colorectal cancer risk. Now back in Edinburgh to complete his specialty training, he's focused on renal surgery. We're also joined by Doctor keeps Simpson clinical development fellow with the urology team in Edinburgh. Without further ado, I would like to invite Mr Blackman to deliver his presentation. All right. Good evening, everyone. Hopefully you can. Here. I'll just share my screen. Yeah. Uh huh. So, if you could all just answer that question, I'll answer later. Uh, lovely, lovely. So I hope you can all see that screen. I can't see you so we can see good. Yeah, perfect. So I'll start off with a little introduction to urology, and then we'll go on to some cases. So I think urology is often a sort of, um, hidden specialty, in a way. So certainly for the Edinburgh audience, and I think that's probably true of most places. You only get two weeks of urology during your undergraduate curriculum, which, given that, you know, by comparison, you get sort of 67 weeks of respiratory, and then you think about the breadth of conditions that fall underneath the urology umbrella. Whether that be, um, cancers. So prostate cancer bladder cancer, renal cancer, testicular cancer. Um, and whether that be also they're spreading into benign disease is like stones, but also stuff like recurrent urine infections. And also moving into your, uh, gynecology things like stress, urinary incontinence that will affect a huge proportion of women, particularly after childbirth. There basically is no escape from urology. You will come across it even if you don't want to. During your, um, career and for me, you know, there's also a lot of stereotypes about Urologists were a bit hidden from the undergraduate curriculum, were a bit hidden from with a lot of sort of outpatient work. And we're a bit hidden from specialties even around the hospital. So the stereotype obviously, is that urologist spent an awful lot of time playing golf and, um, spend quite a bit of time in private practice. Both of those to some degree, are true. I played golf today, but I am on nights tonight, so I'm making up for it. But I think the key thing is this is a picture of me versus a typical anyone working within a specialty with General in the title. In that urologists tend to be quite happy. We'll have hobbies. We see our families, and we find the specialty Pretty interesting. You see an awful lot of people doing anything, general. So general practice, general medicine, general surgery tend to be pretty furious about their lot. The on call is far busier, and they're training is far worse. So why did I choose urology? I certainly didn't start off wanting to do it. And I only really selected urology when I was a court trainee. Um, but I think it's an interesting range of operations. Um, from the quite complicated, down to the benign and quite simple. Um, there's an interesting range of clinics. There's a good training progression. So we sort of see when people are more junior and you come into the specialty, you might learn how to do a cystoscopy. So a flexible cystoscopy to look in someone's bladder, and that's how you start off. But we do so many of them that you quickly pick that up. Um uh, Doctor Simpson, who's with me today, uh, sort of helping out with this presentation in the break out rooms? Um, so he's sort of new to the specialty, having been there a year and a bit, but actually, Keith can already do quite an awful lot of these sort of basic urology type things so he can safely do a flexible cystoscopy by himself and run a clinic doing that. You can do a urinary extent, so you put a camera into a bladder and put a stent up to unblock the kidney. Um, and then from that you can move on and springboard into the rest of training that you can do. If you can do a stent, you can do a ureteroscopy. If you do a rigid ureteroscopy, you can do a flexible ureteroscopy and then you can do stone disease. Similarly, you sort of start to pick up more benign pathology so you can drain an abscess. You can do a hydrocele repair, you can do a circumcision, and that leads onto being able to do much more technically challenging operations like big open bladder or kidney surgery. And I think it's also for me quite nice to have a specialty, which is shielded from the general on call. So I'm currently sat in the Western General. I start my on call at eight o'clock, but actually I'm nonresident on call, So I will go home and I spend most of my own call a sleep in my bed. Um, and for me, that's quite nice. It provides a really good work life balance. And I said about the range of operations. You know, urology really is a pretty broad church, and we're certainly, I think, the most technologically advanced specialty just because of the broad range of technologies that we use and utilize so in the top left of the screen here, as you look at it, you can see someone doing a robotic partial nephrectomy. It's like a heavy nephrectomy, and in the middle you can see a robot. So the Davinci robot, very widely used in urology, whether that be for prostate, bladder or kidney surgery. Um, then in the top, right? Uh, you can see somebody having a neobladder created. So if someone's had their bladder removed and then they'll be for a cancer operation, usually and you can then take their daily, um, and then re so it and then re plumbing onto their urethra so that that person has a continent urinary diversion. Below that is a picture of someone who's had probably a cystectomy, and then they've had a pelvic lymph node dissection. So there you can see there. So it's muscle. But then the iliac artery and vein and the brand, the internal and external iliac branches of that. And you know, I'm always struck that, you know, next to that in the middle, on the far right. Is someone doing microscopic surgery that might be a microscopic vasectomy or a micro t Z for fertility type operations. So you can see that within urology, you might have someone doing microscopic operations for fertility on the same day in the theater next door, you might have someone doing a massive general surgery bowel type operation to remove somebody's bladder lymph nodes and then construct a neobladder out of Ireland fundamentally do a bowel resection to actually piece that all together again. And in the bottom left, you have some endoscopic surgery, so you can see in the middle of someone undertaking a flexible ureteroscopy and laser to blast up some stones. Uh, you can see someone under using a basket, and then the very bottom left. You can see someone undertaking a t u r p t. So a transurethral resection of bladder tumor. And really, it's that broad range of operations that I've always thoroughly enjoyed. And if you are a little bit of a computer nerd, you like computer games and you like technology for me. I think it's definitely a specialty to consider. Um, so how do you get there? Well, I think, certainly. As with all these surgical specialties, the key thing is to be interested as a medical student and as an F Y, particularly when you're an F y to you have to try and get a couple of jobs, which is surgically minded. Also, be really mindful of looking at the person's specification for what the next jump in the ladder might be, or even two jumps in the bladder. And make sure you're taking the boxes for audit publications teaching. Occasionally you'll find that, and I'm sure people are aware of the sudden change in the core training applications coming up for this year. A new hurdle will suddenly appear. There's nothing you can do about that. It's always just deeply frustrating when it happens, but all you can do is try and control the variables that you can have some impact on. So make sure you keep your log book. Make sure if you can go, of course is um and then keep an eye out. For what? You know how you take all those other boxes. And then in the UK, you can go through either run through training. So you get appointed to urology at ST one, or you can get a course surgical programs, and that's certainly what they used to have. So in Scotland, we've still got a couple of run through jobs, but I think elsewhere that largely core training that keeps changing from time to time. Um, within that you need to make sure that you got at least six months of urology and ideally, that you've got a urology themes program with one year of urology within that, and I see here that surgery is a verb, so make sure you go to surgery. Everyone expects that the CT one on their first day will be pretty rubbish. Doing surgery. You've just got to get over that hurdle you've got there and think Great. You know, I've reached that. I'm really you know, I've been a real high achiever. The hurdle before, and you suddenly realize that you're not very good at the next step. Everyone has been there. And the thing that I always struck me or someone told me years ago was that it's perfectly acceptable to be, you know, not a very capable core training on day one. When you get to be an S T three on day one, people will expect that you can do all the things that are very good CT one and C T two would do. And the only way you can do that is to get to surgery, get to theater, help with the on call and try and get to clinic. Um, as they basically look at the person's specification for jobs and try and match your CB towards that. So we're going to run through one scenario, and I'm very happy for people to speak out or ask questions. And we've got a couple of polls as we go through this, Um, for this scenario to make it interesting, we're going to have it that we're in a sort of bgh type setting. So you are the f Y one on the surgery at nighttime. So you cover all the kind of general surgical type specialties. There's an F Y to also covering the same, and they're somewhere in the hospital. And with the on call, you've got a general surgery Reg who's resident on call so they're also present. You've got a neurology registrar who's at home. You've got a radiology registrar who's at home and anesthetics registrar. They're covering I T. U. So they're resident, and then you've got all the other type of consultants that you might expect, but they're all at home, so you can call them if you need to. But equally, a lot of these people will be working the day before and the day after this overnight on call people never mind being phone about something that's sensible, but people are always quite upset when they get phoned and say you have not looked at the patient or assess them properly. Um, we don't like being woken up for that. So imagine it's Wednesday at one AM and you're in the acute surgical receiving unit. When a 26 year old man, uh, appears with left sided abdominal pain. The nurses are quite worried about him. He's sweaty, and he has a Su score or new score or moves, score or food score wherever you work of three. He says that his pain is colicky in nature and he's nauseated and his arms are as written. Um, so, first of all, any thoughts on what a differential diagnosis might be, and then we'll move on to some investigations in treatment. Mhm. You know, people can speak out on this, but if anyone wants to type or anyone wants to say what they think might be a diagnosis, I'm very happy to have some suggestions. If people can't type and I can't see it, Keith, you can shout out if anyone is reading anything. Nothing so far. Nothing. Silence. Well, I think the first thing to say here is that this person is probably septic. We've had a we've got We've got one that says renal or bladder stone. And another one is piling nephritis. Yeah, yeah, both of those sensible differential. Um, the trick here, as well, is to think that this is obviously a urology talk and both Keith and I urologist, but it doesn't necessarily mean that the patients present with definitely urology problems and one of the things that you as a doctor can bring to the table is being able to keep an open mind. Question the diagnosis that everyone said before you try and make sure you're treating the patient. So yeah, stones pile on arthritis. Then also, you want to make sure that somebody is not got, for example, a ruptured spleen. Or they've got some GI I pathology particular. Whether that's a ruptured duodenal ulcer, whether that's bowel pathology of funny presentation of Crohn's disease, for example, an older patient, maybe diverticulitis. And most importantly, in a in an older patient, you have to make sure that this is not a ruptured Triple A. So keep an open mind and try and cross off these different differentials as you go along. Always those patients mail. And so you would expect that this person does not have a gynecological type pathology, Um, but again keep an open mind for the patient's past history. So the first thing to say this person, as I said, certainly seems like they've got sepsis, So initial resuscitation follows the lines of the sepsis six protocol, so you need to get IV access and bloods that would include blood cultures and send off some urine cultures as well In those bloods, make sure you send off a lactate as well as checking their renal function. White count crp, et cetera. Um, you don't want to give him some IV fluids? Um, it depends where you work as to what resource fluids will be acceptable. Most of the time, people are using something like heartburns or plasmalyte, occasionally saline. Um then also, you want to make sure that you get IV antibiotics on board quickly. You sort of got a temper. Whatever antibiotic you use, based upon the local protocol, how sick the patient is and also what you think are likely diagnosis might be. So in this case, we think the patient might have euro sepsis, in which case we want to tailor it towards urinary type microbes. So particularly related to E. Coli. Another grand negatives. So it's probably imperative that we get an antibiotic broad spectrum like gentamicin that's going to cover, uh, gram negative organisms. We also tend to combine that with amoxicillin to broaden the cover. On top of that, the patient saw you probably give me some analgesia, but also in this case, if the patient's sick, I would usually expect that the f Y one would escalate that to the F Y two. Who then might get in touch with me as the registrar to tell me that somebody has been admitted Septic. And we think this might be a urology type pathology underlying this. So I'm not sure I can start this because I've got a full screen. But if someone else can run the pole for what investigations are going, otherwise I'll I can close it and come out. I'll do that. So we're going to run a pole now? For what investigations? Is that working? Yep. Yeah, I'm just waiting on a couple more responses. Right. So it seems there's a split between ultrasound Reno and C T K U B and CT abdomen pelvis. Okay, so each of these different investigations can basically what? What was the winner? Um, it was a three way split, so yeah, there's no way to really no real winner. Okay, Keep you go for I would pick the CT. Can you be personally one in the morning? Yeah. Um, so in this setting, um, basically different investigations give you different or answers to different questions. And the tip when you're in the you're asking for different investigations is sort of think about what questions you want answered. And it's similar when you go to request scans of radiologists and talk about your scans is to go along with the question, as opposed to going along with simply saying, I want this scan and I don't really know why. Um, and if you are like an F Y one or F Y two or any other grade really are being asked to request a scan, you have to know roughly what questions you want answered, and then you'll get a better scan. And it might be that the radiologist change the scan that you requested because actually, they think something better would give a better answer to the question. You're asking so of the collection of different options, something like an abdominal X ray and ultrasound. So Abdul X ray might tell you that you got stones there, but you can have calcification for lots of different reasons, and often particularly for patients obese, which is pretty common in the U. K. You won't be able to pick up a stone, particularly confidently, um so Abdul x ray or an X Ray KB might be useful if you're somewhere without a CT scanner, but in most places people have a CT scanner. So that's our kind of what you wouldn't use an outdoor X ray, usually in the first instance. Now an ultrasound scan. For that, you have to have a radiologist or a sonogra for to do it in real time. So at one o'clock in the morning, that would involve the radiologist coming into the hospital. And usually they don't like doing that. Additionally, um, it can tell you if somebody's hydronephrotic, but it won't be able to see a Euro Terek Stone so you can't find out why someone is hydronephrotic. You might presume it's a stone, but you don't know why, how big the stone is or at what level. It also doesn't tell you anything else about the anatomy so often we would go for a CT scan of some description, so a CT KB kidneys your bladder is a noncontrast CT that's useful for two parts. One. It's quite quick, and it also the contrast is white, so a stone is white and the contrast is white. We're not really bothered about the extra information that A that would come with giving contrast. So we just want a quick scan that will tell us if there's a stone and we don't know to be a question about. Or maybe it's a stone. Or maybe it's just a little blob of contrast sitting there that we're not sure about. Additionally, um, contrast is potentially nephrotoxic. So we don't want patients with kidney upset who've had some gentamicin and have infection, and two are hypertensive and a bit dehydrated, also getting contrast on top of things to mess up their kidney function. And so, for that reason we go for a CT KB the other investigation. So a CT, abdomen, pelvis that tends to be one. With contrast, you might get that if you're looking for either cancer or G. I type pathology. So diverticulitis, appendicitis or a tumor. Um, and then I think the final option I put down was whether you wanted to get an MRI urogram. So you'd only really get an MMR urogram if you were dealing with a pregnant patient or someone that you particularly wanted to avoid giving, um, ionizing radiation, too. So, in a pregnant patient, you might think about getting an ultrasound first and then getting an MRI urogram. But that's much more complicated and very much case dependent. So fundamentally in this sort of setting a CT KB is the right thing to go for. So you get your CT kb and it shows that you've got this a six millimeter proximal left ureter IQ stone. So will flick to poll number two. What treatment do you think you would offer? So there's a range of different treatments available. What do you think should be offered to this patient? Obviously you're an f Y one. So you're not going to be giving this treatment. But what do you think the urology registrar should come in and do? And again, I can't see the polls if someone just let me know what? How? That's running. Just waiting for some more answers. We only got four answers so far. Okay, so 11 answers and we've got a big winner. Is your enteroscopy and stone fragmentation and then distant. Second place is ureter extent insertion. Okay, So, um, what would you do, Keith? I would agree with the people who are in second place and do the ureter extent. I would Yeah, the only other one was I can't remember if nephrostomy was an option. So yeah, that's probably what I would ask for it because you don't want to come in. Correct. Yeah. So I think we put down a range of different options for treating stones. So, um, when you're treating a stone, you can either treat them with allergies here and see what happens. So watchful waiting Or the nice guidelines have a funny phrase. That's like assisted stone passage or something like that related to basically giving you, um, giving the patient analgesia. When I was training initially as a medical student, we used to give people tamsulosin as well. That's kind of gone out of vogue to help the stone passage. But occasionally people use that as well. I won't go into. That person wants to ask me later about it. You can, um, in this case, though, you've got a six millimeter proximal stones. So well, come on to what the chances are of that passing and every minute. But also, um, you've got to be aware that this patient septic so treatment like lithotripsy we'll talk about and also ureteroscopy you're going to put the patient to a longer operation involving either shattering the stone up with external, um, shock waves or using ureteroscopy and pressure irrigation. The risk of doing that is you make this patient extremely septic, and you might run into the, uh, forgive me for any orthopedic surgeons in the audience. But the classical orthopedic adage of the operation was a success, but the patient died so you might well treat the stone. But the patient might end up in intensive care because of their profound urosepsis. So in this case, you need to think of it like an abscess. Ignore the stone. You want to drain the pus and then let the patient get better and come back and fight the stone another day. And for that we can do two things, really. One is a stent, which is done under anesthetic, and one is a nephrostomy. Um, so we'll talk a little bit about stone treatment now. So in basic terms, when you're assessing a patient with the ureteric stone, you have to decide is the stone. Is the stone size so big that it's unlikely to pass? Is the pain uncontrolled with analgesia? Do they have renal failure. And are they septic? If the answer to all of those is no, then you can try some conservative management, give them analgesia and trying to bring them back in a couple of weeks. If the answer is yes to any of those, you have to decide what to do. And basically, if the size is large, the pain is uncontrolled or the patient is as an acute kidney injury. You might consider ureteroscopy and lithotripsy. And if the patient is septic, maybe also with acute kidney injury, you think about just unobstructed them as fast as you can. So a stent or a nephrostomy. So how successful is conservative treatment? Which is a very nice study from the Burst Collaborative, which is a kind of student and trainee collaborative across the UK and worldwide that made some very effective studies on the numerous things? One of the first studies was about stones, so they collected large data in this mimics study on rates of stone passage. And I think this is a really good example of collaborative research producing something that's been really useful, and I quote these numbers all the time to patients that we see so if a patient doesn't have any of the things above, but they come in with basically pain controlled, their renal function is okay and they're not septic, and they say, have a 5 to 7 millimeters stone in the distal ureter. You can tell them they have about a 60% chance of passing the stone by themselves, and we will then just bring them back for monitoring a bit later. So what is a stent? This is obviously a stent on the right hand side, with a few of the arrows of other bits of calcification on it. Basically, a A stent is a plastic hollow tube, which you've got curly and that sits in the renal pelvis and curly and that sits in the bladder. You can see they're in. The Yellow Arrow shows that there's a a mid ureteric stone. It's just being pushed out of the way so the stent doesn't help with the stone passage. It's simply there to drain things and unobstructed. The other stones you can see on there. In the red arrows are probably gallstones. And in the left kidney, you see, on the left hand side, you've got a staghorn stone in the left kidney. So slightly interesting X ray with multiple pathologies on it. So I'm gonna try and show some videos now. Excellent. Um, so this one is I'm going to talk over this one because the chat and this one's a bit tedious. Um, this is basically what we do we're looking at when we're doing a cystoscopy on a patient. So this is you You coming along their urethra, uh, coming up towards the bulb urethra now and then coming up towards membranous, urethra through their pelvic floor muscles and then into the prostatic urethra in the mail before heading over the bladder neck into the bladder, giving us a nice view of that prostatic urethra there. We don't tend to inspect that in quite as much detail. This is a very full bladder is already pretty blown up, and we then have a look around the bladder to see if there's anything there. Now you'll see a little hole there in the middle of the screen. That's the right ureteral orifice. And then this pale white appearance with blood vessels running through it is completely typical of the bladder. So this is exactly what we're looking for And you see the left ureteral orifice might show a little ureteric jet in a second, where the urine Paris douses into the bladder and then basically this individual look around the bladder. See if there are any lesions or any stones that might be causing anything of interest. So that, fundamentally, is what a ureteroscopy entails. Now I think it's useful just to have some idea of what the different procedures are, so your doctor has recommend. Hopefully, you can hear that between you and your bladder. The medical term for this is a double J stent. The stent allows drainage of Europe from the kidney into the bladder by temporarily relieving any blockage caused by a stone in the urethra or an internal swelling outside of the urethra. The renal pelvis is the area where the kidney attached to one of the ureters urine flows from the kidney through the urethra into the bladder. When emptying your bladder, the urethra transports the urine from the bladder to the outside of the body. This animation shows a blockage in the urethra caused by a stone. Urine is unable to flow from the kidney to the bladder, causing congestion and sometimes pain. The procedure is usually done under general anesthesia. A tube with a tiny optic camera is inserted through the urethra into your bladder, the bladder is inspected and the urinary opening is located. A contrast study may be performed to assess the urinary tract and to locate the obstruction. X ray images can now clearly outline the your Rita and the obstruction. A so called guidewire is introduced through the camera into the kidney. The Double J stent is inserted over this guidewire. J shaped curls are present at both ends of the stent to hold the tube in place. X ray is used to check that both ends are in place in the kidney and the bladder. The stent is later on removed or is sometimes used as a temporary intervention before the removed. So that's basically the procedure for putting in a stent in um, and then, fundamentally, you'd allow the infection to settle, so the nephrostomy sort of put it in a similar type of way, but usually about an interventional radiologist in the UK for people working in America and Europe. Often a urologist will put that in, but it's not part of our training in the UK um, and then subsequently later on, ideally, 4 to 6 weeks later, infection settled and we come and try and treat the stone. And in this case, you might consider a ureteroscopy. So you have two different types of your ureteroscope. You've got a semi rigid, which is the long thin one at the bottom, or a flexible ureteroscope, which is often used for treating stones in the proximal urata in the kidney. Because you can actually get around the kidney, Um, have a proper look in each of the different callouses. And hopefully I can get this to play as well, hoping also that you can hear these videos. Your doctor, a ureteroscope with a tiny fiberoptic camera, is inserted through the urethra and bladder into the urethra or kidney. Ureteroscopy is used to remove kidney or urinary stones and enables a direct view of the ureter and kidney to confirm or rule out other abnormalities. This animation shows the removal of the kidney stone ureteroscopy is typically performed with the patient under general anesthesia. A small tube is passed through the urethra into the bladder, and from there up into the urethra and into the kidney. A contrast study may be performed to assess the anatomy of the renal collecting system Before stone removal. A contrast agent or die is administered through the tube into the ureter. As X ray images clearly outline the urinary channel and exact position of the stone. A so called safety wire that helps guide the ureteroscope through the urethra is inserted depending on the location of the stone. A rigid or flexible ureteroscope is passed through the urethra into the bladder, following the safety wire into the urethra, the small tube that drains urine from the kidney to the bladder. Once the stone is located, it may be pulled out directly with the so called stone basket. Or a laser was used to break the stone into smaller pieces before extraction. Using the basket after stone extraction, the collecting system is checked to ensure that there we go as simple as that. I apologize for the heinous way that they those videos, pronounce the word urata but hopefully get an impression. They're of how we clear a stone out and how we put a stent in. It's actually a remarkably satisfying procedure. Um, so the other way we can treat stones particularly popular in Edinburgh, is we can do lithotripsy. So here you have a little trip basically has an external shock wave device that focuses the beam of shock waves. Um, they're either, uh, if anyone's interested, we can talk about how literature has worked. Later on, there's a bit of fancy physics behind it, but basically it produces shockwaves focused on the stone, breaks them up, and then the patient pees out the stones themselves. And there's a pretty good success rate. And they're pretty comparable for your, uh, uric stones, at least between Lithotripsy and Ureteroscopy. And a lot of what you decide to offer is dependent on what you've got available in your unit and how easy it is to access, either, particularly as an urgent case. Um, in Edinburgh, we offer a lot of lithotripsy because we've got very good access to Lithotripsy outside of Edinburgh in Scotland. Most people probably go through a ureteroscopy first because they haven't got good access to lithotripsy Aberdeen's. Maybe the exception that, um, but fundamentally for a proximal ureteric stones, you might think about offering lithotripsy first the disk or urinary stones, maybe enteroscopy first but it's very dependent on the patient of what you've got available. So in summary, um, urology is great. I really enjoy both my specialty and my life. Um, infected obstructive kidneys, our urological emergency. The first step to do is resuscitate patients. Give him antibiotics and fluid early escalate, and then think about future management, which depends a lot on stone size location, and then the patient factors whether it be paying acute kidney injury or infection. Um, and I'm going to stop there, and then we'll move into the stop sharing my screen. All right, so we've got a question from the audience. Would spy glass gland a scope be be considered for treating stones? Uh, no, not really. At least I've not seen it used. I mean, Calagna scope, uh, is obviously for looking at stones within the biliary tree. Uh, so no, we don't tend to use that. Great. So there's no other questions. Thank you, Mr Blackman, for the fantastic presentation. We will now be moving into a breakout session for some case discussions. So these breakouts sessions can be found on the left side of the screen. Um, please kindly join the room which corresponds to your levels. Study. There are two rooms. So one is for clinical year students and f Y one and above, and the other is for pre clinical students. Um, so if you guys could just go to the break out rooms, uh, we'll see him there.