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Hi guys. Can everyone hear me? Just put a message in the chat if you can? Ok, great. Um So hi, my name's Pavia. Um I'm one of the fifth years at Manchester. Um I am just gonna be hosting the session today. Um So I'll just be in the background monitoring the chat, making sure everything's going smoothly. So today's gonna be a split session. It's on dermatology for the first hour and then there's gonna be ay teaching as well, so try and stay for that cos it is really useful. Um So without further ado I will hand over to Samia. Hi guys. Um just checking. Can you also hear me? Is my audio? Ok, I can hear you. Yeah, perfect. Ok. Yeah. Um So I'm one of the fifth years um at with Ensure uh and um I'm giving the teaching on ontology. So um in terms of the conditions that you need to know for finals, um these are the ones that come up on the UK MLA map. Um So this is like good to just have a like in the back of your mind of conditions that could come up um and things that you probably need to know for sure going into um like your Aussies. So, and these are, we're not gonna cover all of the conditions because some of the conditions are covered in other um like lectures. But yeah, uh so we're gonna go through eczema psoriasis acne the cancers. Um And then some like very brief ay tips on just how to describe skin things. Cos it's quite tricky to describe skin things. I find um uh some like brief counseling and then um a little bit of spikes but all of these things are probably better if you practice them rather than like me talking. Uh So just a quick little visual. Um So yeah, the skin is the epidermis, the dermis and then sometimes people call it the hypodermis or you can call it like subcutaneous fat just at the bottom. So yeah, so eczema. Um so I think most people will know what eczema looks like but it just um it's just good to recap. So uh people come in with quite dry skin um generally in like the flexor region. So in the like elbow creases um and then like on the face um it's quite itchy, it's very common in Children. Um they might have a family history of like asthma um or like hay fever. Er And as you can see this is so this is like a typical, I don't know if you can see my mouse but um the hand picture is like a very typical presentation of eczema. Um, and then the bottom picture of the child, um, that's actually eczema hepaticum, which is, um, when her herpes simplex virus is like overlaying the eczema. And that is, um, something that you'll need to refer to, um, the same day, pediatric assessment units. It's quite serious. Um, and the pediatricians will want to see that, um, that child. So, um, there's really no investigations for it. It's, um, clinically diagnosed. Er, and, um, it's, the mainstay treatment is really emollients. So, um, you want them to be consistently using emollients, even when they're not having a flare up, just the, the just getting into the habit of always, um, putting emollients on, um, is really beneficial to prevent future flare ups, uh, when they are having a flare. Um, you can think about things like, uh, topical steroids. Um, and like if necessary, if there is an overlying infection th thinking about antibiotics, uh, with Children, um, specifically you need to get everybody involved. So you need to, um, you might very well have a station where you're counseling parents on eczema because often times Children don't really like emollients, they think they're sticky and they smell weird. Um, and so, er, it's like important that the parents are really, um, invested in making sure their child is, uh, using the emollients cos otherwise, uh, you know, they're just gonna keep having these flare ups. Um, and in this little box here is, uh, just sort of like how you would describe, um, to somebody how they might use their emollients. So, um, there are loads of different ones. There's like dermal hydro base. Er, and like the honestly, there are so many, um, and some of them can be used as like soap substitutes. Um, and some of them are moisturizers, some you can use as soap and as moisturizer. So, uh it might be worth like learning one or two. just in case like this does come up as a station just to chat about. And also in GP, you'll be seeing a lot of eczema, right? This is the like eczema treatment ladder. I'm sorry, it's blurry. I couldn't find a less blurry picture but effectively like you're starting with emollients and they should be used the whole time on as much as the body as possible. And then you would go up and you would think about stuff like steroids. Um You might prescribe a steroid. It's very unlikely that like you, they will be going to see a dermatologist by the time, you know, there's like immunomodulators get involved or like um phototherapy. This is good to know cause it might be useful to be able to like counsel, but like you, I you would not be um involved in the care at this point unless you were obviously a dermatologist. Um And then just thinking ahead for like the P SA um and just like, generally like prescribing. Uh So you prescribe creams um as topical one application. That's how you write it in the like, um I like the, the software that they make us use for prescriptions. Um And it's good to have an idea of like one steroid per potency. So, on the um on the left here you can see that there's like a little acronym thing. So it's like help bud dermatologist. So hate being hydro. Um So thinking about like hydrocortisone cream as your mildest cream and then Yote going up one betnovate again, going up to potent and then Dermovate going up to very potent um with potent and very potent. You um can't prescribe them to be used on the face. So that's just something to think about. Um OK. Right. Uh So yeah, if any, no one has any questions on eczema, we'll move on to psoriasis. So, um psoriasis typically starts as a rash. It's more on the extensors rather than the flexors. So um on your like the backs of your elbow uh unlike your lower legs, um it can be quite dryer and very itchy. Um And there might be some associated nail changes which we can talk about. Um II have a picture on the other side. So um psoriasis typically has like a trigger so it could be alcohol or stress. Um And if you were taking a history from someone with psoriasis, it'd be good to figure out what it is that triggers their psoriasis because the best thing they can do apart from obviously take the medication is to avoid their trigger. Um So again, on your examination, you might find that they have psoriatic nails. Um but they will, if they have chronic plaque psoriasis, which is the most common type of psoriasis, they'll have um these like scaly red plaques. Um that will be very, very itchy, the other two types of psoriasis that are worth knowing. Um So gutte psoriasis is uh like it comes up on passed. Um So it's typically after like a strep throat infection and um you can google the picture but it's like little red dots basically on someone's back. Um And you, they'll need to be referred to dermatology. Uh And then the other one is pustular psoriasis and that's an emergency admission. That's like a red flag. Um Again, you can google an image of that, but because most likely what they're gonna give up you in an OSC would be a chronic plaque psoriasis. So, chronic plaque psoriasis, um you use potent topical steroids and a Vitamin D analog. Um and these can be used long term, the uh Vitamin D analogs, they can use long term and you want them to avoid their triggers. Um If that isn't controlling it. Uh again, things like phototherapy and then like systemic immunomodulators like methotrexate um could be used and then um there are also additional therapies like a tar based shampoo that, um, can be prescribed by, uh, I think dermatologists mainly, um, to use on the scalp. Um, someone with psoriasis, they can be managed in GP, but they will need to see a dermatologist first. So I guess that's worth thinking about if you're like, trying to counsel. Um, and then just down here there's some, uh, screening questionnaires that you can, um, sort of, I guess, offer, um, when you're thinking about, again, like investigations cos there really aren't investigations like this is clinically diagnosed. So, you know, you, you can think about, um, how it's affecting their daily life. Cos I think people with psoriasis tend to, um, it tends to really affect them. So, like thinking about how it would affect, yeah, their mental health and their like activities of daily living, um, with psoriasis, uh, you need to also if they do have psoriatic nails which look like this. Um, so again, you've got this pitting, um, you've got the oncolysis and the like redness all around the fingertip if they have that. And they also have associated joint swelling, um, specifically in psoriatic arthritis, they get whole finger swelling. It's called dactylysis. So, uh, if somebody has chronic plaque psoriasis, it's worth asking, do you have any joint swelling? Do you find that like a whole finger swells up or a whole toe? Um, uh, and then like asking if you, they've noticed any nail changes. Um, just to make sure that they, they don't have like an another condition alongside their psoriasis. Um ok, I hope that all makes sense. Uh So um what I wanted to talk about very briefly is erythroderma, which is basically an umbrella term for any time a skin condition takes over 90% or more of someone's body. This is um an emergency in dermatology. Er And so you can get like erythroderma with eczema, you can get it with psoriasis, you can get it with a, any dermatitis. Um and this person needs to be referred straight to hospital um because they'll likely be actually losing a lot of fluids from how like irritated their skin is. So they'll need fluid replacement and they'll need um they might need like nurses to come in and do like bandaging and things. So, yeah, it's good to just say like how much of your body is being affected by this rash. Uh just so that like the examiner and also just for safety, I think in the future. Right? Ok. Um The next thing is um acne. So again, I think these are things that like people might have come across in their own lives, but it's, here's a photo just in case. Um so it's an inflammatory condition where you get these bumps from the sebaceous glands and in the hair follicles around the face and you can have them also on the chest and the back and in the anal genital regions. So, um again, it's clinically diagnosed, but there are some uh like scales and scoring systems you can use to just, you know, I guess um further assess the acne uh you with, as with all um as you might know this if you've done the um of dermatology like block, yeah, but like with all skin conditions, you should offer a skin exam and that will involve like a head to toe check. Um So, yeah, worth noting. Um and then there's like some scoring systems that you can look into. Um acne can really affect people's self esteem. So you could do some like you could ask about like, how is this affecting your daily life? How is it affecting like, yeah, your self esteem and just good to get like a holistic view. Uh Yeah. So you, you'll mainly be seeing pustules, um Coumadins like papules and nodules with this again in like hair bearing regions. Um with the management, it's a little bit complicated and it is worth knowing um one or two. So, um with like mild to moderate acne, um you're gonna try a 12 week course of um topical Adele and then topical benzoyl peroxide. Um You uh so only a dermatologist can start a retinoid. So if that's something that's been considered, then you would um counsel the patient that they would have to go see a um a dermatologist um because um retinoid therapy with someone on retinal therapy they need to um if they're a woman, they do need to be on um some kind of uh contraception. Um And there's also some discussion around whether or not there's like mental health side effects from retinoid therapy. Um Again, I'm not gonna read them all out cos they are there and you will get the slides after. But um these are the ones uh that commonly are like the, the treated causes um for somebody with an Acne flare. Um And then down here, you can just see that um there are some indications for like oral retinoid therapy. There's an image in the chart. Oh OK. Uh Right. OK. Now, on to the cancers. Um So does anyone have any questions so far or I'll just wait? OK. OK. That's fine. So um we'll start with a ba basal cell carcinomas. So I've got a few photos up. Um They're typically these like pearly white firm nodules um that have some associated um like telling ectasia, which is just uh like blood vessels, basically like small blood vessels being seen. Um And they have something um that we call it rolled borders. So if you can see on the edges, it kind of like rolls in and then there's like a little dip in the middle. So like that rolling is like the rolled border and then it's got white and shiny. So it's like pearly. Um And then mostly like it's like typical risk factors and like in the places that you would expect to be exposed to a lot of sun in someone's lifetime. Um, so again, you should ask about like childhood, um, sunburns, like, were you in the sun a lot as a child? Um, did you ever wear sun cream? Did you ever have very bad sunburns if someone has quite fair skin, if they're like a Fitzgerald type one, that's, um, a risk factor. So that typically is people who are like very pale. Um, it can be people who have red hair, things like that. Um, and then people asking people about their radiation exposure if they've had um, like chemotherapy before. Uh, so with the skin cancers, it's, you need to two week wait people as you would expect. Um, and then they will go and see a dermatologist who will, um, do ad dermatoscopy, which is basically like a magnifying glass and they just like, look at the lesion under the, the dermatoscope, um, and they will do a skin biopsy and they'll send that to the lab. Um, and then if they worried there might be a staging ct scan, um, that's pretty much the same for all of the, um, skin cancers, which it's quite easy to remember. Um, in terms of management, it's just, it's basically just getting rid of it. Um, so, yeah, so if they're fit for surgery, um, you can just cut it out effectively. Er, and then if there's any need later on, like, because of the staging or because of the immunohistochemistry, they can have radiotherapy. Um, but if they're not fit for surgery for whatever reason, if they just don't think they would tolerate it, um, or they're just not very f, like, they're not, well, um, you can try things like cryotherapy. Um, and this, like, special, like chemo cream. Ok. So that's basal cell carcinomas. Um, so squamous cell carcinomas. Er, they're, they're a little bit like crustier. I, if that's a word, like they're just like, um I've shown a lot of photos cos I wanted to kind of like you to get the sort of spread of like how they can present. Um but they're typically crusted because it's like they're, they're hyper um keratotic, like there's a lot of like um keratosis production, like keratin production. Um and these are quite painful and they're growing quite quickly and they're on their own. Um And they might have like a central ulceration. Um but they, but also they could just be like a uh like a spot basically that's just like, not going away and is like crusting and, and never healing. Like a lot of, especially in, like GP people will come in and say like, oh, I have this like, um I have something on my head and it just like, it's just not healing. I keep, I keep putting creams on it and it's just not going away and that's a really that's like a sort of a buzzer in your head to think this could be a cancer cos it's just not quite going away. Um, and then there's, yeah, so again, it's the same thing of like two week, wait them, um, get a dermatologist to look at it and then you just remove it effectively and then stage it and if they need chemo or radiotherapy, then that's like a decision for the skin cancer. MDT. Um, so with squamous cell carcinomas, there's a little bit like extra with them, I suppose. So, uh, people can have acetonic keratosis, which, um, is like a dysplasia but it's not necessarily like precancerous, it's just dysplasia, like the cells aren't quite right. But they're not, it's not like for sure going to turn into cancer. It's, yeah, it's just a dysplasia. Um, and they're quite common, like on the tops of like men's bald heads. Cos obviously that's getting a lot of skin ex, um, sun exposure. Er, and that can be treated with, um, this like Efudex cream and basically patients put it on for like a certain number of weeks. I think it's like five weeks. Um, and then you ask them to come back in to GP and just reassess, um, if it's worked and then they can have another, like, um, tube of cream and then if it's, if it hasn't gone away, so that's quite common, um, on people's heads and they're not very pain, they're not painful at all. Um, and yeah, and then the next one along so it's a little bit more dysplasia, but again, it's not quite precancerous. It's just like if you, you want to treat it because it could turn to cancer but it might not turn to cancer type of thing. It's bow disease. Um, so, yeah, this one is like, typically on the legs rather than on the head. Um, and it's a single plaque, er, again, and you treat that with cryotherapy and then if those two things were to be left untreated and you were very unlucky, um, that could then turn into a squamous cell carcinoma, um, which is painful and like, yeah, as you can see it's not very pleasant. Ok. And then, um, finally, um, malignant melanomas. So, um, these are, you're like, I think this is what people typically think of when they think of skin cancer. Um, so as you can see, um, there's lots of different, I have put, you know, lots of different pictures up. Um, but effectively it's a mole that doesn't look quite right. You know, so it's asymmetrical. Um, it's got an irregular border, it might have lots of different colors in it. So, like lots of, like darker browns and blacks. Um, it's growing importantly. Um, and then the other, and the other thing is that it just doesn't really quite fit in, it just doesn't look like the other surrounding moles. Um, so in terms of risk factors. It's the same as, as usual and it's people who have had a lot of sun exposure as a child. Um, people who sunburn a lot, people who don't use suncream, people who use sunbed. Um, yeah, people with like very light hair or red hair. Uh and then people who've previously had skin cancer will be at risk of having skin cancer, obviously because they've already got those risk factors. Um As with all of the skin cancers, you, you take it out. Uh and then you check it that it hasn't spread anywhere and with the Melanoma, um you're asked to come back um for a follow up. Um So yeah, that's something you can think about when you're counseling. Um And then just down at the bottom, I've got the two week wait criteria for a Melanoma. So yeah, it's a new mole that's growing quickly. Um or a mole that's changing in shape or color or a mole that has three or more colors and has lost its symmetry. Um And you can find those criteria on the nice guidelines as well. OK. So that's kind of like the information part. Um I know it was quite quick but I think, I mean, dermatology is only a week long, so it, I don't want to overwhelm you as well with like information and as you saw at the beginning, the UK MLA map isn't massive. Um I think it's just important that you get like a good foundation. Um So with skin cancer counseling, uh this is potentially a station that might come up. So just somebody who's had skin cancer before is seeking advice on how to stop um how to like minimize their risk factors in the future. So, um things like always wear a hat in the sun, try to never burn, stay inside um during like peak hours and then checking your sun cream rating. So you want it to be um of like SPF 30 to 50 then have a star rating of, of three or four and you want it to protect against UVA and UVB. Um And then saying things like, you know, always apply your sun cream before exposure, apply it after you go into the water cos it like comes off, um apply it every two hours, make sure that you're wearing um thickly weaved fabric so that you're not gonna burn through the fabric of your clothing. Um and wear dark colors in the sun if you have to be outside, obviously. And then other things like, you know, avoid sunbed exposure. Um It's really hard skin cancer because it's cumulative. So like you can't necessarily undo or you can't undo the sun exposure that you've had in your lifetime, but you can minimize further sun exposure, right? Um And then here's the things like this is the thing I found the trickiest. Um and still find quite tricky is like describing lesions and describing rashes. Uh So I'm just gonna go through them. I think this is a good side to like maybe screenshot and like, you know, just have it in your head. So um the first thing you want to do is like, is it one lesion or is it many uh that will kind of narrow down things pretty quickly if it's just one thing like a, so you think it's maybe a cancer versus like if it's many things, then you're thinking more like rash. Um And then what is the lesions? So these are all the like dermatology words to describe lesions? So, is it a macule, is it a patch? Is it a papule? A nodule, a plaque, a vesical bulla pustule wheel? Um It's yeah, it's good to just have these to just learn them er because they do really help with description and then is it a discrete lesion? So is it on its own? Is it confluent? Is it like merging with the other lesions around it? If there are other lesions around it? Is it linear or um like annular discoid? Uh Targetoid? Er So that's sort of like describing the actual shape of the lesion. And then you're gonna start to think like, I mean, you can do where is the lesion wherever but um I think when you phrase it, it's like use what it's like a solitary lesion like a solitary plaque that that's discrete on the elbow, you know, if you were gonna say talk about like psoriasis. So, yeah, remember to, to say where the lesion is cos that's really important. Um And then talking about color. So um erythematous just means red and puric is like purple. And so then you're identifying like if it's a small purple dot then it's like petite K and then so on and so forth. Um Hyper pigmented obviously means like lots of color and then hypo would be less um like kind of duller and then depigmented like there's no color to it. Um And then finally, you can add in things like um is it crusting? Is it bleeding? Uh Is it like eroded in any way? So like it has like the superficial epidermis, like is it, is that gone? Is it ulcerated? Um Is there like any um like associated like scratching that you can see? So that's like ation. Um A lynch education is like when you can see like rough well-defined skin um from all of like the scratching. So you get that in like eczema typically. So, um I think I'm just gonna ask you guys to 00 no. OK. I thi this was supposed to come up as like two different um slides. It doesn't matter. So, right. Um Does anybody wanna guess at what this lesion is in the chart? Like what, what's the diagnosis? Yeah. Yeah. So it's a, it's ABCC. Um And then on the side I've described it. So um in a way that would maybe like if you were say to have it um given to you in an ay, you could say, OK, so I can see that this is a singular lesion. You can honestly just say like on the cheek, um a singular lesion on the cheek, it's well defined. It's erythematous circular in shape with shiny roll, rolled edges. You can see there's a some central um umbilication with like and it's ulcerated and then there's some associated Te Taia. So yeah. Um could the station be described the lesion? And with the um I do, I don't think so because in fourth year, what I really remember is there were like lots of um half and half stations like it was a lot of like take a history and then look at this data um or like take a history, then do an exam. That was, they quite liked that in fourth year. So I think it's more likely that you would have a station where this would, would either be like maybe an sbar. So like they would show you the picture and then you'd have to um maybe an sbar. Um but it's, I mean, I don't know why would it, it's not an emergency. So I don't know or like they showed you the photo that you had to counsel the patient or they showed you a picture. Um And you had to, yeah, like explain or you took a history and then, and then they showed you the picture and then you had to explain. Yeah, one of those, like they tend to mix things up a bit in fourth year to make it even trickier. Um OK. Right. And then, um this is more of a rash. So this is multiple lesions. Um They're patches as you can see because it's flat and it's over a centimeter. Uh it's bilateral on both legs. Um And there's like some on the knees as well. It's erythematous. They're irregularly shaped like you wouldn't be able to really define necessarily a strict border all like on all of them all the way. Um And they're confluent in some areas. So that's meaning like the borders are a bit muddled. Uh This one's a bit trickier but does anyone know what this is? No. Um OK. So this one is Erythema nodosum. Oh, yeah. Well done Joseph. Yeah, it is tricky. Um I just thought it'd be a good example of like a rash so that we could do like a lesion and a rash. Um OK. Right. And then, OK, so the next thing I wanted to cover with you guys is counseling. So um I had a psoriasis counseling, IOP psoriasis drug counseling station um in my Aussies. Um So it's very, it's, it's quite, it's definitely something that they can examine you on. Um I think probably at this point most people do know how to counsel. So like it is obviously you can use this like B CS like these um you can use the acronym if it helps you. But generally speaking, like you just need to ask the patient, you know, like just cos it's the first time we've met like, do you mind telling me a little bit about like what's brought you here checking? Like OK, like what do you understand about the diagnosis you've been given? Right? Is there anything you're worried about? And then um I've just gone a little bit into like the explanation part cause I think that's probably the trickiest part when you are counseling psoriasis or like any condition really. So, psoriasis is a systemic autoinflammatory condition where the top layer of your cells are overstimulated um which then creates um oh hang on, I'll just finish, which then creates these like thickened plaques um that are red and very sore and itchy because obviously you have all this extra skin that's built up. Um It can be caused by stress factors. Um But also it's often times genetic and people just have a genetic predisposition to developing psoriasis. Um And the thing that we're concerned about with psoriasis is that we don't want it to become um if we don't want it to obviously affect your daily life and we don't want it to get to a point where it covers a lot of your body because that would then obviously be you could be in a lot of pain and you'd have to come into hospital to have treatment for it. So we want to manage it now, at home with um some creams. So we're gonna give you some um, like thick moisturizing type creams, which are called emollients. Um And then we'll also give you um, some creams that have like Vitamin D in them and that can really help with the um overproduction of the skin cells. Um Things that you can do at home are finding out what your trigger is and avoiding it. So if your trigger is alcohol or smoking, um cutting down and trying to stop. Um And yeah, things like weight management because with psoriasis and eczema, um sweat can really aggravate these um these conditions. So like just trying to um make the patient as healthy as possible. Um Obviously, it's like in the summer, it's gonna be unavoidable, but, you know, just something to think about. Um just to answer Joseph's question. So, did you have to explain the management of psoriasis? Um So what you had to do was, oh, hang on, you were given. Um So a patient came in and they were having a medication change for their psoriasis and you had to explain, you had to basically find out why they were having the medication change. Do a brief explanation of what psoriasis is. Cos they were like, they didn't quite know and then explain how this medication change was going to um help them with their psoriasis and then there were like a few questions from the examiner at the end about the medication. Um Yes. So I hope that answers your question. Uh in terms of when you're like, feeling a bit confused because with these like one week blocks, it's quite easy to just get, I think, a bit like, overwhelmed because there's so much content and it's just all coming at you. Um, I found that podcasts are really helpful. So, yeah, if you find, if there's like one specific or a couple of conditions that you just really, like, can't get your head round and you didn't manage to see them whilst you're on placement. Um, podcasts are really good. So, er, this, there's like shorter ones. So this one on the left is only six minutes and then this one on the right is um, like half an hour, but just tailor it to like how much you want to understand and how confused you are. And I think that would, that's really gonna help. Um, I listened to the psoriasis one personally and I found that quite useful because um, they really go into like the causes of psoriasis. Whereas, um sometimes, like, I think people would just say, oh, it's just like, you know, it's a bit genetic, like it, it, sometimes it happens. So it just depends on like your, um, like how much, how confused you are and also how much time you have. Right. Um, and then really briefly, um, there is the possibility that in fourth year you need to break bad news. Um, and so they could ask you to do a skin cancer breaking bad news, um, or like really any dermatological condition, you could potentially have to, um, great bad news, but I suppose more likely to be a skin cancer. Um, so I've just written out the two week wait criteria down there and then um the spikes. So again, I think it's pretty like you guys probably know this and if you don't know it, then really don't worry about it because they go over spikes a lot in um like M and M and then also you go over a lot in like the f in like the beginning of fifth year. So yeah, like setting. So make sure, I mean, you're obviously in an osk scenario. So like you're, you, you will be in a side room and you will be un uninterrupted, but like, you know, you can say like, are you comfortable with me having a chat with you here? Would you like anybody else in the room with you? Um Then polite perception. So what is it that like you be, you, you were hoping to discuss today, you know, like, because we don't know what they think they're coming in for and most likely they'll be like, oh, like I'm here for like the results of my biopsy and then you would say like, ok, like um that's fine. Like would you like me then to just discuss the biopsy with you? I can go through the results with you today and they'll be like, yeah, that's great. Please do. Um and then you can say, and then that's when you get into like the knowledge bit and you need to kind of give, I suppose like your warning shot. So saying, like, unfortunately the biopsy shows that, um, the mole had a more serious, uh, cos and then, um, yeah, you give it like a pause. It's important to give pauses. Um, it helps, I think a lot with like setting the tone and not feeling like you're rushing through it. Um, and then saying, so, like we carried out the investigations on the biopsy and we found that it was a skin cancer giving them pause. Um, I think with spikes, the most important thing to do is let the patient or like, and especially in an osk, let the sp like have time to, so don't be afraid to just not really say anything for a bit. I know it's like counterintuitive cos it's an exam and you're like, obviously time inhibit, like inhibited. But like, I think sometimes with spikes the, it would be honestly worse to say the wrong thing than it would be to say just to like, let someone sit with it. Um, so, yeah, that would be my top tip is to deliver the bad news in like short increments of very direct messaging. Like, don't say, oh, we think maybe that like just say, like, you know, be direct, say it concisely and um and then just pause and just wait uh obviously remember to be empathetic the whole time. And um at the end, you can say, uh so we've had a chat with the other members of the team. Um, and they think that it would be a good idea for you to start some, um radiotherapy just to make sure that we get all of the cancer and we haven't accidentally left any behind. How do you feel about that? Yeah, something like that. Um I think it'd be quite a nice one, to get, to be honest. Um, because uh yeah, I think you, you can do it quite well. Right? Ok. Uh So that's the end of the, like um the, my talk basically, er, and then if you want to stay, um, there's like an OSK style revision session happening um, in a little bit. Ok. So thank you. Do you have any questions? Um Thanks Samia. That was really useful. Um Can you guys just let me know if you're gonna stay for the osteopro by just popping a yes in the chat? Ok, great. So as far as the osk practice goes, our facilitators will probably join in a couple of minutes. Um, but I think in the meantime, you can probably just join the breakout rooms and wait those couple of minutes for them to join. Um, I think that's probably the best way of doing it. So, um, how many are you? Yeah. 123456. Ok. So let's see. So maybe Joseph Faze and Irene if you want to join. Oh, actually, sorry. Oh, with the slides, um basically you'll get sent feedback um automatically if you just fill out that feedback, you'll get the slide sent to you afterwards. Um Yeah, so maybe Joseph faze if you join Danny's Breakout room. Um Irene and Netra, if you join Sag's Breakout room and then Anastasia and Ravi her. If you join Wah's Breakout room, then I think that's the best way of doing it. Um F if you join Danny's breakout room, um and Dania and you just wanna join your breakout rooms, they're just on the left and you just click on them to join.