1 00:00:06,172 --> 00:00:10,343 >> GOOD AFTERNOON, EVERYONE. 2 00:00:10,343 --> 00:00:12,178 WELCOME TO THE NEW YEAR. WE 3 00:00:12,178 --> 00:00:14,780 WILL START OFF WITH A CPC CASE 4 00:00:14,780 --> 00:00:16,782 AND THOSE INTERESTED IN 5 00:00:16,782 --> 00:00:18,551 OBTAINING CME FOR TODAY'S TALK 6 00:00:18,551 --> 00:00:22,521 THE CME CODE IS 57869 AND TEXT 7 00:00:22,521 --> 00:00:24,557 THIS CODE TO HOPKINS NUMBER THAT 8 00:00:24,557 --> 00:00:26,659 IS ON THE SLIDE TO RECEIVE 9 00:00:26,659 --> 00:00:28,227 CREDIT FOR THIS LECTURE. 10 00:00:28,227 --> 00:00:29,762 A COUPLE HOUSEKEEPING THINGS 11 00:00:29,762 --> 00:00:31,397 BEFORE WE BEGIN, WE WOULD 12 00:00:31,397 --> 00:00:32,999 APPRECIATE IT IF YOU COULD 13 00:00:32,999 --> 00:00:35,034 PROVIDE US FEEDBACK FOR THIS 14 00:00:35,034 --> 00:00:37,503 TALK AND ALL CLINICAL CENTER 15 00:00:37,503 --> 00:00:39,772 GRAND ROUNDS TALKS THROUGH THE 16 00:00:39,772 --> 00:00:42,541 LINK PROVIDED WHEN YOU SUBMIT 17 00:00:42,541 --> 00:00:45,478 YOUR CME AND GET AN E-MAIL AND 18 00:00:45,478 --> 00:00:47,513 IF YOU COMPLETE THAT, THAT WOULD 19 00:00:47,513 --> 00:00:49,148 BE VERY MUCH APPRECIATED TO USE 20 00:00:49,148 --> 00:00:51,684 THAT TO PREPARE FOR FUTURE GRAND 21 00:00:51,684 --> 00:00:53,719 ROUNDS TOPICS AND WE WILL SAVE 22 00:00:53,719 --> 00:00:55,321 THE QUESTIONS UNTIL THE END OF 23 00:00:55,321 --> 00:00:57,323 THE TALK AND QUESTIONS FROM THE 24 00:00:57,323 --> 00:00:58,758 LIVE AUDIENCE, WE WOULD 25 00:00:58,758 --> 00:01:01,027 APPRECIATE IT IF YOU WOULD MOVE 26 00:01:01,027 --> 00:01:03,195 TO THE AISLES AND USE 27 00:01:03,195 --> 00:01:05,698 MICROPHONES TO AISLES AND THOSE 28 00:01:05,698 --> 00:01:07,533 VIEWERS ONLINE A LIVE FEEDBACK 29 00:01:07,533 --> 00:01:09,502 BUTTON ON THE PAGE TO USE THAT 30 00:01:09,502 --> 00:01:11,570 AND SUBMIT QUESTIONS TO GET TO 31 00:01:11,570 --> 00:01:13,172 THE END OF THEM AND END OF THE 32 00:01:13,172 --> 00:01:15,207 TALK IF TIME PERMITS AND TODAY'S 33 00:01:15,207 --> 00:01:17,777 SPEAKERS ARE GOING TO TALK ABOUT 34 00:01:17,777 --> 00:01:23,182 THE GLOBAL MULTI-DISCIPLINARY 35 00:01:23,182 --> 00:01:24,850 MANAGEMENT OR SEVERE 36 00:01:24,850 --> 00:01:27,353 TUBERCULOSIS AND THANKS FOR 37 00:01:27,353 --> 00:01:29,121 JOINING ME WITH [INDISCERNIBLE] 38 00:01:29,121 --> 00:01:33,092 FELLOW AT CENTER FOR CANCER 39 00:01:33,092 --> 00:01:35,761 RESEARCH AT SKI AND 40 00:01:35,761 --> 00:01:38,464 [INDISCERNIBLE] A CHIEF OF THE 41 00:01:38,464 --> 00:01:40,066 BODY IMAGING SECTION THERE AT 42 00:01:40,066 --> 00:01:44,070 CLINICAL CENTER AND DR. SHAMIS 43 00:01:44,070 --> 00:01:48,274 CAR ASSOCIATE RESEARCH PHYSICIAN 44 00:01:48,274 --> 00:01:50,843 IN THORACICS BRANCH AND 45 00:01:50,843 --> 00:01:54,480 [INDISCERNIBLE] AN ANO-TOMIC 46 00:01:54,480 --> 00:01:55,381 PATHOLOGY RESIDENT IN LABORATORY 47 00:01:55,381 --> 00:02:00,553 AT NCI AND LAST BUT NOT LEAST 48 00:02:00,553 --> 00:02:04,924 KEVIN FEN ELLY WHO IS IN 49 00:02:04,924 --> 00:02:07,727 CRITICAL CARE MEDICINE AND 50 00:02:07,727 --> 00:02:09,228 PULMONARY BRANCH OF LBI. 51 00:02:09,228 --> 00:02:13,933 WITH THAT I WILL HAND IT TO DR. 52 00:02:13,933 --> 00:02:14,266 LORRAINE. 53 00:02:14,266 --> 00:02:18,304 THANK YOU. 54 00:02:18,304 --> 00:02:20,072 >> ALL RIGHT. WONDERFUL AND 55 00:02:20,072 --> 00:02:22,008 THANKS FOR THAT INTRODUCTION. 56 00:02:22,008 --> 00:02:24,343 I WILL BEGIN TALKING A LITTLE 57 00:02:24,343 --> 00:02:26,379 ABOUT THE PATIENT PRESENTATION 58 00:02:26,379 --> 00:02:28,014 AND CLINICAL COURSE AND NEITHER 59 00:02:28,014 --> 00:02:32,084 I NOR PRESENTERS TODAY HAVE ANY 60 00:02:32,084 --> 00:02:34,620 DISCLOSURES AND NOTABLY WE WILL 61 00:02:34,620 --> 00:02:36,622 TALK ABOUT DUR ANNACE ALPHA AND 62 00:02:36,622 --> 00:02:38,691 USE DURING THIS CASE AND ALSO 63 00:02:38,691 --> 00:02:41,193 SHOWING PATIENT PHOTOGRAPHS THAT 64 00:02:41,193 --> 00:02:42,895 PATIENT CONSENT HAS BEEN 65 00:02:42,895 --> 00:02:47,566 OBTAINED AND THIS IS A 20 YEAR 66 00:02:47,566 --> 00:02:48,601 OLD GENTLEMAN WHO PRESENTED 67 00:02:48,601 --> 00:02:52,004 INITIALLY IN APRIL 2023 TO LOCAL 68 00:02:52,004 --> 00:02:54,273 OUTPATIENT CLINIC IN GAMMIA AND 69 00:02:54,273 --> 00:02:56,976 WITH ONE MONTH OF SYMPTOMS 70 00:02:56,976 --> 00:02:59,011 INCLUDING FEVER AND PRODUCTIVE 71 00:02:59,011 --> 00:03:00,646 COUGH AND NOTABLE FOR NIGHT 72 00:03:00,646 --> 00:03:03,082 SWEATS AND WEIGHT LOSS AND 73 00:03:03,082 --> 00:03:05,251 OTHERWISE HEALTHY AND NO KNOWN 74 00:03:05,251 --> 00:03:07,119 PAST MEDICAL HISTORY OR NO PRIOR 75 00:03:07,119 --> 00:03:09,622 TB AND HISTORY WAS NOTABLE FOR 76 00:03:09,622 --> 00:03:11,223 HIM BEING A STUDENT LIVING AT 77 00:03:11,223 --> 00:03:13,459 HOME WITH MOTHER AND SISTERS AND 78 00:03:13,459 --> 00:03:15,428 HAVING NO KNOWN SICK CONTACTS OR 79 00:03:15,428 --> 00:03:18,631 CONTACTS WITH TB AND INITIAL 80 00:03:18,631 --> 00:03:22,735 WORKUP DEMONSTRATED A POSITIVE 81 00:03:22,735 --> 00:03:28,074 SPUTIM AFB SMEAR AND MOLECULAR 82 00:03:28,074 --> 00:03:31,043 ASSAY POSITIVE FOR TUBERCULOSIS 83 00:03:31,043 --> 00:03:32,278 AND [INDISCERNIBLE] RESISTANCE 84 00:03:32,278 --> 00:03:37,416 AND WAS HIV NEGATIVE HE WAS 85 00:03:37,416 --> 00:03:40,086 STARTED ON THERAPY ON OUTPATIENT 86 00:03:40,086 --> 00:03:42,188 BASIS AND PRESENTED AGAIN 1 87 00:03:42,188 --> 00:03:44,290 MONTH LATER WITH ONGOING 88 00:03:44,290 --> 00:03:46,492 SYMPTOMS FEVER AND WORSENING OF 89 00:03:46,492 --> 00:03:48,060 SHORT BREATH AND AMBULATION AND 90 00:03:48,060 --> 00:03:49,462 HAD IMPROVEMENT IN COUGH AND 91 00:03:49,462 --> 00:03:52,064 SPEED OF PRODUCTION AND VITALS 92 00:03:52,064 --> 00:03:53,699 WERE NOTABLE FOR TACKICARDIA 93 00:03:53,699 --> 00:03:57,837 WITH HEART RATE IN 150S AND 94 00:03:57,837 --> 00:03:59,371 DESATURATIONS TO LOWER 90S AND 95 00:03:59,371 --> 00:04:02,007 UPPER 80S AND AT THIS POINT 96 00:04:02,007 --> 00:04:04,043 ADMITTED TO MEDICAL RESEARCH 97 00:04:04,043 --> 00:04:05,978 CENTER IN GAMMIA AND 98 00:04:05,978 --> 00:04:09,982 DEMONSTRATING LARGE RIGHT SIDED 99 00:04:09,982 --> 00:04:10,683 HYDROPNEUMOTHORAX AND 100 00:04:10,683 --> 00:04:12,318 [INDISCERNIBLE] AND INFILL RATES 101 00:04:12,318 --> 00:04:14,420 ON THE LEFT AND INSERTED AT THIS 102 00:04:14,420 --> 00:04:17,089 TIME WITH MINIMAL IMPROVEMENT. 103 00:04:17,089 --> 00:04:20,426 HE WAS ALSO STARTING ON 104 00:04:20,426 --> 00:04:21,627 ANTI-BIOTICSES FOR POSSIBLE 105 00:04:21,627 --> 00:04:24,730 SUPERIMPOSED COMMUNITY ACQUIRED 106 00:04:24,730 --> 00:04:28,767 PNEUMONIA AND CHILD ON MULTIPLE 107 00:04:28,767 --> 00:04:30,736 REGIMENTS SEEN ON SLIDE WITH 108 00:04:30,736 --> 00:04:34,440 MINIMAL IMPROVEMENT AND ONGOING 109 00:04:34,440 --> 00:04:35,908 FEVERS THRU ENTIRE HOSPITAL 110 00:04:35,908 --> 00:04:39,445 COURSE AND REPEATED AND SHOWED 111 00:04:39,445 --> 00:04:42,348 LARGE HYDROPNEUMOTHORAX AND THIS 112 00:04:42,348 --> 00:04:45,951 POINT KERTING A TRAPPED LUNG 113 00:04:45,951 --> 00:04:49,688 FROM [INDISCERNIBLE] 50ULA AND 114 00:04:49,688 --> 00:04:51,590 GIVEN MINIMAL CLINIC IMPROVEMENT 115 00:04:51,590 --> 00:04:53,459 THAT THIS PAKIENT HAD TEAM 116 00:04:53,459 --> 00:04:55,728 DECIDED TO PLACE INTERNATIONAL 117 00:04:55,728 --> 00:04:57,730 REFERRALS INCLUDING CT SURGERY 118 00:04:57,730 --> 00:05:00,199 TEAM IN SENEGAL AND PULMONARY 119 00:05:00,199 --> 00:05:02,668 TEAM IN UNITED KINGDOM AND BOTH 120 00:05:02,668 --> 00:05:03,969 WHICH FELT THEY DIDN'T HAVE 121 00:05:03,969 --> 00:05:05,905 ANYTHING FURTHER TO OFFER THE 122 00:05:05,905 --> 00:05:07,806 PATIENT AND AT THIS POINT THEY 123 00:05:07,806 --> 00:05:11,110 REACHED OUT TO NIH THROUGH MEANS 124 00:05:11,110 --> 00:05:13,779 OF ANYAD AND NLBI AND FURTHER 125 00:05:13,779 --> 00:05:16,015 DISCUSSIONS FELT WE HAD OPTIONS 126 00:05:16,015 --> 00:05:17,683 FOR PATIENT AND ARC CREPTED AND 127 00:05:17,683 --> 00:05:19,652 ULTIMATELY TRANSFERRED TO NIH IN 128 00:05:19,652 --> 00:05:23,923 AUGUST OF 2023 AND TRANSFER WAS 129 00:05:23,923 --> 00:05:25,357 UNCOMPLICATED WITH A TEST TUBE 130 00:05:25,357 --> 00:05:26,358 IN PLACE AND INITIAL 131 00:05:26,358 --> 00:05:29,228 PRESENTATION HERE AT NIH VITALS 132 00:05:29,228 --> 00:05:32,064 WERE NOTABLE FOR TACKICARDIA AS 133 00:05:32,064 --> 00:05:33,699 WELL AS NOTABLY HIS WEIGHT WAS 134 00:05:33,699 --> 00:05:38,404 44 KILOS WITH BMI OF 14 135 00:05:38,404 --> 00:05:40,739 CONSISTENT PRETTY SEVERE 136 00:05:40,739 --> 00:05:42,808 MALNUTRITION AND PHYSICAL EXAM 137 00:05:42,808 --> 00:05:46,845 NOTABLE FOR CABBING AXIA AND 138 00:05:46,845 --> 00:05:49,248 SEVERE MOTOR SENSORY 139 00:05:49,248 --> 00:05:50,549 NEUROPATHIES AND ADDITIONAL 140 00:05:50,549 --> 00:05:53,285 WORKUP WAS DONE AND CRP WAS 66 141 00:05:53,285 --> 00:05:55,521 AND BLOOD CULTURES AND IMAGING 142 00:05:55,521 --> 00:06:00,726 WAS DONE AND NOTABLY HIS RIGHT 143 00:06:00,726 --> 00:06:03,429 PLURA FLUID GREW A 144 00:06:03,429 --> 00:06:04,597 [INDISCERNIBLE] STENOAND 145 00:06:04,597 --> 00:06:09,535 PSEUDOMOWNIS CONSISTENT WITH 146 00:06:09,535 --> 00:06:12,771 POLYMICROBIAL AND MPIEMA AND 147 00:06:12,771 --> 00:06:16,075 REGIMENT AND NOTABLY AMBEAUTAL 148 00:06:16,075 --> 00:06:16,909 AND [INDISCERNIBLE] WERE HELD 149 00:06:16,909 --> 00:06:21,513 GIVEN NEUROPATHIES AND AMMI 150 00:06:21,513 --> 00:06:23,682 CASEIN WERE ADDED TO REGIMENT. 151 00:06:23,682 --> 00:06:25,618 MULTIPLE TEAMS INVOLVED IN HIS 152 00:06:25,618 --> 00:06:31,824 CARE INCLUDING ANYAD AND HIB 153 00:06:31,824 --> 00:06:42,101 PULMONARY TEAM. 154 00:06:44,136 --> 00:06:46,272 IT WAS DECIDED PATIENT NEEDED 155 00:06:46,272 --> 00:06:48,641 FURTHER OPTIMIZATION PRIOR TO 156 00:06:48,641 --> 00:06:51,377 PROCEEDING TO OR TO ENSURE BEST 157 00:06:51,377 --> 00:06:53,746 OUTCOMES FOR PATIENT AND ABLE TO 158 00:06:53,746 --> 00:06:55,781 REGAIN 6 KILOS AND WORK 159 00:06:55,781 --> 00:06:57,383 DILIGENTLY WITH PCHLTD T AND OT 160 00:06:57,383 --> 00:07:00,085 PRIOR TO PROCEEDING TO OR AND 161 00:07:00,085 --> 00:07:03,522 ENDED UP UNDERGOING RIGHT 162 00:07:03,522 --> 00:07:06,592 THOROUGH CLOTOMY AND RIGHT NUM 163 00:07:06,592 --> 00:07:08,460 ONECTOMY AND FLAP CREATIONS IN 164 00:07:08,460 --> 00:07:10,763 SEPTEMBER OF 2023 AND FURTHER 165 00:07:10,763 --> 00:07:12,064 DETAILS OF THE SURGICAL 166 00:07:12,064 --> 00:07:13,632 MANAGEMENT WILL BE DISCUSSED BY 167 00:07:13,632 --> 00:07:16,869 DR. CAR IN A LITTLE MORE DEPTH 168 00:07:16,869 --> 00:07:19,538 IN UPCOMING PORTION OF THIS 169 00:07:19,538 --> 00:07:19,905 TALK. 170 00:07:19,905 --> 00:07:22,141 HIS POST-OP ITERATIVE COURSE WAS 171 00:07:22,141 --> 00:07:24,009 AS EXPECTED AND HE WAS TAKEN TO 172 00:07:24,009 --> 00:07:26,712 THE ICU FOR RECOVERY AND 173 00:07:26,712 --> 00:07:28,714 UNDERWENT MULTIPLE PLANNED RIGHT 174 00:07:28,714 --> 00:07:30,716 VATS AND WASHOUTS DEMONSTRATING 175 00:07:30,716 --> 00:07:32,551 NO SIGNS OF INFECTION IN THE 176 00:07:32,551 --> 00:07:37,356 RIGHT CHEST AS WELL AS IN TACT 177 00:07:37,356 --> 00:07:40,125 BRONXIAL STUMP AND DOWNGRADED TO 178 00:07:40,125 --> 00:07:43,162 FLOOR POST-OP DAY 12 AND 179 00:07:43,162 --> 00:07:44,196 CONTINUED TO DO WELL FOR QUITE 180 00:07:44,196 --> 00:07:46,432 SOME TIME PREPARING FOR LOS OR 181 00:07:46,432 --> 00:07:48,934 FLAP REVERSAL AND CHEST CLOSURE 182 00:07:48,934 --> 00:07:50,369 AND WORKING WELL WITH NUTRITION 183 00:07:50,369 --> 00:07:53,872 AND PT AND OT THAT IS UP UNTIL 184 00:07:53,872 --> 00:07:55,841 END OF JANUARY OR EARLY FEBRUARY 185 00:07:55,841 --> 00:07:58,110 WHEN HE DEVELOPED FEVERS AS WELL 186 00:07:58,110 --> 00:08:01,213 AS A NEW LEUKOCYTOSIS AND RISING 187 00:08:01,213 --> 00:08:05,551 CRP AS CAN BE SEEN ON RESPECTIVE 188 00:08:05,551 --> 00:08:06,952 CURVES HERE AND WORKUP 189 00:08:06,952 --> 00:08:09,221 DEMONSTRATED HE HAD A 190 00:08:09,221 --> 00:08:10,823 PSEUDOMOWNUS INFECTION 191 00:08:10,823 --> 00:08:12,391 COMPLICATED BY BIOFILM 192 00:08:12,391 --> 00:08:13,459 PRODUCTION IN THAT RIGHT CHEST 193 00:08:13,459 --> 00:08:18,564 THAT WAS RESISTENT TO OUR 194 00:08:18,564 --> 00:08:20,065 TYPICAL ANTI-BIOTICSES SEEN BY 195 00:08:20,065 --> 00:08:22,234 MULTIPLE SPIKES IN CRP AS WELL 196 00:08:22,234 --> 00:08:25,504 AS WHITE COUNTS HERE ON THESE 197 00:08:25,504 --> 00:08:25,771 CURVES. 198 00:08:25,771 --> 00:08:30,642 WE ULTIMATELY ENDED UP EMPLOYING 199 00:08:30,642 --> 00:08:32,745 A NOVEL INTRAPLURAL THERAPY 200 00:08:32,745 --> 00:08:35,748 USING DORNASE WE WILL TALK ONCE 201 00:08:35,748 --> 00:08:37,850 AGAIN IN GREATER DETAIL AND WE 202 00:08:37,850 --> 00:08:41,754 ARE ABLE TO SUCCESSFULLY CLEAR 203 00:08:41,754 --> 00:08:44,623 THIS INFECTION. 204 00:08:44,623 --> 00:08:46,759 SO HERE IS HIS SUMMARY OF HIS 205 00:08:46,759 --> 00:08:48,560 TREATMENT TIMELINE AND YOU CAN 206 00:08:48,560 --> 00:08:50,562 SEE THAT IT IS QUITE PROLONGED 207 00:08:50,562 --> 00:08:52,464 GIVEN COMPLEXITIES OF HIS CASE 208 00:08:52,464 --> 00:08:54,366 AND ULTIMATELY WE WERE ABLE TO 209 00:08:54,366 --> 00:08:56,702 CLEAR THAT INFECTION FROM HIS 210 00:08:56,702 --> 00:08:58,670 RIGHT CHEST AND SUCCESSFULLY 211 00:08:58,670 --> 00:09:02,474 CLOSE HIS CHEST WITH LOS OR FLAP 212 00:09:02,474 --> 00:09:04,910 REVERSAL IN MAY FOLLOWED BY 213 00:09:04,910 --> 00:09:05,978 SUCCESSFUL DISCHARGE. 214 00:09:05,978 --> 00:09:08,113 PATIENT IS NOW THREE MONTHS OUT 215 00:09:08,113 --> 00:09:10,516 AND CONTINUES TO DO QUITE WELL 216 00:09:10,516 --> 00:09:11,984 AT CLINICAL FOLLOWUP. 217 00:09:11,984 --> 00:09:14,019 NEXT, WE WILL DIVE INTO A FEW 218 00:09:14,019 --> 00:09:15,487 MORE DIFFERENT ASPECTS OF THE 219 00:09:15,487 --> 00:09:17,856 CASE STARTING WITH RADIOLOGY. 220 00:09:17,856 --> 00:09:26,832 THAT WILL BE WITH DR. MELIARY. 221 00:09:26,832 --> 00:09:35,607 >> THANK YOU DR. LORAINE. 222 00:09:35,607 --> 00:09:37,075 THIS IS A PATIENT PRESENTATION 223 00:09:37,075 --> 00:09:39,678 COMING TO NIH. YOU CAN SEE HERE 224 00:09:39,678 --> 00:09:43,015 THERE IS A LARGE RIGHT 225 00:09:43,015 --> 00:09:46,785 HYDROPNEUMOTHORAX AND MTS BASE 226 00:09:46,785 --> 00:09:47,686 HERE PNEUMOTHORAX AND SMALL 227 00:09:47,686 --> 00:09:49,822 MRURO FUSION AND PUT NORMAL 228 00:09:49,822 --> 00:09:51,690 CHEST X-RAY ON RIGHT SIDE TO SEE 229 00:09:51,690 --> 00:09:54,827 WHAT IS THE DIFFERENCE BETWEEN 230 00:09:54,827 --> 00:09:57,296 THE TWO. 231 00:09:57,296 --> 00:10:01,767 IN ADDITION TO FINDINGS OF RIGHT 232 00:10:01,767 --> 00:10:04,069 HEMOTHORAX THERE IS OPACITIES ON 233 00:10:04,069 --> 00:10:08,106 RIGHT SIDE THAT ENDED UP BEING 234 00:10:08,106 --> 00:10:09,942 INFECTIOUS IN NATURE. 235 00:10:09,942 --> 00:10:11,944 HERE IS THE INITIAL CT WE DID 236 00:10:11,944 --> 00:10:15,581 FOR THE PATIENT. YOU CAN SEE 237 00:10:15,581 --> 00:10:16,849 HERE HYDROPNEUMOTHORAX ON THE 238 00:10:16,849 --> 00:10:19,051 RIGHT AND RIGHT LUNG IS 239 00:10:19,051 --> 00:10:22,054 COMPLETELY OPACIFIED AND BARELY 240 00:10:22,054 --> 00:10:23,822 ANY NORMAL LUNG CAN BE SEEN AND 241 00:10:23,822 --> 00:10:26,425 ON THE LEFT SIDE, YOU CAN SEE 242 00:10:26,425 --> 00:10:28,293 SEVERAL FULL SIDE OF 243 00:10:28,293 --> 00:10:29,428 CONSOLIDATION OF THE MEAT 244 00:10:29,428 --> 00:10:31,730 PORTION OF THE LEFT LUNG AND FOR 245 00:10:31,730 --> 00:10:33,332 COMPARISON YOU CAN SEE A NORMAL 246 00:10:33,332 --> 00:10:37,269 LUNG ON THE LEFT WITH NICELY 247 00:10:37,269 --> 00:10:42,207 SHOWN VESSELS AND A BRONXIAL 248 00:10:42,207 --> 00:10:52,484 TREE. 249 00:10:52,484 --> 00:10:55,454 THIS PROFUSES IN A HOMOGENIS WAY 250 00:10:55,454 --> 00:10:59,091 AND OPPOSED TO SCAN FROM OUR 251 00:10:59,091 --> 00:11:02,394 PATIENT THAT THERE IS LOTS OF 252 00:11:02,394 --> 00:11:03,529 ARCHITECTURAL DISTORTION AND 253 00:11:03,529 --> 00:11:05,597 AREAS NOT PROFUSED BY CONTRAST 254 00:11:05,597 --> 00:11:07,266 AND A LITTLE CONTRAST IN THE 255 00:11:07,266 --> 00:11:11,870 SUPERIOR PORTION OF THE LEFT 256 00:11:11,870 --> 00:11:12,571 LUNG. 257 00:11:12,571 --> 00:11:16,074 SO, AGAIN, THIS PATIENT HAD A 258 00:11:16,074 --> 00:11:17,643 PERSISTENT PNEUMOTHORAX ON RIGHT 259 00:11:17,643 --> 00:11:20,045 SIDE AND ONE INTERESTING THING 260 00:11:20,045 --> 00:11:22,948 FINDING THIS PATIENT WAS 261 00:11:22,948 --> 00:11:26,351 BRONCHIAL MRURO 50ULA AND WE CAN 262 00:11:26,351 --> 00:11:28,387 SEE HERE COMMUNICATION WITH 263 00:11:28,387 --> 00:11:31,890 BRONCHIAL TREE AND PLURAL SPACE 264 00:11:31,890 --> 00:11:33,926 CAUSING AIR INTO THE SPACE AND 265 00:11:33,926 --> 00:11:35,093 PNEUMOTHORAX AND SEE AGAIN ON 266 00:11:35,093 --> 00:11:39,097 THE LEFT SIDE THERE ARE AREAS OF 267 00:11:39,097 --> 00:11:40,666 CONSOLIDATION AS WELL. 268 00:11:40,666 --> 00:11:42,267 INTERESTINGLY, ON THE SOFT 269 00:11:42,267 --> 00:11:43,669 TISSUE IMAGES, YOU CAN SEE THERE 270 00:11:43,669 --> 00:11:46,371 ARE MULTIPLE AREAS OF 271 00:11:46,371 --> 00:11:48,140 HYPODENSITY IN THE RIGHT LUNG 272 00:11:48,140 --> 00:11:51,176 THAT ARE MOST LIKELY ABSCESSES. 273 00:11:51,176 --> 00:11:54,179 THE RIGHT LUNG IS COMPLETELY 274 00:11:54,179 --> 00:11:55,013 OPACIFIED. 275 00:11:55,013 --> 00:11:56,481 INTERESTINGLY, ON THE RIGHT, YOU 276 00:11:56,481 --> 00:12:00,018 CAN SEE THE PLURA IS THICKENED 277 00:12:00,018 --> 00:12:03,989 AND PLURA SHOULD BE BARELY 278 00:12:03,989 --> 00:12:06,024 PERCREPTABLE IN A NORMAL PATIENT 279 00:12:06,024 --> 00:12:08,093 OR NORMAL SITUATION AND YOU CAN 280 00:12:08,093 --> 00:12:10,929 SEE HERE THAT IT IS THICKENED 281 00:12:10,929 --> 00:12:11,597 HERE. 282 00:12:11,597 --> 00:12:14,399 YOU HAVE PLURA A FUSION AND 283 00:12:14,399 --> 00:12:18,103 PLURA THICKENING IS INDICATIVE 284 00:12:18,103 --> 00:12:21,707 AND EXECUTIVE NATURE OF PLURA 285 00:12:21,707 --> 00:12:23,308 FUNCTIONING AND NEUROPLASM AND 286 00:12:23,308 --> 00:12:25,110 HERE IS ONE MONTH AFTER. YOU 287 00:12:25,110 --> 00:12:28,614 CAN SEE THAT THE PATIENT 288 00:12:28,614 --> 00:12:29,982 UNDERWENT RIGHT PNEUMONEKT MY 289 00:12:29,982 --> 00:12:31,717 WITH PACKING MATERIAL IN THE 290 00:12:31,717 --> 00:12:35,854 RIGHT HEMITHORAX HERE AND 291 00:12:35,854 --> 00:12:37,322 PERSISTENT CONSOLIDATIONS IN THE 292 00:12:37,322 --> 00:12:38,190 LEFT LUNG AGAIN. 293 00:12:38,190 --> 00:12:40,025 TWO MONTHS AFTER, YOU CAN SEE 294 00:12:40,025 --> 00:12:44,062 THAT THE PACKING MATERIAL IS 295 00:12:44,062 --> 00:12:48,400 REMOVED AND THERE IS A DIRECT 296 00:12:48,400 --> 00:12:50,102 COMMUNICATION BETWEEN RIGHT 297 00:12:50,102 --> 00:12:52,037 HEMOTHORAX AND RIGHT PLURAL 298 00:12:52,037 --> 00:12:56,475 SPACE AND OUTSIDE AND OPEN 299 00:12:56,475 --> 00:12:58,343 THOROUGH COTOMY THAT IS DONE AND 300 00:12:58,343 --> 00:13:00,045 SEE HERE CONSOLIDATIONS ON THE 301 00:13:00,045 --> 00:13:02,381 LEFT ARE GETTING BETTER AND 5 302 00:13:02,381 --> 00:13:04,016 MONTHS LATER IS BEND IN 303 00:13:04,016 --> 00:13:05,651 PATIENT'S TRAJECTORY. 304 00:13:05,651 --> 00:13:08,086 YOU CAN SEE THERE IS A CAVITY 305 00:13:08,086 --> 00:13:10,355 FORMATION IN THE LEFT LUNG WITH 306 00:13:10,355 --> 00:13:12,290 THICK WALL AND SMALL 307 00:13:12,290 --> 00:13:17,562 PNEUMOTHORAX. IF YOU CAN SEE IT 308 00:13:17,562 --> 00:13:17,763 HERE. 309 00:13:17,763 --> 00:13:20,799 THAT ENDED UP BEING PSEUDOMONA 310 00:13:20,799 --> 00:13:24,069 AND DR. FEN ELE WILL ELABORATE 311 00:13:24,069 --> 00:13:26,071 ON THIS FURTHER AND IN ADDITION 312 00:13:26,071 --> 00:13:28,407 ON THE RIGHT SIDE PLURA IS 313 00:13:28,407 --> 00:13:30,609 GETTING VERY THICK, WHICH I 314 00:13:30,609 --> 00:13:34,980 THINK IS A BIOFILM THAT DR. KARL 315 00:13:34,980 --> 00:13:37,683 WILL DISCUSS MORE. 316 00:13:37,683 --> 00:13:39,384 SO THIS IS FIVE MONTHS AFTER THE 317 00:13:39,384 --> 00:13:40,485 IMAGE ON THE LEFT. 318 00:13:40,485 --> 00:13:44,322 YOU CAN SEE THAT THE CAVITY IS 319 00:13:44,322 --> 00:13:47,893 ALMOST GONE WITH SOME AREAS OF 320 00:13:47,893 --> 00:13:50,028 CALCFICTION THAT ARE LIKELY 321 00:13:50,028 --> 00:13:51,329 DISTROUGH FIBBING IN NATURE AND 322 00:13:51,329 --> 00:13:54,332 RIGHT LUNG IS FILLED WITH FLUID 323 00:13:54,332 --> 00:13:56,268 DENSITY MATERIAL AND AGAIN DR. 324 00:13:56,268 --> 00:13:58,136 CAR WILL ELABORATE FURTHER ON 325 00:13:58,136 --> 00:14:00,505 THIS IN HIS TALK AND THIS IS 326 00:14:00,505 --> 00:14:01,840 MOST RECENT SCAN WE HAVE FROM 327 00:14:01,840 --> 00:14:02,607 THE PATIENT. 328 00:14:02,607 --> 00:14:05,043 YOU CAN SEE THAT THE 329 00:14:05,043 --> 00:14:06,912 CONSOLIDATIONS ARE MUCH BETTER 330 00:14:06,912 --> 00:14:09,347 AND THERE IS SOME VOLUME ON THE 331 00:14:09,347 --> 00:14:11,750 RIGHT THAT PLURA CAVITY IS 332 00:14:11,750 --> 00:14:14,453 FILLED IN WITH FLUID. 333 00:14:14,453 --> 00:14:16,054 HERE, WE PUT THESE IMAGES HERE 334 00:14:16,054 --> 00:14:19,958 FOR YOU TO SEE THAT THE CLOSURE 335 00:14:19,958 --> 00:14:23,929 OF OPEN THROKOTOMY AND 336 00:14:23,929 --> 00:14:24,963 APPRECIATE VOLUME LOSS ON THE 337 00:14:24,963 --> 00:14:26,998 RIGHT AND CONSOLIDATIONS THAT 338 00:14:26,998 --> 00:14:28,467 ARE ALMOST GONE IN THE LEFT 339 00:14:28,467 --> 00:14:28,767 LUNG. 340 00:14:28,767 --> 00:14:32,037 WITH THAT, I WILL HAND IT OVER 341 00:14:32,037 --> 00:14:35,073 TO DR. CARR, WHO WILL DISCUSS 342 00:14:35,073 --> 00:14:38,410 THE SURGICAL COURSE OF THIS 343 00:14:38,410 --> 00:14:39,945 PATIENT. 344 00:14:39,945 --> 00:14:50,489 >> THANK YOU VERY MUCH. WE WILL 345 00:14:52,858 --> 00:14:54,760 PICK UP AND KIND OF GO BACK A 346 00:14:54,760 --> 00:14:56,762 LITTLE BIT IN TIME AND KIND OF 347 00:14:56,762 --> 00:14:59,931 TALK A LITTLE BIT ABOUT THE 348 00:14:59,931 --> 00:15:01,032 SURGICAL ISSUES THAT WE HAD TO 349 00:15:01,032 --> 00:15:02,734 CON TEMPLATE WHEN WE WERE 350 00:15:02,734 --> 00:15:05,303 GETTING READY TO MANAGE THIS 351 00:15:05,303 --> 00:15:05,570 PATIENT. 352 00:15:05,570 --> 00:15:07,773 THESE PATIENTS, LOTS OF THEM 353 00:15:07,773 --> 00:15:10,542 WITH CHRONIC DISEASE HAVE 354 00:15:10,542 --> 00:15:11,910 INCREDIBLY POOR NUTRITION AS 355 00:15:11,910 --> 00:15:13,111 DEMONSTRATED BY OUR PATIENT THAT 356 00:15:13,111 --> 00:15:17,082 IS WEIGHING 42 TO 44 KILOS JUST 357 00:15:17,082 --> 00:15:20,051 FOR KIND OF -- HE STANDS ABOUT 358 00:15:20,051 --> 00:15:24,523 177 CENTIMETERS AND 5 FOOT 9 AND 359 00:15:24,523 --> 00:15:26,258 WEIGHING BARELY 90 POUNDS AND WE 360 00:15:26,258 --> 00:15:28,894 HAVE TO WORRY ABOUT ACTIVE 361 00:15:28,894 --> 00:15:31,062 INFECTION AND POOR NUTRITION CAN 362 00:15:31,062 --> 00:15:32,898 LEAD TO POOR WOUND HEALING AND 363 00:15:32,898 --> 00:15:34,800 ACTIVE INFECTION LEADS TO THINGS 364 00:15:34,800 --> 00:15:36,368 FALLING APART ON US AND 365 00:15:36,368 --> 00:15:38,103 OPERATING PATIENTS OPTIMIZE 366 00:15:38,103 --> 00:15:39,337 NUTRITION AND ENSURE THAT THEY 367 00:15:39,337 --> 00:15:41,139 DON'T HAVE ACTIVE INFECTION 368 00:15:41,139 --> 00:15:43,275 ONGOING AND ADDITIONALLY WE WILL 369 00:15:43,275 --> 00:15:46,178 OPERATE ON PATIENTS AND IN CHEST 370 00:15:46,178 --> 00:15:47,579 SURGERY WE OPERATE ON -- IF 371 00:15:47,579 --> 00:15:50,081 OPERATING ON THE RIGHT LUNG WE 372 00:15:50,081 --> 00:15:51,049 ACTUALLY COLLAPSE THE RIGHT LUNG 373 00:15:51,049 --> 00:15:52,751 AND DON'T VENT LATE IT AND YOU 374 00:15:52,751 --> 00:15:54,052 ARE ONLY VENTILATING ONE SIDE 375 00:15:54,052 --> 00:15:56,555 AND HAVE TO BE ABLE TO SURVIVE 376 00:15:56,555 --> 00:15:58,657 AN OPERATION WHILE ONLY USING 377 00:15:58,657 --> 00:16:00,358 ONE OF YOUR TWO LUNGS AND WANT 378 00:16:00,358 --> 00:16:01,760 TO MAKE SURE THAT LUNG IS ABLE 379 00:16:01,760 --> 00:16:03,328 TO SUPPORT THE PATIENT. 380 00:16:03,328 --> 00:16:05,397 WE FINALLY PUT THIS ALL TOGETHER 381 00:16:05,397 --> 00:16:06,932 WITH AN OVERALL FUNCTION IN 382 00:16:06,932 --> 00:16:08,834 STATUS AND FRAILTY AND TRY TO 383 00:16:08,834 --> 00:16:10,402 DECIDE IS THIS PERSON GOING TO 384 00:16:10,402 --> 00:16:11,236 REALLY DO WELL? 385 00:16:11,236 --> 00:16:14,439 IN OUR CASE WE HAVE A VERY -- 20 386 00:16:14,439 --> 00:16:16,474 YEAR MALE THAT IS OTHERWISE 387 00:16:16,474 --> 00:16:17,976 HEALTHY BEFORE COMING DOWN WITH 388 00:16:17,976 --> 00:16:19,077 THIS OPPOSED TO SOMEONE YOU CAN 389 00:16:19,077 --> 00:16:21,046 IMAGINE THAT IS INCREDIBLY FRAIL 390 00:16:21,046 --> 00:16:24,883 THAT IS MUCH OLDER AND HAD SOME 391 00:16:24,883 --> 00:16:25,116 ISSUES. 392 00:16:25,116 --> 00:16:27,085 NEXT PART THAT WE HAVE TO WORRY 393 00:16:27,085 --> 00:16:28,587 ABOUT WHEN CONSIDERING SURGERY 394 00:16:28,587 --> 00:16:30,155 IS WHAT ARE OTHER INDICATIONS 395 00:16:30,155 --> 00:16:33,058 AND THERE ARE CLINICAL SIGNS 396 00:16:33,058 --> 00:16:34,893 THAT CAN FORCE OUR HAND AND WE 397 00:16:34,893 --> 00:16:37,162 LOOK AT THEM IN THREE 398 00:16:37,162 --> 00:16:41,199 CATEGORIES, EMERGENT, URGIENT 399 00:16:41,199 --> 00:16:42,000 AND NONURGENT. 400 00:16:42,000 --> 00:16:46,338 EMERGENT ARE PATIENTS WITH 401 00:16:46,338 --> 00:16:48,707 MASSIVE HOM OPT SIS COUGHING UP 402 00:16:48,707 --> 00:16:51,877 KIDNEY BASE IN 24 HOURS AND LUNG 403 00:16:51,877 --> 00:16:52,978 HEMORRHAGE HEMORRHAGING ON 404 00:16:52,978 --> 00:16:54,512 [INDISCERNIBLE] AND NOT 405 00:16:54,512 --> 00:16:56,214 CONNECTED TO AIRWAYS BUT YOU SEE 406 00:16:56,214 --> 00:17:00,819 PROCESS GETTING WORSE. URGENT 407 00:17:00,819 --> 00:17:01,820 IRREVERSIBLE PROGRESSION DESPITE 408 00:17:01,820 --> 00:17:05,056 APPROPRIATE THERAPIES OR 409 00:17:05,056 --> 00:17:07,058 RECURRENT SUBHOM OPT SIS AND 410 00:17:07,058 --> 00:17:10,262 PATIENT HAD NONE OF THESE 411 00:17:10,262 --> 00:17:13,064 [INDISCERNIBLE] PATIENTS WITH 412 00:17:13,064 --> 00:17:17,002 BRONXAL PLURA 50ULA THAT PATIENT 413 00:17:17,002 --> 00:17:22,073 HAD ANDFISTULA THAT 414 00:17:22,073 --> 00:17:28,947 PATIENT HAD AND. 415 00:17:28,947 --> 00:17:31,583 >> REMINDER WE WER TALK BEING HE 416 00:17:31,583 --> 00:17:33,285 MENTIONED ABOUT SOFT TISSUE 417 00:17:33,285 --> 00:17:35,153 AREAS RIGHT IN HERE AND WANT TO 418 00:17:35,153 --> 00:17:36,655 DRAW ATTENTION TO THAT. WE 419 00:17:36,655 --> 00:17:38,456 DIDN'T FULLY PICK UP WHAT THAT 420 00:17:38,456 --> 00:17:39,791 WAS UNTIL WE GOT INTO THE 421 00:17:39,791 --> 00:17:40,792 OPERATING ROOM AND THAT IS 422 00:17:40,792 --> 00:17:42,794 SOMETHING THAT ACTUALLY BECOMES 423 00:17:42,794 --> 00:17:45,096 KIND OF IMPORTANT DOWN THE ROAD, 424 00:17:45,096 --> 00:17:47,933 WHICH LIKELY WOULD HAVE GIVEN US 425 00:17:47,933 --> 00:17:49,834 MAYBE BETTER RECOGNIZE MIGHT 426 00:17:49,834 --> 00:17:51,202 HAVE GIVEN US OR BEEN ABLE TO 427 00:17:51,202 --> 00:17:52,704 TALK TO THE PAISHIENT MORE ABOUT 428 00:17:52,704 --> 00:17:55,173 THE LIKELIHOOD OF HIM NEEDING A 429 00:17:55,173 --> 00:17:57,309 NUM ONECTOMY AND OUR PLAN FOR 430 00:17:57,309 --> 00:18:00,045 SURGERY WAS EVENTUALLY TO GET 431 00:18:00,045 --> 00:18:01,546 HIM NUTRITIONALLY OPTIMIZED AND 432 00:18:01,546 --> 00:18:06,418 TRY TO SAVE THIS RIGHT LUNG. 433 00:18:06,418 --> 00:18:09,154 SO WE TOOK A MULTI-DISCIPLINARY 434 00:18:09,154 --> 00:18:10,555 APPROACH AND NUTRITION AND 435 00:18:10,555 --> 00:18:12,590 PHYSICAL AND OCCUPATIONAL 436 00:18:12,590 --> 00:18:15,126 THERAPY AND RESPIRATORY THERAPY 437 00:18:15,126 --> 00:18:17,595 INFECTIOUS DISEASE PULMONARY AND 438 00:18:17,595 --> 00:18:19,364 NEUROLOGY AND LIST GOES ON AND 439 00:18:19,364 --> 00:18:21,599 ON AND WORK TO GET PATIENTS 440 00:18:21,599 --> 00:18:24,069 PROTEIN LEVELS UP AND WEIGHT UP 441 00:18:24,069 --> 00:18:26,771 AND OPTIMIZE FROM ANTI-BOTIC 442 00:18:26,771 --> 00:18:28,707 REJIM TO MAKE SURE DIDN'T HAVE 443 00:18:28,707 --> 00:18:30,875 ACTIVE FUNCTION ONGOING AND 444 00:18:30,875 --> 00:18:32,477 PHYSICAL THERAPY RESPIRATORY 445 00:18:32,477 --> 00:18:33,812 THERAPY AND OCCUPATIONAL THERAPY 446 00:18:33,812 --> 00:18:35,880 TO GET PATIENT UP AND WALKING 447 00:18:35,880 --> 00:18:38,583 AND MOVING AND WHEN HE ARRIVED 448 00:18:38,583 --> 00:18:41,019 TO SEE US HE HAD NOT BEEN OUT OF 449 00:18:41,019 --> 00:18:42,787 A HOSPITAL BED IN FOUR MONTHS 450 00:18:42,787 --> 00:18:44,255 WHILE BEING IN THE GAMMIA. 451 00:18:44,255 --> 00:18:48,760 WE HAD A LONG WAY TO GO. 452 00:18:48,760 --> 00:18:50,362 SO AFTER APPROXIMATELY A MONTH 453 00:18:50,362 --> 00:18:53,031 IN THE HOSPITAL, WE TOOK HIM TO 454 00:18:53,031 --> 00:18:54,899 THE OPERATING ROOM. 455 00:18:54,899 --> 00:18:57,535 ON YOUR LEFT IS THE BEGINNING OF 456 00:18:57,535 --> 00:18:59,037 THE CASE AND THE BEFORE. BEFORE 457 00:18:59,037 --> 00:19:00,305 WE STARTED TO REALLY GET 458 00:19:00,305 --> 00:19:02,173 INVOLVED THAT IS OPENING LOOK 459 00:19:02,173 --> 00:19:04,075 INSIDE OF THE CHEST. YOU CAN 460 00:19:04,075 --> 00:19:05,643 SEE HERE THROUGH THE RETRACTOR 461 00:19:05,643 --> 00:19:07,445 THAT YOU CAN SEE THE LUNG HERE 462 00:19:07,445 --> 00:19:11,182 THAT IS THICK AND HEAVY AND LOTS 463 00:19:11,182 --> 00:19:13,785 OF WHITE SPLOTCHES AND DOTS ALL 464 00:19:13,785 --> 00:19:15,920 OVER THAT ARE ACTUALLY 465 00:19:15,920 --> 00:19:18,089 GRANULOMAS AND AFTER PICTURE IS 466 00:19:18,089 --> 00:19:21,326 AFTER WE DID DECOURTICATION AND 467 00:19:21,326 --> 00:19:23,261 TRYING TO PEEL VISCERAL PLURA 468 00:19:23,261 --> 00:19:26,531 OFF THE LUNG AND CHEST AS 469 00:19:26,531 --> 00:19:28,066 PARIETAL MRUR YA LINE INSIDE OF 470 00:19:28,066 --> 00:19:30,902 THE CHEST AND VISCERAL PLURA 471 00:19:30,902 --> 00:19:32,637 LINING THE LUNG AND PEEL IT OFF 472 00:19:32,637 --> 00:19:35,040 AND GET THE LUNG TO REEXPAND 473 00:19:35,040 --> 00:19:36,474 THAT WAS OUR HOPE AND 474 00:19:36,474 --> 00:19:38,843 UNFORTUNATELY WE FOUND AN 475 00:19:38,843 --> 00:19:41,012 INCREDIBLY DENSE AND 476 00:19:41,012 --> 00:19:42,080 CONSOLIDATED LUNG DAMAGED WITH 477 00:19:42,080 --> 00:19:43,715 SIGNIFICANT AMOUNT OF GRANULOMAS 478 00:19:43,715 --> 00:19:46,084 YOU CAN SEE DEPENDING HOW LIGHTS 479 00:19:46,084 --> 00:19:48,520 ARE AND PROBABLY BETTER ONLINE 480 00:19:48,520 --> 00:19:51,122 AND WE WERE UNFORTUNATELY ABLE 481 00:19:51,122 --> 00:19:52,424 TO GET THE LUNG TO EXPAND AND 482 00:19:52,424 --> 00:19:54,659 THIS PICTURE ON THE AFTER SIDE, 483 00:19:54,659 --> 00:19:55,960 YOU ARE RIGHT. 484 00:19:55,960 --> 00:19:58,496 IT IS WITH THE PATIENT ON TWO 485 00:19:58,496 --> 00:19:59,564 LUNG VENTILATION THAT IS STILL 486 00:19:59,564 --> 00:20:02,567 NOT FILLING THIS SPACE AND SEE 487 00:20:02,567 --> 00:20:03,835 THERE CONTINUES TO BE CAVITY 488 00:20:03,835 --> 00:20:06,271 THAT LUNG IS NOT EXPANDING INTO 489 00:20:06,271 --> 00:20:07,972 AND LEAVE A CHEST LIKE THAT YOU 490 00:20:07,972 --> 00:20:09,841 WILL GET COMPLICATIONS AND END 491 00:20:09,841 --> 00:20:12,911 OF THORACIC SURGICAL PROCEDURE 492 00:20:12,911 --> 00:20:15,113 LEAVING LUNG BEHIND YOU HAVE 493 00:20:15,113 --> 00:20:16,681 PLURAL PLURAL APPLICATION SO 494 00:20:16,681 --> 00:20:18,016 LUNG MUST TOUCH THE CHEST WALL. 495 00:20:18,016 --> 00:20:21,386 WE WERE UNABLE TO DO THAT AND 496 00:20:21,386 --> 00:20:23,321 NEEDED TO PERFORM A NUM ONECTOMY 497 00:20:23,321 --> 00:20:25,223 AND ARE INTEROPERATIVE PICTURES 498 00:20:25,223 --> 00:20:28,059 THAT WE WILL REVIEW THE 499 00:20:28,059 --> 00:20:29,761 PATHOLOGY SHORTLY AND THIS IS 500 00:20:29,761 --> 00:20:31,096 THE RIGHT MIDDLE LOBE HERE ON 501 00:20:31,096 --> 00:20:33,665 YOUR LEFT. YOU CAN SEE 502 00:20:33,665 --> 00:20:35,033 GRANULOMAS THROUGHOUT THE LUNG 503 00:20:35,033 --> 00:20:37,302 AND THIS PICTURE HERE IS ENTIRE 504 00:20:37,302 --> 00:20:39,671 RIGHT LUNG THAT YOU CAN SEE IS 505 00:20:39,671 --> 00:20:41,806 INCREDIBLY DENSE AND FIBROUS AND 506 00:20:41,806 --> 00:20:45,376 NOT COMPRESSING AND IS A BIG 507 00:20:45,376 --> 00:20:45,877 SOLID MASS. 508 00:20:45,877 --> 00:20:49,514 SO WHAT DO WE DO? RIGHT NUM 509 00:20:49,514 --> 00:20:54,252 ONECTOMY AND DID A ROTATIONAL 510 00:20:54,252 --> 00:20:56,054 PERICARDIAL PATCH TO PATCH THE 511 00:20:56,054 --> 00:20:58,223 BRONCHIAL STUMPS HIGH RATE 512 00:20:58,223 --> 00:21:01,059 FALLING APART AND MORE COMMON ON 513 00:21:01,059 --> 00:21:03,595 RIGHT THAN LEFT SIDE OF 514 00:21:03,595 --> 00:21:05,530 BRONCHIAL STUMP FALLING APART 515 00:21:05,530 --> 00:21:09,501 AND IDEA VASCULARIZED HEALTHY 516 00:21:09,501 --> 00:21:12,537 TISSUE ON BRONCHIAL STUMP TO 517 00:21:12,537 --> 00:21:17,742 PROTECT IT TO HAVE THAT DREADED 518 00:21:17,742 --> 00:21:21,646 COMPUTATION AND THIS SPACE IS 519 00:21:21,646 --> 00:21:25,316 INFECTED WITH ENHIGHEMIA AND 520 00:21:25,316 --> 00:21:27,552 CLOSED UP WOULDN'T HAVE GOTTEN 521 00:21:27,552 --> 00:21:30,288 ALL BACTERIA OUT AND ALLOWING 522 00:21:30,288 --> 00:21:31,890 FLUID TO EGRESS OUT OF THE CHEST 523 00:21:31,890 --> 00:21:34,592 THAT WE WILL TALK ABOUT IN A 524 00:21:34,592 --> 00:21:36,928 SECOND AND GIVE US A CHANCE TO 525 00:21:36,928 --> 00:21:38,496 LET US HEAL AND TALKED ABOUT WHY 526 00:21:38,496 --> 00:21:42,901 WE DID THIS SENSE OF LUNG 527 00:21:42,901 --> 00:21:44,068 DESTRUCTION IN [INDISCERNIBLE] 528 00:21:44,068 --> 00:21:46,738 WHAT IS LOSER FLAP THIS IS 529 00:21:46,738 --> 00:21:52,544 INVENTED BY LEO LOSER THORACIC 530 00:21:52,544 --> 00:21:54,078 SURGEON AT STANFORD IMMIGRATED 531 00:21:54,078 --> 00:21:56,781 UP FROM MEXICO AND 1936 532 00:21:56,781 --> 00:21:58,850 DESCRIBED A WIN DOUGH INTO THE 533 00:21:58,850 --> 00:22:01,853 CHEST FOR USE AND TREATMENT OF 534 00:22:01,853 --> 00:22:07,525 PATIENTS WITH TUBERCULOSIS AND 535 00:22:07,525 --> 00:22:17,902 EMPIEMYEMA. 536 00:22:21,606 --> 00:22:22,173 THIS IS THE PATIENT WITH LOSER 537 00:22:22,173 --> 00:22:23,641 FLAP CREATED ALLOWING WINDOW 538 00:22:23,641 --> 00:22:27,912 INTO THE CHEST TO EASILY DO 539 00:22:27,912 --> 00:22:29,681 DRESSING CHANGES AT BEDSIDE. 540 00:22:29,681 --> 00:22:35,253 YOU MAY HAVE HEARD OF A CLAGET 541 00:22:35,253 --> 00:22:37,288 WIN DOUGH SIMILAR BUT DIFFERENT. 542 00:22:37,288 --> 00:22:40,592 TWO PICTURES HERE CLAGET WINDOW 543 00:22:40,592 --> 00:22:42,293 CUT OUT SKIN AND CHEST WALL IN 544 00:22:42,293 --> 00:22:43,595 ONE SHOT AND TAKE IT STRAIGHT 545 00:22:43,595 --> 00:22:49,601 DOWN AND WORKS SIMILAR TO LOSER 546 00:22:49,601 --> 00:23:00,278 FLWE WANTED TO ENSURE WE HAD 547 00:23:05,550 --> 00:23:08,119 SOMETHING THAT WAS EASY AND 548 00:23:08,119 --> 00:23:11,589 SIMPLE AND STRAIGHTFORD WE COULD 549 00:23:11,589 --> 00:23:22,800 CLOSE AND DR. LO ESKER HIELOE 550 00:23:26,738 --> 00:23:26,838 AT. 551 00:23:26,838 --> 00:23:27,672 WE DIVIDE INTO EARLY AND LATE 552 00:23:27,672 --> 00:23:29,407 STAGES EARLY AND LATE 553 00:23:29,407 --> 00:23:30,875 COMPLICATIONS ARE SIMILAR IN 554 00:23:30,875 --> 00:23:31,709 LOTS OF WAYS. 555 00:23:31,709 --> 00:23:36,047 BIG PICTURE HERE IS THAT ABOUT 556 00:23:36,047 --> 00:23:39,584 40% OF THE TIME THEY HAVE SOME 557 00:23:39,584 --> 00:23:42,420 COMPLICATION PATIENT DID 558 00:23:42,420 --> 00:23:43,521 REQUIRED REINTUBATION AND COUPLE 559 00:23:43,521 --> 00:23:45,356 COMPLICATIONS IN ICU AND NOT 560 00:23:45,356 --> 00:23:48,593 EXPECTED BUT HE DID QUITE WELL. 561 00:23:48,593 --> 00:23:51,729 WE TALKED ABOUT WE DID PLANNED 562 00:23:51,729 --> 00:23:54,432 VATS WASHOUTS AND DID THIS TO 563 00:23:54,432 --> 00:23:57,735 GET THE TISSUE TO HEAL AND GET 564 00:23:57,735 --> 00:23:59,737 ANY BIT OF BACTERIA WE COULD OUT 565 00:23:59,737 --> 00:24:02,874 OF THE SYSTEM POST-OP ITERATIVE 566 00:24:02,874 --> 00:24:05,576 DAY 4 TOOK PERSON TO THE FIRST 567 00:24:05,576 --> 00:24:07,345 AND LOOKING UP DIAPHRAGM TOWARDS 568 00:24:07,345 --> 00:24:08,613 APEX OF THE CHEST AND THIS IS 569 00:24:08,613 --> 00:24:12,150 TOP OF THE CHEST THAT IS RIGHT 570 00:24:12,150 --> 00:24:12,884 UP HERE. 571 00:24:12,884 --> 00:24:15,253 ARROW HERE IS POINTING AT 572 00:24:15,253 --> 00:24:16,354 PERICARDIAL PATCH THAT IS 573 00:24:16,354 --> 00:24:18,723 SITTING ON TOP OF THE BRONCHIAL 574 00:24:18,723 --> 00:24:19,524 STUMP. 575 00:24:19,524 --> 00:24:20,725 AFTER CLEANING IT OUT AND 576 00:24:20,725 --> 00:24:22,894 WASHING IT OUT AND REPACKING IT, 577 00:24:22,894 --> 00:24:24,362 WE TOOK PATIENT BACK TO THE 578 00:24:24,362 --> 00:24:26,030 OPERATING ROOM TWO DAYS LATER. 579 00:24:26,030 --> 00:24:29,167 YOU SEE MARKED IMPROVEMENT IN 580 00:24:29,167 --> 00:24:30,535 PARIETAL PLURA THAT BECOMES 581 00:24:30,535 --> 00:24:32,437 HEALTHY AND GRANULATES AND 582 00:24:32,437 --> 00:24:33,871 LIKELIHOOD OF INFECTION BEGINS 583 00:24:33,871 --> 00:24:35,673 TO GO DOWN AND CONTINUE THIS 584 00:24:35,673 --> 00:24:37,508 PROCESS MULTIPLE TIMES. 585 00:24:37,508 --> 00:24:39,143 AGAIN, ONCE WE KNEW THAT THE 586 00:24:39,143 --> 00:24:41,312 PATIENT WAS BETTER WE HOPE TO 587 00:24:41,312 --> 00:24:42,547 CLOSE THE CHEST. 588 00:24:42,547 --> 00:24:45,850 THIS WAS DESCRIBED WELL BY GROUP 589 00:24:45,850 --> 00:24:49,487 AT MAYO CLINIC IN NUMBER OF 590 00:24:49,487 --> 00:24:51,622 PATIENTS YOU CAN'T CLOSE OPEN 591 00:24:51,622 --> 00:24:55,226 THORIA COTOMY BUT WE CAN TRY. 592 00:24:55,226 --> 00:24:56,627 IDEA IS ONCE EVERYTHING IS 593 00:24:56,627 --> 00:24:59,864 CLEANED UP CULTURE IS NEGATIVE 594 00:24:59,864 --> 00:25:02,100 TAKE PERSON TO OPERATING ROOM 595 00:25:02,100 --> 00:25:05,069 AND FILL CHEST WITH SALINE OF 596 00:25:05,069 --> 00:25:07,105 ANTIBIOTIC THAT IS AGAINST 597 00:25:07,105 --> 00:25:08,639 BACTERIA GROWING AND CLOSE CHEST 598 00:25:08,639 --> 00:25:13,344 IN A WATER TIGHT MANNER. 599 00:25:13,344 --> 00:25:14,979 DR. LORRAINE HAS SHOWN PICTURES 600 00:25:14,979 --> 00:25:19,283 HERE AND FIRST TIME PATIENTS CRP 601 00:25:19,283 --> 00:25:20,985 AND WHITE COUNT SPIKED WE 602 00:25:20,985 --> 00:25:24,956 NOTICED THIS PROBLEM PATIENT 603 00:25:24,956 --> 00:25:28,059 DIAGNOSED WITH PSEUDOMOWNIS AND 604 00:25:28,059 --> 00:25:30,094 HAVE ANTI-BIOTICSES AND THINGS 605 00:25:30,094 --> 00:25:33,798 ARE BETTER AND WE WILL GO AND NO 606 00:25:33,798 --> 00:25:36,000 RISING COUNT OF COP AGAIN AND AT 607 00:25:36,000 --> 00:25:39,237 THIS POINT TOOK PATIENT TO OR 608 00:25:39,237 --> 00:25:40,304 AND RE-EVALUATED RIGHT CHEST TO 609 00:25:40,304 --> 00:25:41,639 SEE IF THERE IS ANYTHING GOING 610 00:25:41,639 --> 00:25:42,039 ON. 611 00:25:42,039 --> 00:25:43,741 THIS IS WHAT WE FOUND. 612 00:25:43,741 --> 00:25:45,610 THINK ABOUT THE PRIOR PICTURE 613 00:25:45,610 --> 00:25:49,547 WITH PLURA THAT IS HEALTHY AND 614 00:25:49,547 --> 00:25:52,517 PINK AND RED. 615 00:25:52,517 --> 00:25:54,852 YOU WANT TO SEE A LIME GREEN 616 00:25:54,852 --> 00:25:56,621 COLORED BIOFILM COVERING THE 617 00:25:56,621 --> 00:25:59,390 CHEST AND PICTURES ARE TAKEN 618 00:25:59,390 --> 00:26:01,592 FROM SAME ANGLE BY DIAPHRAGM 619 00:26:01,592 --> 00:26:03,661 LOOKING AT APEX OF THE CHEST YOU 620 00:26:03,661 --> 00:26:06,464 SEE HERE AND HERE THIS IS 621 00:26:06,464 --> 00:26:07,765 ANTERIOR ON THIS SIDE AND ON 622 00:26:07,765 --> 00:26:10,001 THIS SIDE AND THIS IS DIAPHRAGM 623 00:26:10,001 --> 00:26:12,503 KIND OF BULGING RIGHT THERE AND 624 00:26:12,503 --> 00:26:14,906 BIOFILM WAS EASY WE WIPED IT OWE 625 00:26:14,906 --> 00:26:17,475 OF PIECE OF CAKE AND TRIED 626 00:26:17,475 --> 00:26:18,843 ANTI-BIOTICSES THIS WILL BE FINE 627 00:26:18,843 --> 00:26:21,145 AND UNFORTUNATELY WE HAD ANOTHER 628 00:26:21,145 --> 00:26:24,015 SPIKE OF WHITE COUNT IN CRP 629 00:26:24,015 --> 00:26:26,050 DESPITE BEST THERAPIES THAT ARE 630 00:26:26,050 --> 00:26:28,052 INSTILLED IN ANTI-BIOTICSES AND 631 00:26:28,052 --> 00:26:33,558 WE MADE A DECISION TO ADD DNA 632 00:26:33,558 --> 00:26:35,960 DOR NEIGHS ALPHA AND PULL MA 633 00:26:35,960 --> 00:26:40,064 SDIEM THAT IS COMMONLY USED IN 634 00:26:40,064 --> 00:26:41,599 THORACIC SURGERY TO BREAK UP 635 00:26:41,599 --> 00:26:44,202 LOCKULATIONS IN CHEST TO EASILY 636 00:26:44,202 --> 00:26:46,270 DRAIN OUT THROUGH A CHEST TUBE 637 00:26:46,270 --> 00:26:49,941 AND IDEA HERE THAT DR. FENNELLY 638 00:26:49,941 --> 00:26:52,043 WILL SPEAK ABOUT IN MORE DETAIL 639 00:26:52,043 --> 00:26:56,647 IS USED TO HELL DOR NEIGHS ALPHA 640 00:26:56,647 --> 00:26:59,650 TO BREAK UP FILM TO GET AT IT 641 00:26:59,650 --> 00:27:01,052 AND BACTERIA NO PLACES TO HIDE 642 00:27:01,052 --> 00:27:07,758 AND CONTINUE INSTALLATION WITH 643 00:27:07,758 --> 00:27:10,928 ANTI-BIOTICSESNASE ALPHA TO 644 00:27:10,928 --> 00:27:11,562 BREAK UP FILM TO GET AT IT AND 645 00:27:11,562 --> 00:27:12,196 BACTERIA NO PLACES TO HIDE AND 646 00:27:12,196 --> 00:27:12,763 CONTINUE INSTALLATION WITH 647 00:27:12,763 --> 00:27:16,067 ANTI-BIOTICSES. 648 00:27:16,067 --> 00:27:16,634 THIS IS A VIDEO LOOKING IN 649 00:27:16,634 --> 00:27:17,268 TOWARDS APEX OF THE CHEST YOU 650 00:27:17,268 --> 00:27:18,102 CAN SEE IT UP HERE. 651 00:27:18,102 --> 00:27:20,905 THINK ABOUT THE LAST FILM WHERE 652 00:27:20,905 --> 00:27:23,741 YOU HAD GREEN BIOFILM COVERING 653 00:27:23,741 --> 00:27:26,043 EVERYTHING AND BIOFILM HAD BEEN 654 00:27:26,043 --> 00:27:27,945 RESOLVED AND WE TAKE THIS AND 655 00:27:27,945 --> 00:27:29,881 HAVE ARTICLE CURRENTLY WE WORKED 656 00:27:29,881 --> 00:27:31,482 ON WITH OTHER MEMBERS OF THE 657 00:27:31,482 --> 00:27:36,354 TEAM THAT IS CURRENTLY IN PRESS. 658 00:27:36,354 --> 00:27:39,891 SO POST UPDATE 226, THINGS ARE 659 00:27:39,891 --> 00:27:42,660 GOING WELL AND THIS IS WHAT 660 00:27:42,660 --> 00:27:44,362 ELOESSOR FLAP SHOULD LOOK LIKE 661 00:27:44,362 --> 00:27:47,398 226 DAYS LATER AND TOOK PATIENT 662 00:27:47,398 --> 00:27:50,401 TO OPERATING ROOM FOR CLOSURE. 663 00:27:50,401 --> 00:27:54,105 THIS IS CLOSURE OF ELOESSOR FLAP 664 00:27:54,105 --> 00:27:56,541 AND SEE YOU TAKE DOWN SKIN FLAP 665 00:27:56,541 --> 00:27:58,376 HERE AND RUN STITCHES BETWEEN 666 00:27:58,376 --> 00:27:59,877 CHEST WALL AND DIAPHRAGM THAT IS 667 00:27:59,877 --> 00:28:02,513 THIS MUSCLE HERE AND PULL UP AND 668 00:28:02,513 --> 00:28:04,916 PARACHUTE IT TOGETHER TO 669 00:28:04,916 --> 00:28:06,551 ABLITERRATE AND PULL DIAPHRAGM 670 00:28:06,551 --> 00:28:08,786 UP TO CHEST WALL AND OBLITERATE 671 00:28:08,786 --> 00:28:10,788 THAT OPENING AND TIE IT OFF AND 672 00:28:10,788 --> 00:28:12,023 BEFORE CLOSING YOU FILL UP CHEST 673 00:28:12,023 --> 00:28:12,623 WITH FLUID. 674 00:28:12,623 --> 00:28:14,625 THIS IS WHAT IT LOOKS LIKE WHEN 675 00:28:14,625 --> 00:28:17,528 IT IS ALL SAID AND DONE AND HAVE 676 00:28:17,528 --> 00:28:20,064 NICE ELLIPSOID PARABOLIC 677 00:28:20,064 --> 00:28:21,232 INCISION RIGHT THERE AND CHEST 678 00:28:21,232 --> 00:28:24,035 FILLED WITH THOUSANDS OF CCS 679 00:28:24,035 --> 00:28:27,538 WITH SALINE WITH 5 HUNDRED MG OF 680 00:28:27,538 --> 00:28:30,641 AMMA CASEIN AND PSEUDOMOWNIS WE 681 00:28:30,641 --> 00:28:32,343 HAD BEFORE WAS SENSITIVE TO IT 682 00:28:32,343 --> 00:28:35,346 AND CLOSURE HAD TO BE 683 00:28:35,346 --> 00:28:36,547 HYDROSTATIC AND FINAL CHEST 684 00:28:36,547 --> 00:28:39,083 RADIO GRAPH SHOWING WHAT DR. 685 00:28:39,083 --> 00:28:40,451 MALIARI HAS ALREADY TALKED TO US 686 00:28:40,451 --> 00:28:43,354 ABOUT AND YOU CAN SEE HERE THAT 687 00:28:43,354 --> 00:28:45,957 CRP IS NORMAL AT FOLLOW UP A FEW 688 00:28:45,957 --> 00:28:49,126 WEEKS AGO AND BRIEF REVIEW OF 689 00:28:49,126 --> 00:28:49,860 SURGICAL COURSE AND AT THIS 690 00:28:49,860 --> 00:28:53,831 POINT I WOULD LIKE TO INVITE DR. 691 00:28:53,831 --> 00:28:57,802 AKABILAD TO THE PODIUM TO HELP 692 00:28:57,802 --> 00:29:08,212 DISCUSS THE PATHOLOGY. 693 00:29:12,683 --> 00:29:14,485 >> THANK YOU. WHAT WE RECEIVED 694 00:29:14,485 --> 00:29:18,389 IN THE LAB FROM THIS PATIENT IS 695 00:29:18,389 --> 00:29:21,392 RIGHT NUM OWNECTOMY SPECIMEN 696 00:29:21,392 --> 00:29:23,094 PARTS AND THIS SECTION BELONGS 697 00:29:23,094 --> 00:29:25,763 TO RIGHT, MIDDLE AND 698 00:29:25,763 --> 00:29:28,032 [INDISCERNIBLE] MONTH AND THIS 699 00:29:28,032 --> 00:29:29,600 IS PLURAL SURFACE AND TISSUE 700 00:29:29,600 --> 00:29:32,036 THAT COVERS SURFACE OF THE LUNG 701 00:29:32,036 --> 00:29:34,672 AND LOW MAGNIFICATION, WE CAN 702 00:29:34,672 --> 00:29:38,442 SEE THAT WHOLE LUNG TISSUE IS 703 00:29:38,442 --> 00:29:40,978 INVOLVED WITH INFLAMMATORY AND 704 00:29:40,978 --> 00:29:43,848 DISTRACTIVE PROCESS AND DIVER 705 00:29:43,848 --> 00:29:47,084 SIFTIC LESIONS IN CHIMA AND 706 00:29:47,084 --> 00:29:47,585 ASSOCIATED HEMORRHAGE. 707 00:29:47,585 --> 00:29:49,720 ON RIGHT IS EXAMPLE OF HEALTHY 708 00:29:49,720 --> 00:29:54,659 LUNG TISSUE AND HOW IT SHOULD 709 00:29:54,659 --> 00:29:56,560 LOOK UNDER THE MICROSCOPE AND 710 00:29:56,560 --> 00:29:59,030 ALVEOLI ARE NICELY OPENED AND 711 00:29:59,030 --> 00:30:01,432 YOU SEE STRIKING DIFFERENCE IN 712 00:30:01,432 --> 00:30:04,068 PATIENT'S LUNG THERE IS NO OPEN 713 00:30:04,068 --> 00:30:05,703 AIRWAY SPACE LEFT. 714 00:30:05,703 --> 00:30:09,340 WHEN WE LOOK AT CLOSER, WHOLE 715 00:30:09,340 --> 00:30:13,244 LUNG PERICHIMA WAS INVOLVED WITH 716 00:30:13,244 --> 00:30:14,478 ILL-DEFINED GRANULOMAS AND ONE 717 00:30:14,478 --> 00:30:19,250 IS CIRCLED HERE AND COMPOSED OF 718 00:30:19,250 --> 00:30:25,389 [INDISCERNIBLE] AND MULTINUCLEIC 719 00:30:25,389 --> 00:30:27,158 GIANT SELLS AND NECK 720 00:30:27,158 --> 00:30:30,895 RECEIPTIZING AREAS WITHIN 721 00:30:30,895 --> 00:30:33,764 GRANUL 722 00:30:33,764 --> 00:30:34,699 GRANULOMAS, INFLAMMATION AND 723 00:30:34,699 --> 00:30:36,067 FIBROSIS PROCESS WAS INVOLVING 724 00:30:36,067 --> 00:30:40,404 THE LUNG ALL THE WAY TO THE 725 00:30:40,404 --> 00:30:40,638 PLURA. 726 00:30:40,638 --> 00:30:45,676 THE CYSTIC AREAS WERE ALSO 727 00:30:45,676 --> 00:30:48,045 SURROUNDED WITH THESE GIANT 728 00:30:48,045 --> 00:30:51,215 MULTINUCLEIC CELLS AND IN 729 00:30:51,215 --> 00:30:53,017 BACKGROUND CHRONIC INFLAMMATION 730 00:30:53,017 --> 00:30:56,654 IS GOING ON TOO AND RIGHT UPPER 731 00:30:56,654 --> 00:30:59,457 LOBE SIMILAR FINDINGS THAT YOU 732 00:30:59,457 --> 00:31:00,825 SEE LUNG TISSUE IS DESTROYED 733 00:31:00,825 --> 00:31:03,894 WITH THIS PROCESS AND WE HAD 734 00:31:03,894 --> 00:31:07,031 LARGE NECK RECEIPTIZING AREAS IN 735 00:31:07,031 --> 00:31:11,202 THE LOBE TOO AND PERFORMED AFB 736 00:31:11,202 --> 00:31:13,771 STAIN ON MULTIPLE SECTIONS AND 737 00:31:13,771 --> 00:31:15,039 SCATTERED STRUCTURES THAT ARE 738 00:31:15,039 --> 00:31:16,841 HIGHLIGHTED WITH ARROWS HERE. 739 00:31:16,841 --> 00:31:19,243 ONLY A FEW OF THEM. 740 00:31:19,243 --> 00:31:22,513 WE ALSO RECEIVED VISCERAL PLURAL 741 00:31:22,513 --> 00:31:24,482 FRAGMENTS THAT WAS THICKENED 742 00:31:24,482 --> 00:31:27,685 MEASURING 2.5 MILLIMETERS HERE 743 00:31:27,685 --> 00:31:31,122 AND NORMAL AND HEALTHY PLURA 744 00:31:31,122 --> 00:31:33,057 SHOULD ONLY MEASURE .2 745 00:31:33,057 --> 00:31:34,592 MILLIMETERS AND WHEN LOOKING AT 746 00:31:34,592 --> 00:31:37,661 IT CLOSER PLURA IS INVOLVED WITH 747 00:31:37,661 --> 00:31:39,997 CHRONIC INFLAMMATORY PROCESS 748 00:31:39,997 --> 00:31:44,502 WITH THIS REACTIVE VASCULAR 749 00:31:44,502 --> 00:31:45,269 PROLIFERATIONS. 750 00:31:45,269 --> 00:31:49,106 PLURA ALSO HAD NECK RECEIPTIZING 751 00:31:49,106 --> 00:31:49,573 GRANOMAS. 752 00:31:49,573 --> 00:31:51,776 HERE, THE ARROW POINTS TO 753 00:31:51,776 --> 00:31:55,880 NECROSIS THAT IS SURROUNDED WITH 754 00:31:55,880 --> 00:31:58,516 MULTINUCLEIC GIANT CELLS AND 755 00:31:58,516 --> 00:32:00,918 RECEIVED A COUPLE LYMPH NODES 756 00:32:00,918 --> 00:32:03,387 THAT WERE INVOLVED WITH 757 00:32:03,387 --> 00:32:05,089 GRANULOMAS ARROW POINTING HERE 758 00:32:05,089 --> 00:32:07,458 AND NECK RECEIPTIZING GRANULOMA 759 00:32:07,458 --> 00:32:11,395 IN THE LYMPH NODE AND OVERALL 760 00:32:11,395 --> 00:32:13,330 PATH OL OJIC FINDINGS 761 00:32:13,330 --> 00:32:16,033 INFLAMMATION AND FIBROSIS AND 762 00:32:16,033 --> 00:32:17,668 HEMORRHAGE EXTENSIVELY MOVING 763 00:32:17,668 --> 00:32:19,937 LOBES OF THE RIGHT LUNG AND 764 00:32:19,937 --> 00:32:22,206 VISCERAL PLURA AND NO RESIDUAL 765 00:32:22,206 --> 00:32:23,941 LEFT AND REGIONAL LYMPH NODES 766 00:32:23,941 --> 00:32:27,645 WERE INVOLVED BY INFLAMMATION 767 00:32:27,645 --> 00:32:31,182 AND SPECIAL STAINS IS CONSISTENT 768 00:32:31,182 --> 00:32:33,050 WITH [INDISCERNIBLE] 769 00:32:33,050 --> 00:32:35,319 TUBERCULOSIS IS IDENTIFIED AND 770 00:32:35,319 --> 00:32:36,687 HISTMORPHOLOGIC FINDINGS ARE 771 00:32:36,687 --> 00:32:39,423 SUPPORTIVE OF TB AND ASSOCIATED 772 00:32:39,423 --> 00:32:40,491 SEVERE LUNG DAMAGE AND THANK 773 00:32:40,491 --> 00:32:46,764 YOU. I WILL HAND IT OVER TO DR. 774 00:32:46,764 --> 00:32:49,934 FENNELLY. 775 00:32:49,934 --> 00:33:00,377 >> THANK YOU. THE FINAL 776 00:33:01,979 --> 00:33:05,216 CLINICAL DIAGNOSIS HERE IS TB 777 00:33:05,216 --> 00:33:06,317 DESTROYED LUNG. AS DR. JUST 778 00:33:06,317 --> 00:33:09,119 SHOWED YOU, THERE WERE NO 779 00:33:09,119 --> 00:33:10,821 ALVEOLI PRESENT. THE ENTIRE 780 00:33:10,821 --> 00:33:17,261 LUNG WAS ESSENTIALLY JUST SIMPLY 781 00:33:17,261 --> 00:33:17,561 DESTROYED. 782 00:33:17,561 --> 00:33:21,265 JUST A FEW COMMENTS ABOUT TB IN 783 00:33:21,265 --> 00:33:25,936 GENERAL, THE TRAGEDY IS THAT TB 784 00:33:25,936 --> 00:33:27,705 IS PREVENTABLE AND CURABLE. 785 00:33:27,705 --> 00:33:30,574 UNFORTUNATELY IT IS THE NO. 1 786 00:33:30,574 --> 00:33:32,109 KILLER AMONG ALL INFECTIOUS 787 00:33:32,109 --> 00:33:32,376 DISEASES. 788 00:33:32,376 --> 00:33:34,311 WE HAD A SHORT PERIOD THERE 789 00:33:34,311 --> 00:33:36,513 WHERE THE PANDEMIC TOOK OVER. 790 00:33:36,513 --> 00:33:38,682 IT IS ODD NOW TO HEAR TB 791 00:33:38,682 --> 00:33:40,918 COLLEAGUES SAYING, HEY, WE ARE 792 00:33:40,918 --> 00:33:42,419 NO. 1 AGAIN. 793 00:33:42,419 --> 00:33:44,488 IT HAS BEEN THAT WAY FOR MANY 794 00:33:44,488 --> 00:33:46,757 YEARS BEFORE THE PANDEMIC AND 795 00:33:46,757 --> 00:33:49,126 OVER 10 MILLION PEOPLE ARE ILL 796 00:33:49,126 --> 00:33:52,029 EACH YEAR AND OFTEN HOSPITALIZED 797 00:33:52,029 --> 00:33:53,330 WITH OCTAVE TB. 798 00:33:53,330 --> 00:33:56,033 ABOUT 25% OF THE WORLD'S 799 00:33:56,033 --> 00:33:58,269 POPULATION IS THOUGHT TO BE 800 00:33:58,269 --> 00:34:00,004 INFECTED AND IS TO HAVE LATENT 801 00:34:00,004 --> 00:34:02,373 TB MEANING WE INHALED IT AND THE 802 00:34:02,373 --> 00:34:05,576 BODY HAS CONTROLLED IT AND ARE 803 00:34:05,576 --> 00:34:09,013 AT RISK FOR REACTIVATING TB AT 804 00:34:09,013 --> 00:34:11,916 SOME TIME IN THE FUTURE. 805 00:34:11,916 --> 00:34:14,285 THIS CURVE HERE, IT IS JUST A 806 00:34:14,285 --> 00:34:16,053 DEMONSTRATION OF WHAT HAPPENED 807 00:34:16,053 --> 00:34:17,288 WITH THE PANDEMIC. 808 00:34:17,288 --> 00:34:21,258 NOT THAT TB WENT AWAY BUT ALL 809 00:34:21,258 --> 00:34:23,494 PUBLIC HEALTH PEOPLE SUCK 810 00:34:23,494 --> 00:34:26,497 CRUMBED TO TAKING CARE OF COVID 811 00:34:26,497 --> 00:34:29,099 CASES NO TB NOTIFICATIONS TO WHO 812 00:34:29,099 --> 00:34:31,502 AND ARE IN A REBOUND CATCHING UP 813 00:34:31,502 --> 00:34:36,407 ALL CASES NOW BEING IDENTIFIED. 814 00:34:36,407 --> 00:34:39,476 SO IN GAMBIA THOSE THAT DON'T 815 00:34:39,476 --> 00:34:42,413 KNOW IT IS A VERY SMALL COUNTRY 816 00:34:42,413 --> 00:34:43,614 IN WESTERN AFRICA. 817 00:34:43,614 --> 00:34:47,685 IT HAS A VERY HIGH RATE OF TB, 818 00:34:47,685 --> 00:34:51,088 ABOUT 150 PER 100,000 CASES AND 819 00:34:51,088 --> 00:34:53,891 FRAME OF REFERENCE WERE UNDER 5 820 00:34:53,891 --> 00:34:54,925 PER HUNDRED THOUSAND NOW IN 821 00:34:54,925 --> 00:34:59,129 GENERAL IN THE US. 822 00:34:59,129 --> 00:35:00,931 FORTUNATELY THERE IS NOT MUCH 823 00:35:00,931 --> 00:35:04,835 MULTIDRUG RESISTENT TB AND 824 00:35:04,835 --> 00:35:06,603 TRAGEDY IS CASE FATALITY RATIO 825 00:35:06,603 --> 00:35:09,173 IS 23% AND MEANING ABOUT A 826 00:35:09,173 --> 00:35:11,342 QUARTER OF PEOPLE WHO DEVELOPED 827 00:35:11,342 --> 00:35:14,678 TB IN GAMBIA DIE FROM THE 828 00:35:14,678 --> 00:35:16,981 DISEASE AND HAVE NO DOMESTIC 829 00:35:16,981 --> 00:35:20,017 FUNDING AND 100% OF CARE IS FROM 830 00:35:20,017 --> 00:35:21,318 INTERNATIONAL FUNDING AND 831 00:35:21,318 --> 00:35:22,453 MEDICAL RESEARCH CENTER THAT YOU 832 00:35:22,453 --> 00:35:25,556 HEARD ABOUT IS FROM THE UK, THE 833 00:35:25,556 --> 00:35:28,058 MEDICAL RESEARCH COUNCIL THAT 834 00:35:28,058 --> 00:35:29,526 PROVIDES CARE THERE AND THERE 835 00:35:29,526 --> 00:35:32,429 ARE NO PULMONOLOGISTS OR 836 00:35:32,429 --> 00:35:35,299 THORACIC SURGEONS IN THE WHOLE 837 00:35:35,299 --> 00:35:36,233 COUNTRY AND THESE POOR GENERAL 838 00:35:36,233 --> 00:35:38,602 DOCTORS WERE TRYING TO TAKE CARE 839 00:35:38,602 --> 00:35:41,171 OF THIS VERY COMPLICATED CASE 840 00:35:41,171 --> 00:35:43,841 PUTTING IN CHEST TUBES TO BE 841 00:35:43,841 --> 00:35:46,010 CONGRATULATED FOR WHAT THEY 842 00:35:46,010 --> 00:35:46,643 COULD DO. 843 00:35:46,643 --> 00:35:48,512 ONE THING THAT IS UNUSUAL ABOUT 844 00:35:48,512 --> 00:35:53,250 THE GAMBIA TO REST OF SUBIS A 845 00:35:53,250 --> 00:35:56,053 HAIRANT AFRICA IS HIV IS NOT 846 00:35:56,053 --> 00:35:58,222 MAIN UNDERLYING CAUSE BUT IT IS 847 00:35:58,222 --> 00:36:02,126 REALLY MALNUTRITION THAT OUR 848 00:36:02,126 --> 00:36:03,627 PATIENT DEMONSTRATED. 849 00:36:03,627 --> 00:36:06,096 SO, TB DESTROYED LUNG IS FAIRLY 850 00:36:06,096 --> 00:36:08,232 UNUSUAL AND CAN BE SEEN IN 851 00:36:08,232 --> 00:36:10,034 PEDIATRIC CASES. 852 00:36:10,034 --> 00:36:15,372 MOSTLY IN ADULTS AND AS IN OUR 853 00:36:15,372 --> 00:36:17,508 CASE, ONE LOBE IS -- ONE LUNG IS 854 00:36:17,508 --> 00:36:20,044 DESTROYED AND CONTRALATERAL 855 00:36:20,044 --> 00:36:23,447 UPPER LOBE IS EFFECTED AS DR. 856 00:36:23,447 --> 00:36:25,582 MALIARY DEMONSTRATED AND SOME OF 857 00:36:25,582 --> 00:36:28,619 THE BEST RECENT DATA COMES FROM 858 00:36:28,619 --> 00:36:31,889 BEIJING AND CHINA AND 1% OF TB 859 00:36:31,889 --> 00:36:33,290 PATIENTS WILL DEVELOP THIS AND 860 00:36:33,290 --> 00:36:34,992 FORTUNATELY THEY HAVE FAIRLY 861 00:36:34,992 --> 00:36:36,393 GOOD SURVIVAL IN THE FIRST FEW 862 00:36:36,393 --> 00:36:38,629 YEARS THAT YOU CAN SEE OUT TO 863 00:36:38,629 --> 00:36:43,000 FIVE OR SO YEARS, THEY CAN BE I 864 00:36:43,000 --> 00:36:46,570 HAD A POINTER HERE WE GO. 90% 865 00:36:46,570 --> 00:36:48,038 STILL ALIVE AFTER FIVE YEARS AND 866 00:36:48,038 --> 00:36:50,941 IT DROPS OFF AND THEY 867 00:36:50,941 --> 00:36:53,644 DEMONSTRATED THAT SURGICAL 868 00:36:53,644 --> 00:36:57,748 TREATMENT DEFINITELY IMPROVES 869 00:36:57,748 --> 00:36:59,883 SURVIVAL AND OLDER DATA FROM 870 00:36:59,883 --> 00:37:02,453 NIGERIA LOOKED AT 20 871 00:37:02,453 --> 00:37:04,488 NUMONECTOMIES AND LUNGS REMOVED 872 00:37:04,488 --> 00:37:06,990 BECAUSE OF TB AND ALL TREATED 873 00:37:06,990 --> 00:37:08,258 FOR OVER THREE YEARS AT THAT 874 00:37:08,258 --> 00:37:10,094 TIME AND HAD NEGATIVE CULTURES 875 00:37:10,094 --> 00:37:11,628 WHEN THEY WENT TO SURGERY. 876 00:37:11,628 --> 00:37:18,836 SOME WERE REFERRED BECAUSE OF 877 00:37:18,836 --> 00:37:29,580 MASSIVE HEEM OPTMOPTYSIS. 878 00:37:32,116 --> 00:37:35,519 UNFORTUNATELY AT THAT TIME IN 879 00:37:35,519 --> 00:37:39,022 NIGERIA, 18% OF CASES OF 880 00:37:39,022 --> 00:37:40,691 PULMONARY TB CARRIED TOTAL 881 00:37:40,691 --> 00:37:42,326 DESTROYED LUNG AND AT THAT TIME 882 00:37:42,326 --> 00:37:46,530 NO DIRECTLY OBSERVED THERAPY AND 883 00:37:46,530 --> 00:37:47,731 THINGS IMPROVED FAIRLY 884 00:37:47,731 --> 00:37:49,099 DRAMATICALLY THIS IS A TABLE OF 885 00:37:49,099 --> 00:37:56,039 THE KNOWN CASES WE HAVE OF 886 00:37:56,039 --> 00:37:57,307 POST-OP ITERATIVE BRONXAL PLURAL 887 00:37:57,307 --> 00:37:59,943 FISTULA AND REFERRING TO THIS 888 00:37:59,943 --> 00:38:04,648 THIS IS NOT BRONCHIAL FISTULA 889 00:38:04,648 --> 00:38:06,049 YOUNG MAN PRESENTED WITH BUT 890 00:38:06,049 --> 00:38:11,321 AFTER A SURGEON REMOVES WHOLE 891 00:38:11,321 --> 00:38:13,457 LUNG AND RISK IS IF AREA IS 892 00:38:13,457 --> 00:38:16,026 INFECTED IN OTHER WORDS IF DR. 893 00:38:16,026 --> 00:38:19,363 CARR GOES IN AND STAPLES ACROSS 894 00:38:19,363 --> 00:38:21,832 A SEGMENT AND IF AIRWAYS ARE 895 00:38:21,832 --> 00:38:24,801 INFECTED WITH TB AND THEY BREAK 896 00:38:24,801 --> 00:38:27,938 DOWN PATIENT DEVELOPS TB 897 00:38:27,938 --> 00:38:28,205 EMPYEMA. 898 00:38:28,205 --> 00:38:31,375 IT IS FATAL AND I HAVE SEEN 899 00:38:31,375 --> 00:38:36,180 CASES FROM NONTUBERCULOSIS 900 00:38:36,180 --> 00:38:36,980 MICROBACTERIAL DISEASE AND THIS 901 00:38:36,980 --> 00:38:41,118 FROM 1978 FROM HANKINS WAS FROM 902 00:38:41,118 --> 00:38:43,353 UNIVERSITY OF MARYLAND IN 903 00:38:43,353 --> 00:38:44,621 BALTIMORE AND THEY FOUND IF 904 00:38:44,621 --> 00:38:46,356 THERE WAS A POSITIVE CULTURE 905 00:38:46,356 --> 00:38:50,227 THAT 42% DEVELOPED A BPF. 906 00:38:50,227 --> 00:38:52,996 OBVIOUSLY, THAT WAS NOT A GOOD 907 00:38:52,996 --> 00:38:55,299 FINDING AND SUBSEQUENTLY WORK 908 00:38:55,299 --> 00:38:57,067 LARGELY AT NATIONAL JEWISH -- 909 00:38:57,067 --> 00:39:01,238 YOU KNOW, MY SENIOR COLLEAGUE 910 00:39:01,238 --> 00:39:04,841 AND MENTOR MIKE EISMAN PUBLISHED 911 00:39:04,841 --> 00:39:10,414 THIS PAPER ON TOP OF TB COULDN'T 912 00:39:10,414 --> 00:39:15,152 GET CULTURE NEGATIVE IF SMEAR 913 00:39:15,152 --> 00:39:16,687 NEGATIVE AND LOW AMOUNT PATIENTS 914 00:39:16,687 --> 00:39:18,889 DID MUCH BETTER. 915 00:39:18,889 --> 00:39:21,058 WHAT IS THE PERFECT TIMING? 916 00:39:21,058 --> 00:39:24,361 WE DON'T REALLY KNOW. AS DR. 917 00:39:24,361 --> 00:39:25,729 HANKINS POINTED OUT WAY BACK IN 918 00:39:25,729 --> 00:39:29,099 THE 70S, AVOIDANCE OF RESECTION 919 00:39:29,099 --> 00:39:31,868 WHEN PATIENTS ARE STILL CULTURE 920 00:39:31,868 --> 00:39:33,403 POSITIVE AS PREFERRED AND JUST 921 00:39:33,403 --> 00:39:37,608 BECAUSE OF HIGH RISK OF THAT 922 00:39:37,608 --> 00:39:39,743 TISSUE BREAKING DOWN. 923 00:39:39,743 --> 00:39:42,546 EARLY INTERVENTION SEEMS TO HAVE 924 00:39:42,546 --> 00:39:47,618 ADVANTAGE OF REDUCING RISK OF TB 925 00:39:47,618 --> 00:39:48,785 PROGRESSION REQUIRING DRUG 926 00:39:48,785 --> 00:39:50,520 RESISTANCE AND IF YOU CAN WAIT 927 00:39:50,520 --> 00:39:52,489 YOU CAN PRETREAT WITH EFFECTIVE 928 00:39:52,489 --> 00:39:54,391 DRUGS WE DID IN THIS CASE AND 929 00:39:54,391 --> 00:39:56,393 ARE AGGRESSIVELY TREATING THIS 930 00:39:56,393 --> 00:39:59,429 YOUNG MAN SO HE WOULDN'T HAVE A 931 00:39:59,429 --> 00:40:01,565 BPF DUE TO TISSUE BREAKDOWN AND 932 00:40:01,565 --> 00:40:04,067 WERE ABLE TO GET NUTRITION UP AS 933 00:40:04,067 --> 00:40:07,871 DR. CA ARE, R MENTIONED AND 934 00:40:07,871 --> 00:40:09,806 APPEARS SOMETIME AROUND 2 TO 4 935 00:40:09,806 --> 00:40:13,043 MONTHS IS PROBABLY OPTIMAL AND 936 00:40:13,043 --> 00:40:14,678 WHAT WE ARE -- AROUND FIVE 937 00:40:14,678 --> 00:40:17,848 MONTHS OR SO AND KEY THING TO 938 00:40:17,848 --> 00:40:21,451 HAVE PATIENT BE SMEAR NEGATIVE 939 00:40:21,451 --> 00:40:24,354 AND CULTURE NEGATIVE. 940 00:40:24,354 --> 00:40:28,025 SO THIS WAS A POINT I GOT 941 00:40:28,025 --> 00:40:31,495 ANXIOUS AS DR. MALIARI 942 00:40:31,495 --> 00:40:34,364 DEMONSTRATED IN JANUARY THAT WE 943 00:40:34,364 --> 00:40:36,400 SAW THIS LARGE NODULE HERE 944 00:40:36,400 --> 00:40:38,268 CAVITIATE AND ONE THING I WAS 945 00:40:38,268 --> 00:40:41,305 CONCERNED ABOUT IS HOW DO YOU 946 00:40:41,305 --> 00:40:43,573 DEVELOP DRUG RESISTENT TB AND 947 00:40:43,573 --> 00:40:45,475 WERE WE IN FOR TROUBLE AFTER 948 00:40:45,475 --> 00:40:47,344 THAT AND PULMONARY FELLOW WITH 949 00:40:47,344 --> 00:40:50,280 ME THOUGHT I WAS CRAZY. OH, 950 00:40:50,280 --> 00:40:53,850 YEAH IT IS PSEUDOMOWNIS WE CAN 951 00:40:53,850 --> 00:40:57,421 TREAT IT AND IT WAS NOT DRUG 952 00:40:57,421 --> 00:40:57,854 RESISTENT. 953 00:40:57,854 --> 00:41:00,957 SO, DR. CARR MENTIONED BIOFILM. 954 00:41:00,957 --> 00:41:04,227 I WANTED TO JUST REVIEW A FEW 955 00:41:04,227 --> 00:41:04,494 CONCEPTS. 956 00:41:04,494 --> 00:41:09,633 ONE IS THAT THERE IS NO 957 00:41:09,633 --> 00:41:12,869 CONCENSUS AGREEMENT WHAT BIOFILM 958 00:41:12,869 --> 00:41:14,404 IS AND SIMPLE DEFINITION LOOKING 959 00:41:14,404 --> 00:41:16,773 AT IT GROSSLY AS WE DID IN THE 960 00:41:16,773 --> 00:41:18,675 CHEST OF THE YOUNG MAN IS IT 961 00:41:18,675 --> 00:41:21,345 LOOKS LIKE SLIME THAT WAS JUST 962 00:41:21,345 --> 00:41:23,013 THIS GREEN, SMOOTH MATERIAL 963 00:41:23,013 --> 00:41:25,048 COVERING UP THE PLURAL SURFACE. 964 00:41:25,048 --> 00:41:27,217 LOOKING AT IT MICROSCOPICALLY, 965 00:41:27,217 --> 00:41:29,052 OLD THOUGHT WAS IT WAS JUST A 966 00:41:29,052 --> 00:41:32,055 BUNCH OF THE SAME BACTERIA THAT 967 00:41:32,055 --> 00:41:36,827 IS IMBEDDED IN THIS MATRIX. 968 00:41:36,827 --> 00:41:39,129 THERE WAS A BARRIER TO 969 00:41:39,129 --> 00:41:43,166 PENETRATION AND WE KNOW NOW IT 970 00:41:43,166 --> 00:41:46,103 IS NOT QUITE SO SIMPLE AND THERE 971 00:41:46,103 --> 00:41:49,906 IS TO AND FRO ACTIVITY WITH 972 00:41:49,906 --> 00:41:51,475 ORGANISMS GOING INTO THE MATRIX 973 00:41:51,475 --> 00:41:53,577 AND IS USUALLY NOT JUST ONE 974 00:41:53,577 --> 00:41:56,046 ORGANISM AND PUBLISHED A PAPER 975 00:41:56,046 --> 00:41:59,015 SEVERAL YEARS AGO AND I WAS 976 00:41:59,015 --> 00:42:00,851 SURPRISED TO LEARN THERE WAS 977 00:42:00,851 --> 00:42:02,786 FUNGI AND BACTERIA AND THINGS 978 00:42:02,786 --> 00:42:05,856 INSIDE OF THE BIOFILM. 979 00:42:05,856 --> 00:42:08,125 SO, THE KEY THING WE WANTED TO 980 00:42:08,125 --> 00:42:11,795 DO IS, YOU KNOW, SCRAPING OFF 981 00:42:11,795 --> 00:42:12,829 BIOFILM WASN'T WORKING. 982 00:42:12,829 --> 00:42:15,365 WHAT WE WANTED TO DO WAS GET 983 00:42:15,365 --> 00:42:18,702 BUGS IN THE GANGS INSIDE OF THE 984 00:42:18,702 --> 00:42:21,104 BIOFILM. WE WANTED TO GET THE 985 00:42:21,104 --> 00:42:25,609 BIOFILM BROKEN UP SO THE 986 00:42:25,609 --> 00:42:27,511 PLANKTONIC BACTERIA OUT HERE AND 987 00:42:27,511 --> 00:42:30,714 SINGLE BACTERIA AND BACHELORS 988 00:42:30,714 --> 00:42:32,048 ONCE SEPARATED ARE MORE 989 00:42:32,048 --> 00:42:34,284 SUSCEPTIBLE TO ANTI-BIOTICSES 990 00:42:34,284 --> 00:42:37,154 SHOWN IN PEDIATRICS FOR MIDDLE 991 00:42:37,154 --> 00:42:40,023 EAR INFUSIONS AND OTHER TYPES OF 992 00:42:40,023 --> 00:42:40,924 BIOFILM INFECTIONS. 993 00:42:40,924 --> 00:42:43,393 SO THIS IS A NICE PAPER THAT 994 00:42:43,393 --> 00:42:46,129 REVIEWED HOW DO WE GET RID OF 995 00:42:46,129 --> 00:42:51,468 THIS SLIME? THIS EXTRA CELLULAR 996 00:42:51,468 --> 00:42:53,236 POLYMERIC SUBSTANCE AND NUMBER 997 00:42:53,236 --> 00:42:55,405 OF METHODS PROPOSED AND ONLY 998 00:42:55,405 --> 00:42:57,808 PRACTICAL THING WE HAVE 999 00:42:57,808 --> 00:43:00,310 AVAILABLE IS DORI NEIGHS ALPHA 1000 00:43:00,310 --> 00:43:04,915 OR DNASE DR. CA ARE, R MENTIONS 1001 00:43:04,915 --> 00:43:08,385 AND WE USE IN CYSTIC FIBROSIS 1002 00:43:08,385 --> 00:43:10,720 PATIENTS THAT INHALE IT AND 1003 00:43:10,720 --> 00:43:13,590 BREAK UP PSEUDOMOWNUS BIOFILM 1004 00:43:13,590 --> 00:43:15,425 AND BE [INDISCERNIBLE] AND BREAK 1005 00:43:15,425 --> 00:43:18,028 UP VERY THICK SECRETIONS CF 1006 00:43:18,028 --> 00:43:20,997 PATIENTS HAD AND DR. CARR 1007 00:43:20,997 --> 00:43:23,300 MENTIONED IT IS USED ROUTINELY 1008 00:43:23,300 --> 00:43:25,502 NOW OFTEN ALONG WITH FIBRO 1009 00:43:25,502 --> 00:43:27,270 ANALYTICS IN COMPLICATED 1010 00:43:27,270 --> 00:43:30,373 INFUSIONS WHERE THERE IS 1011 00:43:30,373 --> 00:43:34,144 INFECTION IN PLURA SPACE AND 1012 00:43:34,144 --> 00:43:37,981 ALLOW THEM TO DRAIN OUT OF A 1013 00:43:37,981 --> 00:43:38,682 CHEST TUBE. 1014 00:43:38,682 --> 00:43:42,219 WHERE WERE WE AT END OF THE 1015 00:43:42,219 --> 00:43:45,322 YOUNG MAN'S COURSE? LOOKING AT 1016 00:43:45,322 --> 00:43:46,923 PULMONARY FUNCTION THINKING DID 1017 00:43:46,923 --> 00:43:50,393 WE DO HIM ANY FAVORS? LUNG 1018 00:43:50,393 --> 00:43:52,996 FUNCTION IS 25% OF NORMAL. 1019 00:43:52,996 --> 00:43:58,034 YOU HAVE TO REMEMBER HE IS 1020 00:43:58,034 --> 00:44:01,505 MISSING A WHOLE LUNG NOT 50% 1021 00:44:01,505 --> 00:44:03,673 PREDICTED BUT DISEASE IN 1022 00:44:03,673 --> 00:44:05,575 CONTRALATERAL LUNG AND DOING 1023 00:44:05,575 --> 00:44:07,477 QUITE WELL IN 6-MINUTE WALK THAT 1024 00:44:07,477 --> 00:44:09,679 IS ACTUALLY A VERY NICE AND 1025 00:44:09,679 --> 00:44:11,581 SIMPLE TEST OF PHYSICAL 1026 00:44:11,581 --> 00:44:14,084 FUNCTIONING IS A DECENT DISTANCE 1027 00:44:14,084 --> 00:44:16,653 THAT HE DOESN'T DESATURATE AND 1028 00:44:16,653 --> 00:44:17,554 GOOD OXYGEN SATURATION AND 1029 00:44:17,554 --> 00:44:20,056 DOESN'T NEED TO STAY ON OXYGEN 1030 00:44:20,056 --> 00:44:23,627 AND DOESN'T HAVE RISK FOR 1031 00:44:23,627 --> 00:44:24,394 DEVELOPING PULMONARY 1032 00:44:24,394 --> 00:44:24,728 HYPERTENSION. 1033 00:44:24,728 --> 00:44:27,497 SO WE ARE NOW LEFT WITH POST TB 1034 00:44:27,497 --> 00:44:30,700 LUNG DISEASE THAT IS ACTUALLY A 1035 00:44:30,700 --> 00:44:32,836 FAIRLY NEW CONCEPT. 1036 00:44:32,836 --> 00:44:34,971 NIAD JUST RELEASED FUNDING FOR 1037 00:44:34,971 --> 00:44:38,008 THIS WITHIN THE LAST TWO YEARS. 1038 00:44:38,008 --> 00:44:40,844 FOR MOST OF MY CAREER, WE SAID 1039 00:44:40,844 --> 00:44:43,513 OH, GOSH WE ARE GREAT DOCTORS 1040 00:44:43,513 --> 00:44:46,850 AND CURED TB AND PEOPLE ARE LEFT 1041 00:44:46,850 --> 00:44:50,554 WITH DEBILITATING RESPIRATORY 1042 00:44:50,554 --> 00:44:52,689 IMPAIRMENTS. GLOBALLY IS 1043 00:44:52,689 --> 00:44:55,659 ESTIMATED ABOUT 155 MILLION TB 1044 00:44:55,659 --> 00:44:57,894 SURVIVORS AND ABOUT HALF OF THEM 1045 00:44:57,894 --> 00:45:00,263 HAVE POST TB LUNG DISEASE AND 1046 00:45:00,263 --> 00:45:02,933 CLEARLY OUR YOUNG MAN CLEARLY 1047 00:45:02,933 --> 00:45:06,002 HAS BRONXY ECT CIS AND WE ARE 1048 00:45:06,002 --> 00:45:08,505 NOT SEEING LUNG FIBROSIS AND 1049 00:45:08,505 --> 00:45:10,607 LONGSTANDING PATIENTS DEVELOP 1050 00:45:10,607 --> 00:45:13,643 AND HAD MINOR CAVITATION THAT 1051 00:45:13,643 --> 00:45:15,912 CLEARED UP AND MICEO TOMORROWAS 1052 00:45:15,912 --> 00:45:18,048 REFERS TO MOLD GETTING INTO 1053 00:45:18,048 --> 00:45:19,716 CAVITIES CAUSING PROBLEMS AND 1054 00:45:19,716 --> 00:45:23,320 DOESN'T APPEAR TO HAVE PULMONARY 1055 00:45:23,320 --> 00:45:24,988 HYPERTENSION THAT IS HIGH BLOOD 1056 00:45:24,988 --> 00:45:27,357 PRESSURE INSIDE OF THE LUNGS AND 1057 00:45:27,357 --> 00:45:29,326 CHRONIC PULMONARY CHRONIC 1058 00:45:29,326 --> 00:45:31,695 DISEASE AND ALL IN ALL, HE SEEMS 1059 00:45:31,695 --> 00:45:33,597 TO BE DOING QUITE WELL AND WHAT 1060 00:45:33,597 --> 00:45:35,565 CAN BE DONE? 1061 00:45:35,565 --> 00:45:37,367 A LOT OF OUR LUNG DISEASE 1062 00:45:37,367 --> 00:45:41,137 PATIENTS DO WELL TO GET THEM TO 1063 00:45:41,137 --> 00:45:42,572 PULMONARY REHABILITATION AND 1064 00:45:42,572 --> 00:45:44,040 GRATIFYING THING IN MY CAREER 1065 00:45:44,040 --> 00:45:48,044 HAS BEEN TO SEE SOME OF OUR 1066 00:45:48,044 --> 00:45:50,380 FORMER COLLEAGUES IN UGANDA WHO 1067 00:45:50,380 --> 00:45:53,717 HAVE TAKEN ON FIELDS LIKE THIS. 1068 00:45:53,717 --> 00:45:55,885 BRUCE WHO WAS INVOLVED IN A 1069 00:45:55,885 --> 00:46:06,162 PAPER WITH AFANIA AND NIDI AND I 1070 00:46:06,162 --> 00:46:08,765 WAS IN A STUDY THAT WAS 20 YEARS 1071 00:46:08,765 --> 00:46:11,468 AGO AND WAS A FASCINATING PIECE 1072 00:46:11,468 --> 00:46:13,737 OF WORK. BRUCE WAS GREAT TO 1073 00:46:13,737 --> 00:46:14,537 WORK WITH. 1074 00:46:14,537 --> 00:46:18,408 HE AND COLLEAGUES DID THIS VERY 1075 00:46:18,408 --> 00:46:20,543 SMALL PILOT STUDY AND ENDED UP 1076 00:46:20,543 --> 00:46:24,714 HAVING 29 PATIENTS THAT 1077 00:46:24,714 --> 00:46:26,750 COMPLETED PROGRAM AT MAIN MILL 1078 00:46:26,750 --> 00:46:29,252 AGROHOSPITAL IN UGANDA AND 1079 00:46:29,252 --> 00:46:30,787 DEMONSTRATED WITH TWICE A WEEK 1080 00:46:30,787 --> 00:46:34,891 PROGRAM THERE ARE SYMPTOMS AND 1081 00:46:34,891 --> 00:46:36,393 THEIR WALK DISTANCE IMPROVED AND 1082 00:46:36,393 --> 00:46:38,395 THEY HAVE ADDITIONAL FUNDING AND 1083 00:46:38,395 --> 00:46:43,033 ARE DOING PULMONARY REHAB FOR 1084 00:46:43,033 --> 00:46:43,233 THIS. 1085 00:46:43,233 --> 00:46:46,970 A WHILE BACK, THE ATS, AMERICAN 1086 00:46:46,970 --> 00:46:49,572 THORACIC SOCIETY RELEASED 1087 00:46:49,572 --> 00:46:52,042 GUIDELINES FOR PULMONARY 1088 00:46:52,042 --> 00:46:54,878 REHABILITATION AND FORGOT TO 1089 00:46:54,878 --> 00:46:58,248 INCLUDE TUBERCULOSIS MAJOR CAUSE 1090 00:46:58,248 --> 00:47:01,284 OF RESPIRATORY IMPAIRMENT IN THE 1091 00:47:01,284 --> 00:47:04,020 WORLD NOW AND [INDISCERNIBLE] 1092 00:47:04,020 --> 00:47:05,655 AND BRUCE AND I WROTE THIS 1093 00:47:05,655 --> 00:47:07,357 REVIEW AND CALLED ATTENTION TO 1094 00:47:07,357 --> 00:47:11,061 THAT AND IS IFEANYI HERE? I 1095 00:47:11,061 --> 00:47:12,896 DON'T THINK HE IS HERE. IF YOU 1096 00:47:12,896 --> 00:47:16,666 KNOW DR. ANIDI, HE IS CURRENTLY 1097 00:47:16,666 --> 00:47:18,168 CONDUCTING A STUDY HERE TO TRY 1098 00:47:18,168 --> 00:47:21,337 TO BETTER UNDERSTAND THE IMMUNE 1099 00:47:21,337 --> 00:47:22,972 RESPONSE IN THE LUNG VERSUS 1100 00:47:22,972 --> 00:47:23,206 BLOOD. 1101 00:47:23,206 --> 00:47:25,041 WE WOULD LOVE TO HAVE YOU 1102 00:47:25,041 --> 00:47:28,044 VOLUNTEER FOR THAT STUDY IF YOU 1103 00:47:28,044 --> 00:47:32,248 ARE SO INCLINED. 1104 00:47:32,248 --> 00:47:35,885 SO THIS IS A PICTURE OF OUR 1105 00:47:35,885 --> 00:47:38,621 PATIENT AT HIS GOING AWAY PARTY 1106 00:47:38,621 --> 00:47:40,590 AND NINE MONTHS AFTER LIVING AT 1107 00:47:40,590 --> 00:47:43,860 CLINICAL CENTER HE HAD OBVIOUSLY 1108 00:47:43,860 --> 00:47:46,062 IN-PATIENT PULMONARY REHAB AND 1109 00:47:46,062 --> 00:47:47,697 PHYSICAL DEPARTMENT AND 1110 00:47:47,697 --> 00:47:49,432 OCCUPATIONAL THERAPY AND DR. 1111 00:47:49,432 --> 00:47:52,035 CARR IS SAYING WHOLE TEAM HERE 1112 00:47:52,035 --> 00:47:53,903 HAD BEEN AMAZING AND MICHAEL 1113 00:47:53,903 --> 00:47:56,039 WHEN WE SAW HIM HAD FOOT DROP 1114 00:47:56,039 --> 00:48:00,677 FROM SEVERE MOTOR NEUROPATHY AND 1115 00:48:00,677 --> 00:48:03,580 FROM DRUGS FOR TB AND IS NOW 1116 00:48:03,580 --> 00:48:05,181 WALKING ON OWN DOING GREAT AND 1117 00:48:05,181 --> 00:48:07,584 YOU CAN SEE FEELING WELL AND 1118 00:48:07,584 --> 00:48:09,018 THIS HAS BEEN ONE OF MOST 1119 00:48:09,018 --> 00:48:10,987 GRATIFYING CASES OF MY CAREER. 1120 00:48:10,987 --> 00:48:13,289 IT HAS BEEN MY PLEASURE AND 1121 00:48:13,289 --> 00:48:15,058 PRIVILEGE TO HAVE WORKED WITH 1122 00:48:15,058 --> 00:48:18,561 DR. CA ARE, R AND HIS AMAZING 1123 00:48:18,561 --> 00:48:24,033 TEAM AND INCLUDING DR. LORRAINE. 1124 00:48:24,033 --> 00:48:26,669 AND KAREN FOREST IS PART OF THE 1125 00:48:26,669 --> 00:48:29,172 LONDON SCHOOL OF HYGIENE AND 1126 00:48:29,172 --> 00:48:31,608 TROPICAL MEDICINE AND STAFF IN 1127 00:48:31,608 --> 00:48:34,611 THE GAMBIA HAS BEEN IN 1128 00:48:34,611 --> 00:48:35,845 COMMUNICATION WITH US ON A 1129 00:48:35,845 --> 00:48:36,546 REGULAR BASIS. 1130 00:48:36,546 --> 00:48:37,814 I WON'T GO THROUGH ALL THESE 1131 00:48:37,814 --> 00:48:38,047 PEOPLE. 1132 00:48:38,047 --> 00:48:40,049 YOU CAN SEE IT REALLY TAKES A 1133 00:48:40,049 --> 00:48:42,485 VILLAGE AND TAKES THE ENTIRE 1134 00:48:42,485 --> 00:48:42,719 GROUP. 1135 00:48:42,719 --> 00:48:44,554 IT WAS VERY GRATIFYING TO BE 1136 00:48:44,554 --> 00:48:44,754 HERE. 1137 00:48:44,754 --> 00:48:46,823 ONE OF THE REALLY AMAZING THINGS 1138 00:48:46,823 --> 00:48:50,827 FOR ME WORKING AT NIH IS THE 1139 00:48:50,827 --> 00:48:52,395 EXCELLENCE AND PRIDE PEOPLE TAKE 1140 00:48:52,395 --> 00:48:55,598 IN THEIR WORK. 1141 00:48:55,598 --> 00:48:56,399 AND HELPING. 1142 00:48:56,399 --> 00:48:58,902 AND LAST BUT NOT LEAST IS 1143 00:48:58,902 --> 00:49:00,637 ACTUALLY OUR PATIENT AND HIS 1144 00:49:00,637 --> 00:49:03,106 FAMILY THAT WERE INCREDIBLY 1145 00:49:03,106 --> 00:49:03,406 SUPPORTIVE. 1146 00:49:03,406 --> 00:49:05,842 YOU KNOW, HELPED HIM GET HERE. 1147 00:49:05,842 --> 00:49:07,811 I DON'T KNOW IF IT WAS CLEAR TO 1148 00:49:07,811 --> 00:49:08,077 YOU. 1149 00:49:08,077 --> 00:49:11,915 HE ARRIVED WITH A CHEST TUBE 1150 00:49:11,915 --> 00:49:15,351 HANGING OUT OF HIS CHEST 1151 00:49:15,351 --> 00:49:18,254 CONNECTED TO A HIEM LICK VALVE 1152 00:49:18,254 --> 00:49:20,056 MAKING LONG TRIP FROM AFRICA TO 1153 00:49:20,056 --> 00:49:23,092 HERE IS BAD ENOUGH IN ECONOMY. 1154 00:49:23,092 --> 00:49:26,496 AND HE -- HE ARRIVED IN -- WENT 1155 00:49:26,496 --> 00:49:29,332 -- WENT THROUGH A REALLY TOUGH 1156 00:49:29,332 --> 00:49:30,333 COURSE AND HAS DONE WELL. 1157 00:49:30,333 --> 00:49:32,602 WITH THAT, I WILL WRAP IT UP AND 1158 00:49:32,602 --> 00:49:36,206 SEE IF THERE ARE QUESTIONS FOR 1159 00:49:36,206 --> 00:49:43,713 OUR TEAM. 1160 00:49:43,713 --> 00:49:50,353 >> [OFF MIC]. LET ME SEE IF 1161 00:49:50,353 --> 00:49:53,156 THERE ARE ANY QUESTIONS ONLINE. 1162 00:49:53,156 --> 00:49:55,892 >> THERE IS SILENCE. 1163 00:49:55,892 --> 00:49:57,227 >> WE ACTUALLY DO HAVE A 1164 00:49:57,227 --> 00:49:59,028 QUESTION FROM THE ONLINE 1165 00:49:59,028 --> 00:49:59,295 AUDIENCE. 1166 00:49:59,295 --> 00:50:02,098 THE QUESTION IS IS THE BCG 1167 00:50:02,098 --> 00:50:05,802 VACCINE NOT AVAILABLE IN THE 1168 00:50:05,802 --> 00:50:06,169 GAMBIA. 1169 00:50:06,169 --> 00:50:08,605 >> NO. THE QUESTION IF THOSE 1170 00:50:08,605 --> 00:50:12,675 DIDN'T HEAR IT IS BCG VACCINE 1171 00:50:12,675 --> 00:50:18,514 AVAILABLE IN GAMBIA? IT IS 1172 00:50:18,514 --> 00:50:22,785 AVAILABLE IN GAMBIA AND MOST OF 1173 00:50:22,785 --> 00:50:24,754 THE SUB IS A HAIRANT WORLDED AND 1174 00:50:24,754 --> 00:50:27,757 IN WORLD WHERE HIGH RATE OF 1175 00:50:27,757 --> 00:50:30,159 TUBERCULOSIS HAVE BCG GENE AND 1176 00:50:30,159 --> 00:50:33,663 IT IS PREVENTIVE IN REACTIVATION 1177 00:50:33,663 --> 00:50:35,698 OF TB IN ADULTS. 1178 00:50:35,698 --> 00:50:37,333 >> I'M CURIOUS ABOUT FLUID IN 1179 00:50:37,333 --> 00:50:39,769 LUNG THAT YOU LEFT WITH 1180 00:50:39,769 --> 00:50:42,572 ANTIBIOTICS AND WHAT HAPPENS TO 1181 00:50:42,572 --> 00:50:44,674 IT OVER TIME. THANK YOU. 1182 00:50:44,674 --> 00:50:45,441 >> GO FOR IT. 1183 00:50:45,441 --> 00:50:47,210 >> IT ACTUALLY STAYS. 1184 00:50:47,210 --> 00:50:53,116 SO WHAT HAPPENS IS THE MRPLURA 1185 00:50:53,116 --> 00:50:55,885 SPACE WILL CONTINUE TO PRODUCE A 1186 00:50:55,885 --> 00:50:56,786 PROTEIN RICH FLUID. 1187 00:50:56,786 --> 00:50:59,422 IT CHANGES THIS NORMAL SALINE. 1188 00:50:59,422 --> 00:51:03,059 OVER TIME IT ESSENTIALLY NOT TO 1189 00:51:03,059 --> 00:51:05,128 DISSUADE ANYBODY FROM EATING 1190 00:51:05,128 --> 00:51:07,463 JELL-O ANYMORE IT TURNS INTO A 1191 00:51:07,463 --> 00:51:09,699 JELL-O MOLD INSIDE OF THE CHEST 1192 00:51:09,699 --> 00:51:11,434 AND PROTEIN IS LEECHED IN AND 1193 00:51:11,434 --> 00:51:13,569 STAYS AND OVER TIME FORMS WHAT 1194 00:51:13,569 --> 00:51:15,905 WE CALL A FIBRO THORAX THAT 1195 00:51:15,905 --> 00:51:18,875 SHOULD BE A JELL-O MOLD INSIDE 1196 00:51:18,875 --> 00:51:21,678 OF THE CHEST. 1197 00:51:21,678 --> 00:51:23,413 >> LET ME ADD A COMMENT THAT 1198 00:51:23,413 --> 00:51:26,215 LOTS WENT ON IN CASE OVER NINE 1199 00:51:26,215 --> 00:51:28,685 MONTHS WE CAN'T POSSIBLY ADDRESS 1200 00:51:28,685 --> 00:51:29,585 EVERY BIT OF. 1201 00:51:29,585 --> 00:51:31,788 YOU -- SOME MAY KNOW THAT THERE 1202 00:51:31,788 --> 00:51:36,960 IS A KIND OF CULTURE HERE OF NOT 1203 00:51:36,960 --> 00:51:38,494 USING NAMMO CASEIN OR 1204 00:51:38,494 --> 00:51:40,196 GLYCOCRIEDS AND SOMETHING I HAVE 1205 00:51:40,196 --> 00:51:43,166 BEEN VERY COMFORTABLE WITH AND 1206 00:51:43,166 --> 00:51:45,268 WHEN STARTING TO DO PLURAL 1207 00:51:45,268 --> 00:51:48,037 WASHES WITH AMMI CASEIN LEAVING 1208 00:51:48,037 --> 00:51:51,040 IT IN FOR A WHILE DR. CARR'S 1209 00:51:51,040 --> 00:51:53,209 TEAM DID NICE STUDIES AND GOT 1210 00:51:53,209 --> 00:51:57,180 LEVELS DONE AFTER EACH OF THE 1211 00:51:57,180 --> 00:51:59,015 AMACACIN TREATMENTS 1212 00:51:59,015 --> 00:51:59,816 DEMONSTRATING SYSTEMIC LEVELS 1213 00:51:59,816 --> 00:52:02,552 WERE VERY LOW AND FOLLOWED 1214 00:52:02,552 --> 00:52:04,187 HEARING TEST ALL THROUGH THE 1215 00:52:04,187 --> 00:52:04,420 COURSE. 1216 00:52:04,420 --> 00:52:08,057 HIS HEARING HAS BEEN UNAFFECTED 1217 00:52:08,057 --> 00:52:18,401 AND IS 100% NORMAL. 1218 00:52:21,270 --> 00:52:24,407 >> THIS IS FROM REBECCA CROOK. 1219 00:52:24,407 --> 00:52:27,076 I WORKED WITH THIS CHAP. WE 1220 00:52:27,076 --> 00:52:29,479 KNEW HIM BY HIS NICKNAME ISRAEL 1221 00:52:29,479 --> 00:52:32,749 FOR MOST OF JOURNEY IN GAMBIA. 1222 00:52:32,749 --> 00:52:34,550 WE CAN'T THANK YOU ENOUGH FOR 1223 00:52:34,550 --> 00:52:36,552 ALL YOU HAVE DONE FOR HIM IT IS 1224 00:52:36,552 --> 00:52:38,888 NICE TO SEE HIM UP AND WITH 1225 00:52:38,888 --> 00:52:41,357 WEIGHT AND IT IS AN ACHIEVEMENT 1226 00:52:41,357 --> 00:52:42,258 AND GOOD WORK, TEAM. 1227 00:52:42,258 --> 00:52:45,928 >> THANKS SO MUCH. THAT IS FROM 1228 00:52:45,928 --> 00:52:47,430 GAMBIA? THAT IS RIGHT IF 1229 00:52:47,430 --> 00:52:49,732 ANYBODY IN THE GAMBIA CAN STILL 1230 00:52:49,732 --> 00:52:51,434 HEAR US YOU ARE MORE THAN 1231 00:52:51,434 --> 00:52:54,470 WELCOME. IT WAS REALLY OUR 1232 00:52:54,470 --> 00:52:55,638 PLEASURE TO HELP. 1233 00:52:55,638 --> 00:52:57,407 >> THANK YOU FOR STARTING OFF. 1234 00:52:57,407 --> 00:52:59,409 THANK YOU FOR STARTING OFF THE 1235 00:52:59,409 --> 00:53:01,377 YEAR WITH THIS FANTASTIC 1236 00:53:01,377 --> 00:53:01,778 PRESENTATION. 1237 00:53:01,778 --> 00:53:03,913 AGAIN, I WOULD ENCOURAGE 1238 00:53:03,913 --> 00:53:05,381 EVERYONE TO GIVE FEEDBACK VIA 1239 00:53:05,381 --> 00:53:07,016 THE LINK THAT YOU WILL RECEIVE 1240 00:53:07,016 --> 00:53:10,319 IF YOU COMPLETE YOUR CME. IF 1241 00:53:10,319 --> 00:53:12,455 YOU TEXT OR IF YOU ACTUALLY SCAN 1242 00:53:12,455 --> 00:53:14,257 THE CODE, THERE WILL BE A LINK 1243 00:53:14,257 --> 00:53:15,758 THERE AS WELL TO PROVIDE 1244 00:53:15,758 --> 00:53:19,462 FEEDBACK TO US AND THANKS AGAIN. 1245 00:53:19,462 --> 00:53:20,997 TAKE CARE! 1246 00:53:20,997 --> 00:53:31,407 >> AUDIENCE: [APPLAUSE]