1 00:00:11,440 --> 00:00:13,640 Welcome to the Clinical Center Grand Rounds, 2 00:00:13,640 --> 00:00:17,440 a weekly series of educational lectures for physicians and 3 00:00:17,440 --> 00:00:20,080 health care professionals broadcast from the Clinical 4 00:00:20,080 --> 00:00:23,040 Center at the National Institutes of Health in 5 00:00:23,040 --> 00:00:24,840 Bethesda, MD. 6 00:00:24,840 --> 00:00:28,400 The NIH Clinical Center is the world's largest hospital totally 7 00:00:28,400 --> 00:00:32,080 dedicated to investigational research and leads the global 8 00:00:32,080 --> 00:00:35,040 effort in training today's investigators and discovering 9 00:00:35,040 --> 00:00:37,200 tomorrow's cures. 10 00:00:37,200 --> 00:00:46,680 Learn more by visiting us online at http://clinicalcenter.nih.gov 11 00:00:46,680 --> 00:00:52,080 >>TODAY WE ARE HONORED TO HOST 12 00:00:52,080 --> 00:00:53,480 DR. TERRIE TAYLOR 13 00:00:53,480 --> 00:00:54,080 INTERNATIONALLY RECOGNIZED 14 00:00:54,080 --> 00:00:56,480 SCIENTIST AND PHYSICIAN, A 15 00:00:56,480 --> 00:00:57,560 DISTINGUISHED PROFESSOR OF 16 00:00:57,560 --> 00:01:00,520 SURGERY AND MSU FOUNDATION 17 00:01:00,520 --> 00:01:02,960 PROFESSOR FOR THE COLLEGE OF 18 00:01:02,960 --> 00:01:04,440 OSTEOPATHIC MEDICINE AT THE 19 00:01:04,440 --> 00:01:06,040 COLLEGE OF MICHIGAN STATE 20 00:01:06,040 --> 00:01:07,240 UNIVERSITY. 21 00:01:07,240 --> 00:01:10,440 DR. TAYLOR EARNED HER DOCTOR OF 22 00:01:10,440 --> 00:01:12,680 OSTEOPATHIC MEDICINE FROM THE 23 00:01:12,680 --> 00:01:14,000 OSTEOPATHIC MEDICINE COLLEGE AND 24 00:01:14,000 --> 00:01:16,320 COMPLETED INTERNSHIP AT THE 25 00:01:16,320 --> 00:01:18,280 RIVER SIDE OSTEOPATHIC HOSPITAL 26 00:01:18,280 --> 00:01:20,840 IN TRENTON, MICHIGAN. 27 00:01:20,840 --> 00:01:22,480 SUBSEQUENTLY SHE PURSUED A 28 00:01:22,480 --> 00:01:23,800 RESIDENCY IN INTERNAL MEDICINE 29 00:01:23,800 --> 00:01:26,760 AT THE OSTEOPATHIC HOSPITAL. 30 00:01:26,760 --> 00:01:28,320 DR. TAYLOR THEN EARNED A MASTERS 31 00:01:28,320 --> 00:01:29,760 OF TROPICAL MEDICINE FROM THE 32 00:01:29,760 --> 00:01:31,920 LIVER POOL SCHOOL OF TROPICAL 33 00:01:31,920 --> 00:01:35,000 MEDICINE IN LIVER POOL UNITED 34 00:01:35,000 --> 00:01:35,280 KINGDOM. 35 00:01:35,280 --> 00:01:40,240 WHILE EARNING HER MASTERS SHE 36 00:01:40,240 --> 00:01:41,680 MET MALCOM [INDISCERNIBLE] THE 37 00:01:41,680 --> 00:01:44,320 PIONEERING RESEARCHER IN 38 00:01:44,320 --> 00:01:44,920 MALARIA. 39 00:01:44,920 --> 00:01:47,520 THIS PROFESSIONAL PARTNERSHIP 40 00:01:47,520 --> 00:01:48,680 INSPIRED DR. TAYLOR TO COMMIT 41 00:01:48,680 --> 00:01:50,480 HERSELF TO UNDERSTANDING AND 42 00:01:50,480 --> 00:01:53,040 CONQUERING 1 OF THE MOST 43 00:01:53,040 --> 00:01:57,120 INFECTIOUS DISEASE MALADIES IN 44 00:01:57,120 --> 00:01:59,560 THE WORLD TODAY, MALARIA. 45 00:01:59,560 --> 00:02:00,840 TOGETHER THEY DESIGNED A CHROMA 46 00:02:00,840 --> 00:02:05,200 SCALE THAT IS USED TO ASSESS 47 00:02:05,200 --> 00:02:06,360 MALARIA IN CHILDREN. 48 00:02:06,360 --> 00:02:08,400 SINCE 1986 DR. TAYLOR HAS BEEN 49 00:02:08,400 --> 00:02:11,640 LIVING AND WORKING IN MALAWI FOR 50 00:02:11,640 --> 00:02:14,640 6 MONTHS EACH YEAR CONDUCTING 51 00:02:14,640 --> 00:02:16,760 AND TREATING FOR MALARIA 52 00:02:16,760 --> 00:02:18,160 RESEARCH, THE MAJORITY OF WHOM 53 00:02:18,160 --> 00:02:19,480 ARE CHILDREN. 54 00:02:19,480 --> 00:02:21,080 DR. TAYLOR'S RESEARCH FOCUSES ON 55 00:02:21,080 --> 00:02:22,920 THE PATHOGENESIS OF CEREBRAL 56 00:02:22,920 --> 00:02:24,560 MALARIA, HER TEAM PROVIDES 57 00:02:24,560 --> 00:02:26,640 CLINICAL CARE FOR CHILDREN WITH 58 00:02:26,640 --> 00:02:28,560 CEREBRAL MA LAIAR AND IN THAT 59 00:02:28,560 --> 00:02:33,640 CONTEXT, STUDY OF THE DISEASE. 60 00:02:33,640 --> 00:02:36,720 HER WORK HAS RECOGNIZED MALARIAL 61 00:02:36,720 --> 00:02:38,360 RETINAL LOCATIONIN OPEN 62 00:02:38,360 --> 00:02:40,400 MEETINGATHY AND ESTABLISHING 63 00:02:40,400 --> 00:02:42,880 IMPORTANCE AND ORCH CHESTERATING 64 00:02:42,880 --> 00:02:46,440 THE AUTOPSIES OF FATAL CEREBRAL 65 00:02:46,440 --> 00:02:52,600 MALARIA AND COORDINATION OF MRI 66 00:02:52,600 --> 00:02:53,840 IN MALAWI. 67 00:02:53,840 --> 00:02:56,000 SHE HAS ALSO SERVED AS TD 68 00:02:56,000 --> 00:02:59,120 DIRECTOR OF FOR THE CENTERS OF 69 00:02:59,120 --> 00:03:01,200 EXCELLENCE RESEARCH IN MALARIA 70 00:03:01,200 --> 00:03:04,040 FOR THE CENTER'S SUPPORT, SHE 71 00:03:04,040 --> 00:03:06,920 HAS ESTABLISHED THE FIELD WORK 72 00:03:06,920 --> 00:03:09,480 IN MALAWI. 73 00:03:09,480 --> 00:03:11,800 EXECUTED CROSS PATIENTAL 74 00:03:11,800 --> 00:03:13,840 SURVEYS, AND ACTIVELY CONDUCTING 75 00:03:13,840 --> 00:03:15,080 LONGITUDE FLAL COHORT STUDIES, 76 00:03:15,080 --> 00:03:20,560 CASE CONTROL STUDY AND A QUALITY 77 00:03:20,560 --> 00:03:31,080 INQUIRY INTO BARRIERS THWARTING 78 00:03:33,120 --> 00:03:34,320 MALARIA CONTROLS. 79 00:03:34,320 --> 00:03:36,120 DR. TAYLOR HAS BEEN THE 80 00:03:36,120 --> 00:03:37,440 RECIPIENT OF COUNTLESS HONORS 81 00:03:37,440 --> 00:03:40,160 AND AWARDS INCLUDING THE 82 00:03:40,160 --> 00:03:41,200 AMERICAN MEDICAL ASSOCIATION, 83 00:03:41,200 --> 00:03:43,360 FOUNDATION EXCELLENCE AND 84 00:03:43,360 --> 00:03:44,040 MEDICINE AWARD. 85 00:03:44,040 --> 00:03:48,600 THE AMERICAN OFTIO MATHIC 86 00:03:48,600 --> 00:03:49,360 ASSOCIATION, OSTEOPATHIC PIONEER 87 00:03:49,360 --> 00:03:51,400 AWARD AND AMERICAN SOCIETY OF 88 00:03:51,400 --> 00:03:53,000 TROPICAL MEDICINE AND THE 89 00:03:53,000 --> 00:03:54,400 HIGREEN BEN KING AWARD. 90 00:03:54,400 --> 00:03:57,520 SHE HAS AUTHORED OR CO AUTHORED 91 00:03:57,520 --> 00:03:59,160 WELL OVER 200 PEER REVIEW 92 00:03:59,160 --> 00:04:02,360 PUBLICATIONS AND HAS RECEIVED 93 00:04:02,360 --> 00:04:06,160 OVER 35 MILLION IN GRANT AWARDS. 94 00:04:06,160 --> 00:04:14,520 THE TITLE OF DR. TAYLOR'S 95 00:04:14,520 --> 00:04:15,640 LECTURE IS THE PATHOGENESIS OF 96 00:04:15,640 --> 00:04:16,280 PEDIATRIC CEREBRAL MALARIA, AN 97 00:04:16,280 --> 00:04:17,800 ONGOING STORY OF SERENDIPITY AND 98 00:04:17,800 --> 00:04:18,080 SURPRISES. 99 00:04:18,080 --> 00:04:20,040 WELCOME DR. TAYLOR. 100 00:04:20,040 --> 00:04:21,640 THANK YOU SO MUCH. 101 00:04:21,640 --> 00:04:23,240 IT'S AN HONOR BEING HERE AND I 102 00:04:23,240 --> 00:04:26,480 ENJOYED HAVING COFFEE WITH THE 103 00:04:26,480 --> 00:04:27,280 STUDENTS EARLIER TODAY. 104 00:04:27,280 --> 00:04:30,640 LET ME START BY DISCLOSING THAT 105 00:04:30,640 --> 00:04:31,200 I DO SERVE IN AN ADVISORY 106 00:04:31,200 --> 00:04:33,160 CAPACITY FOR A COUPLE OF 107 00:04:33,160 --> 00:04:35,040 DIFFERENT ENTITIES WITHIN 108 00:04:35,040 --> 00:04:36,520 NOVARTIS BUT THAT DOESN'T AFFECT 109 00:04:36,520 --> 00:04:37,800 ANYTHING I WILL PRESENT AND I 110 00:04:37,800 --> 00:04:38,920 HOPE THAT BY THE EPPED OF THE 111 00:04:38,920 --> 00:04:41,920 HOUR, YOU WILL HAVE A BETTER 112 00:04:41,920 --> 00:04:46,320 UNDERSTANDING OF HOW KIDS WITH 113 00:04:46,320 --> 00:04:48,040 CEREBRAL MALARIA PRESENT AND 114 00:04:48,040 --> 00:04:48,920 EVOLVE WHILE THEY'RE BEING CARED 115 00:04:48,920 --> 00:04:51,000 FOR AND THAT YOU WILL UNDERSTAND 116 00:04:51,000 --> 00:04:53,840 THE SIGNIFICANCE OF INCREASED 117 00:04:53,840 --> 00:04:56,120 BRAIN VOLUME IN THEIR DISEASE. 118 00:04:56,120 --> 00:04:59,080 I INCLUDED SERENDIPITY IN THE 119 00:04:59,080 --> 00:04:59,880 TITLE. 120 00:04:59,880 --> 00:05:01,880 SERENDIPITY BEING AN UNPLANNED 121 00:05:01,880 --> 00:05:03,040 FORTUNATE DISCOVERY BECAUSE 122 00:05:03,040 --> 00:05:05,920 REALLY IT HAS STUDDED OUR--MY 123 00:05:05,920 --> 00:05:10,440 JOURNEY THROUGHOUT MY TIME IN 124 00:05:10,440 --> 00:05:10,920 MALAWI. 125 00:05:10,920 --> 00:05:12,960 AND I WANT TO TO TAKE A BRIEF 126 00:05:12,960 --> 00:05:14,240 MOMENT IN THE BEGINNING TO TALK 127 00:05:14,240 --> 00:05:16,760 ABOUT CAREERS IN GLOBAL HEALTH. 128 00:05:16,760 --> 00:05:17,720 BECAUSE 1 OF THE GREAT THINGS 129 00:05:17,720 --> 00:05:19,200 ABOUT THE FIELD IS THAT 130 00:05:19,200 --> 00:05:20,520 EVERYBODY SORT OF ENTERS AT A 131 00:05:20,520 --> 00:05:25,640 DIFFERENT POINT AND FOLLOWS 132 00:05:25,640 --> 00:05:26,200 DIFFERENT TRAJECTORIES. 133 00:05:26,200 --> 00:05:28,640 I STARTED IN A SMALL TOWN IN 134 00:05:28,640 --> 00:05:29,360 NORTHERN MICHIGAN GRADUATING 135 00:05:29,360 --> 00:05:32,200 FROM HIGH SCHOOL IN 1973 WANTING 136 00:05:32,200 --> 00:05:33,640 TO DO SOMETHING INTERESTING AND 137 00:05:33,640 --> 00:05:35,720 USEFUL, I HAD WONDERFUL 138 00:05:35,720 --> 00:05:36,680 UNDERGRADUATE EDUCATION BUT 139 00:05:36,680 --> 00:05:38,160 REALIZED I WASN'T GOING TO BE A 140 00:05:38,160 --> 00:05:39,360 BENCH SCIENTIST SO I WENT ON TO 141 00:05:39,360 --> 00:05:40,640 MEDICAL SCHOOL WHERE I THOUGHT 142 00:05:40,640 --> 00:05:44,160 MAYBE I WOULD DO RURAL MEDICINE 143 00:05:44,160 --> 00:05:46,080 BUT WHEN IT CAME TIME TO DECIDE 144 00:05:46,080 --> 00:05:48,080 ABOUT A RESIDENCY WHICH WE DID 145 00:05:48,080 --> 00:05:50,040 DURING OUR INTERNSHIP IN THOSE 146 00:05:50,040 --> 00:05:53,040 DAYS, I COULDN'T MAKE A DECISION 147 00:05:53,040 --> 00:05:55,120 AND SO, RATHER THAN JUMP 148 00:05:55,120 --> 00:05:57,200 PREMATURELY, I THOUGHT LET ME 149 00:05:57,200 --> 00:05:58,320 SEE THE WORLD. 150 00:05:58,320 --> 00:06:01,080 I'VE GOT A SELLABLE SKILL AND AS 151 00:06:01,080 --> 00:06:04,920 IT HAPPENED, I ENDED UP IN THE 152 00:06:04,920 --> 00:06:05,160 SUDAN. 153 00:06:05,160 --> 00:06:07,920 I ENDED UP IN SUDAN BECAUSE I 154 00:06:07,920 --> 00:06:09,080 STARTED FROM MICHIGAN STATE 155 00:06:09,080 --> 00:06:10,400 UNIVERSITY COLLEGE OF OFTIO 156 00:06:10,400 --> 00:06:13,360 PALGTIC MEDICINE, THE DEAN THERE 157 00:06:13,360 --> 00:06:15,040 HAD A VISION, NIH FUNDED 158 00:06:15,040 --> 00:06:16,080 INVESTIGATORS AT MICHIGAN STATE 159 00:06:16,080 --> 00:06:17,240 WERE HAVING TROUBLE GETTING 160 00:06:17,240 --> 00:06:18,640 TRACTION WITH THE CLINICAL STUDY 161 00:06:18,640 --> 00:06:22,440 IN SUDAN BECAUSE THEY WERE ALL 162 00:06:22,440 --> 00:06:24,840 Ph.D.s AND THEY DIDN'T 163 00:06:24,840 --> 00:06:27,040 HAVE--TOOK A WHILE TO WORK THEIR 164 00:06:27,040 --> 00:06:29,320 WAY INTO THE CLINICAL COMMUNITY 165 00:06:29,320 --> 00:06:30,120 IN SUDAN. 166 00:06:30,120 --> 00:06:33,840 AND SO THE DEAN THOUGHT, AH, I 167 00:06:33,840 --> 00:06:35,080 COULD BUILD CAPACITY AND MY 168 00:06:35,080 --> 00:06:36,040 FACULTY AND HELP OUT THIS 169 00:06:36,040 --> 00:06:37,760 PROJECT AND I SAID NO, NO, NO, 170 00:06:37,760 --> 00:06:41,200 THIS IS REALLY JUST AN ADVENTURE 171 00:06:41,200 --> 00:06:44,680 FOR A YEAR, MAYBE I HAVE TO 172 00:06:44,680 --> 00:06:45,960 RETHINK MY DECISION ABOUT 173 00:06:45,960 --> 00:06:47,720 ORTHOPEDICS AND HE SENT ME OFF 174 00:06:47,720 --> 00:06:53,040 TO THE SUDAN ANYWAY KNOWING THAT 175 00:06:53,040 --> 00:06:54,880 I REALLY WASN'T PLANNING ON THIS 176 00:06:54,880 --> 00:06:55,640 AS A CAREER. 177 00:06:55,640 --> 00:06:57,360 BUT I REALLY LIKED IT, THERE 178 00:06:57,360 --> 00:07:01,080 WERE THESE DISEASES WHICH WERE 179 00:07:01,080 --> 00:07:04,520 VERY UNDERSTUDIED. 180 00:07:04,520 --> 00:07:06,440 THE SUDANESE CLINICIANS DO WHAT 181 00:07:06,440 --> 00:07:08,040 EVERY DOCTOR DOES WHICH IS TAKE 182 00:07:08,040 --> 00:07:09,160 CARE OF PATIENT. 183 00:07:09,160 --> 00:07:11,880 AND THERE WERE STREAMS OF 184 00:07:11,880 --> 00:07:12,720 PATIENTS, THE SUDANESE COULD 185 00:07:12,720 --> 00:07:14,360 NEVER GET ON TOP OF IT ENOUGH TO 186 00:07:14,360 --> 00:07:17,040 THINK ABOUT A RESEARCH PROJECT 187 00:07:17,040 --> 00:07:17,880 OR REQUESTY THAT MIGHT STENCH 188 00:07:17,880 --> 00:07:19,600 THE FLOW OF THOSE PATIENTS, NOT 189 00:07:19,600 --> 00:07:22,720 BECAUSE THEY COULDN'T DO IT 190 00:07:22,720 --> 00:07:23,560 INDLECTUALLY, THEY JUST WERE 191 00:07:23,560 --> 00:07:27,600 SWAMPED WITH PATIENTS AND SO I 192 00:07:27,600 --> 00:07:28,880 BEGAN TO REALLY APPRECIATE THE 193 00:07:28,880 --> 00:07:32,680 UTILITY OF A WESTERN PERSPECTIVE 194 00:07:32,680 --> 00:07:36,400 AND ACTUALLY ACCESS TO RESEARCH 195 00:07:36,400 --> 00:07:37,960 SUPPORT AND 1 DAY I WAS LOOKING 196 00:07:37,960 --> 00:07:39,120 AT THESE KIDS WHO WERE PLAYING 197 00:07:39,120 --> 00:07:40,640 NEXT DOOR AND I WAS THINKING 198 00:07:40,640 --> 00:07:44,120 ABOUT GOING BACK UP TO CARTU, 199 00:07:44,120 --> 00:07:47,120 AND STARTING TO BONE UP ON THE 200 00:07:47,120 --> 00:07:49,000 ORTHOPEDIC WORK, AND I AM LIKE 201 00:07:49,000 --> 00:07:50,680 HMM, MAYBE YOU SHOULD DO THIS SO 202 00:07:50,680 --> 00:07:51,880 IT WAS THIS MOMENT. 203 00:07:51,880 --> 00:07:54,760 I THOUGHT, OKAY, I WILL DO IT, I 204 00:07:54,760 --> 00:07:57,600 HAD TO COMMUNICATE TO THE DEAN 205 00:07:57,600 --> 00:08:01,200 AT MICHIGAN STATE FROM RURAL 206 00:08:01,200 --> 00:08:03,560 SUDAN, WHICH WAS TRICKY AND 207 00:08:03,560 --> 00:08:03,840 PREINTERNET. 208 00:08:03,840 --> 00:08:06,400 HE SAID GO TO DO A RESIDENCY, AT 209 00:08:06,400 --> 00:08:08,560 THAT POINT IT WAS EASY TO CHOOSE 210 00:08:08,560 --> 00:08:09,600 INTERNAL MEDICINE BECAUSE HIBEEN 211 00:08:09,600 --> 00:08:11,760 SO FASCINATED BY THE PARASITIC 212 00:08:11,760 --> 00:08:13,160 INFECTIONS I WAS ENCOUNTERING. 213 00:08:13,160 --> 00:08:17,840 SO I CAME BACK, I DID A MEDICINE 214 00:08:17,840 --> 00:08:18,640 RESIDENCY IN DETROIT ALWAYS 215 00:08:18,640 --> 00:08:23,520 KNOWING I WOULD BE GETTING BACK 216 00:08:23,520 --> 00:08:32,560 TO THE BUSH AND FOR THAT I 217 00:08:32,560 --> 00:08:33,800 IGNORED EVERYONE'S INVITES TO 218 00:08:33,800 --> 00:08:36,680 STAY IN THE U.S. AND OPTED TO 219 00:08:36,680 --> 00:08:38,600 STAY IN THE LIVER POOL SCHOOL OF 220 00:08:38,600 --> 00:08:40,680 MEDICINE BECAUSE IT OFFERED A 221 00:08:40,680 --> 00:08:41,640 MASTER STUDENTS TO FIELD WORK 222 00:08:41,640 --> 00:08:42,880 AND I REALLY WANTED TO BE IN THE 223 00:08:42,880 --> 00:08:44,320 FIELD AND NOT IN THE LAB. 224 00:08:44,320 --> 00:08:47,720 BEFORE A LEFT FOR LIVER POOL, I 225 00:08:47,720 --> 00:08:49,880 MET AGAIN WITH THE DEAN TO 226 00:08:49,880 --> 00:08:51,080 REASSURE HIM OF MY INTEREST EXPW 227 00:08:51,080 --> 00:08:55,440 HE SAID, YOU KNOW IF YOU COME 228 00:08:55,440 --> 00:08:57,280 BACK FROM LIVER POOL AND YOU'VE 229 00:08:57,280 --> 00:08:58,680 IDENTIFIED A RESEARCH PROJECT 230 00:08:58,680 --> 00:09:00,760 SOMEWHERE WHERE I COULD SEND OUR 231 00:09:00,760 --> 00:09:01,520 STUDENTS ON ELECTIVE, I WILL 232 00:09:01,520 --> 00:09:05,320 GIVE YOU A JOB, SO I LEFT FOR 233 00:09:05,320 --> 00:09:08,160 LIVER POOL WITH THAT ADMONITION 234 00:09:08,160 --> 00:09:09,080 IN MY EARS. 235 00:09:09,080 --> 00:09:12,640 HERE IS THE DEAN, MIKE MEGAN AND 236 00:09:12,640 --> 00:09:17,960 HERE IS HIS VISION AND MALAWI 237 00:09:17,960 --> 00:09:18,880 WAS SERENDIPITOUS EEIVET NUMBER 238 00:09:18,880 --> 00:09:19,120 2. 239 00:09:19,120 --> 00:09:22,000 I WAS SENT THERE TO DO MY 240 00:09:22,000 --> 00:09:25,200 STUDENT PROJECT BECAUSE MALCOM 241 00:09:25,200 --> 00:09:27,280 CANNED WHAT 1 OF MY PROFESSORS 242 00:09:27,280 --> 00:09:29,480 IN LIVER POOL HAD A LONG 243 00:09:29,480 --> 00:09:31,840 STANDING CONNECTION IN MALAWI, 244 00:09:31,840 --> 00:09:35,720 HE WAS REVERED, IT WAS A 245 00:09:35,720 --> 00:09:36,320 HOSPITABLE PLACE FOR THE 246 00:09:36,320 --> 00:09:38,720 STUDENTS TO GO AND I REALIZED IN 247 00:09:38,720 --> 00:09:40,680 A NANO SECOND THAT WOULD BE 248 00:09:40,680 --> 00:09:43,280 PERSPECT FOR THE MICHIGAN STATE 249 00:09:43,280 --> 00:09:43,720 STUDENTS. 250 00:09:43,720 --> 00:09:46,000 IT'S A SMALL LAND LOCKED COUNTRY 251 00:09:46,000 --> 00:09:50,080 OF FORMER BRITISH PROTECTORATE, 252 00:09:50,080 --> 00:09:51,960 IT WAS KNOWN AS [INDISCERNIBLE] 253 00:09:51,960 --> 00:09:54,800 THEN AND REALLY IT'S OF NO 254 00:09:54,800 --> 00:09:57,040 GEOPOLITICAL INTEREST TO ANYBODY 255 00:09:57,040 --> 00:09:58,560 AND SO IT'S VERY PEACEFUL AND 256 00:09:58,560 --> 00:10:03,760 VERY NICE PLACE TO WORK. 257 00:10:03,760 --> 00:10:07,640 ON THIS PATH, ON THE 1 MOUNTAIN 258 00:10:07,640 --> 00:10:10,120 IN MALAWI, WE STARTED DISCUSSING 259 00:10:10,120 --> 00:10:11,880 RESEARCH OPPORTUNITIES AND 260 00:10:11,880 --> 00:10:13,280 MALCOM HAD VISITED THE MINISTRY 261 00:10:13,280 --> 00:10:16,160 OF HEALTH TO INQUIRE ABOUT 262 00:10:16,160 --> 00:10:17,560 RESEARCH PRIORITIES THERE AND 263 00:10:17,560 --> 00:10:20,600 THEY IDENTIFIED SEVERE MALARIA 264 00:10:20,600 --> 00:10:22,160 IN CHILDREN HIS BOSS SHOWN BELOW 265 00:10:22,160 --> 00:10:25,400 HIM IN THIS SLIDE, MARCEL HUMLE 266 00:10:25,400 --> 00:10:27,640 HAD DONE WORK ON PRIMATE MODELS 267 00:10:27,640 --> 00:10:29,480 OF MALARIA THAT SUGGESTED A 268 00:10:29,480 --> 00:10:31,480 HYPOTHESIS WE COULD TEST AND I 269 00:10:31,480 --> 00:10:32,200 PERSUADED MALCOM THAT EVEN 270 00:10:32,200 --> 00:10:35,240 THOUGH I WAS A NOVICE, I COULD 271 00:10:35,240 --> 00:10:36,320 BE IN MALAWI FOR LONGER THAN HE 272 00:10:36,320 --> 00:10:41,240 COULD WITH ALL OF HIS FAMILY AND 273 00:10:41,240 --> 00:10:42,160 TEACHING RESPONSIBILITIES IN THE 274 00:10:42,160 --> 00:10:44,600 UK SO WE HATCHED THE IDEA FOR 275 00:10:44,600 --> 00:10:53,000 THIS PROJECT AND WE'RE READY TO 276 00:10:53,000 --> 00:10:53,520 START IN 1986. 277 00:10:53,520 --> 00:10:58,520 WE HAD BEEN WELCOMED BY THE SOLE 278 00:10:58,520 --> 00:11:00,920 PEDIATRICIAN AT THE HOSPITAL IN 279 00:11:00,920 --> 00:11:03,080 AND WE KNEW IT WOULD BE AT THE 280 00:11:03,080 --> 00:11:04,240 SCHOOL EVENTUALLY, THE MINISTRY 281 00:11:04,240 --> 00:11:06,600 OF HEALTH HAD IDENTIFIED ITS 282 00:11:06,600 --> 00:11:06,880 PRIORITY. 283 00:11:06,880 --> 00:11:12,920 WE WERE JUST NAIVE, WE WERE TOTE 284 00:11:12,920 --> 00:11:13,720 AMILLIO NOVICES HAVING NEVER 285 00:11:13,720 --> 00:11:16,320 DONE ANY RESEARCH BEFORE THAT. 286 00:11:16,320 --> 00:11:19,000 THIS IS DR. [INDISCERNIBLE] THE 287 00:11:19,000 --> 00:11:21,840 PEDIATRICIAN WHO WELCOMED US 288 00:11:21,840 --> 00:11:22,960 INTERNISTS INTO HER DEPARTMENT 289 00:11:22,960 --> 00:11:25,600 AND THIS IS MALCOM AND ME 290 00:11:25,600 --> 00:11:27,360 WORKING TO ESTABLISH INTRAVENOUS 291 00:11:27,360 --> 00:11:28,600 ACCESS IN THE YOUNG PATIENT IN 292 00:11:28,600 --> 00:11:33,560 THAT FIRST YEAR, THE FALL OF 293 00:11:33,560 --> 00:11:33,760 1986. 294 00:11:33,760 --> 00:11:35,840 SO SINCE THEN WE'VE BEEN BASED 295 00:11:35,840 --> 00:11:37,400 AT THE QUEEN ELIZABETH HOSPITAL 296 00:11:37,400 --> 00:11:40,080 HERE IN SOUTHERN MALAWI. 297 00:11:40,080 --> 00:11:42,360 WE STARTED WITH NOT A LOT OF 298 00:11:42,360 --> 00:11:44,800 MONEY, KIND OF TAKES A WHILE FOR 299 00:11:44,800 --> 00:11:48,440 GRANTS TO BEAR FRUIT. 300 00:11:48,440 --> 00:11:50,080 SO, I HAD 5000-POUNDS OF SEED 301 00:11:50,080 --> 00:11:53,560 MONEY FROM A DEAN AT MICHIGAN 302 00:11:53,560 --> 00:11:56,440 STATE AND THE WELCOME TRUST GAVE 303 00:11:56,440 --> 00:11:58,200 MALCOM 5000-POUNDS SO WE START 304 00:11:58,200 --> 00:11:59,920 WIDE THAT, WE WERE EVERYTHING, 305 00:11:59,920 --> 00:12:03,400 WE WERE THE LAB TECH, WE WERE 306 00:12:03,400 --> 00:12:04,840 NURSES, WE WERE EVERYTHING IN 307 00:12:04,840 --> 00:12:05,600 THE VERY FIRST YEAR. 308 00:12:05,600 --> 00:12:08,040 IT WAS VERY BUSY AND WE HAD--WE 309 00:12:08,040 --> 00:12:09,280 WERE LIKING INITIALLY AT LOW 310 00:12:09,280 --> 00:12:11,280 BLOOD SUGAR IN KIDS WITH 311 00:12:11,280 --> 00:12:12,880 MALARIA, WE HAD TONS OF 312 00:12:12,880 --> 00:12:13,880 PATIENTS. 313 00:12:13,880 --> 00:12:16,440 LOTS OF DATA AND IT TURNS OUT 314 00:12:16,440 --> 00:12:18,040 THAT HYPOGLYCEMIA IS VERY 315 00:12:18,040 --> 00:12:20,800 IMPORTANT AND WE WROTE IT UP AND 316 00:12:20,800 --> 00:12:25,120 AGAIN WITH KIND OF THE NAIVEETY 317 00:12:25,120 --> 00:12:26,680 OF NOVICES AND WE SUBMITTED IT 318 00:12:26,680 --> 00:12:29,080 TO THE NEW ENGLAND JOURNAL WHICH 319 00:12:29,080 --> 00:12:30,480 HADN'T HAD ANYTHING ON MALARIA 320 00:12:30,480 --> 00:12:31,960 IN AGES AND SO THEY PUBLISHED IT 321 00:12:31,960 --> 00:12:36,800 AND WE WERE OFF TO THE RACES 322 00:12:36,800 --> 00:12:37,400 AFTER THAT. 323 00:12:37,400 --> 00:12:38,800 FOR THOSE OF YOU WHO ARE NOT 324 00:12:38,800 --> 00:12:41,960 FAMILIAR WITH THE LIFE CYCLE OF 325 00:12:41,960 --> 00:12:43,680 THE PARASITE, I WON'T BELAYOR IT 326 00:12:43,680 --> 00:12:48,920 HERE EXCEPT TO SAY THAT THE FORM 327 00:12:48,920 --> 00:12:50,560 OF THE PARASITE, THE STAGE AND 328 00:12:50,560 --> 00:12:52,280 LIFE CYCLE THAT'S RELEVANT TO US 329 00:12:52,280 --> 00:12:55,280 IS HERE, THE INTRA ARITHROUGH 330 00:12:55,280 --> 00:12:58,160 ATOM SITTIC FORM WHEN THE 331 00:12:58,160 --> 00:13:02,280 PARASITE INVADES CELLS, AND FOR 332 00:13:02,280 --> 00:13:03,200 [INDISCERNIBLE], THE MOST 333 00:13:03,200 --> 00:13:05,160 INTERESTED IN BECAUSE IT'S THE 1 334 00:13:05,160 --> 00:13:06,520 ASSOCIATED WITH MOST MORBIDITY 335 00:13:06,520 --> 00:13:07,960 AND MORTALITY, THAT LIFE CYCLE 336 00:13:07,960 --> 00:13:13,320 IS 48 HOURS. 337 00:13:13,320 --> 00:13:15,720 SO FROM 11 [INDISCERNIBLE] TO 338 00:13:15,720 --> 00:13:17,760 16-32 OF THE NEXT GENERATION 339 00:13:17,760 --> 00:13:20,480 TAKES ABOUT 48 HOURS AND THE RED 340 00:13:20,480 --> 00:13:22,200 CELL IS DEFORMED IN THE PROCESS, 341 00:13:22,200 --> 00:13:23,960 MUCH OF THE HEMOGLOBIN IS 342 00:13:23,960 --> 00:13:26,520 DIGESTERRED AND THE RED CELL 343 00:13:26,520 --> 00:13:29,320 BECOMES LESS DEFORMABLE AND WERE 344 00:13:29,320 --> 00:13:31,320 IT TO BE REMAIN IN THE 345 00:13:31,320 --> 00:13:33,600 PERIPHERAL BLOOD, IT WOULD BE 346 00:13:33,600 --> 00:13:34,560 CALLED BY THE SPLEEN. 347 00:13:34,560 --> 00:13:37,280 IT WOULD BE SO ABNORMAL. 348 00:13:37,280 --> 00:13:39,400 SO TO AVOID THAT FATE, THE 349 00:13:39,400 --> 00:13:47,320 PARASITE HAS DEVELOPED THE 350 00:13:47,320 --> 00:13:51,040 CAPACITY TO CYTO ADHERE TO 351 00:13:51,040 --> 00:13:51,680 ENDOTHELIAL CELLS, CAPILLARY 352 00:13:51,680 --> 00:13:52,680 TISSUES THROUGHOUT THE BODY AND 353 00:13:52,680 --> 00:13:54,960 IMPORTANTLY THE BRAIN BUT NOT 354 00:13:54,960 --> 00:13:59,040 EXCLUSIVELY THE BRAIN. 355 00:13:59,040 --> 00:14:01,880 AND THAT CYTO ADHERENCE, THE 356 00:14:01,880 --> 00:14:04,880 SEQUESTRATION OF THE MATURE 357 00:14:04,880 --> 00:14:05,920 ARITHROCYTE ALLOWS IT TO HIDE 358 00:14:05,920 --> 00:14:07,800 FROM THE SPLEEN AND CONTINUE ITS 359 00:14:07,800 --> 00:14:09,720 LIFE CYCLE. 360 00:14:09,720 --> 00:14:14,440 IT ALSO IS SORT OF IRRESISTIBLE 361 00:14:14,440 --> 00:14:15,240 TO ATTRIBUTE PATHOGENETIC 362 00:14:15,240 --> 00:14:17,280 SIGNIFICANCE TO THIS, BECAUSE 363 00:14:17,280 --> 00:14:19,400 THESE POST CAPILLARY 364 00:14:19,400 --> 00:14:21,320 VENOUSLIULES ARE COMPLETELY 365 00:14:21,320 --> 00:14:23,520 OBSTRUCTED OFTEN WITH THESE 366 00:14:23,520 --> 00:14:28,080 PARASITIZED RED BLOOD CELLS. 367 00:14:28,080 --> 00:14:28,800 ANOTHER IMPORTANT AND 368 00:14:28,800 --> 00:14:29,440 DEVELOPMENTAL ENDOCRINOLOGYIOUS 369 00:14:29,440 --> 00:14:39,960 FEATURE OF THIS PARASITE IF YOU 370 00:14:50,840 --> 00:14:53,960 MADE A DIAGRAM WOULD BE 371 00:14:53,960 --> 00:14:54,360 AFFECTED. 372 00:14:54,360 --> 00:14:58,600 MANY OF THESE CAN CO EXIST WITH 373 00:14:58,600 --> 00:15:00,480 THE PARASITE WITHOUT DEVELOPING 374 00:15:00,480 --> 00:15:00,760 SYMPTOMS. 375 00:15:00,760 --> 00:15:02,640 THIS RESERVOIR OF PARASITES IS 376 00:15:02,640 --> 00:15:04,480 CENTRAL TO THE ONGOING 377 00:15:04,480 --> 00:15:07,720 TRANSMISSION OF THE PARASITE TO 378 00:15:07,720 --> 00:15:08,120 MOSQUITOES. 379 00:15:08,120 --> 00:15:12,960 THESE ASYMPTOMATIC INDIVIDUALS 380 00:15:12,960 --> 00:15:14,240 THOUGH, CAN BE DOUBLE AT 381 00:15:14,240 --> 00:15:16,320 DIAGNOSIS AS YOU WILL SEE. 382 00:15:16,320 --> 00:15:19,640 EVENTUALLY SOME PEOPLE DEVELOP 383 00:15:19,640 --> 00:15:21,360 UNCOMLICATED MALARIA, FEVER, 384 00:15:21,360 --> 00:15:22,400 CHILLS, NAUSEA, HEADACHE, 385 00:15:22,400 --> 00:15:24,600 VOMITING AND A TINY PORTION GO 386 00:15:24,600 --> 00:15:28,240 ON TO DEVELOP WHAT WE'RE 387 00:15:28,240 --> 00:15:30,160 INTERESTED IN WHICH IS 388 00:15:30,160 --> 00:15:31,640 [INDISCERNIBLE]. 389 00:15:31,640 --> 00:15:34,880 SO IN THE GRAND SPECTRUM OF 390 00:15:34,880 --> 00:15:36,280 SEEREBERAL MALARIA IS RARE, BUT 391 00:15:36,280 --> 00:15:37,840 BECAUSE SO MEAN PEOPLE ARE 392 00:15:37,840 --> 00:15:41,080 INFECTED THAT ACTUALLY TOTALS 393 00:15:41,080 --> 00:15:46,360 QUITE A FEW INCIDENCES OF 394 00:15:46,360 --> 00:15:53,720 DISEASE AND DEATH OVER ON 395 00:15:53,720 --> 00:15:54,920 AN ANNUAL BASIS. 396 00:15:54,920 --> 00:15:57,000 WHEN WE STARTED THE CASE 397 00:15:57,000 --> 00:15:58,960 DEFINITION OF MALARIA WERE 398 00:15:58,960 --> 00:16:00,920 MOSTLY ADJECTIVES, WHICH WERE 399 00:16:00,920 --> 00:16:04,040 HARD TO QUANTIFY, KIDS WERE 400 00:16:04,040 --> 00:16:07,080 STIEWPEROUS, KROWZY, IT WAS 401 00:16:07,080 --> 00:16:09,080 NECESSARY TO DEVELOP THE PLANTAR 402 00:16:09,080 --> 00:16:09,760 [INDISCERNIBLE] SCORE WHICH 403 00:16:09,760 --> 00:16:11,480 RELIES ON INFLECTING PAIN EITHER 404 00:16:11,480 --> 00:16:14,840 ON A NAIL BED OR SUPER ORBITAL 405 00:16:14,840 --> 00:16:16,040 RIDGE AND LOOKING TO SEE WHAT 406 00:16:16,040 --> 00:16:17,680 THE RESPONSE IS, IS THERE ANY 407 00:16:17,680 --> 00:16:19,680 RESPONSE, IS FROM A MOON, A 408 00:16:19,680 --> 00:16:22,200 GRIMACE, CAN THE PATIENT 409 00:16:22,200 --> 00:16:23,600 LOCALIZE THE PAINFUL STIMULUS OR 410 00:16:23,600 --> 00:16:26,480 NOT, WHAT'S THE QUALITY OF THE 411 00:16:26,480 --> 00:16:28,000 CRY AND CAN THEY FOLLOW A MOVING 412 00:16:28,000 --> 00:16:29,680 OBJECT SO YOU CAN GET 5. 413 00:16:29,680 --> 00:16:33,920 IF YOU CAN DO ALL OF THAT AND 414 00:16:33,920 --> 00:16:34,840 SUCCESSFULLY LESS, A COMA SCORE 415 00:16:34,840 --> 00:16:36,560 OF 2 OR LESS, BASICALLY 416 00:16:36,560 --> 00:16:39,040 REPRESENTS SOMEONE WHO IS SO 417 00:16:39,040 --> 00:16:41,000 [INDISCERNIBLE] THAT THEY CAN'T 418 00:16:41,000 --> 00:16:42,480 LOCALIZE A PAINFUL STIMULUS. 419 00:16:42,480 --> 00:16:44,320 IN ADDITION, THERE NEEDS TO BE 420 00:16:44,320 --> 00:16:46,560 PARASITE, THERE NEEDS TO BE 421 00:16:46,560 --> 00:16:48,360 PARASITES PRESENT IN NO OTHER 422 00:16:48,360 --> 00:16:51,600 OBVIOUS CAUSE OF COMA AND THE 3 423 00:16:51,600 --> 00:16:54,800 LEADING OTHER CAUSES OF COMA IN 424 00:16:54,800 --> 00:16:56,680 THIS GROUP ARE ARE HYPOGLYCEMIA 425 00:16:56,680 --> 00:16:59,120 AS WE REALIZED IN THE FIRST 426 00:16:59,120 --> 00:17:07,120 YEAR, SOME KIDS CAME AROUND WITH 427 00:17:07,120 --> 00:17:09,440 INTRAVENOUS, 50% DEXTROSE AND 428 00:17:09,440 --> 00:17:12,440 OTHERS STAYED IN COMAS. 429 00:17:12,440 --> 00:17:14,680 MENIN GIETIS CAN ALSO BE A SIDE 430 00:17:14,680 --> 00:17:16,640 EFFECT OF MALARIA AND WE DO A 431 00:17:16,640 --> 00:17:18,120 LUMBAR PUNCTURE FOR THAT, AND 432 00:17:18,120 --> 00:17:21,360 SEIZE OURS CAN HAVE A 433 00:17:21,360 --> 00:17:23,720 POST-ICTALL STATE WHICH MAY 434 00:17:23,720 --> 00:17:26,440 OFTEN OBSCURE THE DIAGNOSIS. 435 00:17:26,440 --> 00:17:27,520 WE DON'T DELAY TREATMENT WAITING 436 00:17:27,520 --> 00:17:30,280 FOR THAT STATE OR NOT, WE TREAT 437 00:17:30,280 --> 00:17:32,600 PATIENTS BUT THEY GET 438 00:17:32,600 --> 00:17:35,000 CATEGORIZED AS CEREBRAL MALARIA 439 00:17:35,000 --> 00:17:36,240 DEPENDING ON HOW LONG IT TAKES 440 00:17:36,240 --> 00:17:38,400 THEM TO COME AROUND FROM HAVING 441 00:17:38,400 --> 00:17:41,200 HAD A COMA. 442 00:17:41,200 --> 00:17:42,360 THE CLINICAL ILLNESS AND OFTEN 443 00:17:42,360 --> 00:17:48,000 VERY RAPID IN ITS ONSET, THESE 444 00:17:48,000 --> 00:17:49,400 ARE CHILDREN WHO HAVE MANY 445 00:17:49,400 --> 00:17:51,240 FEVERS OVER THE COURSE OF A YEAR 446 00:17:51,240 --> 00:17:53,040 AND THE PARENTS HAVE NO WAY OF 447 00:17:53,040 --> 00:17:55,320 KNOWING WHAT'S A DANGEROUS FEVER 448 00:17:55,320 --> 00:17:57,320 UNTIL THE CHILD STARTS 449 00:17:57,320 --> 00:17:58,800 CONVULSING OR LAPSES INTO COMA 450 00:17:58,800 --> 00:18:05,760 AND THEN THEY RUSH INTO THE 451 00:18:05,760 --> 00:18:06,200 HOSPITAL. 452 00:18:06,200 --> 00:18:07,440 AND WE STABILIZE THEM HERE, THIS 453 00:18:07,440 --> 00:18:09,200 IS THE ADMISSIONS AREA OF OUR 454 00:18:09,200 --> 00:18:09,560 RESEARCH WARD. 455 00:18:09,560 --> 00:18:12,800 IT'S WHERE WE CAN MACK SURE THAT 456 00:18:12,800 --> 00:18:18,400 THERE ARE ADEQUATELY OX 457 00:18:18,400 --> 00:18:21,040 GENERATED 8ED, WE CAN GET A 458 00:18:21,040 --> 00:18:23,480 VENUS LINE, AND WE CAN GET A 459 00:18:23,480 --> 00:18:24,560 COMA SCORE ASK THEN THEY'RE 460 00:18:24,560 --> 00:18:26,040 MOVED TO THE WARD FOR THE REST 461 00:18:26,040 --> 00:18:27,520 OF THEIR STAY. 462 00:18:27,520 --> 00:18:28,800 THE PARENTS STAY THROUGHOUT HERE 463 00:18:28,800 --> 00:18:33,320 AND THIS IS WHAT WE'VE ALWAYS 464 00:18:33,320 --> 00:18:34,520 DONE ON OUR RESEARCH WARD IN 465 00:18:34,520 --> 00:18:36,160 TERMS OF LOOKING FOREVER THE 466 00:18:36,160 --> 00:18:36,440 PATIENT. 467 00:18:36,440 --> 00:18:40,560 SO WE KEEP AN EYE ON THEIR 468 00:18:40,560 --> 00:18:41,920 MALARIA PARASTIETS. 469 00:18:41,920 --> 00:18:44,920 LET HEMEAT O CRIT IS A WAY TO 470 00:18:44,920 --> 00:18:50,280 ASSESS ANEMIA RATHER THAN TO RUN 471 00:18:50,280 --> 00:18:52,280 A BLOOD TEST. 472 00:18:52,280 --> 00:18:57,760 GLUCOSE IS A FACTOR LACTIC 473 00:18:57,760 --> 00:19:02,760 ACIDOSEISATE, CBC, SOME KIDS ARE 474 00:19:02,760 --> 00:19:04,080 CONCURRENTLY BACTERIAOREMMIC AND 475 00:19:04,080 --> 00:19:06,360 GENERALLY WE START ANTIBIOTIC 476 00:19:06,360 --> 00:19:08,120 FIST THEY'RE BACTERIAOREMMIC AND 477 00:19:08,120 --> 00:19:10,400 HYPOTENSIVE AND WE DO A LUMBAR 478 00:19:10,400 --> 00:19:12,960 PUNCTURE TO CHECK FOR 479 00:19:12,960 --> 00:19:13,920 MENINGITIS. 480 00:19:13,920 --> 00:19:15,120 WE THEN ADMINISTER ANTIMALARIA 481 00:19:15,120 --> 00:19:25,640 MEDS AND WHEN WE STARTED IT WAS 482 00:19:26,560 --> 00:19:29,120 QUININE, AND NOW IS ARTESUNATE, 483 00:19:29,120 --> 00:19:31,280 AND I NEED TO EXPLAIN THAT SOME 484 00:19:31,280 --> 00:19:32,400 OF MY PRONOUNCEIATIONS ARE 485 00:19:32,400 --> 00:19:33,680 DIFFERENT THAN THE WAY THESE 486 00:19:33,680 --> 00:19:34,560 WORDS ARE PRONOUNCED IN THE 487 00:19:34,560 --> 00:19:41,800 STATE AND I THOUGHT IT WAS A 488 00:19:41,800 --> 00:19:44,640 POINT OF JOCKULARRITY WHEN WE 489 00:19:44,640 --> 00:19:47,040 WERE FIRST STARTING. 490 00:19:47,040 --> 00:19:53,440 WE WERE TREATING SEER 491 00:19:53,440 --> 00:19:56,040 EASTBOUNDERAL MALARIA? 492 00:19:56,040 --> 00:20:00,320 WERE WE TREATING PEOPLE VIA A 493 00:20:00,320 --> 00:20:02,480 SHEDULE OR A SCHEDULE. 494 00:20:02,480 --> 00:20:04,160 THERAY SO MANY DIFFERENT WORDS 495 00:20:04,160 --> 00:20:06,040 IN THE ENGLISH LANGUAGE AND HE 496 00:20:06,040 --> 00:20:07,680 FINALLY SAID WE COULD PRONOUNCE 497 00:20:07,680 --> 00:20:10,440 THESE WORDS YOUR WAY OR WE COULD 498 00:20:10,440 --> 00:20:11,160 PRONOUNCE THEM PROPERLY. 499 00:20:11,160 --> 00:20:13,720 THAT'S WHY I'VE BEEN STUDYING 500 00:20:13,720 --> 00:20:15,280 CEREBRAL MALARIA AND WHY WE 501 00:20:15,280 --> 00:20:19,560 STARTED TREATING WITH QUININE. 502 00:20:19,560 --> 00:20:23,440 WE ALSO GIVE BLOOD TRANSFUSIONS 503 00:20:23,440 --> 00:20:25,240 THERE'S AN INEVITABLE LOSS OF 504 00:20:25,240 --> 00:20:26,680 RED BLOOD CELLS OVER THE COURSE 505 00:20:26,680 --> 00:20:28,040 OF MALARIA INFECTION AND THAT IS 506 00:20:28,040 --> 00:20:29,160 VERYENTIOUS FICIENT AT OUR 507 00:20:29,160 --> 00:20:30,240 HOSPITAL, WAY FASTER I THINK 508 00:20:30,240 --> 00:20:33,400 THAN IN THE U.S., WE SEIZURES 509 00:20:33,400 --> 00:20:35,640 AND WE KEEP AN EYE ON THE KIDS. 510 00:20:35,640 --> 00:20:37,000 WE WATCH THEM. 511 00:20:37,000 --> 00:20:38,280 THE NURSES DO 2 HOURLY 512 00:20:38,280 --> 00:20:40,040 OBSERVATIONS FOR VITAL SIGNS AND 513 00:20:40,040 --> 00:20:46,960 6 HOURLY CHECKS OF THE GLUCOSE, 514 00:20:46,960 --> 00:20:47,800 LACTIC ACIDOSEISATE, HEMEAT O 515 00:20:47,800 --> 00:20:49,400 CRIT AND ET CETERA. 516 00:20:49,400 --> 00:20:51,640 AND WE WILL ALSO BE CHECKING THE 517 00:20:51,640 --> 00:20:52,240 BLOOD VESSELS AND WE'RE 518 00:20:52,240 --> 00:20:53,440 INTERESTED IN THE BACK OF THE 519 00:20:53,440 --> 00:20:53,920 EYE. 520 00:20:53,920 --> 00:20:56,680 WE'RE VERY INTERESTED IN 521 00:20:56,680 --> 00:20:57,720 SEIZURES AND WE'RE VERY 522 00:20:57,720 --> 00:20:58,680 INTERESTED IN WHAT'S HAPPENING 523 00:20:58,680 --> 00:20:59,600 IN THE BRAIN. 524 00:20:59,600 --> 00:21:02,080 BUT THOSE 3 WERE LATE ADD-ONS 525 00:21:02,080 --> 00:21:03,160 AND THE FIRST BITS ARE WHAT 526 00:21:03,160 --> 00:21:08,640 WE'VE DONE RIGHT FROM THE VERY 527 00:21:08,640 --> 00:21:09,080 FIRST SEASON. 528 00:21:09,080 --> 00:21:10,720 WE HAVE A CHART TAKEN--THEY WE 529 00:21:10,720 --> 00:21:12,120 KEEP AN EYE--EVERYBODY TAKES 530 00:21:12,120 --> 00:21:13,200 TURNS WITH THEIR OBSERVATIONS SO 531 00:21:13,200 --> 00:21:15,760 WHEN WE DO OUR ROUNDS OR CALLED 532 00:21:15,760 --> 00:21:17,000 TO THE BEDSIDE FOR THE CHANGE IN 533 00:21:17,000 --> 00:21:18,880 THE DON DITION OF A PATIENT, WE 534 00:21:18,880 --> 00:21:20,600 CAN SEE AT AN INSTANT WHAT'S 535 00:21:20,600 --> 00:21:22,920 HAPPENING AND WE KEEP TRACK ON A 536 00:21:22,920 --> 00:21:28,200 WHITE BOARD ON THE BOARD BECAUSE 537 00:21:28,200 --> 00:21:29,840 BECAUSE TIME 0 IS DIFFERENT FOR 538 00:21:29,840 --> 00:21:30,520 EVERY PATIENT. 539 00:21:30,520 --> 00:21:31,880 THEY APPEAR AT ALL HOURS OF THE 540 00:21:31,880 --> 00:21:32,440 DAY AND NIGHT. 541 00:21:32,440 --> 00:21:35,640 THE CARE THAT WE PROVIDE IS NOT 542 00:21:35,640 --> 00:21:39,440 IS HIGHLY SOPHISTICATED. 543 00:21:39,440 --> 00:21:42,320 THERE'S INTRAVENOUS FLUIDS AND 544 00:21:42,320 --> 00:21:43,960 NASOGASTRIC [INDISCERNIBLE] AS 545 00:21:43,960 --> 00:21:45,960 WELL AS ATTENTIVE NURSING AND 546 00:21:45,960 --> 00:21:46,280 CLINICAL CARE. 547 00:21:46,280 --> 00:21:49,600 THE USUAL CLINICAL COURSE IS 548 00:21:49,600 --> 00:21:51,040 ASTONISHINGLY RAPID CONSIDERING 549 00:21:51,040 --> 00:21:52,760 THESE KIDS HAVE BEEN PLUNGED 550 00:21:52,760 --> 00:21:54,760 INTO COMA, THEY'RE OFTEN 551 00:21:54,760 --> 00:21:55,440 SEIZING, THAT'S LOOK LIKE 552 00:21:55,440 --> 00:21:58,360 THEY'VE HAD A CLOSED HEAD INJURY 553 00:21:58,360 --> 00:22:01,400 AND THE VAST MAJORITY ARE UP AND 554 00:22:01,400 --> 00:22:04,000 AT THEM IN A COUPLE DAYS. 555 00:22:04,000 --> 00:22:05,400 THE PARASIGNIFY TEEMIA CLEARS 556 00:22:05,400 --> 00:22:06,840 QUICKLY, IF THEY DON'T WAKE UP 557 00:22:06,840 --> 00:22:10,080 RIGHT AWAY WE GIVE THEM 558 00:22:10,080 --> 00:22:11,600 NASOGASTRIC TUBE FEEDS, WE TREAT 559 00:22:11,600 --> 00:22:15,200 THE SEIZURES, WE USE ANTIBIOTICS 560 00:22:15,200 --> 00:22:15,800 ASSOCIATIONALLY, BLOOD 561 00:22:15,800 --> 00:22:18,080 TRANSFUSIONS, BUT MOST KIDS GO 562 00:22:18,080 --> 00:22:22,000 HOME ON DAY 3 OR 4, THE SURVIVAL 563 00:22:22,000 --> 00:22:22,880 RATE AND 80-85%. 564 00:22:22,880 --> 00:22:25,720 WE DO FOLLOW UP VISITS IN THE 565 00:22:25,720 --> 00:22:27,840 NEUROLOGICAL SEQUEL I OF THIS 566 00:22:27,840 --> 00:22:33,200 DISEASE BUT I WON'T TALK ABOUT 567 00:22:33,200 --> 00:22:34,640 THAT TODAY. 568 00:22:34,640 --> 00:22:36,040 BUT 15-20% DIE AND OVER THE 569 00:22:36,040 --> 00:22:40,040 COURSE OF THE FIRST SEVERAL 570 00:22:40,040 --> 00:22:43,880 YEARS, WE BECAME--WE BECAME ABLE 571 00:22:43,880 --> 00:22:45,640 TO RECOGNIZE THIS INEVITABLE 572 00:22:45,640 --> 00:22:46,160 SEQUENCE OF EVENTS. 573 00:22:46,160 --> 00:22:48,680 IN ABOUT 2/3RDS OF PATIENTS THEY 574 00:22:48,680 --> 00:22:50,600 WOULD HAVE RESTIER REVIEWATTORY 575 00:22:50,600 --> 00:22:50,960 ARREST. 576 00:22:50,960 --> 00:22:52,000 ANYTHINGLY, THE MOMS WOULD 577 00:22:52,000 --> 00:22:54,640 FANATIC IT OUT FIRST AND BECOME 578 00:22:54,640 --> 00:22:55,360 FRIGHTENED AND WOULD START 579 00:22:55,360 --> 00:22:57,280 CRYING AND THEN THE NURSES WOULD 580 00:22:57,280 --> 00:22:59,480 NOTICE THAT THE RESPIRATORY RATE 581 00:22:59,480 --> 00:23:02,200 WAS BECOMING IRREGULAR, AND THEN 582 00:23:02,200 --> 00:23:03,280 WE WOULD COME BECAUSE THE 583 00:23:03,280 --> 00:23:05,680 PATIENT HAD REACHED THE GASPING 584 00:23:05,680 --> 00:23:07,360 STAGE AND IF WE MADE IT TO THE 585 00:23:07,360 --> 00:23:09,440 BEDSIDE AND WE WERE ABLE TO 586 00:23:09,440 --> 00:23:10,520 START RESUSCITATING WITH A BAG 587 00:23:10,520 --> 00:23:16,680 AND A MASK, WE COULD SUSTAIN 588 00:23:16,680 --> 00:23:17,640 CARDIAC ACTIVITY INDEFINITELY. 589 00:23:17,640 --> 00:23:19,640 SO FOR MALCOM AND ME STANDING AT 590 00:23:19,640 --> 00:23:21,720 THE BEDSIDE WATCHING THIS, IT 591 00:23:21,720 --> 00:23:23,880 LOOKED LIKE THE CLASSIC 592 00:23:23,880 --> 00:23:27,360 DESCRIPTIONS OF WHAT'S CALLED 593 00:23:27,360 --> 00:23:29,120 PERMEATION OR AS WE CALL IT IN 594 00:23:29,120 --> 00:23:33,120 THE UK THEY CALL IT CONING, AND 595 00:23:33,120 --> 00:23:36,840 WHAT THAT IS, IS THE INEVITABLE 596 00:23:36,840 --> 00:23:40,560 OUTCOME OF A SWOLLEN BRAIN. 597 00:23:40,560 --> 00:23:42,000 SO HERE'S A BRAIN CONTAINED 598 00:23:42,000 --> 00:23:43,600 WITHIN THE SKULL AND AS THE 599 00:23:43,600 --> 00:23:50,360 BRAIN GETS LARGER AND LARGER FOR 600 00:23:50,360 --> 00:23:52,640 WHATEVER REASON BRAIN TUMOR OR 601 00:23:52,640 --> 00:23:54,640 WHATEVER, IT GETS FORCED OUT BY 602 00:23:54,640 --> 00:23:56,320 THE ONLY OPENING HAD WHICH IS 603 00:23:56,320 --> 00:23:58,520 THE FRAME AND MAGNUM AT THE BASE 604 00:23:58,520 --> 00:24:02,960 OF THE SKULL AND UNFORTUNATELY 605 00:24:02,960 --> 00:24:05,680 THERE IN THE MEDULLA IS THE 606 00:24:05,680 --> 00:24:07,320 RESPIRATORY CENTER AS THAT SPACE 607 00:24:07,320 --> 00:24:10,200 IS ENCROACHED UPON THE REZONING 608 00:24:10,200 --> 00:24:11,280 PIRATTORY CENTER HAS PRESSURE IS 609 00:24:11,280 --> 00:24:14,840 APPLIED TO IT AND PEOPLE STOP 610 00:24:14,840 --> 00:24:15,720 BREATHING, THERE'S RESPIRATORY 611 00:24:15,720 --> 00:24:16,000 ARREST. 612 00:24:16,000 --> 00:24:17,400 THAT'S WHAT IT LOOKED LIKE BUT 613 00:24:17,400 --> 00:24:18,600 WE REALLY DIDN'T HAVE ANYWAY TO 614 00:24:18,600 --> 00:24:19,640 KNOW. 615 00:24:19,640 --> 00:24:20,240 THIS IS A PICTORIAL 616 00:24:20,240 --> 00:24:23,120 DEMONSTRATION OF THAT PROCESS, 617 00:24:23,120 --> 00:24:23,840 THE CEREBELLAR TONSILS EXTRUDE 618 00:24:23,840 --> 00:24:29,040 THROUGH THE FRAME AND MAGNUM AND 619 00:24:29,040 --> 00:24:31,760 COMPRESS THAT AND THIS IS WHAT 620 00:24:31,760 --> 00:24:34,200 IT'S LIKE IN A GROSS SAMPLE OF A 621 00:24:34,200 --> 00:24:35,960 BRAIN THAT'S BEEN REMOVED FROM 622 00:24:35,960 --> 00:24:38,280 THE SKULL ON A PERSON WHO 623 00:24:38,280 --> 00:24:39,600 PROBABLY WAS ON LIFE SUPPORT FOR 624 00:24:39,600 --> 00:24:41,680 QUITE A WHILE AND THEN DIED. 625 00:24:41,680 --> 00:24:44,640 BUT YOU CAN SEE DEEP GROOVING 626 00:24:44,640 --> 00:24:54,760 HERE FROM THE BONY IMPRESSION OF 627 00:24:54,760 --> 00:24:56,720 THE PREMIUM MAGNUM, SO THAT'S 628 00:24:56,720 --> 00:24:58,480 THE OVER ALL MORTALITY WITH 629 00:24:58,480 --> 00:25:02,480 ABOUT 2/3RDS OF THE KIDS GOING 630 00:25:02,480 --> 00:25:03,280 32 THIS RESPIRATORY ARREST AND 631 00:25:03,280 --> 00:25:05,280 THE OTHERS HAD A CARDIO 632 00:25:05,280 --> 00:25:07,920 PULMONARY ARREST AND THEN, WE 633 00:25:07,920 --> 00:25:10,040 HAD THE NEXT SERENDIPITOUS EVENT 634 00:25:10,040 --> 00:25:12,600 WHICH IS A CURIOUS 635 00:25:12,600 --> 00:25:14,640 OPHTHALMOLOGIST, I WAS THERE FOR 636 00:25:14,640 --> 00:25:15,200 SUPPER 1 NIGHT. 637 00:25:15,200 --> 00:25:17,160 I WAS DESCROIBING WHAT I JUST 638 00:25:17,160 --> 00:25:19,680 WAS DESCRIBING TO YOU, THIS 639 00:25:19,680 --> 00:25:20,600 RESPIRATORY ARREST SEEMED VERY 640 00:25:20,600 --> 00:25:21,600 CURIOUS AND SHE SAID HAVE YOU 641 00:25:21,600 --> 00:25:23,120 EVER LOOKED IN THE EYES, WHICH 642 00:25:23,120 --> 00:25:27,320 WE KIND OF HAD BUT NOT PROPERLY, 643 00:25:27,320 --> 00:25:28,360 NOT WITH FULL DILATION. 644 00:25:28,360 --> 00:25:31,560 SO SHE DID THIS ON NIGHTS AND 645 00:25:31,560 --> 00:25:33,880 WEEKENDS AND THERE WERE 646 00:25:33,880 --> 00:25:35,280 PHENOMENAL FINDINGS WHICH THERE 647 00:25:35,280 --> 00:25:37,280 WERE ALLUSIONS TO THESE FINDINGS 648 00:25:37,280 --> 00:25:39,240 IN THE LITERATURE BUT THEY WERE 649 00:25:39,240 --> 00:25:41,200 VERY SCATTERED SO 1 FIND SUGGEST 650 00:25:41,200 --> 00:25:42,960 CALLED VESSEL CHANGES WHERE THE 651 00:25:42,960 --> 00:25:44,920 COLOR OF THE COLUMN OF THE BLOOD 652 00:25:44,920 --> 00:25:47,960 IN THE VESSEL ACTUALLY CHANGES 653 00:25:47,960 --> 00:25:49,720 FROM RED WHICH IS NORMAL TO 654 00:25:49,720 --> 00:25:52,760 ORANGE OR YELLOW, THERE ARE 655 00:25:52,760 --> 00:25:53,680 AWLTS HEMORRHAGES, THAT'S SHOWN 656 00:25:53,680 --> 00:25:55,440 IN THE SECOND SLIDE AND THEN 657 00:25:55,440 --> 00:25:57,120 THERE WAS ANOTHER CHANGE CALLED 658 00:25:57,120 --> 00:25:59,280 THE WHITENING, THERE'S A LOT OF 659 00:25:59,280 --> 00:26:00,800 WHITENING AROUND THESE 660 00:26:00,800 --> 00:26:01,720 HEMORRHAGES AND THEN IN THE 661 00:26:01,720 --> 00:26:03,480 BOTTOM SLIDE THERE'S A PICTURE 662 00:26:03,480 --> 00:26:04,640 WITH ONLY WHITENING AND THAT WAS 663 00:26:04,640 --> 00:26:07,680 A CHANGE THAT WAS OBSERVED IN 664 00:26:07,680 --> 00:26:15,320 BETWEEN THE BLOOD VUSESLES IN 665 00:26:15,320 --> 00:26:16,120 THE FUNDUS. 666 00:26:16,120 --> 00:26:18,080 AND THEY WERE NOT ALL THE SAME 667 00:26:18,080 --> 00:26:20,360 BETWEEN THE PATIENTS, THEY COULD 668 00:26:20,360 --> 00:26:20,960 BE DIFFERENT COMBINATIONS BUT 669 00:26:20,960 --> 00:26:22,440 THEY WERE NOT IN EVERY PATIENT. 670 00:26:22,440 --> 00:26:24,320 SO THIS AGAIN WAS DIFFICULT TO 671 00:26:24,320 --> 00:26:25,240 FIGURE OUT BECAUSE THESE WERE 672 00:26:25,240 --> 00:26:28,200 KID WHO IS ALL MET THAT STANDARD 673 00:26:28,200 --> 00:26:31,360 CLINICAL CASE DEFINITION OF 674 00:26:31,360 --> 00:26:32,640 CEREBRAL MALARIA, SOME HAD 675 00:26:32,640 --> 00:26:33,640 COMPLETELY NORMAL EYES AND 676 00:26:33,640 --> 00:26:35,800 OTHERS HAD 1 OR MORE OF THESE 677 00:26:35,800 --> 00:26:41,880 FEATURES, SO THAT WAS A 678 00:26:41,880 --> 00:26:42,160 CONUNDRUM. 679 00:26:42,160 --> 00:26:44,040 SO AT THAT POINT IN THE MID90S 680 00:26:44,040 --> 00:26:50,360 WE DECIDED THAT WE HAD TO GO BA 681 00:26:50,360 --> 00:26:53,320 BEING TO SQUARE 1 AND DO 682 00:26:53,320 --> 00:26:53,960 AUTOPSIESS, WHAT WERE THEY 683 00:26:53,960 --> 00:26:54,880 EXPERIENCING ISSUES WHAT WAS THE 684 00:26:54,880 --> 00:26:56,400 NAME OF THE SEQUESTRATION, WHAT 685 00:26:56,400 --> 00:26:59,960 WAS GOING ON SO WE LAUNCHED OUR 686 00:26:59,960 --> 00:27:00,920 AUTOPSIES STUDY WHICH WAS 687 00:27:00,920 --> 00:27:02,360 FASCINATING AND ALL THE WORK 688 00:27:02,360 --> 00:27:07,240 HERE IN THE MOTORUEARY OF THE 689 00:27:07,240 --> 00:27:07,920 QUEEN ELIZABETH CENTRAL HOSPITAL 690 00:27:07,920 --> 00:27:09,200 AND I PUT THE SLIDE IN BECAUSE 691 00:27:09,200 --> 00:27:10,960 WHEN YOU DO A STUDY LIKE THIS, 692 00:27:10,960 --> 00:27:14,280 YOU DEVELOP A VERY KIND OF DARK 693 00:27:14,280 --> 00:27:16,240 GALLOWS SENSE OF HUMOR SO AFTER 694 00:27:16,240 --> 00:27:17,680 A WHILE IT BECAME KIND OF FUNNY 695 00:27:17,680 --> 00:27:21,040 TO US THAT ON THIS BUILDING 696 00:27:21,040 --> 00:27:27,080 MARKED THE MOTORUARY IT WAS 697 00:27:27,080 --> 00:27:28,160 OMINOUSLY NOTED THAT THERE WAS 698 00:27:28,160 --> 00:27:34,800 ONLY 1 WAY OUT OF THE MOTORUARY. 699 00:27:34,800 --> 00:27:37,360 THE AUTOPSIES WERE QUITE 700 00:27:37,360 --> 00:27:40,440 EXTENSIVE, JUST SO YOU KNOW THE 701 00:27:40,440 --> 00:27:42,040 PARATHYROIDS WERE THE KEY TO THE 702 00:27:42,040 --> 00:27:43,560 MYSTERY AND WE TRIED TO GEM THEM 703 00:27:43,560 --> 00:27:45,000 OUT OF EVERY PATIENT AND WE 704 00:27:45,000 --> 00:27:46,200 SAVED THE TISSUES MANY DIFFERENT 705 00:27:46,200 --> 00:27:47,280 WAYS SOPHISTICATEDY WE COULD 706 00:27:47,280 --> 00:27:48,360 PROBE THEM WITH MANY DIFFERENT 707 00:27:48,360 --> 00:27:49,320 TECHNIQUES TO TRY TO UNDERSTAND 708 00:27:49,320 --> 00:27:55,000 WHAT WAS HAPPENING AND OVER THE 709 00:27:55,000 --> 00:27:59,200 COURSE OF 14 YEARS WE DID 103 710 00:27:59,200 --> 00:27:59,480 AUTOPSIES. 711 00:27:59,480 --> 00:28:01,360 WE DID AUTOPSIES ON KIDS WHO MET 712 00:28:01,360 --> 00:28:03,800 THE CASE DIFFERENT OF CEREBRAL 713 00:28:03,800 --> 00:28:06,160 MALARIA, WE HAD KID WHO IS HAD 714 00:28:06,160 --> 00:28:07,640 NO MALARIAL PARASITES AND DIED 715 00:28:07,640 --> 00:28:11,600 AND WE HAD KIDS WITH MALARIAL 716 00:28:11,600 --> 00:28:12,520 PARASITES AND THEY DIED FOR 717 00:28:12,520 --> 00:28:13,720 OTHER REASON SAYS AND WE 718 00:28:13,720 --> 00:28:15,400 COMPARED ALL OF THEM. 719 00:28:15,400 --> 00:28:18,480 AND WHAT I WANT TO FOCUS ON ARE 720 00:28:18,480 --> 00:28:21,680 THE FINDINGS IN THE KIDS WHO MET 721 00:28:21,680 --> 00:28:24,080 THAT CASE DEFINITION OF CEREBRAL 722 00:28:24,080 --> 00:28:25,360 MALARIA, SO ANYONE IN THE WORLD 723 00:28:25,360 --> 00:28:28,520 IN THE WORLD WOULD HAVE CALLED 724 00:28:28,520 --> 00:28:30,800 THEM CEREBRAL MALARIA, IN THAT 725 00:28:30,800 --> 00:28:32,920 GROUP WE SAW 3 DIFFERENT 726 00:28:32,920 --> 00:28:35,560 HISTOLOGIC FINDINGS IN THE 727 00:28:35,560 --> 00:28:39,680 BRAIN. 728 00:28:39,680 --> 00:28:42,080 THIS IS 1 WHERE WE HAD 729 00:28:42,080 --> 00:28:44,120 SEQUESTRATION ONLY WHERE HE HAD 730 00:28:44,120 --> 00:28:48,600 IT IN THE BRAIN CHOKED FULL OF 731 00:28:48,600 --> 00:28:49,240 CELLS. 732 00:28:49,240 --> 00:28:51,080 ANOTHER FINDING WAS 733 00:28:51,080 --> 00:28:52,480 SEQUESTRATION ONLY IN OTHER 734 00:28:52,480 --> 00:28:54,520 PATHOLOGY, THERE WERE DIFFERENT 735 00:28:54,520 --> 00:28:56,560 THROMBY IN THE BLOOD VESES ELTS, 736 00:28:56,560 --> 00:28:58,560 DIFFERENT HEMORRHAGES ON THE 737 00:28:58,560 --> 00:28:59,880 PATHWAY GIVES RENK MA OF THE 738 00:28:59,880 --> 00:29:02,840 BRAIN, BUT THERE WAS ALSO 739 00:29:02,840 --> 00:29:03,200 SEQUESTRATION. 740 00:29:03,200 --> 00:29:06,680 THE THIRD GROUP REALLY THREW US, 741 00:29:06,680 --> 00:29:08,560 BECAUSE THESE KIDS HAD NO 742 00:29:08,560 --> 00:29:10,480 SEQUESTRATION, NO PARASITES IN 743 00:29:10,480 --> 00:29:13,680 THE BRAIN AND IN EVERY OTHER WAY 744 00:29:13,680 --> 00:29:16,240 MET THE DEFINITION OF CEREBRAL 745 00:29:16,240 --> 00:29:16,480 MALARIA. 746 00:29:16,480 --> 00:29:18,400 AND IN THIS GROUP WE FOUND 747 00:29:18,400 --> 00:29:21,520 ANOTHER CAUSE OF DEATH THAT WE 748 00:29:21,520 --> 00:29:22,680 HADN'T SUSPECTED HAD WE NOT DONE 749 00:29:22,680 --> 00:29:23,080 THE AUTOPSIESS. 750 00:29:23,080 --> 00:29:25,360 SO THIS WAS EXTREMELY 751 00:29:25,360 --> 00:29:25,680 ILLUMINATING. 752 00:29:25,680 --> 00:29:27,200 WE NEVER FOUND ALTERNATIVE OR 753 00:29:27,200 --> 00:29:28,640 ADDITIONAL CAUSES OF DEATH IN 754 00:29:28,640 --> 00:29:36,720 THE CM1s AND THE CM2s. 755 00:29:36,720 --> 00:29:44,080 WE WERE ALSO LOOKING FOR 756 00:29:44,080 --> 00:29:46,360 SWELLING, ALL BRAINS WERE 757 00:29:46,360 --> 00:29:47,480 SWOLLEN IRRESPECTIVE OF CAUSE OF 758 00:29:47,480 --> 00:29:47,680 DEATH. 759 00:29:47,680 --> 00:29:48,960 BY THE WAY IN THIS SETTING WHEN 760 00:29:48,960 --> 00:29:50,320 YOU TRY TO EXAMINE THE BRAIN, 761 00:29:50,320 --> 00:29:54,320 YOU HAVE TO IN THE MORTUARY PEEL 762 00:29:54,320 --> 00:29:55,880 BACK THE SCALP AND TAKE A BONE 763 00:29:55,880 --> 00:29:58,640 SAW AND GO AROUND THE HEAD AND 764 00:29:58,640 --> 00:30:01,280 REMOVE WILL CALVARIUM AND VERY 765 00:30:01,280 --> 00:30:03,400 GENTLY DISSECT DOWN THROUGH THE 766 00:30:03,400 --> 00:30:04,360 SKULL, LOOSEN UP THE BRAIN, 767 00:30:04,360 --> 00:30:05,880 SEVERE MITRALLER IT AT THE 768 00:30:05,880 --> 00:30:09,320 SPINAL CORD, LIFT IT OUT OF THE 769 00:30:09,320 --> 00:30:11,520 SKULL AND FLIP IT OVER TO SEE IF 770 00:30:11,520 --> 00:30:13,360 THERE ANY SIGNS OF HERNIATION 771 00:30:13,360 --> 00:30:16,440 AND WE DID THIS EAGERLY WITH 772 00:30:16,440 --> 00:30:17,280 EVERY AUTOPSIES. 773 00:30:17,280 --> 00:30:18,960 SO HERE'S THE FRAME AND MAGNUM, 774 00:30:18,960 --> 00:30:20,240 HERE'S THE SKULL CAN THE BONE, 775 00:30:20,240 --> 00:30:23,200 THIS IS NOT A REAL SKULL, WITH 776 00:30:23,200 --> 00:30:27,080 THE BONE SAW AROUND IT AND THEN 777 00:30:27,080 --> 00:30:28,720 WE WOULD FINGER DISSECT DOWN AND 778 00:30:28,720 --> 00:30:37,880 LIFT THE BRAIN OUT OF THE SKULL. 779 00:30:37,880 --> 00:30:39,320 LOOKING FOR THESE TELL TALE 780 00:30:39,320 --> 00:30:39,920 SIGNS OF HERNIATION. 781 00:30:39,920 --> 00:30:42,040 NOW, WE NEVER SAW IT. 782 00:30:42,040 --> 00:30:44,280 SO THAT WAS FRUSTRATING. 783 00:30:44,280 --> 00:30:46,880 HOWEVER, WE LEARNED A LOT, WE'VE 784 00:30:46,880 --> 00:30:48,640 LEARNED THAT THEY'RE AT LEAST AT 785 00:30:48,640 --> 00:30:50,400 THE HISTOLOGIC LEVEL, THERE ARE 786 00:30:50,400 --> 00:30:52,280 3 DIFFERENT TYPES OF CEREBRAL 787 00:30:52,280 --> 00:30:54,800 MALARIA SO THIS GROUP THAT MEETS 788 00:30:54,800 --> 00:30:56,800 THE CLINICAL CASE DEFINITION IS 789 00:30:56,800 --> 00:30:58,880 ACTUALLY MORE--IS NOT SO 790 00:30:58,880 --> 00:31:01,080 MONOCHROMEATIC AT ALL, IT'S 791 00:31:01,080 --> 00:31:01,840 ACTUALLY QUITE HETEROGENIUS AND 792 00:31:01,840 --> 00:31:04,840 THERE ARE SOME KIDS IN THERE WHO 793 00:31:04,840 --> 00:31:06,040 DON'T ACTUALLY HAVE SEEREBERAL 794 00:31:06,040 --> 00:31:07,680 MALARIA, THOSE ARE COLORED BLUE 795 00:31:07,680 --> 00:31:10,400 HERE, THEY HAVE SOMETHING ELSE 796 00:31:10,400 --> 00:31:13,280 AND IT BEHOOVES US AS THE 797 00:31:13,280 --> 00:31:14,960 CLINICIANS TO DETERMINE THAT. 798 00:31:14,960 --> 00:31:17,800 SO WE SPENT QUITE A LOT OF TIME 799 00:31:17,800 --> 00:31:22,800 LOOKING FOR CLUES IN LIFE FOR 800 00:31:22,800 --> 00:31:25,960 THAT GROUP WE WANTED TO NOT 801 00:31:25,960 --> 00:31:28,080 STUDY THEM AS CEREBRAL MALARIA, 802 00:31:28,080 --> 00:31:29,360 THEY WERE POLLUTING OUR POOL 803 00:31:29,360 --> 00:31:32,320 BIEW WE ALSO WANTED TO GIVE THEM 804 00:31:32,320 --> 00:31:35,240 THE RIGHT TREATMENT AND LOW AND 805 00:31:35,240 --> 00:31:36,240 BEHOLD THE RETINAL LOCATIONIN 806 00:31:36,240 --> 00:31:37,080 OPEN MEETINGATHY STATUS WERE THE 807 00:31:37,080 --> 00:31:38,040 KEY. 808 00:31:38,040 --> 00:31:40,360 SO THE KIDS WITH NORMAL EYES 809 00:31:40,360 --> 00:31:42,240 WERE NO SEQUESTRATION, THE KIDS 810 00:31:42,240 --> 00:31:43,640 WITH FINDINGS OF MALARIAL 811 00:31:43,640 --> 00:31:44,720 RETINAL LOCATIONIN OPEN 812 00:31:44,720 --> 00:31:46,840 MEETINGATHY HAD ALL EVIDENCE OF 813 00:31:46,840 --> 00:31:48,240 MALARIA INFEC IN THEIR BRAIN SO 814 00:31:48,240 --> 00:31:50,520 THEN WE ALL BECAME INTENSELY 815 00:31:50,520 --> 00:31:53,840 INTERESTED IN EYE EXAMS AND OVER 816 00:31:53,840 --> 00:31:55,360 TIME WE WERE ABLE TO WORK OUT 817 00:31:55,360 --> 00:31:59,720 WHAT THOSE EYE FINDINGS 818 00:31:59,720 --> 00:32:00,800 REPRESENTED. 819 00:32:00,800 --> 00:32:01,800 THE WHITENING IS IMPAIRED 820 00:32:01,800 --> 00:32:04,000 PROFUSION, WE HAD TO DO INJURY 821 00:32:04,000 --> 00:32:06,000 GRAMS FOR THAT BUT YOU COULD SEE 822 00:32:06,000 --> 00:32:07,680 THE FLOWER ESTIMATE THADING WITH 823 00:32:07,680 --> 00:32:08,880 STOP, THE BLOOD FLOW WOULD STOP 824 00:32:08,880 --> 00:32:10,840 AND BEYOND THAT WAS THE 825 00:32:10,840 --> 00:32:11,320 WHITENING. 826 00:32:11,320 --> 00:32:13,840 SO THAT WAS INOXIC OR HIPOXIC 827 00:32:13,840 --> 00:32:15,800 AREAS OF THE EYE. 828 00:32:15,800 --> 00:32:17,600 THE HEMORRHAGES OF THE EYE 829 00:32:17,600 --> 00:32:18,520 HISTOLOGICALLY LOOKED JUST LIKE 830 00:32:18,520 --> 00:32:20,160 THE HEMORRHAGES IN THE BRAIN AND 831 00:32:20,160 --> 00:32:23,800 MY PERSONAL FAVORITE OF THE EYE 832 00:32:23,800 --> 00:32:27,240 FINDINGS IS THE VESSEL CHANGES. 833 00:32:27,240 --> 00:32:33,800 SO WHERE THE BLOOD BECOME ORANGE 834 00:32:33,800 --> 00:32:38,160 THOSE ARE ACTUALLY PARASITIZED 835 00:32:38,160 --> 00:32:39,400 CELLS, WITH HEMOGLOBIN IN THEM, 836 00:32:39,400 --> 00:32:40,720 THEY'RE PALER THAN YOUR AVERAGE 837 00:32:40,720 --> 00:32:48,280 RED CELL AND YOU CAN SEE IT IN 838 00:32:48,280 --> 00:32:48,800 THE EYES. 839 00:32:48,800 --> 00:32:50,760 SO IF WE TAKE OUT THOSE THAT ARE 840 00:32:50,760 --> 00:32:53,480 RED NEGATIVE, WE ARE LEFT WITH A 841 00:32:53,480 --> 00:32:56,360 GROUP TO MORE TRULY LIKELY TO 842 00:32:56,360 --> 00:32:57,240 HAVE SEEREBERAL MALARIA AND 843 00:32:57,240 --> 00:32:58,520 THUGS THEY BECAME THE FOCUS OF 844 00:32:58,520 --> 00:32:59,960 OUR WORK. 845 00:32:59,960 --> 00:33:01,480 HOWEVER, YOU MAY RECALL WE STILL 846 00:33:01,480 --> 00:33:04,640 DON'T KNOW WHY THEY'RE DYING. 847 00:33:04,640 --> 00:33:06,640 THIS IS A VERY INTERESTING FIND, 848 00:33:06,640 --> 00:33:08,200 SO WE DELVED DEEPLY INTO THE 849 00:33:08,200 --> 00:33:09,720 NEURAL PATHOLOGY, THERE WAS A 850 00:33:09,720 --> 00:33:12,400 LOT OF INTERESTING 851 00:33:12,400 --> 00:33:13,760 NEUROPATHOLOGY, BUT NONE OF IT 852 00:33:13,760 --> 00:33:22,200 WAS REALLY FATAL, SO, WE HAD TO 853 00:33:22,200 --> 00:33:23,880 ADMIT THERE ARE FLAWS IN THE 854 00:33:23,880 --> 00:33:24,760 AUTOPSIES, WE ARE LOAMACY BEING 855 00:33:24,760 --> 00:33:26,640 AT THOSE WHO DIE, WE ARE LOOKING 856 00:33:26,640 --> 00:33:28,080 AT THEM IN THE MOMENT OF DEATH, 857 00:33:28,080 --> 00:33:29,600 WE HAVE NO IDEA HOW THOSE 858 00:33:29,600 --> 00:33:31,800 FINDINGS COMPARED TO THE 859 00:33:31,800 --> 00:33:35,240 SURVIVORS SO WE NEEDED TO DO 860 00:33:35,240 --> 00:33:37,720 NEUROIMAGING, A PIPE DREAM IN 861 00:33:37,720 --> 00:33:39,320 MALAWI, WE COULDN'T EVEN KEEP 862 00:33:39,320 --> 00:33:43,400 THE RAG X-RAY MACHINES 863 00:33:43,400 --> 00:33:43,680 FUNCTIONING. 864 00:33:43,680 --> 00:33:44,800 SERENDIPITOUS EVENT NUMBER 865 00:33:44,800 --> 00:33:47,320 ENOUGH WAS E. JAMES POACHIN, 866 00:33:47,320 --> 00:33:49,280 VISIONARY HEAD OF RADIOLOGY AT 867 00:33:49,280 --> 00:33:55,680 MICHIGAN STATE WHO PERSUADED 868 00:33:55,680 --> 00:33:59,360 THEM TO DONATE A MRI MACHINE TO 869 00:33:59,360 --> 00:33:59,600 US. 870 00:33:59,600 --> 00:34:01,920 PHENOMENAL ARRIVED ON WORLD 871 00:34:01,920 --> 00:34:03,880 MALARIA DAY 2008 AND BY 2009 WE 872 00:34:03,880 --> 00:34:05,920 WERE ABLE TO IMAGE ALL OF OUR 873 00:34:05,920 --> 00:34:07,160 KIDS THROUGHOUT THE COURSE OF 874 00:34:07,160 --> 00:34:13,720 THEIR ILLNESS AND THE FIRST 875 00:34:13,720 --> 00:34:17,280 PATIENT WHO CAME IN IN 2009, 876 00:34:17,280 --> 00:34:19,240 WENT THROUGH THEIR CLINICAL 877 00:34:19,240 --> 00:34:22,120 COURSE HAD 2 MRIs IN FACT, 878 00:34:22,120 --> 00:34:23,840 DIED, WE GOT PERMISSION TO DO 879 00:34:23,840 --> 00:34:24,920 THE AUTOPSIES THAT CASE BLUE 880 00:34:24,920 --> 00:34:25,880 OPEN THE WHOLE THING. 881 00:34:25,880 --> 00:34:31,920 THIS WAS A TYPICAL CEREBRAL 882 00:34:31,920 --> 00:34:33,160 MALARIAL PATIENT, PARASITEMMIC, 883 00:34:33,160 --> 00:34:35,760 EYE FINDINGS, NO SEIZURES HAD A 884 00:34:35,760 --> 00:34:37,120 PRETTY BENIGN CLINICAL COURSE 885 00:34:37,120 --> 00:34:43,040 UNTIL HE WENT THROUGH THAT 886 00:34:43,040 --> 00:34:45,960 INEVITABLE RESPIRATORY CYCLE OF 887 00:34:45,960 --> 00:34:46,640 EVENTS, RESPIRATORY 888 00:34:46,640 --> 00:34:47,160 DESENSITIZATION AND DIED. 889 00:34:47,160 --> 00:34:49,400 THIS WAS EARLY ON, HE CAME IN ON 890 00:34:49,400 --> 00:34:51,720 FRIDAY AFTERNOON HAD AN MRI, 891 00:34:51,720 --> 00:34:53,000 ANOTHER ON SATURDAY MORNING AND 892 00:34:53,000 --> 00:34:55,080 THEN HE PASSED AWAY AND WE WERE 893 00:34:55,080 --> 00:34:57,360 ABLE TO DO THE AUTOPSIES THE 894 00:34:57,360 --> 00:35:00,560 SAME DAY SO WE TRY ALWAYS TO DO 895 00:35:00,560 --> 00:35:03,040 THE AUTOPSIESS SHORTLY AFTER 896 00:35:03,040 --> 00:35:03,280 DEATH. 897 00:35:03,280 --> 00:35:05,120 THE DEATH WOULD OCCUR SHORTLY 898 00:35:05,120 --> 00:35:06,000 AFTER THE RESPIRATORY ARREST, WE 899 00:35:06,000 --> 00:35:08,600 WOULD TRY TO DO THE AUTOPSIES AS 900 00:35:08,600 --> 00:35:12,520 QUICKLY AS WE COULD AFTER THAT 901 00:35:12,520 --> 00:35:14,160 AND WE WERE JUST NERVOUS ABOUT 902 00:35:14,160 --> 00:35:15,360 GOING ON, TURNING ON THE MACHINE 903 00:35:15,360 --> 00:35:17,960 AND LOOKING AT THE IMAGES, THEN 904 00:35:17,960 --> 00:35:19,240 WE DIDN'T, BUT NOW WE KNOW HOW 905 00:35:19,240 --> 00:35:19,880 TO DO IT. 906 00:35:19,880 --> 00:35:20,960 SO WE DID THAT AUTOPSIES WITHOUT 907 00:35:20,960 --> 00:35:23,160 THE BENEFIT OF HAVING SEEN THE 908 00:35:23,160 --> 00:35:24,600 MRI FINDINGS AND WAS JUST LIKE 909 00:35:24,600 --> 00:35:29,880 EVERY OTHER 1, THE BRAIN WAS 910 00:35:29,880 --> 00:35:31,080 SWOLLEN, CELL SIDE NARROWS 911 00:35:31,080 --> 00:35:33,400 LOOKED AT THE BASE OF THE BRAIN, 912 00:35:33,400 --> 00:35:35,600 STILL NOTHING, NO EVIDENCE OF 913 00:35:35,600 --> 00:35:38,040 HERNIATION. 914 00:35:38,040 --> 00:35:40,280 THEN ON MONDAY, WE REVIEWED THE 915 00:35:40,280 --> 00:35:42,320 FINDINGS WITH THE RADIOLOGIST 916 00:35:42,320 --> 00:35:45,160 AND JUST TO ORIENT YOU OR 917 00:35:45,160 --> 00:35:47,440 ORIENITATE YOU AS MALCOM WOULD 918 00:35:47,440 --> 00:35:49,480 SAY, THIS IS WHAT IT LOOKED LIKE 919 00:35:49,480 --> 00:35:51,360 IN OUR MAGNET. THIS IS A T1 920 00:35:51,360 --> 00:35:54,600 IMAGE EVERYTHING THAT'S BLACK IS 921 00:35:54,600 --> 00:35:56,600 CEREBRAL SPINAL FLUID SO 922 00:35:56,600 --> 00:36:00,000 NORMALLY THE BRAIN IS BATHED AND 923 00:36:00,000 --> 00:36:03,440 BUOYANT IN CEREBRAL SPINAL 924 00:36:03,440 --> 00:36:04,040 FLUID. 925 00:36:04,040 --> 00:36:05,000 OUR AREA OF INTEREST IS RIGHT 926 00:36:05,000 --> 00:36:07,800 HERE WE ARE LOOKING AT BRAIN 927 00:36:07,800 --> 00:36:10,120 IMPINGING ON THE FRAME AND 928 00:36:10,120 --> 00:36:10,360 MAGNUM. 929 00:36:10,360 --> 00:36:11,880 SO HERE'S OUR PATIENT ON 930 00:36:11,880 --> 00:36:12,920 ADMISSION IN FRIDAY, CLEARLY 931 00:36:12,920 --> 00:36:13,720 SOMETHING DIFFERENT IS 932 00:36:13,720 --> 00:36:17,680 HAPPENING, THE BRAIN IS SWOLLEN 933 00:36:17,680 --> 00:36:19,560 AND BY SATURDAY, OURS BEFORE HE 934 00:36:19,560 --> 00:36:24,440 DIED THERE WAS CLEAR EVIDENCE OF 935 00:36:24,440 --> 00:36:27,160 HERNIATION, THE RADIOLOGIST HAD 936 00:36:27,160 --> 00:36:28,520 NO DOUBT SO WE'RE LIKE WHAT? 937 00:36:28,520 --> 00:36:32,800 AND THEN IT DAWNED ON US EXACTLY 938 00:36:32,800 --> 00:36:34,080 WHAT HAD BEEN HAPPENING AND IT 939 00:36:34,080 --> 00:36:36,640 WAS A BRILLIANT EXAMPLE OF THE 940 00:36:36,640 --> 00:36:37,640 HIGHSEN BURG UNCERTAINTY 941 00:36:37,640 --> 00:36:42,200 PRINCIPLE WHICH WAS THE ACT OF 942 00:36:42,200 --> 00:36:43,480 MEASURING SOMETHING, IF YOU 943 00:36:43,480 --> 00:36:46,800 RECALL WE EXPOSED THE SKULL, WE 944 00:36:46,800 --> 00:36:48,920 HAD A BONE SAW, WE GO ALL THE 945 00:36:48,920 --> 00:36:53,360 WAY AROUND AND WE LIFT OFF THE 946 00:36:53,360 --> 00:36:55,800 CALVARIUM AND WHAT DOES THAT DO, 947 00:36:55,800 --> 00:36:57,720 RELIEVES ALL THE PRESSURE, THE 948 00:36:57,720 --> 00:36:59,200 BRAIN MOVES UP AND ALL THE SIGNS 949 00:36:59,200 --> 00:37:00,280 THAT WE'RE LOOKING FOR AT THE 950 00:37:00,280 --> 00:37:01,600 BRACE OF THE BRAIN WHICH DIDN'T 951 00:37:01,600 --> 00:37:03,200 HAVE LONG TO APEERP BECAUSE THE 952 00:37:03,200 --> 00:37:04,600 CHILD DIED AND WE WENT 953 00:37:04,600 --> 00:37:07,040 IMMEDIATELY TO AUTOPSIES, THE 954 00:37:07,040 --> 00:37:09,360 VERY FINDING THAT WE WERE 955 00:37:09,360 --> 00:37:10,840 LOOKING FOR WAS OBLIT RATED. 956 00:37:10,840 --> 00:37:14,360 WE NEVER WOULD HAVE CAUGHT THIS 957 00:37:14,360 --> 00:37:16,120 WITHOUT THE MRI. 958 00:37:16,120 --> 00:37:18,000 SO, FAST FORWARD SEVERAL YEARS 959 00:37:18,000 --> 00:37:19,160 WE ACCUMULATE A BUNCH OF 960 00:37:19,160 --> 00:37:20,920 PATIENTS AND NEARLY ALL THE 961 00:37:20,920 --> 00:37:23,360 DEATHS ARE ASSOCIATED WITH 962 00:37:23,360 --> 00:37:23,920 INCREASED BRAIN VOLUME. 963 00:37:23,920 --> 00:37:25,880 MANY PATIENTS WITH INCREASED 964 00:37:25,880 --> 00:37:27,880 BRAIN VOLUME SURVIVE, WHICH WAS 965 00:37:27,880 --> 00:37:29,080 REASSURING, BUT NEARLY ALL THE 966 00:37:29,080 --> 00:37:31,280 DEATHS CAN BE ATTRIBUTED IN 1 967 00:37:31,280 --> 00:37:33,720 WAY SHAPE OR FORM FOCUSED ON 968 00:37:33,720 --> 00:37:34,400 INCREASE BRAIN VOLUME. 969 00:37:34,400 --> 00:37:36,840 THE RESOLUTION IN THOSE WHO 970 00:37:36,840 --> 00:37:38,240 SURVIVE IS RAPID, CONSISTENT 971 00:37:38,240 --> 00:37:43,240 WITH THE RAPID CLINICAL 972 00:37:43,240 --> 00:37:46,080 IMPROVEMENT THAT WE SEE @ 973 00:37:46,080 --> 00:37:51,680 BEDSIDE, SO NOW OUR MARADIME AND 974 00:37:51,680 --> 00:37:53,240 CLAIMED IT VIA--NOT SAYING 975 00:37:53,240 --> 00:37:55,200 CAUSED YET BUT BRAIN SWELLING 976 00:37:55,200 --> 00:37:56,640 AND THE RAISED INTRA CRANIAL 977 00:37:56,640 --> 00:37:58,120 PRESSURE THAT IT BRINGS ALONG 978 00:37:58,120 --> 00:38:00,800 WITH IT ARE STRONG PREDICTERS 979 00:38:00,800 --> 00:38:04,320 EVER DEATH IN OUR PATIENT 980 00:38:04,320 --> 00:38:04,600 POPULATION. 981 00:38:04,600 --> 00:38:12,120 SO NOW WE'RE LIKE, OKAY, WHY ARE 982 00:38:12,120 --> 00:38:12,920 THESE BRAINS SWOLLEN. 983 00:38:12,920 --> 00:38:15,520 AND THERE ARE SEVERAL, ACTUALLY 984 00:38:15,520 --> 00:38:17,080 POTENTIALLY 4 EXPLANATIONS FOR 985 00:38:17,080 --> 00:38:18,120 THE BRAIN SWELLING. 986 00:38:18,120 --> 00:38:19,240 THE BRAIN VOLUME, THE BRAIN 987 00:38:19,240 --> 00:38:21,440 TISSUE ITSELF COULD BE EXPANDING 988 00:38:21,440 --> 00:38:24,080 OR THE VOLUME OF BLOOD IN THE 989 00:38:24,080 --> 00:38:29,520 BRAIN COULD BE INCREASING SO WE 990 00:38:29,520 --> 00:38:31,720 KNOW THERE'S THE PONLT OF VASE O 991 00:38:31,720 --> 00:38:33,840 GENIC, WE KNOW THERE'S A BLOOD 992 00:38:33,840 --> 00:38:38,080 BARRIER BREAK DOWN, WE SAW THOSE 993 00:38:38,080 --> 00:38:38,480 HISTOLOGICALLY. 994 00:38:38,480 --> 00:38:43,720 WE SUSPECT THESE ARE CYTOTOXIC 995 00:38:43,720 --> 00:38:45,000 EDEMA FROM THE ISCHEMIA, WE KNOW 996 00:38:45,000 --> 00:38:46,560 THAT IN THE EYE, THERE'S 997 00:38:46,560 --> 00:38:51,840 PROBABLY A CORRELATE TO THAT IN 998 00:38:51,840 --> 00:38:52,640 THE BRAIN. 999 00:38:52,640 --> 00:38:55,240 THE BRAIN ITSELF IS EXQUISITELY 1000 00:38:55,240 --> 00:38:56,680 CAPABLE OF ADJUSTING ITS OWN 1001 00:38:56,680 --> 00:38:59,960 BLOOD FLOW AND IT CAN INCREASE 1002 00:38:59,960 --> 00:39:00,680 BLOOD FLOW IF NECESSARY AND 1003 00:39:00,680 --> 00:39:04,320 THERE ARE LOTS OF REASONS IN 1004 00:39:04,320 --> 00:39:06,520 MALARIA WHY A BRAIN NIGHT NEED 1005 00:39:06,520 --> 00:39:09,960 MORE BLOOD, KIDS ARE ANEMIC, 1006 00:39:09,960 --> 00:39:11,680 SEIZING, FEB RILE, ALL THOSE 1007 00:39:11,680 --> 00:39:15,080 WOULD COMBINE TO INCREASED BLOOD 1008 00:39:15,080 --> 00:39:15,400 FLOW. 1009 00:39:15,400 --> 00:39:16,760 MY PERSONAL FAVORITE AMONG THE 1010 00:39:16,760 --> 00:39:19,000 POTENTIAL SOURCES OF INCREASED 1011 00:39:19,000 --> 00:39:21,440 BRAIN VOLUME IS THAT THE 1012 00:39:21,440 --> 00:39:27,680 SEQUESTERED MASS OF PARASITES IS 1013 00:39:27,680 --> 00:39:29,640 IMPEDING VENUS OUTFLOW AND WE 1014 00:39:29,640 --> 00:39:32,240 DO, HISTOLOGICALLY WE SAW LOTS 1015 00:39:32,240 --> 00:39:34,320 OF CONGESTION IN THE BRAIN AND I 1016 00:39:34,320 --> 00:39:35,640 LIKE THAT 1 BECAUSE IT'S ALSO 1017 00:39:35,640 --> 00:39:37,040 CONSISTENT WITH THE RAPID 1018 00:39:37,040 --> 00:39:41,040 RECOVERY ONCE KIDS ARE ON 1019 00:39:41,040 --> 00:39:41,480 TREATMENT. 1020 00:39:41,480 --> 00:39:42,440 BUT WE DIDN'T KNOW WHAT THEY 1021 00:39:42,440 --> 00:39:43,880 WERE AND IT KIND OF MATTERS 1022 00:39:43,880 --> 00:39:45,440 BECAUSE THE CLINICAL TREATMENT, 1023 00:39:45,440 --> 00:39:47,080 THE MANAGEMENT STRATEGY WOULD BE 1024 00:39:47,080 --> 00:39:50,760 DIFFERENT DEPENDING ON WHICH OF 1025 00:39:50,760 --> 00:39:51,160 THESE IT WAS. 1026 00:39:51,160 --> 00:39:54,760 BUT TIME IS PASSING. 1027 00:39:54,760 --> 00:39:56,520 KIDS ARE DYING SO WE THOUGHT, 1028 00:39:56,520 --> 00:39:59,240 WELL, MAYBE IT DOESN'T REALLY 1029 00:39:59,240 --> 00:40:01,080 MATTER BECAUSE SO MANY KIDS 1030 00:40:01,080 --> 00:40:01,520 SURVIVE. 1031 00:40:01,520 --> 00:40:03,400 MAYBE IF WE COULD JUST GRIEVE 1032 00:40:03,400 --> 00:40:06,080 FOR THEM INSTEAD OF STANDING AT 1033 00:40:06,080 --> 00:40:08,160 THE BEDSIDE BEGGING AND ASKING, 1034 00:40:08,160 --> 00:40:11,720 CAN'T DO THAT INDEFINITELY, IF 1035 00:40:11,720 --> 00:40:13,800 WE BREATHE FOR THEM AND NATURE 1036 00:40:13,800 --> 00:40:15,880 TOOK ITSELF COURSE AND THE BRAIN 1037 00:40:15,880 --> 00:40:17,520 VOLUME RESOLVED WE MIGHT BE ABLE 1038 00:40:17,520 --> 00:40:20,000 TO TIE THEM OVER THE VULNERABLE 1039 00:40:20,000 --> 00:40:20,320 PERIOD. 1040 00:40:20,320 --> 00:40:23,680 THAT WAS A PIPE DREAM UNTIL 1041 00:40:23,680 --> 00:40:24,640 SERENDIPITOUS EEIVET NUMBER 6 1042 00:40:24,640 --> 00:40:32,040 WHICH WAS THE ARRIVAL IN MALAWI 1043 00:40:32,040 --> 00:40:35,200 OF MADONNA, SHE TOOK MALAWI INTO 1044 00:40:35,200 --> 00:40:38,920 HER HEART AND SHE TOOK ON THE 1045 00:40:38,920 --> 00:40:41,360 SURGEONS AND WHOSE SURGEONS WERE 1046 00:40:41,360 --> 00:40:43,360 BEING COMPLICATED BY THE LACK OF 1047 00:40:43,360 --> 00:40:44,400 POST OPERATIVE CARE. 1048 00:40:44,400 --> 00:40:46,160 SO THEY WOULD DO BRILLIANT 1049 00:40:46,160 --> 00:40:52,840 SURGERIES BUT THERE WASN'T A 1050 00:40:52,840 --> 00:40:56,080 PLACE TO ALLOW THEM TO HEAL 1051 00:40:56,080 --> 00:40:58,280 AFTER THESE SURGERIES. 1052 00:40:58,280 --> 00:41:01,720 SO MADONNA BUILT A POST CARE 1053 00:41:01,720 --> 00:41:06,600 FACILITY, JUST WHEN WE WERE 1054 00:41:06,600 --> 00:41:08,760 INTERESTED IN THE POST SURGICAL 1055 00:41:08,760 --> 00:41:10,040 CARE OF OUR PATIENT POPULATION. 1056 00:41:10,040 --> 00:41:12,800 THIS IS A GORGEOUS FACILITY WE 1057 00:41:12,800 --> 00:41:18,040 DESIGNED A 3 ARM CLINICAL TRIAL 1058 00:41:18,040 --> 00:41:18,840 TO INVESTIGATE TREATMENTS THAT 1059 00:41:18,840 --> 00:41:21,160 MIGHT HELP THESE KIDS. 1060 00:41:21,160 --> 00:41:23,360 WE ORIGINALLY WERE HOPING TO 1061 00:41:23,360 --> 00:41:24,880 ENROLL 258 PATIENTS. 1062 00:41:24,880 --> 00:41:28,400 WE HAVE A GREAT STUDY TEAM OF 1063 00:41:28,400 --> 00:41:30,160 CLINICIANS IN MALAWI AND 1064 00:41:30,160 --> 00:41:31,200 RADIOLOGYSISTS AROUND THE WORLD 1065 00:41:31,200 --> 00:41:33,680 BECAUSE WE NEED BRAIN VOLUME 1066 00:41:33,680 --> 00:41:34,640 INTERPRETATIONS AT ALL HOURS OF 1067 00:41:34,640 --> 00:41:42,800 THE DAY OR NIGHT AND WE ARE 1068 00:41:42,800 --> 00:41:44,080 STUDYING THE INCREASED 1069 00:41:44,080 --> 00:41:45,120 ASSOCIATION OF BRAIN VOLUME FOR 1070 00:41:45,120 --> 00:41:47,320 OUTCOMES IN OUR KIDS WITH THE 1071 00:41:47,320 --> 00:41:48,560 HYPOTHESIS BEING THAT ANY 1072 00:41:48,560 --> 00:41:51,360 INTERVENTION THAT COULD REDUCE 1073 00:41:51,360 --> 00:41:53,120 THE BRAIN VOLUME OR SUPPORT 1074 00:41:53,120 --> 00:41:54,440 VENTILATION WOULD INL PROVE 1075 00:41:54,440 --> 00:41:56,560 SURVIVAL RATES. 1076 00:41:56,560 --> 00:41:59,640 SO 1 ARM IS IMMEDIATE VENT 1077 00:41:59,640 --> 00:42:01,400 LATTERY SUPPORT AND ANOTHER ARM 1078 00:42:01,400 --> 00:42:02,120 IS OSMOTIC THERAPY AND THERE 1079 00:42:02,120 --> 00:42:03,680 WERE A NUMBER OF THINGS WE COULD 1080 00:42:03,680 --> 00:42:08,760 HAVE CHOSEN BUT WE CHOSE 3% HYPE 1081 00:42:08,760 --> 00:42:12,160 OR TONIC SALINE BECAUSE IT CAN 1082 00:42:12,160 --> 00:42:13,880 BE ADMINISTERED THROUGH A 1083 00:42:13,880 --> 00:42:15,240 PERIPHERAL IV AND MORE EASILY 1084 00:42:15,240 --> 00:42:17,360 MANAGED THAN OTHER FORMS OF 1085 00:42:17,360 --> 00:42:17,840 OSMOTIC THERAPY. 1086 00:42:17,840 --> 00:42:20,160 THE USUAL CARE AND CONTROL ARM 1087 00:42:20,160 --> 00:42:21,760 AS IT WERE IS TO PUT KIDS IN A 1088 00:42:21,760 --> 00:42:26,880 BED WITH THE HEAD OF THE BED 1089 00:42:26,880 --> 00:42:29,160 ELEVATED TO ASSIST WITH THE 1090 00:42:29,160 --> 00:42:30,560 VENUS DRAINAGE. 1091 00:42:30,560 --> 00:42:31,520 THE OUTCOMES ARE TREATMENT 1092 00:42:31,520 --> 00:42:34,400 SUCCESS OR FAILURE AT 7 DAYS. 1093 00:42:34,400 --> 00:42:36,840 SO DO KIDS SURVIVE OR NOT? 1094 00:42:36,840 --> 00:42:39,440 AND THEN HOW WELL DO THEY 1095 00:42:39,440 --> 00:42:39,760 SURVIVE? 1096 00:42:39,760 --> 00:42:41,480 ARE THEY VERY DAMAGED AND CAN WE 1097 00:42:41,480 --> 00:42:44,080 IDENTIFY SOME OTHER WAY OF 1098 00:42:44,080 --> 00:42:45,880 PICKING UP THE KIDS WITH 1099 00:42:45,880 --> 00:42:47,640 INCREASED BRAIN VOLUME BECAUSE 1100 00:42:47,640 --> 00:42:49,520 MRIs ARE NOT UCIBOLLITIOUS, 1101 00:42:49,520 --> 00:42:52,200 FAR FROM IT ON THE CONTINENT SO 1102 00:42:52,200 --> 00:42:53,080 OTHER BIOMARKERS EVER INCREASED 1103 00:42:53,080 --> 00:42:54,720 BRAIN VOLUME SHOULD WE IDENTIFY 1104 00:42:54,720 --> 00:42:56,280 SOMETHING SUCKER ASSESSESFUL 1105 00:42:56,280 --> 00:42:57,320 WOULD BE EASIER TO SCALE IT UP 1106 00:42:57,320 --> 00:42:59,720 IF WE DIDN'T HAVE TO RELY ON 1107 00:42:59,720 --> 00:42:59,960 MRIs. 1108 00:42:59,960 --> 00:43:04,720 SO PLAN A WAS TO ENROLL OVER 6 1109 00:43:04,720 --> 00:43:11,240 SEASONS AND RANDOMIZE A COUPLE 1110 00:43:11,240 --> 00:43:12,040 HUNDRED KIDS. 1111 00:43:12,040 --> 00:43:14,080 THEN WE RAN INTO CHALLENGES. 1112 00:43:14,080 --> 00:43:17,880 ONE WAS DECREASING PATIENTS WITH 1113 00:43:17,880 --> 00:43:19,040 CEREBRAL MALARIA PATIENTS COMING 1114 00:43:19,040 --> 00:43:19,480 INTO OUR HOSPITAL. 1115 00:43:19,480 --> 00:43:20,880 THAT'S A GOOD THING. 1116 00:43:20,880 --> 00:43:22,880 IT'S HARD NOT TO BE DELIGHT WIDE 1117 00:43:22,880 --> 00:43:23,320 THAT. 1118 00:43:23,320 --> 00:43:24,880 IT'S FRUSTRATING IF YOU'RE 1119 00:43:24,880 --> 00:43:26,240 ENROLLING THEM BUT IT'S GOOD 1120 00:43:26,240 --> 00:43:31,200 OVERALL AND THIS IS A SUCCESS OF 1121 00:43:31,200 --> 00:43:32,520 MALAWI'S PUBLIC HEALTH SYSTEM. 1122 00:43:32,520 --> 00:43:35,360 THE FIRST YEAR, THE ICU WAS 1123 00:43:35,360 --> 00:43:37,280 STILL UNDER CONSTRUCTION SO WE 1124 00:43:37,280 --> 00:43:38,200 COULDN'T START. 1125 00:43:38,200 --> 00:43:40,440 YEARS 2 AND 3 THE MALAWI 1126 00:43:40,440 --> 00:43:42,680 EQUIVALENT OF THE FDA WAS VERY 1127 00:43:42,680 --> 00:43:44,280 CAUTIOUS ABOUT IMPORTING THE 1128 00:43:44,280 --> 00:43:46,440 HYPERTONIC SALINE SO WE COULD 1129 00:43:46,440 --> 00:43:48,520 ONLY HAVE THE VENT ARM. 1130 00:43:48,520 --> 00:43:51,080 AND THEN IN YEAR 4, THE MRI 1131 00:43:51,080 --> 00:43:53,400 CRASHED AND WE COULDN'T FIX IT 1132 00:43:53,400 --> 00:43:54,040 BECAUSE OF COVID. 1133 00:43:54,040 --> 00:43:59,640 SO THAT WAS REALLY FRUSTRATING. 1134 00:43:59,640 --> 00:44:02,120 SO TO RESPOND TO THAT ALL, WE 1135 00:44:02,120 --> 00:44:02,720 DEVELOPED A REGIONAL REFERRAL 1136 00:44:02,720 --> 00:44:04,360 SYSTEM WHICH WAS A LOT OF FUN 1137 00:44:04,360 --> 00:44:06,800 BRINGING KIDS IN FROM ALL THE 1138 00:44:06,800 --> 00:44:08,400 HOSPITALS WITHIN AN HOUR'S 1139 00:44:08,400 --> 00:44:11,520 DRIVE. 1140 00:44:11,520 --> 00:44:13,560 WE ULTIMATELY PERSUADED MALAWI 1141 00:44:13,560 --> 00:44:18,040 MEDICINE AND POISONS AND 1142 00:44:18,040 --> 00:44:19,760 MEDICINES SALINE WE BOUGHT THIS 1143 00:44:19,760 --> 00:44:21,920 VERY FUN SMALL PURPLE MRI FROM A 1144 00:44:21,920 --> 00:44:23,880 COMPANY CALLED HYPER FINE WHICH 1145 00:44:23,880 --> 00:44:25,680 HAS BEEN FANTASTIC, AND WE 1146 00:44:25,680 --> 00:44:26,600 CHANGED THE STUDY DESIGN A 1147 00:44:26,600 --> 00:44:30,600 LITTLE BIT TO ALLOW US TO GET BY 1148 00:44:30,600 --> 00:44:31,240 WITH FEWER PATIENTS. 1149 00:44:31,240 --> 00:44:34,160 SO NOW WHERE WE ARE RIGHT NOW AS 1150 00:44:34,160 --> 00:44:38,840 WE SPEAK IS THAT WE'VE SCREENED 1151 00:44:38,840 --> 00:44:39,920 187 PATIENTS. 1152 00:44:39,920 --> 00:44:41,960 OF THOSE 50% HAVE HAD INCREASED 1153 00:44:41,960 --> 00:44:43,360 BRAIN VOLUME AND ALL THE 1154 00:44:43,360 --> 00:44:44,920 FAMILIES AGREED TO BE HAND 1155 00:44:44,920 --> 00:44:45,440 ONLYIZED. 1156 00:44:45,440 --> 00:44:52,240 SIXTEEN HAVE GONE TO USUAL CARE, 1157 00:44:52,240 --> 00:44:54,200 22 TO IMMEDIATE VENT LATTERY 1158 00:44:54,200 --> 00:44:57,560 SUPPORT AND 12 TO HYPERTONIC 1159 00:44:57,560 --> 00:44:57,840 SALINE ARM. 1160 00:44:57,840 --> 00:44:59,480 IT IS TOO EARLY TO KNOW IF ANY 1161 00:44:59,480 --> 00:45:00,640 OF THEM IS WORKING OR NOT 1162 00:45:00,640 --> 00:45:02,440 WORKING AND IN ORDER TO GET TO 1163 00:45:02,440 --> 00:45:07,920 AN ANSWER, WE JUST NEED TO 1164 00:45:07,920 --> 00:45:08,840 RANDOMIZE THE PATIENTS NEXT AND 1165 00:45:08,840 --> 00:45:12,280 WE WILL HAVE AN ANSWER 1 WAY OR 1166 00:45:12,280 --> 00:45:13,880 OTHER. 1167 00:45:13,880 --> 00:45:16,040 SO, JUST TO RECAP, WE STARTED 1168 00:45:16,040 --> 00:45:19,200 WITH THIS POPULATION OF CHILDREN 1169 00:45:19,200 --> 00:45:21,200 SOME OF WHOM REMAIN UNINFECTED, 1170 00:45:21,200 --> 00:45:24,000 SOME ARE INFECTED AND 1171 00:45:24,000 --> 00:45:25,920 ASYMPTOMATIC, SOME DEVELOP 1172 00:45:25,920 --> 00:45:29,040 UNCOMPLICATED MALARIA, A TINY 1173 00:45:29,040 --> 00:45:31,560 PROPORTION TO DEVELOP INTO A 1174 00:45:31,560 --> 00:45:34,200 COMA AND IN THAT GROUP, THERE 1175 00:45:34,200 --> 00:45:36,280 ARE SOME WHO ARE UNCONSCIOUS AND 1176 00:45:36,280 --> 00:45:39,360 INFECT WIDE MALARIA FOR REASONS 1177 00:45:39,360 --> 00:45:40,840 OTHER THAN MALARIA. 1178 00:45:40,840 --> 00:45:46,240 THOSE ARE THE RET-NEGATIVE KIDS 1179 00:45:46,240 --> 00:45:49,640 BUT OUR FOCUS HAS BEEN ON THE 1S 1180 00:45:49,640 --> 00:45:51,320 THAT ARE RETINOPATHY POSITIVE 1181 00:45:51,320 --> 00:45:54,160 AND ALONG THAT GROUP, ARE THE 1S 1182 00:45:54,160 --> 00:45:57,080 WITH THE HIGHEST INCREASE BRAIN 1183 00:45:57,080 --> 00:45:58,240 VOLUME BECAUSE THE VOOF THE 1184 00:45:58,240 --> 00:46:02,680 MORTALITY OCCURS IN THAT. 1185 00:46:02,680 --> 00:46:04,640 THIS IS AS YOU CAN SEE AN 1186 00:46:04,640 --> 00:46:05,240 EVOLVING STORY. 1187 00:46:05,240 --> 00:46:06,480 SO WATCH THIS SPACE. 1188 00:46:06,480 --> 00:46:08,400 KEEP OUR FINGERS CROSSED WE CAN 1189 00:46:08,400 --> 00:46:11,600 ENROLL 20 MORE PATIENTS. 1190 00:46:11,600 --> 00:46:15,840 THIS HAS TAKEN A LEAP OVER THE 1191 00:46:15,840 --> 00:46:16,920 YEARS. 1192 00:46:16,920 --> 00:46:19,280 WE'VE NEEDED PATHOLOGISTS, 1193 00:46:19,280 --> 00:46:20,120 RADIOLOGISTS AND 1194 00:46:20,120 --> 00:46:23,680 OPHTHALMOLOGISTS, STATISTICIANS, 1195 00:46:23,680 --> 00:46:26,200 AS WELL AS THE REGULAR 1196 00:46:26,200 --> 00:46:27,760 [INDISCERNIBLE] SO IT'S BEEN 1197 00:46:27,760 --> 00:46:30,320 QUITE A JOURNEY. 1198 00:46:30,320 --> 00:46:31,600 THIS IS THE [INDISCERNIBLE] 1199 00:46:31,600 --> 00:46:35,400 PARTY CELEBRATING WITH 1 OF OUR 1200 00:46:35,400 --> 00:46:36,360 SURVIVORS WE'RE HOPEFUL THAT AT 1201 00:46:36,360 --> 00:46:38,080 THE END OF THE CLINICAL TRIAL 1202 00:46:38,080 --> 00:46:42,000 WITH AN ANSWER TO OUR QUESTIONS 1203 00:46:42,000 --> 00:46:42,280 IN A YEAR. 1204 00:46:42,280 --> 00:46:44,080 AND I WOULD LIKE TO CONCLUDE 1205 00:46:44,080 --> 00:46:48,880 WITH 1 OF MY FAVORITE 1206 00:46:48,880 --> 00:46:50,520 [INDISCERNIBLE] PROVERBS: 1207 00:46:50,520 --> 00:46:52,880 [SPEAKING FOREIGN LANGUAGE ] 1208 00:46:52,880 --> 00:46:55,760 WHICH TRANSLATES TO, IT'S A 1209 00:46:55,760 --> 00:46:57,080 LITTLE ENIGMATIC. 1210 00:46:57,080 --> 00:47:02,800 IT TRANSLATES TO: THE 1 WHO 1211 00:47:02,800 --> 00:47:04,920 DIDN'T ASK ATE THE WAX. 1212 00:47:04,920 --> 00:47:06,200 NOT IMMEDIATELY OBVIOUS BUT THE 1213 00:47:06,200 --> 00:47:07,000 BACKGROUND STORY IS THAT A 1214 00:47:07,000 --> 00:47:10,560 PERSON WAS GIVEN A GIFT OF A JAR 1215 00:47:10,560 --> 00:47:16,000 OF HONEY WITH THE BEES WAX IN IT 1216 00:47:16,000 --> 00:47:18,160 AND HE DIDN'T KNOW WHAT IT WAS, 1217 00:47:18,160 --> 00:47:20,080 AND HE DIDN'T ASK ANYBODY WHAT 1218 00:47:20,080 --> 00:47:22,920 IT WAS AND HE JUST ATE THE WAX 1219 00:47:22,920 --> 00:47:24,880 AND DIDN'T ENJOY THE HONEY. 1220 00:47:24,880 --> 00:47:27,680 SO THIS SAY PROVERB THAT IS VERY 1221 00:47:27,680 --> 00:47:28,960 USEFUL FOR ILLICITTING QUESTIONS 1222 00:47:28,960 --> 00:47:32,280 FROM AN AUDIENCE, I USE IT JUST 1223 00:47:32,280 --> 00:47:33,760 ABOUT EVERY TIME WE DISCHARGE A 1224 00:47:33,760 --> 00:47:35,960 PATIENT FROM THE RESEARCH WARD 1225 00:47:35,960 --> 00:47:37,000 BAWSES WE HAVE A LOT OF 1226 00:47:37,000 --> 00:47:38,920 INFORMATION TO IMPART TO THE 1227 00:47:38,920 --> 00:47:40,400 MOM, TAKE THESE MEDICATIONS, 1228 00:47:40,400 --> 00:47:44,560 COME BACK ON SUCH AND SUCH DAY 1229 00:47:44,560 --> 00:47:46,800 IF THE CHILD IS SICK BEFORE 1230 00:47:46,800 --> 00:47:48,280 THEM, COME BACK ANY TIME, BLAH, 1231 00:47:48,280 --> 00:47:51,240 BLAH, BLAH AND WE SAY 1232 00:47:51,240 --> 00:47:52,280 [INDISCERNIBLE] AND ANY MORE 1233 00:47:52,280 --> 00:47:56,120 QUESTIONS AND THE MOTHER WOULD 1234 00:47:56,120 --> 00:47:59,440 SAY OH NO AND I WOULD SAY 1235 00:47:59,440 --> 00:48:00,240 [SPEAKING FOREIGN LANGUAGE ] AND 1236 00:48:00,240 --> 00:48:01,560 THEY LAUGH BECAUSE THEY THINK 1237 00:48:01,560 --> 00:48:02,760 HOW DID SHE KNOW THIS BUT THEN 1238 00:48:02,760 --> 00:48:04,640 THEY ASK A QUESTION OR 2, SO 1239 00:48:04,640 --> 00:48:10,920 IT'S A VERY SUCCESSFUL PROVERB 1240 00:48:10,920 --> 00:48:13,040 IN TERMS OF ELICITING QUESTIONS. 1241 00:48:13,040 --> 00:48:15,440 SO I WOULD LIKE TO STOP AT THIS 1242 00:48:15,440 --> 00:48:19,000 POINT AND I WOULD BE VERY HAPPY 1243 00:48:19,000 --> 00:48:26,640 TO TAKE QUESTIONS. 1244 00:48:26,640 --> 00:48:27,440 >>THANKS DR. TAYLOR. 1245 00:48:27,440 --> 00:48:28,560 THAT WAS A WONDERFUL LECTURE AND 1246 00:48:28,560 --> 00:48:29,840 THANK YOU SO MUCH FOR SHARING 1247 00:48:29,840 --> 00:48:30,760 YOUR LIFE A WORK WITH US. 1248 00:48:30,760 --> 00:48:32,240 WE LOOK FORWARD TO THE NEXT YEAR 1249 00:48:32,240 --> 00:48:36,280 AS YOU HAVE A LOT OF EXCITING 1250 00:48:36,280 --> 00:48:36,520 RESULTS. 1251 00:48:36,520 --> 00:48:44,520 >>LET'S HOPE SO. 1252 00:48:44,520 --> 00:48:44,880 >>YEAH. 1253 00:48:44,880 --> 00:48:45,800 >>I GUESS I CAN START WITH A 1254 00:48:45,800 --> 00:48:47,000 QUESTION AS WE WAIT FOR 1255 00:48:47,000 --> 00:48:48,120 QUESTIONS TO COME IN. 1256 00:48:48,120 --> 00:48:50,560 DURING YOUR EARLY TIME IN 1257 00:48:50,560 --> 00:48:52,280 MALAWI, WHAT TRIALS AND 1258 00:48:52,280 --> 00:48:54,240 TRIBULATIONS DID YOU HAVE IN 1259 00:48:54,240 --> 00:48:56,680 TERMS OF CULTURAL ACCLIMATION IN 1260 00:48:56,680 --> 00:48:58,400 MALAWI AND THEN ALSO TO DEVELOP 1261 00:48:58,400 --> 00:49:01,520 TRUST WITH THE MALAWIANS TO 1262 00:49:01,520 --> 00:49:05,120 ALLOW THEM TO DO RESEARCH WITH 1263 00:49:05,120 --> 00:49:05,280 YOU? 1264 00:49:05,280 --> 00:49:07,040 >>EXCELLENT QUESTION. 1265 00:49:07,040 --> 00:49:10,960 I WAS VERY FORTUNATE TO BE 1266 00:49:10,960 --> 00:49:16,280 ASSOCIATED WITH RIGHT FROM THE 1267 00:49:16,280 --> 00:49:20,560 DEBEGINNING WITH 2 HIGHLY 1268 00:49:20,560 --> 00:49:23,040 REVERED CLINICIANS. 1269 00:49:23,040 --> 00:49:24,160 DR. [INDISCERNIBLE] AND 1270 00:49:24,160 --> 00:49:24,960 DR. MALCOM [INDISCERNIBLE] SO 1271 00:49:24,960 --> 00:49:26,800 WHEN WE STARTED THERE WASN'T A 1272 00:49:26,800 --> 00:49:28,160 MEDICAL SCHOOL IN MALAWI, AND 1273 00:49:28,160 --> 00:49:31,880 THE JOKE WAS THERE WERE MORE 1274 00:49:31,880 --> 00:49:34,280 MALAWI ANS BEING DOCTORS IN 1275 00:49:34,280 --> 00:49:35,920 MANCHESTER THAN IN MALAWI, 1276 00:49:35,920 --> 00:49:36,920 PEOPLE WOULD LEAVE FOR MEDICAL 1277 00:49:36,920 --> 00:49:42,840 TRAINING AND VERY FEW CAME BACK. 1278 00:49:42,840 --> 00:49:43,960 SO THERE WEREN'T PEOPLE WHO 1279 00:49:43,960 --> 00:49:45,240 REALLY HAD ANY MATTER IN THE 1280 00:49:45,240 --> 00:49:49,240 CHOICE OF THEIR CLINICAL CARE, 1281 00:49:49,240 --> 00:49:49,920 WE WERE IT. 1282 00:49:49,920 --> 00:49:51,680 SO I THINK TO A LARGE EXTENT, 1283 00:49:51,680 --> 00:49:56,000 THE PROOF IS IN THE PUDDING AND 1284 00:49:56,000 --> 00:49:57,760 PEOPLE WOULD SEE THESE KIDDINGS 1285 00:49:57,760 --> 00:50:03,040 GET BETTER AND GO HOME AND THAT 1286 00:50:03,040 --> 00:50:04,920 WAS THE--PROBABLY THE MOST 1287 00:50:04,920 --> 00:50:05,800 IMPORTANT DETERMINANT OF THEIR 1288 00:50:05,800 --> 00:50:06,680 TRUST IN US. 1289 00:50:06,680 --> 00:50:10,320 SO WE STARTED IN 86 AND THEN THE 1290 00:50:10,320 --> 00:50:11,720 MEDICAL SCHOOL STARTED IN 91 AND 1291 00:50:11,720 --> 00:50:14,960 IT RAMPED UP SLOWLY, 4 OR 5 1292 00:50:14,960 --> 00:50:16,560 GRADUATES A YEAR AND THEN 10 AND 1293 00:50:16,560 --> 00:50:20,080 25 AND NOW THERE ARE A LOT AND 1294 00:50:20,080 --> 00:50:21,360 AT THIS POINT, IT'S VERY EASY TO 1295 00:50:21,360 --> 00:50:25,880 BE PART OF A DEAM OF MIXED 1296 00:50:25,880 --> 00:50:27,400 NATIONALILITYS THAT ARE LOOKING 1297 00:50:27,400 --> 00:50:33,560 AFTER PATIENTS AND HONESTLY THE 1298 00:50:33,560 --> 00:50:34,880 CULTURAL ASPECTS OF IT HAVE 1299 00:50:34,880 --> 00:50:37,840 BECOME SO MUCH CLEARER NOW THAT 1300 00:50:37,840 --> 00:50:40,520 WE HAVE MALAWIANS WHO ARE 1301 00:50:40,520 --> 00:50:41,880 WORKING WITH US WHO CAN EXPLAIN 1302 00:50:41,880 --> 00:50:45,160 A LOT OF THE NUANCES SO IT'S 1303 00:50:45,160 --> 00:50:48,080 REALLY BEEN FASCINATING. 1304 00:50:48,080 --> 00:50:48,760 >>THAT'S GREAT. 1305 00:50:48,760 --> 00:50:52,560 SO TO FOLLOW UP ON THAT I KNOW 1306 00:50:52,560 --> 00:50:55,000 THE OFFICIAL LANGUAGE IN MALAWI 1307 00:50:55,000 --> 00:50:57,640 IS ENGLISH BUT UNDOUBTEDLY WITH 1308 00:50:57,640 --> 00:50:59,080 SUCH ENRICHMENT OF DIFFERENT 1309 00:50:59,080 --> 00:50:59,880 LANGUAGES THERE, I GUESS WHAT 1310 00:50:59,880 --> 00:51:01,920 LANGUAGES HAVE YOU PICKED UP? 1311 00:51:01,920 --> 00:51:04,720 >>O NO, SO THE FIRST COUPLE 1312 00:51:04,720 --> 00:51:07,840 YEARS I HAD A TUTOR AND I WORKED 1313 00:51:07,840 --> 00:51:10,280 ASSIDUOUSLY BUT AS YOU SAY, 1314 00:51:10,280 --> 00:51:12,320 WHILE THERE ARE 2 OFFICIAL 1315 00:51:12,320 --> 00:51:13,800 LANGUAGES, [INDISCERNIBLE] AND 1316 00:51:13,800 --> 00:51:15,360 ENGLISH AND EVERYONE WHO HAS 1317 00:51:15,360 --> 00:51:17,320 BEEN BEYOND SECOND ISARY SCHOOL 1318 00:51:17,320 --> 00:51:19,640 SPEAKS ENGLISH AND I WAS ALWAYS 1319 00:51:19,640 --> 00:51:22,440 AT A CENTRAL HOSPITAL SO I WAS 1320 00:51:22,440 --> 00:51:24,520 NEVER FORCED TO SPEAK 1321 00:51:24,520 --> 00:51:25,160 [INDISCERNIBLE]. 1322 00:51:25,160 --> 00:51:27,080 SO I HAVE VERY RUDIMENTARY 1323 00:51:27,080 --> 00:51:29,000 [INDISCERNIBLE] AND THAT'S 1 OF 1324 00:51:29,000 --> 00:51:30,440 THE REASONS WHY I TRY TO LEARN 1325 00:51:30,440 --> 00:51:33,760 THE PROVERBS BECAUSE IF YOU DROP 1326 00:51:33,760 --> 00:51:36,400 THE RIGHT PROVERB IN THE RIGHT 1327 00:51:36,400 --> 00:51:38,360 MOMENT, PEOPLE ARE LIKE WHOA, 1328 00:51:38,360 --> 00:51:39,280 SHE KNOWS [INDISCERNIBLE] WHICH 1329 00:51:39,280 --> 00:51:41,880 I DON'T REALLY BUT I KNOW--I 1330 00:51:41,880 --> 00:51:43,280 KNOW TIMING OF THE MOMENT FOR 1331 00:51:43,280 --> 00:51:44,880 USING A PROVERB AND THERE ARE 1332 00:51:44,880 --> 00:51:48,760 SOME WORDS WHICH ARE EXTREMELY 1333 00:51:48,760 --> 00:51:49,000 USEFUL. 1334 00:51:49,000 --> 00:51:50,000 THERE IS--THERE ARE WORDS THAT 1335 00:51:50,000 --> 00:51:52,320 ARE REALLY FUN SO FOR INSTANCE, 1336 00:51:52,320 --> 00:51:55,680 THE WORD THAT MEANS TO BE COLD 1337 00:51:55,680 --> 00:51:57,920 IS [SPEAKING FOREIGN LANGUAGE ] 1338 00:51:57,920 --> 00:51:59,120 IT SOUNDS LIKE YOU'RE SHIVERING 1339 00:51:59,120 --> 00:52:00,560 WHEN YOU SAY IT. 1340 00:52:00,560 --> 00:52:03,280 THE WORD FOR HIPPO SOUNDS LIKE A 1341 00:52:03,280 --> 00:52:07,200 HIPPO IN THE WATER IT'S 1342 00:52:07,200 --> 00:52:08,520 [SPEAKING FOREIGN LANGUAGE ] BUT 1343 00:52:08,520 --> 00:52:10,640 THE 1 WORD THAT HAS REALLY 1344 00:52:10,640 --> 00:52:12,440 HELPED, THERE A SINGLE WORD, 1 1345 00:52:12,440 --> 00:52:15,240 SINGLE WORD IN [INDISCERNIBLE] 1346 00:52:15,240 --> 00:52:17,040 WHICH MEANS THAT YOU KNOW WHAT 1347 00:52:17,040 --> 00:52:18,720 HAS HIT THE FAN AND YOU CAN SAY 1348 00:52:18,720 --> 00:52:20,840 IT ALL IN 1 WORD AND THE WORD 1349 00:52:20,840 --> 00:52:22,840 IS] SPEAKING FOREIGN LANGUAGE ] 1350 00:52:22,840 --> 00:52:24,440 AND HONESTLY IF IT'S A CRAZY DAY 1351 00:52:24,440 --> 00:52:26,320 ON THE RESEARCH WARD, THE 1352 00:52:26,320 --> 00:52:28,360 PATIENTS ARE REALLY SICK, 1353 00:52:28,360 --> 00:52:30,640 THEY'RE SEIZING RIGHT AND LEFT 1354 00:52:30,640 --> 00:52:33,720 AND YOU CAN'T GET IVs, IF YOU 1355 00:52:33,720 --> 00:52:36,000 GO [SPEAKING FOREIGN LANGUAGE ], 1356 00:52:36,000 --> 00:52:38,280 EVERYBODY LAUGHS AND IT BREAKS 1357 00:52:38,280 --> 00:52:40,160 THE TENSION AND EVERYBODY MOVES 1358 00:52:40,160 --> 00:52:40,400 ON. 1359 00:52:40,400 --> 00:52:42,120 SO IT'S STRATEGIC WHAT I'VE 1360 00:52:42,120 --> 00:52:42,360 LEARNED. 1361 00:52:42,360 --> 00:52:42,800 >>THAT'S GREAT. 1362 00:52:42,800 --> 00:52:45,880 SO I GUESS ALSO, TOO, DURING MY 1363 00:52:45,880 --> 00:52:47,080 INTRODUCTION, YOU KNOW YOU SET 1364 00:52:47,080 --> 00:52:51,480 UP A NICE COURSE BACK IN 1365 00:52:51,480 --> 00:52:53,680 MICHIGAN TO TRAIN INDIVIDUALS. 1366 00:52:53,680 --> 00:52:56,120 YOU ALSO ALLUDED TO A MEDICAL 1367 00:52:56,120 --> 00:52:57,400 SCHOOL IN MALAWI, SO DO THE 1368 00:52:57,400 --> 00:52:59,400 STUDENTS IN THE MEDICAL SCHOOL 1369 00:52:59,400 --> 00:53:00,720 IN MALAWI ROTATE WITH YOU WHILE 1370 00:53:00,720 --> 00:53:01,680 YOU'RE OUT THERE, YOU KNOW 1371 00:53:01,680 --> 00:53:05,360 DURING YOUR TIME OUT THERE? 1372 00:53:05,360 --> 00:53:08,000 >>SO THE MSU STUDENTS ARE NOT 1373 00:53:08,000 --> 00:53:09,280 WITH ME PER SE. 1374 00:53:09,280 --> 00:53:11,000 IT'S KIND OF FEAST OR FAMINE ON 1375 00:53:11,000 --> 00:53:13,200 THE RESEARCH WARD, YOU NEVER 1376 00:53:13,200 --> 00:53:14,640 KNOW WHEN IT'LL BE BIEWZY OR 1377 00:53:14,640 --> 00:53:17,360 QUIET AND THE MSU STUDENTS ARE 1378 00:53:17,360 --> 00:53:18,160 SCATTERED AROUND THE HOSPITAL 1379 00:53:18,160 --> 00:53:21,080 AND THEY DO WORK SIDE BY SIDE 1380 00:53:21,080 --> 00:53:23,480 WITH THE MALAWI, AND THEY'RE 1381 00:53:23,480 --> 00:53:24,880 MALAWI AND COUNTERPARTS AND A 1382 00:53:24,880 --> 00:53:27,880 LOT OF SOCIALIZING WE ALL SHARE 1383 00:53:27,880 --> 00:53:31,520 1 BIG HOUSE AND THE MALAWI 1384 00:53:31,520 --> 00:53:32,800 STUDENTS ARE OFTEN OVER FOR 1385 00:53:32,800 --> 00:53:34,840 DINNER WITH THE MSU STUDENTS SO 1386 00:53:34,840 --> 00:53:45,240 THATIA BEEN EXCELLENT. 1387 00:53:46,320 --> 00:53:47,520 >>THAT SOUNDS LIKE A GREAT 1388 00:53:47,520 --> 00:53:47,960 EXPERIENCE. 1389 00:53:47,960 --> 00:53:48,840 SO WE'VE REACHED THE TOP OF OUR 1390 00:53:48,840 --> 00:53:50,440 HOUR AND I WANT TO THANK YOU FOR 1391 00:53:50,440 --> 00:53:52,840 GIVING US THIS EXCELLENT TALK 1392 00:53:52,840 --> 00:53:59,600 TODAY AND I ALSO WANT TO THANK 1393 00:53:59,600 --> 00:53:59,920 OUR AUDIENCE. 1394 00:53:59,920 --> 00:54:00,640 THANK YOU VERY MUCH AND STAY 1395 00:54:00,640 --> 00:54:01,280 WELL AND WE WILL SEE YOU NEXT 1396 00:54:01,280 --> 00:54:14,360 TIME.