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 --> 00:00:47,440 Learn more by visiting us online at http://clinicalcenter.nih.gov 11 00:00:47,440 --> 00:00:52,320 OUR TEACHER IS SARAH S. LONG AT 12 00:00:52,320 --> 00:00:55,400 DREXEL SCHOOL OF MEDICINE AND AT 13 00:00:55,400 --> 00:00:57,840 ST. CHRISTOPHER'S HOSPITAL FOR 14 00:00:57,840 --> 00:00:59,840 CHILDREN IN PHILADELPHIA, 15 00:00:59,840 --> 00:01:00,240 PENNSYLVANIA. 16 00:01:00,240 --> 00:01:03,400 DR. LONG EARNED HER MEDICAL 17 00:01:03,400 --> 00:01:05,400 DEGREE FROM JEFFERSON MEDICAL 18 00:01:05,400 --> 00:01:07,360 COLLEGE AND COMPLETED HER 19 00:01:07,360 --> 00:01:09,800 FELLOWSHIP IN PEDIATRIC 20 00:01:09,800 --> 00:01:10,800 INFECTIOUS DISEASES AT 21 00:01:10,800 --> 00:01:13,200 ST. CHRISTOPHER'S HOSPITAL FOR 22 00:01:13,200 --> 00:01:20,440 CHILDREN FOLLOWED BY AN NIH 23 00:01:20,440 --> 00:01:21,560 RESEARCHSHIP IN PHILADELPHIA. 24 00:01:21,560 --> 00:01:24,960 DR. LONG IS NATIONALLY 25 00:01:24,960 --> 00:01:26,520 RECOGNIZED FOR HER RESEARCH IN 26 00:01:26,520 --> 00:01:27,960 VACCINE PREVENTIBLE DISEASES IN 27 00:01:27,960 --> 00:01:30,800 CHILDREN. 28 00:01:30,800 --> 00:01:33,080 SHE CURRENTLY PROVIDES CLINICAL 29 00:01:33,080 --> 00:01:37,320 CONSULTATIVE CARE TO ENABLE THE 30 00:01:37,320 --> 00:01:38,320 BEST DECISIONS FOR 31 00:01:38,320 --> 00:01:40,040 PHILADELPHIA'S UNDER PRIVILEGED 32 00:01:40,040 --> 00:01:45,000 CHILDREN AND MENTOR STUDENTS AND 33 00:01:45,000 --> 00:01:46,320 INFECTIOUS DISEASES CLINICAL 34 00:01:46,320 --> 00:01:46,560 FELLOWS. 35 00:01:46,560 --> 00:01:48,600 AS AN ACADEMIC AND INSTITUTIONAL 36 00:01:48,600 --> 00:01:53,320 LEADER, DR. LONG HAS SERVED AS 37 00:01:53,320 --> 00:01:54,360 CHAIR OF THE FIRST SUBSPECIALTY 38 00:01:54,360 --> 00:01:56,040 BOARD OF PEDIATRIC INFECTIOUS 39 00:01:56,040 --> 00:01:57,320 DISEASES AT THE AMERICAN BOARD 40 00:01:57,320 --> 00:01:58,400 OF PEDIATRICS. 41 00:01:58,400 --> 00:02:01,000 AS CHAIR OF THE BOARD OF 42 00:02:01,000 --> 00:02:02,720 DIRECTORS OF THE AMERICAN BOARD 43 00:02:02,720 --> 00:02:04,160 OF PEDIATRICS, AS PRESIDENT OF 44 00:02:04,160 --> 00:02:08,200 THE PEDIATRIC INFECTIOUS 45 00:02:08,200 --> 00:02:09,520 DISEASES SOCIETY AND AS 46 00:02:09,520 --> 00:02:11,480 PRESIDENT OF THE MEDICAL STAFF 47 00:02:11,480 --> 00:02:12,640 AT ST. CHRISTOPHER'S HOSPITAL 48 00:02:12,640 --> 00:02:13,320 FOR CHILDREN. 49 00:02:13,320 --> 00:02:15,080 SHE IS BOTH THE FOUNDING AND 50 00:02:15,080 --> 00:02:18,200 CURRENT CHIEF EDITOR OF THE 51 00:02:18,200 --> 00:02:20,280 TEXTBOOK PRINCIPLES IN PRACTICE 52 00:02:20,280 --> 00:02:22,240 OF PEDIATRIC INFECTIOUS DISEASES 53 00:02:22,240 --> 00:02:25,480 WHICH IS NOW IN ITS SIXTH 54 00:02:25,480 --> 00:02:27,160 EDITION AND IS AN ASSOCIATE 55 00:02:27,160 --> 00:02:31,200 EDITOR OF THE JOURNAL OF 56 00:02:31,200 --> 00:02:31,800 PEDIATRICS. 57 00:02:31,800 --> 00:02:34,200 BETWEEN 2006 AND 2021, SHE WAS 58 00:02:34,200 --> 00:02:36,520 AN ASSOCIATE EDITOR FOR FIVE 59 00:02:36,520 --> 00:02:38,960 EDITIONS OF THE RED BOOK REPORT 60 00:02:38,960 --> 00:02:40,360 OF THE COMMITTEE OF INFECTIOUS 61 00:02:40,360 --> 00:02:45,360 DISEASES OF THE AMERICAN ACADEMY 62 00:02:45,360 --> 00:02:47,360 OF PEDIATRICS. 63 00:02:47,360 --> 00:02:50,600 AND DR. LONG SERVES AS A PAST 64 00:02:50,600 --> 00:02:54,200 MEMBER OF THE VACCINES AND 65 00:02:54,200 --> 00:02:57,200 RELATED BIOLOGICAL COMMITTEE OF 66 00:02:57,200 --> 00:02:58,200 THE U.S. FOOD AND DRUG 67 00:02:58,200 --> 00:02:59,920 ADMINISTRATION AND CURRENTLY AS 68 00:02:59,920 --> 00:03:04,440 A MEMBER OF THE ADVISORY 69 00:03:04,440 --> 00:03:05,440 COMMITTEE ON IMMUNIZATION 70 00:03:05,440 --> 00:03:07,400 PRACTICES FOR THE CENTERS OF 71 00:03:07,400 --> 00:03:08,200 DISEASE CONTROL AND PREVENTION 72 00:03:08,200 --> 00:03:09,120 IN ATLANTA. 73 00:03:09,120 --> 00:03:11,800 SHE'S A RECIPIENT OF NUMEROUS 74 00:03:11,800 --> 00:03:15,040 NATIONAL AWARDS AND PROFESSIONAL 75 00:03:15,040 --> 00:03:17,080 HONORS INCLUDING A LIFE TIME 76 00:03:17,080 --> 00:03:18,240 CONTRIBUTION FROM THE AMERICAN 77 00:03:18,240 --> 00:03:20,360 ACADEMY OF PEDIATRICS AND 78 00:03:20,360 --> 00:03:21,200 DISTINGUISHED PHYSICIAN AWARD 79 00:03:21,200 --> 00:03:23,760 FROM THE PEDIATRIC INFECTIOUS 80 00:03:23,760 --> 00:03:25,400 DISEASES SOCIETY WHICH IS GIVEN 81 00:03:25,400 --> 00:03:28,160 TO A PHYSICIAN WHO HAS AN 82 00:03:28,160 --> 00:03:29,000 EXTENSIVE AND DISTINGUISHED 83 00:03:29,000 --> 00:03:31,920 CAREER IN PEDIATRIC INFECTIOUS 84 00:03:31,920 --> 00:03:34,160 DISEASES AS A CLINICIAN, 85 00:03:34,160 --> 00:03:35,960 EDUCATOR AND/OR INVESTIGATOR. 86 00:03:35,960 --> 00:03:39,680 THE TITLE OF DR. LONG'S 87 00:03:39,680 --> 00:03:41,520 PRESENTATION IS CLINICAL 88 00:03:41,520 --> 00:03:43,200 OBSERVATION CATALYZES DISCOVERY. 89 00:03:43,200 --> 00:03:45,360 JOIN ME IN WELCOMING TODAY'S 90 00:03:45,360 --> 00:03:53,200 GREAT TEACHER, DR. SARAH LONG. 91 00:03:53,200 --> 00:03:55,800 >> YOU CAN IMAGINE HOW THRILLED 92 00:03:55,800 --> 00:04:02,640 I AM TO BE ASKED TO GIVE THIS 93 00:04:02,640 --> 00:04:08,040 PRESENTATION AND IT IS DAUNTING 94 00:04:08,040 --> 00:04:11,640 AND TO DO IT WITH ZOOM IT'S AS 95 00:04:11,640 --> 00:04:14,640 DIFFICULT AS THE WORDS THAT GO 96 00:04:14,640 --> 00:04:15,760 TOGETHER. 97 00:04:15,760 --> 00:04:18,240 I HAVE NO DISCLOSURES I CALLED 98 00:04:18,240 --> 00:04:20,640 THIS CATALYZES DISCOVERY BECAUSE 99 00:04:20,640 --> 00:04:22,360 IDEAS HAVE TO START SOMEWHERE 100 00:04:22,360 --> 00:04:24,720 AND FOR ME THEY HAVE STARTED 101 00:04:24,720 --> 00:04:29,640 EITHER WITH A PATIENT IN FRONT 102 00:04:29,640 --> 00:04:32,800 OF ME OR SOMETHING IN THE MICRO 103 00:04:32,800 --> 00:04:33,960 BIOLOGY UNDERSTOOD OR NEED TO 104 00:04:33,960 --> 00:04:35,360 EXPLAIN FURTHER. 105 00:04:35,360 --> 00:04:37,840 WE SEE THE LEARNING OBJECTIVES 106 00:04:37,840 --> 00:04:38,240 HERE. 107 00:04:38,240 --> 00:04:43,840 I HOPE WE CAN LEARN TOGETHER 108 00:04:43,840 --> 00:04:45,120 TODAY TO LEARN A LITTLE BIT 109 00:04:45,120 --> 00:04:49,840 ABOUT THE PATHOGENESIS OF INFANT 110 00:04:49,840 --> 00:04:51,960 BOTULISM HAPPENS TO INFANTS AND 111 00:04:51,960 --> 00:04:54,560 THE CHALLENGES OF PERTUSSIS AND 112 00:04:54,560 --> 00:05:00,360 THE CHANGES IN THE EPIDEMIOLOGY 113 00:05:00,360 --> 00:05:01,520 IN THE VACCINE EVENTS AND WHAT 114 00:05:01,520 --> 00:05:06,440 THE NEXT GENERATION OF PERTUSSIS 115 00:05:06,440 --> 00:05:07,720 VACCINES MIGHT NEED TO BE AND 116 00:05:07,720 --> 00:05:09,320 HOPE YOU TAKE TAKEAWAY A FEW 117 00:05:09,320 --> 00:05:13,040 THINGS OF THE PROCESS OF 118 00:05:13,040 --> 00:05:14,120 CLINICAL REASONING AND SOMETHING 119 00:05:14,120 --> 00:05:15,600 THAT MAY HELP WITH YOUR CAREER 120 00:05:15,600 --> 00:05:15,880 DEVELOPMENT. 121 00:05:15,880 --> 00:05:25,040 LET'S GET STARTED. 122 00:05:25,040 --> 00:05:28,480 WHEN YOU GET DOWN THE LINE YOU 123 00:05:28,480 --> 00:05:30,080 MAY ASK YOURSELF HOW DOES THAT 124 00:05:30,080 --> 00:05:32,240 AMAZING CAREER I HAD. 125 00:05:32,240 --> 00:05:33,960 YOU MIGHT AT THAT POINT HAVE 126 00:05:33,960 --> 00:05:35,080 THINGS YOU WOULD LIKE TO PASS 127 00:05:35,080 --> 00:05:35,440 ON. 128 00:05:35,440 --> 00:05:40,800 I THOUGHT OF A FEW THINGS I 129 00:05:40,800 --> 00:05:42,960 THINK INFLUENCED MY ABILITY TO 130 00:05:42,960 --> 00:05:44,320 BE SUCCESSFUL I'D LIKE TO PASS 131 00:05:44,320 --> 00:05:45,040 ON TO YOU. 132 00:05:45,040 --> 00:05:46,760 THE FIRST IS GOING TO BE JUMP 133 00:05:46,760 --> 00:05:47,840 INTO YOUR EDUCATION AND CAREER 134 00:05:47,840 --> 00:05:53,000 AND FIND A MENTOR. 135 00:05:53,000 --> 00:05:54,520 WELL, I GREW UP IN THE TERRITORY 136 00:05:54,520 --> 00:05:56,840 OF ALASKA. 137 00:05:56,840 --> 00:05:57,400 IT'S INTERESTING. 138 00:05:57,400 --> 00:05:59,560 THIS LITTLE PICTURE OF ME WHEN 139 00:05:59,560 --> 00:06:04,960 I'M ABOUT FIVE I THINK I HAD 140 00:06:04,960 --> 00:06:07,800 ALASKAN NATIVES AND AMERICAN 141 00:06:07,800 --> 00:06:10,400 INDIANS AS MY FRIEND BUT FOR 142 00:06:10,400 --> 00:06:12,280 SOME REASON I WAS ALWAYS WEARING 143 00:06:12,280 --> 00:06:14,440 THE DIME STORE PLASTIC HEAD 144 00:06:14,440 --> 00:06:18,160 DRESS AND THIS TELLS YOU 145 00:06:18,160 --> 00:06:21,280 SOMETHING ABOUT ME, THE MOST 146 00:06:21,280 --> 00:06:23,080 WONDERFUL MOST LOYAL DOG THERE 147 00:06:23,080 --> 00:06:24,640 WAS, I'M SURE IF I RIP UP THE 148 00:06:24,640 --> 00:06:27,000 SIDES OF HIS MOUTH LIKE THAT I 149 00:06:27,000 --> 00:06:29,240 CAN MAKE HIM SMILE SO I HAVE 150 00:06:29,240 --> 00:06:34,080 NEVER TAKEN NO FOR AN ANSWER. 151 00:06:34,080 --> 00:06:36,680 A COLLEAGUE RECENTLY SENT ME 152 00:06:36,680 --> 00:06:38,960 THIS PICTURE WHEN SHE VISITED 153 00:06:38,960 --> 00:06:41,520 JUNO AND TITLED IT RUSH HOUR AT 154 00:06:41,520 --> 00:06:42,640 TEA HARBOR. 155 00:06:42,640 --> 00:06:45,760 AS I GREW UP LOCKED BY MOUNTAINS 156 00:06:45,760 --> 00:06:46,920 IN THIS GORGEOUS PLACE, THERE 157 00:06:46,920 --> 00:06:48,920 WERE ABOUT 7,000 PEOPLE AND IT 158 00:06:48,920 --> 00:06:52,720 WAS QUITE A REMARKABLE THING 159 00:06:52,720 --> 00:06:53,840 WHEN I CAME TO PHILADELPHIA FROM 160 00:06:53,840 --> 00:07:00,880 FOR MEDICAL SCHOOL AND SPENT MY 161 00:07:00,880 --> 00:07:04,080 MEDICAL SCHOOL AND RESIDENCY AND 162 00:07:04,080 --> 00:07:06,840 MY ENTIRE CAREER AS WAS 163 00:07:06,840 --> 00:07:08,560 MENTIONED NORTH PHILADELPHIA 164 00:07:08,560 --> 00:07:11,760 HOPING TO BRING THE BEST MEDICAL 165 00:07:11,760 --> 00:07:15,600 POSITIONS TO CHILDREN IN THE 166 00:07:15,600 --> 00:07:17,840 SECOND MOST VULNERABLE FOOD 167 00:07:17,840 --> 00:07:18,440 VULNERABLE ZIP CODE IN THE 168 00:07:18,440 --> 00:07:18,840 UNITED STATES. 169 00:07:18,840 --> 00:07:21,040 IT'S BEEN A PRIVILEGE TO WORK 170 00:07:21,040 --> 00:07:23,280 WITH AND LEARN FROM THOSE 171 00:07:23,280 --> 00:07:24,280 PATIENTS AND FAMILIES. 172 00:07:24,280 --> 00:07:29,080 SO HERE'S JEFFERSON ON THE DAY I 173 00:07:29,080 --> 00:07:30,520 ARRIVED, 1025 WALNUT AND THIS IS 174 00:07:30,520 --> 00:07:33,440 ALL ONE PICTURE ON THE LEFT AND 175 00:07:33,440 --> 00:07:36,040 THERE WAS A HUGE STAIRWAY IN 176 00:07:36,040 --> 00:07:40,520 FRONT OF YOU THAT LED TO THE 177 00:07:40,520 --> 00:07:42,360 CLINIC AT THE TO THE STAIRS 178 00:07:42,360 --> 00:07:44,360 THAT'S NOW BEEN PUT INTO MUSEUMS 179 00:07:44,360 --> 00:07:46,800 BUT IT GREETED ME EVERY DAY. 180 00:07:46,800 --> 00:07:48,880 I DIDN'T GO UP, I WENT DOWN TO 181 00:07:48,880 --> 00:07:52,320 WHAT WAS KNOWN AS THE PIT. 182 00:07:52,320 --> 00:07:55,760 HERE IS OUR CLASS AND I HAD 183 00:07:55,760 --> 00:08:00,120 PHENOMENAL MENTORS AT JEFFERSON. 184 00:08:00,120 --> 00:08:02,600 THERE WERE 10, 11 OF US WOMEN 185 00:08:02,600 --> 00:08:03,960 AND 180 SOMETHING MEN. 186 00:08:03,960 --> 00:08:06,680 I DON'T KNOW IF I GOT SPECIAL 187 00:08:06,680 --> 00:08:07,840 ATTENTION BUT I FELT THESE 188 00:08:07,840 --> 00:08:09,680 PEOPLE WERE THERE FOR ME AND 189 00:08:09,680 --> 00:08:13,640 THEY WERE ALL DIFFERENT. 190 00:08:13,640 --> 00:08:23,160 GONZALO APONTE WAS CHARISMATIC, 191 00:08:23,160 --> 00:08:26,720 OPERATIC AND BIGGER THAN LIFE 192 00:08:26,720 --> 00:08:32,760 AND THE ENDOCRINOLOGIST WAS 193 00:08:32,760 --> 00:08:36,440 FUNNY AND JOHN TEMPLETON A FUNNY 194 00:08:36,440 --> 00:08:39,320 SENSE OF RUMOR AND SOUTH 195 00:08:39,320 --> 00:08:41,400 EXCELLENT AND JOE RODGERS THE 196 00:08:41,400 --> 00:08:42,560 FIRST MASTER CLINICIAN I GOT TO 197 00:08:42,560 --> 00:08:46,240 KNOW AND HERE'S MY GRADUATION 198 00:08:46,240 --> 00:08:46,440 PICTURE. 199 00:08:46,440 --> 00:08:48,960 I WAS SENT TO MY HUSBAND'S 200 00:08:48,960 --> 00:08:51,040 INTERNAL MEDICINE WARD WHERE HE 201 00:08:51,040 --> 00:08:52,920 WAS THE RESIDENT WHEN I I WAS A 202 00:08:52,920 --> 00:08:54,240 THIRD-YEAR MEDICAL STUDENT AND 203 00:08:54,240 --> 00:08:57,320 HE SAID, IF YOU GOT BEHIND ME IN 204 00:08:57,320 --> 00:09:00,440 AN ELEVATOR YOU CAN'T SEE AROUND 205 00:09:00,440 --> 00:09:03,920 THAT ALL HAIR SO YOU'LL SEE SOME 206 00:09:03,920 --> 00:09:06,000 HAIRSTYLES AS WE GO ON AS WELL. 207 00:09:06,000 --> 00:09:10,720 THEN I WENT TO ST. CHRISTOPHER'S 208 00:09:10,720 --> 00:09:13,240 WHERE I HAD INNUMERABLE MENTORS 209 00:09:13,240 --> 00:09:18,640 AND I HAD THE FATHER OF 210 00:09:18,640 --> 00:09:21,760 PEDIATRICS AND HERE I AM WITH MY 211 00:09:21,760 --> 00:09:23,280 MAJOR MENTOR MASTER CLINICIAN 212 00:09:23,280 --> 00:09:25,320 DAVID SMITH AND THEN NANCY WONG 213 00:09:25,320 --> 00:09:28,000 TAUGHT ME WHAT I KNEW ABOUT 214 00:09:28,000 --> 00:09:28,280 ANTIBIOTICS. 215 00:09:28,280 --> 00:09:33,960 SHE WAS A PULMONOLOGIST, CYSTIC 216 00:09:33,960 --> 00:09:36,840 FIBROSIS AND A HEMATOLOGIST AND 217 00:09:36,840 --> 00:09:41,600 TWO PATHOLOGISTS, STRIKINGLY 218 00:09:41,600 --> 00:09:43,480 DIFFERENT ERA. 219 00:09:43,480 --> 00:09:45,800 MOLLY DEPINA AND WHEN A CHILD 220 00:09:45,800 --> 00:09:47,640 DIED AT ST. CHRISTOPHER'S ONE 221 00:09:47,640 --> 00:09:49,800 WOULD GO OUT TO THE FAMILY AND 222 00:09:49,800 --> 00:09:51,600 DESCRIBE AN AUTOPSY AND THEY HAD 223 00:09:51,600 --> 00:09:55,320 AN AUTOPSY RATE OF OVER 80% AND 224 00:09:55,320 --> 00:09:58,160 EVERY TIME THERE WAS AN AUTOPSY 225 00:09:58,160 --> 00:10:00,840 YOU WOULD HERE AN OVERHEAD PAGE 226 00:10:00,840 --> 00:10:05,040 THAT SAID PAGING DR. POST. 227 00:10:05,040 --> 00:10:07,080 PAGING DR. POST. 228 00:10:07,080 --> 00:10:10,360 WE FLED TO THE AUTOPSY SUITE 229 00:10:10,360 --> 00:10:12,800 WHERE ALWAYS THESE PEOPLE AND 230 00:10:12,800 --> 00:10:16,840 JOHN KIRKPATRICK, A FABULOUS 231 00:10:16,840 --> 00:10:19,040 RADIOLOGIST WERE THERE AND WE 232 00:10:19,040 --> 00:10:23,680 WOULD WATCH THESE INCREDIBLY 233 00:10:23,680 --> 00:10:25,000 BRILLIANT PEOPLE LEARN NEW 234 00:10:25,000 --> 00:10:30,560 THINGS IT'S WHERE THE DEGEORGE 235 00:10:30,560 --> 00:10:33,560 SYNDROME WERE DISCOVERED AND 236 00:10:33,560 --> 00:10:37,840 THEN SERENDIPITY IN MY NIH 237 00:10:37,840 --> 00:10:38,640 FELLOWSHIP HERE IN MICROBIOLOGY 238 00:10:38,640 --> 00:10:44,920 I WAS PLUNKED IN A SEAT NEXT TO 239 00:10:44,920 --> 00:10:48,040 A BRAND NEW FACULTY MEMBER IN 240 00:10:48,040 --> 00:10:49,480 INTERNAL MEDICINE AND INFECTIOUS 241 00:10:49,480 --> 00:10:50,920 DISEASES AND TURNED OUT TO BE A 242 00:10:50,920 --> 00:10:53,640 FABULOUS TEACHER AND I REALLY 243 00:10:53,640 --> 00:10:55,960 STOLE ALL OF HIS ABILITY I COULD 244 00:10:55,960 --> 00:11:00,160 TO LEARN HOW TO TEACH. 245 00:11:00,160 --> 00:11:02,040 THE NEXT THING I WOULD SUGGEST 246 00:11:02,040 --> 00:11:03,680 YOU COLLABORATE WITH EXPERTS. 247 00:11:03,680 --> 00:11:05,560 I HAD LOTS OF LABORATORY EXPERTS 248 00:11:05,560 --> 00:11:08,400 I COLLABORATED WITH AND FOR AN 249 00:11:08,400 --> 00:11:12,520 INFECTIOUS DISEASE DOCTOR THE 250 00:11:12,520 --> 00:11:14,640 CDC IS A WEALTH OF RESOURCE AND 251 00:11:14,640 --> 00:11:17,200 THIS IS WHEN VACCINE NOT COMING 252 00:11:17,200 --> 00:11:18,360 FROM ACADEMIA BUT MORE MUCH 253 00:11:18,360 --> 00:11:21,040 INDUSTRY WHERE THEY HAD $100 254 00:11:21,040 --> 00:11:24,320 MILLION TO THROW AT A NEW IDEA 255 00:11:24,320 --> 00:11:26,440 AND BE WILLING TO FAIL WHICH 256 00:11:26,440 --> 00:11:30,280 THEY DID WITH MOST OF THEM AND I 257 00:11:30,280 --> 00:11:31,440 ALWAYS LEARNED A LOT FROM 258 00:11:31,440 --> 00:11:34,280 COLLEAGUES. 259 00:11:34,280 --> 00:11:35,760 I WAS RAISED TO BE TOUGH AND I 260 00:11:35,760 --> 00:11:37,840 HAVE BEEN A TOUGH MENTOR. 261 00:11:37,840 --> 00:11:43,000 I THINK SOMETIMES MEDICAL 262 00:11:43,000 --> 00:11:44,840 STUDENTS DON'T UNDERSTAND THIS 263 00:11:44,840 --> 00:11:46,480 IS NOT A JOB. 264 00:11:46,480 --> 00:11:47,360 THEY'RE RESPONSIBLE FOR PEOPLE'S 265 00:11:47,360 --> 00:11:51,720 LIVES AND I TAKE IT VERY 266 00:11:51,720 --> 00:11:52,000 SERIOUSLY. 267 00:11:52,000 --> 00:11:56,440 SO I TAKE THAT I'M A TOUGH 268 00:11:56,440 --> 00:11:56,680 MENTOR. 269 00:11:56,680 --> 00:11:58,320 SO EVERYBODY KNOWS BEFORE 270 00:11:58,320 --> 00:11:59,840 PRESENTING AT LONG'S ROUNDS 271 00:11:59,840 --> 00:12:02,160 WHICH WENT ON EVERY DAY I WAS ON 272 00:12:02,160 --> 00:12:04,120 SERVICE, EVERY DAY FOR THE FIRST 273 00:12:04,120 --> 00:12:05,560 FIVE, SIX YEARS OF MY CAREER AND 274 00:12:05,560 --> 00:12:10,560 AT LEAST 50% OF THE TIME I HAVE 275 00:12:10,560 --> 00:12:14,960 MAINTAINED MY ROLE AS AN IN 276 00:12:14,960 --> 00:12:15,960 PATIENT CONSULTING PHYSICIAN TO 277 00:12:15,960 --> 00:12:17,600 CONTINUE TO LEARN FROM MY 278 00:12:17,600 --> 00:12:18,320 PATIENTS AND PARENTS AND 279 00:12:18,320 --> 00:12:19,400 COLLEAGUES AND THINGS THAT CAME 280 00:12:19,400 --> 00:12:21,320 TO ME. 281 00:12:21,320 --> 00:12:24,840 BUT YOU DON'T PRESENT AT LONG 282 00:12:24,840 --> 00:12:25,880 ROUNDS WITHOUT A FIRST PERSON 283 00:12:25,880 --> 00:12:27,880 HISTORY INCLUDING PRECISE AND 284 00:12:27,880 --> 00:12:31,240 CONCISE TIME LINE AND EXPOSURE 285 00:12:31,240 --> 00:12:32,440 AND EXACTING PHYSICAL 286 00:12:32,440 --> 00:12:34,760 EXAMINATION, STARTING WITH THE 287 00:12:34,760 --> 00:12:36,280 GLOBAL OBSERVATION OF THE 288 00:12:36,280 --> 00:12:38,840 PATIENT, CARDIAL FEATURES OF THE 289 00:12:38,840 --> 00:12:42,680 PATIENT'S PROBLEM USING MEDICAL 290 00:12:42,680 --> 00:12:46,640 TERMINOLOGY, YOU SYNTHESIZE THE 291 00:12:46,640 --> 00:12:48,400 PROBLEM NOT WHO SAID WHAT TO WHO 292 00:12:48,400 --> 00:12:50,680 WHERE AND WHEN BUT FIVE TO SIX 293 00:12:50,680 --> 00:12:52,240 WORDS THAT DESCRIBE THE PROBLEM 294 00:12:52,240 --> 00:12:54,720 AND THE FEATURES OF THE SIMPLE 295 00:12:54,720 --> 00:12:56,840 LABORATORY TEST AND YOU WILL 296 00:12:56,840 --> 00:12:58,360 HAVE HAD A PERSONAL EXCHANGE 297 00:12:58,360 --> 00:12:59,640 WITH THE CONSULTING PHYSICIANS 298 00:12:59,640 --> 00:13:00,880 TO SEE WHAT IT IS THEY'RE 299 00:13:00,880 --> 00:13:03,040 WORRIED ABOUT AND WHAT THE 300 00:13:03,040 --> 00:13:05,440 LABORATORY PERSONNEL ABOUT HOW 301 00:13:05,440 --> 00:13:07,560 CAN WE BEST SOLVE THIS PROBLEM. 302 00:13:07,560 --> 00:13:10,640 SO I JUST WANT TO INTRODUCE A 303 00:13:10,640 --> 00:13:12,840 FEW OF YOU TO SOMETHING ABOUT 304 00:13:12,840 --> 00:13:14,600 CLINICAL REASONING. 305 00:13:14,600 --> 00:13:17,960 CLINICAL REASONING PICK ALL 306 00:13:17,960 --> 00:13:22,040 THESE THINGS AND IT IS HOW AN 307 00:13:22,040 --> 00:13:24,440 EXPERT THINKS. 308 00:13:24,440 --> 00:13:26,640 IT'S A PROCESS WHERE WE ARRIVE 309 00:13:26,640 --> 00:13:30,800 AT A DIAGNOSIS OR DECISION. 310 00:13:30,800 --> 00:13:32,640 IT'S NOT TAUGHT EXPLICITLY. 311 00:13:32,640 --> 00:13:34,520 I HAD ALL THESE WONDERFUL 312 00:13:34,520 --> 00:13:37,040 MENTORS AND ABOUT 15 YEARS INTO 313 00:13:37,040 --> 00:13:41,280 MY FACULTY POSITION I BEGAN TO 314 00:13:41,280 --> 00:13:42,640 FEEL LIKE DR. SMITH. 315 00:13:42,640 --> 00:13:48,000 I TALKED WITH FAMILIES, I 316 00:13:48,000 --> 00:13:49,840 PURSUED PROBLEMS, I HAD AN 317 00:13:49,840 --> 00:13:51,400 APPROACH AND HAD A CONFIDENCE IN 318 00:13:51,400 --> 00:13:53,160 MY UNDERSTANDING MAYBE NOT OF 319 00:13:53,160 --> 00:13:55,520 THE DIAGNOSIS BUT WHERE WE OUGHT 320 00:13:55,520 --> 00:13:57,520 TO GO WE WOULD HAVE HAD AND TOLD 321 00:13:57,520 --> 00:14:02,320 HIM I BEGIN TO FEEL LIKE YOU. 322 00:14:02,320 --> 00:14:03,480 I CANNOT TELL HOW MANY 323 00:14:03,480 --> 00:14:05,280 PHYSICIANS WHO WERE RESIDENTS AT 324 00:14:05,280 --> 00:14:09,560 ST. CHRISTOPHER'S HAVE SENT ME A 325 00:14:09,560 --> 00:14:11,720 NOTE, 15 TO 20 YEARS AFTER THEY 326 00:14:11,720 --> 00:14:15,640 HAD LEFT AND SAID I SAW A 327 00:14:15,640 --> 00:14:18,240 PATIENT TODAY AND I FELT I WAS 328 00:14:18,240 --> 00:14:18,400 YOU. 329 00:14:18,400 --> 00:14:21,800 I FELT THAT I WAS PURSUING THAT 330 00:14:21,800 --> 00:14:24,640 IN THE WAY YOU MIGHT. 331 00:14:24,640 --> 00:14:27,880 NOW THAT MAKES A TEACHER'S HEART 332 00:14:27,880 --> 00:14:30,600 SING BUT WE NOW KNOW WE CAN GET 333 00:14:30,600 --> 00:14:33,240 THERE SOONER THAN 15 YEARS. 334 00:14:33,240 --> 00:14:34,400 BECOMES AN EXPERT REQUIRES 335 00:14:34,400 --> 00:14:38,840 KNOWLEDGE AND EXPERIENCE. 336 00:14:38,840 --> 00:14:40,800 EXPERTS TAKE CLINIC SCENARIOS, 337 00:14:40,800 --> 00:14:43,440 WHAT YOU HEAR IN THE HISTORY AND 338 00:14:43,440 --> 00:14:45,600 SYNTHESIZE INTO PROBLEM 339 00:14:45,600 --> 00:14:53,440 REPRESENTATIONS THAT INCLUDE SOW 340 00:14:53,440 --> 00:14:55,840 SOMATIC QUALIFIERS AND HERE'S A 341 00:14:55,840 --> 00:14:57,520 REPRESENTATION WITH SOMATIC 342 00:14:57,520 --> 00:14:57,840 QUALIFIERS. 343 00:14:57,840 --> 00:15:01,080 THIS PERSON HAS THE ACUTE ONSET 344 00:15:01,080 --> 00:15:06,480 OF UNREMITTING PROGRESSIVE, 345 00:15:06,480 --> 00:15:09,600 EXQUISITE UPPER ABDOMINAL PAIN. 346 00:15:09,600 --> 00:15:11,280 THAT'S THE SYNTHESIS OF THE 347 00:15:11,280 --> 00:15:13,120 PATIENT'S PROBLEM. 348 00:15:13,120 --> 00:15:15,720 THE SEMANTIC QUALIFIERS ARE ALL 349 00:15:15,720 --> 00:15:18,120 THE MEDICAL ADJECTIVES I ADDED 350 00:15:18,120 --> 00:15:18,680 TO THEM. 351 00:15:18,680 --> 00:15:19,840 HERE'S ANOTHER ONE. 352 00:15:19,840 --> 00:15:22,960 THE PATIENT HAS A SUBACUTE 353 00:15:22,960 --> 00:15:29,000 REMITTING WAXING AND WANING 354 00:15:29,000 --> 00:15:33,840 COURSE OF INTERMITTENT ABDOMINAL 355 00:15:33,840 --> 00:15:37,400 PAIN THAT IS ASSOCIATED WITH 356 00:15:37,400 --> 00:15:42,440 LOOSE STOOLS AND WEIGHT LOSS. 357 00:15:42,440 --> 00:15:44,040 THAT'S A DIFFERENT PROBLEM 358 00:15:44,040 --> 00:15:45,840 REPRESENTATION, ISN'T IT? 359 00:15:45,840 --> 00:15:48,840 WE COMPARE THE PROBLEM 360 00:15:48,840 --> 00:15:52,000 REPRESENTATIONS WITH SCRIPTS. 361 00:15:52,000 --> 00:16:04,480 ACUTE PANCREATITIS AND EXQUISITE 362 00:16:04,480 --> 00:16:05,520 PAIN, SUBACUTE PAIN AND I'M 363 00:16:05,520 --> 00:16:08,480 LOSING THE WORD WHEN YOU LOSE 364 00:16:08,480 --> 00:16:10,760 THE PAIN THAT IS EPISODIC. 365 00:16:10,760 --> 00:16:14,440 AND THERE'S USUALLY WEIGHT LOSS 366 00:16:14,440 --> 00:16:16,600 INVOLVED AND THERE FREQUENTLY IS 367 00:16:16,600 --> 00:16:17,000 ANEMIA. 368 00:16:17,000 --> 00:16:19,160 YOU MATCH THE ILLNESS TO WHAT 369 00:16:19,160 --> 00:16:22,880 YOU HAVE DECIDED IS THE PROBLEM 370 00:16:22,880 --> 00:16:24,840 BUT YOU HAVE TO BE CAREFUL IN 371 00:16:24,840 --> 00:16:25,400 DOING THAT. 372 00:16:25,400 --> 00:16:29,480 WE'RE GOING TO USE A FEW OF 373 00:16:29,480 --> 00:16:32,640 THOSE THINGS TO ILLUSTRATE HOW 374 00:16:32,640 --> 00:16:34,040 PAYING ATTENTION AND OBSERVING 375 00:16:34,040 --> 00:16:36,840 CAN LEAD TO DISCOVERY. 376 00:16:36,840 --> 00:16:39,440 HERE'S THE INFANT BOTULISM 377 00:16:39,440 --> 00:16:39,800 STUDY. 378 00:16:39,800 --> 00:16:41,720 IT'S ALSO GOING TO ILLUSTRATE 379 00:16:41,720 --> 00:16:43,920 HOW I THINK STAYING CLOSE TO 380 00:16:43,920 --> 00:16:47,240 YOUR PRIMARY PROVIDERS IS 381 00:16:47,240 --> 00:16:48,840 CRITICAL AND COLLABORATE WITH 382 00:16:48,840 --> 00:16:54,640 THOSE PRIMARY PROVIDERS. 383 00:16:54,640 --> 00:16:56,320 SO WARREN GROVER IS A 384 00:16:56,320 --> 00:16:57,440 NEUROLOGIST AT ST. CHRISTOPHER'S 385 00:16:57,440 --> 00:16:59,840 AND IS SMARTER THAN ANYTHING AND 386 00:16:59,840 --> 00:17:05,800 THEY DISTRIBUTED -- DESCRIBED 387 00:17:05,800 --> 00:17:10,680 NINE PATIENTS WITH ACUTE 388 00:17:10,680 --> 00:17:17,720 REVERSIBLE POLY NEUROPATHY AND 389 00:17:17,720 --> 00:17:20,600 BEFORE YOU TELL ME THE PHYSICAL 390 00:17:20,600 --> 00:17:28,280 SCHANGS -- EXAMINATION AND 391 00:17:28,280 --> 00:17:29,560 HEART AND LUNGS SOUND LIKE IF 392 00:17:29,560 --> 00:17:33,840 IT'S ACTIVE OR UNATTENTIVE, 393 00:17:33,840 --> 00:17:36,880 UNRESPONSIVE, IRRITABLE, NOT 394 00:17:36,880 --> 00:17:37,840 IRRITABLE CHILD. 395 00:17:37,840 --> 00:17:39,320 THINK OF HOW YOU WOULD DESCRIBE 396 00:17:39,320 --> 00:17:40,520 WHAT YOU SEE ON THE LEFT. 397 00:17:40,520 --> 00:17:42,520 AFTER THEY DESCRIBED THIS AND 398 00:17:42,520 --> 00:17:44,560 PUBLISHED IT, IN CALIFORNIA THE 399 00:17:44,560 --> 00:17:47,080 SAME KIND OF INFANTS WERE SEEN 400 00:17:47,080 --> 00:17:54,320 AND THEY HAD ELECTROMYOGRAPHY 401 00:17:54,320 --> 00:17:55,760 AND THEY SAID THESE BRIEF SHORT 402 00:17:55,760 --> 00:18:00,040 OVER ABUNDANT FOR THE STIMULUS 403 00:18:00,040 --> 00:18:02,280 GIVEN TO ACTION POTENTIALS THAT 404 00:18:02,280 --> 00:18:05,560 INCREASE WITH REPETITIVE 405 00:18:05,560 --> 00:18:07,240 STIMULATION HAVE ONLY ONE 406 00:18:07,240 --> 00:18:11,400 ETIOLOGY AND THEY ARE BOTULISM. 407 00:18:11,400 --> 00:18:16,920 IT'S AND THEY WERE ABLE TO FIND 408 00:18:16,920 --> 00:18:24,760 THE TOXIN OF BOHULINUN AND THEN 409 00:18:24,760 --> 00:18:27,280 THE DEPARTMENT OF HEALTH BEGAN 410 00:18:27,280 --> 00:18:28,600 TO DESCRIBE PATIENTS IN WHICH 411 00:18:28,600 --> 00:18:30,840 THEY FOUND THE ORGANISMS AND THE 412 00:18:30,840 --> 00:18:32,320 TOXINS IN THE PATIENT'S STOOL. 413 00:18:32,320 --> 00:18:36,000 THESE WERE YOUNG INFANTS AND HAD 414 00:18:36,000 --> 00:18:39,560 NOT INGESTED PREFORM TOXIN WHICH 415 00:18:39,560 --> 00:18:42,360 IS BOTULISM INTOXICATION AND 416 00:18:42,360 --> 00:18:44,840 WERE NOT EATING GREEN BEANS, 417 00:18:44,840 --> 00:18:47,000 THEY WERE FOUR AND FIVE MONTHS 418 00:18:47,000 --> 00:18:51,400 OLD SO THEY GOT BOTULISM FROM 419 00:18:51,400 --> 00:19:07,120 THE CONSUMPTION OR INGESTION AND 420 00:19:07,120 --> 00:19:09,400 IT WAS FROM HONEY AND THE INFANT 421 00:19:09,400 --> 00:19:11,400 BOTULISM IS NOT RELATED TO HONEY 422 00:19:11,400 --> 00:19:13,400 ANY MORE. 423 00:19:13,400 --> 00:19:25,440 IT'S A NATURAL OCCURRENCE. 424 00:19:25,440 --> 00:19:27,880 THERE WERE SOME WONDERFUL MICE 425 00:19:27,880 --> 00:19:30,440 EXPERTS ASKING IF THE MICE GUT 426 00:19:30,440 --> 00:19:34,000 PERMISSIVE TO OUT GROWTH OF 427 00:19:34,000 --> 00:19:36,280 BOTULISM SPORES AND IF THERE'S 428 00:19:36,280 --> 00:19:37,520 VEGETATION OR OUTGROWTH OF THE 429 00:19:37,520 --> 00:19:38,840 SPORES IT WILL PRODUCE TOXIN AND 430 00:19:38,840 --> 00:19:41,960 YOU CAN THEN HAVE THE TOXIN 431 00:19:41,960 --> 00:19:42,240 ABSORBED. 432 00:19:42,240 --> 00:19:45,840 HERE ON THE LEFT YOU'LL SEE THE 433 00:19:45,840 --> 00:19:47,480 ANIMALS HE EXPERIMENTED WITH AND 434 00:19:47,480 --> 00:19:49,640 FED THEM THE SPORES NOT THE 435 00:19:49,640 --> 00:19:51,040 TOXIN AND I'M ANSWERING THE 436 00:19:51,040 --> 00:19:55,040 QUESTION FOUR, DID THE ANIMALS 437 00:19:55,040 --> 00:20:10,360 GET BOTULISM? 438 00:20:10,360 --> 00:20:13,200 AND HERE'S DAY ONE YES, BOTULISM 439 00:20:13,200 --> 00:20:16,440 AND HERE A NEONATE IN THE COLONY 440 00:20:16,440 --> 00:20:20,000 FOR THREE DAYS, FED THE SPORES, 441 00:20:20,000 --> 00:20:22,000 NO BOTULISM AND HERE'S GERM-FREE 442 00:20:22,000 --> 00:20:24,440 WITH A LIMITED FLORA THEY'VE 443 00:20:24,440 --> 00:20:27,000 BEEN FED AND GO FROM SUSCEPTIBLE 444 00:20:27,000 --> 00:20:38,280 TO NOT SUSCEPTIBLE AND WITH 445 00:20:38,280 --> 00:20:46,960 SUCCESSIVE POLLINATION AND YOU 446 00:20:46,960 --> 00:20:50,040 CAN MAKE THEM SUSCEPTIBLE TO 447 00:20:50,040 --> 00:20:51,920 INFANT BOTULISM AND WE 448 00:20:51,920 --> 00:20:54,320 OCCASIONALLY SEE AN ADULT. 449 00:20:54,320 --> 00:20:58,240 USUALLY WHO HAS HAD SURGERY ON 450 00:20:58,240 --> 00:21:00,600 THE ABDOMEN SO THE ANTI-MOTILITY 451 00:21:00,600 --> 00:21:02,600 AND ANTIBIOTIC THAT HAPPEN TO 452 00:21:02,600 --> 00:21:20,800 HAVE OCCURRENCE OF THE INFANT 453 00:21:20,800 --> 00:21:22,640 BOTULISM AND CALIFORNIA IS THE 454 00:21:22,640 --> 00:21:26,560 HOTTEST SPOT AND WE STILL HAVE 455 00:21:26,560 --> 00:21:31,320 100 PLUS CASES OF INFANT 456 00:21:31,320 --> 00:21:31,720 BOTULISM. 457 00:21:31,720 --> 00:21:33,440 IT'S BEEN RECOGNIZED IN 49 458 00:21:33,440 --> 00:21:48,680 STATES FOR SURE. 459 00:21:48,680 --> 00:21:55,240 AND A CLINICIAN STOPPED AND WAS 460 00:21:55,240 --> 00:21:56,920 COLLECTING SOIL SAMPLES AND 461 00:21:56,920 --> 00:21:59,760 LOOKING FOR THE CLUSTERING OF 462 00:21:59,760 --> 00:22:02,720 THE BOTULINUM IN THE SOIL AND 463 00:22:02,720 --> 00:22:05,320 FOUND 24% OF SAMPLES WERE 464 00:22:05,320 --> 00:22:08,160 POSITIVE FOR BOTULINUM AND THE 465 00:22:08,160 --> 00:22:10,000 NEUROTOXIC AND IN THE EAST WAS 466 00:22:10,000 --> 00:22:14,600 ALL B AND WHEN YOU BEGAN TO GET 467 00:22:14,600 --> 00:22:17,640 TO WHERE THE ROCKY MOUNTAIN 468 00:22:17,640 --> 00:22:20,240 RISES OUT OF THE PLANES YOU 469 00:22:20,240 --> 00:22:25,640 BEGIN TO SEE NEUROTOXINA AND 470 00:22:25,640 --> 00:22:27,880 THEY MATCHED PERFECTLY THE 471 00:22:27,880 --> 00:22:30,160 INFANT TYPES OF BOTULISM. 472 00:22:30,160 --> 00:22:34,480 I HAD DONE MY RESEARCH ON 473 00:22:34,480 --> 00:22:35,640 ANAEROBIC MICROBIOLOGY AND 474 00:22:35,640 --> 00:22:39,440 DECIDED I WAS INTERESTED IN HOW 475 00:22:39,440 --> 00:22:40,440 FLORA WAS ESTABLISHED AND SHOWED 476 00:22:40,440 --> 00:22:45,120 ON THE FIRST DAY OF LIFE IF YOU 477 00:22:45,120 --> 00:22:46,720 SCRAPE GENTLY WITH A TONGUE 478 00:22:46,720 --> 00:22:48,960 DEPRESSOR THE INSIDE OF THE ORAL 479 00:22:48,960 --> 00:22:51,000 MUCOSA AND PUT THAT ON A SLIDE 480 00:22:51,000 --> 00:22:55,720 IN THE LABORATORY THAT ONLY 481 00:22:55,720 --> 00:23:01,040 WANTS TO ADHERE THAT TURNS INTO 482 00:23:01,040 --> 00:23:01,880 NORMAL FLORA. 483 00:23:01,880 --> 00:23:04,640 HEALTHY PEOPLE WHO ARE OLDER DO 484 00:23:04,640 --> 00:23:11,040 NOT WANT TO ADHERE E. COLI THEY 485 00:23:11,040 --> 00:23:13,440 WANT THE NORMAL FLORA AND I DID 486 00:23:13,440 --> 00:23:15,840 STUDIES ON THE ESTABLISHMENT OF 487 00:23:15,840 --> 00:23:18,920 FECAL FLORA IN INFANTS AND FOUND 488 00:23:18,920 --> 00:23:20,680 IT WAS DEPENDENT ON THE METHOD 489 00:23:20,680 --> 00:23:25,320 OF BIRTH, VAGINAL, YES OR NO AND 490 00:23:25,320 --> 00:23:27,320 WHAT THEY WERE FED AND FUND THAT 491 00:23:27,320 --> 00:23:30,320 THAT WAS ALSO EXTREMELY 492 00:23:30,320 --> 00:23:30,640 PREDICTABLE. 493 00:23:30,640 --> 00:23:32,520 SO I THOUGHT MAYBE THIS MUST 494 00:23:32,520 --> 00:23:34,640 HAVE SOMETHING TO DO WITH HOW 495 00:23:34,640 --> 00:23:36,640 BOTULISM OCCURRED IN INFANTS. 496 00:23:36,640 --> 00:23:39,800 SO WE REPORTED 44 CASES FROM 497 00:23:39,800 --> 00:23:41,200 BOTULISM IN PHILADELPHIA AND 498 00:23:41,200 --> 00:23:42,800 IT'S IN QUOTES REMEMBER THAT'S 499 00:23:42,800 --> 00:23:44,720 IN QUOTES. 500 00:23:44,720 --> 00:23:50,240 AND THEY WERE ALL 43 WERE B AND 501 00:23:50,240 --> 00:23:51,600 OF AWAS SOMEONE VISITING UNDER 502 00:23:51,600 --> 00:23:52,560 CALIFORNIA AND ALL UNDER 12 503 00:23:52,560 --> 00:23:55,000 MONTHS AND SINCE THEN THE MORE 504 00:23:55,000 --> 00:23:57,960 THAN 1,000 CHILDREN FROM INFANT 505 00:23:57,960 --> 00:23:59,920 BOTULISM HAVE BEEN UNDER IS IT 506 00:23:59,920 --> 00:24:01,480 MONTHS OF AGE. 507 00:24:01,480 --> 00:24:04,200 INTERESTINGLY, I TOLD YOU WHERE 508 00:24:04,200 --> 00:24:06,040 I WAS PRACTICING IN NORTH 509 00:24:06,040 --> 00:24:07,760 PHILADELPHIA, ALL WHITE, TWO 510 00:24:07,760 --> 00:24:10,200 PARENT FAMILIES, INSURANCE AND 511 00:24:10,200 --> 00:24:14,400 PURELY OR PREDOMINANTLY BREAST 512 00:24:14,400 --> 00:24:14,560 FED. 513 00:24:14,560 --> 00:24:16,960 TWO-THIRDS HAD THEIR FIRST 514 00:24:16,960 --> 00:24:18,000 NON-HUMAN SUBSTANCE LESS THAN 515 00:24:18,000 --> 00:24:19,400 FOUR WEEKS BEFORE ONSET. 516 00:24:19,400 --> 00:24:21,360 THAT SPECIFICALLY IS LOOKING FOR 517 00:24:21,360 --> 00:24:24,640 A PIECE OF HISTORY THAT WE DID 518 00:24:24,640 --> 00:24:25,400 FIND. 519 00:24:25,400 --> 00:24:27,840 ANOTHER PIECE OF HISTORY, HALF 520 00:24:27,840 --> 00:24:35,760 THE FATHERS HADDOCK -- HAD 521 00:24:35,760 --> 00:24:37,240 OCCUPATIONS THAT HAD DAILY 522 00:24:37,240 --> 00:24:41,040 INTERACTION WITH THE SOIL AND I 523 00:24:41,040 --> 00:24:43,800 COLLECTED FATHERS AND FATHER'S 524 00:24:43,800 --> 00:24:51,880 WORK BOOTS SAMPLES AND IN EVERY 525 00:24:51,880 --> 00:24:54,160 INSTANCE FOUND BOTULINUM SPORES 526 00:24:54,160 --> 00:24:56,400 OF IDENTICAL TYPE IN THE SOIL. 527 00:24:56,400 --> 00:25:05,360 I ALSO DID QUANTITATIVE FECAL 528 00:25:05,360 --> 00:25:12,440 FLORA WAS NOT THAT OF A FORMULA 529 00:25:12,440 --> 00:25:14,760 FED BABY THAT WOULD BE 530 00:25:14,760 --> 00:25:18,640 INHIBITORY AND NOT TYPICAL OF 531 00:25:18,640 --> 00:25:22,080 THE FERMENTATED FLORA OF BREAST 532 00:25:22,080 --> 00:25:24,000 FED BABIES WHO FLORA IS ALSO 533 00:25:24,000 --> 00:25:25,840 EXPECTED TO BE INHIBITORY BUT 534 00:25:25,840 --> 00:25:27,360 WAS SOMEWHERE IN BETWEEN. 535 00:25:27,360 --> 00:25:31,080 WE DID A CASE CONTROL STUDY 536 00:25:31,080 --> 00:25:33,120 GETTING PEDIATRICIANS FOR EACH 537 00:25:33,120 --> 00:25:36,800 CASE OF INFANT BOTULISM FIND 538 00:25:36,800 --> 00:25:38,560 FOUR INFANTS WHO THEY MATCHED 539 00:25:38,560 --> 00:25:43,600 FOR THE BIRTH DATE AND BIRTH 540 00:25:43,600 --> 00:25:45,640 HOSPITAL WITH INFANT BOTULISM TO 541 00:25:45,640 --> 00:25:48,040 SEE IF THEY'RE DEMOGRAPHICS WERE 542 00:25:48,040 --> 00:25:49,320 DIFFERENT OR IF THAT'S WHERE ALL 543 00:25:49,320 --> 00:25:51,200 THE INFANTS WHERE THE PATIENTS 544 00:25:51,200 --> 00:25:55,680 CAME FROM WERE LIKE. 545 00:25:55,680 --> 00:25:58,280 WE FOUND IN FACT THESE WERE 546 00:25:58,280 --> 00:26:00,680 SIGNIFICANT DIFFERENCES AND MOST 547 00:26:00,680 --> 00:26:05,240 IMPORTANTLY 100% OF THE INFANTS 548 00:26:05,240 --> 00:26:22,440 WITH BOTULINUM WERE BREAST FED 549 00:26:22,440 --> 00:26:24,280 AND IF YOU USE YOUR PROBLEM 550 00:26:24,280 --> 00:26:25,440 REPRESENTATION YOU NEVER HAVE A 551 00:26:25,440 --> 00:26:28,000 PROBLEM OF THE DIAGNOSIS OF 552 00:26:28,000 --> 00:26:29,400 INFANT BOTULISM. 553 00:26:29,400 --> 00:26:32,680 IT'S DESCENDING AND ALWAYS 554 00:26:32,680 --> 00:26:34,680 INVOLVING CRANIAL NERVES. 555 00:26:34,680 --> 00:26:35,240 THERE'S ALWAYS HEAD LAG. 556 00:26:35,240 --> 00:26:38,240 THE MOTHER'S THE FIRST TO NOTICE 557 00:26:38,240 --> 00:26:40,000 SOMETHING ABOUT HER BABY THAT'S 558 00:26:40,000 --> 00:26:41,840 WRONG AND IT'S BECAUSE IT 559 00:26:41,840 --> 00:26:43,960 DOESN'T HAVE THE STRENGTH OF 560 00:26:43,960 --> 00:26:45,240 FACIAL EXPRESSION AND YOU 561 00:26:45,240 --> 00:26:46,400 OBSERVE THAT PATIENT WHO I 562 00:26:46,400 --> 00:26:48,320 SHOWED YOU, YOU SHOULD HAVE BEEN 563 00:26:48,320 --> 00:26:52,760 ABLE TO OBSERVE NOT IN THE 564 00:26:52,760 --> 00:26:54,040 PICTURE BUT IN PERSON THAT THE 565 00:26:54,040 --> 00:26:56,840 PATIENT IS ALERT BUT UNABLE TO 566 00:26:56,840 --> 00:26:57,120 MOVE. 567 00:26:57,120 --> 00:27:03,000 SO THEIR EYES, IF THEY DON'T 568 00:27:03,000 --> 00:27:11,080 HAVE COMPLETE OPTHALAL PLASIA 569 00:27:11,080 --> 00:27:13,840 THEY CAN'T MOVE OR MAKE AN 570 00:27:13,840 --> 00:27:16,320 EXPRESSION AND I ALWAYS TELL THE 571 00:27:16,320 --> 00:27:17,360 TRAINEES, RECOGNIZE HOW AN 572 00:27:17,360 --> 00:27:22,240 INFANT MAKES YOU FEEL. 573 00:27:22,240 --> 00:27:33,280 AN INFANT WITH SEPTOCEMIA AND 574 00:27:33,280 --> 00:27:35,600 YOU WANT TO RUN AND HAVE SOMEONE 575 00:27:35,600 --> 00:27:39,560 HELP YOU RESUSCITATE THE INFANT 576 00:27:39,560 --> 00:27:41,400 AND THEY FEEL VULNERABLE AND YOU 577 00:27:41,400 --> 00:27:43,560 DON'T WANT TO TALK LOUD BECAUSE 578 00:27:43,560 --> 00:27:45,240 THEY'RE NOT DOING THAT SO I 579 00:27:45,240 --> 00:27:49,480 TEACH PEOPLE TO PAY ATTENTION. 580 00:27:49,480 --> 00:27:50,960 BACK TO THE BREAST FEEDING THE 581 00:27:50,960 --> 00:27:54,240 HUMAN MILK AND FORMULA, ONLY IN 582 00:27:54,240 --> 00:27:56,480 THE FIRST WEEK OF LIFE ARE 583 00:27:56,480 --> 00:28:01,840 FORMULA FED BABIES THE ONES 584 00:28:01,840 --> 00:28:06,400 GETTING INFANT BOTULISM MORE 585 00:28:06,400 --> 00:28:06,640 LIKELY. 586 00:28:06,640 --> 00:28:10,640 AFTER THEY RAPIDLY ALTER THEIR 587 00:28:10,640 --> 00:28:12,360 FLORA AND MOST ANTIBIOTICS DON'T 588 00:28:12,360 --> 00:28:13,840 SO MUCH AND LESS LIKELY TO BE 589 00:28:13,840 --> 00:28:16,840 THE ONES GETTING INFANT BOTULISM 590 00:28:16,840 --> 00:28:20,040 AS TIME GOES ON WHEREAS THOSE 591 00:28:20,040 --> 00:28:23,760 FED HUMAN MILK PURELY WILL GET 592 00:28:23,760 --> 00:28:27,440 BOTULISM UNTIL THEY BEGIN TO -- 593 00:28:27,440 --> 00:28:30,120 THEY'LL BE SUSCEPTIBLE TO 594 00:28:30,120 --> 00:28:32,240 BOTULISM BECAUSE THEY HAVE TO 595 00:28:32,240 --> 00:28:36,440 WEAN AT SOME POINT AND IT'S THAT 596 00:28:36,440 --> 00:28:39,560 POINT OF WEANING WHERE THEY HAVE 597 00:28:39,560 --> 00:28:42,440 FLORA PERTURBED AND PERMISSIBLE 598 00:28:42,440 --> 00:28:55,640 TO THE SPORES. 599 00:28:55,640 --> 00:28:57,920 AND IN PITTSBURGH THERE WERE 600 00:28:57,920 --> 00:29:02,040 MANY CHILDREN AS IN PENNSYLVANIA 601 00:29:02,040 --> 00:29:05,840 AND IT WAS ODD DISTRIBUTION 602 00:29:05,840 --> 00:29:07,120 THOUGH WE'RE IN PHILADELPHIA 603 00:29:07,120 --> 00:29:08,600 NONE OF THE CASES LIVED IN THE 604 00:29:08,600 --> 00:29:09,560 HEART OF PHILADELPHIA. 605 00:29:09,560 --> 00:29:12,840 ONE WAS ON THE BORDER AND THEY 606 00:29:12,840 --> 00:29:16,560 WERE IN THE COUNTY SURROUNDING 607 00:29:16,560 --> 00:29:19,440 PHILADELPHIA WITH NO CASES IN 608 00:29:19,440 --> 00:29:23,200 THE COUNTY SURROUNDING THOSE. 609 00:29:23,200 --> 00:29:26,800 WE DID A COUNTY CONTROL STUDY 610 00:29:26,800 --> 00:29:28,200 THESE BEING PHILADELPHIA CASE 611 00:29:28,200 --> 00:29:33,440 AND THE UPPER COUNTIES AND 612 00:29:33,440 --> 00:29:36,400 YOU'LL SEE AGAIN I SOLICITED THE 613 00:29:36,400 --> 00:29:39,800 HELP OF 22 PEDIATRICIANS GOT ME 614 00:29:39,800 --> 00:29:44,680 700 CHARACTERISTICS FROM 700 615 00:29:44,680 --> 00:29:46,960 INFANTS BORN IN THE IMMEDIATE 616 00:29:46,960 --> 00:29:48,680 BIRTH DATE OF BOTULISM CASES TO 617 00:29:48,680 --> 00:29:50,800 SEE IF WE CAN UNDERSTAND BETTER 618 00:29:50,800 --> 00:29:54,000 HOW CASES WERE OCCURRING IN THE 619 00:29:54,000 --> 00:29:55,600 UNEVEN DISTRIBUTION. 620 00:29:55,600 --> 00:29:57,160 YOU'LL SEE CONSIDERATION CASE 621 00:29:57,160 --> 00:29:58,240 COUNTIES AND PHILADELPHIA 622 00:29:58,240 --> 00:30:01,720 COUNTIES, THERE WERE LOTS OF 623 00:30:01,720 --> 00:30:02,480 DIFFERENT THE MOST IMPORTANT 624 00:30:02,480 --> 00:30:05,520 BEING -- SORRY, I DIDN'T TELL 625 00:30:05,520 --> 00:30:08,400 YOU THIS RIGHT, 64% OF THE CASE 626 00:30:08,400 --> 00:30:10,400 COUNTY BABE YES WERE BREAST FED 627 00:30:10,400 --> 00:30:12,640 AND 37% OF THE PHILADELPHIA 628 00:30:12,640 --> 00:30:13,040 COUNTIES. 629 00:30:13,040 --> 00:30:15,480 SO THAT MIGHT EXPLAIN SOME OF 630 00:30:15,480 --> 00:30:17,640 THE UNEQUAL DISTRIBUTION OF 631 00:30:17,640 --> 00:30:19,440 CASES BUT LOOK AT THE CASE 632 00:30:19,440 --> 00:30:21,480 COUNTIES WHERE ALL THE CASES 633 00:30:21,480 --> 00:30:23,720 WERE IN THE UPPER COUNTIES WHERE 634 00:30:23,720 --> 00:30:27,840 NO CASES WERE. 635 00:30:27,840 --> 00:30:29,600 AND THEY ARE IDENTICAL INCLUDING 636 00:30:29,600 --> 00:30:30,280 THE AMOUNT OF BREAST FEEDING 637 00:30:30,280 --> 00:30:42,520 THAT GOES ON. 638 00:30:42,520 --> 00:30:46,840 WE KNOW THERE'S INFANT BOTULISM 639 00:30:46,840 --> 00:30:52,640 FOR THE ANIMAL POPULATION. 640 00:30:52,640 --> 00:30:57,760 LOOSE NECK IN DUCK AND HORSES 641 00:30:57,760 --> 00:30:59,760 GET A FORM AND THERE'S LOTS OF 642 00:30:59,760 --> 00:31:02,720 ANIMALS WITH INFANT BOTULISM. 643 00:31:02,720 --> 00:31:05,280 INFANT BOTULISM OCCURS FROM IN 644 00:31:05,280 --> 00:31:08,400 AVOIDABLE EXPOSURE TO SPORES IN 645 00:31:08,400 --> 00:31:09,080 THE ENVIRONMENT. 646 00:31:09,080 --> 00:31:11,120 BREAST FEEDING IS A RISK FACTOR 647 00:31:11,120 --> 00:31:13,640 VULNERABILITY IS AT THE TIME OF 648 00:31:13,640 --> 00:31:14,360 WEANING. 649 00:31:14,360 --> 00:31:19,360 THERE'S AN UNEVEN DISTRIBUTION 650 00:31:19,360 --> 00:31:20,640 OF SPORES IN THE SOIL MATCHING 651 00:31:20,640 --> 00:31:24,280 CASE DENSITY. 652 00:31:24,280 --> 00:31:25,880 THAT'S INFANT BOTULISM. 653 00:31:25,880 --> 00:31:28,000 THERE'S A HAPPY ENDING. 654 00:31:28,000 --> 00:31:29,880 IF YOU'RE THERE TO INTUBATE THE 655 00:31:29,880 --> 00:31:33,040 BABY WHEN THEY DON'T HAVE THE 656 00:31:33,040 --> 00:31:35,960 STRENGTH TO BREATHE AND HAVE 657 00:31:35,960 --> 00:31:37,040 METICULOUS CARE OF THEM MOST ON 658 00:31:37,040 --> 00:31:39,880 A VENTILATOR 19 TO 21 DAYS AND 659 00:31:39,880 --> 00:31:40,440 DO SURVIVE. 660 00:31:40,440 --> 00:31:43,080 THEY HAVE LAG FOR A LONG TIME 661 00:31:43,080 --> 00:31:45,440 BUT THERE'S NO AFFECT ON THEIR 662 00:31:45,440 --> 00:31:49,800 BRAIN OR INTELLECTUAL FUNCTION 663 00:31:49,800 --> 00:31:54,840 OR EVENTUAL MUSCULAR FUNCTION 664 00:31:54,840 --> 00:31:57,880 AND HERE HE IS NOW 42 AND I 665 00:31:57,880 --> 00:32:00,640 STILL HEAR FROM HIM AND HIS 666 00:32:00,640 --> 00:32:02,440 FAMILY ABOUT ONCE A CHRISTMAS. 667 00:32:02,440 --> 00:32:04,040 YOU PROBABLY ALSO KNOW THERE'S 668 00:32:04,040 --> 00:32:06,200 BEEN DERIVED TREATMENT FROM 669 00:32:06,200 --> 00:32:08,440 INFANT BOTULISM SO THE INFANTS 670 00:32:08,440 --> 00:32:10,240 DON'T HAVE TO GO THROUGH 21 DAYS 671 00:32:10,240 --> 00:32:16,240 OF BEING ON A VENTILATOR. 672 00:32:16,240 --> 00:32:21,240 BY USE OF ANTI-TOXIN RAISED BY 673 00:32:21,240 --> 00:32:24,720 IMMUNIZING ADULTS AND THEN 674 00:32:24,720 --> 00:32:29,440 PURIFYING AND GIVEN TO INFANTS. 675 00:32:29,440 --> 00:32:33,920 IT WAS STUDIED IN CALIFORNIA AND 676 00:32:33,920 --> 00:32:37,040 PASSIONATE RELEASE AND TREAT 677 00:32:37,040 --> 00:32:39,040 MONDAY IN THE '90s AND IT'S 678 00:32:39,040 --> 00:32:41,280 CLEAR MANY YEARS LATER WITH 1200 679 00:32:41,280 --> 00:32:42,600 INFANTS AT LEAST TREATED IT 680 00:32:42,600 --> 00:32:45,120 REDUCES THE LENGTH OF STAY FROM 681 00:32:45,120 --> 00:32:46,440 FIVE WEEKS TO TWO WEEKS AND IT 682 00:32:46,440 --> 00:32:50,680 HAS PREVENTED MORE THAN 65 YEARS 683 00:32:50,680 --> 00:32:54,120 OF HOSPITALIZATION AND $85 684 00:32:54,120 --> 00:32:57,400 BILLION IN HOSPITAL CHARGES AND 685 00:32:57,400 --> 00:33:00,920 WHEN STEVE ARNON WROTE THESE TWO 686 00:33:00,920 --> 00:33:05,040 ARTICLES FOR THE JOURNAL OF 687 00:33:05,040 --> 00:33:05,920 PEDIATRICS I WROTE IN SAYING 688 00:33:05,920 --> 00:33:12,920 WELL DONE TO A COUNTRY THAT 689 00:33:12,920 --> 00:33:14,720 FEDERALLY MANDATED THE ORPHAN 690 00:33:14,720 --> 00:33:17,240 DRUG ACT AND WOULD ALLOW FOR THE 691 00:33:17,240 --> 00:33:18,720 DEVELOPMENT OF SUCH A MARVELOUS 692 00:33:18,720 --> 00:33:22,360 PRODUCT THAT COULD BE USED IN 693 00:33:22,360 --> 00:33:23,920 100, 150 CHILDREN A YEAR. 694 00:33:23,920 --> 00:33:33,640 WELL DONE TO THE LEADERS AND 695 00:33:33,640 --> 00:33:35,440 IMMUNIZED DON'T DEPARTMENT OF 696 00:33:35,440 --> 00:33:38,640 HEALTH AND TO RECOGNIZE AN 697 00:33:38,640 --> 00:33:40,880 UNCOMMON CONDITION TO PROVIDE 698 00:33:40,880 --> 00:33:41,760 REMARKABLY EFFECTIVE THERAPY. 699 00:33:41,760 --> 00:33:52,560 THIS IS A HAPPY STORY. 700 00:33:52,560 --> 00:33:54,120 LET'S GO ON TO MY THIRD THING, 701 00:33:54,120 --> 00:33:56,520 LISTEN TO YOUR PATIENTS. 702 00:33:56,520 --> 00:33:59,240 WE CAN'T ABANDON THEM BECAUSE WE 703 00:33:59,240 --> 00:34:01,640 DON'T UNDERSTAND THEIR PROBLEM. 704 00:34:01,640 --> 00:34:03,520 AND HERE'S DR. SMITH LISTENING 705 00:34:03,520 --> 00:34:04,480 TO A LITTLE PATIENT AND HERE'S 706 00:34:04,480 --> 00:34:07,400 ME WITH ONE OF MY PATIENTS IN 707 00:34:07,400 --> 00:34:11,320 THE '70s, EARLY 80s. 708 00:34:11,320 --> 00:34:15,040 I SURMISE FROM BOTH OF OUR 709 00:34:15,040 --> 00:34:16,680 HAIRDOS AND THE CHARMING LITTLE 710 00:34:16,680 --> 00:34:17,560 PATIENT. 711 00:34:17,560 --> 00:34:19,160 I'M ALSO GOING TO TALK A LITTLE 712 00:34:19,160 --> 00:34:24,640 BIT ABOUT PURSUING WHAT WE DON'T 713 00:34:24,640 --> 00:34:26,480 UNDERSTAND, THE PERTUSSIS STORY. 714 00:34:26,480 --> 00:34:32,200 WHEN THE DUCKS DON'T LINE UP, 715 00:34:32,200 --> 00:34:37,280 SOMETIMES YOU HAVE TO LOOK A 716 00:34:37,280 --> 00:34:39,240 LITTLE BIT AND YOU'LL MAKE SOME 717 00:34:39,240 --> 00:34:42,840 NEW DISCOVERY. 718 00:34:42,840 --> 00:34:45,880 HERE IT WAS. 719 00:34:45,880 --> 00:34:47,880 1975 I'D BEEN THE ONLY 720 00:34:47,880 --> 00:34:49,440 INFECTIOUS DISEASE DOCTOR AND 721 00:34:49,440 --> 00:34:51,760 CHIEF AS MY FIRST JOB FOR TWO 722 00:34:51,760 --> 00:34:54,040 MONTHS WHEN A THREE--WEEK-OLD 723 00:34:54,040 --> 00:34:58,400 WAS HELICOPTERED IN BECAUSE HE 724 00:34:58,400 --> 00:35:04,400 HAD CONGENITAL LEUKEMIA AND HE 725 00:35:04,400 --> 00:35:07,640 GOT THERE AND HIS LABORATORY 726 00:35:07,640 --> 00:35:11,040 TESTS CAREFUL HOW YOU LOOK AND 727 00:35:11,040 --> 00:35:16,160 INTERPRET AND THEN REPORT 728 00:35:16,160 --> 00:35:30,680 LABORATORY TEST FINDINGS FINDINGS HE 729 00:35:30,680 --> 00:35:33,600 DIDN'T HAVE LARGE LYMPHOCYTES 730 00:35:33,600 --> 00:35:36,000 AND THERE'S A SHORT LIST OF THE 731 00:35:36,000 --> 00:35:37,120 REACTION AND PERTUSSIS WAS ON 732 00:35:37,120 --> 00:35:38,960 THE LIST. 733 00:35:38,960 --> 00:35:44,640 WE HAD A FABULOUS LABORATORY. 734 00:35:44,640 --> 00:35:50,200 WE HAD SOMEONE THAT HAD 735 00:35:50,200 --> 00:35:54,040 PERTUSSIS AND HE WAS RAPIDLY 736 00:35:54,040 --> 00:35:55,160 INTUBATED AND DID NOT HAVE A 737 00:35:55,160 --> 00:35:55,840 COUGH. 738 00:35:55,840 --> 00:36:02,640 HE HAD GAGGING AND GASPING AND 739 00:36:02,640 --> 00:36:18,640 DEVELOPED STAPHOCOCCAL PNEUMONIA 740 00:36:18,640 --> 00:36:21,760 AND DIED AND I SAID WHERE DID 741 00:36:21,760 --> 00:36:25,840 THIS BABY GET PERTUSSIS AND WHY 742 00:36:25,840 --> 00:36:28,240 DID THIS MOTHER HAVE SUCH A 743 00:36:28,240 --> 00:36:30,240 TERRIBLE COUGH? 744 00:36:30,240 --> 00:36:31,800 PERTUSSIS DID NOT OCCUR IN 745 00:36:31,800 --> 00:36:34,720 INFANTS OR IN ADULTS IN 1975. 746 00:36:34,720 --> 00:36:37,440 WELL IN THE NEXT YEAR WE SAW A 747 00:36:37,440 --> 00:36:41,640 FEW MORE BABIES WITH INFANT 748 00:36:41,640 --> 00:36:43,240 PERTUSSIS AND HERE'S A LITTLE 749 00:36:43,240 --> 00:36:47,600 BABY THREE WEEKS OLD WHO GOT 750 00:36:47,600 --> 00:36:50,240 PERTUSSIS WHOSE FATHER WAS A 751 00:36:50,240 --> 00:36:51,640 PEDIATRIC RESIDENT WHO CARED FOR 752 00:36:51,640 --> 00:36:54,880 AN INFANT IN INTENSIVE CARE WITH 753 00:36:54,880 --> 00:36:56,600 PERTUSSIS WHOSE WIFE AT THE TIME 754 00:36:56,600 --> 00:37:00,040 WAS DELIVERING AND GOT A 755 00:37:00,040 --> 00:37:03,640 TERRIBLE COUGH AFTER HE HAD HAD 756 00:37:03,640 --> 00:37:05,640 A TERRIBLE AWFUL COUGH AND WHERE 757 00:37:05,640 --> 00:37:08,400 THEY'RE BABY GOT PERTUSSIS. 758 00:37:08,400 --> 00:37:11,560 THE BABY DID WELL AND HERE THEY 759 00:37:11,560 --> 00:37:14,040 ARE TWO YEARS LATER. 760 00:37:14,040 --> 00:37:20,200 MEGAN IS NOW A MICROBIOLOGIST 761 00:37:20,200 --> 00:37:23,320 AND THEIR BABY AND I SHOW YOU 762 00:37:23,320 --> 00:37:24,640 THIS CHRISTMAS CARD PICTURE OF 763 00:37:24,640 --> 00:37:27,160 THEIRS TO BE ABLE TO SAY TO YOU 764 00:37:27,160 --> 00:37:29,840 THEY HAD THE SAME PEDIATRICIAN 765 00:37:29,840 --> 00:37:31,440 IN NORTH PHILADELPHIA. 766 00:37:31,440 --> 00:37:36,440 THEY GREW UP IN PHILADELPHIA. 767 00:37:36,440 --> 00:37:39,520 HE HAD IMPECCABLE RECORDS. 768 00:37:39,520 --> 00:37:41,960 TOM HAD HAD PERTUSSIS AS A CHILD 769 00:37:41,960 --> 00:37:45,520 AND HIS WIFE SUE HAD BEEN FULLY 770 00:37:45,520 --> 00:37:47,240 VACCINATED. 771 00:37:47,240 --> 00:37:51,800 WE THOUGHT AT THE TIME DISEASE 772 00:37:51,800 --> 00:37:55,320 AND VACCINE CONFER LIFE TIME 773 00:37:55,320 --> 00:37:56,440 PROTECTION. 774 00:37:56,440 --> 00:38:02,040 SERENDIPITY NUMBER 2, ADVANTAGE 775 00:38:02,040 --> 00:38:05,840 NUMBER 2, RESOURCE WE HAD A 776 00:38:05,840 --> 00:38:08,240 VIROLOGIST WHO WAS ALSO A 777 00:38:08,240 --> 00:38:09,680 WONDERFUL SEROLOGIST AND SHE 778 00:38:09,680 --> 00:38:14,920 SERVED MULTIPLE, MULTIPLE TIMES 779 00:38:14,920 --> 00:38:18,240 FOR THE CDC AS THE SITE FOR 780 00:38:18,240 --> 00:38:20,200 DETERMINING ZERO PREVALENCE OF 781 00:38:20,200 --> 00:38:20,960 VACCINE PREVENTIBLE DISEASES IN 782 00:38:20,960 --> 00:38:28,400 THE UNITED STATES SO WE DID 783 00:38:28,400 --> 00:38:31,480 MULTIPLE, MULTIPLE IMMUNIZATION 784 00:38:31,480 --> 00:38:37,640 TRIALS AND HERE I'M SHOWING 785 00:38:37,640 --> 00:38:40,320 EDDIE ROTHSTEIN IN THE SUBURBS 786 00:38:40,320 --> 00:38:41,840 WHO DID STUDIES WITH US. 787 00:38:41,840 --> 00:38:44,160 I'M GOING TO SHOW YOU BRIEFLY WE 788 00:38:44,160 --> 00:38:48,440 MADE LOTS OF DISCOVERIES ABOUT 789 00:38:48,440 --> 00:38:48,680 PERTUSSIS. 790 00:38:48,680 --> 00:38:51,240 ONE WAS THAT BECAUSE OUR 791 00:38:51,240 --> 00:38:53,680 RESIDENTS KNEW WHAT PERTUSSIS 792 00:38:53,680 --> 00:38:59,880 WAS ONE OF THE RESIDENTS EDITH 793 00:38:59,880 --> 00:39:02,320 CASALES BECAME A PHYSICIAN FOR 794 00:39:02,320 --> 00:39:03,640 HANDICAPPED CHILDREN AND 795 00:39:03,640 --> 00:39:06,640 REALIZED THEY HAD AN OUTBREAK OF 796 00:39:06,640 --> 00:39:08,160 COUGH THAT SOUNDED LIKE 797 00:39:08,160 --> 00:39:09,440 PERTUSSIS TO HER AND WE CAME IN 798 00:39:09,440 --> 00:39:11,440 AND STUDIED THEM AND IN FACT IT 799 00:39:11,440 --> 00:39:14,400 WAS PERTUSSIS. 800 00:39:14,400 --> 00:39:16,440 WE LEARNED THE ATTACK RATE IN 801 00:39:16,440 --> 00:39:21,920 THE FACILITY WHERE THE CHILDREN 802 00:39:21,920 --> 00:39:31,200 WERE EXQUISITELY IMMUNIZED THE 803 00:39:31,200 --> 00:39:38,840 ATTACK RATE WAS 66% AND 804 00:39:38,840 --> 00:39:40,440 TWO-THIRDS WERE SUBCLINICAL AND 805 00:39:40,440 --> 00:39:43,680 WE LEARNED SEROLOGY WAS MORE 806 00:39:43,680 --> 00:39:47,080 SENSITIVE THAN CULTURE THAN 807 00:39:47,080 --> 00:39:50,200 DIRECT FLUORESCENT ANTIBIOTIC 808 00:39:50,200 --> 00:39:51,800 SAMPLING AND THERE WAS A LOT OF 809 00:39:51,800 --> 00:39:53,440 PERTUSSIS IN THE FACILITY SILENT 810 00:39:53,440 --> 00:39:55,440 AND SOME WERE COUGHING ILLNESS 811 00:39:55,440 --> 00:39:59,120 AS WELL. 812 00:39:59,120 --> 00:40:02,640 WE THEN STUDIED FOUR INFANTS TO 813 00:40:02,640 --> 00:40:05,120 STUDY THEIR FAMILY FOR A WHOLE 814 00:40:05,120 --> 00:40:05,840 YEAR. 815 00:40:05,840 --> 00:40:07,000 TURNED OUT WE DIDN'T NEED TO 816 00:40:07,000 --> 00:40:08,600 THOUGH WE DID AND WE FOUND IN 817 00:40:08,600 --> 00:40:14,800 THE FAMILIES 83% OF FAMILY 818 00:40:14,800 --> 00:40:16,800 MEMBERS HAD EVIDENCE OF 819 00:40:16,800 --> 00:40:18,840 PERTUSSIS DURING THIS SIEGE AND 820 00:40:18,840 --> 00:40:23,440 ONLY A THIRD WERE CLINICAL. 821 00:40:23,440 --> 00:40:27,160 ALL THE INFANTS HAD A COUGHING 822 00:40:27,160 --> 00:40:29,040 ADULT IN THE HOUSEHOLD BEFORE 823 00:40:29,040 --> 00:40:31,000 THEY BECAME ILL BEFORE THEY 824 00:40:31,000 --> 00:40:32,040 BEGAN TO COUGH. 825 00:40:32,040 --> 00:40:34,640 AND ONLY 20% OF THE INFECTED 826 00:40:34,640 --> 00:40:36,840 HAVE POSITIVE CULTURE. 827 00:40:36,840 --> 00:40:39,040 AGAIN, SEROLOGY WAS THE WAY TO 828 00:40:39,040 --> 00:40:41,440 MAKE THE DIAGNOSIS AND ALL THE 829 00:40:41,440 --> 00:40:45,840 INFECTED CONTACTS HAD DIAGNOSTIC 830 00:40:45,840 --> 00:40:46,840 SEROLOGY AT THE TIME OF THE 831 00:40:46,840 --> 00:40:48,400 RECOGNITION OF THE INDEX CASE. 832 00:40:48,400 --> 00:40:49,800 THAT STANDS TO REASON. 833 00:40:49,800 --> 00:40:57,200 THE THREE-WEEK-OLD ARE THE 834 00:40:57,200 --> 00:40:59,920 VICTIM OF WHAT WAS UNRECOGNIZED 835 00:40:59,920 --> 00:41:01,240 PERTUSSIS IN OLDER INDIVIDUALS. 836 00:41:01,240 --> 00:41:03,280 THEN THIS ONE IS GOING TO BE THE 837 00:41:03,280 --> 00:41:04,720 LAST ONE. 838 00:41:04,720 --> 00:41:06,640 I'M GOING TO DESCRIBE IT'S VERY 839 00:41:06,640 --> 00:41:08,600 INTERESTING BECAUSE THE CDC 840 00:41:08,600 --> 00:41:12,080 WANTED TO KNOW COULD WE BE SO 841 00:41:12,080 --> 00:41:15,680 AUDACIOUS AS TO GIVE TWO 842 00:41:15,680 --> 00:41:17,240 INJECTIONS ON THE SAME DAY AND 843 00:41:17,240 --> 00:41:20,240 HAVE THE INFANTS RESPONSES TO 844 00:41:20,240 --> 00:41:22,640 ALL OF THOSE VACCINES BE AS 845 00:41:22,640 --> 00:41:25,200 ROBUST AS IF THEY WERE GIVEN ON 846 00:41:25,200 --> 00:41:26,040 SEPARATE DAYS. 847 00:41:26,040 --> 00:41:28,840 WE DID THE STUDY OF PROVING THAT 848 00:41:28,840 --> 00:41:37,760 YOU COULD GIVE MMR AND DPT 849 00:41:37,760 --> 00:41:39,520 PERTUSSIS INJECTIONS ON THE SAME 850 00:41:39,520 --> 00:41:41,280 DAY AND THE WAY WE DID THE STUDY 851 00:41:41,280 --> 00:41:43,520 IS EVERYBODY GOT MMR ON THE 852 00:41:43,520 --> 00:41:45,040 FIRST DAY AND HALF THE CHILDREN 853 00:41:45,040 --> 00:41:47,680 WHO WERE THE CONTROLS RECEIVED A 854 00:41:47,680 --> 00:41:49,840 PLACEBO INJECTION ON THE FIRST 855 00:41:49,840 --> 00:41:53,400 DAY AND TWO MONTHS LATER THEY 856 00:41:53,400 --> 00:41:55,640 REVERSED AND HALF GOT DT AND PER 857 00:41:55,640 --> 00:42:02,040 TUS IS -- PERTUSSIS AND THE 858 00:42:02,040 --> 00:42:03,200 OTHER GOT THE PLACEBO AND THOSE 859 00:42:03,200 --> 00:42:12,400 IN THE CONTROL DID NOT GET DTP 860 00:42:12,400 --> 00:42:14,720 AND THEY DIDN'T HAVE RISES IN 861 00:42:14,720 --> 00:42:17,000 THEIR ANTIBIOTICS TO D OR T 862 00:42:17,000 --> 00:42:19,400 BEFORE THEY GOT THEIR REAL DTP 863 00:42:19,400 --> 00:42:21,480 IN THE TWO MONTHS. 864 00:42:21,480 --> 00:42:24,800 JUST HAVING RECEIVED DT 865 00:42:24,800 --> 00:42:26,760 WHOLESALE P AT TWO, FOUR AND SIX 866 00:42:26,760 --> 00:42:29,760 MONTHS, 11% OF THE URBAN AND 3% 867 00:42:29,760 --> 00:42:34,440 OF THE SUBURBAN CHILDREN HAD 868 00:42:34,440 --> 00:42:37,080 SPONTANEOUS FOURFOLD RISES IN 869 00:42:37,080 --> 00:42:38,640 PERTUSSIS ANTIBODIES AND NO 870 00:42:38,640 --> 00:42:40,720 SYMPTOMS. 871 00:42:40,720 --> 00:42:44,760 WE BEGAN TO THINK YOU GET 872 00:42:44,760 --> 00:42:48,560 FREQUENT INFECTIONS THAT BOOST 873 00:42:48,560 --> 00:42:49,960 YOUR PROTECTION AGAINST 874 00:42:49,960 --> 00:42:50,840 PERTUSSIS AND IF YOU GET THEM 875 00:42:50,840 --> 00:42:53,120 RIGHT AWAY, YOU WON'T HAVE 876 00:42:53,120 --> 00:42:58,360 CLINICAL SYMPTOMS BUT AS THERE 877 00:42:58,360 --> 00:43:06,040 IS MORE TIME TO RE-INFECT AND 878 00:43:06,040 --> 00:43:07,360 PERTAINING TO A PAPER OF 879 00:43:07,360 --> 00:43:09,600 IMMUNIZATION OF ADULTS BY 880 00:43:09,600 --> 00:43:11,880 INTERNISTS WE SUGGESTED WHILE 881 00:43:11,880 --> 00:43:13,280 URGING PROVIDERS FOR ADULTS TO 882 00:43:13,280 --> 00:43:16,720 GET ON BOARD WITH ADULT 883 00:43:16,720 --> 00:43:18,080 IMMUNIZATIONS WHICH I THINK THEY 884 00:43:18,080 --> 00:43:20,840 STILL ONLY ARE 30 YEARS LATER 885 00:43:20,840 --> 00:43:24,920 INCLUDING DECENNIAL PD WE SHOULD 886 00:43:24,920 --> 00:43:26,080 CONSIDER WHETHER PERTUSSIS 887 00:43:26,080 --> 00:43:27,640 VACCINE SHOULD BE ADDED. 888 00:43:27,640 --> 00:43:28,720 HERE'S THE MAP OF WHAT HAPPENED 889 00:43:28,720 --> 00:43:30,960 TO PERTUSSIS AFTER THE 890 00:43:30,960 --> 00:43:32,840 INTRODUCTION OF WHOLESALE 891 00:43:32,840 --> 00:43:33,240 VACCINE. 892 00:43:33,240 --> 00:43:36,920 IT WAS AN INESCAPABLE PART OF 893 00:43:36,920 --> 00:43:43,640 INFANCY AND BY 197 6 THE LOWEST 894 00:43:43,640 --> 00:43:46,320 NUMBER WERE REPORTED IN THE 895 00:43:46,320 --> 00:43:48,720 UNITED STATES BUT BY 1990s THERE 896 00:43:48,720 --> 00:43:51,280 WERE MORE CASES IN TWO AGE 897 00:43:51,280 --> 00:43:51,520 GROUPS. 898 00:43:51,520 --> 00:43:54,320 THE YOUNG AGE GROUP IN CHILDREN 899 00:43:54,320 --> 00:43:57,520 AND THE ADOLESCENTS AND YOUNG 900 00:43:57,520 --> 00:43:59,120 ADULTS, NOT SO MUCH INCREASE IN 901 00:43:59,120 --> 00:44:01,240 THOSE THAT WERE RIGHT AROUND THE 902 00:44:01,240 --> 00:44:03,240 TIME OF RECEIVING FIVE DOSES OF 903 00:44:03,240 --> 00:44:08,880 WHOLESALE VACCINE. 904 00:44:08,880 --> 00:44:12,200 BY EARLY 2000s THE HIGHEST 905 00:44:12,200 --> 00:44:14,200 INCIDENTS WAS IN THE AGE GROUP 906 00:44:14,200 --> 00:44:18,440 UNDER SIX MONTHS WITH A 907 00:44:18,440 --> 00:44:19,720 SECONDARY RISE NOTICE YOUNG 908 00:44:19,720 --> 00:44:21,960 ADOLESCENT AND IN THAT YEAR MOST 909 00:44:21,960 --> 00:44:23,280 CASES WERE OCCURRING IN THE 910 00:44:23,280 --> 00:44:25,120 BROAD AGE GROUP FROM 10 TO 20 911 00:44:25,120 --> 00:44:29,640 YEARS OF AGE. 912 00:44:29,640 --> 00:44:31,560 WELL, WE WERE WRITING ABOUT THIS 913 00:44:31,560 --> 00:44:34,000 AND PRESENTING POSTERS AND 914 00:44:34,000 --> 00:44:35,840 TALKING TO EACH OTHER AND 915 00:44:35,840 --> 00:44:36,680 APPRECIATION LITTLE OF ANYBODY 916 00:44:36,680 --> 00:44:39,080 ELSE AT THAT TIME BECAUSE 917 00:44:39,080 --> 00:44:39,840 PERTUSSIS WAS NOT RECOGNIZED AS 918 00:44:39,840 --> 00:44:44,880 A PROBLEM. 919 00:44:44,880 --> 00:44:50,040 I WAS INVITED TO THIS STORIED 920 00:44:50,040 --> 00:44:52,800 PLACE IN THE MANSOUR AUDITORIUM 921 00:44:52,800 --> 00:44:56,120 AT NIH TO PRESENT AT THE SIXTH 922 00:44:56,120 --> 00:44:57,840 INTERNATIONAL SYMPOSIUM ON 923 00:44:57,840 --> 00:44:59,160 PERTUSSIS AND PRESENTED PRETTY 924 00:44:59,160 --> 00:45:03,840 MUCH WHAT I SHOWED YOU SO FAR 925 00:45:03,840 --> 00:45:06,360 AND WE BECAME FRIENDS AND HE WAS 926 00:45:06,360 --> 00:45:07,920 THE CHIEF AT THE INSTITUTION 927 00:45:07,920 --> 00:45:13,120 DOWN THE STREET, CHILDREN'S 928 00:45:13,120 --> 00:45:15,440 HOSPITAL OF PHILADELPHIA AND 929 00:45:15,440 --> 00:45:17,720 STANLEY GOT UP AT THE END MIFF 930 00:45:17,720 --> 00:45:20,840 TALK AND I WAS SO PROUD I WAS 931 00:45:20,840 --> 00:45:23,800 PRESENTING AT THE NIH AND HE 932 00:45:23,800 --> 00:45:24,840 SAID WHY IS NORTH PHILADELPHIA A 933 00:45:24,840 --> 00:45:26,400 PIT OF PERTUSSIS. 934 00:45:26,400 --> 00:45:32,720 WHAT IS THE MATTER WITH NORTH 935 00:45:32,720 --> 00:45:33,720 PHILADELPHIA? 936 00:45:33,720 --> 00:45:35,120 IT TURNED OUT IT WASN'T THE 937 00:45:35,120 --> 00:45:38,000 COUNTRY WAS A PIT OF PERTUSSIS 938 00:45:38,000 --> 00:45:41,240 AND AS WE UNDERSTOOD THE CHANGE 939 00:45:41,240 --> 00:45:45,600 IN EPIDEMIOLOGY IS PARTIAL 940 00:45:45,600 --> 00:45:51,800 CONTROL LED TO FEWER BOOSTS AND, 941 00:45:51,800 --> 00:45:53,600 PARTIAL CONTROL LED TO IT STILL 942 00:45:53,600 --> 00:45:57,600 BE AROUND AND THE FIRST SET OF 943 00:45:57,600 --> 00:46:00,600 PARENTS DID DPT THAT LEFT MORE 944 00:46:00,600 --> 00:46:03,120 PEOPLE SUSCEPTIBLE. 945 00:46:03,120 --> 00:46:04,600 VACCINE FAILURE WAS VERY 946 00:46:04,600 --> 00:46:07,640 IMPORTANT AND STILL IS IMPORTANT 947 00:46:07,640 --> 00:46:09,240 AND PERTAINS TO CORONAVIRUS AS 948 00:46:09,240 --> 00:46:09,640 WELL. 949 00:46:09,640 --> 00:46:12,240 IF YOU HAVE A MUCOSAL INFECTION 950 00:46:12,240 --> 00:46:16,920 WHICH PERTUSSIS IS, WHICH 951 00:46:16,920 --> 00:46:19,040 CORONAVIRUS IS, YOU CAN'T EXPECT 952 00:46:19,040 --> 00:46:23,040 TO PUT AN ANTIGEN INTO A MUSCLE 953 00:46:23,040 --> 00:46:26,040 AND EXPECT TO GET PERFECT 954 00:46:26,040 --> 00:46:27,120 MUCOSAL IMMUNITY. 955 00:46:27,120 --> 00:46:29,240 SO PERTUSSIS VACCINE ON THE DAY 956 00:46:29,240 --> 00:46:31,760 AFTER YOU FINISH YOUR SERIES IS 957 00:46:31,760 --> 00:46:35,720 ONLY 85% PROTECTIVE AGAINST A 958 00:46:35,720 --> 00:46:37,120 THREE-WEEK ILLNESS. 959 00:46:37,120 --> 00:46:39,960 THAT'S NOT PERFECT AND IT'S 960 00:46:39,960 --> 00:46:44,520 NEVER GOING TO BE STERILIZING 961 00:46:44,520 --> 00:46:44,840 IMMUNITY. 962 00:46:44,840 --> 00:46:47,360 BUT THE MAIN PROBLEM IS THERE 963 00:46:47,360 --> 00:46:49,080 WAS WANING VACCINE IMMUNITY 964 00:46:49,080 --> 00:46:52,080 AFTER HAVING RECEIVED THE LAST 965 00:46:52,080 --> 00:46:53,440 PERTUSSIS VACCINE AT 46 YEARS OF 966 00:46:53,440 --> 00:46:54,000 AGE. 967 00:46:54,000 --> 00:46:55,920 WHY DID WE HAVE PERTUSSIS IN 968 00:46:55,920 --> 00:46:56,760 YOUNG INFANTS? 969 00:46:56,760 --> 00:47:01,720 FOR THE FIRST TIME IN MEDICAL 970 00:47:01,720 --> 00:47:02,880 HISTORY, THOSE PATIENTS AND 971 00:47:02,880 --> 00:47:06,000 THOSE LITTLE INFANTS WE WERE 972 00:47:06,000 --> 00:47:07,640 SEEING THAT WERE DESCRIBED 973 00:47:07,640 --> 00:47:10,520 NATIONALLY, THE FIRST TIME IN 974 00:47:10,520 --> 00:47:12,240 MEDICAL HISTORY WAS BECAUSE WE 975 00:47:12,240 --> 00:47:15,360 HAD PARTIALLY CONTROLLED 976 00:47:15,360 --> 00:47:21,040 PERTUSSIS BUT MOTHER'S IMMUNITY 977 00:47:21,040 --> 00:47:26,320 WAS WANING AND TRANS-PLACENTAL 978 00:47:26,320 --> 00:47:27,880 ANTIBIOTICS WERE WANING AND THE 979 00:47:27,880 --> 00:47:30,960 INFANTS WERE SUSCEPTIBLE. 980 00:47:30,960 --> 00:47:34,040 WE MADE TWO TRUTHS. 981 00:47:34,040 --> 00:47:35,880 PERTUSSIS DISEASE AND VACCINE 982 00:47:35,880 --> 00:47:37,880 PROVIDE LIFE TIME PROTECTION 983 00:47:37,880 --> 00:47:42,240 WERE NOT CORRECT. 984 00:47:42,240 --> 00:47:43,440 WHAT WE THOUGHT WAS LIFE TIME 985 00:47:43,440 --> 00:47:46,000 PROTECTION FROM EITHER WAS 986 00:47:46,000 --> 00:47:51,560 REALLY ENOUGH REINFORCING 987 00:47:51,560 --> 00:47:55,080 INFECTIONS WITH BORDATELLA 988 00:47:55,080 --> 00:47:56,640 PERTUSSIS THAT KEEP THE PEOPLE 989 00:47:56,640 --> 00:47:57,200 FROM THE DISEASE. 990 00:47:57,200 --> 00:47:58,880 THAT'S WRONG. 991 00:47:58,880 --> 00:48:03,600 THERE IS NOT LIFE TIME 992 00:48:03,600 --> 00:48:03,960 PROTECTION. 993 00:48:03,960 --> 00:48:08,040 WE INTRODUCED DTAP IN 2006 AND 994 00:48:08,040 --> 00:48:10,000 FOR A WHILE IT TOOK THE EDGE OFF 995 00:48:10,000 --> 00:48:11,240 THE NEW CASES. 996 00:48:11,240 --> 00:48:16,160 AND THEN THE NEXT THING HAPPENED 997 00:48:16,160 --> 00:48:17,080 OH, MY GOODNESS. 998 00:48:17,080 --> 00:48:18,560 REMEMBER THERE WASHINGTON MANY 999 00:48:18,560 --> 00:48:21,920 CASES MUCH PERTUSSIS IF THE 6 TO 1000 00:48:21,920 --> 00:48:23,640 10-YEAR-OLD AGE GROUP WHEN WE 1001 00:48:23,640 --> 00:48:26,640 HAD WHOLESALE VACCINE AND IN THE 1002 00:48:26,640 --> 00:48:28,440 BEGINNING OF THE PERTUSSIS 1003 00:48:28,440 --> 00:48:30,600 VACCINE BUT LOOK AT THE 1004 00:48:30,600 --> 00:48:32,920 7-YEAR-OLDS. 1005 00:48:32,920 --> 00:48:34,920 2006, 7 AND 8-YEAR-OLDS, AND 1006 00:48:34,920 --> 00:48:40,600 2008, 7, 8, 9, 10-YEAR-OLDS WITH 1007 00:48:40,600 --> 00:48:42,280 WERE THE MOST PREVALENT CASES IN 1008 00:48:42,280 --> 00:48:43,840 THAT AGE GROUP. 1009 00:48:43,840 --> 00:48:45,000 WHAT'S THAT ABOUT? 1010 00:48:45,000 --> 00:48:46,840 HERE WE SEE IT IN A DIFFERENT 1011 00:48:46,840 --> 00:48:47,040 WAY. 1012 00:48:47,040 --> 00:48:52,240 HERE WE SEE THE AGES OF THE 1013 00:48:52,240 --> 00:48:53,960 CASES OF PERTUSSIS. 1014 00:48:53,960 --> 00:49:04,360 THE FIRST IN 2010 IS THIS GROUP 1015 00:49:04,360 --> 00:49:07,840 HERE BEFORE WE HAD THESE THESE 1016 00:49:07,840 --> 00:49:09,880 WERE THE PEAK AND THEN WITH THE 1017 00:49:09,880 --> 00:49:13,000 VACCINE WE DON'T SEE 11 AND 1018 00:49:13,000 --> 00:49:14,560 12-YEAR-OLDS BUT WE SEE THE 10 1019 00:49:14,560 --> 00:49:16,680 AND 11-YEAR-OLDS COMING UP AND 1020 00:49:16,680 --> 00:49:18,440 THEY WERE VACCINATED BUT SOON 1021 00:49:18,440 --> 00:49:24,640 AFTER THAT BY 2014 WE HAD 59,000 1022 00:49:24,640 --> 00:49:26,920 CASES IN THE UNITED STATES AS 1023 00:49:26,920 --> 00:49:29,640 MANY AS WE HAD 50 YEARS BEFORE 1024 00:49:29,640 --> 00:49:30,920 THOUGH THIS PROTECTS CHILDREN, 1025 00:49:30,920 --> 00:49:33,040 IT PROTECTS THEM FOR A SHORT 1026 00:49:33,040 --> 00:49:35,600 PERIOD OF TIME AND BY THE TIME 1027 00:49:35,600 --> 00:49:40,520 THOSE 10 AND 11-YEAR-OLDS ARE 14 1028 00:49:40,520 --> 00:49:41,680 THEY'RE BACK UP AND SUSCEPTIBLE 1029 00:49:41,680 --> 00:49:43,400 TO PERTUSSIS. 1030 00:49:43,400 --> 00:49:44,800 WHAT IS THAT ABOUT? 1031 00:49:44,800 --> 00:49:45,400 IT'S REALLY INTERESTING. 1032 00:49:45,400 --> 00:49:48,240 THIS WAS A LETTER TO THE EDITOR 1033 00:49:48,240 --> 00:49:50,840 IN JAMA FROM AUSTRALIA THAT IS 1034 00:49:50,840 --> 00:49:54,640 WHAT TURNS OUT TO BE THE DEAL. 1035 00:49:54,640 --> 00:49:56,720 HERE IS THE DEAL. 1036 00:49:56,720 --> 00:49:59,840 IN AUSTRALIA THEY STARTED A 1037 00:49:59,840 --> 00:50:02,280 CELLULAR PERTUSSIS VACCINE ABOUT 1038 00:50:02,280 --> 00:50:05,440 WHEN WE DID 2000 AND GAVE IT TO 1039 00:50:05,440 --> 00:50:06,120 HALF THE POPULATION. 1040 00:50:06,120 --> 00:50:08,680 HALF CONTINUED TO GET THE 1041 00:50:08,680 --> 00:50:10,840 WHOLESALE VACCINE AND IN 2014 1042 00:50:10,840 --> 00:50:13,360 THEY HAD A PERTUSSIS OUTBREAK IS 1043 00:50:13,360 --> 00:50:14,920 THEY LEARNED WITH YOU WERE LEAST 1044 00:50:14,920 --> 00:50:18,800 LIKELY TO HAVE PERTUSSIS IF YOU 1045 00:50:18,800 --> 00:50:21,440 HAD HAD ALL WHOLESALE VACCINE OR 1046 00:50:21,440 --> 00:50:22,920 IF YOUR FIRST DOSE WAS WHOLESALE 1047 00:50:22,920 --> 00:50:27,480 VACCINE. 1048 00:50:27,480 --> 00:50:29,440 YOU WERE MOST LIKELY TO GET 1049 00:50:29,440 --> 00:50:31,800 PERTUSSIS IF YOUR FIRST DOSE 1050 00:50:31,800 --> 00:50:34,640 WITH US A CELLULAR VACCINE. 1051 00:50:34,640 --> 00:50:36,920 SO THE CHANGES IN THE 1052 00:50:36,920 --> 00:50:40,120 EPIDEMIOLOGY IN PERTUSSIS IF THE 1053 00:50:40,120 --> 00:50:42,640 ACELLULAR ERA ARE ANOTHER 1054 00:50:42,640 --> 00:50:43,960 REMARKABLE THING. 1055 00:50:43,960 --> 00:50:50,920 WE BEGAN DTAP REPLACING BY 1997. 1056 00:50:50,920 --> 00:50:53,520 EVERYBODY SINCE 2000 CAN ONLY 1057 00:50:53,520 --> 00:50:55,480 HAVE RECEIVED ALL ACELLULAR 1058 00:50:55,480 --> 00:50:57,440 VACCINES. 1059 00:50:57,440 --> 00:51:04,320 SO THESE GUYS HERE IN 2002 STILL 1060 00:51:04,320 --> 00:51:05,600 RECEIVED WHOLESALE AS THEIR 1061 00:51:05,600 --> 00:51:08,040 BEGIN BUT PRETTY SOON THE OLDER 1062 00:51:08,040 --> 00:51:11,320 ONES HAD RECEIVED ALL ACELLULAR 1063 00:51:11,320 --> 00:51:14,840 AND THE EPIDEMIOLOGY SHOWS THE 1064 00:51:14,840 --> 00:51:20,040 AFFECT OF AN AGING COHORT OF ALL 1065 00:51:20,040 --> 00:51:21,520 ACELLULAR VACCINE AND THOUGH 1066 00:51:21,520 --> 00:51:24,320 THEY'RE EFFECTIVE THEY DRIVE THE 1067 00:51:24,320 --> 00:51:27,880 IMMUNOLOGIC RESPONSE THAT LEADS 1068 00:51:27,880 --> 00:51:33,640 TO IMMEDIATE WANING AND ALSO 1069 00:51:33,640 --> 00:51:35,240 INABILITY TO ADEQUATELY BOOST. 1070 00:51:35,240 --> 00:51:37,760 SO IS THE SKY FALLING ON 1071 00:51:37,760 --> 00:51:38,640 PERTUSSIS VACCINE. 1072 00:51:38,640 --> 00:51:41,720 YES, IN FACT IT IS. 1073 00:51:41,720 --> 00:51:44,440 WE HAVE HAD A RESPITE AS ALL 1074 00:51:44,440 --> 00:51:46,280 OTHER CONTAGIOUS INFECTIOUS 1075 00:51:46,280 --> 00:51:47,440 DISEASES HAVE BEEN LESS COMMON 1076 00:51:47,440 --> 00:51:51,240 BUT IT WILL BE ROARING BACK. 1077 00:51:51,240 --> 00:51:55,640 UNTIL WE HAVE A BETTER MOUSE 1078 00:51:55,640 --> 00:51:58,040 TRAP AND VACCINE, WE ARE DOUBLED 1079 00:51:58,040 --> 00:52:00,760 DOWN ON PREVENTING PERTUSSIS AND 1080 00:52:00,760 --> 00:52:05,920 THAT'S ALL IN THE FIRST THREE 1081 00:52:05,920 --> 00:52:15,560 MONTHS OF LIFE SO THE 1082 00:52:15,560 --> 00:52:19,000 RECOMMENDATION IS TO HAVE THIS 1083 00:52:19,000 --> 00:52:20,960 IS SO MOTHERS HAVE 1084 00:52:20,960 --> 00:52:23,080 TRANSPLACENTAL ANTIBIOTIC TO 1085 00:52:23,080 --> 00:52:24,400 PASS TO THE INFANT TO PROTECT 1086 00:52:24,400 --> 00:52:26,040 THEM FOR THE FIRST TWO MONTHS OF 1087 00:52:26,040 --> 00:52:26,520 LIFE. 1088 00:52:26,520 --> 00:52:29,800 THAT'S WHAT WE CAN HOPE TO DO 1089 00:52:29,800 --> 00:52:32,800 WITH THE VACCINES WE HAVE. 1090 00:52:32,800 --> 00:52:36,120 WE NOW KNOW IT WOULD NOT BE 1091 00:52:36,120 --> 00:52:39,120 REASONABLE TO RECOMMEND 1092 00:52:39,120 --> 00:52:44,200 UNIVERSAL REVACCINATION OF THE 1093 00:52:44,200 --> 00:52:45,800 ENTIRE POPULATION BECAUSE WE 1094 00:52:45,800 --> 00:52:47,960 KNOW THE ACELLULAR VACCINE 1095 00:52:47,960 --> 00:52:51,040 PRIMING WHICH ALL YOUNG PEOPLE 1096 00:52:51,040 --> 00:52:53,440 IN THE UNITED STATES HAVE RIGHT 1097 00:52:53,440 --> 00:52:57,960 NOW IS NOT BOOSTABLE. 1098 00:52:57,960 --> 00:53:00,120 AND THAT THE VACCINE ANTIBODY 1099 00:53:00,120 --> 00:53:03,480 THAT YOU GET FROM A BOOSTER 1100 00:53:03,480 --> 00:53:05,360 DOSE, FOR INSTANCE, ONLY LASTS 1101 00:53:05,360 --> 00:53:06,440 ABOUT TWO YEARS. 1102 00:53:06,440 --> 00:53:07,640 AS IF THAT WASN'T ENOUGH AND 1103 00:53:07,640 --> 00:53:10,600 THERE'S MORE OBSERVATIONS TO 1104 00:53:10,600 --> 00:53:17,240 COME, WE CONTINUED TO TRY TO 1105 00:53:17,240 --> 00:53:23,960 ISOLATE AND FREEZE BORDATELLA 1106 00:53:23,960 --> 00:53:29,760 PERTUSSIS AND STILL HAD A BEVY 1107 00:53:29,760 --> 00:53:32,120 OF THIS SO WHEN J & J WANTED TO 1108 00:53:32,120 --> 00:53:34,720 BEGIN TO EXPLORE A NEW VACCINE 1109 00:53:34,720 --> 00:53:44,640 THEY ASKED US FOR OUR ISOLATES 1110 00:53:44,640 --> 00:53:46,640 AND THEY SAID THEY HEARD FROM J 1111 00:53:46,640 --> 00:53:54,640 & J AND THEY WERE ALL PERTACTIN 1112 00:53:54,640 --> 00:53:57,520 DEFICIENT AND IT'S A DETACHMENT 1113 00:53:57,520 --> 00:54:00,080 OF THE ORGANISM AND A SAID THEY 1114 00:54:00,080 --> 00:54:02,960 DID IT WRONG BECAUSE THERE'S NO 1115 00:54:02,960 --> 00:54:04,800 PERTACTIN ORGANISMS AND THEY DID 1116 00:54:04,800 --> 00:54:07,760 IT RIGHT NOT TO MENTION THEY DID 1117 00:54:07,760 --> 00:54:10,840 WHOLE GENOME SEQUENCING SO THEY 1118 00:54:10,840 --> 00:54:14,200 REALLY KNEW AND WE DISCOVERED 1119 00:54:14,200 --> 00:54:19,720 AND DR. KEENAN FROM J&J REPORTED 1120 00:54:19,720 --> 00:54:21,560 IN THE NEW ENGLAND JOURNAL 1121 00:54:21,560 --> 00:54:25,280 VARIANTS OF PERTUSSIS THAT WERE 1122 00:54:25,280 --> 00:54:26,600 PROTECTANT DEFICIENT AND TURNED 1123 00:54:26,600 --> 00:54:30,600 OUT AS WE LOOKED AT OURS THE 1124 00:54:30,600 --> 00:54:52,840 FIRST ISOLATE AND IT WAS THOUGHT 1125 00:54:52,840 --> 00:54:56,560 PERTACTIN IS A VIRULENCE FACTOR 1126 00:54:56,560 --> 00:54:58,440 FOR DETACHMENT OF DISEASE BUT 1127 00:54:58,440 --> 00:54:59,480 YOU HAVE TO THINK SOMETHING WAS 1128 00:54:59,480 --> 00:55:02,040 GOING ON ABOUT ESCAPE OF AN 1129 00:55:02,040 --> 00:55:03,440 ORGANISM FROM THE VACCINE 1130 00:55:03,440 --> 00:55:06,640 PRESSURE WHICH WAS WHAT'S GOING 1131 00:55:06,640 --> 00:55:15,440 ON RIGHT NOW. 1132 00:55:15,440 --> 00:55:15,640 DEF I 1133 00:55:18,280 --> 00:55:20,720 I HAVE TO GIVE THANKS FOR 1134 00:55:20,720 --> 00:55:22,440 HELPING US UNDERSTAND AND HAVE A 1135 00:55:22,440 --> 00:55:27,840 MODEL OF PERTUSSIS IN A BABOON. 1136 00:55:27,840 --> 00:55:30,600 WE DON'T HAVE A SEROLOGIC PARKER 1137 00:55:30,600 --> 00:55:31,720 OF PROTECTION. 1138 00:55:31,720 --> 00:55:33,000 THERE'S NO ANTIBIOTIC TESTS THAT 1139 00:55:33,000 --> 00:55:33,800 SAYS YOU'RE PROTECTED AND YOU'RE 1140 00:55:33,800 --> 00:55:41,960 NOT. 1141 00:55:41,960 --> 00:55:43,880 AND WE STILL DON'T KNOW WHAT 1142 00:55:43,880 --> 00:55:46,640 CAUSE THE COUGH BECAUSE IF YOU 1143 00:55:46,640 --> 00:55:52,320 INJECT IT INTO THE ANIMAL 1144 00:55:52,320 --> 00:55:57,040 THEY'LL GET LYMPHOCYTOSIS BUT 1145 00:55:57,040 --> 00:56:01,600 WON'T COUGH SO IT HELPS BUT 1146 00:56:01,600 --> 00:56:04,160 THERE'S MANY COMPANIES IN MANY 1147 00:56:04,160 --> 00:56:06,560 COUNTRIES LOOKING FOR THE NEXT 1148 00:56:06,560 --> 00:56:09,640 PERTUSSIS VACCINE. 1149 00:56:09,640 --> 00:56:15,920 IT'S A MUCOSAL INFECTION AND YOU 1150 00:56:15,920 --> 00:56:18,320 NEED SOMETHING AND IT LEECHES 1151 00:56:18,320 --> 00:56:22,040 OUT INTO THE MUCOSA. 1152 00:56:22,040 --> 00:56:24,320 THE PROBLEM WITH PURELY MUCOSAL 1153 00:56:24,320 --> 00:56:25,680 THEY USUALLY DON'T HAVE LONG 1154 00:56:25,680 --> 00:56:26,840 LEGS OR MEMORY. 1155 00:56:26,840 --> 00:56:28,280 SO THERE'S MULTIPLE AVENUES 1156 00:56:28,280 --> 00:56:29,400 BEING APPROACHED. 1157 00:56:29,400 --> 00:56:33,520 ONE ATTENUATED, LIVE ATTENUATED 1158 00:56:33,520 --> 00:56:35,880 VACCINE WITH A GENETICALLY 1159 00:56:35,880 --> 00:56:39,840 INACTIVATED PERTUSSIS TOXIN AND 1160 00:56:39,840 --> 00:56:41,840 DELETION OF OTHER VIRULENCE 1161 00:56:41,840 --> 00:56:42,440 GENES. 1162 00:56:42,440 --> 00:56:46,640 ANOTHER IS GENETICALLY MODIFIED 1163 00:56:46,640 --> 00:56:50,080 PT. IT TURNED OUT IN WHOLESALE 1164 00:56:50,080 --> 00:56:52,080 AND ACELLULAR VACCINES THE 1165 00:56:52,080 --> 00:56:54,960 PERTUSSIS TOXIN WAS INACTIVATED 1166 00:56:54,960 --> 00:56:57,040 BY A CHEMICAL PROCESS WHICH 1167 00:56:57,040 --> 00:57:00,320 CHANGES IT IN SUCH A WAY AND 1168 00:57:00,320 --> 00:57:02,160 RECOMBINANT PERTUSSIS TOXIN IS 1169 00:57:02,160 --> 00:57:06,000 MUCH BETTER IN THAT IT MAINTAINS 1170 00:57:06,000 --> 00:57:10,080 THE NATIVE EPITOPE STRUCTURE AND 1171 00:57:10,080 --> 00:57:11,520 IMMUNOGENICITY AND THAT WAS 1172 00:57:11,520 --> 00:57:13,960 LICENSED IN EUROPE AND SALES 1173 00:57:13,960 --> 00:57:17,520 WERE HIGH AND ANOTHER IS TO 1174 00:57:17,520 --> 00:57:19,480 APPROACH POTENT ADJUVANTS. 1175 00:57:19,480 --> 00:57:21,040 THIS IS ALL BEGINNING TO SOUND 1176 00:57:21,040 --> 00:57:22,920 FAMILIAR TO YOU NOW WITH WHAT 1177 00:57:22,920 --> 00:57:28,720 YOU ALL KNOW ABOUT CORONAVIRUS 1178 00:57:28,720 --> 00:58:47,600 VACCINES IN THE LAST YEAR.