>> HELLO, EVERYBODY. IT'S GOOD TO SEE ALL OF YOU, WE ARE A MIX OF SOME LONG STANDING FOLKS HERE AND SOME NEW MEMBERS MORE ON THAT IN JUST A FEW MINUTES. I'M LAURA FORESE, I'M THE CHAIR OF THIS BOARD AND DELIGHTED TO SEE ALL OF YOU. WE ARE VERY EXCITED BY THE PROSPECT THAT OUR JULY MEETING WILL BE IN PERSON SO EVERYBODY KEEP YOUR FINGERS CROSSED ON THAT 1. WE'VE NOT BEEN ABLE TO GATHER AT THE CAMPUS LO THESE MANY MULTIPLE YEARS NOW SO IT WOULD BE TERRIFIC PARTICULARLY AS WE HAVE SOME NEW MEMBERS. I'M GOING TO TURN IT OVER TO LARRY IN HIS ROLL AS ACTING DIRECTOR IN DR. TAWAK IN JUST A MOMENT. I ALSO WANT TO WELCOME DR. TARA SCHWETZ, AS ACTING DEPUTY DIRECTOR, AND SHE WILL BE WITH US FOR PART OF THE MEETING AND THEN AS SHE--NEW ROLE SINCE WE'VE ALL BEEN TOGETHER LAST. THE ONLY BOARD MEMBER WHO COULDN'T MAKE IT TODAY WAS DR. JULIE [INDISCERNIBLE] SO WE HAVE A QUORUM AS I SAID AND WE'VE BEEN WORKING ON THE MEMBERSHIP OVER THE LAST COUPLE OF MONTHS, I WOULD SAY, JIM, TARA, LARRY AND MYSELF AND THE FIRST THING WE HAVE TO DO IS THAT WE'RE GOING TO SAY GOODBYE AFTER THIS MEETING TO OUR LONG STANDING MEMBER ELEN BERG WHO'S BEEN WITH US THE ENTIRE 6 YEARS, FOR ANYBODY WHO'S NEW TO ELEN YOU MUST NOW PICK UP THE MANTEL OF THIS FABULOUS COSTUMES AND ELEN DO YOU WANT TO UNMUTE AND SAY A FEW WORDS, WE ARE SURE GOING TO MISS YOU. YOU'VE BEEN A WONDERFUL BOARD MEMBER. >> S WHY, I WOULD LIKE TO SAY THAT I HAVE TRULY ENJOYED AND LEARNED SO MUCH FROM BEING A MEMBER OF GROUP AND I WANT TO SAY ON BEHALF OF PATIENTS EVERYWHERE IN THE WORLD, THANK YOU, EACH 1 OF YOU FOR ALL YOU DO. THANK YOU. >> THANK YOU SO MUCH. THANK YOU SO MUCH ELLEN, YOU HAVE BEEN A STALWART--RUTH BRINKLEY AND RICK AND I ARE ALSO GOING TO BE LEAVING THE BOARD THIS YEAR, ALSO MEMBERS FROM THE VERY BEGINNING. WE WILL STAGGER THAT A LITTLE BIT SO THAT WE WILL BE ABLE TO DO A SMOOTH TRANSITION AND IT LOOKS LIKE RICK AND I WILL BE HERE FOR THE JULY MEETING AGAIN, HOPEFULLY IN PERSON. ONE OTHER NOTE IN TERMS OF MEMBERSHIP, BILL HEIGHT LET US KNOW THAT UNFORTUNATELY HE WAS GOING TO NEED TO WITHDRAW DUE TO SOME OTHER COMMITMENTS SO WE THANK HIM. I GOT A CHANCE TO SPEAK TO HIM JUST A LITTLE WHILE AGO AND I KNOW HE ALSO APPRECIATED THE SERVICE. SO WITH THAT, AGAIN, I WANT TO WELCOME ALL OF OUR NEW MEMBERS AS WELL AS ALL OF OUR ONGOING MEMBERS. WE'RE EXCITED ABOUT EVERYTHING THAT'S TO COME. YOU'VE SEEN THE AGENDA. WE WILL HEAR ABOUT A NUMBER OF EXCITING THINGS, SOME OF WHICH IS NEW AND SOME OF WHICH IS A CONTINUATION OF WHAT WE'VE BEEN DOING AND WITH THAT, LARRY, I WILL TURN IT OVER TO YOU. THANK YOU. >> GREAT. THANK YOU SO MUCH LAURA AND GOOD MORNING TO ALL OF YOU. SO AS LAURA MENTIONED, THE LAST TIME I SPOKE TO YOU BACK IN JULY OF 21, I WAS SERVING AS THE PRINCIPAL DEPUTY DIRECTOR OF NIH AND I WAS FILLING IN FOR FRANCIS WHO WAS UNABLE TO ATTEND. SO NOW AS YOU'VE HEARD, FAST FORWARD, TODAY I'M HERE IN THIS NEW ROLE AS ACTING DIRECTOR OF NIH BUT MY ROLE WILL BE PRETTY MUCH THE SAME. I'M JUST GOING TO GIVE YOU A QUICK UPDATE ON NIH AND A FEW OF ITS ACTIVITIES. BUT FIRST, I ALSO WANT TO THANK ELLEN. YOU KNOW, AS I FOUNDING MEMBER AND AS A FORMER NIH RESEARCH PARTICIPANT, REALLY, YOU HAVE PROVIDED US WITH SUCH IMPORTANT INSIGHT OVER THESE YEARS AND I JUST--WE REALLY OWE YOU A DEBT OF GRATITUDE SO PERSONALLY I WANT TO EXTEND MY THANKS AND I KNOW THAT FRANCIS WOULD ALSO LIKE TO SEND THOSE THANKS TO YOU AS WELL. SO ELLEXER EN, THANK YOU SO VERY MUCH. >> YOU'RE VERY WELCOME. >> WE DO HAVE AS LAURA MENTIONED, NEW MEMBERS OF THE BOARD AND I'M GOING TO INTRODUCE THEM AND I BELIEVE 3 OF THE 4 HAVE BEEN ABLE TO JOIN US. THE FIRST DR. CRAIG SAMUT, MANAGING DIRECTOR OF ITO ADVISORS WHICH IS A HEALTHCARE ADVISORY AND INVESTMENT FIRM. CRAIG IS A NATIONALLY RECOGNIZED THOUGHT LEADER ON INDUSTRY TRANSFORMATION, CARE DELIVERY AND HEALTHCARE POLICY, SO CRAIG, WELCOME, THANK YOU SO MUCH FOR BEING WITH US. DR. DAVID CHIN, DIRECTOR OF EXECUTIVE EDUCATION AND CO-DIRECTOR OF THE MPH MBA PROGRAM AT THE HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH. DAVID IS ALSO CHAIRS THE BOARD OF THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE. SO DAVID, WELCOME. THANK YOU SO MUCH FOR DOING THIS, WE HAVE 2 PATIENT REPRESENTATIVES. ANTWON ETICS ROYSTER IS WITH US TODAY, SHE'S A CIVIC MINDED ACTIVIST BORN AND RAISED IN WASHINGTON D. C. AND LIVES IN ALLEGEHENY COUNT NEUROECTODERMAL, MARYLAND. ANTOINETTE IS--WELCOME AND THANK YOU SO MUCH FOR BEING WILLING TO DO THIS. OUR FINAL MEMBER, ALSO A PATIENT REPRESENTATIVE IS DAVID [INDISCERNIBLE] ON WHO UNFORTUNATELY IS NOT ABLE TO BE WITH US, I WAS TOLD EMPLOY SO AT THE NEXT MEETING WE WILL GIVE HIM A PROPER INTRODUCTION BUT JUST FOR ALL OF YOUR AWARENESS, HE IS MANAGING DIRECTOR OF THE QX GROUP, HE HAS EXTENSIVE PUBLIC AND PRIVATE SECTOR EXPERIENCE WITH INNOVATIST TECHNOLOGY AND CROSS FUNCTIONAL TEAMS TO ACHIEVE MISSION REQUIREMENTS. AND SO, I'M SURE YOU WILL ALL AGREE JUST BY LISTENING TO THESE VERY, VERY BRIEF BIOS OF THESE VERY ACCOMPLISHED PEOPLE THAT WE ARE VERY FORTUNATE TO HAVE ALL OF THEM COME TO SERVE ON THE BOARD AND TO PROVIDE US WITH THEIR UNIQUE INSIGHTS. YES, ELLEN,. >> ANTOINETTE, I WOULD LIKE TO SAY, I WILL BE WILLING TO LOAN YOU ANY COSTUME ACCESSORYS YOU MIGHT BE NEEDING. >> [LAUGHTER] >> THANKS, ELLEN. >> OKAY. WELL, WE LOOK FORWARD TO THAT JULY MEETING NOW, ANTOINETTE, WE CAN'T WAIT. [LAUGHTER] SO LET ME JUST COVER A FEW THINGS. SO WE ARE NOW IN A TRANSITION PERIOD IN TERMS OF LEADERSHIP AT NIH AND OF COURSE FOR MANY OF YOU, YOU HAVE NEVER EXPERIENCED THIS BEFORE BECAUSE FRANCIS' TENURE AS NIH DIRECTOR SPANNED 12 YEARS WHICH WAS UNPRECEDENTED. MULTIPLE ADMINISTRATIONS AND SO, YOU WOKE UP EVERY DAY KNOWING THAT FRANCIS WAS THE NIH LEADER AND THEN THIS DECISION OF HIS TO STEP BACK SEEMINGLY ONLY FOR A FEW WEEKS TO HIS LABORATORY BECAUSE HE IS NOW THE ACTING SCIENCE ADVISOR TO THE PRESIDENT. IT IS ALSO UNIQUE IN THAT WE ARE COMING UP TOWARDS MIDTERM ELECTIONS AND THAT ALWAYS ADDS A LITTLE INTRIGUE AND FRANKLY SOME UNCERTAINTY, PARTICULARLY VIS A VIS THE BUDGETARY PROCESS, AND I THINK THAT, YOU KNOW THOSE OF US WHO HAVE BEEN HERE LONGER THAN THE 12 YEARS OF FRANCIS' TENURE, KNOW THAT EVERYTHING WILL BE FINE. WE WILL ORDERLY, SEE THE APPOINTMENT OF A NEW PERMANENT NIH DIRECTOR IN DUE COURSE AND HE OR SHE WILL INHERIT A SPECTACULAR LEADERSHIP TERM WHO WILL WORK VERY CLOSELY WITH THEM AS THEY BEGIN TO THINK THROUGH THEIR OWN NEW PERSPECTIVE, NEW AGENDA AND OBVIOUSLY, WE AT NIH LOOK FORWARD TO THAT, FOR THE NEW MEMBERS OF THE BOARD WHO MAY NOT BE AS FAMILIAR WITH THIS AS OTHERS, WHAT THIS ENTAILS IS A NOMINATION BY THE PRESIDENT TO THE SENATE AND THEN THE SENATE NEEDS TO HAVE A CONFIRMATION PROCESS FOR THE NIH DIRECTOR POSITION. SO IT IS A PRESIDENTIAL APPOINTEE WITH SENATE CONFIRMATION. THE TIMING TONY FAUCI SAID TO ME, ANYONE WHO TELLS YOU THEY KNOW, DOESN'T. IT'S THE SORT OF THING THAT YOU JUST HAVE TO LET THE PROCESS WORK ITSELF THROUGH AND YOU KNOW I AM VERY CONFIDENT THAT THE PRESIDENT WILL NOMINATE A SPECTACULAR CANDIDATE AND HOPEFULLY THE SENATE WILL IN VERY DUE COURSE CONFIRM HIS NOMINEE. AGAIN AS LAURA ALLUDED TO DURING THIS INTERIM PERIOD, I AM REALLY, REALLY FORTUNATE TO HAVE 3 SPECTACULAR LEADERS WHO HAVE STEPPED INTO ACTING ROLES, DR. TARA SCHWETZ, WHO IS WITH US ON THE CALL NOW, TARA WAS ON DETAIL TO ASTP WHERE SHE WAS ARCHITECTING WHAT HAS BECOME ARPA-H. AND I WAS VERY FORTUNATE TO HAVE HER COME BACK. I'M NOT SURE HOW SHE FEELS ABOUT IT BUT THIS IS REALLY BEEN AN ENORMOUS HELP TO ME BEING ABLE TO COUNT ON TARA FOR ALL MATTER OF THINGS. IN TURN, DR. COURTNEY ACKLAND WHO WILL BE JOINING YOU LATER IN THE DAY--CARRY WOLLENETZ, WHO IS THE HEAD OF SCIENCE POLICY IS ON DETAIL TO OSTP AND SO DR. LYRIC JOGGERRENSON IS ACTING DIRECTOR OF THE OFFICE OF SCIENCE POLICY, SO AGAIN, I AM VERY GRATEFUL TO THESE 3 LEADERS AND THEY ARE MAKING MY LIFE A WHOLE LOT EASIER. ONE MORE APPOINTMENT TO NOTE AND THAT IS ON MARCH 1st, THE FOUNDATION FOR NIH, THE FNIH ANNOUNCED THE APPOINTMENT OF FORMER CDC DIRECTOR AND MERK EXECUTIVE DR. JULIE [INDISCERNIBLE] AS ITS NEXT CHIEF EXECUTIVE OFFICER. JULIE HAS ALREADY ASSUMED A BOARD ROLE WITH THE FOUNDATION BUT SHE WILL NOT BECOME THE CEO OFFICIALLY OF THE FOUNDATION UNTIL MAY 16th AS SHE FINISHES UP SOME OBLIGATIONS IN HER CURRENT ROLE. SO WE'RE LOOKING FORWARD TO BEING ABLE TO WORK WITH THE DOCTOR. A NUMBER OF US HAVE WORKED WITH HER IN THE PAST AND HER PREVIOUS GOVERNMENTAL SERVICE ROLES AND SO, OBVIOUSLY WE ARE CERTAINLY LOOKING FORWARD TO THAT. FUNDING, LOTS GOING ON, WE HAD THIS FASCINATING NEXUS OF BEING FORTUNATE TO GET THE FY22 BUDGET IN THE FORM OF AN OMNIBUS OF NOT TOO LONG AGO AND THEN VERY SHORTLY THEREAFTER, THE RELEASE OF THE PRESIDENT'S PROPOSED FY23 BUDGET. AND WHEN THESE THINGS COME CLOSE TO 1 ANOTHER, IT CAN LEAD TO A LITTLE CONFUSION, BUT WE ARE FIRST, IN TERMS OF THE FY22 BUDGET WHICH WE NOW HAVE, AS IT HAS PASSED TO CONGRESS, WE ARE EXTREMELY GRATEFUL TO THE CONGRESS FOR THEIR SUPPORT. THE TOTAL BUDGET FOR FY22 IS 45.18 BILLION DOLLARS. THAT'S AN INCREASE OF 2.24 BILLION OVER FISCAL YEAR 21 AND THAT'S A 5.2% INKRES. SO THAT'S RATHER SPECTACULAR IN MY OPINION GIVEN THE STATE OF THE WORLD AFFAIRS AND SO FORTH. THE GENERAL INCREASE TO INSTITUTES AND CENTERS WAS 3.4%. A NUMBER OF SPECIFIC INCREASES WERE INCLUDED, ALZHEIMER'S DISEASE, AN ADDITIONAL $289 MILLION. CANCER RESEARCH AN ADDITIONAL 150 MILLION. RESEARCH FOR OPIOID USE DISORDER, AN ADDITIONAL 75 MILLION, THE BRAIN INITIATIVE, AN ADDITIONAL 60 MILLION AND THEN FINALLY AN ADDITIONAL $50 MILLION TO SUPPORT HEALTH DISPARITIES RESEARCH. AND SO THAT IS MUCH APPRECIATED. IN ADDITION WITHIN THIS BUDGET, CONGRESS APPROPRIATED 1 BILLION DOLLARS TO ESTABLISH THE ADVANCED RESEARCH PROJECTS AGENCY FOR HEALTH OR ARPA-H WITHIN THE DEPARTMENT OF HEALTH AND HUMAN SERVICES JUST A COUPLE DAYS AGO, THE SECRETARY ANNOUNCED THAT HE IS USING HIS AUTHORITY TO TRANSFER ARPA-H AUTHORITIES AND FUNDS TO THE NIH. THE ARPA-H DIRECTOR WILL BE A PRESIDENTIAL APPOINTEE NOT REQUIRING SENATE CONFIRMATION BUT WILL BE A PRESIDENTIAL APPOINTEE. SO THIS IS EQUIV LEAPT TO THE CANCER CENTER DISTRICTOR. SO SOME OF YOU KNOW AT NIH WE ONLY HAVE 2 POLITICAL APPOINTEES, THE NIH DIRECTOR WHICH IS A POLITICAL APPOINTEE REQUIRING SENATE CONFIRMATION AND THE NCI DIRECTOR WHO IS A POLITICAL APPOINTEE, THERE WILL NOW BE A THIRD AND THAT WILL BE THE ARPA-H DIRECTOR. HOWEVER WHAT IS UNIQUE ABOUT THIS POSITION IS IT THAT THE ARPA-H DIRECTOR WILL REPORT TO THE HHS SECRETARY. HE OR SHE WILL HAVE A DIRECT REPORT TO THE SECRETARY AND WILL HAVE AUTHORITY FOR ADMINISTRATION AND OPERATIONS OF ARPA-H. NIH IS POISED TO HELP PROVIDE ADMINISTRATIVE AND OPERATIONAL SUPPORT FOR THIS NEW ENTITY. TO GET IT UP AND RUNNING, AS RAN EDUCATIONALLY AND EFFICIENTLY AS POSSIBLE. AND AGAIN WE LOOK FORWARD TO WORKING WITH THAT INDIVIDUAL TO FACILITATE THE STAND UP OF THIS NEW ORGANIZATION. AS I MENTIONED THE PRESIDENT'S FY23 BUDGET PLAN WAS RELEASED ON MONDAY. WE NOW HAVE APPROPRIATIONS HEARINGS SET. THE HOUSE APPROPRIATIONS HEARING WILL BE ON MAY 11th, THE SENATE HEARING WILL BE ON MAY 18th GIVEN THE TIMING FOR THE APPOINTMENT OF THE NEW PERMANENT DIRECTOR, I'M IT AND SO IT WILL BE MY PRIVILEGE TO REPRESENT NIH IN THIS MANNER TOGETHER WITH A NUMBER OF INSTITUTE AND CENTER DIRECTORS WHO ARE SELECTED BY THE RESPECTIVE BODIES OF CONGRESS. SO I JUST WOULD LIKE TO CLOSE WITH A PIECE OF GREAT NEWS FOR THE FUTURE OF NIH RESEARCH. I WANT TO CONGRATULATE THE CLINICAL CENTER ON THE RECENT AWARD OF A CONTRACT FOR THE NEW SURGERY RADIOLOGY AND LABORATORY MEDICINE WING. NOW FOR THOSE OF YOU ON THE BOARD YOU KNOW THIS IS A BIG DEAL. OF COURSE, THE BOARD IS ONLY 6 YEARS OLD. THIS HAS GONE WAY BEFORE THAT IN TERMS OF PLANNING AND ASPIRATION AND SO FORTH AND SO WE'RE REALLY VERY, VERY EXCITED TO SEE THIS FRUITION OF THIS. I GUESS AT THE PRESENT TIME THE BUILD OUT DATE IS 2028. SO MOST OF YOU WILL BE ABLE TO SEE THIS AND BENEFIT FROM IT BUT REALLY LOOKING FORWARD TO THIS FOR SURE. AND SO WITH THAT, I AM VERY PLEASED TO TURN THINGS OVER TO JIM AND WISH YOU ALL THE BEST FOR TODAY'S DISCUSSIONS AND DELIBERATIONS. >> HEY, LARRY JUMP BACK IN, THAT IS FABULOUS NEWS. YES, WE'VE BEEN TALKING ABOUT THAT FOR AT LEAST 6 YEARS AS YOU SAID AND MANY PEOPLE FOR PLANE YEARS BEFORE THAT, IT'S FANTASTIC. BEFORE WE LET YOU GO, I JUST WANT TO SEE IF THERE ARE ANY QUESTIONS FOR YOU. ANYTHING ANYBODY WANTS TO RAISE? YOU CAN JUST UNMUTE YOURSELF IF YOU WANT TO ASK LARRY A QUESTION. >> SO LARRY, THIS IS STEPHANIE, JUST ACTUALLY MORE OF A CURIOSITY AND IF TIME DOES NOT PERMIT, CAN TAKE IT OFFLINE BUT CURIOUS ABOUT ARPA-H AND THE DECISION TO HAVE IT HOUSED SORT OF IN 2 DIFFERENT PLACES AND JUST WONDERING IF YOU HAVE A PERSPECTIVE AS TO WHAT THAT WILL MEAN, WHAT ARPA-H WILL ULTIMATELY BE ABLE TO ACCOMPLISH THAT IT WILL BE HOUSE INDEED 2 DIFFERENT PLACES? >> WELL, I WILL ASK TARA TO RESPOND AS WELL, BUT FROM MY PERSPECTIVE, I THINK WE HAVE, YOU KNOW THE BEST OF THE BOTH WORLDS. EVERYBODY IN CONTEMPLATING THIS NEW ORGANIZATION, INDICATE THAD IT NEEDED TO BE UNENCUMBERED AND INDEPENDENT BUT WE HAVE CERTAIN EQUITIES HERE AT NIH THAT I THINK WILL INSURE A VERY RAPID AND ROBUST START FOR THE ORGANIZATION. SO I THINK WE HAVE THE BEST OF BOTH WORLDS BUT TARA WHO ARCHITECTED THIS WHILE AT OSTP AND HAS CONTINUED TO WORK VERY HARD ON THESE ISSUES HAS JOINED US, TARA WHAT ARE ARE YOUR THOUGHTS ON THIS, PLEASE? >> YES. THANKS. I THINK YOU'RE RIGHT. YOU HIT THE NAILOT HEAD THERE. I MEAN, THERE ARE LOTS OF VERY OPERATIONAL AND STRUCTURAL FUNCTIONALITIES THAT HAVE TO BE BUILT WHEN YOU'RE BUILDING UP A BRAND NEW ORGANIZATION AND WE GET THE BENEFIT OF BEING ABLE TO LEVERAGE THOSE AT NIH AS WELL AS YOU KNOW HAVING A CLOSE CONNECTION TO MANY OF THE SCIENTISTS HERE AT NIH AND TO BENEFIT FROM SOME OF THEIR SCIENTIFIC KNOWLEDGE AND EXPERTISE, WHILE ALSO MAINTAINING AN ESSENTIAL ELMETROPOLITAN OF WHAT THEY CALL THIS ARPA-H MODEL WHICH, YOU KNOW KIND OF 1 OF THE FUNDAMENTAL TENANTS IS AUTONOMY. SO HAVING THAT DIRECT CONNECTION TO THE SECRETARY WILL SORT OF CHECK THAT BOX. IT'S ALSO SIMILAR TO HOW IN THE ENERGY SECTOR THERE'S AN ARP A-E AND SIMILAR TO HOW THEY ARE STRUCTURED WITHIN THE DEPARTMENT OF ENERGY. >> THANK YOU, TARA, I WILL ADMIT MY IGNORANCE, I DIDN'T KNOW THERE WAS AN ARP A-E. OKAY, THANK YOU. >> YEAH, THERE'S BEEN A PROLIFERATION--TO SHARE THIS INFORMATION. >> LEARNING EXPERIENCE FOR ME. >> THANK YOU. >> GREAT. ANYONE ELSE, QUESTION FOR LARRY? HAD. >> KD--SALLY HA. >> CAN YOU REPEAT THAT PLEASE? >> WHAT ARE THE ACRONYMS OR HOW DO YOU SPELL THE ARPA-H. >> IT'S-- >> GO AHEAD TARA. >> IT'S THE ADVANCED RESEARCH PROJECTED PS AGENCY FOR HEALTH. A-R-P A- H. >> ONE MORE TIME? >> A-R-P-A-H. >> OKAY, THANK YOU. ADVANCED RESEARCH PROJECT AGENCY FOR HEALTH. >> THANKS. >> IT'S A RIFF OFF OF DARPA, WHICH IS THE PROTOTYPICAL MODEL BUT THERE'S ALSO--NOW I'M OUT OF MY ELEMENT, ARP A E, ARPI,. >> ARPI IS ALSO THERE'S HS ARPA. THERE'S A LITTLE GROUP OF THEM, BUT DARPA IS THE DEFENSE VERSION BEEN AROUND SINCE THE 60S AND HAD A ROLE IN CREATING A BUNCH OF THINGS WE APPRECIATE TODAY INCLUDING INTERNET AND SELF-DRIVING CARS AND GPS. >> WE ARE NOT GOING TO HAVE A QUIZ AT THE END OF ALL OF THESE, BUT WE WILL HAVE THOSE IN THE MINUTES. SO WE CAN KEEP TRACK OF THEM. OKAY, NOT SEEING ANYONE ELSE JUMP IN, LARRY, THANKS SO MUCH FOR BEING HERE TODAY AND THANKS FOR EVERYTHING YOU'RE DOING AND YOU'RE RIGHT, YOU'RE ABLY ASSISTED BY A GREAT TEAM. >> INDEED. THANK YOU. >> AND WITH THAT, JIM, WE WILL HEAD OVER TO YOU FOR THE CEO REPORT. >> BEFORE YOU PUT UP THE SLIDES, TAKE THE SLIDES DOWN FOR JUST A MINUTE, WITH SO MANY NEW MEMBERS, I WANT TO INTRODUCE THE FOLKS HERE FROM THE CLINICAL CENTER WHRO SOME OF YOU MAY OR MAY NOT KNOW. FIRST OF ALL, FROM HERE IN THE CLINICAL CENTER, BUT SOMEBODY WHO'S A REGULAR AT THESE MEETINGS, HAS BEEN THROUGHOUT IS DR. MICHAEL GOTTESBE MAN, AND DR. GOTTESMAN IS THE DEPUTY DIRECTOR OF THE NIH FOR INTRAMURAL RESEARCH AND THE CLINICAL CENTER SITS SQUARELY IN THE MIDDLE OF THE INTRAMURAL RESEARCH PROGRAM. THE SECOND PERSON I WANT TO INTRODUCE IS COLLEEN HADIGAN, COLLEEN IS THE CHIEF MEDICAL OFFICER OF THE CLINICAL MEDICAL CENTER IF YOU REMEMBER BACK AT OUR OCTOBER MEETING, COLLEEN SIGNED THE AGREEMENT ACCEPTING THE POSITION IN THE OCTOBER MEETING WHICH WAS QUITE EVENTFUL. PIAS, [INDISCERNIBLE] IS THE CHIEF OPERATING OFFICER OF THE CLINICAL CENTER OF NIH, PIAS HAS BEEN HERE A BIT MORE THAN A YEAR OR LESS THAN I HAVE BEEN AND BARBARA JORDAN IS THE ACTING CHIEF NURSING OFFICER OR THE CLINICAL CENTER AND YOU WILL SEE THAT WE'RE IN THE PROCESS OF THE NATIONAL RECRUITING EFFORT TO FIND THE NEXT CNO FOR THE CLINICAL CENTER THERE ARE 3 PEOPLE ON THAT YOU WILL HEAR FROM A BIT, AND I WON'T INTRODUCE THEM, THAT'S DAVID LANG, CHEF OF THE PATIENT SAFETY AND CLINICAL QUALITY, AND MARILYN FARINRE, WHO IS THE CHIEF OF PHARMACY OPERATIONS WHO YOU WILL HEAR ABOUT IN A LITTLE BIT AND LAST BUT NOT LEAST, I WANT TO ACKNOWLEDGE THE EFFORTS OF NATASHA POINTER AND PAT PURRINGER, THERE ARE A LOT OF HOUSEKEEPING ISSUES TRANSFERRED FROM SORT OF THE NIH CENTRAL TO THE CLINICAL CENTER AND PAT AND NATASHA HAVE BEEN IN COMMUNICATION WITH ALL OF YOU, I THINK. I THINK YOU ALL HAVE THEIR E-MAIL ADDRESSES AND THEY HAVE BEEN VERY DILIGENT IN TRYING TO MAKE SURE THIS FIRST EPISODE OF THE CLINICAL CENTER RESEARCH HOSPITAL BOARD FOR WHICH THEY HAVE A GREAT DEAL OF RESPONSIBILITY HAS BEEN PULLED TOGETHER PRETTY WELL AND SO I WANT TO ACKNOWLEDGE THEM. AND NOW, I THINK WE CAN GO TO THE SLIDES. GO AHEAD AND GO TO THE NEXT SLIDE. SO AGAIN, WELCOME TO ALL THE NEW MEMBERS. >> BOARD BUT ALSO CONNECTED ME WITH OTHER PEOPLE INCLUDING DR. SA MITT, WHO ALSO AGREED TO BE A MEMBER OF THIS BOARD. WE GOT A REGRET YESTERDAY FROM DAVID BAUM, I'M VERY SORRY HE CAN'T BE HERE TODAY BUT DAVID WILL BE A REGULAR PARTICIPANT AND WE'RE VERY HAPPY TO HAVE ANTOINETTE, ROYSTER, THOSE WHO HAVE BEEN ON THE CLINICAL CENTER RESEARCH BOARD FOR A WHILE WILL REMEMBER ANTOINETTE AND THEY CAME FROM THE SAME RESEARCH POPULATION OR PATIENT POPULATION AND IT WAS VERY INTERESTING BUT JUST ABOUT THE TIME WE CELTED ON ASKING ANTOINETTE TO JOIN US, SHE WAS RECEIVING REQUESTS FROM BEEs FAMILY AND WONDERING WHAT WOULD HAPPEN WITH BEE'S SPOT, NOW ELLEN IS LEAVING THE CCRHB BUT SHE'S NOT LEVELS INCREASING THE PATIENT CENTER OR THE PATIENT ADVISORY GROUP. SO ELEN WE HAVE A MEETING COMING UP IN A COUPLE WEEKS, I EXPECT TO SEE YOU THERE AND AND I CAN'T WAIT TO SEE LAWN MOWER YOU'RE GOING TO WEAR FOR US ON THAT DAY. BUT ELLEN IS 1 OF THOSE SPECIAL PEOPLE WHO MAKE ITS MORE FUN TO GET UP AND COME TO THE MEETING AND THAT AND EVERY GROUP THAT'S INVOLVED IN SERIOUS BUSINESS NEEDS AT LEAST 1 PERSON WHO WILL DO THAT FOR THE GROUP AND ELLENOIR HAS BEEN THAT PERSON AT THE SAME TIME PROVIDING PROFOUND PATIENT INSIGHTS AND ASKING QUESTIONS THAT WERE IMPORTANT. NEXT SLIDE. SO WE USUALLY BEGIN THESE BY ACKNOWLEDGING THE CONTRIBUTION OF THE CLINICAL CENTER STAFF AND THIS ITERATION, WE WANT TO INDICATE HOW PROUD WE ARE OF OUR 2 BOARD MEMBERS LISTED IN THE 2022 CLASS OF TOP WOMEN LEADERS IN HEALTHCARE AND THAT'S OUR CHAIR DR. FORESE AND ALSO RUTH WILLIAMS-BRINKLEY. 1 OTHER NOTE ABOUT RUTH IS RIEWGHTD WILL BE LEAVING THE BOARD AS LAURA WILL BE LEAVES OVER THE COURSE OF THE NEXT FEW MONTHS. RUTH IS 1 OF THE HEALTHCARE EXEC TIEVERS WHO BROUGHT A NURSING BACKGROUND TO THE CLINICAL CENTER RESEARCH HOSPITAL BOARD, THE OTHER WAS JANET ERICSON, AND NOW WITH RUTH LEAVING WITH THAT LEFT A VOID IN THE--WITH SOMEBODY WHO COULD BRING THE VOICE OF THE NURSE TO THE CLINICAL CENTER RESEARCH HOSPITAL BOARD AND THAT AND IT'S A LITTLE EARLY BUT I WOULD SAY THAT I HAD A VERY GOOD--I HAD A VERY GOOD CONVERSATION YESTERDAY WITH A NURSE EXECUTIVE, NOT A NURSE EXECUTIVE BUT A CEO OF A HOSPITAL THAT YOU WOULD ALL RECOGNIZE AND VERY EXCITED ABOUT THE POSSIBILITY OF JOINING THE BOARD AND SO HOPEFULLY BY JULY, WILL HAVE THAT TAKEN CARE OF AND WILL AT LEAST BE ABLE TO HAVE AN INITIAL ANNOUNCE NLT OF A NEW BOARD MEMBER WHO WILL WHO WILL REPRESENT THE VOICE OF A GREAT HEALTHCARE EXECUTIVE AND A PREOF THEIGEIOUS ORGANIZATION, BUT ALSO WILL BRING THE NURSING BACKGROUND TO THE BOARD AND I THINK THAT THAT'S VERY IMPORTANT IN THE CLINICAL CENTER. WHERE ABOUT A THIRD OF OUR STAFF ARE NURSES AND THEY ARE THE 1 WHO IS ARE WITH OUR PATIENTS ALL THE TIME AND ARE VERY, VERY IMPORTANT FOR OUR PATIENTS SAFETY EFFORTS, EXTREMELY IMPORTANT FOR THE PATIENT EXPERIENCE EFFORTS AND HAVE BEEN GREAT SUPPORTERS OF THE CHANGES WE'VE BEEN MAKING SINCE 2017. OKAY, NEXT SLIDE. SO NOW, THEN, THAT GIVES ME A CHANCE TO BRAG ABOUT THE CLINICAL CENTER NURSING DEPARTMENT. SO THE PRESS GANEY AWARD FOR NDNQI FOR METRICS IN 2021 IS HERE IN THE CLINICAL CENTER AND WE ARE VERY, VERY PROUD OF THIS AND MANY HOSPITALS PARTICIPATE IN THIS EFFORT AND YOU CAN SEE THE PATIENT SAFETY METRICS THAT ARE INVOLVED HERE AND I WOULD SAY I HAVE 2 FOLKS FROM NCQA--IT IS SOMETHING WE'RE CELEBRATING AND IT IS 1 OF THE 6 HEGHT CARE ORGANIZATIONS TO RECEIVE THE AWARD AND WE RECEIVED THE AWARD FOR THE TOP TEACHING HOSPITAL AND JUST AS WE DID A FEW YEARS AGO WHEN WE HAD AN AWARD FROM THE NATIONAL RESEARCH NRC, NATIONAL RESEARCH GROUP OUT OF BOSTON WE WANTED TO MAKE SURE THAT EVERYTHING THAT HAD ANYTHING TO DO WITH THIS AWARD, WHICH BASICALLY MEANT ALL OF THE NURSING STAFF HAD A CHANCE TO SEE THE AWARD, HAD A CHANCE TO TOUCH IT AND HAD A CHANCE TO TO HAVE THEIR PICTURE TAKEN WITH IT AND THESE ARE A COUPLE OF THE PICTURES THAT ARE FROM THE TOUR. SO FOR THOSE WHO ARE SPORTS FANS, THIS IS SORT OF THE STANLEY CUP OR THE--OR THE [INDISCERNIBLE] FOR WINNING THE BRITISH OPEN AND IT'S OUR JOB TO MAKE SURE THAT ANYBODY WHO KNOWS AND HAD ANYTHING TO DO WITH THIS GRAND ACCOMPLISHMENT IT'S A CHANCE TO FEEL LIKE THEY'RE PART OF THIS AWARD RECEPTION. THANKS. NEXT SLIDE. WE ALSO HAVE SINCE THE LAST TIME WE MET, WE'VE HAD NIH DIRECTORS AWARDS, MORE THAN--AND THE NIH PROBABLY 40,000 STAFF MEMBERS WHO ARE ELIGIBLE FOR AWARDS AND YOU CAN SEE THAT THE CLINICAL CENTER WAS WELL REPRESENTED IN BOTH THE INDIVIDUAL AND GROUP AWARD CATEGORIES IN DECEMBER, WE DO THE CLINICAL CENTER CEO AWARDS AND I DESCRIBE THIS EVERY YEAR AND IT PERSISTS AS THE BEST DAY I HAVE IN THE CLINICAL STRRKS CAN YOU SEE THE NUMBER OF CLINICAL CENTER STAFF MEMBERS WHO ARE HONORED WITH INDIVIDUAL AND GROUP AWARDS AND THERE'S A NEW AWARD THAT'S BEEN DEVELOPED BY HHS, WHICH IS SORT OF SOMETHING BIGGER CALLED THE PART OF SOMETHING BIGGER AWARD AND IT WILL INVOLVE--IT BASICALLY INVOLVES THE ACTIVITIES OF NIH STAFF MEMBERS OR HHS STAFF MEMBERS WHEN THEY'RE AWAY FROM THE WORKPLACE BUT THEY'RE STILL CONTRIBUTING TO THE GOALS OF OF HEALTH AND HUMAN EVERYBODY'SS AND THIS GOES TO A COUPLE OF OUR STAFF MEMBER WHO IS IN THEIR OWN TIME WORKED WITH SOME OF THE MASS IMMUNIZATION SITES FOR COVID-19 VACCINES. AND SO, WE'RE--THERE ARE STILL SOME GLITCHES IN THIS AWARD AND THE RECOGNITION BUT WE HAVE WORKED OUT THE INDIVIDUAL RECOGNITION AND AGAIN, THERE WILL BE A WEBSITE AT HHS WHERE THEIR NAMES WILL LIVE FOR AS LONG AS THE WEBSITE'S THERE. NEXT SLIDE. IF YOU LOOK AT OUR STRAY --STRATEGIC PLAN, YOU WOULD KNOW THAT WE NEED TO DID A LOT OF RECRUITING TO REPLACE SENIOR RETIREMENT AGE STAFF MEMBER WHO IS ARE LEAVING THE CLINICAL CENTER AND IN ADDITION TO THAT, THERE ARE A COUPLE OF OTHER POSITIONS THAT HAVE OPENED UP THAT WE REALLY DIDN'T THINK WE WERE GOING TO HAVE TO DEAL WITH SO SOON BUT BE THAT AS IT MAY, WE HAVE TO. WE HAVE A NUMBER OF LEADERSHIP VACANCIES THAT WE'RE ACTIVELY RECRUITING FOR. THE USA JOBS HAS JUST POSTED THE ANNOUNCEMENT FOR THE CHIEF NURSING OFFICER. MARIE JOYCE AS RETIRED SINCE THE LAST TIME WE GOT TOGETHER, SHE WAS THE CFO FOR THE CLINICAL CENTER FOR A LONG TIME AND [INDISCERNIBLE] HAS ASSUMED THE RESPONSIBILITIES IN THE INTERIM BUT WE'RE IN THE PROCESS OF BEGINNING THE SEARCH FOR A NEW CFO. DR. RICK [INDISCERNIBLE] HAS DONE A GREAT JOB AS INTERIM CHIEF OF PHARMACY FOR 3 YEARS BUT IT'S NOW TIME TO BEGIN RECRUITING FOR THE PERMANENT POSITION. WE HAVE FILLED NOW THE CHIEF OF MATERIALS MANAGEMENT THAT ENVIRONMENTAL SERVICES AND THAT CAME FROM A PROMOTION IN HOUSE AND WE HAVE BOB LIMBO WHO RAN OUR OFFICE OF CLINICAL TRAINING AND MEDICAL EDUCATION FOR THE LAST SEVERAL YEARS THAT HAS RETIRED AND WE ARE IN THE PROCESS OF THAT SEARCH AS WELL. WE HAVE COMPLETED A SEARCH FOR THE DESIGNATED INSTIEWTIONZAL OFFICIAL AND ALL OF YOU KNOW THAT'S THE PERSON WHO INTERFACES WITH THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION FOR THOSE FELLOWSHIPS THAT WE HAVE HERE IN THE CLINICAL CENTER THAT ARE ACG ME RECOGNIZED. WE HAVE AN AWFUL LOT OF FELLOWSHIPS THAT ARE FAIRLY SPECIFIC--WE SPEND A LOT OF TIME WORKING ABOUT HOW WE WILL WORK IN THE NEW ENVIRONMENT, IN THE CLINICAL CENTER IT'S NOT AS MUCH AS SOME AREAS OF THE NIH WHERE PEOPLE REALLY CAN DO REMOTE WORK AN AWFUL LOT OF THE TIME. WE WILL BE DOING TELEWORK AND REMOTE WORK MORE. AND MORE STAFF MEMBERS WILL BE DOING IT FROM THE CLINICAL CENTER BUT MOST OF OUR WORK IS HERE IN THE BELLING AND SO THIS IS--IS ACTUALLY MORE I THINK OF AN ISSUE OF DISCUSSION AND DEBATE IN THE REST OF THE NIH THAN IT IS HERE. NEXT SLIDE. SO WE--ALL OF THAT YOU HAVE BEEN PART OF THIS GROUP FOR THE LAST 5 YEARS, TO KNOW THAT I HELD A TOWN HALL WITHIN THE FIRST WEEK OF TAKING THE JOB IN 2017. WE HAD TO GO TO VIRTUAL TOWN HALLS DURING THE PANDEMIC AND WE ARE STILL IN A VIRTUAL TOWN HALL ENVIRONMENT. WE DID CHANGE THE FORMAT IN A PRETTY SIGNIFICANT WAY THIS QUARTER, SO IN JANUARY, WHICH WAS THE LAST TIME WE DID A TOWN HALL, AND WE INCORPORATED MORE OF THE EXECUTIVE LEADERSHIP FROM THE CLINICAL CENTER IN THE PRESENTATION. THAT WAS VERY WELL RECEIVED, WE DO SOLICIT QUESTIONS AHEAD OF TIME AND WE DO MAKE EVERY EFFORT TO RESPOND TO THOSE. AND SO I THINK IT WAS WELL RECEIVED. WE WILL USE THIS FORMAT FOR THE NEXT YEAR OR SO AND SEE HOW IT GOES. THE NEXT TOWN HALL WILL DEAL MOSTLY WITH DIVERSITY, EQUITY INCLUSION AND ACCESSIBILITY ISSUES. I MAY HAVE A LITTLE BIT MORE OF A SPEAKING PART AT THAT 1 THAN I HAD AT THE 1 IN JANUARY, BUT THESE ARE ISSUES THAT ARE VERY MUCH ON THE RADAR SCREEN AT THE CLINICAL CENTER OF THE THE NIH AND WE WILL BE WORKING ON THOSE. NEXT SLIDE. WE HOSTED--WE CO-HOSTED WITH NCATS THE RARE DISEASE, AGAIN THIS USED TO BE HELD IN-PERSON IN OUR LARGE AUDITORIUM HERE AND THEN IT GOT TOO BIG FOR THAT, AND MOVED OVER TO THE NATCHER BUILDING AND THE LARGER VENUE THAT WAS THERE AND THEN LAST YEAR AND THIS YEAR IT HAD TO BE A VIRTUAL CONFERENCE WHICH MADE SOME OF THE LOGISTICS EASIER, IT USED TO BE THE HARDEST DAY TO GET ON CAMPUS AT THE NIH BECAUSE WE HAD HUNDREDS OF PEOPLE TRYING TO DRIVE ON CAMPUS WHO WERE NOT USED TO COMING ON CAMPUS, AND SO, THE VIRTUAL MEETING HELPED US A LOT IN THAT REGARD BUT IT IS SOMETHING THAT THE CLINICAL CENTER HAS BEEN VERY PROUD TO CO-HOST FOR A NUMBER OF YEARS AND WAS A BIG SUCCESS. AGAIN, I THINK 3 OR 4 MEMBERS OF CONGRESS WHO ARE PART OF THE RARE DISEASE CAUCUS MADE APPEARANCES. IT'S REALLY BECOME QUITE AN EVENT. NEXT SLIDE. I WILL SHOW YOU A COUPLE SLIDES THAT SHOW YOU SOME CHANGES THAT OUR OFFICE OF COMMUNICATIONS AND MEDIA RELATIONS AND PATIENT RECRUITMENT OR OCMR HAVE MADE AND THESE HAVE TO DO WITH LEVERAGING SOCIAL MEDIA TO--IN AN EFFORT TO ADVERTISE OUR STUDIES TO GET AND FIND PATIENTS WHO MIGHT BE INTERESTED IN PARTICIPATING IN STUDIES AND IT'S MORE ACTIVE BUT STILL INTEREST BASED. PEOPLE CAN GO BY IT VERY QUICKLY IF THEY WANT TO AND WE ARE ABLE TO TARGET OUR FACEBOOK ADS AND OTHER SOCIAL MEDIA EFFORTS TO POPULATIONS THAT WE THINK MIGHT BE ENRICHED FOR THE KINDS OF INTERESTS WE'RE LOOKING FOR. THIS IS AN INCREDIBLY COST EFFICIENT OR LOW COST EFFORT AND WE--ALL OF THIS ACTIVITY FOR ALL OF THE INSTITUTES THAT ARE ON THEIR, I THINK IS COSTING US LESS THAN $5000 PER YEAR AND AGAIN WE CAN NARROWLY TARGET OR WE CAN GO MUCH, MUCH MORE BROADLY. WE HAVE--WE'VE HAD AT LEAST A HALF MILLION PEOPLE SEE OUR FACEBOOK POSTS AND WE HAVE A NUMBER OF POST ENGAGEMENTS AND WE ARE NOW TRACKING THOSE PATIENTS WHO ACTUALLY CALL US, MEDIA EFFORTS TO TRY TO IMPROVE OUR OUTREACH AND PATIENT RECRUITMENT EFFORTS. NEXT SLIDE. AND AGAIN, WE LIKE FOR PEOPLE TO KNOW THAT THE CLINICAL CENTER IS AT THE HOSPITAL AND IS AT THE NIH AND WE'RE VERY PROUD OF WHAT WE DO AND WE WANT PEOPLE TO KNOW ABOUT IT. WE HAVE A BIT OF AN IDENTITY ISSUE IN THAT WE'RE A CENTER AND WE'RE FOCUS ON THE CALLED A HOSPITAL, SO THESE EFFORTS AGAIN ARE ALSO LOW COST BUT THEY'RE TRYING TO GET OUR PRESENCE AND OUR EFFORTS OUT INTO THE COMMUNITY. NEXT SLIDE. THIS IS OUR AVERAGE DAILY CENSUS AND AS YOU MIGHT IMAGINE, WE HAVE A 200 BED HOSPITAL. WE'VE BEEN OPERATING AT A MUCH LOWER CENSUS THROUGHOUT THE PANDEMIC AND WITH THE OMICRON VARIANT AND THE USUAL DROP IN DECEMBER HIT AT THE SAME TIME, WE ARE RECOVERING FROM AND WE ARE IN A RECOVERY MODE. OUR PATIENT POPULATION IS GOING UP, YOU WILL SEE ON THE NEXT SLIDE THAT OUR OUTPATIENT NUMBERS ARE GOING UP AND OUR NEW PATIENT NUMBERS ARE GOING UP WHICH IS REALLY, REALLY IMPORTANT TO US. OBVIOUSLY 2021 WAS ALSO A PANDEMIC YEAR AND WAS WELL BELOW OUR 3 YEAR AVERAGE, IT'S SPOTTY. OUR CANCER UNITS AND BONE MARROW TRANSPLANT UNITS HAVE BEEN VERY BUSY AND VERY FULL. SOME OF THE OTHER UNITS THAT TAKE CARE OF PATIENTS WHO CAN WAIT FOR A LITTLE BIT MORE OF THE RESOLUTION OF THE COVID-19 ACTIVITY ARE NOT AS BUSY. WE JUST HEARD THIS MORNING THAT IN MARCH, OUR O. R.s HAD THE BUT BUSIEST MONTH WE'VE EVER RECORDED. SO OUR ACTIVITY IS COMING UP AND WE LOOK FORWARD TO BEING BUSIER DURING THE SUMMER MONTHS. NEXT SLIDE. SO THESE ARE IN PATIENT ADMISSIONS, STILL DOWN ON 21, BUT IF YOU GO DOWN AND LOOK AT OUTPATIENT VISITS YOU CAN SEE WOO HAVE A 20% INCREASE IN THE NUMBER OF OUTPATIENT VISITS AND ANOTHER--AND OUR NEW PATIENTS, THE LAST SLIDE, THE LAST LINE ON THE SLIDE THERE A 10% INCREASE. NEXT SLIDE. AS MANY OF YOU MAY BE AWARE BEFORE THE PANDEMIC WE HAD NO TELEHEALTH PRESENCE AND WE HAD VERY LIMITED AND I WOULD SAY, OUR VISION FOR THE USE OF TELEHEALTH WAS SORT OF FOCUSED ON THE RESEARCH ENVIRONMENT, BUT WITH THE PANDEMIC, WE'VE FOUND THAT WE NEEDED TO USE TELEHEALTH TO A MUCH GREATER EXTENT. OUR HEALTH INFORMATION MANAGEMENT FOLKS AND THE DEPARTMENT OF CLINICAL RESEARCH INFORMATICS DEVELOPED A PLATFORM. WE DEVELOPED POLICY, AND YOU CAN SEE AT THIS TIME, A YEAR AGO, WE WERE SEEING OVER 1200 PATIENTS A MONTH. YOU CAN'T DRAW BLOOD IN A TELEHEALTH VISIT, YOU CAN'T DO AN IMAGING STUDY IN A TELEHEALTH VISIT. SO THERE ARE--CAN YOU DO A LOT OF FOLLOW UP, BUT THERE ARE SOME THINGS THAT YOU CANNOT DO AND SO, AFTER THAT INITIAL SURGE, THINGS DROPPED OFF A LITTLE BIT BUT WE'RE STILL VERY MUCH IN THE 800-THOUSAND VISITS A MONTH TELEHEALTH WORLD AND IT'S BEEN VERY IMPORTANT TO US DURING THE PANDEMIC. NEXT SLIDE. YOU'RE GOING TO HEAR A LOT FROM CLIFF LANE A LITTLE BIT WHO WILL TALK AND GIVE THE COVID-19 UPDATE, WE REMAIN AND OUR BASIC POSTURE DURING THE PANDEMIC. WE HAVE A HIGH PERCENT OF PATIENT WHO IS ARE IMMUNO SUPPRESSED AND IMMUNO COMPROMISED AND WE HAVE A NUMBER COME TO US THAT WAY BECAUSE OF THEIR DISEASE AND WE HAVE A NUMBER OF THEM THAT WAY BECAUSE OF THE TREATMENTS WE RECEIVE HERE IN THE CLINICAL CENTER. AND SO, WE ARE ALWAYS--WE HAVE A VERY HIGH FOCUS ON INFECTION, CONTROL AND PREVENTION OF THE SPREAD OF INFECTION FROM STAFF TO PATIENT--COMMUNITY AND WE'RE BEGINNING TO PEEL BACK ON THOSE A LITTLE BIT NOW AND WE'RE DOING THAT NOT BECAUSE WE THINK THE PANDEMIC IS OVER, BUT BECAUSE WE THINK FOR THE LAST 2 YEARS WE DEMONSTRATED THAT WE CAN TAKE CARE OF PATIENTS SAFELY DURING THIS PANDEMIC AS LONG AS WE PAY ATTENTION TO SOME FAIRLY BASIC TENANTS. SINCE 2 APRIL SO EXACTLY 2 YEARS WE'VE ALL BEEN MASKED, EVEN WHEN OTHERS BEGAN UNMASKING, WE KEPT OURS ON AND WE'VE--WE STILL GIVE YOU A CLEAN MASK WHEN YOU COME IN THE HOSPITAL. IT'S BEEN A LONG TIME SINCE WE'VE--AND WE HAVE MAINTAINED VERY DETAILED CAREFUL CONTACT TRACING THROUGHOUT THE PANDEMIC. BOTH TARA P A LMORE WHO IS OUR CHIEF OF HOSPITAL EPIDEMIOLOGY AND BROOK BECKER WHO IS CURRENTLY OUR CHIEF OF HOSPITAL EPIDEMIOLOGY AND THEIR STAFFS, THEY HAVE DONE VERY METICULOUS CONTRACT TRACING WITH THE OCCUPATIONAL MEDICINE SERVICE AND IT'S BEEN ALMOST 2 YEARS SINCE WE'VE DOCUMENTED OUR PATIENT TO STAFF TRANSMISSION AND WE HAVE YET TO DOCUMENT A SINGLE STAFF TO PATIENT TRANSMISSION. IT'S A TRACK RECORD, WE'RE VERY PROUD OF BUT WE--IT'S ONLY THROUGH THE DEDICATION OF THE STAFF AND THEIR WILLINGNESS TO PUT UP WITH ALL OF THE EXTRA EFFORT INVOLVED IN TRYING TO MAINTAIN THAT RECORD. BUT NOW, WE ARE THE NIH AND IN ORDER TO PROVE PATIENT TO STAFF TRANSMISSION, IT REQUIRES GENOMIC ANALYSIS TO INDICATE THAT WE ARE DEALING WITH, YOU KNOW THE SAME VIRUS. BUT STILL, WE THINK OUR TRACK RECORD IS PRETTY GOOD AND IT'S BECAUSE THE STAFF HAVE BEEN WILLING TO DEAL WITH ALL OF THESE ISSUES AND PERIODICALLY, WE HAVE LAPSES BUT, FOR THE MOST PART, EVERYBODY'S BEEN VERY COOPERATIVE. NEXT SLIDE. >> THESE ARE JUST SOME NUMBERS, THE SCREENING WE'RE RAPIDLY APPROACHING 3 MILLION PERSONS WHO HAVE COME THROUGH THE DOOR AND ASYMPTOMATIC TESTING AND DURING THE OMICRON, THE DAYS OF OMICRON, MAYBE 1 OUT OF 20 THAT WE WERE TESTING WERE EITHER ASYMPTOMATIC SITE WERE TESTING POSITIVE, WE'RE NOW DOWN TO ABOUT 1 OUT OF 700 OR 1 OUT OF A THOUSAND. NNEXT SLIDE. AND THESE ARE STILL THE THINGS WE DO AND WE EMPHASIZE REGULARLY AND WE I WOULD SAY THE FACE SHIELDS AND THE GOGGLES ARE THE THING WE HAVE TO REMIND FOLKS ABOUT THE MOST OFTEN. NEXT SLIDE. AS ALL OF YOU ARE AWARE, THIS IS--THIS IS AN ISSUE FOR ALL OF US AND IT'S AN ISSUE, IT'S A NATIONAL ISSUE. IT'S NOT LIMITED TO US IN HEALTHCARE BUT IT'S A REALLY IMPORTANT ISSUE TO THE NIH, IT'S REALLY IMPORTANT ISSUE TO THE CLINICAL CENTER AND SO, WE HAVE LAUNCHED A COMPREHENSIVE DIVERSITY EQUITY INCLUSION AND ACCESSIBILITY PROGRAM WITH AN ANOWNTMENT IN JANUARY. WE HAVE--WE LOG OUR ACTIVITYS ON A SPECIAL WEBPAGE AND WE HAVE FORMED AN ADVISORY COMMITTEE THAT REPORTS DIRECTLY TO ME ON THESE ISSUES. NEXT SLIDE. WE POSTED A VIDEO THAT INCLUDED A NUMBER OF OUR STAFF AND WE HAVE SET ASIDE RESOURCES TO SUPPORT THESE EFFORTS. WE HAVE DONE SOME--HAVE REGULAR ASSESSMENTS OF OUR CLINICAL CENTER WORKFORCE DEMOGRAPHICS AND IN ADDITION WE HAVE COMPLETED A SURVEY THAT ABOUT A THIRD OF THE CLINICAL CENTER STAFF RESPONDED TO THAT WE HAVE SEEN THE RESULTS OF AND WE KNOW IT CLEARLY INDICATES THAT THERE'S SOME AREAS WE NEED TO WORK ON. AND THAT SURVEY IS BEING FOLLOWED UP WITH FOCUS GROUPS OR WHAT I THINK IS HAS BEEN TERMED LISTENING SESSIONS TO TRY TO GAIN MORE INSIGHTS INTO PERCEPTIONS AND AS WELL AS REALITY AND WHAT IS BEHIND THEM. TODAY IS 1 APRIL AND TODAY WAS OUR DAY TO TURN IN OUR INITIAL EFFORT AT NIH RACIAL AND ETHNIC EQUITY PLAN OR REEP AND I'VE BEEN WORKING DALE WEB CONNECTED THE GROUP FROM THE CLINICAL CENTER OVER THE COURSE OF THE LAST 2 WEEKS TO GET THAT INTO FINAL FORM AND WE'RE PRETTY HAPPY--PLAN SO FAR. IT'S A LIVING DOCUMENT. WE'RE CERTAINLY NOT DONE. IF WE DO EVERYTHING THAT WAS IN THE PLAN, WE STILL WOULDN'T BE DONE, THERE WILL BE MORE INITIATIVES ADDED OVER TIME BUT THIS WAS TURNED IN, ACTUALLY IT'S DR. SCHWETZ, AND DR. TABAK WHO ARE THE ARBITERS OF WHETHER OUR PLAN MEETS THE MARK. AND WE LOOK FORWARD TO THEIR FEEDBACK AND I'M SURE THEY'LL HAVE SOME AND WILL NEED TO GO BACK AND MAKE SOME CHANGES. AND WE'RE ALREADY RECEIVING SOME FEEDBACK FROM OUR STAFF, BUT IN GENERAL MOST OF THE FEEDBACK'S BEEN PRETTY GOOD. NEXT SLIDE. WE HAD BLACK HISTORY MONTH LAST MONTH AND THIS IS--WE JUST FINISHED WOMEN'S HISTORY MONTH AND THESE MONTHS, I THINK WE ARE DOING A BETTER JOB OF ACKNOWLEDGING AND RECOGNIZING AS PART OF OUR OVERALL EFFORT, THIS IS THE STUFF THAT'S EASY TO DO WITH OUR RACIAL AND ETHNIC EQUITY PLAN. WE REALLY TRY TO GET TO THE SUBSTANCE OF WHAT THE ISSUES ARE, WE DID NOT LOOK FOR LOW HANGING FRUIT. WE TACKLED--WE DID A CAREFUL GAP ANALYSIS WHERE THE BIGGEST PROBLEMS WERE AND WE DESIGNED INITIATIVES TO ADDRESS THE GAPS, NOT JUST LOOK AT ACTIVITIES THAT WOULD BE NONCONTROVERSIAL AND EASY TO DO. NEXT SLIDE. FOR THE--THIS IS ESPECIALLY FOR THE NEWER MEMBERS OF THE BOARD BUT IN TWEBT 19 WE PUBLISHED THIS DOCUMENT CALLED THE STRATEGIC PLAN WHICH WAS THE NIH CLINICAL CENTER AT 65 YEARS OF EXISTENCE. PEOPLE, PLACES, CAPABILITIES, IT WILL BE THE FOCAL POINT FOR OUR JULY PRESENTATIONS TO THE CLINICAL CENTER RESEARCH HOSPITAL BOARD. AND I THINK IT WILL BE A GREAT WAY FOR THE NEWER MEMBERS TO FIND OUT WHAT WE'VE BEEN DOING EVEN DURING THE PANDEMIC TO TRY TO GET AT THE STRATEGIC ISSUES AND AS WELL AS SOLICIT YOUR THOUGHTS ON WHAT THE NEXT DOCUMENT THAT'S GENERATED FOR THE STRATEGIC DIRECTION SHOULD LOOK LIKE. NEXT SLIDE. OKAY, THIS IS FOR TODAY'S AGENDA AND WE'RE PRETTY MUCH ON TIME WHICH GOOD. THE NEXT PRESENTATION WILL BE DAVID LANG CHIEF OF OFFICE PATIENT SAFETY AND CLINICAL QUALITY, AND DAVID WILL GIVE AN UPDATE ON THE CLINICAL METRICS. THESE ARE ALSO POSTED ON THE CLINICAL CENTER WEBSITE. AFTER DAVID PRESENTED LAST TIME, HE'S PRESENTING THIS TIME, FOR THE JULY MEETING, THE CHANCES ARE THAT THESE WILL BE PROVIDED TO YOU IN A PRESENTATION, BUT MAY BE NOT ON THE AGENDA. THIS HAS BEEN A ROUTINE PRESENTATION AT JUST ABOUT EVERY CLINICAL CENTER RESEARCH HOSPITAL BOARD. AND THEN WE WILL HAVE A PRESENTATIONOT COVID-19 UPDATE. I KEEP THINKING THIS SHOULD BE THE LAST 1 OF THOSE, BUT YOU NEVER KNOW. WE'RE VERY GRATEFUL IN THE CLINICAL CENTER TO HAVE DR. CLIFF LANE WHO IS THE CLINICAL DIRECTOR FOR NIAID WHO WILL PROVIDE THAT FOR US. AFTER DISCUSSION REGARDING THAT PRESENTATION, MARILYN FARINRE HO IS THE CHIEF OF PHARMACY FROM THE PHARMAC SKPE BAKUGAN WE ARE WITHIN THE PROCESS, WE ARE WITHIN WEEKS OF MOVING BACK INTO THE PERMANENT HOME OF THE PHARMACY AND FOR THOSE OF YOU THAT HAVE BEEN HERE FOR 5 OR 6 YEARS YOU WILL KNOW IT'S JUST ABOUT HOW THE RED TEAM STARTED BUT IT WASN'T JUST ABOUT THE PHARMACY BUT IT WAS ABOUT THE PHARMACY SO WITH THE MOVE BACK WE BEGIN THE PROCESS OF REALLY HAVING PHARMACY FACILITIES AND PHARMACY OPERATIONS THAT THE CLINICAL CENTER REALLY NEEDED. THIS HAS BEEN--THIS HAS REALLY BEEN--IF YOU COUNT THE PLANNING, IT'S BEEN 7 YEARS IN THE PLANNING, THE PHARMACY STAFF HAS BEEN OPERATING OUT AT SWING SPACE AND DOING A GREAT JOB OVER THE COURSE OF THE LAST 3 OR 4 YEARS AND THEY'RE LOOKING FORWARD TO GETTING BACK IN 1 LOCATION SO MARILYN WILL DESCRIBE THAT FOR YOU. AFTER THE BREAK, THEN DAN WHEELAND WILL UPDATE YOU ON IMPORTANT CLINICAL CENTERS FACILITIES PROJECTS AND THEEN WILL VERMEN INFECTED A RERESEARCH PRESENTATION BY DR. MARSTON LINEHAN KOOH IS THE CHIEF OF THE UROLOGIC SURMINGRY AND THE UROLOGIC ONCOLOGY BRANCH, CENTER FOR CANCER RESEARCH, NCI. AND OVER A PERIOD OF YEARS WAS THE LARGEST IN THE CLINICAL CENTER AND HIS PRESENTATION ILLUSTRATES WHAT THE CLINICAL CENTER CAN DO WITH THE ABILITY TO SUSTAIN THESE PROGRAMS OVER LONG PERIOD OF TIME AND BRING PATIENTS IN WITHOUT HAVING TO WORRY ABOUT WHETHER THEIR INSURANCE WILL HELP PAY THE BILLS. SO THAT'S WHAT WE HAVE BY THE WAY FOR AGENDA TODAY. SO LAURA I WILL NOW OPEN FOR QUESTIONS AND/OR COMMENTS. >> PERFECT. THANK YOU JIM. LET'S TAKE THE SLIDES DOWN IF WE COULD. LET ME SEE IF ANYBODY HAS A QUESTION FOR JIM, I THINK IT WILL BECOME OBVIOUSLY OVERTIME AND I SEE JOHN GALLEN JOINED US, GOOD TO SEE YOU AS ALWAYS. ANTOINETTE, I SEE YOUR HAND IS UP. >> DR. GILMAN, I THINK YOU MAY HAVE ALREADY ANSWERED THE QUESTION BUT YOU MENTION TD ON FACEBOOK THAT THAT'S ANOTHER MEDIUM WHEREBY WE'RE TRYING TO RECRUIT MORE PATIENTS. AND ON THERE, I THOUGHT IT SAID REMOTE CLINICAL STUDY? WHAT EXACTLY IS THAT AGAIN? AND--AHEAD. >> SO REMOTE CLINICAL STUDIES COULD VOLVE STUDIES WHERE THE PATIENTS DON'T EACH HAVE TO COME TO THE HOSPITAL. >> SO WHAT IF THEY NEED BLOOD WORK OR ULTRA SOUND OR JUST STUDIES THAT DON'T REQUIRE BLOOD WORK. >> YEAH, SO IT COULD BE SURVEY INFORMATION, OKAY AND YOU KNOW THERE IS THE ABILITY TO HAVE OR THE ABILITY FOR SOME STUDIES FOR PATIENTS WHO NEED TO HAVE LAB WORK GO TO LABCORP OR ANOTHER COMMERCIAL PROVIDER AND HAVE THEIR BLOOD DRAWN. AGAIN, THIS IS NOT JUST AT THE CLINICAL CENTER, THIS IS BECOMING A THING AT LOTS OF PLACES TO HAVE THE ABILITY TO DO STUDIES OF THIS KIND AND AGAIN, YOU HAVE TO HAVE THE RIGHT DOCUMENTATION, YOU HAVE TO--I MEAN, THEY HAVE TO MEET INCLUSION CRITERIA, THEY HAVE BE CAREFULLY SCREENED. THEY HAVE TO FILL OUT AN ELECTRONIC CONSENT, BUT THIS IS STUDIES PATIENTS AND THEIR ENVIRONMENT RATHER THAN OUR ENVIRONMENT. >> ALL RIGHT. THANK YOU. >> RICK? >> RICK? >> JIM, THANKS FOR A TERRIFIC UPDATE, 2 COMMENTS. AS YOU THINK ABOUT THE DNI ANDA WORK, AND LOOKING AT THE DEMOGRAPHICS OF THE NIH CLINICAL CENTER, I HOPE WE WILL DO THAT BY JOB CLASS. THE AGGREGATE PICTURE IS 1 THING BUT WHAT WE SEE OFTEN IS THAT PEOPLE OF COLOR TEND TO BE RELEGATED TO THE LOWER RANKS OF THE INSTITUTION SO I THINK THAT WILL BE HELPFUL AND OBVIOUSLY WE'RE ALL KEENLY AWARE OF THE GREAT WORK YOU AND JOHN GALLAN HAVE DONE IN CREATING PIPELINES FOR INVESTIGATORS FROM HBCUs AND OTHER ORGANIZATIONS, SO I WOULD BE VERY INTERESTED IN SEEING HOW THAT WORK TRANSLATES INTO THE DEMOGRAPHIC OF CERTAIN JOB CLASSES. >> YEAH, LET ME MAKE A COUPLE OF COMMENTS, FIRST OF ALL WE HAVE THAT INFORMATION BY THE KIND OF JOB AND THE LEVEL. AND THERE IS AN INITIATIVE THAT IS FOCUSED SPECIFICALLY ON THE ISSUE YOU POINTED OUT THAT IS IT ISN'T ENOUGH JUST TO HAVE PEOPLE OF COLOR OR HISPANIC STAFF IN THE CLINICAL CENTER BUT YOU HAVE TO LOOK AT NOT ONLY THE JOB SERIES BUT ALSO THE LEVEL. AND THAT'S WHERE WE COME UP SHORT AND I DON'T THINK THAT MAKES US UNIQUE, I THINK THERE ARE AN AWFUL LOT OF GROUPS THAT ARE LIKE THAT AND SO THERE IS 1 INITIATIVE WHERE WE ARE TRYING TO TO GETTA THAT. THAT'S NUMBER 1. NUMBER 2 TARA IS IN THE MEETING AND SHE'S HEARD LARRY TALK ABOUT, YOU KNOW WE CAN'T BE SATISFIED WITH PIPELINE INIT WHYATIVES. WE HAVE TO--PIPELINE INITIATIVES ARE FINE--NO MORE THAN 5 OR 6 INITIATIVES TO BETO BEGIN WITH BECAUSE THESE ARE THINGS WE'RE REALLY GOING TO DO, THESE ARE NOT THINGS WE ARE GOING TO TALK ABOUT DOING SO IT WON'T BE A BUNCH OF MOTION, WE WILL ACTUALLY DO--WE ACTUALLY HAVE THE SURPRISING THING TO ME IS WE HAVE A LOT OF BASE LINE DATA AS YOU KNOW, THE HARDEST PART OF TRYING TO MAKE SOMETHING BETTER IS BEING PATIENT WHILE YOU FIGURE OUT WHAT THE BASE LINE IS, BUT IT'S NOT PERFECT DATA, IT'S NOT ALL THE DATA WE WOULD WANT TO HAVE BUT WE HAVE PRETTY GOOD DATA DISP AND WE HAVE DATAS ABOUT REALITY AND WE HAVE DATA ABOUT PERCEPTIONS AND SO, BUT I SAID, LET'S LIMIT THE PIPELINE INITTIAIVE ITS TO 1 BECAUSE OTHERWISE WE WILL SPEND ALL OF OUR TIME TALKING ABOUT THE PIPELINE AND I'M NOT SAYING THE PIPELINE ISN'T IMPORTANT, I'M JUST SAYING, WORKING ON THE PIPELINE ISN'T SUFFICIENT AND THAT'S WHAT WE'VE DONE AND IT DOES FOCUS A LITTLE BIT ON OUR RELATIONSHIP HBCUs AND OTHER MINORITY SERVING INSTITUTIONS AND AMONG OTHER THINGS DOES A BETTER JOB OF TRYING TO FIGURE OUT WHETHER THAT IS WORKING. AND SORT OF THE PROGRAM EVALUATION PIECE BY BEING ABLE TO TRACK THE CONTACT WE MAKE WITH HBCUs AND MINORITY SERVING INSTITUTIONS. WE SPENT A LOT OF TIME TALKING TO STUDENTS AND OTHERS IN THOSE INSTITUTIONS BUT WE HAVE NO DATA TO SHOW WHETHER THOSE FOLKS ACTUALLY APPLY FOR NIH OPPORTUNITIES OR ARE ACCEPTED FOR NIH OPPORTUNITIES AND WE NEED TO FIGURE THAT OUT. HEY, CRAIG, THANKS. >> LET'S GO TO CRAIG AND THEN JOHN. >> MORNING JIM AND LAURA, THANKS FOR HAVING ME, I HAVE--I HAVE A QUESTION ABOUT CENTER OCCUPANCY FOR MANY HEALTH SYSTEMS AND THERE ARE OTHERS ON THE CALL THAT CAN ADDRESS THIS MORE SPECIFICALLY. WHEN YOU EXTRACT COVID RELATED VOLUMES OF ADMISSIONS, IT LOOKS LIKE HEALTH SYSTEMS ARE SETTLING IN AT OCCUPANCY RATE THAT'S LOWER THAN PRECOVID. ANYWHERE FROM 10-15%. SO HOW ARE YOU THINKING ABOUT THAT FROM THE CENTER PERSPECTIVE? O. R.s ARE CLEARLY BUSY, NEW MEMBERSHIP IS UP BUT DO YOU PREDICT YOU'RE GOING TO SETTLE INTO A NEW NORMAL WHERE OCCUPANCY PER PATIENT OR PER MEMBER IS LOWER THAN WE SAW BEFORE COVID? >> WHAT I THINK WILL HAPPEN, CRAIG, IS THAT FIRST OF ALL, OUR COVID-19 OCCUPANCY NEVER WAS THAT OF A COMMUNITY HOSPITAL. EVERY COVID PATIENT WAS ON A RESEARCH PROTOCOL. WE DID TAKE A VERY SMALL NUMBER OF PATIENTS FROM THE STATE OF MARYLAND WHEN THEY WERE OVERRUN ESPECIALLY IN THE DECEMBER TIME FRAME OF 2020. SO THAT--BUT I THINK OUR OCCUPANCY HAS BEEN DOWN BECAUSE OF LIMITATIONS ON TRAVEL AND THE FACT THAT YOU KNOW 50% OF OUR RESEARCH PROTOCOLS ROUGHLY ARE NATURAL HISTORY PROTOCOLS. THEIR PATH ARE INTERVENTIONAL PROTOCOLS, AND HALF ARE NATURAL HISTORY PROTOCOLS, SO IF YOU ARE ENROLL NOTHING AN NIH STUDY WHICH WAS MORE OF A NATURAL HISTORY PROTOCOL AND YOU--AND YOU HAD TO TRAVEL A LONG WAY INCLUDING INTERNATIONALLY, THEN MAYBE THAT'S BEST TO PUSH THAT OFF. SO I THINK WE WILL GET BACK TO WHERE WE ARE AS A RESEARCH HOSPITAL. WE WILL NEVER OCCUPY 80-85% OF THE BEDS BECAUSE WE HAVE A NUMBER OF SPECIALTY BEDS THAT YOU CAN'T--IT'S NOT A GENERAL MED SURGE POPULATION, BUT I THINK WE WILL GET BACK TO THAT 3 YEAR AVERAGE OVER THE COURSE OF THE NEXT YEAR OR SO GREAT, THANK YOU. >> THANK YOU. >> THANK YOU, I JUST WANTED TO EXPAND A LITTLE BIT ON THE COMMENT ABOUT DIVERSITY ACROSS THE RESEARCH PROGRAMS WE VIEW OUR JOB AS MORE DIVERSITY WITHIN THE CLINICAL CENTER ACTIVITIES BUT REALLY ACROSS THE WHOLE INTRAMURAL PROGRAM FOR CLINICAL RESEARCH AND THE APPROACH OF ESTABLISHING REGIONAL PARTNERSHIPS WITH NOW 9 INSTITUTIONS IS HELPING, PARTICULARLY OUR PARTNERSHIP WITH HOWARD UNIVERSITY--THE HEART LUNG AND BLOOD INSTITUTE, THE CHILD HEALTH INSTITUTE AND OTHERS AT NIAID HAVE REALLY ESTABLISHED NEW PROGRAMS THAT ARE BRINGING A WHOLE SPECTRUM OF INVESTIGATORS TO THE NIH FROM UNDERGRADUATE STUDENTS TO MEDICAL STUDENTS TO DENTURED TRACKS, ET CETERA AND SO I THINK WHEN WE HAVE AN OPPORTUNITY TO PRESENT HOW WE'VE DONE, YOU WILL BE PLEASED, AT LEAST WE'RE PLEASED THAT PROGRESS IS BEING MADE THROUGH THESE PARTNERSHIPS WITH OTHER INSTITUTIONS. >> THANK YOU. GOOD TO HEAR AND LOOK FORWARD TO HEARING MORE OVER TIME. I DON'T SEE ANYONE ELSE WITH A HAND UP SO I THINK WE WILL TURN IT OVER TO DAVID LANG. >> HI, GOOD MORNING, I WILL SHARE MY SCREEN REAL QUICK. AND OKAY, THAT SHOULD DO IT. ALL RIGHT. >> ALL RIGHT, SO GOOD MORNING EVERYBODY, I AM DAVID LANG, I AM THE OFFICE OF PATIENT SAFETY AT THE CLINICAL CENTER, I WOULD LIKE TO THANK THE COLLEAGUES ACROSS THE CLINICAL CENTER WHO PROVIDED THIS DATA AND WHO ALSO MORE IMPORTANTLY EVERY DAY ARE WORKING HARD TO MAKE SURE THAT THESE METRICS GO IN THE RIGHT DIRECTION. AS DR. GILMAN ALLUDED TO EVEN IF WE ARE AT OR WHERE WE WANT TO BE WITH OUR BENCHMARKS OR GOAL IS ULTIMATELY 0 HARM SO WHETHER HUNDRED PERCENT OR 0% DEPENDING ON WHICH WAY THE METRIC IS GOING. THE FIRST TOPIC I WILL TALK ABOUT IS EFFECTIVE CONTROL METRIC. WE SEE OUR HAND HYGIENE DATA THESE ARE WHERE STATE REGULATOR OF ARE ASKED TO JUST OBSERVE AS YOU SEE ANYBODY GOING IN THE ROOM, DID THEY WASH THEIR HANDS, USE HAND HYGIENE AND THE SAME WHEN THEY COME OUT AND TO ENTER THESE IN AND WE ENCOURAGE STAFF TO DO THIS, YOU KNOW AGAIN WITHOUT OTHERS KNOWING SO IT'S NOT A MATTER OF OH THEY'RE HERE, LET'S TAKE A ELECTRIC AT IT AND AND AS CAN YOU SEE, WE HAVE BEEN CONSISTENT IN THE 95% AREA AND OF COURSE WE WOULD LIKE TO BE A AIAN HUNDRED PERCENT FOR THAT. LOOKING AT RATES, AFTER HAVING SEEN A REDUCTION IN THE PREVIOUS 5-QUARTERS WE DID SEE AN INCREASE IN THE PAST 2. I WOULD LIKE TO POINT OUT THAT THIS INCREASE, THESE ARE LOW NUMBERS, THE INCREASE REPRESENTS 1 ADDITIONAL CLABSI EACH QUARTER COMBINED WITH DECREASED LINE DAYS SO THAT THE PERCENTAGES YOU KNOW SEEMS A LOT HIGHER, NOW THAT SAID WHAT OUR HOSPITAL ADVICES FOR EVERY CLABSI, THERE'S INVESTIGATION, INCLUDING NURSING AND HOSPITAL EPIDEMIOLOGY SERVICE TO SEE BOTH WHAT HAPPENED DURING THAT EVENT AND ALSO SEE IF WE'RE SEEING TRENDS. AND WE HAVE IDENTIFIED OPPORTUNITIES WHICH HAVE ALREADY BEEN PLACED TO REEDUCATE AND REDEDICATE THROUGH THE BEST PRACTICES OF LINE CARE AND THESE DATA, ALBEIT LOW, HELP US KNOW THAT WE NEED TO KEEP PUSHING AND MAKING SURE THOSE PRACTICES ARE ALWAYS BEING USED. OT NEXT SLIDE WE WILL SEE THE IACU NUMBERS AND THESE AGAIN WITH A SMALLER POPULATION, MORE VARIABILITY, THEY HAD GONE UP A BIT AND THEN CAME BACK DOWN, THE BENCHMARK USED FOR THIS IS THE NHSN NATIONAL HEALTHCARE SAFETY NETWORK, WHICH YOU SEE ENDED HERE, THERE'S NEW DATA COMING OUT FOR 2022, BUT THOSE HAVEN'T BEEN PUBLISHED YET, SO WE WILL HAVE A NEW BENCHMARK COMING UP FOR THAT. STAYING IN THE ICU, WE SEE OUR [INDISCERNIBLE] WHICH IS THE URNANNY TRACT INFECTION RIGHT AND THIS HAS GONE DOWN TO 0 AND REMAINED AT 0 FOR 3-QUARTERS WHICH IS OF COURSE WHAT OUR GOAL IS. AND SIMILARLY THE CAUTI, ON THE SURGICAL ONCOLOGY UNITS HAD ALSO COME DOWN TO 0. AND STAYING WITH SURGERY FOR A MINUTE, LOOKING AT SURGICAL SITE INFECTIONS USING AS A COMPARISON CLINICAL CENTER AVERAGE OVER THE COURSE OF A COUPLE YEARS 2019 AS A MARKER OF WHERE WE WERE AND YOU SEE THAT AGAIN WITH LOW NUMBERS HAD HAS BEEN MOVING AROUND THE AVERAGE THERE FOR WHERE WE ARE WITH THE SURGICAL SITE AND AGAIN WITH EACH OF THESE EVENTS, THERE'S INVESTIGATION BOTH OF THE INDIVIDUAL EVENTS AND THEN OF IF THERE ARE ANY [INDISCERNIBLE] TO SEE WHAT WE DO WITH THAT. --AND WE ALSO LOOK AT FALLS OR INJURIES. THE RATES HAVE REMAINED AT OR AROUND THE BASE LINE, SO THESE SORT OF GRAY AND BLACK ARE THE NDNQI BENCHMARKS AND THEN YOU WILL SEE OUR RATES. AGAIN IN VARIABILITY IN OUR RATE AND BELOW THE BASE LINE THERE AND PLEASE SAY WE'VE REMAINED LOW AND FALSE WITH INJURIES. AND EACH OF THOSE ARE LOOKED AT. NOW OUR ORGANIZATION IS LOOKING AT STRATEGIES TO EVEN OF COURSE, REDUCE THESE FURTHER AND SOMETHING THAT'S BEEN NEWLY IMPLEMENTED IS SOMETHING CALLED THE BEDSIDE MOBILITY ASSESSMENT TOOL, THE AIM OF WHICH IS TO REDUCE OCCUPATIONAL INJURIES AS WELL AS HAVING POTENTIAL REDUCING IN PATIENT INJURIES AND PATIENT FALLS. SO WE'LL HOPE TO SEE THESE NUMBERS CONTINUE TO STAY LOW AND GO EVEN LOWER. AND THEN THE PRESSURE INJURY PREVALENCE, YOU WILL SEE SORT OF AGAIN, SORT OF EBBING AND FLOWING RIGHT AROUND THE NDNQI MEAN AND PLEASE TO SAY THAT FOR MANY QUARTERS IN A ROW, THE MORE SEVERE STAGE 3 AND 4 PRESSURE INJURIES HAVE BEEN AT 0 WHICH IS OF COURSE WHERE WE WANT THEM TO BE. OKAY, THIS IS A METRIC OF PROCESS, MEANING IS THE PROCESS OF MEDICATION ADMINISTRATION BAR CODING BEING USED WHICH IS A WAY TO INSURE PATIENT, THE CORRECT MEDICATION IS GOING TO THE CORRECT PATIENT. OUR GOAL IS 100% USE OF WHAT'S CALLED KBMA WHICH IS THE NAME OF OUR BAR CODING SYSTEM AND YOU WILL SEE WE'RE CONSISTENTLY UP AROUND 90, 99%, SO IT'S A HANDFUL OF IERK TEMS, THERE ARE A SMALL NUMBER OF CIRCUMSTANCES WHERE THE KBMA CAN NOT BE USED AND THOSE ARE KNOWN AND THE STAFF TAKE ADDITIONAL CARE IN THOSE CIRCUMSTANCES BUT AGAIN, WHATEVER IS NOT USED OUR NURSING QUALITY OF PEOPLE ARE ALERTED TO THAT AND SEE WHAT THE CIRCUMSTANCE WAS TO INSURE THAT IT'S BEING USED, ALWAYS OR ALWAYS WHEN POSSIBLE. I'M SWITCHING NOW TO EMERGENCY RESPONSE DATA WHICH IS A RAPID RESPONSE SYSTEM AND I WILL REMIND THE PANEL FOR THE MEMBERS AND NEW MEMBERS YOU KNOW WE DON'T HAVE AN EMERGENCY ROOM SO OUR CODE BLUE TEAM IS CALLED TO ALL TYPES OF EMERGENCIES IN ADDITION TO CARDIAC AARREST. WHEN WE WILL SEE HERE AND THIS ALSO WOULD INCLUDE PATIENTS BUT VISITORS AND EMPLOYEES. SO SORT OF ANYBODY WHO'S FOUND WHO NEEDS ACUTE EMERGENCY CARE IF SOMEBODY CALLS A CODE BLUE THAT'S WHO WOULD COME. SO I'M LOOKING HERE AT THE NUMBERS FOR THE YEAR AND EACH QUARTER OF 2021 AND AGAIN, THESE ARE ABSOLUTE NUMBERS RATHER THAN A RATE, SO THERE WOULD BE VARIABILITY BASED ON THE CENSUS THAT WE HAVE HERE. AS WE'VE BEEN ABLE TO WELCOME MORE PEOPLE BACK TO THE CLINICAL CENTER, THERE HAVE BEEN SOME SHIFT IN PROPORTIONS ABOUT YOU TO GET A COMPARISON, I THINK I MENTIONED THIS LAST TIME, I LOOKEDDA THE 4-QUARTERS FOR CALENDAR YEAR OF 2019, THAT BEING THE LAST FULL YEAR BEFORE THE PANDEMIC AND ACTUALLY THE TOTAL NUMBER OF CODE BLUES CALLED IN 2021, VERSUS 2019 WAS ALMOST IDENTICAL. IT WAS OFF BY 1 AS WAS WE WILL SEE ON THE NEXT 1 THE TYPE OF CODE. BUT WE WILL SEE THAT HALF OF THEM ARE FOR IN-PATIENTS AND THEN ANOTHER THIRD MAY BE IN OUT-PATIENTS AND THEN VISITORS AND EMPLOYEES MAKING UP THE REST OF THEM. AND HEAR THE NUMBERS ARE BROKEN UP BY TYPE OF EVENT AND AS I MENTIONED, THE CARDIAC ARREST RATE IS ABOUT 15%. SO ABOUT 15% ARE, YOU KNOW A CARDIAC ARREST BUT MANY ACUTE EMERGENCIES AND MANY ACTUALLY ARE WHERE THEY DEEMED TO BE STABLE EVENTS, MAYBE SOMEBODY SAW SOMEBODY TRIP AND FALL AND THOUGHT THEY NEED ASSISTANCE AND THE CODE TEAM COMES, EVALUATES THEM OF COURSE AND DEEMS THEM TO BE STABLE EVENT. THE CODE BLUE DISPOSITION AS WE SEE ABOUT A QUARTER OF THEM GO TO THE ICU AFTER THE CODE BLUE AND ABOUT A THIRD WIND UP STAYING ON THE UNIT. THE BLUE IS A TRANSFER TO THE OUTSIDE HOSPITAL THAT WOULD BE MOST--THE ALMOST EXCLUSIVELY GOING TO BE A VISIT ON OR AN EMPLOYEE WHO THE CODE TEAM EVALUATES AND THEN DEEMS TO NEED MORE CARE RATHER THAN GOING TO AN OUTSIDE HOSPITAL FOR THAT. JUMPING FROM CODE BLUE TO RAPID RESPONSE, I THINK WE KNOW--RESPONSE TEAM AND THAT'S SOMETHING ANYBODY CAN CALL FOR BUT LOOKING AT WHAT HAPPENED TO THE PEOPLE FROM THE RAPID RESPONSES, WHICH SOMETIMES CAN BE AN INDICATOR OF MAYBE A CODE BLUE SHOULD HAVE BEEN CALLED INSTEAD, WE SEE HERE THAT MOST DO GET EVALUATED AND CARE FOR RECOMMENDATIONS ARE GIVEN, MAYBE GO TO ANOTHER UNIT OR SWITCH TO ANOTHER AUTOPSY SERIES, THIS MIGHT BE A OUT PATIENT, HEY, YOU SHOULD BE ADMITTED BUT WE'RE NOT GOING TO HAVE TO NECESSARILY ADMIT YOU TO THE ICU, YOU WILL GO TO AN IN-PATIENT UNIT AND THEN LIKE I SAID, ABOUT 20% ARE GOING TO THE--ABOUT 15% ARE GOING TO THE ICU. ONE OF THE THINGS WE LOOK AT AS A TEAM AFTER EACH CODE BLUE IT'S DEBRIEFED BY THE CODE TEAM IN THE ICU AND THEN IT'S LOOKED AT A MULTIDISCIPLINARY GROUP IN ADDITION TO THAT 1 LOOKED AT AS THE GROUP OF CODE BLUES ARE LOOKED AT, BY A MULTIPLE CODE BLUE COMMITTEE, THOSE THINGS ARE LOOKED AT AGAIN, NOT JUST FOR TRENDS BUT ANY PROCESS ISSUES AND THEN WITH RAPID RESPONSE, ONCE AGAIN WE ASKED IS THIS SOMETHING THAT MAY BE THEY SHOULD HAVE CALLED A CODE BLUE FOR AND MAYBE AN OPPORTUNITY TO DO THAT AND WE WOULD SEE, YOU KNOW WHY ARE PEOPLE CALLING, CHOOSING TO PICK THE KIND THAT THEY DO. MOVING NOW TO TRANSFUSION MEDICINE METHODS INVOLVING BLOOD PRODUCTS. LOOKING AT THE CROSS MATCH TO TRANSFUSION RATIO, THIS WOULD BE THE LOWER IS THE BETTER BECAUSE THAT WOULD MEAN THAT THE BLOOD THAT WAS CROSS MATCHED WAS INDEED USED SO IT'S A MATTER OF HOW MUCH AND HOW TO RESERVE VERSUS GOING TO THE PATIENT AND WE SEE THAT OUR GOAL IS A RATIO OF 2-1 AND WE'RE WELL BELOW THAT, AND THOSE NUMBERS HAVE BEEN PRETTY STABLE OVER THE COURSE OF THIS PAST YEAR. LOOKING AT TRANSFUSION REACTIONS BY CLASS, THIS IS OVERALL BEEN ABOUT 1% OR BELOW 1% FOR THE YEAR. MAJORITY OF THESE ARE FEVER WITHOUT HEMOLYTIC REACTION AND YOU WILL SEE WE ACTUALLY DO NOT HAVE ANY OF THE GRAY WHICH WOULD BE SOME OF THE MORE SEVERE REACTIONS THAT MAY INDICATE THAT THE PERSON GOT AND NOT PROPERLY MATCHED UNIT AND WE DON'T HAVE ANY OF THOSE IN THESE--YOU KNOW WITH SMALLER NUMBERS, THERE'S A LITTLE BIT OF A JACKED LINE BUT PRETTY CONSISTENT AND ALWAYS BELOW 1% TURNOVER. SO LOOKING AT UNACCEPTABLE BLOOD BANK SPECIMENS, THIS JUST IS AN INDICATOR IF THE TYPE AND SCREEN IS SENT AND THERE'S SOMETHING SUCH THAT IT CANNOT BE USED, THAT WOULD ALWAYS BE THEN DECLINED BECAUSE OF COURSE, THE TYPE AND SCREEN OF HAVING THE PROPER LABELING ON IT AND MATCHING WITH THE PATIENT IS 1 OF THE CRUCIAL STEPS OF INSURING THAT A PERSON DOES NOT INADVERTENTLY RECEIVE MISMATCHED BLOOD. BUT WE ALSO WANT TO SEE, EVEN, ARE THESE UNACCEPTABLE PESMENS COMING. THREE% BEING THE GOAL, WE'VE BEEN WELL BELOW THAT AGAIN, EVERY SINGLE 1 OF THESE WOULD THEN BE DISCARDED AND ASKED FOR A NEW SPECIMEN. FOR THE NEXT SLIDE WE WILL TALK ABOUT SOME OF OUR CLINICAL COCK DOCUMENTATIONS, OUR THE NEXT SET OF SLIDES ARE CLINICAL DOCUMENTATION METRICS. LOOKING AT DELINQUENT RECORDS WHICH IS DEFINED AS GREATER THAT KNOW 30 DAYS POST DISCHARGE UNTIL THE DOCUMENTATION IS IN ORDER. WE RUN AROUND 5, 6, 7%, WITH ACTUALLY THE JOINT COMMISSION BENCHMARK BEING 50% SO OBVIOUSLY WE HAVE THAT, ABOUT YOU WE DO WANT TO STAY STABLY DOWN HERE AS CLOSE TO 0 AS POSSIBLE ESPECIALLY AS WE GO TO A POINT WHERE PEOPLE MIGHT BE BEING TRANSFERRED, THERE MIGHT BE SOME CARE THAT'S AT VARIOUS DIFFERENT PLACES, WE WANT TO BE SURE THAT THE DOCUMENTATION IS ALL IN ORDER. AND LOOKING FOR AGENT 4 COUNTER PROCEDURES. SO WE HAVE A STRICT POLICY ON WHAT TYPES OF THINGS CAN HAVE A VERBAL ORDER OR AN AGENT FOR ORDER WHERE 1 PERSON PRESENTS THE ORDER AND WITH THE PHYSICIAN'S APPROVAL AND SHOWING IT HAS TO BE SIGNED BUT THEN IT HAS TO BE SIGNED WITHIN 72 HOURS, OUR GOAL IS 100% MEETING THAT AND WE SORT OF KEEP UP IN THAT MID90S. SOME OF THE STEPS THAT ARE TAKEN IS THAT THE PERSON FOR WHOM THE ORDER WAS PLACED GETS AN E-MAIL ALERT AND EVERY TIME THAT PERSON LOGS ON TO OUR COMPUTER ENTRY SYSTEM CALLED C RES, THEY WILL BE TOLD YOU HAVE UNSIGNED ORDERS SO GO AHEAD AND DO THAT. IFINEALLY DO NOT USE ABBREVIATION ADHERENCE, THIS IS SOMETHING THAT WOULD--UNACCEPTABLE ABBREVIATIONS WHERE THERE COULD BE CONFUSED GRAPHICALLY LIKE A U FOR UNITS LOOKING LIKE A 0, MEANING WHICH MAKES IT 10 FOLD ERROR OR SOMETHING, YOU KNOW SHORT ABBREVIATION THAT BEING BE MULTIPLE THINGS. SO WE HAVE OUR DO NOT USE, AGAIN WITH THE GOAL OF 100% IN OUR ORDER ENTRY, THESE THINGS YOU WON'T BE ABLE TO PLACE MOST OF THESE THINGS BUT IN SOME OF THE FREE CHECKS AREAS, SOMETIMES PEOPLE ARE ABLE TO SO WE NEED TO BE VIGILANT ABOUT THAT ASK KEEPING THIS NUMBER AS CLOSE TO 100% OR IN THAT CASE, 0% USE OF THEM RATHER I SHOULD SAY AS POSSIBLE. AND THEN THE ACCURACY OF RECORD CLEARING, THIS IS DONE BY AUDIT, BY HEALTH INFORMATION MANAGEMENT SYSTEM, AND ACCURACY OF CODING HAS BEEN IN THE MID TO HIGH 90S WITH THE HOSPITAL SETTING A GOAL OF AT LEAST 90% AND WE'VE REMAINED BOTH STABLE AND ABOVE THAT. THE LAST TOPIC, LAST BUT NOT LEAST IS EMPLOYEE SAFETY. TALKING ABOUT OCCUPATIONAL INJURIES AND ILLNESSES, COMPARING TO OTHER U.S. HOSPITALS. SO AT THE LAST MEETING WHEN I SHOWED DATA THERE WAS A REQUEST FOR SOME BENCHMARKS AGAINST U.S. HOSPITALS, I WILL SAY THAT THE BURRO OF LABOR AND STATISTICS WHO PROVIDES THIS DATA, THE 2021 DATA ARE NOT FULLY COMPILED, EXCUSE ME, SO THE BLUE IS THE DATA FOR U.S. HOSPITALS ACROSS THE LAST SEVERAL YEARS I WILL SAY IT'S USUALLY PRETTY STABLE BUT WE DON'T KNOW WHAT THE 21 WOULD BE BUT THAT SAID, WHERE ARE WE WITH TOTAL REPORTABLE CASES AND OTHER REPORTABLE CASES FREQUENTLY AND CERTAINLY THIS YEAR AND THE LAST YEAR'S BELOW THE NATIONAL AVERAGE FOR A HOSPITAL OUR SIZE. AND AS WE WILL MOVE ON TO SOME OF THE OTHER THINGS, DAYS OF JOB TRANSFER, RESTRICTION OR DAYS AWAY FROM WORK. WHERE WE ARE. AND LOOKING AT A COMBINED CALLED DAYS AWAY OR RESTRICTED OR TRANSFERRED. I WILL SAY THAT THE MAJORITY OF OUR DARTS, DAYS AWAY OR RESTRICTED OR TRANSFERS ARE E LIEWCIALLY DUE TO MUSCULOSKELETAL INJURIES AND THIS GOES BACK TO SOMETHING I MENTIONED EARLIER THAT OUR HOSPITAL IS TAKING STEPS TO PUT IN PROCESSES THAT WOULD HELP REDUCE SOME OF THOSE ERRORS, I MENTIONED THE BEDSIDE MOBILITY ASSESS WILL TOOL, 1 OTHER THING THEY PUT INTO PLACE IS AN AIR MATTRESS SYSTEM FOR MOVING PATIENTS FROM BED TO BED. THIS CAN HELP REDUCE STAFF INJURIES, IT CAN ALSO HELP REDUCE PATIENT INJURIES AND DISCOMFORT, YOU KNOW A PATIENT MOVE FRIDAY 1 BED TO ANOTHER RATHER THAN SOMEBODY LIFTING THEM OR MAYBE GETTING TWISTED A LITTLE BIT, THE AIR MATTRESS JUST LIED THAT PERSON OVER. SO 1 OF THE THINGS WE WANT TO DO IS INSURE THIS IS USED AS MUCH AS POSSIBLE IN ANY OF THESE STEPS, BOTH TO KEEP OUR PATIENTS SAFE BUT ALSO TO KEEP OUR EMPLOYEES SAFE FROM INJURY. THAT WAS THE FINAL METRIC I HAD. AND I WILL SEE IF THERE'S ANY QUESTIONS? I WILL GET MY--TRY TO STOP SHARING. >> THANK YOU DAVID AND RIGHT NOW I FEEL PAUL O'NEIL SMILING DOWN ON US FOR NEW MEMBERS OF THE BOARD. PAUL O'NEIL WAS 1 OF OUR ORIGINAL BOARD MEMBERS AND WAS VERY FOCUSED THROUGHOUT HIS CAREER ON TEAM MEMBER SAFETY. AND SO AS WE'VE TALKED ABOUT PATIENT SAFETY, HE WOULD ALWAYS RIGHT THERE. SO IT'S GREAT TO SEE THE FOCUS ON THAT. LET ME SEE IF ANYBODY WANTS TO ASK A QUESTION, MAKE A COMMENT? ANTOINETTE. >> JUST A QUICK QUESTION DR. LANG, YOU SAID THERE WAS A 0% UTI INFECTION RATE. HOW WERE YOU ALL ABLE TO ACCOMPLISH THAT? WAS IT DUE TO THE NURSES WERE DOING OR IS IT SOME SORT OF THE CATHETER TYPE DEVICES THAT ARE USED NOW DAYS? >> YEAH THAT'S A GREAT QUESTION. THE 0% UTI ASSOCIATED WITH A CATHETER AND I THINK IT'S CERTAIN PRACTICES, CERTAIN NURSING PRACTICES THAT ARE PUT IN AND IN FOLLOWING THOSE BEST PRACTICES ARE THE THINGS THAT HELP KEEP THAT VALUE LOW. SO THANK YOU FOR ASKING. >> VERY IMPRESSIVE. >> I WOULD LIKE TO ASK 1 OTHER QUESTION AND I'M NOT SURE TO WHICH TEAM MEMBERS I'M DIRECTING THIS TO BUT PERHAPS SEVERAL, VANDERBILT JUST 10 DAYS OR SO AGO, I KNOW IN MY AREA, IT'S BEEN A HUGE TOPIC OF CONVERSATION AROUND SUPPORTING OUR STAFF, I THINK THE STORY ITSELF IS COMPLICATED, WE'VE TRIED TO STAY AWAY FROM THAT BUT SUPPORTING OUR STAFF AND FOR BARBARA OR DAVEED COLLEEN, SOMEWHERE IN THERE, IS THERE CONVERSATION NOW GOING ON WITH YOUR TEAM AND HOW ARE YOU THINK BEING APPROACHING SOME OF THAT? >> YEAH, SO, THANK YOU FOR THAT QUESTION. I SHARED WITH THE NURSES, THROUGHOUT THE NURSING DEPARTMENT AS WELL AS OUR EXTRA DEPARTMENTMENTAL NURSES, FORWARDED THE STATEMENTS FROM THE MARYLAND NURSE'S ASSOCIATION AND THE AMERICAN NURSE'S ASSOCIATION ALONG WITH MY COMMENTS TO CONTINUE TO SUPPORT 1 ANOTHER AND TO REACH OUT. AND I RECEIVED VERY FAVORABLE RESPONSES BUT IT IS A CONCERN AND WE WANT PEOPLE TO NOT FEAR RETALIATION, BUT OVER THE PAST SEVERAL YEARS WE'VE FOCUSED ON A JUST CULTURE, THE OPEN DISCUSSION OF EVENTS AND WORK TO RESOLVE ISSUES AND OUR FOCUS ON SAFETY. HOPEFULLY PEOPLE FEEL THAT SUPPORT AND CAN COME FORWARD IF THEY HAVE CONCERNS OR ISSUES. WE HAVE TO REALLY FOCUS ON A NONPUNITIVE ENVIRONMENT AND WE HAVE TO MODULATE OUR RESPONSES, YOU KNOW WHEN EVENTS OCCUR BUT AGAIN TO BE VERY SUPPORTIVE OF THE STAFF. >> THANK YOU. STEVE, I SEE YOUR HAND GOING UP THERE. >> YEAH, I WOULD JUST COMMENT, WE ACTUALLY STARTED THE DISTRICT ATTORNEY AT 6:30 THIS MORNING WITH A MEETING ON THIS SUBJECT. THERE ARE PECULIARITIES OF THE TENNESSEE LAW WHICH OBVIOUSLY PLAY INTO THIS AND THE ISSUE OF OVERRIDE PICKS US PARTICULARLY WHEN WHAT YOU HAVE RECEIVED, IF THE LOOK AT THE FACTS OF THE CASE THAT HAS WARNINGS ON IT THAT WERE IGNORED. SO I--THAT LED US TO DO IS TO ACTUALLY FORM A GROUP PREDOMINANTLY COMPRISED OF NURSES THAT ARE LOOKING WITH OUR RCA SYSTEM AROUND THE ISSUES OF WHETHER OR NOT THERE ARE CHECKS AND BALANCES THAT NEED TO BE INITIATED FURTHER THAT WILL ENHANCE THE ABILITY OF A STAFF MEMBER NOT TO MAKE A MENTAL ERROR AT AN IMPORTANT TIME BECAUSE THESE THINGS, AS WE KNOW THESE THINGS WILL HAPPEN. NOW THERE'S NO CASE LAW IN NEW YORK STATE THAT WE'VE HAD OTHER CASES AND IF FACT WE COULDN'T FIND ANY OTHER CASES NATURALLY BUT THIS IS VERY PARTICULAR AND I DO THINK IT GOES TO THE ISSUE OF OVERRIDE, OF [INDISCERNIBLE] AND HOW DO YOU RECEIVE THE CHECK OF WHAT YOU WANTED AND THEN YOU GET INTO A WHOLE ISSUE OF PATIENT MONITORING, ET CETERA. SO IT'S REALLY--I DON'T KNOW THIS GOES BACK TO 2017 SO I DON'T KNOW THE RESPONSE OF VANDERBILT AT THAT TIME AND WHERE THEY CHOSE TO PURSUE IT THE WAY THEY DID. >> YES, JUST TO BE VERY CLEAR, I DIDN'T WANT TO GET INTO THAT, I REALLY WAS JUST WANTING TO HEAR AND BARBARA I THINK YOU SHARED IT AND I KNOW YOU ARE SUPPORTING YOUR STAFF SO I KNOW PEOPLE ARE TALKING ABOUT IT. GOOD, THANK YOU. I SEE STEPHANIE AND THEN RICK. >> THANKS, LAURA. SO MY COMMENT IS ALSO JUST DIRECTED, I GUESS AT THE WHOLE TEAM OR MAYBE IN GENERAL COMMENT. IT SEEMS AS THOUGH WE'RE SEEING LEVELS OF FATIGUE, ALL KINDS OF FATIGUE AMONG OUR TEAMS, MENTAL HEALTH ISSUES BUT PERHAPS NOT QUITE THAT SERIOUS ISSUES JUST INCREDIBLE FATIGUE AND I CAN'T HELP BUT THINK IT HAS AN IMPACT ON EVERYTHING WE DO, SAFETYENTIOUS SPECIALLY OR AT LEAST IT HAS THE POTENTIAL OF THAT SO WONDERING, ARE YOU--THERE'S BEEN SO MUCH OPTIMISM SHARED TODAY WHICH IS SO HELPFUL FOR ALL OF US AND OUR MENTAL HEALTH BUT I WONDER, ARE YOU ALSO SEEING JUST THIS INCREDIBLE LEVEL OF FATIGUE THAT WE SEEM TO BE SENSING ELSEWHERE? >> I WOULD SAY YES THAT WAS A TOPIC OF CONVERSATION AT OUR NURSE EXECUTIVE COMMITTEE MEETING YESTERDAY IS JUST, WE HAVE TO KEEP FOCUSING ON MAKING SURE WE ARE OUT AND AVAILABLE WITH OUR WITH SCHEDULING AND STAFFING AND JUST MAKING SURE--YOU KNOW WE HAVE PEOPLE THAT WORK HERE AND LIVE PRETTY FAR AWAY AND THEY LIKE TO BUNCH ALL THEIR SHIFTS TOGETHER AND IT'S LIKE, WE LOOK AT THINGS FROM PATIENT SAFETY AND THE STAFF SAFETY PERSPECTIVE BUT WE ARE SEEING THE SIGNS OF FATIGUE AS ELSEWHERE ACROSS THE COUNTRY AND SO, YOU KNOW WE'RE VERY FOCUSED ON WHAT WE DO AND THE CLINICAL CENTER AND DR. GILMAN MAY WANT TO SPEAK MORE TO AGAIN, WE'VE--WE HAD REOPENED THE CRISIS LINE, THE HOT LINE FOR PEOPLE TO CALL TO GET SUPPORT TO HAVE SOMEBODY TO SPEAK WITH BECAUSE, YOU KNOW WE'RE STILL FEELING IT AS OUR PEOPLE BUT ALSO AS HEALTHCARE INSTITUTIONS. YEAH, I THINK LIKE DR. FORESE, WITHOUT GETTING INTO THE DETAILS OF THE VANDERBILT CASE, 1 THING WE LOOK AT IS 1 MAKING SURE WE HAVE PROCESSES THAT HELP PREVENT PEOPLE FROM DOING ERRORS BUT THEN IF PEOPLE DON'T FOLLOW THOSE, THE QUESTION IS WHY ARE THEY NOT FOLLOWING THEM? AND GIVING THE ASSUMPTION IT'S GOING TO BE EXTREMELY, EXTREMELY OUTLYING CASE WHERE SOMEBODY'S INTENTIONALLY TRYING TO HARM SOMEBODY SO WE'RE SETTING THAT ASIDE, WHY ARE THEY NOT FOLLOWING THESE? IT'S INTERFERING WITH SOME OTHER THING WHETHER IT'S THE NEED--THE PERCEIVED NEED FOR RUSHING OR FEELING SO FATIGUED THAT IT'S LIKE, WELL I HAVE 17 MEDICINES TO USE SO I'M JUST GOING TO--I DIDN'T MEAN TO GRAB THE FIRST 1 THAT WAS THERE BUT I HAD TO THAT KIND OF THING, I THINK ALL THOSE THINGS TIE IN TOGETHER. >> YEAH, THANK YOU. THANK YOU. >> OKAY, WE WILL TAKE 1 MORE AND THEN WE WILL GET OVER ON CLIFF, GREAT CONVERSATION, GREAT REPORT, DAVID. >> RICK? >> YES, THANK YOU DAVID AND MAYBE THIS IS FOR BARBARA, OBVIOUSLY THE FATIGUE AT THE CLINICAL CENTER ISN'T DUE TO COVID, MEANING YOU DON'T HAVE COVID CASES. YOUR CENSUS IS WAY DOWN SO THE IDEA OF BEING OVERBURDENED ALSO AT LEAST FROM THE NUMBERS ISN'T THE ISSUE. MY QUESTION IS WHAT ABOUT TURNOVER? AND ARE YOU SEEING THE SAME CHALLENGES EITHER WITH RESPECT TO STAFF SHORTAGES OR WITH RESPECT TO TURNOVER AND NEW NURSES CAN WHICH LEAD TO DRIFT ASK THEREFORE MORE SAFETY EVENTS? >> YES, TO ALL OF THE ABOVE. SO WE'VE HAD--WE'VE HAD TURNOVER JUST AS ANY OTHER ORGANIZATION HAS HAD AND ALSO WHAT WE SAW, WE DO USE SOME CONTRACT STAFF TO SUPPLEMENT BUT WE HAD GREAT DIFFICULTY IN FILLING THOSE NEEDS BECAUSE OF THE EXORBITANT COSTS AND/OR THE MONEY THAT PEOPLE CAN MAKE EITHER GOING TO THE HIGHLY HIT PANDEMIC AREAS. BUT THE FATIGUE, THE PATIENTS AS DR. GILMAN PRESENTED, THE 1S THAT CONTINUE TO COME DURING ALL THIS TIME ARE VERY ACUTE, VERY COMPLEX. OUR PATIENT ACUITY IS VERY HIGH AND SO THAT AGAIN, THE DAY-TO-DAY, BUT OUR, THE FATIGUE JUST COMES FROM LIVING IN THIS DIFFERENT WORLD AND TAKING CARE OF PATIENTS BUT THEN HAVING TO GO HOME AND, YOU KNOW HOME SCHOOL YOUR CHILDREN THAT YOU WEREN'T PLANNING TO DO ALL THOSE KINDS OF THINGS SO WE'VE SEEN THE SAME THINGS HERE AS OTHERS, YOU KNOW IN THE COUNTRY. >> ABSOLUTELY, I THINK WE ALSO HAVE--YOU KNOW PEOPLE NEEDING TO MASK, PEOPLE NEEDING TO NOT BE ABLE TO EAT TOGETHER, PATIENTS NONAPOPTOTIC THE HAVING VISITORS, SO THINGS THAT ARE COVID SECOND ORDER OF CONSEQUENCES EVER COVID ARE DEFINITELY AFFECTING OUR STAFF IN ADDITION TO THE COVID PATIENTS THEMSELVES. SO, YEAH. JUST I DO THINK COVID IS PART OF IT. >> SO EVERYTHING THAT BARBARA JUST SAID. WE HAVE EXPERIENCED THE IMPACT OF THE GREAT RESIGNATION AS WE TALKED ABOUT IN OUR OCTOBER MEETING AND WE DO OPERATE IN A PERSONNEL SYSTEM THAT MAKES IT EASY TO LEAVE IN A COUPLE WEEKS AND VERY HARD TO COME AND IT TAKES MONTHS TO BRING THE NEW STAFF ONLINE. AND THERE A INFLEXIBILITIES THAT I THINK MANY OTHER PLACES DON'T HAVE TO DEAL WITH. WE DO WORK UNDER--WE DO EMPHASIZE THE JUST CULTURE, WE ALSO EMPHASIZE REPEATEDLY THAT HELP SEEKING IS A SIGN OF--AND WE'VE DONE A FAIR AMOUNT OF THAT. WE ARE--WE DO AT THE PRESENT TIME DEAL WITH SORT OF THE PUSH AND THE PULL OF INVESTIGATORS WHO WANT TO REENERGIZE THEIR CLINICAL PROGRAMS THAT HAVE--THAT HAVE BEEN ON LOW SPEED FOR THE LAST COUPLE OF YEARS AND WHO WANT TO--WE HAVE INVESTIGATORS THAT ARE ON TENURED TRACK WHEN THERE'S A CLOCK TICKING AND DR. GOTTESMAN DOESIS BEST TO REASSURE THEM THAT THEY WILL GET THE EXTRA TIME THEY NEED BUT I KNOW THEY ARE STILL FEELING, THEY NEVER ARE SURE WHEN THEIR EXTRA TIME WILL BE UP AND SO THERE'S A LOT OF STRESS IN AND AMONG THE INVESTIGATORS AND I THINK IN THE PAST, IT MIGHT HAVE LED TO MAYBE TOO MANY--MORE PATIENTS THAN WE CAN REALLY TAKE GOOD CARE OF IN THE CLINICAL CENTER, I THINK--WHILE IT'S A BALANCING ACT EVERY DAY, TRYING TO TAKE CARE OF AS MANY PATIENTS AS WE CAN SAFELY, THEN I THINK--BUT IT'S A CONSTANT TOPIC OF DISCUSSION AND SOMETIMES THE DISCUSSIONS GET A LITTLE WARM BUT I THINK WE'RE DOING THE BEST WE CAN. >> GREAT. WELL, THANK YOU. RICK JUST PUT A LINK INTO THE CHAT AS WELL. THANK YOU RICK. WELL, THANK YOU ALL. THIS IS A GREAT CONVERSATION AND THERE'S SOME THINGS THAT ARE UNIVERSAL HERE THAT WE CAN CERTAINLY ALL RELATE TO ALL RIGHT. WE'RE GOING TO SWITCH GEARS NOW, A BIT. AND GO OVER TO CLIFF. CLIFF SORRY TO KEEP YOU WAITING. THANKS VERY MUCH FOR BEING HERE AND WE'RE LOOKING FORWARD TO HEARING YOUR COMMENTS. >> GREAT. THANKS, VERY MUCH. ARE MY SLIDES SHOWING ALL RIGHT? AND GOOD, YOU CAN HEAR ME? OKAY. SO THANKS FOR THE OPPORTUNITY TO PROVIDE WHAT I THINK MUST BE NOW THE THIRD UPDATE TO THE GROUP ON SOME THINGS GOING ON HERE AND OBVIOUSLY GLOBALLY WITH REGARD TO COVID-19. I KNOW YOU HAVE COPIES OF THE SLIDES AND I KNOW WHERE YOU ARE IN TERMS OF SCHEDULE SO SOME OF THE STUFF I WILL GO THROUGH PRETTY QUICKLY, SO THIS IS JUST SORT OF THE OUTBREAK AS A COUPLE OF DAYS AGO, I WILL COME BACK TO THIS LAST PEAK IN A MINUTE BECAUSE IT OBVIOUSLY REPRESENTS OMICRON, IT DOESN'T SHOW ANY IMPACT YET IN THE U.S. OF THE BA.2 VARIANT. SOPHISTICATED I WILL TALK ABOUT THE NORG OZIOMATION AT THE NATIONAL LEVEL AND THEN TALK ABOUT PATHOGENESIS, DIAGNOSTIC, THERAPEUTICS, PREVENTION AND POST ACUTE SEQUELAE. SO ANDY CANNED WHAT WAS THE SENIOR ADVISOR AT WHITE HOUSE, HE HAS LEFT. JEFF ZIENTS, WHO IS CURRENTLY THE CORONAVIRUS RESPONSE COORDINATOR WILL BE LEAVING IN A FEW DAYS. HE WILL JEFF WILL BE REPLACED BY--WHOOPS, S ORRY--DR. ASHISH JHA, AND NOUNSING HIS APPOINTMENT THE PRESIDENT NOTED HE IS 1 OF THE LEADING PUBLIC HEALTH EXPERTS IN AMERICA AND WELL KNOWN FIGURE TO MANY AMERICANS FROM HIGHS WEDNESDAY AND CALMING PRESENCE STRESSING THE LAT LATTER PHRASE THERE. I KNOW THOSE OF YOU WHO KNOW HIM AND SEEN HIM ON CNN WILL PROBABLY AGREE WITH THAT SENTIMENT. THERE ARE TRANSITIONS THAT BEEN TAKING PLACE AT THE LEVEL OF HHS, REGARDING THE COVID-19 RESPONSE VENLT THE INITIAL RESPONSE KNOWN AFFECTATELY AS OPERATION WARP SPEED WAS REALLY A COMBINED EFFORT BETWEEN THE DEPARTMENT OF DEFENSE AND THE DEPARTMENT OF HEALTH AND HUMAN SERVICES THAT WAS UNDERAN MOU THAT EXPIRED AT THE END OF LAST YEAR AND OPERATION WARP SPEED THEN TRANSITIONED OVER TO SOMETHING CALLED H-CORE, OR HHS ACCORD NATION OPERATIONS AND RESPONSE ELEMENT. THIS COMES OUT OF THE OFFICE OF SECTIONAL ANALYSIS FOR PREPAREDNESS AND RESPONSE WHICH IS DON O'CONNELL, AND ITS LED BY DR. JASON ROOS, CHIEF OPERATING OFFICER AND DR. DAVID KESSLER WHO WAS THE HHS CHIEF SCIENCE OFFICER FOR COVID-19. I MENTION THESE THING BECAUSE IT'S HELPFUL TO KNOW WHO THE PLAYERS ARE AND WHERE THE DECISIONS ARE BEING MADE. THE WHITE HOUSE RELEASE THE NATIONAL COVID-19 PREPAREDNESS PLAN ON MARCH 2nd. IT HAS 4 MAIN ELEMENTS. THE FUNDING WAS IN THE COVID-19 SUPPLEMENT THAT DID NOT GET PASSED. SO AGAIN, THERE'S A LOT OF UNCERTAINTY RIGHT NOW ABOUT WHAT ELEMENTS OF THIS PLAN IN FACT ARE GOING TO COME INTO BEING OR NOT. SO JUST TO GIVE A FEW COMMENTS ABOUT PATHOGENESIS, THIS IS A SLIDE I USED IN THE EARLIER PRESENTATION TO THE GROUP UTALKING ABOUT SORT OF THE CONVENTIONAL WISDOM ABOUT THIS DEC THAT THERE'S, YOU KNOW RANGING FROM ASYMPTOMATIC TO MECHANICAL VENTILATION AND DEATH. THAT THAT EARLY PHASE APPEARS TO BE DRIVEN LARGELY BY THE VIRUS FOR WHICH ANTIVIRAL STRATEGIES SEEM TO HAVE THE BIGGEST IMPACT, THE LATTER STAGES PERHAPS THE IMMUNE RESPONSE TO THE VIRUS AND ASSOCIATE ANY INFLAMMATION WHERE IMMUNO MODLATTORY STRATEGY VS THE BEST EFFECT AND THEN AGAIN LOOKING AT THE ROLE OF COAGULATION THROUGHOUT. SOME MORE RECENT DATA THAT'S EMERGING IT'S REALLY NOT OUT THERE VERY MUCH BUT I WANTED TO MENTION IT TO THE GROUP, HAS SUGGESTED THAT THERE MAY BE VIRAL LOGIC ELEMENTS THROUGHOUT THE COURSE OF ILLNESS AND IN PARTICULAR, NOW THAT WE'RE USING SUCH IMOWN O SUPPRESSION IN THE ADVANCED STAGES THAT THE VIRUS ACTUALLY MAY BE PLAYING A ROLE THROUGHOUT THE COURSE OF INFECTION. WE'RE USING THIS TECHNOLOGY DEVELOPED BY QUANTERIX, IT'S A NANO TECHNOLOGY USING TINY MAGNETIC BEADS CODED WITH ANTIBODIES TO THE CORE PROTEIN OF SARS-COV-2 SO CAN YOU MEASURE DOWN TO THE PICOGRAM LEVELS OF CIRCULATING SARS-COV-2 NUCLEOCAP SID PROTEIN IN THE PLASMA OR SERUM OF INFECTED INDIVIDUALS. AND HERE WE'RE LOOKING AT THE COHORT OF PATIENTS WHO ARE ENROLLED IN THE ACTIVE 3 THERAPEUTIC TRIALS, THESE ARE PATIENTS WHO ARE HOSPITALIZED WITH COVID-19 AND WHAT YOU SEE AS YOU GO FROM PATIENTS WITH MILD DISEASE, ONLY ON ROOM AIR THROUGH PROGRESSIVE LEVELS OF OXYGEN SUPPORT UP TO NONINVASIVE VENTILATION OR HIGH FLOW, CAN YOU SEE THAT THE PLASMA LEVELS OF ANTIGEN ACTUALLY PROGRESSIVELY INCREASE SUGGESTING THAT THESE MORE SEVERELY ILL PATIENTS ACTUALLY HAVE HIGHER LEVELS OF CIRCULATING PLASMA ANTIGEN, HOW THIS PRECISELY RELATES TO VIRAL REPLICATION, WE'RE NOT SURE BUT I THINK IT DOES RAISE THE QUESTION ABOUT WHETHER OR NOT WE MIGHT BE FOCUSING ADDITIONAL ANTIVIRAL THERAPIES IN THIS ADVANCED GROUP AS I MENTIONED EARLIER, PARTICULARLY GIVEN THE AMOUNT OF IMMUNO SUPPRESSION WE'RE CURRENTLY GIVING THEM SO BEAN IT MAY BE THAT WE NEED TO ELECTRIC AT ANTIVIRAL STRATEGIES THROUGHOUT THE COURSE OF COVID-19. YOU KNOW WOOF THE BIG WORRIES AND--1 OF THE BIG WORRIES AND AREAS OF FOLK SUS LOOKING AT THE NEW VARIANTS AS THEY COME UP, THE MOST RECENT 1 BEING OMICRON, THAT I THINK MOST OF YOU ARE PRETTY AWARE AS A WHOLE ARRAY OF ADDITIONAL CHANGES FROM ITS PREDECESSOR DELTA AND EVEN MORE SO FROM THE ANCESTRAL STRAINS. AGAIN THIS HAS BIG TIME IMPLICATIONS IN TERMS OF PATHOGENESIS, WHERE IT DOESN'T APPEAR TO BE AS PATHOGENIC AS SAY DELTA, BUT ALSO IN TERMS OF THE ABILITY OF COUNTERMEASURES PARTICULARLY THE MONOCLONAL ANTIBODIES TO EXERT THEIR EFFECT. THIS JUST SHOWS THE MOST RECENT DATA FROM CDC LOOKING AT THE EVOLUTION OF DIFFERENT VALID AND RELIABLE YABTS, WITHIN THE U.S. POPULATION, THE FIRST BARS UP TO THE LAST 2 ARE ACTUAL DATA, THE LAST 2 BARS ARE WHAT CDC PROJECTIONS WILL BE THE CASE IN THE NEXT 2 WEEKS. ONCE THE DAILY BASIS AT FROM THE PRIOR 2 WEEKS ARE AVAILABLE, AND YOU CAN SEE GOING BACK HERE THIS, IS JUST GOING BACK TO DECEMBER, THE END OF DECEMBER OF 2021, WHERE YOU STILL HAD SOME ELEMENT OF DELTA, AND YOU HAD BA.1 JUST SHOWING UP AS 1 OF THE VARIANTS WITHIN OMICRON, AND OMICRON, RANGING FROM DARK PURPLE TO LIGHT PURPLE AND YOU CAN SEE IT TOOK OVER IN A MONTH'S TIME AND THE TREND IS NOW FOR THE EMERGENCE OF BA.2, SUBVARIANT OF OMICRON IS, THE REASON THIS IS IMPORTANT IS BECAUSE THIS DOES REFLECT CHAIMPLES AND THE ABILITY OF THE MONOCLONAL ANTIBODIES TO WORK. [INDISCERNIBLE] THE MAIN ANTIBODY OUT THERE WITH EFFICACY AGAINST OMICRON, DOES NOT SEEM TO HAVE EFFICACY AGAINST BA.2. THE ONLY THING AVAILABLE IS METRICS TIEWZ MAB. BUT THIS I THOUGHT WAS AN INTERESTING THING TO LOOK AT AND THIS ISN'T IN THE SLIDE DECK. I JUST PUT THIS TOGETHER EARLIER TODAY, LOOKING AT THE CHANGES IN NEW CASES IN FRANCE COMPARED TO THE U.S., AGAIN THIS IS TRYING TO GET UNDERSTANDING OF WHAT'S GOING TO HAPPEN IN THE U.S. WITH BA.2. I THINK MOST PEOPLE ARE ANTICIPATING WE WILL SEE A SURGE WITH BA.2. WE ARE CERTAINLY SEEING A SHIFT TO BA.2, BUT THUS FAR THERE AREN'T A LOT OF DATA TO SUPPORT THAT AND THAT LOOKS LIKE THAT EPIDEMIOLOGY MAY BE END UP BEING DIFFERENT IN THE U.S. THAN IT IS SHOWN HERE IN FRANCE. AGAIN, I THINK THIS MOST LIKELY REFLECTS DIFFERENCES SOMETHING THAT NCATS SUPPORTS AND IT'S A VERY NIFTY COMPILATION OF DATA THAT ALLOWS YOU TO LOOK AT THE EFFICACY OF ALL DIFFERENT COUNTERMEASURES, SERUM FROM VEHICLEINATED INDIVIDUALS, DIFFERENT MONOCLONAL ANTIBODIES, THE DIFFERENT ANTIVIRALS, OR CONVALESCENT PLAZ MIDS PLACENTA OR SERUM, AND IF YOU CLICK ON OMICOON, CAN YOU GET WHAT YOU SEE ON THE RIGHT AND YOU SLEEP APNEA AND OBESITYY ALL THOSE YELLOW DOTS OVER THE TO RIGHT FOR MONOCLONAL SHOWING THAT THEY ARE NOW MUCH LESS ACTIVE AGAINST TD OMICRON VARIANT. IN EMERGINGS OF DIAGNOSTICS THINGS HAVEN'T CHANGED SO MUCH, RTPC R REMAINS THE MOST SENSITIVE TOOL AND IT REMAIN POSITIVE FOR A PROLONGED PERIOD OF TIME AND LOOKING AT WHETHER OR NOT YOU'RE GETTING AMPLIFICATION OF THE S-GENE AND TO IDEPT BIFY VARIANTS AND SUBVARIANTS OF OMICRORKS ON, ANTIGEN TESTING WHILE LESS SENSITIVE IT DOES TYPICALLY REPRESENT A HIGHERVILLEERAL LOAD AND IT'S VERY EASILY USED IN THE HOME, THESE ARE ALL AVAILABLE UNDER EMERGENCY USE AUTHORIZATION, BUT IF WE DO GET TO THE END OF THE PUBLIC HEALTH EMERGENCY, THEY WILL NEED TO HAVE SOME SORT OF MORE FORMAL FDA APPROVAL TO CONTINUING USE. IN TALKING ABOUT THERAPEUTICS AND THE REMAINS A VERY EXTENSIVE CLINICAL TRIALS INFRASTRUCTURE THAT'S BEEN PUT TOGETHER TO LOOK AT DIFFERENT THERAPEUTIC STRATEGIES AND AMPLATTORY AND HOSPITALIZED PATIENTS, THE ACCELERATING COVID-19 THERAPEUTIC INTERVENTION VACCINE, PUBLIC PRIVATE PARTNERSHIP IS DOING MUCH OF THIS WORK FOR NIH. ACTIVES 1, 3, 4, A AND 5, LOOK AT HOST DIRECTED THERAPIES AND ANTIVIRALS AND HOSPITALIZED PATIENTS. ACTIVE 2 LOOKING AT AMBULATORY PATIENTS AND ACTIVE 6 LOOKING AT REPURPOSES DRUGS SUCH AS IVERMECTIN AND [INDISCERNIBLE] IN PATIENTS. IT'S AN AMAZING LABD SCAPE WHEN YOU LOOK AT WHAT'S REPORTED AND WHAT'S AVAILABLE FOR TREATING PATIENTS WITH COVID-19. IF YOU DO A SEARCH OF CLINICALTRIALS.GOV, YOU GET OVER 4000 HITS. IF YOU LOOK FOR ARTICLES ON PUBMED IT'S OVER 5000 HITS AND IF YOU DO A GOOGLE SEARCH IT'S OVER 4 BILLION HITS SOPHISTICATEDY TRYING TO KEEP TRACK OF ALL OF THIS IS EXTREMELY DIFFICULT. FORTUNATELY THERE ARE A SEER OF DIFFERENT TREATMENT GUIDELINES, WE HAVE 1 THAT COMES OUT OF NIH THAT BEBAN, ORIGINS WERE IN MARCH, IT WAS A REQUEST FROM THE WHITE HOUSE TASK FORCE AND THEN FROM SECRETARY AZAR TO PUT TOGETHER A GROUP TO ISSUE A LIVING SET OF GUIDELINES THE FIRST RELEASE CAME OUT IN APRIL OF 2020 FOR THAT TYPO, AS OF JUST THIS WEEK, WE'VE HAD 48 UPDATES, THERE MAY BE ANOTHER 1 TODAY OR MONDAY AND OVER 34 MILLION PAGE VIEWS. THE LIED LINES PROVIDE 2 TYPES OF RATINGS. ONE IS THE STRENGTH OF THE RECOMMENDATION, STRONG, MODERATE OR WEAK AND THE SECOND IS THE STRENGTH OF THE EVIDENCE SUPPORT THAGOREAN RECOMMENDATION, 1 BEING DATA FROM ROBUST, OR RANDOMIZED CONTROL TRIALS, SECOND BEING DAT FROM OTHER TRIALS OR OBSERVATIONAL STUDIES, OR SUBSET OF RANDOMIZED TRIALS AND THEN THE THIRD BEING EXPERT OPINION. SO WITHIN THE GUIDELINES WE BREAK IT OUT INTO RECOMMENDATIONS FOR NONHOSPITALLIZED PATIENTS, THIS IS IN THE PROCESS OF BEING UPDATED, THE BOTTOM LINE FROM THE CURRENT RECOMMENDATION, THAT WE FEEL IS PROBABLY THE GO TO THERAPY FOR PATIENTS WHO ARE PATIENTS WHO ARE AMPLATTORY WITH PILED MODEL CITIZEN MODERATE COVID-19 AT HIGH RISK FOR DISEASE PROGRESSION. IN TERMS OF MONOCLONALS AS BA.2 COMES INTO PLACE, THE ONLY 1 IS BEBTELOVIMAB AND THAT WILL BE REFLECTED IN THE NEXT UPDATE, REMDESIVIR CAN BE GIVEN LOOKING GOOD BUT IT'S A INFUSION, IT'S REQUIRED FOR 3 CONSECUTIVE DAYS AND VERY IMPORTANT IN AMBULATORY PATIENTS WHO DO NOT NEED STEROIDS, IT'S THE DATA ARE CLEAR THAT GIVING STEROIDS TO THIS POPULATION RESULTS IN WORSE OUTCOMES THAN NOT GIVINGSTER OITDS. NERMALS OF HOSPITALIZED PATIENTS, THERE ALSO IS AN ENORMOUS AMOUNT OF DAT AAGAIN IF THEY DON'T REQUIRE SUPPLEMENTAL OXYGEN, IF AVOID STEROIDS IF THEY DO REQUIRE OXYGEN AMONG THE DRUGS THAT HAVE SHOWN EFFICACY, REMDESIVIR, DEXAMETHA SEWN, BARICITINIB, AND USE THESE ALONE OR IN COMBINATION AND WE TRY TO PROVIDE THAT TYPE OF GUIDANCE AND GUIDE LINES WITH THE ASSOCIATED CAVEAT. THE CLINICAL TRIALS DAILY BASIS THEA SHOULD SUGGESTS THAT EVERYONE SHOULD BE [INDISCERNIBLE] AND THEN PLUS OR MINUS BARI CITINIB, BLOCKADE, SO THE U.S. GOVERNMENT HAS BEEN INVOLVED HEAVILY IN THE DEVELOPMENT OF 6 OF--THERE AN EUA ON THE PFIZER VACCINE FOR AGES 5-15. JOHNSONS & JOHNSONS ADENO 26 PLATFORM AS BEEN AVAILABLE UNDER EMERGENCY USE IN THE U.S., IT'S NOT CLEAR WHERE ASTRAZENECA, WHETHER OR NOT THEY'RE GOING TO BE PURSUING OPERATION IN THE U.S. AND THEN TO RECOMBIN ANT PROTEIN AND ADJUVANT VACCINES HAVE UA REQUESTS IN AND THEY PROBABLY WOULD BE USED MORE LIKELY IN BOOSTER REGIMENS. THOSE 6 ARE JUST A SUBSET OF THE 10 VACCINES THAT HAVE BEEN APPROVED FOR USE BY W. H. O. AGAIN, W. H. O. HAS APPROVED 2 OR AUTHORIZED 2 PROTEIN VACCINES, 2 RNA VACCINES, 3 ADEN O VIRUS BASED VACCINES AND THEN 3 ENACTIVATED VIRUS VACCINES. JUST TO TALK FOR A FEW MOMENTS OF THE EFFICACY FROM THE VACCINES FROM THE U.S. POPULATION, THESE I THINK ARE EXTRAORDINARILY COMPELLING DATAOT IMPACT OF VACCINATION, THIS IS LOOKING AT AGE ADJUSTED RATINGS OF CONFIRMATION 19 HOSPITALIZED BY VACCINE STATUS OCTOBER 21st TO JANUARY OF 2022. YOU CAN SEE THOSE, FULLY VACCINATED THAT MEANS 1 DOSE OF J& J OR 2 DOSES OF RNA, 9.8 PER HUNDRED THOUSAND WITH A BOOSTER, WITHOUT A BOOST ARE 35.2 AND WITHOUT ANY VACCINE, 145. SO THE ABILITY OF THESE VACCINES TO PREVENT HOSPITALIZATION IS PRETTY SECURE. THE QUESTION ABOUT A BOOSTER AND NOW WE'RE TALKING ABOUT A SECOND BOOSTER, OR A FOURTH DOSE OF RNA, IS A VERY HOT TOPIC AT THE MOMENT. THERE ARE REALLY, REALLY GOOD DATA, I THINK ON THE THIRD SHOT OR THE FIRST BOOSTER FOR RNA, THESE ARE RANDOMIZED CONTROL TRIAL DATA FROM PFIZER TAKING THEIR INITIAL PHASE 3 COHORT AND RANDOMIZING THEM TO AN ADDITIONAL SHOT OR BOOSTER AS ARE OPPOSE TO NOT GETTING ADDITIONAL SHOT WHICH IS THE RED. YOU CAN SEE THE IMPACT OF THAT ADDITIONAL SHOT ON INCIDENCE OF NEW CASES, IT REALLY IS THE THIRD SHOT AS A LOT IN TERMS OF EFFICACY. THOSE DISA OF COURSE ARE GENERATED PRIOR TO OMICRON, SO THE QUESTION IS WELL, YOU KNOW I WAS VOCINATED WITH ANCESTRAL STRAIN, SPIKE PROTEIN, WHAT WILL THAT DO FOR OMICOON THESE DATA SHOW THAT EACH THOUGH YOU'RE BOOSTED WITH A VACCINE DIRECTED PERIODS THE ANCESTRAL, IT GIVES YOU INCREASE IN IMMUNITY TO THE VARIANTS AS WELL, SO HERE WE'RE LOOKINGA THE NEUTRALIZING ANTIBODY TO EITHER THE WILD TYPE OR TO OMICRON, CAN YOU SEE HERE IN THE FAR LEFT WHICH SHOWS TITER SEVERAL MONTHS AFTER THE RNA, MODEL CITIZEN DENERVATA AND BEFORE THE BOOSTER, YOU CAN SEE THE TITERS ARE LOWER AND YOU GIVE THE BOOST AND TITERS GO UP, SO AGAIN BOOSTING WITH ANCESTRAL DOES INCREASE TITERS OF ANTIBODY TO OMICOON, SO THIS IS A VERY IMPORTANT PIECE OF LABORATORY DATA. THE BOOSTING THAT YOU SEE, CAN YOU SEE REGARDLESS OF WHAT BOOST YOU GIVE, SO THESE ARE LOOKING AT PATIENTS WHO ARE INITIALLY IMMUNIZED WITH EITHER AD26, THE JNJ, MRNA, MODEL CITIZEN DENERVATA OR THE PFIZER RNA, AND THEN BOOSTED FROM MODERNA, THE JNJ AND THE PFIZER, CAN YOU SEE IN EACH INSTANCE IT DOESN'T MATTER WHAT YOU GOT IPT GREATER I SHALY THAT IN FACT ANY OF THESE SCRAK SEENS WILL GIVE YOU A GOOD BOOST. YOU CAN TELL EVEN THOUGH THIS IS NOT A RANDOMIZED CONTROL TRIAL, THESE DATA WERE DEVELOPED LONGITUDINALLY SO THERE ARE A LOT OF CONFOUNDERS BUT BY AND LARGE YOU ARE GETTING HIGHER ANTIBODY TITERS WITH A BOOST WITH RNA THAT DOESN'T TELL YOU ABOUT DURABILITY AND AS I MENTION INDEED A MOMENT THAT'S STILL 1 OF OUR UNANSWERED QUESTIONS. SO WHAT WE DO KNOW IS THAT IN ADULTS THESE VACCINES LOOK REALLY SAFE, REALLY EFFECTIVE AND THERE'S CLEAR ADDITIONAL PROTECTION FROM A THIRD DOSE, IN CHILDREN, AT LEAST FOR PFIZER, WHERE WE HAVE EMERGENCY AUTHORIZATION, THEY APPEAR SAFE AND EFFECTIVE IN AGES 5-17. WE DON'T HAVE ANY GOOD LABORATORY CORRELATES PROTECTION THAT COULD HELP THEN INFORM HOW OFTEN 1 MIGHT NEED A BOOST, WE DON'T KNOW THEN, DURATION OF PROTECTION FROM EITHER INFECTION, SYMPTOMATIC DISEASE, HOSPITALIZES OR DEATH AND IT'S UNCLEAR THIS FAR WHAT IS THE BEST REGIMEN FOR CONCERN UNDER 5 YEARS OF AGE ALTHOUGH THERE ARE DATA BEING REVIEWED AT THE MOMENT. SO EARLIER THIS WEEK, THE FDA AUTHORIZED A FOURTH DOSE FOR ADDITIONAL INDIVIDUALS OR A SECOND BOOSTER THIS, IS FOR ANYONE 50 YEARS OF AGE OR OLDER AND AT LEAST 4 MONTHS AFTER RECEIPT OF A FIRST BOOSTER DOSE, FORRIFIES THERAPY AND INCLUDES PEOPLE, AGAIN, 50 YEARS OF AGE AND OLDER AND ANYONE 12 AND OLDER PRETTY EXTENSIVE FROM A LOT OF THE WORK THEY'VE DONE IN PARTICULAR, SOME OF THE WORK IN ISRAEL, THEY HAVE SAFETY DATA NOW IN 700,000 PERSONS. THERE'S NOT AS MUCH SAFETY DAT ON MODERNA ON THE FOURTH DOSE SO THAT'S A SMALLER SOMEBODY, IT'S VERY CLEAR WHERE PEOPLE HAVE LOOKED AT ANTIBODY TITERS AFTER A SECOND BOOSTER THAT ANTIBODY TITERS GO UP AND DATA THAT HAS GOTTEN A LOT OF PLAY COMING FROM ISRAEL AND I THOUGHT IT WAS IMPORTANT TO TRY TO GIVE DETAIL ON THAT. SO THIS--THESE DATA COME FROM A NONRANDOMMIZED COHORT OF 500,000 INDIVIDUALS AGES 60-100 WHO WERE FOLLOWED FOR 40 DAYS. SO WHAT HAPPEN INDEED IN COHORT, THEY WERE GETTING A FOURTHS SHOT, SO WHAT THE INVESTIGATORS DID HERE, THEY LOOKED AT THE RATES OF DEATH IN THE INDIVIDUALS WHO HAD ALREADY GOTTEN THE FOURTH SHOT VERSUS THOSE WHO HAD NOT. SO IT'S SORT OF AN IMMEDIATE, VERUS DEFERRED LOOK, AGAIN THERE ARE ENORMOUS CONFOUNDERS IN THIS TYPE OF ANALYSIS, BECAUSE OFTEN THOSE WHO SHOW UP FIRST TO GET THE ADDITIONAL DOSE HAVE HEALTH SEEKING BEHAVIOR AND OTHER REASONS WHY THEY MIGHT NOT GET INFECTED, MIGHT NOT DIE. IN ANY EVENT WITH THOSE CAVEATS THERE WERE 232 DEATHS AND THOSE THAT DID NOT RECEIVE THE FOURTH DOSE, THOSE RIENCHLING FROM 12,000 TO 328,000. AND THERE WERE 92 DEATHS IN THOSE WHO DERECEIVE A FOURTH DOSE, FROM 550,000 TO 233,000. SO THE ADJUSTED HAZARD RATIO FOR DEATH, SO THE DECREASE IN MORTALITY FROM THOSE OVERALL IN THIS STUDY, WAS .22 SO THATIA A PRETTY REDUCTION IN DEATH BASED ON GETTING A FOURTH DOSE. LAST FEW WORDINGS ON POST ACUTE SEQUELAE OF COVID-19 OR P A SC, THIS IS BEING STUDIED LARGELY THROUGH THE RESEARCH AND COVID TO ENHANCE RECOVERY INITIATIVE OR RECOVER. THIS IS BEING PREDOMINANTLY CO LED BY HEART LUNG AND BLOOD AND UROLOGY AND SEEKS TO UNDERSTAND PREVENT AND TREAT P A SC INCLUDING LONG COVID. THERE ARE ALSO 3 PROTOCOLS AT THE NIH CLINICAL CENTER, GO GOING ON RIGHT HERE IN THE HOSPITAL. I JUST TELL YOU A LITTLE BIT ABOUT THE 1 STUDY HERE IN THE HOSPITAL. IT'S LOOKING AT 3 COHORTS THAT NIAID. AND MIKE SNELLER S&P THE PI, LOOKING AT ADULTS OF INDIVIDUAL WITH A HISTORY OF COVID AND PERSISTENT SYMPTOMS, HISTORY OF COVID AND NO PERSISTENT SYMPTOMS AND AN INDIVIDUAL WITHOUT A HISTORY OF COVID WHO HAD BEEN IN CONTACT WITH SOMEONE WHO HAD. DATA COLLECTION IS PRETTY EXTENSIVE, INDIVIDUAL HISTORIES AND PHYSICALS, ROUTINE LABS, MARKERS OF INFLAMMATION, COAGULATION, DIRECTED STUDIES OF SARS-COV-2 IMMUNOLOGY AND I HAVEROLOGY. MENTAL HEALTH EVALUATION, EKG, ECHO CARDIO GRAMS AND A PET AND 6 MINUTE WALKING TEST. THESE ARE SYMPTOMS THAT ARE MORE PREPTULENT IN THE SURVIVORS AND CONTROL GROUP AND YIEF SEEN FROM MANY OTHER STUDIES ARE A BIT MORE ANECDOTA BECAUSE THEY'RE OFTEN FROM LARGE HOSPITAL BASED RECORDS BUT AT LEAST WE HAVE A CONTROL GROUP TO LOOK AT, FATIGUE, DISNIA, CONCENTRATIONING, ANOSMIA, TROUBLE SLEEPING, CHEST PAIN AND DISCOMFORT ARE ALL SIGNIFICANTLY GREATER IN THE COVID-19 COHORT. IF YOU THEN LOOK AT ALL THE SURVIVORS AND COMPARE THOSE WHO HAVE SYMPTOMS FOR THOSE WHO DO NOT. NOTED A LOT FALLS OUT FOR US ISSUES THE 2 THINGS THAT FALL OUT WERE FEMALE GENDER IDENTITIER AND HISTORY OF AN ANXIETY DISORDER. IF YOU LOOK AT THE ANTIBODY TITERS IN THESE COHORTS, I THINK IT'S REALLY QUITE INTERESTING, YOU HEAR A LOST DISCUSSION OF WHETHER WELL I WAS INFECTED, I'M PROTECTED I DON'T NEED GOAT VACCINATED. HERE WE'RE USING AN ASSAY AS A SURROGATE FOR NEUTRALIZATION. LOOKINGA THE INHIBITION OF THE SPIKE PROTEIN BIND TO ACE 2, YOU CAN SEE FOR NONVACCINATED INDIVIDUALS WHERE PART OF OUR CONTROL GROUP, AGAIN THIS STUDY STARTED IN JUNE OF 2020. NO 1 WITH ANTIBODY LEVELS TO SARS-COV-2. WHEN THAT GROUP, THE VACCINATED 1 YOU SEE THE ANTIBODY TITERS GO UP, IF YOU LOOK AT THE SURVIVORS THAT ARE NOT VACCINATED YOU SEE AN AMAZING ARRAY OF ANTIBODY TITERS WITH A LARGE PERCENTAGE OF THEM NOT HAVING WHAT WOULD BE CONSIDERED A POSITIVE ANTIBODY RESPONSE, SO IN OTHER WORDS AS HAS BEEN SEEN WITH OTHER CORONAVIRUSS, THE HOST IMMUNE SYSTEM DOESN'T NECESSARILY KICK INTO HIGH GEAR. IN CONTRAST, THE INFECTED INDIVIDUALS WERE VACCINATED ARGUE LEEBL HAVE THE HIGHEST ANTIBODY TITERS AND THIS IS THE GROUP WE LOOK TO DEVELOP HYPER IMMUNE IMMUNO GLOBUE LYNN FOR OTHER STUDIES. LOOKING AT DECLINE IN ANTIBODY LEVELS OVER TIME IN THE INFECTED INDIVIDUALS INTERESTINGLY THAT RATE OF DECLINE DOESN'T APPEAR TO BE QUITE AS RAPID AS WHAT WE SEE WITH SO IN TUMRY THEN ON THAT STUDY FROM THE INTRAMURAL PROGRAM, PARTICIPANTS IN THE COVID-19 GROUP REPORTED MORE SYMPTOMS THAN THOSE OF THE CONTROL GROUP, FACAS TIGER DATABASE, DISNEYA, INSOMNIA, IMPAIRMENT, CHEST DISCOMFORT AND AGENT, HOWEVER FINDING THIS ON THE LAB EXAM UNCOMMON TO FIND THEM THERE, THEY WERE NONAPOPTOTICET ASSOCIATE WIDE THOSE INDIVIDUAL WHO IS WERE SURVIVORS AND HAD SYMPTOMS SO JUST IN MY LAST SLIDE TO GIVE YOU THOSE 2 WEBSITES I THINK WERE IMPORTANT TO KNOW, 1 NEAR THE NIH TREATMENT GUIDELINE THE OTHER FOR THE NCATS WEBSITE THAT TALKS ABOUT VARIANTS AND THE ACTIVITY OF THE DIFFERENT COUNTERMEASURES SO I KNOW THAT WAS FAST. I APOLOGIZE BUT THANK YOU VERY MUCH FOR YOUR ATTENTION EMPLOY. >> WELL, AS ALWAYS IT'S A MASTER CLASS AND EVERYTHING THAT'S GOING ON AND THANK YOU FOR THE GREAT SUMMARY. CRAIG? >> THANKS CLIFF, GREAT PRESENTATION SO I HIGHLIGHTED THAT BA2 IS THE DOMAIN NABT OMIKRON SUBVARIANT. MY QUESTION IS ABOUT FUTURE POTENTIAL INTEL ABOUT FUTURE POTENTIAL VARIANTS. WHAT'S THE SURVEILLANCE MECHANISM, I ASSUME IT'S AN INTERNATIONAL SURVEILLANCE FOR NEW VARIANTS AND IS THERE ANY CONCERN OR INTEL ABOUT ABOUT SOMETHING COMING ON THE HORIZON? >> SO THERE ISN'T ANYTHING I'M AWARE OF ON THE HORIZON. THE BULK OF THE DATA THAT ARE GENERATED YOU KNOW COME FROM A VARIETY OF RESOURCES. NCATS THROUGH THEIR PORTAL I SHOWED HAS BEEN TRYING TO COLLECT DATA FROM ANY SOURCE THEY CAN. SO THEY WILL ACTUALLY GET DATA FROM COMPANIES WHO ARE VERY INTERESTED IN THEIR OWN PRODUCTS. THEY WILL GET DATA FROM THE CDC SURVEILLANCE, EFFORTS THAT GOES ON, THEY WILL TRY TO GET SURVEILLANCE FROM THE GROUP IN GERMANY THAT'S COLLECTING VARIANTS SO THEY'RE TRYING TO PULL IN EVERYTHAT THEY CAN, WITHIN THE U.S. GOVERNMENT THERE'S A GROUP LOOKING AT THAT SPECIFICALLY FROM ALL DIFFERENT AREAS TO TRY TO GET AHEAD OF THINGS. THE 1 THING THAT GETS A LITTLE BIT OF BUZZ IS SOMETHING THAT'S KAWLTED DELTA CRON, A VARIANT OF DELTA AND OMICRON, SO FOR THERE'S NOTHING BIOLOGIC ASSOCIATED WITH THAT, THE DISCUSSION GOES FROM YOU KNOW WE NEED TO KEEP AN EYE ON IT ON SOME OF THIS IS JUST PC R ARTIFACT AND CONTAMINATION, SO IT'S INTERESTING BECAUSE OMICRON IS SUCH A VARIANT FROM DEALTA AND YOU KNOW THE SPECULATION IS THAT THIS MIGHT HAVE BEEN SOMETHING THAT JUST WAS BREWING IN A PATIENT FOR A VERY, VERY LONG PERIOD OF TIME THAT THEN GOT INTO THE GENERAL POPULATION. BUT THAT'S, YOU KNOW SPECULATIVE. I HAVE TO SAY IT'S STILL PRETTY AMAZING TO ME THAT WE'RE NOT SEEING A BUMP IN BA2 REFLECTED IN THE NUMBERS OF CASES AND YOU KNOW EVERYONE SORT OF WATCHING, YOU KNOW AND HOLDING THEIR BREATH TO SEE WHAT WILL HAPPEN THERE. >> THANK YOU. THANK YOU. STEPHANIE. >> EASY QUESTION, THAT'S A JOKE. DO YOU THINK WE'RE BETTER PREPARED AS A NATION OR AS A PLANET FOR THE NEXT PANDEMIC BASED ON EVERYTHING WE'VE LEARN FRIDAY THIS 1? >> I THINK WE'RE BETTER AWARE OF HOW DIFFICULT IT CAN BE TO DEAL WITH SOMETHING LIKE THIS AND THERE'S A LOT OF TALK ABOUT HOW WE NEED TO BE BETTER PREPARED AND THERE'S A LOT OF EFFORT GOING INTO LESSONS LEARNED THAT WE COULD TAKE INTO THE NEXT OUTBREAK BUT THE ACTUAL ACTIVITY THAT I THINK NEEDS TO TAKE PLACE TO BE ABLE TO DO THAT IS STILL IN THE FUTURE. >> THANK YOU. >> ELEGANTLY PUT. ANY OTHER QUESTIONS? CLIFF, AGAIN, THANK YOU SO MUCH. AS LARRY SAID OR JIM SAID, KEY KEEP THINKING IT'S THE LAST TIME WE WILL NEED TO BE UPDATED BUT WE ARE VERY APPRECIATIVE OF ALL OF THE WORK. THANK YOU. >> ALL RIGHT, LET'S SWITCH GEARS AGAIN AND GO OVER TO MARILYN FRINRE WHO IS OUR SERVICE CHIEF IN PHARMACY OPs AND MARILYN WILL TURN DIRECTLY TO YOU. THANK YOU. GOOD MORNING IT YOU HEAR ME OKAY? >> WE CAN. >> CAN YOU SEE MY SLIDES HOPEFULLY? OKAY, THANK YOU. SO GOOD MORNING EVERYONE. I'M MARILYN FARINRE, AND I AM CHIEF OF OERATIONS HERE AT THE FARNLACY AT THE CLINICAL, IT'S MY PLEASURE TO BE WITH YOU THIS MORNING AND MY PRESENTATION, THE PERMANENT PHARMACY PLACEMENT PROJECT, THAT I WILL REFER TO AS THE P4 PROJECT WILL PROVIDE AN OVERVIEW OF THE--THE FDA CAUSE INSPECTION SET UP A SERIES OF EVENTS THAT BEGAN WITH THE SUSPENSION OF ACTIVITIES IN THE PHARMACEUTICAL DEVELOPMENT SECTION OF THE PHARMACY. IN APRIL 2016, THE ADVISORY COMMITTEE TO THE DIRECTOR AND THE CLINICAL CENTER WORKING GROUP QUAIM OUT WITH A RED TEAM REPORT. AND THAT REPORT IT WAS FOUND THAT PHARMACY FACILITIES PERFORMING CELL PRODUCING OPERATIONS WERE OUT DATED AND FULL REMEDIATION WAS RECOMMENDED. THIS REQUIRED ALL OF OPERATIONS TO MOVE INTO TEMPORARY SPACES. IN APRIL OF 2017 THE INTRAVENOUS ADMIXTURE UNIT MOVED INTO THEIR TEMPORARY SPACE AND IN 2019 THE OUTPATIENT AND UNIT DOSE PHARMACIES MOVED INTO SPACES OF THEIR OWN. RENOVATION OF THE OUTDATED FACILITY BEGAN IN 2021. SO THROUGHOUT THE P4 PROJECT, THE PHARMACY STAFF AS A GROUP HAVE REALLY HELD TRUE TO THEIR MISSION. NOW OUR MISSION IS TO SUPPORT AND CONDUCT CLINICAL RESEARCH BY PROVIDING SPACE, HIGH QUALITY CARE, 1 PATIENT, 1 MEDICATION AT A TIME. SO THE TIMELINE FOR THE PROJECT, IT'S DISCIPLINARY VOIDED INTO 3 MAIN PHASES. THE OUTPATIENT PHARMACY WILL MOVE INTO THEIR SCHEDULED LOCATION OR INTO THEIR SCHEDULED SPACES ON THE SECOND OF MAY. THIS WILL BE FOLLOWED CLOSELY BY THE UNIT DOSE PHARMAC SKPE BAKUGAN THEY WILL START OPERATING ON MAY 24th. INTRAVENOUS ADMIX TOUR UNIT WILL BEGIN OPERATIONS IN THE FALL OF THIS YEAR. SO THE P4 PROJECT IS COMPLICATED WITH MANY MOVING PARTS. AND SO THERE'S HEIGHTENED AWARENESS OF WHAT THE 4 MAIN GOALS OFLET OPERATIONS ARE. AND THAT IS WHEN WE MOVE, WE WANT TO MAKE SURE WE CONTINUE OPERATIONS WITH UNINTERRUPTED PHARMACEUTICAL CARE AND WE WANT TO DO SO SAFELY. WE ALSO WANT TO SUCCESSFULLY IMPLEMENT AND INTEGRATE ALL PHARMACY AUTOMATION. IN ADDITION WE WANT TO MAKE SURE THAT ALL OF OUR SUPPLIES, MEDICATIONS AND SUPPLIES ARE RELOCATED TO THE NEW SPACES AS EFFICIENTLY AS POSSIBLE. AND WE WANT TO MAKE SURE THAT ALL OF OUR STAFF ARE TRAINED AND THAT THEY REMAIN ENGAGED. SO THE RENOVATED PHARMAC SEA LITTLE OVER 10,000 SQUARE FEET. THE OUTPATIENT FAMILIES ARNLACY IS IN YELLOW HERE IN THE SCREEN, THE UNIT DOSE SECTION IS IN THE MIDDLE AND IT OCCUPIES THE BLUE SECTION OF THE FLOOR PLAN. THE IVAU IS THE LARGEST SECTION OF THEM ALL AND THAT OCCUPIES ALL OF THE WHITE AREA ON THE FLOOR PLAN. WE'RE FORTUNATE TO HAVE A BANK GRADE VAULT FOR ALL OF OUR CONTROLLED MEDICATION STORAGE AND WE ALSO HAVE A PHARMACY LOUNGE THAT IS A RELAXING SPACE FOR STAFF TO TAKE SOME BREAKS. SO THE RENOVATED PHARMACY IS IMPRESSIVE BUT MORE IMPORTANTLY IT DOES PROVIDE ALL COMPLIANCE WITH ALL OF REGULATIONS AT THE MOMENT FOR ALL CURRENT REGULATIONS. THE NEW FEATURES INVOLVE SEGREGATED COMPOUNDING AREAS, ENGINEERING CONTROLS TO,A LOW FOR THE PROCESSING OF BOTH HEALTH BENEFITS AND ACTUARIALITANTS AS WELL AS HEALTH BENEFITS AND ACTUARIALITANT MEDICATION, LOSS OF AUTOMATION TO PROVIDE SAFE PROCESSES, STREAMLINED WORK FLOWS, AND COMPREHENSIVE INVENTORY MANAGEMENT. THERE'S ALSO INCREASED CAPACITY IN THE NEW FACILITY AS WELL AS CAPABILITY OF ELECTRONIC DOCUMENTATION THAT PROVIDES FOR ACCURATE AND COMPLETE RECORD KEEPING. A TOTAL OF 5 CAR O CELLS WERE ADDED TO THE OPERATION, 1 IN THE OUTPATIENT FACILITY, 2 IN THE UNIT DOSE FACILITIES AND 2 IN THE IVAU MIX TERAREA. SO THE PIXELSATURE SHOWS 1 OF THE CAR O CELLS IN THE UNIT DOSE AREA AND RIGHT NOW THE WINDOW IS SHET. BUT WHEN IT'S OPEN, YOU WOULD BE ABLE TO SEE THE ROWS AND ROWS OF MEDICATION BINS, THAT'S FOR ALL OF OUR MEDICATION. THIS PROVIDES HIGH DENSITY STORAGE, AS WELL AS INVENTORY SECURITY. BAR CODE SCANNING PROVIDES FOR ACCURATE MEDICATION SELECTION, AND THE INVENTORY CAN BE MONITORED PER MANAGEMENT OF--AND THIS IS ALSO DEPICTED IN THE PICTURE, THIS IS WHAT IT LOOKS LIKE. THEY WILL CHECK IN WHERE THE ARROW IS PLACED, THEY WILL CHECK IN FOR THEIR VISIT AND THEN THEY WILL PROCEED TO ENTER INTO THE PHARMACY TO BE MET BY A PHARMACIST AT 1 OF THE 3 TRANSACTION WINDOWS. --AS WELL AS ROBOTIC DISPENSZING SYSTEM. SO THE STORAGE AND RETRIEVAL SYSTEM IS REALLY IMPORTANT TO PROVIDE ACCURATE AND COMPLETE RETRIEVAL OF PRESCRIPTIONS FOR MEDICATIONS DURING PICK UP. USERS ARE PROMPTED TO MAKE SURE THAT THEY COLLECT ALL OF THE PATIENTS PRESCRIPTIONS AND THANKED OVER DURING THE DISPENSING PROCESS, IT ALSO PROVIDES TO ENHANCE SECURITY AND CHAIN OF CUSTODY REQUIREMENTS FOR BOTH CONTROLLED MEDICATIONS AS WELL AS INVESTIGATIONAL MEDICATION. THE ROBOT AUTOMATES THE FILLING PROCESS AND LIABLES VILES MAKING IT READY FOR DISPENSING AND MAKING TIME FOR THE PHARMACIST TO SPEND ON MORE CLINICAL RESPONSIBILITY HERE'S PICTURES OF WHAT IT LOOKS LIKE NOW, SO THE FIRST PATIENTS IN THE CLINIC UPPER SHOWS THE INTANS INTO THE OUTPATIENT PHARMACY, YOU CAN SEE THE FROSTED GLASS DIVIDERS, THAT SEPARATE THE DIFFERENT TRANSACTION WINDOWS. THE SECOND PICTURE IS OF A NOISE ABSORBING WALL, THAT'S DESIGNED TO DAMPEN SOUND AND THE THIRD PICTURE OF THESE FROM THE INSIDE OF THE PHARMACY AT 1 OF OUR ADA COMPLIANT TRANSACTION WINDOWS. THERE'S ACCESS TO A COMPUTER MONITOR OR COMPUTER SCREEN FOR THE PHARMACIST TO BE ABLE TO BE ABLE TO REVIEW COUNSELING AND TALKING WITH THE PATIENTS. THE PICTUREOT LEFT SHOWS THE ROBOT, THE DISPENSING ROBOT IN THE FACILITY AND THERE'S A MONITOR TO MONITOR THE WORK FLOW AND PRIORITIZE PATIENTS WORKING ON PRESCRIPTIONS. WE HAVE ADDITIONAL STORAGE FOR BULKY ITEMS AND A LOT OF UNITS BOTH REFREJERATED AND FREEZERS IN THIS SPACE. THIS PHARMACIST SHOWS THE VERIFICATION WORKING STATION OR FORM CYST REVIEW ORDERS AND VERIFY THEM FOR PROCESSING. SO THE MAILING OF PRESCRIPTIONS HAS BEEN A BIG PART OF THE PHARMACY OPERATIONS FOR SOMETIME BUT THE PANDEMIC MADE IT OFTEN MORE SO. SO THE FIRST PICTURE SHOWS THE MAIL PACKAGE STATION WHERE PRESTRIPGZS ARE PACKAGED AND READY FOR PICK UP BY MAIL CARRIERS. SO THIS SECOND PICTURE SHOWS 2 CABINETS WHERE PACKAGES ARE TEMPORARILY STORED BEFORE THEY'RE PICKED UP AND THE THIRD PICTURE SHOWS THESE DOORS THAT ARE LEAD INTO THOSE CABINETS BUT FROM THE OUTSIDE. THIS IS WHERE MAIL CARRIERS WILL COMMUNICATE WITH STAFF IN THE PHARMACY VIA VIDEO INTERCOM AND ARE GRANTED ACCESS TO 1 OF THE 2 CABINETS TO PICK UP THOSE PACK PACKAGES. BUT THE UNIT DOSE PHARMACY TOTALS ABOUT 2346 SQUARE FEET. THERE'S A BULL PEN AREA FOR TECHNICIAN AND PHARMACIST WORK STATIONS. THERE'S A PREPARATION AREA FOR PACKAGING OF ORAL SOLUTIONS AND SUSPENSIONS. AND THEN THERE'S A STAGING AREA FOR MEDICATIONS THAT ARE AWAITING DELIVERY TO THE NURSING UNITS FOR ADMINISTRATION. AND OF COURSE, THERE'S ALSO LOTS OF ROOM FOR ALL OF THE AUTOMATION. THERE'S 1 OF THE CAR O CELLS HERE AND THEN THE SECOND CAROUSEL IS IN THE CORNER. SOIE ROBOT AND MEDICATION PACKAGER WAS ADDED TO THE UNIT DOSE SECTION. THE AUTOMATED CENTRAL PHARMACY SYSTEM OR THE XR2 ROBOT AUTOMATES THE MEDICATION FILLING PROCESS, IT FILLS AND LABELS MEDICATION IF A FORM READY FOR DELIVERY. THE MEDICATION PACKAGER BASICALLY DOES WHAT YOU WOULD THINK A PACKAGER DOES. IT TAKES MEDICATION FROM BOTH PACKAGES, AND PUTS THEM INTO SINGLE UNITS OF USE FOR DISPENSING TO PATIENTS. BOTH PIECES OF AUTOMATION MAKE THE DISPENSING PROCESS SAFER AND A LOT MORE EFFICIENT FOR OUR STAFF. SO HERE ARE PICTURES OF THE ACTUAL AUTOMATION. SO THE FIRST PICTURE ON THE LEFT SHOWS THE ROBOT. THE MIDDLE OF THE PICTURE SHOWED THE WALKWAY AND THE ROBOT IS ACTUALLY WAY IN THE BACKGROUND AND THIS, THE BODY OF THE ROBOT SLIDES UP AND DOWN THIS WALKWAY TO RETRIEVE MEDICATIONS FROM THESE TRAYS TO THE LEFT. IT HAS A ROBOTIC ARM THAT WILL RETRIEVE OR RETURN MEDICATIONS TO 1 OF THOSE TRAYS. AND THEN THE THIRD PICTURE IS THAT OF THE MEDICATION PACKAGER. SO HERE ARE MORE PICTURES OF THE ACTUAL PHARMACY SPACE. THE FIRST PICTURES OF THE ORDER VERIFICATION STATION, THAT'S THE BULL PEN WITH THE WORK STATIONS FOR BOTH PHARMACISTSAs WELL AS TECHNICIANS. THIS IS WHAT THE ORAL DOSE FAC PAGS STATION LOOKS LIKE AND THIS IS WHERE LIQUID MEDICATIONS ARE DRAWN UP INTO DOSE SPECIFIC SYRINGES OR CUPS. AND THE THIRD PICTURE OF THE INVENTORY PROCESSING STATION, ARE MEDICATIONS ARE RECEIVED FROM THE BHOAL SALER AND SORTED OR DISTRIBUTIONS BEFORE SORTED TO THE CAR O CELL, ROBOTS OR PACKAGER. SO THE IV, OR THE INTRAVENOUS ADMIXTURE UNIT HAS THE LARGEST LARGEST LAY OUT OF THE THE FACILITY IT IS 12,570 SQUARE FEET AND IT OCCUPIES THE WHITE AREA. SO IT'S IMPORTANT TO HAPPENED THAT THERE'S UNIDIRECTIONAL FLOW OF BOTH PEOPLE AND MATERIALS THROUGH THE CLEAN ROOM OR THE IVAU. THE INTRAVENOUS ADMIXTURE UNIT AND I WILL START WITH BY GOING OVER THESE FLOW OF PEOPLE AND THEN I WILL GO OVER THE FLOW OF MATERIALS. SO STAFF WILL ENTER INTO THE PERMANENT IVAU FACILITY INTO A COMPOUNDING VESTIBLE THAT IS SHOWN HERE. HERE THEY WILL RETRIEVE SCRUBS FROM A VENDING MACHINE. HAY WILL THEN PROCEED INTO A LOCKER ROOM WHERE THEY WILL CHANGE INTO THE SCRUBS AND STATE OF EMERGENCY AWAY THEIR STREET CLOTHES IN LOCKERS. THEY PERFORM HAND HYGIENE IN THE SINK ROOM AND DON ADDITIONAL PERSONAL PROTECTIVE EQUIPMENT SUCH AS HAIR NETS, BOOTIES AND SUITS BEFORE THEY WALK INTO THE CLEAN ROOM. THE IVAU IS DIVIDED INTO 2 SECTIONS. SO THE TOP SECTION WITH THE 5 STARS, IS THE NONHAZARDOUS SECTION OF THE FACILITY, AND IT HAS A TOTAL OF 6 COMPOUNDING ROOMS, SO STAFF WILL WALK INTO THIS ENTRANCE HERE AND PROCEED INTO THE NONHAZARDOUS CORRIDOR HERE AND THEY CAN EITHER ACCESS 1 OF THE ROOMS THROUGH THIS CORRIDOR. AGAIN THERE ARE A TOTAL OF 6 ROOMS. IT'S IMPORTANT TO NOTE THAT WHEN THEY'RE EXITING THE FACILITY, THEY DON'T GO BACKWARDS BUT THEY GO DOWN THE CORRIDOR AND THROUGH THIS EXIT HERE FOLLOWING THE PLURIBU ARROW. THE OTHER SIDE OF THE FACILITY WHICH IS THE BOTTOM HALF OF THE FACILITY IS FOR THE HAZARDOUS COMPOUNDING. THERE ARE A TOTAL OF 6 ROOMS ON THE FACILITY AS WELL AND STAFF IN THIS CASE WILL ENTER THROUGH THIS ENTRANCE SHOWN BY THE RED ARROW HERE. THEY WILL COME INTO THIS ENTRANCE AND EITHER ACCESS THIS CORRIDOR TO THE ACCESS THESE 4 ROOMS OR ACCESS THIS CORRIDOR TO ACCESS THESE 2 ROOMS. WHEN LEAVING THE FACILITY THEY WILL LEAVE THROUGH THIS CORRIDOR, OUT THROUGH THE ENTRANCE, AND BACK INTO THE MAIN CORRIDOR. FOR THESE 2 ROOMS ON THIS SIDE, THEY WILL EXIT THE FACILITY THROUGH THIS CORRIDOR AND INTO THE MAIN CORRIDOR. IN TERMS OF PRODUCT AND MATERIALS AND CLEAN ROOM, THEY FOLLOW A DIFFERENT ROUTE. EACH PRODUCT OR SUPPLY IS THOROUGHLY WIPED DOWN WITH DISINFACT ANT BEFORE BEING PASSED INTO THE CLEAN ROOM. WE HAVE 2 CLEAN ROOMS, WE HAVE 2 CLEAN UP SET UP ROOMS, 1 IS 1 FOR THE HAZARDOUS SECTION AND THE OTHER IS FOR THE NONHAZARDOUS SECTION. SO HAZARDOUS MEDICATIONS ARE PASSED THROUGH IN THE HAZARDOUS SET UP AND NONHAZARDOUS MEDICATIONS ARE PASSED INTO THE NONHAZARDOUS SET UP ROOM. SO WHAT HAPPENS IN A PRODUCT HAS TO BE MADE? SO THE Xs ON THE SCREEN DENOTE THE PASS THROUGH THROUGHOUT THE FACILITY. EACH COMPOUNDING ROOM HAS A TOTAL OF 2 PASS THROUGHS. THEY PASS THROUGH AND AN OUT PASS THROUGH. SO IF A MEDICATION HAS TO BE MADE, DEPENDING ON IF IT'S A HAZARDOUS MEDICATION OR A NONHAZARDOUS MEDICATION THAT WILL ORIGINATE FROM 1 OF THESE 2 ROOMS WHICH IS THE SET UP ROOM, THOSE MEDICATIONS WILL THEN BE TAKEN TO--ONCE THE MEDICATION HAS BEEN COMPOUNDED AND THE FINAL PRODUCT IS READY FOR PHARMACIST VERIFICATION, THE TECHNICIAN WILL PLACE THE ITEM INTO AN OUT PASS THROUGH AND WILL BE PICKED UP AND TAKEN TO THIS PASS THROUGH OVER HERE AND THEN IT WILL BE DELIVERED THROUGH NURSING UNITS OR THE PATIENT CARE UNITS. SO THE IVAU AND THE FACILITY HAS SIGNIFICANT DIFFERENCES AND ALL OF THOSE ARE TO MAKE THE FACILITY SAFER AND MORE EFFICIENT. THERE ARE 12 COMPOUNDING ROOMS IN CONTRAST TO THE 3 COMPOUNDING ROOMS THAT WE HAVE IN THE OLD FACILITY. WE HAVE 10 BIOLOGICAL SAFETY CABINETS, 2 ISOLATORS, WE HAVE A SIGNIFICANT NUMBER OF HIGH NUMBER OF PASS THROUGH CHAMBERS, 38 AS COMPARED TO 6, AND ALL OF THE PASS THROUGH CHAMBERS IN THE NEW FACILITY HAVE HEPA FILTERS TO FILTER THE AIR. ALL OF THE WORK FLOW WILL BE AUTOMATED A HUNDRED% AND IT PROVIDES FOR PREMOTE PRODUCT VERIFICATION BY ALL OF OUR PHARMACISTS. THAT MEANS A PHARMACIST COULD POTENTIALLY VERIFY PRESCRIPTION OR MEDICATION HAS BEEN PREPARED FROM ANYWHERE IN THE FACILITY. SO THE AUTOMATION THAT WILL SUPPORT THE PERMANENT IVAU OR INTRAVENOUS ADMIXTURE UNIT IS THE OMINICELL IVX, THIS IS USED DURING THE COMPOUNDING PROCESS TO GUIDE THE PREPARATION OF EACH PRODUCT. PICTURES ARE TAKEN AT EACH STEP OF THE PROCESS AND BAR CODE SCANNING IS USED WITH VOLUMETRIC MEDICATION SOPHISTICATED INSURE MEDICATIONS ARE PREPARED ACCURATELY AND PROPERLY. HERE ARE SOME PICTURES OF THE IVAU. THIS FIRST PICTURE SHOWS THE MAIN CORRIDOR THAT SEPARATES THE HAZARDOUS SIDE FROM THE NONHAZARDOUS SIDE. THE SECOND PICTURE OF THE LOCKER ROOM WITH A VIEW INTO THE SINK ROOM. THAL THIRD PICTURE IS THE NONHAZARDOUS CORRIDOR OF WHICH EACH DOOR LEADS INTO A NONHAZARDOUS COMPOUNDING ROOM. THESE 2 PICTURES ARE OF BIOLOGICAL SAFETY CABINETS, 1 IS IN THE NONHAZARDOUS COMPOUNDING ROOM AND THIS 1 IS IN THE HAZARDOUS BUFFER ROOM. SO IT DOES TAKE A VILLAGE. THERE'S BEEN A LOT OF PLANNING, ACCORD NATION AND HARD WORK TO MAKE THE PEOPLE AND PROJECT SUCCESSFUL AND THIS TEAM WORK HAS BEEN INCREDIBLE. IT REALLY TAKES A VILLAGE. AND THE PARM PHARMACY DOESN'T WANTS TO GIVE OUT A SPECIAL THANKS TO THE CONSTRUCTION TEAM FOR THE BEAUTIFUL FACILITY. THANK YOU SO MUCH. AND WE HAVE COME A LONG WAY. SO THIS IS THE WAY IT WAS. SO THESE ARE PICTURES FROM THE ARCHIVES. THE 2 ON THE FAR LEFT ARE FROM A 1954 ARTICLE IN THE JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION. AND THIS PICTURE ON THE TOP RIGHT HAND CORNER IS FROM THE 1968 ARTICLE HIGHLIGHTING THE IVAU AT THE TIME. THE OTHER 2 PICTURES ARE UNDATED BUT OBVIOUSLY IN THE PAST. WE'VE DEFINITELY COME A LONG WAY. AND WITH THAT, THANKS FOR YOUR ATTENTION AND I WILL TAKE ANY QUESTIONS. >> MARILYN, THANK YOU SO MUCH, IT'S A GORGEOUS FACILITY, I MEAN IT JUST PUT IN THE CHAT. YOU MUST BE THRILLED. CAN WE PULL THE SLIDES DOWN. >> SURE, THANK YOU. YOU AND YOUR TEAM MUST BE THRILLED TO BE IN THAT NEW SPACE WHERE NOT ONLY DO YOU HAVE EFFICIENT SPACE BUT YOU HAVE A LOT OF SAFETY IN THERE IN TERMS OF SYSTEMS. NOW MUCH PLANNING DID THE ACTUAL TEAM ON THE GROUND, HOW MUCH WERE YOUR TEAM MEMBERS ABLE TO CONTRIBUTE TO THE DESIGN? >> SO THE--SO I'VE BEEN IN MY POSITION SINCE 2019 SO I CAME IN DURING THE TRANSITION, SO WE--MOST OF THE PHARMACY STAFF AND LEADERSHIP AS WELL AS STAFF INHERITED THE DESIGNS, WELL, WE'VE DONE A LOT OF WORK IN TERMS OF TRYING TO UNDERSTAND THE INTENT OF THE DESIGN AND TO MAKE SURE THAT WE HAVE ACCOMMODATED A LOT OF THE MEANS OF OUR STAFF AS WELL AS THE FACILITY. SO WE WEREN'T INVOLVED IN THE ORIGINAL DESIGN BUT WE'VE DEFINITELY TAKEN THE DESIGN AND MADE IT OUR OWN SO TO SPEAK. >> GOOD. JIM? >> I THINK MARILYN SAID IT RIGHT AND SO, THOSE OF YOU THAT HAVE BEEN ON THE BOARD FOR A WHILE, THE FDA CAME IN 2015 AND 2016 AND IT WAS IN 2019 THAT MARILYN AND THEY CAME AND SAID, DR. GILMAN, THIS--THE DESIGN, THAT THE OLD GROUP PUT TOGETHER IS, YOU KNOW SOLVES A LOT OF PROBLEMS BUT IT'S NOT THE WAY WE THINK IT SHOULD BE DESIGNED. WELL, THAT LEADER SHN TEAM WAS GONE AND SO IT WAS A DIFFICULT DECISION TO SAY, OKAY, WE'RE GOING TO POSTPONE--WE'RE GOING TO STOP. THERE HAS TO BE MORE MONEY THAT'S ADDED TO THE PROJECT AND IN ORDER TO GO AND TO DO IT THE WAY THE CURRENT PHARMACY LEADERSHIP TEAM SAYS THAT IT WOULD FUNCTION THE BEST, AND NOT TO THROW ANYBODY THAT USED TO BE HERE UNDER THE BUS BUT THEY SAID, THIS IS THE WAY WE THINK IT SHOULD BE DESIGNED AND DAN WHEELAND AND YOU SAW RICK'S NAME AT THE TOP OF THE SLIDE, RICK WAS THE PROJECT OFFICER, PROGRAM MANAGER FOR THIS AND SO, WE HAD TO TAKE A PAUSE. WE HAD TO GO BACK AND REDO THE DESIGN AND MORE MONEY HAD TO BE ADDED BUT YOU CAN SEE THE WAY IT'S TURNED OUT AND I THINK THAT ALL OF THOSE MEASURES WERE AT LEAST IMPORTANT IF NOT NECESSARY, THANKS. >> GREAT. >> WELL, WELCOME. >> ALL RIGHT, SO I'M GOING TO TAKE THE CHAIR'S PREROGATIVE NOW AND WE'RE GOING TO GO INTO A BREAK. LET'S COME BACK AT ACTUALLY DAN, YOU'RE STILL ON HERE, DAN WHEELAND, CAN WE SKINNY YOURS DOWN JUST A LITTLE BIT. LET'S COME BACK AT 5 OF 12 AND WE WILL THEN STILL AIM FOR OUR KD--SALLY BY 1:00 O'CLOCK, DAN ARE YOU OKAY WITH THAT? >> YES MA'AM. >> ALL RIGHT. THANKS SO MUCH AND WE WILL SEE EVERYBODY AT 5 OF THE HOUR. WELCOME BACK EVERYBODY, AND WE WILL GO AHEAD AND GET STARTED. DAN, THANKS SO MUCH FOR BEING SO FLEXIBLE AND WE GOING TO GO TO YOU TO HEAR IN MORE UPDATES ON FACILITIES AND THEN WE'RE GOING OVER TO MARSTON, SO WE'RE LOOKING FORWARD TO IT AND I AM COMMITTED TO EVERYONE THAT WE WILL FINISH BY 1:00 O'CLOCK SO I VERY MUCH APPRECIATE EVERYBODY HANGING IN THERE WITH US TO GET SOME GOOD TOPICS LEFT. DAN? >> THANK YOU MA'AM. NEXT SLIDE, PLEASE, CARLY. SO WE'RE GOING TO TALK ABOUT PROJECTS RECENTLY AWARDED, THOSE THAT HAVE BEEN SUBSTANTIALLY COMPLETED RECENTLY AND THOSE UNDERCONSTRUCTION IN JUST A BRIEF ANNOUNCEMENT REGARDING POSITIVE RESULTS FROM THE QUARTERLY MEETINGS CONDUCTED WITH THE APPROPRIATIONS COMMITTEE STAFF, 2 GOOD DEVELOPMENTS, 1 IS THAT THE FISCAL YEAR 22 BUILDINGS AND FACILITIES APPROPRIATION WAS INCREASED FROM THE PREVIOUS AMOUNT OF $200 MILLION TO $250 MILLION REPRESENTING A 25% INCREASE WHICH WAS THE LARGEST PERCENT CANCER CENTER INCREASE OF ALL, ALL APPROPRIATIONS AND NOW REPRESENTS THE BASE FOR FUTURE YEAR APPROPRIATIONS. SECONDLY, THE INCREASE IN SPECIAL AUTHORITY WHICH ENABLES US TO TAKE IC APPROPRIATIONS AND USE THEM FOR REPAIRS AND IMPROVEMENTS THAT THRESHOLD WAS MOVED FROM 3.5 TO $5 MILLION PER PROJECT AND IN AGGREGATE FROM $40 MILLION TO $100 MILLION AND I THINK AS EVERYONE MAY RECALL THESE ENGAGEMENTS RESULTED IN THE AFTERMATH OF THE NATIONAL ACADEMIES CONSENSUS STUDY REGARDING OUR BACK LOG OF MAINTENANCE AND REPAIR SO WE'RE STARTING TO SEE SOME VERY POSITIVE DEVELOPMENTS FROM THIS AND THE OTHER THING I WOULD JUST ADD IS THE PRESIDENT'S BUDGET AS DR. TABAK AS JUST RELAYED EARLIER WAS JUST ANOWBSED FOR FISCAL YEAR 23 AND IN THE PRESIDENT'S BUDGET, THE BUILDINGS AND FACILITIES APPROPRIATION WOULD INCREASE FURTHER FROM 250 TO $3 BILLION, SO POSITIVE AN ACTMENTS DUE TO RESOURCES. NEXT SLIDE. SO AS DR. TABAK SHARED WITH YOU, WE RECENTLY AWARDED LAST TUESDAY SPECIFICALLY THIS VERY IMPORTANT PROJECT FOR SURGERY, RADIOLOGY, LABORATORY MEDICINE, AND INCLUDING CATHETERIZATION LABORATORY AND INTERVENTIONAL RADIOLOGY. NEXT SLIDE. --AND THEN THE IN THE LOWER VIEW, YOU CAN SEE A VIEW FROM THE STREET PERSPECTIVE FROM WEST LOOKING TO THE EAST. NEXT SLIDE. THIS IS THE DESIGN BUILD TEAM THAT WAS AWARDED THE PROJECT LED BY HENSEL, PHELPS, WHO WAS THE CONSTRUCTOR, ZGF WAS THE ARCHITECT OF THE RECORD AND THE CRC AND FAMILIAR WITH THE EXISTING BUILDING AND THEN THE PLUMING AND ELECTRICAL DESIGN HAS ELABORATE EXPERIENCE WORKING ON NIH'S SITES, SO WE BELIEVE WE'VE GOT A WORLD CLASS TEAM HERE, THE AMOUNT OF THE AWARD WAS APPROXIMATELY $638 MILLION. SO, WE ARE INVESTING HEAVILY IN THESE KEY AREAS AND WE WANT TO THANK THE BOARD FOR THEIR SUPPORT, I RECALL THAT YOU WROTE AN IMPORTANT LETTER THAT WAS INSTRUMENTAL IN ENABLINGITOUS GET TO THIS CRUCIAL MILESTONE. NEXT SLIDE. --STAFF ALIKE NEXT SLIDE. ANOTHER PROJECT WHICH MAY NOT BE HIGHLY VISIBLE, BUT IS ABSOLUTELY CRUCIAL TO PATIENT SAFETY, WE REPLACED ALMOST A QUARTER OF A MILE OF PIPING IN THE BASEMENT OF THE CLINICAL RESEARCH CENTER MUCH THE EXISTING PIPING WAS OVERICIZED AND THAT MIGHT SEEM LIKE AN ADVANTAGE BUT ACTUALLY IT SLOWED DOWN THE VELOCITY OF WATER ENABLING THE CREATION OF SEDIMENT AND BIOFILM AND SECONDLY WAS CONSTRUCTED OUT OF GALVANIZED PIPE WHICH HAD EXPERIENCED SOME COROCEAN AND SO WE RE--CORROSION AND WE REPLACED IT WITH A SMALLER DIAMETER COPPER PIPE AND THAT INVOLVED A 20 HOUR WATER OUTAGE THROUGHOUT THE ENTIRE HOSPITAL AND I WANT TO THANK THE CLINICAL CENTER FOR THEIR EXCEPTIONAL COLLABORATION IN SCHEDULING AND PULLING OFF THAT IMPORTANT OUTAGE TO IMPROVE THE QUALITY OF THE WATER FOR OUR PATIENTS. NEXT SLIDE. WE ALSO COMPLETED A STERILITY LAB FOR THE LABORATORY OF MEDICINE THAT WILL PROVIDE DRAMATICALLY ENHANCED CAPABILITIES TO LOOK AT THE STATUS OF VARIOUS PRODUCTS WITHIN THE CLINICAL CENTER AND INSURE THERE THEY'RE OF THE PROPER STERILITY, NEXT SLIDE. WE ALSO COMPLETED A SIGNIFICANT PROJECT FOR THE CENTER FOR CELLULAR ENGINEERING, CELL PROCESSING FACILITY, THE COMMISSIONING QUALIFICATION AND VALIDATION WERE COMPLETED OR ARE SCHEDULED FOR COMPLETION THIS MONTH AND THERE WILL BE ENVIRONMENTAL MONITORING, PERFORMANCE QUALIFICATION IN JUNE, ENABLING THE OPERATION OF THIS CRITICAL FACILITY. NEXT SLIDE. SO WE'VE GOT SOME PROJECTS THAT ARE IN VARIOUS PHASES OF CONSTRUCTION. NEXT SLIDE, PLEASE, CARLY. WE'RE CONDUCTING IMPROVEMENTS RELATIVE TO STERILE PROCESSING IN BOTH THE B1 LEVEL AND ON LEVEL 2 TO PROVIDE THE IMPROVED SAFETY PRODUCTION WORK FLOW AND REGULATORY COMPLIANCE RELATIVE TO THE STERILEAISATION PROCESS. IN ADDITION I SHOULD ADD THERE'S A ROBUST STERILIZATION CAPABILITY IN THE BASEMENT OF THE NEW ADDITION THAT I REFERRED TO EARLIER, SO THESE ARE GOING TO BE IMPORTANT NEAR TERM IMPROVEMENTS THAT WILL BE EVEN BUILT UPON WHEN WE CONSTRUCT THE NEW ADDITION. NEXT SLIDE. WE CONTINUE WITH THE RENOVATION OF THE EWING WHICH IS SHOWN WITH THE MRI WOOD COVERED WINDOWS, STILL IN CONSTRUCTION AND WILL PROVIDE A DRAMATICALLY IMPROVED CAPABILITY FOR THE DEPARTMENT OF TRANSFUSION MEDICINE WHICH IN 2011 WAS IDENTIFIED AT THE DEPARTMENT THAT WAS NOT RELOCATED INTO THE CRC THAT NEEDED THE MOST ATTENTION AND HENCE THEY CAME FIRST IN LINE AND THIS WILL PROVIDE CELL PROCESSING AS WELL AS THE BLOOD BANK AND OTHER KEY--AND THIS JUST SHOWS YOU A CROSS SECTION OF THE BUILDING AND THE CLINICAL CENTER RELATED OCCUPANCIES ARE HIGHLIGHTED IN GREEN. NEXT SLIDE. THIS PROJECT AGAIN IS SORT OF BEHIND THE CURTAIN BUT IT WILL ENABLE US TO OPERATE MORE AUTONOMOUSLY RELATIVE TO THE POWER FOR OUR CENTRAL UTILITY PLAN WHICH WILL INDEED ENABLE US TO GENERATE STEAM AND CHILLED WATER ENOUGH TO TREAT THE MOST CRITICAL FUNCTIONS ON CAMPUS INCLUSIVE OF PATIENT OPERATIONS AND GIVEN CLIMATE CHANGE AND EXTREME WEATHER, SOME OF WHICH WE JUST TALKED ABOUT, WE ARE KEENLY AWARE OF THE CRITICALITY TO DEVELOP RESILIENT INFRASTRUCTURE. THIS IS FULLY FUNDED AND SCHEDULES FOR COMPLETION A LITTLE OVER A YEAR FROM NOW. NEXT SLIDE. ON THE SAME TOPIC OF RESILIENT INFRASTRUCTURE, WE'RE INVEST FLG A NEW UTILITY VAULT FOR ALL OF THE ELECTRICAL EQUIPMENT SERVING THE EXISTING BUILDING 10 COMPLEX AS WELL AS THE ADDITION AND WE'RE ALSO INVESTING IN A PATIENT PARKING GARAGE WHICH WILL EVENTUALLY ENABLE US TO REMOVE OR DECOMITION THE UNDERGROUND PARKING WHICH IS SUFFERING FROM DETERIORATED CONCRETE AND ALSO CONSTITUTES TO SOME EXTENT SECURITY RISK AND REQUIRES A HUNDRED PERCENT OF INSPECTION OF ALL THOSE VEHICLES. NEXT SLIDE. THIS IS A PICTURE OF THE PARKING GARAGE. NEXT SLIDE. THIS PICTURE IS THE UTILITY VAULT WHICH WILL HOWES ALL OF THE ELECTRICAL EQUIPMENT SERVING THE ENTIRE BUILDING 10 COMPLEX, NEXT SLIDE. ANOTHER PROJECT INITIATED BY DR. GILMAN IS THE ADDITIONAL PROTECTIVE ISOLATION PATIENT CARE IN THE PEDIATRICS WARD AND WE ARE APPROXIMATELY 50% OF THE WAY THROUGH THAT HAVING WORKED ON THE SOUTHERN PORTION AND COMPLETED THAT AND NOW WE'RE WORKING ON THE NORTHERN PORTION OF THAT WARD. NEXT SLIDE. THIS DESCRIBES A LITTLE BIT OF THE STATISTICS IN TERMS OF THE NUMBER OF ROOMS THAT ARE INVOLVED IN THE CONVERSION OF THOSE INTO THE PROTECTIVE ENVIRONMENT AND AIR BORN INFECTION ISOLATION ROOMS. NEXT SLIDE. THIS JUST GIVES YOU A FLOOR PLAN OF THE SAME. NEXT SLIDE. SO IN SUMMARY, THE INCREASE IN THE BUILDINGS AND FACILITIES APPROPRIATION AND THE SPECIAL AUTHORITY WILL PROVIDE MORE RESOURCES FOR FACILITIES, LIKELY RESULT OF THE NATIONAL ACADEMIES OF CONSENSUS REPORT AND THE RESULT IN QUARTERLY MEETINGS WITH THE APPROPRIATIONS STAFF. THE MOST NOTE WORTHY DEVELOPMENT THIS PRESENTATION OF COURSE IS THE AWARD OF THE SURGERY RADIOLOGY AND LABORATORY MEDICINE PROJECT, WHICH YOU HELPED ADVOCATE FOR AND YOUR SUPPORT IS SIGNIFICANTLY APPRECIATED AND SO THIS CONCLUDES MY PRESENTATION AND SUBJECT TO YOUR QUESTIONS. THANK YOU. >> TERRIFIC, THANK YOU. YEAH, SOMEONE WAS JUST PRIVATELY CHATTING ME THAT IT WAS SEVERAL YEARS AGO THAT THE BOARD HAD A CHANCE TO DO A TOUR OF THE CLINICAL CENTER, OBVIOUSLY SELECT PARTS OF IT WAS HUGE BUT IT WAS REALLY GREAT TO SEE. I HOPE THAT WILL BE SOMETHING THAT THE BOARD CAN RETURN TO IN THE FUTURE. NOTHING LIKE SEEING SOMETHING. LOTS OF GREAT THINGS ON THE HORIZON. ANY QUESTIONS FOR DAN? OR THE REST OF THE TEAM? OKAY, LET'S KEEP MOVING. ALL RIGHT. SO, SIEM SORRY, RICK, GO AHEAD. >> SO LAURA, I THINK THIS IS REALLY EXTRAORDINARY PROGRESS AND PARTICULARLY THE NEW SURGICAL MEDICAL LAB MEDICINE BUILDING AND THE RENOVATIONS TO THE PEDIATRIC SPACE, VERY MUCH CONSISTENT WITH THE RESEARCH DIRECTIONS AROUND BOTH CELL BASED THERAPIES AND GENETICS THAT I THINK WILL LIKELY BECOME AN INCREASING PART OF THE CLINICAL RESEARCH PORTFOLIO OF THE HOSPITAL, SO, THESE ARE I THINK ARE REALLY, REALLY IMPORTANT AND IT'S REALLY GREAT TO SEE THEM COME TO FRUITION OVER THE LAST, YOU KNOW 6 YEARS. >> GREAT STUFF AND NOTHING LIKE NEW, RIGHT? MOVING ON. THANK YOU. WE WILL HEAR FROM DR. MARSTON LINEHAN WHO IS CHIEF THE UROLOGIC SURGERY AND UROLOGIC ONCOLOGY SECTION. THIS IS A REAL TREAT, I HAVE TO SAY FOR US, TO GET TO HEAR SOME OF THE SCIENCE THAT CONNECTS ALL OF US. SO MARSTON, OVER TO YOU. THANK YOU VERY MUCH FOR BEING HERE. >> THANK YOU VERY MUCH FOR INVITING PLEA, IT'S A REAL HONOR. --INVITING ME, - IT IS A REAL HONOR. OKAY. CAN YOU ALL SEE MY SCREEN OKAY. >> YES. >> OKAY. WELL, THANK YOU VERY MUCH. IT'S A REAL HONOR AND I CAN'T TELL YOU HOW MUCH THE INTRAMURAL SCIENTISTS APPRECIATE ALL THE EFFORT AND WORK THAT YOU DO TO SUPPORT THE WORK THAT WE DO AT THIS MARVELOUS CLINICAL CENTER RESEARCH HOSPITAL. THIS AFTERNOON, I WILL SPEAK ABOUT THE IDENTIFICATION OF THE VHL KIDNEY CANCER GENE. HOW IT LED TO MOLECULAR DIAGNOSIS, UNDERSTANDING OXYGEN SENSING AND PRECISION THERAPY. NIWHEN WE START OUR WORK ON KIDNEY CANCER HERE AT THE CLINICAL CENTER, RESEARCH HOSPITAL IN THE EARLY 1980S, KIDNEY CANCER WAS THOUGHT TO BE A SINGLE DISEASE, WE DID THE SAME SURGERY ON EACH PATIENT, WE TREATED PATES WITH METASTATIC DISEASE ALL WITH THE SAME DRUGS, NONE OF WHICH WERE EFFECTIVE, NOW WE KNOW THAT KIDNEY CANCER IS NOT A SINGLE DISEASE, IT'S MADE UP OF A NUMBER OF DIFFERENT TYPES OF CANCER, EACH WITH DIFFERENT HISTOLOGYYS SHOWN HERE, DIFFERENT CLINICAL COURSES, RESPONDING DIFFERENTLY TO THERAPY AND AS I WILL SHOW YOU CAUSED BY DIFFERENT GENES. WE NOW KNOW OF 18 DIFFERENT GENES THAT CAUSE KIDNEY CANCER. AND AS OF 2 DAYS AGO, WE KNOW OF 14 DIFFERENT GENETICALLY DEFINED TYPES OF HEREDITARY KIDNEY CANCER. NOW MOST OF WHAT WE KNOW REALLY ABOUT THE GENETIC BASIS OF KIDNEY CANCER, WE'VE LEARNED FROM STUDYING FAMILIES. WITH THIS MARVELOUS RESEARCH CLINICAL CENTER, WE FOLLOW OVER 3000 PATIENTS FROM NEARLY 1500 FAMILIES, THE LARGEST EXPERIENCE FOR SURE IN THE WORLD WITH CLEAR CELL APPLIED ILLEGALSARY CHROMO, AND ONCOCYTIC RENAL CELL CANCER. NOW, HERE OVER THE PAST 38 YEARS WE'VE DESCRIBED 8 NOVEL DISEASES AT THE CLINICAL CENTER AND WE HAVE IDENTIFIED 9 DISEASE GENES HERE FOR A NUMBER OF DIFFERENT KINDS OF CANCER AND DIFFERENT DISEASES. WE STARTED, OUR WORK BEGAN WITH A PAPER WHICH WE PUBLISHED IN NATURE AND IN THE MIDDLE 80S IN WHICH WE SHOWED CONSISTENT LOSS OF A SEGMENT OF CHROMOSOME 3, THE THIRD CHROMOSOME IN TUMORS FROM PATIENTS WITH CLEAR CELL KIDNEY CANCER THAN WE WERE SEEING HERE. AND I WILL SAY, I WILL TELL YOU THIS, THERE'S NO WAY WE COULD HAVE DONE THIS WORK ANYWHERE ELSE OTHER THAN HERE AT THE CLINICAL CENTER, I MEAN IT JUST WOULD NOT HAVE BEEN POSSIBLE. AND THIS WORK SUGGESTED THAT THERE WAS A KIDNEY CANCER GENE IN THIS LOCATION. NOW THIS WORK BEGAN 17 YEARS BEFORE THE HUMAN GENOME WAS SEQUENCED THERE WAS NO MAP OF THE REGION TO SEARCH, THERE'S NO WAY WE COULD DO THIS BY MAPPING. SO WE TURNED TO THE STUDY OF HEREDITARY KIDNEY CANCERS TO USE THE POWER OF GENETICS TO LOCALIZE AND IDENTIFY KIDNEY CANCER GENES. OUR HOPE WAS THAT THAT WILL ENABLE US TO A-DEVELOP PRECISION DIAGNOSIS, PRECISION SURGERY, PRECISION THERAPY AND TO PROVIDE THE FOUNDATION FOR THE DEVELOPMENT OF TARGETED THERAPY FOR THESE PATIENTS AND I WILL SHOW YOU 1 STORY ON THAT, SO, WE STARTED WITH THE STUDY OF A VON HIPPEL-LINDAU, A HEREDITARY CANCER IN WHICH PATIENTS ARE--MULTIFOCUS CLEAR CELL KIDNEY CANCER. WE ESTIMATE THESE PATIENTS ARE ACTUALLY AT RISK FOR THE DEVELOPMENT OF UP TO 800 TUMORS FOR KIDNEY. THESE WERE CANCER, THESE ARE ADDRESSIVE CANCERS, THEY CAN SPREAD AND KILL THESE PATIENTS, SADLY. WE'VE HAD 63 PATIENTS OVER THE LASTER 38 YEARS WHO'VE DEVELOPED METASTATIC DISEASE, NOW TO PREVENT THAT WE PERFORMED OVER 800 PROCEDURES ON VHL PATIENTS WITH KIDNEY CANCER HERE ADDED THE CLINICAL CENTER. AND WE'VE DEVELOPED A PRECISION CLINICAL MANAGEMENT APPROACH FOR EACH TYPE OF GENETICALLY DEFINED KIDNEY CANCER. FOR VL FOR EXAMPLE, INSTEAD OF REMOVING THE ENTIRE KIDNEY WHICH THEN WOULD HAVE BEEN DONE PRIOR TO THAT TIME WE DEVELOPED AN APPROACH OF ACTIVE SURVEILLANCE, WHICH AT THE TIME WAS CONSIDERED HEARASSY BY MY FIELD, WE RECOMMEND PARTIAL NEFF RECTIFIED ME. NOW AS I MENTIONED WE HAD A NUMBER OF PEOPLE DEVELOP, A NUMBER OF POWER PATIENTS DEVELOP METASTATIC DISEASE OVER THE PAST 34 YEARS WHEN WE INSTITUTED TO APPROACH, WE HAVE NOT YET HAD A SINGLE PATIENT, NOT 1 YET DEVELOP METASTATIC DISEASE WHEN MANAGED IN THIS FASHION. I WANTED TO SHOW YOU THIS. THIS IS A VIDEO OF ROBOTIC PARTIAL NEPHRECTIFIED ME, AND IN WHICH WE ENUCLE8 THIS TUMOR WE COME RIGHT OROUND AND NUCLE8 IT AND TAKE THESE TUMORS OUT AND BECOME CLOSE TO THE TUMOR FOR ANY OTHER GENETICALLY DEFINED TYPES OF CANCER, WEEZ DO A COMPLETELY DIFFERENT OPERATION, FOR PATIENTS FOR EXAMPLE WITH FH DEFICIENCY CANCER, HLRCC, WE DON'T DO ROBOTIC SURGERY, WE DO OPEN SURGERY, WE DON'T DO AN ENUCLEATION LIKE WE DO HERE, WE DO A WIDE MARGIN SO DEPENDS ON THE GENE, IT'S PRECISION SURGICAL THERAPY. NOW OUR PATIENTS ARE ALSO AT RISK FOR PANCREAT CIANCIARULO AND EBD O KRIN NIEWMORS PENT WHICH ARE MALIGNANT AND CAN SPHRED. OUR PATIENTS ARE ALSO AT RISK FOR BRAIN, AND SPINAL HEMAGIAL BLASTOMAS FOR WHICH OUR PATIENTS HAVE UNDERGONE OVER 1200 PROCEDURES AT THE CLINICAL CENTER. THESE ARE VHL ASSOCIATED CEREBELLAR AND SPINAL HEMANGIOBLASTOMAS. AND FINALLY 92% OF OUR PATIENTS TWEP RETINAL ANGIOMAs AND I'M SAT TO SAY WE HAVE A NUMBER OF PATIENT WHO IS COMPLETELY LOST THEIR SIGHT. THIS IS THE FIRST MANIFESTATION OF VHL, WE CAN SEE THESE IN 1 YEAR-OLD. SOPHISTICATEDY WE RECOMMEND GERMLINE MUTATION TESTING IN CHILDREN, IN BABIES TO DETERMINE WHO'S AFFECTED AND WHO'S NOT BECAUSE LASER PHOTO THERAPY CAN HELP PRESERVE VISUAL FIELDS. NOW WE HAVE NO WAY OF KNOWING WHO WAS AFFECTED WHO WASN'T IN THESE FAMILIES SO TO FIND THE VHL GENE WE BROUGHT THESE FAMILIES TO THE MERCHANDISELOUS CLINICAL CENTER RESEARCH HOSPITAL AND THIS IS A TRUE NIH PROJECT. ONE OF MY ASSISTANTS TOLD ME LAST YEAR, SHE SAID, YOU KNOW, OVER THE YEARS YOU'VE WORKED WITH 138 INDIVIDUALS AT NIH FROM 29 LABS AND BRANCHES. FROM 8 DIFFERENT INSTITUTES AT NIH, SO THIS IS TRULY, I'M GIVING THIS TALK BUT THIS IS TRULY AN NIH PROJECT AND HAS BEEN SINCE THE VERY BEGINNING. SO TO FIND THE VHL GENE, WE STUDIED THE FANLLYS HERE AT THE CLINICAL CENTER ASK TRACED THE GENE TO THE SHORT ARM OF CHROMOSOME 3 WHERE WE HAD SEEN THE ABNORMALITY IN SPORADIC CLEAR CELL KIDNEY CANCER, SO WE WERE VERY ENCOURAGED TO SEE THAT. NOW WEINARY ONED THE REGION UP HERE AT THE TOP, WITH GENETIC LINKAGE ANALYSIS, AND THEN DOWN HERE BELOW, WE DID WHAT WAS CALLED PHYSICAL MAPPING, IDENTIFIED THESE ARE CDNAs THEY'RE CALLED AND THE SEVENTH CDNA HERE WE CALL G7 WAS THE SEVENTH CDNA PIECE OF DNA THAT WHEN WE LOOKED AT, AND THIS TURNED OUT TO BE THE VHL GENE IN THE SPRING OF 1993, NEARLY 10 YEARS AFTER WE STARTED THIS PROJECT--MUTATIONS OF THE GENE WHICH SEGREGATED WITH THE DEC IN THE FAMILIES WHICH IS EXACTLY WHAT WE FOUND. WE THEN WENT ON TO DEVELOP A BLOOD TEST WHICH IS USED WORLD WIDE FOR ALL OF OUR GENES WE DEVELOPED AND WAS POSITIVE IN 100% OF OUR FAMILIES. NEXT WE WANTED TO SEE IF THERE THIS WAS THE GENE THAT WE LOOKED FOR FOR SO LONG? WAS THIS THE GENE FOR TUMORS? WE TESTED TUMORS FROM PATIENTS WITH SPORADIC NONFAMILIAL KIDNEY CANCER AND SURE ENOUGH WE FOUND MUTATION OR METHYLATION CHRKS IS THE SILENCING THE GENE IN 91% OF THE TUMORS. NOW WE DID NOT FIND THE VHL GENE MUTATION IN OTHER HISTOLOGIC TYPES OF KIDNEY CANCER THAT I SHOWED YOU A MINUTE AGO, PROVIDING THE FOUNDATION FOR THE DEVELOPMENT OF PRECISION CLINICAL MANAGEMENT, PRECISION THERAPY, AND PRECISION SURGERY BASED ON THE GENO TYPE OF THE CANCER. NOW THIS WAS A COMPLETELY [INDISCERNIBLE] GENE WE HAD NO IDEA WHEN WE FOUND IT HOW IT WORKED. AND WE WANTED TO KNOW HOW THE VHL GENE WORKED SO TO DO THIS, WE FIRST IDENTIFIED 2 PROTEINS, A LONG C AND ELONGIN B HERE WHICH FORMED A COMPLEX WITH VHL AND I WILL PUBLISH THIS IN SCIENCE AND JOINT WEB CONNECTED WITH A YOUNG SCIENTIST BILL KAELIN WHO WILL HEAR MORE ABOUT IN A MINUTE, HOWEVER WE STILL DIDN'T REALLY KNOW OR HAVE A CLUE ON HIGHWAY HOW THIS WORKED. NOW, THE NEXT YEAR, WE AND AGAIN WITH BACK-TO-BACK WITH BILL KAELIN'S GROUP, SHOWED THE VHL GENES THAT ARE OXYGEN SENSITIVE. WELL, HOW'S THAT HAPPEN. WELL, THE FOLLOWING YEAR WITH RICK CLASSENER, WE SHOWED THAT THE VHL COMPLEX INCLUDES A PROTEIN CALLED COL2, A RECENTLY DISCOVERED GENE THE YEAR BEFORE. WE LOOKEDDA THE HOMOLOGOUS YEAST PROTEINS OVER HERE ON THE RIGHT AND YOU CAN SEE THEIR COMPLEX, HOW THEY WORK AND THE REASON VHL HAD TO BE BE BE A DEGRADATION COMPLEX THAT TARGETS TRANSCRIPTION FACTORS THAT REGULATE THE STABILITY OF HYPOXIA INDUCIBLE RNAs, IN OTHER WORDS THAT ARE OXYGEN SENSITIVE, AND WE REASON IT HAD TO BE HYPOXIA INDUCIBLE AND SHORTLY THEREAFTER OUR COLLEAGUE PETER RADCLIFF PROVED THAT, SHOWED THAT, THAT VHL DOES INDEED TARGET HYPOXIA INDUCIBLE FACTOR FOR DEGRADATION, THAT VHL TARGETS HIF FOR DEGRADATION AND THIS IS OXYGEN SENSITIVE. BUT NO 1 KNEW HOW THAT WORKED UNTIL SHORTLY THEREAFTER IN 2001. PETER RADCLIFF AND BILL KAELIN SHOWED THE MECHANISM FOR VHL HIV OXYGEN SENSING. IN RETROSPECT VERY SIMPLE. IT'S PROLEGAL HYDROX ACE, WHICH PUTS HYDROXYL GROUPS WHEN THERE'S OXYGEN IN THE CELL AND NORM OXIA AND THERE ARE COMPLEXES, VHL CAN TARGET AND DEGRADE, HOWEVER IF YOU ARE LOW IN OXYGEN, YOU'RE IN HYPOXIA, YOU CAN'T THROW THOSE ON HERE, THE COMPLEX CAN'T TARGET HIT THE GRADE AND CAN'T ACCUMULATE. AND THAT'S HOW IT WORKS. AND IN 2019, THE NOBEL ASSEMBLY AWARDED BILL KAELYN AND PETER RATCLIFFE, AND GREG SEMENZA THE NOBEL PRIZE OF HOW CELLS SENSE AND ADAPT TO OXYGEN AVAILABILITY, AND THEY WERE VERY GRACIOUS TO CITE OUR WORK AS BEING CRITICAL TO THIS DORPHY. NOW OF COURSE OUR GOAL, OUR EFFORT, OUR TARGET HAD BEEN TO DEVELOP THERAPIES. SO UNDERSTANDING THE VHL PATHWAY HAS PROVIDED THE FOUNDATION FOR THE DEVELOPMENT AND FDA APRAWFAL NONPRECISION THERAPEUTIC AGENTS. TARGETING THE DOWN STREAM GENES REGULATED BY THE VHL HIFF WAGHT WAY. NOW, YOU KNOW HAVE HIGH RESPONSE, WE WERE TARGETING THE DOWN STREAM GENES WUWE WANTED TO DO BETTER. WE WANTED TO TARGET HIF ITSELF, INSTEAD OF JUST THE QUOTE DOWN STREAM GENES. TUMORIGENESIS, AND THIS WORK LED TO THE DEVELOPMENT BY RICK BROOK AND HIS COLLEAGUES OF AN AGENT BELZUTIFAN THAT TARGETS HIF TO ITSELF. SO THEY CONTACTED US AND ASKED IF WE WOULD DO A TRIAL, WE SAID OF COURSE. WE THEN CONDUCTED A MULTICENTER TRIAL LED BY RON KD--SALLY HA IN OUR GROUP EVALUATING THIS AGENT BELZUTIFAN IN VHL PATIENTS. IN THIS TRIAL, WE HAVE SEEN A 98% PARTIAL RESPONSE OR STABLE DISEASE IN RENAL TUMORS IN WHICH 92% OF OUR TARGET LESIONS GET SMALLER. AND CNS AND ANGIO BLASTOMAS WE SEE A 60% RESPONSE WITHA 86% PARTIAL RESPONSE FROM THESE BRAVE PATIENTS WE HAVE WORKED WITH AND BEEN OUR PARTNERS ALL THESE YEARS. AND AGGRESSIVE PANCREATIC INDO KRIN CANCERS WE HAVE A 91% OBJECTIVE--91% OBJECTIVE RESPONSE RATE WITH A 14% COMPLETE RESPONSE RATE IN ENDOCRINE TUMORS. IN 12 VHL PATIENTS WITH 16 RETINAL HEME ANG I DON'T MEANAS, TREATED WITH THIS AGENT, WHICH HAS REALLY VERY MODEST SIDE EFFECTS WE'VE SEEN IMPROVEMENT IN A HUNDRED% OF OUR LESIONS. AND MY COLLEAGUE, IN OPHTHALMOLOGY EMILY CHU HAS BEEN BY OUR SIDE FOR NEARLY 3 DECADES WITH THESE PATIENTS. SHE HAS DONE 6 CLINICAL TRIALS WITH AGENTS TARGETING THIS PATHWAY AND NOT SEEN A WHOLE LOT UNTIL THIS. NOW OR GOAL HAS BEEN OBVIOUSLY TO DEVELOP A THERAPY SO THESE BRAVE PATIENTS WON'T HAVE TO HAVE SURGERY, AFTER SURGERY AFTER SURGERY FOR THEIR TUMORS WHICH WE'VE LIVE WIDE FOR NEITHER 40 YEARS, THE PATIENTS ON THIS TRIAL, CAN YOU LOOK AT THIS SLIDE HERE, THE PATIENTS ON THIS TRIAL, IF YOU LOOK AT THE 2 AND HALF YEARS BEFORE THEY STARTED THERAPY AT 53 SURGICAL PROCEDURES IN THE 2 AND HALF YEARS AFTER WE STARTED DRUG, ONLY 3 SURGICAL PROCEDURES IN THIS PATIENT POP VIEWLINGS. SO WHAT I'VE SHOWN YOU IS THAT KIDNEY CANCER IS NOT KIDNEY CANCER IT'S A NUMBER OF DIFFERENT CANCERS, DIFFERENT MEDICAL COURSES, RESPONDING DIFFERENTLY TO THERAPY, CAUSED BY DIFFERENT GENES WITH DIFFERENT PATHWAYS AND IT'S OUR HOPE THAT OUR CONTINUED STUDY OF KIDNEY CANCER FAMILIAL AND SPORADIC AT THE CLINICAL CENTER, INSTEAD OF STUDYING THESE PATHWAY AND GENES WILL DEVELOP EFFECTIVE FORMS OF THERAPY FOR EVERY PATIENT AFFECTED WITH THIS DISEASE AND I WANT TO ACKNOWLEDGE OUR COLLEAGUES AS I MENTIONED, THIS IS A REAL NIH TRIAL. I'M INDEBTED TO THE COLLEAGUES IN OUR GROUP OUR THERAPEUTICS AND CLINICAL TIME LED BY RON, AND MATT, AND NIH IT WOULD TAKE MY 5 SLIDES TO SHOW EVERYBODY FROM NIH ACROSS THE WHOLE FIELD. OUR COLLEAGUES IN RADIOLOGY ASKING SURGICAL AND NEUROLOGY, AND BEFORE THAT FERS IT ED, I STARTED WORKING WITH ED IN 84 ON THIS. THE MARVIN MUSCAN EVERYBODIOUS EMILY CHU, ENDOCRINE ONCOLOGY, IT GOES BACK TO JEFF NORTON, DOUG, STEVE, I CAN'T TELL YOU HOW MANY SURGICAL COLLEAGUES WE'VE WORKED WITH, THE WONDERFUL MA RIAMOLECULAR MEDICINE, TRACE WHO HELPED US DEVELOP NOVEL APPROACHES TARGETING THE VHL HIF PATHWAY, ENDOCRINOLOGY, WERE ALSO INCREDIBLY APPRECIATIVE OF THE CLINICAL CENTER AND NIH FOR SUPPORTING 2 U01 PROJECTS BASED ON CHL WITH THE INSTITUTE AND OUR WORK WITH BILL KAELIN AND DAVID Mc DORMOT FOR THE VHL CANCERS SO THANK YOU VERY MUCH IT'S BEEN A HONOR TO HAVE AN OPPORTUNITY TO COMMUNICATE WITH YOU, THE WONDERFUL WORK OF THE SMALL PIECE THAT IS ONGOING AT THIS WONDERFUL CLINICAL CENTER. THANK YOU VERY MUCH. >> I SEE A COUPLE HANDS THERE, OKAY. ELEN LET ME GO TO YOU FIRST AND THEN GO TO RICK AND JOHN. >> OKAY. CONGRATULATIONS ON THIS WONDERFUL RESEARCH. THAT'S WHY WE LOVE NIH. BUT I ALSO WANT TO THANK YOU FOR MAKING IT SIMPLE ENOUGH FOR PEOPLE LIKE ME TO UNDERSTAND. SO THANK YOU. >> THANK YOU. >> ELLEN, YOU ARE PRETTY SOPHISTICATED BUT I WILL ALSO GIVE DR. LINEHAN CREDIT FOR MAKING VERY UNDERSTANDABLE AND QUITE AN ACTION PACKED STORY IN TERMS OF DEVELOPMENT. RICK AND THEN JOHN. >> DR. LINEHAN THANK YOU VERY MUCH IT WAS JUST TERRIFIC AND I THINK THAT EARLIER IN THE COURSE OF OUR CONVERSATION THIS MORNING AND TALKING ABOUT EFFORTS AT THE CLINICAL CENTER TO THINK ABOUT ADDRESSING AND I KNOW THAT HISTORICALLY RENAL CELL CANCER, I UNDERSTAND HOW ARE NOT 1 DISEASE BUT IN GENERAL ARE THOUGHT TO HAVE A HIGHER INCIDENCE AMONG AFRICAN-AMERICAN MEN SO I WONDER WHETHER AS PART OF THE CENTER'S EFFORTS TO REALLY FOCUS ON EQUITY WE CAN BEGIN TO REALLY TEASE OUT FOR EXAMPLE, RESPONSE RATES BY RACE, GIVEN AGAIN WITH A DISEASE THAT IS HISTORIC LOAMACYY AND I'M SURE YOU KNOW MORE THAN THIS ABOUT THIS THAN ME BUT HISTORICALLY HAD A HIGH INITANCE AMONG AFRICAN AMERICANS, JUST ANOTHER CONTRIBUTION THE CENTER COULD MAKE TO A NATIONAL CONVERSATION AROUND EQUITY WHERE CLINICAL DISPARITIES ARE ADDRESSED WITH THIS KIND OF SCIENCE. >> ABSOLUTELY. THANK YOU FOR BRINGING THAT UP AND ABSOLUTELY OF COURSE. FOR MANY, MANY REASONS, 1 IS IT'S THE RIGHT THING TO DO BUT ANOTHER OF COURSE, BUT ANOTHER THING IS SCIENTIFICALLY, IT'S VERY IMPORTANT. WHAT IS GOING ON HERE, WHAT IS--HOW DOES THAT WORK, I AGREE, IT'S HIGHER INCIDENCE IN BOTH MALES AND FEMALES, SO PEOPLE WHO ARE OF AFRICAN AMERICAN DESCENT, ANOTHER THING IS THAT ACTUALLY THEY GET A LITTLE DIFFERENT TYPE OF KIDNEY CANCER. THEY GET MORE APPLIEDULARAR SKPE BAKUGAN LESS CLEAR CELL AND THAT'S A VERY--IT'S A VERY IMPORTANT POINT AND WE'RE WORKING VERY HARD TO EXPAND OUR EFFORTS IN THOSE AREAS AND OF COURSE, I'M A NEUROLOGIC SURGEON AND OF COURSE, WE MANAGE PATIENTS WITH PROSTATE CANCER, KIDNEY CANCER, PROSTATE CANCER, BLADDER CANCER AND IN PROSTATE CANCER WE HAVE SIMILAR ISSUES THERE, EARLIER ONSET, WORST DISEASE AND WE'RE MAKING A BIG EFFORT TO EXPAPPED OUR YORK IN THAT AREA AND REACHING OUT TO OUR COLLEAGUES WITH DR. GALLAN'S HELP AT HOWARD'S, MATTER OF FACT 1 OF OUR FORMER FELLOWS IS FORMING ATTENDINGS ARE DOWN THERE AT NEUROLOGIC SURGERY WE'RE WORKING WITH THAT GROUP AND ALSO WORKING WITH OTHER GROUPS THAT HAVE NETWORKS ACROSS THE COUNTRY, IN THIS CASE, AFRICAN AMERICAN PHYSICIAN WHO IS HAVE HIGH PERCENTAGE OF PATIENTS WITH AFRICAN AMERICAN DESCENT AND I AGREE THESE ARE INCREDIBLY IMPORTANT AND IMPORTANT FOR MANY REASONS TO DO IT BUT ALSO SCIENTIFICALLY IT'S SOMETHING THAT'S VERY IMPORTANT TO UNDERSTAND. >> THANK YOU. >> THANK YOU. JOHN AND THEN ANTOINETTE? SO I JUST WANT TO EMPHASIZE A FEW THINGS AND THANK MARSTON WHO I THINK KNOWS I'M 1 OF HIS BIG FANS, HE'S A DOCTOR, I MEANEE TAKES CARE OF PEOPLE, THAT'S WHAT HE DOES 12 HOURS, 14 HOURS, 24 HOURS A DAY AND THIS ALL HAPPENED IN THIS SETTING AND WHAT I REALLY WANT TO EMPHASIZE IS WHAT MARSTON ALLUDED TO AND THAT IS THE PARTNERSHIPS HE CREATED BETWEEN THE BASIC SCIENTISTS COMMUNITY AND THE CLINICIAN SCIENTIST COMMUNITY BOTH ACROSS THE NIH AND ACROSS THE COUNTRY. I MEAN THAT'S WHY THE MAGIC HAPPENS AND THIS IS MAGIC. I MEAN THIS A MONUMENTAL ACCOMPLISHMENT THAT YOU HEARD TODAY, INCLUDING A NOBEL PRIZE. I MEAN, IT DOESN'T GET BETTER THAN THAT. SO, WHEN YOU ASK, WHY DO WE NEED THE NIH? WHAT DOES IT HAVE? IT'S THAT ENVIRONMENT THAT ENABLES THREEZ SORTS OF THINGS--THESE SORTS OF THINGS TO HAPPEN TO ME THAT IS SO SPECIAL. SO MARSTON, THANK YOU FOR PRESENTING THIS AND PRESENTING IT IN A WAY THAT I THINK EVERYBODY CAN CAPTURE THAT MAGIC. >> THANK YOU VERY MUCH. I MEAN I COULDN'T HAVE PUT IT BETTER. I MEAN WE SAY, DR. GALLAN, WE STUDY THE HUMAN MODEL TO ANSWER ARE AND YOU KNOW WE COULDN'T DO IT, I MEAN I COULDN'T HAVE DONE THIS, ANYWHERE ELSE AND AS YOU SAID, ALL THESE OTHER COLLEAGUES--BE SURPRISED THE PROGRESS PEOPLE CAN MAKE WORKING TOGETHER IF YOU'RE NOT SO QUITE CONCERNED WITH WHO GETS CREDIT FOR THE WORK AND YOU CAN LOOK AT THAT AND LOOK AT THE AUTHORSHIP IN THOSE PAPERS, THAT'S THE WAY WE BELIEVE. AND YOU KNOW IT'S THESE MARVELOUS AND OF COURSE WE ALL KNOW IT BUT THESE MARVELOUS BRAVE PATIENTS THAT ARE OUR PARTNERS IN ALL THIS WORK AND WITHOUT THEM, I TELL THEM EVERY WEEK, WITHOUT THEM, WE WOULDN'T HAVE BEEN ABLE TO MAKE ANY PROGRESS BUT HAVING THE OPPORTUNITY TO BRING THOSE PEOPLE HERE, TO WORK IN THIS WOBDERFUL HOSPITAL, WONDERFUL CLINICAL CENTER, I CAN'T IMAGINE ANYTHING BETTER AND FOR SOMEONE LIKE ME, IT'S BEEN THE DREAM OF A LIFETIME AND WE'RE VERY ENCOURAGED BY THE PROGRESS THAT'S BEEN MADE BUT WE HAVE A LONG WAY TO GO BUT WE WILL GET THERE. >> ANTOINETTE. >> THANKS, DR. LINEHAN FOR WHAT YOU'VE BEEN DOING ON THE STUDY OF KIDNEY CANCER AND ISSUES. ALTHOUGH I KNOW I'VE BEEN DIAGNOSED WITH KIDNEY CANCER, I DID HAVE AN ISSUE WITH MY KIDNEYS A LITTLE BIT OVER 10 YEARS AGO AND I KEPT GOING TO THE DOCTOR AND DOCTOR AND DOCTOR, THEY HAD NOT A CLUE WHAT WAS HAPPENING TO ME BECAUSE MY BLOOD WORK WAS SAYING EVERYTHING IS OKAY BUT DUE TO MY SIZE, IT REALLY WASN'T SO MY DR. AT GEORGE TOWN BY THE WAY HER LAST NAME IS MELLIBLE, NEVERROLOGYIST THERE, SHE GOT ME BACK ON TRACK, SHE DID A SPECIAL TEST BECAUSE SINCE I'M [INDISCERNIBLE], I HAD [INDISCERNIBLE] AND THAT'S WHY THE BLOOD WORK WAS REALLY OFF AND TELLING ALL THE DOCTORS EVERYTHING'S OKAY, I KEPT GOING, I DIDN'T KNOW WHAT WAS GOING ON WITH ME TO THE POINT THAT BY THE TIME I WAS ABLE TO GET IN TO SEE DR. NEELABLE, MY KIDNEY FUNCTIONS WERE AT 34% AND THEY DIAGNOSED ME WITH STAGE 3 CHRONIC KIDNEY DISEASE. WELL SHE GOT ME, IT 1 OF THE MEDICATIONS I WAS ON, WAS REALLY DAMAGING MY KIDNEYS SO I WAS TAKEN OFF THE MEDICATION AND SHE'S BEEN MONITORING ME EVERY YEAR SINCE THEN AND EVERY TIME I SEE HER, I SAY THANK GOD FOR DR. NEELABLE, BECAUSE SHE SAVED ME FROM BEING ON KIDNEY DIALYSIS AND SHE SAVED MY KIDNEYS, RIGHT NOW I MOVE FROM WASHINGTON D. C. AND I'M NOW LIVING IN ALLEGEHENYAND WHEN I WAS IN DID D. C. NIGH KIDNEY FUNCTION WAS TO LET STAGE 3 AND THEY WERE BASICALLY LEVELED OFF DUE TO THE TREATMENT THAT DR. NEELABLE HAD GIIVE ME. RIGHT NOW, SINCE I'M LIVING IN THE APPALACHIA MY WATER SUPPLY IS WELL WATER AND MY KIDNEY FUNCTIONS HAVE IMPROVED TO I'M STAGE 2 CHRONIC KIDNEY DISEASE AND EVERYTHING'S REALLY LEVELING OFF AND I DEFINITELY FEEL A WHOLE LOT BETTER AND I'M NOT SURE IF THE DOCTOR IS ON YOUR TEAM IS THE HUSBAND OF THE DOCTOR AT GEORGE TOWN, BUT THAT'S A POWER COUPLE THERE. THANK YOU. >> IT'S FUNNY,IME SO GLAD YOU'RE DOING BETTER AND EVERYTHING, YOU KNOW IT'S 1 OF THE WONDERFUL THINGS ABOUT THE NIH AND THE CLINICAL CENTER IS WE HAVE THE OPPORTUNITY TO SEE SO MANY PATIENTS WITH DIFFERENT DISEASES AND TO HELP THEM AND THE NICE THING WE DON'T HAVE TO CHARGE THEM FOR INSURANCE OR ANY OF THAT SORT OF STUFF, IT MAKES SUCH A DIFFERENCE THAT WE MIGHT, IF WE DO SURGERY WE MIGHT INFLICT PAIN BUT WE DON'T INFLICT FINANCIAL PAIN SO IN OTHER WORDS WE CAN TREAT ALL PATIENTS AND THAT'S A WONDERFUL THING ABOUT WORKING HERE. YOU JUST NEVER HAVE TO WORRY ABOUT THAT. IT'S NEVER AN ISSUE WITH WHO YOU WILL BRING SOMEBODY IN OR NOT. SO WE'RE THRILLED ABOUT THAT AND ALSO, SO GLAD TO HEAR YOU'RE DOING BETTER. THAT IS GREAT. >> YES, ALSO WHAT RICK WAS SAYING REGARDING THE KIDNEYS ISSUES WITH AFRICAN AMERICANS VERSUS OTHER RACES, I ALSO NOTICED WHEN I WAS IN D. C., IT'S LIKE THEY'RE PUTTING THE DIALYSIS CENTERS IN STRIP MALLS, THEY'RE EVERYWHERE NOT IN HOSPITALS LIKE THEY WERE YEARS AGO, NOW THEY'RE JUST LIKE EVERYWHERE. AND I ALSO NOTICED THAT THE KIDS, THE FOLKS ARE GETTING MUCH YOUNGER WHO ARE BEING SUBJECT TO DIALYSIS BECAUSE I USED TO RIDE METROACCESS IN D. C. AND I WOULD LEAVE OUT EARLY IN THE MORNING AND WE WERE DROPPING PEOPLE OFF AT KIDNEY DIALYSIS CENTERS AND STRIP MALLS AND SORE SOME OF THESE BUILDINGS, LIKE--IT WAS LIKE AT LEAST IN THE 70S BY THE TIME THEY NEED THAD TYPE OF INTERVENTION, IF THEY EVER NEEDED IT SO IS THERE SOMETHING GOING ON IN THE INNER CITY OR WITHIN THE BLACK COMMUNITY THAT YOU THINK THAT MAY BE INCREASING THIS DAMAGE TO OUR KIDNEYS? >> WELL I'M A UROLOGIC SURGEON, THE PEOPLE WHO STUDY THAT ARE OTHER KIDNEY DOCTORS AND NEFFROLOGYIST HOWEVER I KNOW THIS IS AN IMPORTANT AREA THAT PEOPLE ARE LOOKING AT. YES THIS, THIS IS AN YSH, NO QUESTION ABOUT IT AND A LOT OF PEOPLE ARE WORKING ON THAT, BIG EFFORT ON THAT. BIG EFFORT TO GOING ON TO HELP PEOPLE WITH THEIR KIDNEY FUNCTION, ABSOLUTELY, VERY IMPORTANT QUESTION. >> OKAY, GREAT. ALL RIGHT. JUST TERRIFIC, WHAT A GREAT WAY FOR US TO CONCLUDE THIS MEETING MARSTON, THANK YOU SO MUCH, THIS REALLY DOES BRING THIS TO LIFE, I WANT TO SAY A SPECIAL THANK YOU TO ELLEN, FOR ALL THE GREAT PARTICIPATION. YOU HEARD WITH ELLEN AND OUR DEPARTED BEE, BY THE WAY THAT WE WERE TALKING ABOUT BEFORE, AND NOW, WITH--YOU SEE HOW IMPORTANT IT IS TO HAVE THE WORDS OF PATIENT, FANTASTIC ELLEN, GLAD YOU ARE NOT LEAVING THE PATIENT GROUP. THAT WILL BE IMPORTANT. THANKS TO OUR NEW MEMBERS ANTOINETTE, DAVID AND CRAIG, I THINK QUIEWR IN FOR A REAL TREAT. JIM, DID WE CONFIRM FRIDAY JULY 15 AS OUR MEETING? >> I BELIEVE WE HAVE AND I BELIEVE THE MOST RECENT DESCRIPTION I HEARD OF THAT MEETING IS, IT WILL BE A HYBRID MEETING WHICH MEANS WE WILL HAVE PEOPLE PRESENT WE ALSO HAVE THE OPTION OF ATTENDING VIRTUALLY AND STILL PARTICIPATING IN THE MEETING. HYBRID MEETINGS WE'RE DOING SOME EXPERIMENTING WITH--IT'S A LITTLE DIFFERENT BUT--I HOPE THAT SOME OF THE NEW MEMBERS CAN COME TO THE CLINICAL CENTER, WE WOULD LOVE TO BE ABLE TO SHOW YOU THE FACILITIES, THERE'S SOME OPPORTUNITIES WE HAVE WHEN YOU'RE HERE THAT WE DON'T HAVE WHEN WE'RE ALL ON THE COMPUTER, SO, I'M HOPEFUL THAT WE CAN SEE SOME OF YOU IN PERSON. >> TERRIFIC. GOOD. WELL, ONCE AGAIN, THANKS ALL, THIS IS A GREAT MEETING. WITH THE SPIRIT OF OPTIMISM ABOUT EVERYTHING THAT'S MOVING FORWARD SO, THANKS TO THE TEAM, THANKS TO OUR ONGOING BOARD MEMBERS VA GREAT REST OF THE DAY, EVERYONE.