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Surgical Neurology International
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and SI Digital Innovations and Learning
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in association with the Sub-Saharan African Neurosurgeons.
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Our pleased sponsor of the Sub-Saharan International Neurosurgery Grand Rounds
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held on the first Sunday of each month
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This third sub-Saharan Africa International Neurosurgery Grand Rounds is entitled Global Solutions to Clinical Challenges in Neurosurgery.
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Their discussions from Africa, Argentina, France, Persia, and the USA. Moderators are Estrada Bernard and James Osmond
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This speaker will be Alvin Do, who is the only neurosurgeon in Liberia, and at the John F. Kennedy Medical Center in Greater Monrovia, Mon Serato County, Liberia Thank you.
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We really appreciate sharing two cases with this esteemed body and for discussion.
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A 47-year-old male, a construction engineer, was presented to the trauma unit of the John F. Kennedy Medical Center two weeks following a high-speed motorbike and truck collision during which he
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sustained soft tissue injuries to his face.
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Actually, he presented because of the persistent auto mental status
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changes,
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because he was initially admitted to a local facility. And when he was discharged two weeks later, due to the confusion, he was to the Joint of Canada Medical Center.
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Approximately 24 hours before presentation, he became increasingly confused and had progressively worsening headaches, accompanied by MSCs, behavioral changes, and copious CSF leak from the left
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ear and nose.
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Can I ask you a question, Alvin? Yes. When he was in the other hospital, what was the reason he was in there?
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He was being managed for suspected brain injury brain injury. So this hospital is about two hours drive from Morovia, where I am. So he was being managed for moderate traumatic brain injury,
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according to them.
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Okay. Okay. So, in our facility, his initial Glasgow Commence Corps was 13 And he presented with anisochoria,
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where in the right eye was about nine millimeters and sluggishly reactive, and the left eye was within, was reactive.
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So
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upon his due to his clinical presentation, and we decided to do a quick CT scan And we show multiple fractures, like around the frontal bone, even the face. and a massive left front door,
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numerous followers, as well as air within the venture code. So the
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patient, when he presented, he was initially maintained with the head of the bed elevated at 30 days.
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But once upon
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the city scan funding, we had to reposition him in a flat configuration and we started immediately high flow oxygen.
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But gradually, after five hours, and what we did upon reviewing the city scan, we decided to do an emergency preoperative investigation for surgery. And normally in our setup, it usually takes
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hours to get the results. So about five hours, his GCS started to decline He begins 11.
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and he little became aphasic.
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So when we received his lab, we had to rush him to the theater and after anesthesia,
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after discussing with the family, getting that consent, we had to do a level of burr hole craniostomy
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And immediately, we put in on post-operatively, he was placed on antibiotics at high doses and some analgesic. And then we also gave him anti-conversing, prophylaxis, and the anti-conversant of
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choice we use was a phenytoine. On post-operative, they won. The patient recovered
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quickly and we observed that his GCS became 15. He began ambulatory He propacized it the way equal and he improved neurologically.
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So this is a post-operative CT scan, and as you can see with the left front door bar home.
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This is a post-operative CT scan as well. Above is the bone window and below is the soft tissue window. And this post-operative CT scan was done 10 days after a surgery, and that could be explained
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due to the fact that the patient usually get money from his pocket to pay for the CT scan, the follow-up CT scan.
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So, I thank you, and the patient is currently in our care, and he is recovering very well, but just that we did ophthalmology consult, and according to the ophthalmologist, he has a traumatic
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optic neuropathic of the right eye, And the left eye, it was confirmed that he has a major peers.
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But currently, he is doing good.
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Well, thank you, thank you, Dr. Nando, for that presentation. So, a couple of questions, the, was the anisochoria documented prior to his arrival at your hospital? Yes, we, yeah, we noted
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that, exactly. We noted that and it was indicated in his medical do see
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And what did you do with the, when you did the burhoo, what was your process? Good, so what we did, when we did the burhoo, we coagulated the dura. And then we did, we did coagulation of the,
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because there was a teen layer of cortex. And, and, and another important technique we use, we use, we had to do a little irrigation We had sea lie, normal sea lie, and about, and gentle
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missing. combine that we had to irrigate. And as we irrigate with suction, we irrigate
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slowly because normally, if you do it forcefully, you, there will be some trauma to the little problem. Hematoma, so that
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was what we did. And as we're doing it, you could see, we observed that there were air coming out.
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Yeah, okay, very good. Any discussion? Actually, if you would stop sharing your screen,
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Dr. Doh will.
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I think I'll leave you had his hand raised. Dr. Consorid, would you like to comment?
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One question was that you see the fracture goes through the front of signers Did he have CSF rhinodia also?
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Professor, he has it. So actually, we taught on that, but our concern was when he was deteriorating because that should be planned for surgery later on. But what was remarkable after the surgery,
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it regrets significantly. Currently there is no CSF leak, but that is why we're still keeping him on an observation because the plan was to try to get, to try to decompress the brain and then plan
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to see how we can repair the drought here.
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Also, did you
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leave some or inject some saline to fill out the ventricle? So that way the air comes out and then wait for the healing of the fractures.
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Oh yeah, yeah, we did We use the line, gentlemen be seen. And we did it this way. We had about
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160 milligram of genta missing in 500 mils of normal saline. OK. Thank you very much. Thank you. Thank you, Professor.
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So Dr. Do, high flow oxygen is a well-known method for addressing pneumocephalus Obviously, with an urgent situation in which the patient is declining, you need to do surgical intervention. But I
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wondered, after surgery, did you continue with high flow oxygen, or was the surgical intervention sufficient? So actually, we had to continue with it. I'm sorry I did not mention that. That is
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a very good point, Professor. Yes, we did. And yeah, we did.
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How long, I think NIMM has a question, yes. Very much, it's a very good, very good case. And I think my question has been answered because I mentioned that CSF leak has stopped. And
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this suggests that there's anterior fractures of the anterior cranial fossa from the CSF leaks because it must have, from the pneumocephalus isable and it was mainly frontal, it must have come from
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somewhere.
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And my only comment is sometimes one may just manage them conservatively and they do resolve, they resolve spontaneously. And then if it increases, if it's increasing, then one may need to, if
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for example, like now in such a case where the CSF are in a rear, what we need to do until the credit. approach and go for the for the site of the leak and to do a repair. Thanks.
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Albin, how long did you leave the
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drain in the ventric or did you just use it to irrigate out the air and then I took it out or what did you do? Okay, so I did that place in the ventricular drain. So rather at the end of the
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surgery we did place a sub-galia drain, a sub-galia drain just over the the barrel hole and and it was removed when we were served. I was removed 48 hours post-operatively due
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to the fact that it was not it was not a it was not a less little Uh, below
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25 CC. So gravity drain.
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Yes, gravity drain. Yeah. Okay. Thank you. I, so did I understand this right that, uh, when you did the burr hole, uh, did you, did you cannulate the ventricle and irrigate the fluid out?
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Or did you just let the subdural air out? What did you do? Okay. So actually, um, if, okay, I will go back to the images. So the ventricle was communicating with the massive air within the
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left, uh, frontal lobe. So once I had the contact to me, that is the calculation of the cortex at that area, the teen area, definitely there was communication. So I did not go into the
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ventricle, but why are irrigating to that opening? Some of the fluids, uh, some of the fluid are coming out. that was what I did. Okay.
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And you've put him on antibiotics. Is that correct? Yes.
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Because this has been, you assumed it was going on for two weeks. I didn't see the CSF show. Did you get any CSF to show any white cells in it or is it elevated? Well, so we, the
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CSF, we did not send it for culture and sensitivity.
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Because immediately after the surgery is stopped. And so we couldn't get it because actually we're watching him up for surgery. Okay. But what we did, we did his complete block count, which was
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not, we did not contribute to infection. We, his C-reactive protein was also requested. And the ESRO, the retrosize sedimentation rate, they were all within number limit. So, but so, so
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actually we should have done this. Yes, it is very important. Thank you for that point, professor.
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Oh, okay. So you put them on the antibiotics on a prophylactic basis, right? In other words, just a simple example. Yeah, exactly, yeah 'Cause those are the points people would, I mean, in
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different parts of the world, people might do it differently. And, but that seems very reasonable. And you were gonna watch him clinically, that would you, you put him on the floor, you watch
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him clinically. It actually might be better than a monitor because it forces somebody to look at the patient, right?
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Yeah. Okay, well, that you got a great result and he did all right, and has mental status improved?
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Yeah, but what he complains of, that was the main reason we, we did ophthalmology consult was his vision.
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So the ophthalmology report stated that he, there was a traumatic optic neuropathy of
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the right eye and the left eye,
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the left eye, I think he mentioned a mitral pia, a mitral pia. So, you know, initially when he came to our facility, he had a dilated pooping on the right side. Yeah, the ophthalmologist that
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you see hemorrhages in the, in the, in the, on the retina or in the, is that how he, was that how he made it a tremendous diagnosis of traumatic eye injury? No, he, he did not mention that
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Yeah, he did not use this sentence report and I went to it.
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And I think I have it here, but it was that, it was not noted in the report. Okay. And did he live, did you ever see him post-operatively or did he come back? 'Cause obviously you're worried
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about the CSF leak. Did he come back or did he live far away and he couldn't come back? So he is currently in the hospital, as I'm speaking with you. He is currently in the hospital. Oh, yes,
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currently in the hospital. And he's saying, yeah, because I decided to keep him, this close, because I already discussed with the machlo-fecher surgeon, because you can see that he had some
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fractures, and also I discussed with the
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ENT. And so we are just watching him closely to see, just in case they see a CFS lead, and to see how we can intervene. Professor Kava has his hand raised, and Professor Nimrod, so let's proceed.
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Professor Cabo, do you have a comment?
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Yeah, respectfully, I saw Professor Nemo's hand fast, so probably just - Oh, okay, thank you. I know, I'll come back, thanks. Professor Nemo, right? Yes, I'd raise my hand, Alia, and
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I've already addressed that issue. Oh, okay. Thank
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you. Thank you. Professor Cabo? So, I just want to make a comment regarding the use of the antibiotics that Austin spoke of. Yes, it's true, in different environment, they might do it the same,
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especially in your environment in the States. But in our sub-regions, I just want to support Dr. Do because
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one of the things we do have is has to do with infection prevention and control. How best we extreme those measures. Now, we are not able to get it as good as elsewhere. So for instance, in our
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set of what we do every three months or four months we try to swap the ward, the theater, the ICU, and everywhere to see what we have. So now we've come out with an anti-biogram, then we know
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that exactly, these are the common infections that we have, and prophylactically, this is what can help. But energy reduction is difficult. And once the patient developed one infection, it just
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continues and continues. So sometimes in our jurisdiction, if you don't have the science of infection, sometimes it's just good to put those and prophylactic antibiotics, because even when the
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patient moves from the water to ICU or from the tetra to ICU or ICU, they are all places that the patient can easily be infected. And you might go into hospitals. You'll be surprised that the IPC,
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the infection prevention and control measures that are being used, people might even touch the neuro cases with the gloves because they are not available or they are available and they are no
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well-earned
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a lot of things happen and sometimes just you know necessary to do. Those are good points, you see the same ethical question. That's a great point. The same as the same as the race. Yeah, man,
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can you hear me? Yes, I can hear you. Yes, I was asked and pleased. We would like to know the take home message from this case.
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What is the presenter trying to
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make us take home a message in case we see a case like that in future? How do we, what does he suggest? What do we do for such cases?
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Thank you so much, Professor. I appreciate this question greatly. So I've, we decided to share this case because we strongly believe that the LA diagnosis and the LA intervention will, will give
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a very good results. And we should not forget also, And another important point is that. Whenever there is a hit injury and there is lot of CSF relief, it's brain area, which you have that as a
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suspicion.
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Thank you. Thank you, Dr. Daufer, for bringing this to discussion. I think I'll cover that. Can I ask a question, please? Please, please, professor Nimrod. Yeah, now can we get some
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clarification on the use of
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antibiotics in these patients who present with CSF leak following traumatic brain injury. I don't know, I mean, it's very, very confusing, especially when I'm teaching students and sometimes some
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of my international colleagues tell me, well, we no longer use prophylactic antibiotics when we get patients with CSF or Torreosis, they're very no real, we just manage them and it stops, we find
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that it's of no use. And I don't know. I still use prophylactic antibiotics for most of the patients who come with a recessive or an area under teria and till the lick stops or sometimes until we
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discharge them. So I find it a bit confusing. And sometimes even my students ask me which is the appropriate thing. And the literature is very confounding in this. So can we get some comments on
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that one, please? Yes, thank you, Professor Nimro, for bringing that up. I was just about to mention that Dr. Osman had indicated that there are different ways of managing it and should be
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pointed out that one of the concerns about prophylactic antibiotics in a situation like this is that it might make one prone to developing organisms, infections with organisms that are that are
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anybody resistant. So certainly in my view, In my practice, in my experience, we have not used prophylactic antibiotics as a
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routine, but Dr. Osman mentioned a confounding factor which may be playing a role with this case and that the patient had had this issue going on for a couple of weeks and perhaps that could factor
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in. But you're right, there's quite a bit of variation in practice and in the regard of
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prophylactic antibiotics in cases of a CSF fistula. But I think there's not good evidence to indicate that there's an advantage to using prophylactic antibodies and that's my understanding.
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Ali, you had your hand raised? Yes, if you don't mind I think there is this discussion always. neurosurgery at UCLA and also one point which came out was about the anti-epileptic drugs in head
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injury and although they use dialanting over there and in US. they use mostly capro but they say if the patient doesn't have any seizure don't start this that's their idea and you know each country
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is different I respect what they have done and it's a great result and each country and the experience of the surgeon nor the surgeon is very important rather than to go with the protocol and these
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are the discussions which may come and the other point I want to bring on is they about the we had cases in France when they had no more cephalos the equation got worse and my mentor was saying
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because of expansion of the air due to the heat of the room or other causes that cause worsening of the situation and the mental changes of the patient. These are the things I think which has to be
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considered. And I know all of you had some experiences and you can comment, but there are
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a lot of differences between the each country and the experience of the neuro trauma people for the head engineer and the cases and what they did a great job And I'm very happy that this doctor
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presented this to share it with us.
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And I think I was a very intelligent management of this patient. It's really, we're talking about penetrating cranius cerebral injury. And then the other controversies about antibiotics are no
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antibiotics. What do you do for the CSF Lake? I think you decided to wait and watch him, which was really intelligent because sending the personal way he doesn't know if he's got a CSF leak, he
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comes late, has all kinds of complications and you've been skipped yet. It's been a
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jitis or something else, or I think it was a smart thing to do. And, but we have, there are people who treat it differently. And is it antibiotic? Is the antibiotics expensive there?
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So we use which is a
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third generation cephalosporine. Yeah. Yeah. And
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the patient pays for that, right? Yes. And is that very expensive or is it not expensive? No, it is not expensive. Oh, okay. Okay, I think Jim is, I think it's interesting to note that with
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Dr. Do's treatment of this case, He didn't enter into the ventricle and might be inclined to place a catheter into the ventricular system if there's air in a ventricle, but he managed it with
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gently introducing saline into the subarachnoid space. And well, the next imaging we have is two weeks. So we don't know if the Noma cephalous was, the air in the ventricle was
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completely addressed at that time. And perhaps the major mass effect contribution was from the subdural Noma cephalous. And the
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component that was in the ventricle resolved over time with the continuation of high-flow oxygen pulsed operatively Is that Dr. Doi? Is that a is that a fair assessment?
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I think so because I deal with the city scan should have been done
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right after the evacuation, not more than 24 hours, but this took us about 10 days, post-operatively to have it done. Right. Yeah. Well, nice, nice presentation. Thank you for all of the
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discussion. We'll have all comment from Professor Kava and then we'll proceed to your next case. Professor Kava Yeah. Thank you so much. I just want to read talk about the use of the antibiotics.
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The point about it is that every hospital, I mean, when you look at it from this purpose of the US, you are part of the Joint Commission International for Infection Prevention and Control. You
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have some facilities in South Africa, they are part of COSASA. But then you have to evaluate your hospital status. When it comes to infection prevention and control. So it's not just about what
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you do in the theatre is the entire the totality of the environment that you find yourself. And in our case, Most of their hospitals don't belong to these extremely well-designed IPC prevention tens.
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So you need to really use them to prevent this kind of infection or else you get the infection. And then it costs more expensive to treat the infection once they get it. And everything is being
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passed to the patient. So prevention is better than cure or as the patient will not have the money to even pay for the antibiotics when the infection is set up So we just have to have that in mind.
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Thank you. Well said. Thank you. Thank you so much.
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Alvin, would you like to proceed with your second case?
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Is it being shared? Yes, we can see it. Okay. Thank you again. So this case has to do with.
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It is a challenging case in our Lori resource So I decided to share with this esteemed group. see how this could be managed.
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So a 10-year-old mill presented to the emergency after a four from a coconut tree. So
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this child after school, he was hungry, he decided to climb a coconut tree and that tree was near a construction.
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The patient slipped and landed on his buttocks and his head on a piece of steel reinforcing bar that penetrated his head from the also petal region.
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So this image as you can see, this is the child and there were a lot of onlookers around. So some good neighbors rushed at the scene and they decided to bring in a sword from a capital shop that was
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nearby and they tried to cut the rebuy from the concrete from which it was embedded. And this tribe was brought to you. to our facility on a motorbike. He was being held by two others on a
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motorbike.
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The patient was
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then
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upon arrival to the trauma. The patient was neutered to be Sunderland with a GCS of 12. The motorbike opened in three, Weber four. So his pupils were equal and reactive The patient was moving all
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extremities continuously, but not following commands.
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So
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we had to do an emergent city scan. We
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show this image.
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And this is the soft tissue window, but due to artifacts were able, apart from the sagittal view, we were able to see some bleed at the midbrain. But we are still not sure, okay? So the
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diagnosis of impelment, perforating impelment traumatic brain injury from its theory was made. Ideally, we were, we do not have, we couldn't do city angiogram in this country. So the child was
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prepped and told me was planned and done. So what we did, interoperatively, we did a cranial to me at the exiting point. We did a cranial to me encompassing the exiting portion of the sea and we
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observed that the third, this portion of the support studies or signers was
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penetrated, was perforated by the sea roll. And we also observed and we did another cranial to me around the portion of the osufita area We observed that the, we observed that. there was the sea
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roar had perforated the confluence of sinuses. And when the cranial tumour was done in middle-day, we got this torrential and
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all contour hemorrhage that we couldn't arrest. We had to, we were just
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there and this patient arrested. So
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we just want to share this case due to our limited resources. Was it right for us to intervene or we should have just leave this case? So I just have to share this with this group.
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Thank you. Thank you, Dr. Doth. Under the death of circumstances, that's an extremely challenging case. You have a through and through penetration of the Sagittas signers and, and.
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That's work, yeah, that's, I'll be interested in hearing comments, but I think in the best of circumstances,
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that's a
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situation that may not be amenable to treatment.
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Ali, you have a comment? Yes, sir. I know it was an emergency, but did they consider to do the angiogram if it is because I know it takes time, and if they had this possibility, maybe it would
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have given them some clue, Well, where is the externalization of the blood and the injury to the sinuses? I know it's hard because of the emergency, and each facility has its own problem.
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Yeah, I think he mentioned he didn't have the capacity to do angiography. They don't have that capacity at his institution. Oh, thank you
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So I don't know if you could stop sharing your screen. going to have further discussion. Well, before he does that, where was the action point? Was the action point above the frame and magnum?
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Or where did the action from?
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The entry was at the taucular, at the confluence. And the exit
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was more proximal in the side of the sun. It grew in true perforation
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Well,
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Sam, you have any thoughts about what was - I mean, this is a dire case, sir. This has got a small child. There doesn't have much blood volume. And he's probably bleeding. It must have been
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bleeding from that. If he had a blood loss of 1, 800, 500ccs.
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Oh, Sam, what you thought about this one?
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There you go.
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Hello,
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this, this is a very strange case. I must say, we've seen penetration injuries, but this type is very intimidating.
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I wanted to know, do you have intensive care facility and the hospital where this case was managed?
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Because, so years, but we are still building intensive care. Yes. Okay. It looks like the patient was fairly stable before, appropriately. The level of consciousness was what I missed. 13 13.
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Yes, so reasonably stable. And was there any possible referral center to far away
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So, I will move to a center that has a center that has a ability for angiography.
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and intensive care service and all that.
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Thank you, Professor. So actually, you know, in Liberia, people pay from their pocket. Even what was done for him was done by some of the neighbors who brought him because the family couldn't
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afford. The CT scan was done free. Even the blood donation were able to get 10 units. It was brought in Now, GFK
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is the only facility with a neurosurgery unit.
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And the next area where CT angiographic who have been done is a private setup and it is about 45 minutes drive. And definitely the private, they will definitely request that the family pay for that
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So that was the challenge, Professor
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Unfortunately, we have problems in private hospital. I manage the private hospital. We have the same situation where patients come to us as an emergency and they don't have the resources. The
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family cannot guarantee payment because we insist on a deposit before admission. Where is an emergency and the patient cannot afford it when a hands are tied. We have to proceed to save life That is
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really important. Government has to be engaged because search case is most government intervention really and assistance Thank you.
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Alvin, that's a very challenging problem. I was thinking about, what do I do? Really, you're really in a very difficult situation. He may be stable, but I wouldn't count on that because I'd be
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worried as you were about this bar going through the tortula and the confluence of sinuses and the venous drainage and
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if he's not bleeding out, he must be bleeding in and I'm not sure you have much chance to think about an angiogram or sending him somewhere else 'cause he's gonna die and so what are your choices
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here? Your choices are to do what you did. You do a craniotomy to look at each side. That's reasonable, you could do that or do you just turn a larger flap and expose at least the dura in the back
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of the head But then you've got a problem of this thing penetrating the sinuses, and you've got to be able to repair that. That's going to be difficult. I mean, this is - no matter how you look at
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this, the odds are against you. And I
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couldn't possibly criticize any approach anybody would take. There's some problems you can't help And
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this is
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a just dire problem. So I don't have any suggestions other than what you've done. I mean, what else can you do under the circumstances you
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have and do the best you can? So anybody else have any thoughts about it? So Nimrod has his hand raised. Oh, yeah. Nim. Oh, yeah. Thanks. Thanks very much. Just have a very interesting guess,
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very unfortunate. I think. this type of situation where really this little you can do and it's one who would really be attempting to do some heroic surgery and hope you can save the patient's life.
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Obviously the tampoline effect was there and that's why the patient was very stable. And once you start doing the surgery then it becomes a problem. One of the ways I would have approached it myself
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is I would have cut barholes along the truck of the road So I cut one barhole and then nibble along the truck one side and as I am nibbling along the truck of that side, put, put, put do some
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tamponades, you know, like brain swabs, et cetera. And then go to the other side and nibble at the same time also in the truck and put either usual, I find cotton balls very useful. So I put
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cotton balls and try to handle the situation as in other words, expose the road along the truck in which it has entered. So cut the bowels instead of doing a granular to me. Cut the bow, cut one
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bowel on one side and as you cut the bowel on one side, leave the entry point so that the iron rod does not become loose. So leave the entry points on both sides intact. So the one, the entrance
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and the one, the exit to leave them intact. So in that way, you are pretty sure that you will not move around And then after you've cut those barrels, then nibble on top again of the iron rod.
42:05
That pearls us out, I've approached it. And then after that, now try to see if I could achieve the
42:15
mustesses under the iron rod and then do
42:19
the last bit, the entrance and the exit, nibble them last so that I could see. And of course, we'll be very prepared to just puck the area and have to puck the area. area then slowly remove the
42:32
pucks and check on the bleaters. But as I see, this is just heroic surgery and you're just trying your luck whether you can serve the patient's life or not and the tamponate effect is what was
42:45
keeping the patient. But once you start doing the surgery then you're very, very much disadvantaged and it's very easy to lose that patient on the table Thanks. It's a reasonable plan to have much.
43:00
I don't think you're going to do anything wrong here but anybody else?
43:07
I think they challenge with this case. Yes, just some words. Go ahead, go ahead. Yes. Don't be worried. Don't be worried about this death. I know the condition to work in your country and
43:25
I'm not sure that it was possible to save this child. Don't worry, Alton.
43:33
Yes, thank you for saying that. I think, as I said earlier, I know the best of circumstances, this problem may not be remediable. The
43:46
looking at the trajectory, you have the missile penetrating from underneath the sinus and then extending to the other side of the sinus. So at any, if you were to remove that rod, you have two
44:06
holes that you have a challenge to repair. I've repaired the size of the sinus, but not having a hole on the bottom and the top. I mean, that's, I don't see how you can manage that. I mean, if
44:20
you have it on the dorsal aspect, you can put frugative balloons, Proximal and distally and the rest flow and deal and repair it. If you have a whole on the ventral aspect as well, I don't know
44:36
how you're gonna get around that. Plus, you have the same thing at the Torquilla.
44:42
I think there's just certain cases that we just can't treat and this might be one of them.
44:51
Any other comments? I think you did a great job under which are. I mean, they're just almost your retrievable circumstance. I think, uh, never outlined a reasonable approach, whether you could
45:07
do it and had time to do it. I mean, all those things factor into it. And in the circumstances, you're in, you have to make a judgment. It's not right or wrong. It's what, what, what it is
45:20
Okay. Well, thank you. Thank you, Dr. Dill for presenting this case. Generated quite a bit of discussion and, and thoughtfulness. Dr. Nimrod will proceed with, with your presentation. We
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45:39
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