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Welcome to the 18th SNI and SNI Digital Bagdad Neurosurgery online meeting, held on October 23, 2022,
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the meeting originator and coordinator with Samir Hawes, Universities of Bagdad and Cincinnati. Meeting subject is neural oncology in Iraq Part one, the historical perspective, 40 minutes,
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lecture and discussion, LD.
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Part two, challenging cases from Iraq, personal experience from two neurosurgeons, 60 minutes, LD Part three,
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the update on neurooncology worldwide, 60 minutes, LD
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The speaker will discuss highlights in history of neuro-oncology with emphasis on practice and research in Iraq.
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The speaker is Professor A. Hadi al-Khalili, former chair of the Department of Neurosurgery at Baghdad University. Hi everybody, so you are welcome here Today we have the 18th surgical neurology
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international Baghdad meeting. This is like 18 months from starting of this event. It started initially as a collaboration between the United States and a working team from Iraq and now we are going
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extra milestones with each meeting and try to make a more collaboration, a wider area to coverage. and the most important to share experience from the front part of the world. So this is the first
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meeting that focus on a specific topic and this is a new trial for us to focus on a specific speciality, try
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to give together what's there in Iraq from background, then what's happening now in Iraq regarding the neuro-oncology And we have also a speaker, we have a guest speaker from the United States just
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also to give us a more update on the same topic. So regarding the program, so the first talk will be from Dr. Salili and then Dr. Moneer, then Dr. Moneer on the last talk will be from Dr. Patil
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And through the talks, we will try to have a. minutes question and answer after each talk and then at the end of a meeting we can have extended question and answer opinion comments it's according to
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the topics. So welcome everybody and I invite Dr Osman to start the introduction for the meeting. The meeting subject is neural oncology in Iraq. Part 1 the historical perspective 40 minutes
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lecture and discussion LD. The
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speaker will discuss highlights in history of neural oncology with emphasis on practice and research in Iraq
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The speaker is Professor A. Hadi al-Khalili, former chair of
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Department of Neurosurgery Baghdad University
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Howdy, you're - You're a towering national figure in Iraq and in the Middle East have tremendous respect for you and can you carry on from here? Yeah, thanks. Chair, a couple, thank you for the
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encouragement for the introduction and for this great project, it's a noble project to helping people, the young view resurgence all over the world, with your leadership, with your expertise and
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with creating this SI international and the fact that chapter of it.
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Mighto could be just highlights on history of neurooncology with emphasis on practice and research in Iraq
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The further backward you can look, the further forward you can likely to see, and that's what is in Churchill. So studying history of the specialty or history of anything is useful really to open
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eyes for better productivity.
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I will touch this on Mesopotamia medicine, Egyptian medicine, Greek medicine, Muslim Arabian medicine, medieval, and modern times and then come to Iraq practice and then also I will touch on the
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cultural difference of the informed content.
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Cancer in Latin means crab and onco again in Latin means tumor, tumor means swelling And glaya means glue and greet
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In
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Mesopotamia and
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medicine, we have this wonderful book of Serlock and Anderson, about more than 800 pages of the book which is studying only the diagnoses in Babylonian and Assyrian medicine. They don't touch on
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treatment, just the diagnosis So in the tumor section, they said, If a falling spell upon him, and it has been falling upon him for one year, and at its sign, it comes over him, its worrisome,
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if seizure comes closely spaced and in the middle of the day, it will be difficult for him.
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In another statement about praying tumor in that book, if he is sick with mild headache and just as an ox continually looks at his. own feet and looks at his own feet, that patient will not do well
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indicating of gaze paralysis or something.
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Edwin Smith in his papyrus about
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Egyptian medicine, there
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was no referral to brain tumors only for cancer of the breasts in the Egyptian medicine. I could not see anything any referral to brain tumors. Hippocrates was the first one to call it carcinoma
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which is carcinoma and it looked as it looked like crab and then gallon viewed cancer as Hippocrates had and considered the patient is incurable after the diagnosis of cancer.
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In the Muslim Arabian medicine we know that arises these leading three figures in medicine and of course there are a lot more. They are leading figures in medicine in the
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first millennium and just after. And the most important one, for our case, is Al-Bukasis, who is Abu Ghassam Zarawi. And he was considered by one author in the states that the father operative
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surgery. And in this picture, he's showing that he's operating on the head And he improvised more than 200 surgical instruments, including for cranial surgery or instruments.
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But then the later on, Amrah Paray, who is considered the father of modern surgery
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in the 16th century. And then he developed these tools to properly open the head
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Then we have Sir William McEwen, McEwen, who is a wonderful person. person if one studies his life. And he was the first perform removal of frontal meningioma in 1879. And in
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one of the lectures in Glasgow, Harvey Cushing was saying about
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him that we merely stand on,
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we merely stand on the shoulders of our predecessor, the strategy contemporary figures of McEwen on one side and horsely on the other side, supporting the arch of modern neurology surgery. So he
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considers these guys as the pillars.
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There are so many nice stories about McEwen, his achievement at his work.
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And then we have Sir Rickman
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Godley, who was the first two operators. on brain tumors in 1884 and diagnosed and they operate on this tumor but was reported in 1885 in this
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article.
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The three giants of modern neurosurgery are Victor Horsley and Harvey Pushing and Walter Dandy. Of course, there are so many other giants in the book of neurosurgical history of feet of clay and
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iron, which possibly have seen that book.
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The important discovery is Mary Curie and her husband, Pierre Curie, discovered radium and they got Nobel Prize for that in 1903. Their daughter Irene and her husband, they artificially created
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radioactive atoms and for For that they got Nobel Prize in 1935.
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And I, myself, used this radium needles when I was a resident for a patient with cancer of the tongue.
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Now, chemotherapy was started for cancer by Paul Eillich, and he got Nobel Prize in 1902,
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while immunotherapy started by William Coley in 1890, and the radiotherapy was started by M. L. Grobe in 1996.
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Breaking therapy, in 1966, Mundinger implanted a radium 192 wires into low-grade glioma. And Gerhard Friedlander used IOD in 125 implanted in 1979 in
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gliomas.
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Practice in Iraq in general, neurosurgical service in Iraq started in 1946 It was trauma, but then it developed including tumor surgery and specialized hospital in 1969 and then 1990, and then more
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centers and developed since then.
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Our means of diagnosis at that time and our time, when we practice at the beginning, was plant, plane, radiography, and pneumon encephalography, and then cerebral angiography with direct
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puncture of the carotid artery, and the technetium brain scan
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And then CT scan came at 90.
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on 1978. You can see this is the vague picture of the skin which we was to depend on for surgery on tumors.
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Treatment in general we use to use of course biopsy only maybe or surgical resection partial or total if possible. And the radiation therapy we only had cobalt 60 and we put marks on the head so the
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direction of the of the radiation would be on that mark all the time when he come to different sessions. Then we have the accelerator with cobalt but because of the sanction cobalt was prevented from
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arriving to Iraq so it was only only the accelerator and we did not have any chemo-therapy them
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Surgery was classical, nothing fancy about surgery we just used that and loop and very simple means of doing this. surgery. But then in the 90s, we have the Kuza aspirator and we have the CO2
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laser. And then in those copies, we didn't have endoscopy. So we used to use this pediatric urethra or cystoscopy set to get vibes from tumors of the brain.
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In fact, I use this and using the bar hall, which was used before for shunt, which was removed and tumor of the ventricle And then we had the microscope later on, and we had the navigation of
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brain lab that we used and it was really very helpful.
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In research, in the European organization of research and treatment of cancer and Brussels, in 1975, they started multi-center studies
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in different centers in Europe, and we were part of that group. And we used CCNU and Procarbazine and
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And these are the four, part of the form, some of the form which we used to fill, fill, and that is a standard for all the centers. And we use Karnoski for rating. And this is the plan of
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treatment, which I put in my hand in writing, so I can remember how to apply the medication. But unfortunately,
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Procarbazine, Lomastin,
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and the CNU and Vincristine were not found to be useful. And they failed to be helpful. And that's in a very big study was done, especially it's not helpful in grade four and grade three,
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glibelastoma.
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And then Iraq, we in the research we had a paper published by one of my junior colleagues and myself in the study of 1287
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cases of brain tumors collected over 10 years and the incidence rate was about 09 per 100, 000 per year
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and the male to female ratio was 13 to 1 Another study was only strictly for gliomas,
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621 cases, and of those was 417 in
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especiatoma and glioblastoma and oligodendronopendymoma
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and these two papers were published at that time. A study which I've done myself some time ago not published and it shows about 1, 180 cases and compare to what the. is in the USA or Germany,
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Japan, Sweden, and India, with some differences between the incidents.
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In 1985, Iraqi cancer world was established, and then we found, and it was a real fact, that after Iraq around war, and after the sanctions, significant increase in
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brain tumors with cancer in general was seen. And this is the population curve of Iraq, and that is the cancer in general, cancer curve in Iraq, which is escalating. In fact, in the meeting in
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2000, I was saying that Iraq will have an epidemic of cancer because of the pollution of the wars which we have had
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For instance, there is a comparison between 1980 and 1980. and the 1997, 1998 and 1999. The war,
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the pollution was in the 1980s and more in 1991 after the Gulf War. So we can see here these are different provinces. These are the southern provinces which were exposed to the pollution of the war
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and you can see the rate of brain tumors is really going very high. These two provinces, they were not exposed to the pollution of the war as much as those. So you don't see that the rate is high
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in these provinces.
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Leukemia, just as a sample of other cancers, you can see the difference in bus reference to the south of the country. Leukemia was about five times more after the pollution of the war and all these,
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this increase compared to the previous 1988 incidents
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or caused morgue leiomas and that was approved by NIH when they say glioblastoma in the general population is 32 cases per hundred thousand per year. According to VA, among post 911 veterans
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averaged 52,
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while the view collectively Vietnam Persian Gulf Wars, the veterans, they got 62 per hundred thousand
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per year.
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In another study, we had in the cancer board study of 153, 132
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cases of cancers in detail. And you can see in the in here the how can you get to the details of that study. It's a very elaborate study there.
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And you can see the each year what what we have at that time. But of course, this is the low rate because there was lack of good registration at that time.
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A study of publication by Iraqi researchers from
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1942 to the year 2000, that was a PhD project,
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which I supervised with the library, especially science professors. She, the lady, the student, she found that in English there were
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662 research articles published by Iraqis in Arabic 34 and French one and papers presented in the rational meetings and national 552
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in English and the books were seven English and 11 in Arabic and there is this database is available to for anybody to go to.
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So that was neurosurgery in the past, but now we are proud to see Iraqi neurosurgery catching up and competing with the world class centers and the specialty with our young neurosurgeons. with
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neurosurgical leaders like Munir and Samar and many others. The other
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point I want to just to end with is cultural differences about the informed consent. Around the world, cancer continues to carry a significant amount of stigma and myths and they call it that
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disease. They don't want to name it in some places Respecting cultural differences without breaching human rights is the important thing to pursue. In the Western culture, informed consent to
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medical treatment is fundamental in both ethics and law.
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Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care
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And if the physician failed to do that, he will have. problems with the law and with the ethical standard.
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In Islamic leaders' proclamation, the doctor must be honest in informing the patient or this is a new thing for the Western culture or his representative of the disease. It causes and complications
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the usefulness of diagnostic and therapeutic procedures and informing them of appropriate alternatives for diagnosis or treatment It is not permissible to tell this patient the truth of his illness if
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that increases the aggravation of
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his illness. So that is something which is not approved, of course, in the Western societies.
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In China, there was a Canadian Chinese doctor who went there and then he was born in Canada, I think, and he was the, he went to China and wrote an article about this. He said doctors and
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relatives are primarily interested in protecting the patient, even from the truth. Thus, patients are commonly uninformed of their medical condition often at the family's request.
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In Japan, physicians in Japan do not have the legal duty to inform patients of a cancer diagnosis. So they can withhold that from them. Our own experience in cancer, it's really what we have done
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in the past. I think Monir and others at the moment, they do the same if there is no change in the cultural mentality. We didn't tell the patient that he has cancer. We never tell the patient that
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he has cancer, unless he is really very, very highly educated and
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responsible. So we choose one of the family members who is really logical and you can. take this bad news well. So we
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tell him separately and then he will tell the family and then maybe compare that to the patient in a very gentle way. You are not to tell the patient directly, you have cancer and then your life is
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threatened. So that's what I have and thank you very much for listening.
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Thank you. Thank you, thank you, Professor
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Thank you for this talk. I have a comment about that, but I will listen to the panel if they have any comment. Dr. Lazaro, thank you very much. Very good talk. I apologize for being on mute and
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you should write it up in the publish it is announced. It's really very worthwhile for young people to everybody to know the
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history you mentioned. It was very good. It's very interesting when I was looking at the differences in the cancer. just in Iraq, which is obviously a very large country.
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And I was wondering, are there some patterns there? I didn't see enough to make any difference. I remember going to Peru and listening to a lecture. I was in the audience, a horrible like this.
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I was stunned when one of the professors from Peru talked about the increasing incidence of myeloma ningosceal in poor people.
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I was stunned to hear that. And because it's obviously meant another factor was involved in the production of this disease and it had to relate to nutrition. So there are interesting things that
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other problem that you have with statistics is sampling
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We can sample from Baghdad, we can sample from sample from. San Francisco, you can sample from different places, but are those samples representative of the world? Population of the
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representative of just small samples. So we have to be very careful about that. Yeah. I personally encountered an experience. I was operating on a general who was in the Moroccan Air Force. He
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came over with his brother, who was a gynecologist and his wife We went to surgery and after surgery, it turned out to be a glioblastoma. And they told me, You can't tell him.
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And that was a new experience for me, Hadi.
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And Vignette, what you're saying is true and it's culturally, it's understandable. And so the young people need to know that they're growing up in a world that has different views about this. And
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none of those views are wrong. They're what are accepted. And the problem is don't let yourself be persuaded that you're wrong because everybody else is doing it. Yeah. If you and your people in
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your country think it's right, you do it. And maybe other people should do what you're doing. So I had that experience, I was very troubled by it.
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But that was the culture And it was like you quote it. If it's going to information, it's going to ruin its life, you can't say that. So I really appreciate what you said. It was a very
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interesting talk and I wanna thank you. I don't know if some of the other people or the students wanna have some questions, but that's, I was really pleased. Thank you. Thank you. Thank you,
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Professor. I have two examples, Jim, about this. One example, one of our professors in general surgery, he was telling us a story when he was senior resident at the hospital. There was a
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patient in the nursing home, a medical general, British medical general. He was a patient there and he went as the chief resident out of respect. He has to be the one to deal with that respectable
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person He's a doctor and general in the army. So that doctor gave him the history so quickly eloquently and nicely so we don't need to ask him any question. So I told him I had some angle melanoma
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and then which was removed and then I had lymph node metastasis in my inguinal area. So they removed it with the lymph vessels. And then I had one in the lung and then probably in the liver, I
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think I have continuous headache. I think I have as metastas in the brain. And this doctor said, I was stunned, because he's telling me as if he's talking about somebody else. He didn't show any
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emotion of being worried or something. So this is one story, and the other story, one of our colleagues who just graduated with us a year after graduation, his father had PO, perhaps of an origin
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And he went to England to be treated and then diagnosed as leukemia, my leukemia. And he came doing well with his medication. And then when the family was gathering, the son, the doctor, the
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physician, brought the report in front of everybody. And then he found that he has leukemia and that this guy was hitting his head and crying, Oh my God, you have cancer. And everybody was really
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distressed. So we have these two extreme views, as you said, which is right, which is wrong. I don't know, but we have to be careful as physicians when we deal with society. If we are here, we
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have to be to abide by the law. If we are in Iraq or somewhere else, we have to to be respect the culture.
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Thank you. Any questions, any questions? Sorry. Yes, no, I have wanted the question. This issue is with cancer or with any other patient I mean, if you have a patient with a carry, if you
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have a patient with any other disease. What can you do? I mean, kindness and stosis, VP Shand. You also talk to the family or you talk to always only on cancer that you are selective in not
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telling the patient the truth about this condition. Thank you for this question It is for cancer and cases which possibly will end in death or very terrible cases or very difficult cases to treat.
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not only cancer, but cancer will be the top of the list. But these are not chaotic and so as you have to talk exactly what you have in mind.
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But those which deal with the end of life, these are you have to be careful with.
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Yeah. I remember when Jorge was,
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how are you saying pediatric neurosurgery at your CLA? He would receive patients from South America
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And some of these patients had very difficult problems to treat and it was his decision not to send him home with a deficit
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because the family would not understand it, the population wouldn't understand it, the person wouldn't understand it. And I know that he was encouraged and criticized because you didn't take
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everything out do and leave the patient paralyzed yourself soon. So the answer to the students here in residence is
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science is wonderful, but we're dealing with people and humans in emotion. And those are
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very important considerations. So that's a message from your talk, Heidi. Yeah, I can do with you.
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Thank you. Thank you, professors. Do you have any other comments? Yeah,
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well, my dear Dr. Maddy or Dr. Patel, any thoughts?
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Thank you. I'm betting my next presentation. Okay.
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Dr. Maddy?
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Any thoughts? Yes, it depends on the age of the patient, you know, because we are not telling the old guys, like those are above 60 or those that are kids, we don't tell them the diagnosis, but
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for those that are 18 years and both, they
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have read the MRI report or the CT report, they know the diagnosis, they have read online and join groups on Facebook that discuss the treatment options, the surgery, the consequences. So it's a
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new thing now, it's a new era. It's in the area of the social media. In the online era, the internet, everybody can access many of the informations and they come to the clinic, they ask you,
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what you are going to do? Are you going to do gross data resection? Is it possible? Is it not?
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Very good point Very good point
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I'm 84 years old, I'm gonna be 85 years old in a couple of months, and I've had four cancers in over 40 years. So it can be age, it can be determined by age, but age is not necessarily the only
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determinant. It's
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physiological health. Yes, sure, but because here in Iraq, they bring the kids, the children, their parents will talk about them, but for all guys, their boys will talk for them. They say he
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don't know the diagnosis, we don't want him to know the diagnosis, tell him that he has a sister in his brain, and need a surgery or infection or whatever, but don't tell them the diagnosis. It
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makes it very complicated for the doctor, but you're absolutely right.
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Okay, everybody else? See the hand, but they're up.
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My hand is not up, but I think, you know, I listened with interest in to all this conversation. It is an interesting balance between paternalism and sort of free dispensation of knowledge that
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happens now And, and
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it's so many my children are here. My husband's on Paul so I'm yeah there's three young kids in the house, but, but, but it is an interesting balance now between paternalism the Indian culture has
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so much of this also need to sort of protect the elderly and the youth from diagnoses that might be disconcerting or emotionally troubling for them to handle and so we should, you know, sort of take
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that on as physicians and dispense knowledge as we find appropriate But on the other hand, as Dr. Monty says, young people now have access to the Internet they know all about what's going on with
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their bodies oftentimes before they come to the position. And so if you're not upfront with them, then they think that you're deceiving them or keeping something from them and it's hard to form a
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trusting relationship in the modern era, whereas 50 years ago, maybe people would have accepted what their physician said, carte blanche without question. And so I think it's a really hard thing
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to navigate and particularly in Eastern cultures, including my own where this element of trying to protect your family members is a very strong feature. Yeah.
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That's actually, it's a terrific discussion for imagine when this video gets up on SNI digital and the whole world can see how it's being, how this problem is approached differently. And no one's
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wrong and no one's right. It's all right. All right
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Yeah, thank you, Professors. I would have a question for
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Dr. Felivi. Maybe the last question for this, then we have the next talk.
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What's your vision for the oncology wise? I mean, your oncology wise for the next generations. What do you think that, how you imagine the next era for Iraq, neurooncology wise and advise wise or
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expectation wise? Well, I think in general neurooncology, the future Dr. Osman, he spoke about this last time very eloquently and then he told us a lot of the new advances and the expected
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advances. In our country for neurooncology, I think this is the responsibility of Dr. Benir and his colleagues just to encourage
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young neurooncology neurosurgeons and young oncologists. to go to this line, which is very important essential. Now it's established in your oncology is a specialty of its own. Nobody can
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interfere with the treatment they recommend, neither the surgeon or the radiotherapist. So they have their own say. And we hope it will be, there will be a sub-specialty of a board within
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neurosurgery of neuro-oncology. That's my hope
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