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Welcome to the 20th SNI and SNI Digital Bagdad Neurosurgery Online meeting, November 26th, 2023. The meeting originator and coordinator is Samur Haaz, University of Bagdad, and Pittsburgh
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Professor A. Hadi Al-Khalili, former chair of the Department of Neurosurgery, Baghdad University. He is speaking on Hyetatid disease, presentation, management, and prevention.
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First, we will start with Professor Abdradi Falevi, who is a
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well-known, actually one of the founders of neurosurgery in Iraq He is a well-known scientist in neurosurgery and mentor for many people within and outside neurosurgery. He's very well-known with
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his encyclopedic approach, and he will talk about Hyetatid disease, presentation, management, and prevention. And yeah, the stage is yours, Professor Falevi, and you are welcome
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My talk will be on Hyetatid disease, presentation as Samara was saying, presentation, management, and prevention. Hydatid in Greek is meant a drop of water. And it can focus in Latin, hedgehog
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and granulosis, as literally grains in Babylonian medicine, Sist was referred to as seen in liver and lung of the carcass.
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And the termhydatosis was used initially by Lamarck in the early
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19th century.
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There are many types of human tapeworms, including Tienia solum, Tienia ecanococcus. Of
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this, we have two types,
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ecanococcus multilacularis and ecanococcus granulosis. Tienia solum, which produces neurocystic psychosis, is rare in our part of the world. And the definitive host is man, but the intermediate
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host is pig.
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and it is more in Central and South America and Africa and Asia and Eastern Europe.
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The presentation usually is headache, seizures, folk neurologic signs, altered mental status, aseptic meningitis and others. And on the MRI, you can see this multiple listsists all over the
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brain, multiple lesions. And the interesting thing on the CT scan you see classified spots spread all over the brain.
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The kind of cochos of multilocalaris,
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definitive host is foxes, more red fox, other candidates including domestic dogs and wolves, intermediate host is rodents, and human is an extended host.
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Distribution of kind of multilocalaris would be in Europe, near East, Russia, Central Asia, China, Japan, Alaska, and maybe other places, and the presentation depends on the size of the cyst,
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from location, complication happened with the cyst, and you can see the CT scan and MRI showing the cyst T1 and T2.
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Hidetic cysts, or hidetic disease, is caused by the taper of telegia, it can be focused the granulosis. 5 species. are known of
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a kinococcus granulosis. Again, a kinococcus granulosis synostrictor, the sheep, which is a commonest, the equinos, the horse, the orthogonle, ortholeptia, the cattle, and the kinetiduses,
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the camel,
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and the felids, the lion. So all these animals, maybe others also will be involved and infected by a kinococcus granulosis
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The dogs are definitive hosts, wild canids, foxes, and wolves, and less commonly cats. Intermediate horse, the sheep, horses, camels, cattle, and lions, and the human is, again, is an
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accidental host, and what happens is when the sheep laid the
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part of the tinier, which I'm going to discuss in details, on the grass, the sheep will eat that, and they will have the cycle of the infection, and then - vegetable or fruits would be taken by
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man accidentally before washing properly and then they will have the cyst developing in the body.
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Global distribution of the granulosis is the Mediterranean areas as you can see from this and Middle East, South America, Australia, New Zealand, Africa and Central Asia. There is no racial
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predilection, females are usually more affected than males, all ages affected and young people are higher than that. The teeny itself is about up to 8 millimeters in length and the head,
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it has four segments, the proglottids, they call it, and the head has four suckers and that has these hooks, they go up to 52 hooks in the head. And in here you can see the bowel of the dog, so
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many teeny are attached to it.
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The gravid, which is the last segment of the tinnia, that's the most dangerous part. What it is laid down, it produces
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the cycle of the disease. And then this is the egg laid from that with the capsule there. And you can see here the egg has ruptured from the capsule and it's in the villi of the small bowel to go to
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the bloodstream.
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The egg each pro-glotid has 200 to
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800 eggs. And daily peak could be called recorded, daily peak of 71, 000 eggs observed from dog harboring 12,
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767 pneen. And eggs can spread up to 80 miles from the site in 10 days. That's when it is dried and there is wind, it will go with the wind to different places up to 80 miles. So it can be
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dangerous even not in the site of the lay down of the pneen
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The cyst has a fluid. which is normally clear, specific gravity is of one or seven, and then up to one or 15, and the pH is 72, 74, containing albumin and other proteins, salts, phosphate,
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calcium sulfate, sugar, fat, and other substances.
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The cyst has layers, and the body will produce reaction around the cyst, which is called adventicia in the case of the body, but in the brain it will be some very, very thin layer of probably the
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layer produced. And the cyst may be fertile and has granules and scoliosis inside, and they have seen a paper from Levenon some time ago, and they said in each one milliliter of fluid, they have
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10, 000 scoluses. So you can imagine how dangerous this if it is ruptures. And also it can be stale, there's no, there's no scoliosis or over inside.
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The growth of the cyst depends on the organ. Of course, if it is in the liver, the liver is a solid organ, the growth will be slow, but in the lung, it can expand quickly. And the brain, again,
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it is not as solid as the liver and not as soft as the
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lung. So it progresses and the increase in size is slower than
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the lung. But it increases normally one to two centimeters diameter in six months and six centimeters in a year and doubling in 10 to 20 weeks.
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Had that, it can involve any organ. They say, well, we haven't seen it in the teeth, but we have seen it literally everywhere. I have seen one in the retina of the eye at one time.
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It kind of wrecked the lung, the liver, the bones. And this is interesting case. A patient came to me with chronic back pain and leg pain.
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What I normally do with every patient I examine, I go to the peripheral pulses, especially in those with back pain. And they found there is no docile speed, there's no popliteal, no femoral, and
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then refer the patient to the cardiovascular surgeon, and he found high-doted in the bifurcation of the commoniliac. And this is really very rare.
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A clinical presentation depends again on the size of the cyst, location, complications like structures, that there is a friction if it obstructs any organ.
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Testing laboratory, cassone tests, indirect imagination,
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immuno-electrophoresis, ELISA, imaging, ultrasound will be helpful in the body-hited CT scan, and MRI are the tests of choice. Treatment, medical benzimidazoles,
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which include albendazole and medendazole, which has been not changed. for decades. In fact, after now, they are the treatment of choice. Also, they can use prasaquantil and decolizamide.
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Treatment surgical is the aim is complete removal. And there are many variations of that and many ideas came. Then cryo freezing was done by Saeedi in Iran in the 70s. And of course, it would not
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be feasible in the brain. It can be feasible somewhere else. But I don't think it was really successful because it was not adopted anywhere else. And pericutaneous injection of maybe hypertonic
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saline, 20 formaldehyde is forbidden now to use it to be used in the past. Sets you might and silver nitrates also be used by some people. But all they have no real damaging effect, complete
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damaging effect on the on the
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Prevention, focusing on dewarming of dogs, by medications to the dogs, vaccination of sheep, and dogs, slaughterhouse hygiene, and public education, washing fruits and vegetables, although it
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is so simple, but it is really very, very effective.
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And it is recommended on the TV, and back then when I invited Professor Gamel
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from New Zealand, and he was advising people on the TV that saying what you need only to wash thoroughly your fruits and vegetables. Professor Gamel, one of the leading WHO specialists on that line.
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And this presentation, we emphasize on the
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hydrolysis of the brain, that's pine and the orbit.
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A study I did in the 90s, studying 1976 to
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1985 cases, there were about 2, 222
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cases. and Medical City Hospital, which is General Hospital, they didn't have neurosurgery at that time. And the patients were 1, 368 patients. If they're in a fees hospital, which is
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exclusively Cardiotharasic hospital, there were 5, 550
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patients and neurosurgical hospital. Under the four patients, there were cerebral and 95 and spinal nine. In this case, we have six spinal cases with the Medical City Hospital.
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The age and percentage can see the spread all over, but 44
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under the 30 years of age. We are talking on high dieting in general, of course. Gender and organs, you can see that
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brain and orbit, again, slightly prediction, the prediction of females and bone and spine, more females than males.
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The organ incidence, you can see that the chest has 29, 30. The abdomen is 667. And the brain and orbit 05 and bone and spine, they have 08 of the total.
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Age and organs, you can see that this is the brain and orbit, you can see more on this side, and this is the spine. You can see it's more on this side, more clearly on this graph You can see the
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brain and orbit on this part of the age scale, and bone and spine on the other part of the age scale.
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Cerebral had at its cysts.
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We didn't have at the big four CT
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scan, even with the CT scan, we can't see that in the plain x-ray, the inner table of the skull at the side of the cyst is lost.
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Well, indirect indication that there is a possibility of hydrated in this area because it's chronic. The bone is not affected. It is just probably by the pulsation and this area made the calcium
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escape from this part. And in children, you can see increase in the widening of the switchers. And in late cases and rare cases, you can see calcification at plain x-ray.
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See this can, you can see well-defined space of calcification, lesion, cystic, swit outline, no peripheral edema, and no change in contrast. And in MRI, you can see that T1, T2, it's very
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classical of a cystic lesion.
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Cerebral high does it can be solitary or associated with other organs or multiple metastatic.
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The solitary and adults usually it is posterior,
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and in children usually it is anterior. And this is supported by many workers, many papers published.
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Associated with other organs, the liver was seen in eighth cases and lung. So associated with all these cases with cerebral high dietid.
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Multiple high dietid, this can be, this is most likely to be metastatic coming from the lung rupture dietid. And this one, multiple, but probably it is due to head injury and trauma, which can
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produce this multiplicity. In a
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study of 95 patients, we've seen 47 males and then over at the 1553 and right and left almost the same.
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Presentation, as you can expect, as a space of grand lesion, nothing really fancy, but headache and vomiting, blurred vision. their consciousness, seizures, and nonspecific in some.
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Papaladema's 19 was seen, hemiparesis in 15, dysphasia, facial palsy, and other training nerve palsy.
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Surgical removal,
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you must ensure large cranial tummy and make sure that the edges of the bone you opened are smooth. There is no spikes in that edge of the bone because it may rupture the cyst as it comes out And
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tawling, you have to make sure that the tawling, you make it in a way that it will enable you to use the maneuvering, just gravitational help in case you need that to make the hydatid cysts on the
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more dependent part of the head to enhance the delivery of the cyst. Dowling Orlando technique, the hydrogen section, when you put this water or lucho later in detail. and in between the cyst wall
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and the brain itself. And while Salva maneuver, you can ask that he says it during your surgery to do while Salva to just make a little bit expansion of the brain and that will push the
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cyst, you know, easy way not easily.
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You can see here, this is a big high diatocyst.
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Solid three one.
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And then when you open the door, I have to be absolutely careful because you don't know that the high diatocyst may be underneath your cut. So it is very small opening you make. And then blunt hook,
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you can use to enlarge that small incision and then use the patty then, the cotton patty to introduce it when you cut And as you cut, you can guide the cotton patty with the tip of your scissors.
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So you protect, as you cut, you protect the brain and the possible hydrated underneath. You can see that the cotton patty is moving with the scissors. And then gently you dissect
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It executes the quality of the video because that was done at the time that was difficult to make any video literally. So use ads in the sector just to smoothly separate and then use the hydrogen
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section
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to push the cyst outside. You can use some pressure, very gentle pressure, if you want, without using excessive pressure, and then the cyst will deliver smoothly and safely
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And then
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the dura
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is closed. I like this,
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it will always provide room for using the whole all exposure area
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So the trick here is really to be very, very careful when you open, sorry,
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yeah, when you open the door, that's the main thing. A cure can be as achieved by the removal of adrupter cysts, and a fracture must remove all cysts parts and start elbendizor It's
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final high that it
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can be
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intramodilary, intradural extramodilary, extradural introspinal, vertebral, cara vertebral. And you can see here, this is a myodeal because at the time we did not have myelogram other than
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myodeal, no cysts can, no MRI, so you can see the block here and this
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curd, curvilinear block The block here, that's all high that of the spencer, the oral high that of the spine.
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You can see here, this is under the skin, and that's in the bone. And presenting symptoms, back pain, swelling, mono perises, para perises, as you expect with any special pressure on the
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spinal cord or the nerves. In the MRI, you can see it is a cyst, as you can see T1, T2. But the interesting thing is, it looks like vertebral osteomyelitis But the
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difference is, there is no osteoporosis, there is no osteolysis or cyclorosis, and the discs are normal. This is very, very important to remember.
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Now we move to orbital high diatocysts, which is my hobby. Presentation usually is proctosis is slow and painless, rarely painful. I had only one case with very, very severe pain, And I took
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that patient immediately to the family hospital and measured the - pressure of the eye, it was very, very high. So acute glaucoma produced by this hydrated of the orbit of that patient. Chemosis
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as subconductible edema, palpyril edema, orbital satellite is visual impairment and the restriction of X-raycular movements.
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In the personal study of 15 patients, they've got some more, but orbital hydrated mostly 10, and
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were under 30 years of age, and 10 females, five males, and right side nine, and left side six.
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Presentation was silent progressive protrusion of the eye vision was normal in four, diminished in three, and lost in eight patients because of late consultations. So most are fortunate for this
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disease to, for the patient to lose to the eye where it can be treated Fondoscopy was seen as a faculty demand for primary optic atrophy and secondary optic atrophy. with normal in three patients.
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Treatment, surgical removal, as soon as possible, and by anterior orbital approach.
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This is the lady, which we have shown, and that's after surgery.
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And another lady here, before and after surgery,
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and that's the highlighted. And this man, in fact, I operated when he was a child, and then one day I went to the Ministry of Health, and then somebody was calling me from behind, and then said,
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Dr. Doctor, do you remember me? And then that was 10 years after his operation, he is doing well without any recurrence.
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And that is just the tricks of the surgery, which I thought would be useful to share with you
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Thanks, Dr. Pudaskin, for the answer you will be there. The
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response you will hear about two centimeters would be just fine for the surgery. I think the tissue is there, or it lies up really and then down to the septum to get things open. This action has to
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be very careful because it doesn't come to rupture
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This is the optic fire, which is mucin, sometimes during that session. So you may need to
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de-thermize it and cut part of it. Now the genital retraction, you can reach to the tissues, what you want to expose the hydrothesis This link to the fire was usually action, but used by the body,
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surrounding the body.
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And that's the truth is it's showing by cutting the ecosystem.
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And the take here, which has to be done properly and that's you have to vote to the virus usually action, but use by the body
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And then you set out all the fluid and gently you do for success should be not good for success and just sliding the indices out of the native processes really gently because as you press very firmly
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On the process, you can see the endo system menu about to give some of them to sit inside where the currency in every level We have to have a gentle plate then of the negative process. All the. the
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right hand and then left hand and gently coming out with some patience you don't do touch and then you must make sure that
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everything is removed as you see the fungus is clearly seaming without being evaporated and then this is the fungus coming out and that's all this is now is out and you can see now that's out and you
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have to wash the area of the tarpa celine that's the other part of the first step then you can see
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that there's a second one the first one you can remove and the surface of celine you can ensure there is no post-operative reaction as there may be some allergic reaction this is this is called and
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then you can switch it to layer by layer and then you listen to all the glass of celine also switch it to a separate layer you get our function or
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closure And then there's actually, when it comes to the scale, then you can see all of it's in there.
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So, orbitally that is, to my satisfaction, is solitary, it is not accompanied with any other hydrated in the body, and there is no recurrence when you rupture it, and I suspect that it is of
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different species, rather than that would affect the sheep, and it is the kind of cocosic virus. This horse has orbital hydrated, in fact, reported
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Now, with the current status of hydrated disease, despite the significant progress in genetics, genomics, molecular epidemiology, and treatment in the 21st century, and real breakthrough has yet
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to be made in hydrated disease management. Hydrated disease remains an ongoing problem and a global challenge, and WHO reported in 2021, WHO estimated the kind of causes to be the cause of 19, 300
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deaths and rounds, so the eighth and end of the day. 807 to 1000 this ability global globally each year and you of course are US three billion dollars for Sweating patient and losing the livestock
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industry our loss in the livestock industry Wcho has also listed a kind of causes as one of the 17 neglected diseases targeted for control or elimination by 2050 And Iraq I that a disease used to be
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called the cancer of Iraq by our professor. How did I do in
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two studies at? MCH that's medical medical City Hospital studying 1971 and 1973 case of three years the rate was eight patients pair 1000 admissions to the hospital but in a study which we jointly
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did in the 90s we studied three years of 1980 and 1982 to compare It was 4,
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000, 1, 000 admission cases, admitted cases to the general hospital. Many studies published from Iraq in the recent years. I'm so happy to see those publications. And in cerebral, we have from
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Mosul, 2013. I'm at Hamoud, 32 intracranial high dietids. From Baghdad, Zeke Hassan and colleagues, eight patients to 2019, Baghdad safe, sorry, and his colleagues' case report. And I think
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Samir was in that case as well. Yeah. And 2021 from Mosul, Hamoud Shah, current colleagues, 19 patients. In general, body-high diet, 2021, Western from Baghdad, Rajav, from
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Rajav of joint, again, the 60 patients. And from Kurdistan, we have Araz Aesir, 64 patients. And interesting that from Basra,
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scientists, they did it on sheep. And they found among 631 sheep, 73
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are infected with hydatid.
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In 1989, we conducted an international symposium on hydatid contributed by renowned international WHO specialists from New Zealand. As I mentioned before, Dr. Gamel, USA from Oregon, Professor
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Rauch, Alaska from Professor Thompson, Canada from the Chandler and Turkey from Adena, Oglo, and others. It was very interesting today meeting. In fact, research, a
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strategy proposal for targeted massacre research proposed in general, hydatid disease research three was proposed, presented, and that research three suggested that the researchers basic research
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and lab diagnosis and surgical treatment animals. these prevention, epidemiology types in the country, radiological diagnosis, medical treatment, education, any project in those lines, they can
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do that within a strategy, maybe three years, four years, and by the end of this time, we can get all the information and tabulate that and reduce the, conclude a proper strategy to, to study
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and to help and to treat the disease, not only nationally, but also internationally. In conclusion, we need more collaborative, multidisciplinary, national, and international teams to study all
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aspects of the disease aiming at its eradication, and thank you so much.
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Thank you, sir.
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Thank you for the nice presentation. I have questions. I think many have some questions as well. I'm comments
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Not only that is expressed that there was a, that there is an interest or a WHO to declare. I thought it ceased one. This is of the past by 2050. Right? Yeah. Now, is this team led or the Iraqi
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doctors have an active participation in
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this project in the WHO? Not to my knowledge, it's just a suggestion. Because, as you show, there are interesting papers from Iraqi doctors, Iraqi neurosurgeons and clinicians, even to 2021.
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There is no literature on, either it sits on syllable like that it sits at least on the American literature or in the Americas, as the old continent of the literature. So I think this is important
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to emphasize that it still is a real problem in all that region because there are papers, the most recent papers are coming from that particular region. A one thing that I found very interesting
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also in your presentation is that you were able to puncture the optic cyst and there was no recurrence. And to what do you attribute, what's your hypothesis or what's your. Yeah, my question is
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about that. I've done, in fact, some of them I've taken the cyst to for microscopy. and there was no scalluses. And
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also, I think this is from different strain. And that's the Aquinas strain. That's the usual one which is sheep, which is common in the brain and then the liver and the lungs and everywhere. So
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this is special strain, which affects only the orbit. And when you have it in the orbit, you don't see it anywhere else in the body, like the brain or the lung or the liver when you see it in
32:55
different places. So probably it is different strain This is an assumption, and I have no proof for that, but it needs to be proved. And this is what I think it is.
33:08
But your primary advice to everybody who is listening and I can transmit to others is if you have an assist of the orbit, it's reasonably to assume that it's safe to puncture the assist, that it
33:23
will not be returns. Of course, there are all the ifs and ifs, no? Yes, provided you remove everything there and you wash. properly and make sure there's no debris left inside and provided to
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take the funders, make sure that the funders is out completely.
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And that case of the, is the, I, that it sees from the, from the horse, the equinose variation, right? Yeah, that's right.
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Yeah, it's from the one thing that puzzles me of I, that it sees, and that is related to also, somehow to Dr. Mantis at the presentation, is that cerebral, I, that it sees, they don't cause
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cerebral edema. Absolutely. Yes. Yeah. There is no perifocal edema at all. This is a very important, and why is that? Yeah. That's right. Because it's very slowly, there's no, no
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inflammatory reaction around it. No irritation. It's very smooth and easy. Yeah. Because a large, I, that it sees to follow in your timetable, which was very good, will be something six months,
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not growing six months, but there are obsolescence of tumors that great devastating edema. So I was standing on that. I don't know if there is any other comments. There was one comment of the
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colleague from Cape Town stating that in South Africa, 50 of the
34:44
cases of phytoticists are associated with
34:49
HIV. That's an interesting phenomenon, whether there is a relation with
34:55
the immunocompromised, no? Dr. Sahara, I think she's available as well.
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Yeah,
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so what are your thoughts of that 50 being related to HIV? Is immune compromise or
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co-insurance? Yes, Dr. Actually, it's a common disease in the farm communities and it affects sheep, but it can transfer to
35:24
human and those human are mainly the immunocontal. compromised. They had a study that showed that there's 50 of the people who are
35:36
infected with high data, who are accidentally discovered are HIV positive. There isn't a lot of papers regarding that topic. There is one that reports seizures, and they couldn't further
35:53
investigate due to COVID And then this case was complicated later on by showing signs of increased intracranial pressures. Yeah,
36:07
sorry, go ahead, please. So there isn't really many documents or many
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published research, but it is still discovered accidentally, and the main treatment is surgery. So they do radical surgery when it is discovered
36:28
Yeah.
36:31
But the cases, or Professor Lazart, the cases which we have dealt with over these years, we never had any reference or any evidence of immune compromised patients. They have normal patients lively
36:46
and everything is fine with them. So this, as you said, needs more work, more study and to see if it is related in a way in South Africa Yes, I think it's because also the farming approach in
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Iraq and in South Africa is different. So it is not common among human. And once the sheep gets infected because they send dogs to look after the sheep, look after the herd. And that's why it gets
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transferred to the sheep And then it is, when it's transferred to human, There is a high percentage of new compromised people. Yeah. You know, HIV is coming in South Africa and the African
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continent. Very interesting. Thank you. Thank you.
37:44
Anybody here?
37:47
Okay.
37:52
Can I comment? Yeah, no, no. Yes, please. You are in charge.
37:58
Actually, I want to say that we have incident because in our lab back and back that the neurosurgery lab we use the sheet paid for simulation of neurosurgical procedure. And within one of the
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courses, one of the training, Dr. Alpha at that time, just call me and say that, oh, this, this will change to a real training There is a vision inside the brain of the sheep. And it was how
38:27
that exists. the training continued to remove the mask. Yeah, this is how it's come on. So, especially in Baghdad at that time. And I have a question for Dr. Khalil, because I think I have a
38:35
case reported or under publishing. It's about how that exists, and the
38:54
cavity of intracerebral hemorrhage, so intracerebral hemorrhage, tranetomy cavity, and now the patient for them to die diathesis, which was very, very rare, unexpected, and difficult to believe
39:05
for me. And I noticed from the presentation that you said something about trauma as well. Yeah, yeah, the multiplicity of the high diatid in the brain usually is metastatic, and they are
39:20
dispersed all over the brain. But if it locally, the multiple, Most likely it is due to the. trauma for head injury and that would shake the assist and make some tear of the wall and then it would
39:34
be metastatic. This is published in fact, we haven't seen it ourselves, but this is published and I just learned it from the literature.
39:43
Yes, thank you. But I got it to produce bleeding. This is, of course, this coincidental, most likely. Yeah, thank you. Thank you. I have, can I make a comment? Please, please. Yes, you.
40:04
First, thank you, Professor Hariri, for this great presentation. You know that we're still endemic and that this is, that this
40:18
can be diagnosed on brain disease, it is cancelled only. There is no need for the MRI to diagnose it. This is number one. Number two, as some remember, we did a CME on cortical incisions back in
40:31
2015 in your surgery teaching hospital. And one of the subjects we were talking about is the length of cortical incision for a high data cyst.
40:44
Yeah. Are we going to do about half of
40:48
the diameter of the cyst, three quarters of the diameter of the cyst, what if it were below the underneath the motor situated, what if it were in the broadcast area, what shall we do, the length
41:00
of the incision. So there are no many literature reviews about this subject.
41:10
Well, the one I showed, in fact, that was showing through the cortex, as you've seen in the video But the length of the incision, I think, will be with enough of the diameter of the system.
41:26
usually assist which is and the brain usually when it is bigger it would show somehow through the the cortex of the brain.
41:36
We haven't seen in fact because our cases were late we haven't seen anything inside which needs a real big cortical incision maybe just you can see thin cortex over it but the majority were showing
41:50
through but in any case i think you're right if there is underneath important centers you have to be really well manipulative and you see they're the best place like by the way to use a navigation
42:06
neuron navigation i use only the intraoperative ultrasound i see because we use neuron navigation for instance at the time in 2002 when i had the patient the doctor in fact the lady doctor she had the
42:21
tumor underneath Brokeless areas.
42:24
And then we have to go decide with the help of the navigation, have to go behind and then gently remove everything there. So I think in this case, this neural navigation would be of help for me.
42:36
And by the way, I was very, very impressed with your work and I'm proud of you really. Very proud of
42:43
you. Thank you, thank you, Professor. Thank you. Yeah, one important thing and I don't say to the professors, I say it for the occasional, for the many future new researchers in the audience
42:54
is, it is vital to ask the patient if he's a left-handed or a right-handed patient and based on where the, it says this, right? I mean, a right parietal system, a left-handed person has a
43:08
different significance than the other way around, no? Absolutely true. And that gives, again, the question that somehow links to Professor Mati, my presentation is you have somebody who says
43:22
that is sitting in the room. or in order to assess that cyst. Fortunately, those mostly are parietal, because of the carotid going straight to the middle server, they're rarely temporal, or not
43:34
temporal at all. I don't remember any cyst growing from the temporal force of backwards. But they, you have a cyst that is sitting on a very eloquent area, so-called eloquent area. What do you do?
43:47
You just sacrifice the cortex and hope for a good rehab And I think that's the approach that has to be done. But the question that you had at the conference about how wide or long has to be the
44:07
corticotomy in a particular patient, speaks volumes of how creative you are. Because I don't know the last one, but I never heard at the conference on how big on white a cortical. incision has to
44:22
be, you know, so that is a fantastic issue for saying that I have a cranial term, we just had the let's give it so and then
44:33
the edges of the bone are spiky and then you have to be absolutely assured that there is no sharp edge in the bone but with the cranial term I think there is no problem of that nature. Yeah, no, no,
44:46
absolutely. I have to be as white as I said the possible. I was saying that
44:52
leans, is there any
44:55
question or no? Can we come to Dr. Matty because of a relative question? Can I have a question first on the hi data please? Please, please. Yeah, just a continuation of discussion because I
45:07
think it's related. I have two points. I think at some point we have been teased to avoid the al-qitra kalupdrol and hi dati tsuz. to use more than mechanical because maybe increase in rupture. So
45:24
obviously this is a controversy one or it depends on personal experiences. I would like to listen to Dr. Khalil opinion as well. And as the point that Dr. Omid raised about the length of
45:40
transition, I think one of the take home messages from this meeting that this is if the surgeon think that it may be glioma, he will do a two centimeter and one centimeter of the cortex. And you
45:53
know, with the resection, you will have more and more space. This is the usual tumor approach for the cortex. Or even if it's just a cyst or cystic tumor, you need to aspirate and that's it.
46:04
While here, we are proposing a different strategy because the high diet, you don't need to squeeze the high diet. That's why Professor Khalil start with saying that should be widely crannied to me
46:17
because. this is hugely different based on the suspicion on the imaging. So I think one of the take home message can be this for general practicing or especially for me or decision would take
46:32
decision on a crannetomy size. The think of how that is, if there is, if there is no argument, if there is justice very smooth, if it's endemic, this have a huge potential to change their
46:44
crannetomy strategy Again, I would ask Dr. Kelly Lee about his comment on the on the thing that I asked.
46:55
Yeah,
46:59
you said that I think, yeah, I agree with you. So, Dr.
47:06
Altamini is asking the question, raise his hand. Yeah, thank you so much I'm really happy to be part of this group of people. As a pharmacist, I may be the only pharmacist or the only
47:20
pharmacologist in this group. And I'm happy that I got the chance to broaden my knowledge about the hydatid, hydatistics. As
47:30
a pharmacist, I, as you know, as a pharmacologist who taught pharmacology for so many years in Baghdad, in America, that my focusing is on the side effects and the, let's say, the pharmacantic
47:49
and pharmacodynamic properties of drugs used in the treatment of the tap forms or the hydatistics. But today, I got like a different opinions or different things. So I, as I said, it's a chance
48:02
for me to know more about this kind of parasite disease. I don't know if Dr. Khalili or Dr. Mitty the tarsam or any other one of the honored people. in this group, has come across the use of
48:20
Ivermectin in the treatment and the treatment as at least experimental laboratory experimental studies on the Ivermectin the controversial drugs, which is we all know that there was some big issue
48:37
about the use of Ivermectin treatment of COVID and it was not approved. But the research done by Moderna to encapsulate the vaccine as the mRNA vaccine in an oily capsules made it very good way or
48:58
very good reason for the experimental studies to go on the proceed with encapsulating Ivermectin and using it at least in animal studies to treat the high dietitist and to limit or to shrink the high
49:15
dietitist. they found some good success or they found some good, they reported good result, if they use either McTienic to use it as a target to the drug.
49:28
And pharmacy these days, the new approaches are to give the drug directly to the area where it should be working. Like for example, in the high that assist and deliver, they send it to the liver
49:43
through, they call targeted administration of drugs rather than giving it through the gastrointestinal tract or oral route of a demonstration. And this
49:57
new technique has shown that in lab studies, that it calls some shrinkage of the high that assist. It may give like a new approach in the future Because albin tazole,
50:14
albin tazole, as you know all.
50:16
They have low absorption, and albin d'azole is better than webin d'azole. The side effects of
50:26
albin d'azole and webin d'azole, vermox antalbenza, as they call them in brand names.
50:30
The prices have gone so high, and the rate of using of this, although it's limited with the better hygiene or better health profile of people, the use of these drugs are less, but still because of
50:47
the domestic pet people have dogs in their houses. So there are drugs used for dogs, which could be the reason why the rate of, or the prevalence
51:02
of infection with the high diet is less and less all over the world. Not only. In regard to the survey given by Dr. Khalili, the number of cases reported in Iraq, I'm wondering if these are
51:15
officials. I mean, I'm adopted by the Ministry of Health, or these are just personal, let's say, communications or limited. If these are official, I feel this good. It's not much bigger than
51:32
what is reported in the United States of America or even in Europe European countries has probably
51:42
015 or 015 per
51:46
100, 000 cases, so those numbers given by Dr. Khalili are,
51:52
I mean, very good numbers in case these are considered to be official or reflect the total numbers in Iraq, although these are just for limited area.
52:03
Thank
52:05
you so much I think, at the end, I need to thank Dr. Lamila and Dr. Sambar. I'm very happy with their presentations as new doctors, compared to your generation. They are doing a great job. I
52:19
congratulate them. If these two guys are your students, I'm happy that these are the best doctors I have seen probably in this area at least this time. Thank you so much. We all do, as the end
52:32
you
52:34
all. Just answering your question, the figures are only SNF figures. Most of them are my personal, some of them are joint surveyed, some of them published, some are not, but they are not
52:47
official figures. One point I would like to mention that in Turkey, they tried to use Mabendezol
52:58
entrasist. 20 of Mabendezol, they injected it in the cyst,
53:02
but I don't know, they claim something, but I'm not sure that's correct because Mabendezol has to be metabolized and the body before it be active Less number one. Number two, as you said, the.
53:16
But then those are what you use it systemically, it's a lot of options. So that's why you use it at least three months with the leaders and thank you. I don't want to take a watch of your time for
53:31
this. Thank you. Mamut Farah, you would have rose your hand, yeah.
53:46
Hi everyone. I'm Mohammad Farah, I'm a 15th stage med school student at the College of Medicine and University of Laudad, firstly, thank you for Dr. Adel-Halyi and Dr. Juanita Samp for the nice
53:49
presentations. It's very interesting,
53:53
Todix. My question is about the high diet assist. Recently during this month, I was observer in surgery for high diet assist The patient was two years old, she would run on the high diet assist to
53:55
us in the general law My question is, what is the best?
54:14
possible source of high dietitist in this age of growth.
54:19
The child that during this age it's a limited exposure to environment on diet, especially in the time of the infection.
54:31
What's the possible source of the
54:36
high dietitist in this child or in children in this age of growth or below the two years old or even in the two years, four years old preschool age, thank you. Thank you, thank you for this
54:52
question.
54:54
In fact, it be reported even one year old child with high dietitist in the brain. So that's why it is in general younger people are affected more than older people in the brain and the orbit as well
55:08
Well, the contamination can be from different sources if. this child you are referring to is living in the farm, just patting on the contaminated dog with eggs and contaminated sheep, this patting
55:24
on it and get some cholices to his or her mouth to ingest. And also they feed them with some vegetables, some grains, even one year old, sometimes they give them. So it is
55:30
always by ingestion and
55:41
the wealth contaminated food, usually vegetables or maybe fruits.
55:50
Dr. Osman, what are you raising the hand? Yes, is everybody finished? I just wanted to ask some questions for Dr. Hadi and Dr. Maddy, but Dr. Hadi first, if you're gonna do it individually.
56:02
Hadi,
56:04
I'm,
56:06
is interested in your presentation, Obviously, a children's disease is. is a disease rampant in the low to middle-income countries. It's not present commonly at all in the higher-income countries.
56:20
And the question I have is relative to public health. If you take a
56:28
high-daptor disease as a parasitic infection, how does that relate in terms of a health problem in Iraq to other infectious diseases, such as tuberculosis, or what are the other more common
56:43
diseases? And I'm approaching this from the perspective of the government. If we have a certain amount of money to spend on diseases, how do we spend that money in order to get the most effective
56:56
treatment to the most people for the least cost? So I'm looking at really what the various distribution is of infections and resources available.
57:10
Well, I'm sorry, I cannot give you exact figures, but surely there are more important diseases to look after other than hide at it, but still hide at it remains very important because it can
57:25
produce problems which are sometimes, even with surgery, can be detrimental when ruptures or to philosophize. At tuberculosis, I'm not sure if it is a big issue in Iraq now Maybe it's some big
57:40
issue in some industrial countries now that are resistant to medication.
57:47
I had to have no figure so I cannot say that but a public health person can answer you properly about this. Maybe Dr. Sahar can jump in here to give an idea.
58:01
Unfortunately, I don't have figures regarding that Okay. So as you said, Jim, write you that. budget has to be spent wisely to more important diseases. And I'm biased about tidated because I
58:20
think it has to be looked after and then done properly, dealt with properly. But I can get you an answer for that from the public health guys from Iraq. Well, it's okay. Let me go on and then
58:32
you'll get the idea of what I'm saying. When I went to Peru, the public health minister was a cardiovascular surgeon. And I asked him a question, if I gave you a billion dollars, what would you
58:43
do with it?
58:48
I expected to receive a different answer. He said I would spend it on sanitation. Yeah, that's right.
58:56
And so we have to think about this. Here we're neurosurgeons, I'm listening to this, we're talking about how long the incision should be or what we should be doing. Neurosurgery is a luxury
59:06
specialty. What are the most important
59:11
illnesses in the country and where should our resources be spent? If I'm in the government issue, that's one of the best what I would do. And that's true in your country, it's true in our country.
59:22
It's true in every country where there are entire low and middle income countries. Of course, if that's not a consideration and there's
59:31
individual liberty and individual freedom and not government control, then obviously it depends upon who has the money and who spends it and the money gets spent on the people who have the most money,
59:42
the treatments do.
59:45
So, one has to remember about that. If you have a certain kind of a health system that allows individuals to get paid for based on what they make and what their position is and so forth, you get
59:60
certain results. If you have government control, then what you have is somebody else selecting what should be treated In Britain, for example, they eliminated the number of hip replacements to
1:00:15
treat, even though there are any more. They've limited a number of drugs that you can treat various diseases with because it costs too much money. And I went to Belgium and there was an orthopedic
1:00:27
surgeon there who needed a hip replacement. He couldn't get it because the country ran out of money. He had to wait another year. So we're dealing with a public health problem Many of the doctors
1:00:38
that recognize the disease. How do you eliminate it earlier? Obviously. You've got to get rid of the contamination that occurs in the rural areas and so forth and so on. And in the improper meat,
1:00:50
that's education. So do we spend money on education?
1:00:54
Do we, the cases that you may see, maybe cases that are extreme? Dr. Madi has some cases like that. So the question I have is that, and then Dr. Ghazi said something about Ivermectin,
1:01:11
Ivermectin, well, I don't want to get into this, but this is an extremely valuable and important contribution. It turns out that in
1:01:22
COVID, Ivermectin, which was an enormously effective treatment in Peru, South Africa, in Africa, in Bangladesh, because they didn't have the funds to go and use vaccines, and it was also an
1:01:38
Indian, the disease disappeared, nobody wanted to report it. That's because there was no honesty in the press and there was no honesty in the reporting because the drug companies were trying to get
1:01:48
everybody to use the manufactured vaccines. But nobody wants to know that yet because it's still being suppressed information. What Ivermectin was an extremely powerful and effective drug could have
1:02:02
eliminated millions of deaths and we would have had a much more successful treatment. He is absolutely right So my question is, what's the cost of the endosome? Is it a treatment that can be, do
1:02:15
you recognize some of the symptoms? You recognize it earlier on when people get it in the brain. It's obviously more advanced. My guess is, what percentage of people get that? Is it 10, 20, 30?
1:02:27
And do they, when they get the drug treatment, is that eliminated right away? So that's become very helpful. Can you answer those questions, Tyler? Yeah, I think you're all right That's why in
1:02:39
my research, I put public education topic in the research, because if you don't educate the people, then you have an effect on the prevalence of the disease. And using this drug, as you mentioned,
1:02:55
and Professor Razi was mentioning earlier, I think so many drugs being used experimentally to get to treat, to hide at it. But none of them really has yet surpassed the Mendezol and the Mendezol.
1:03:10
I think in the near future, we will have something new about so far we don't have any but let me ask you this question the number of people who come in with symptomatic i data disease looks likely
1:03:24
it's going to be cerebral that i'm sure it could be other organs if that does that represent the total number of the people who are infected 10 of the people 20 of the people or 80 of the people well
1:03:37
i would guess nowadays people are aware of what's going on, and there are centers dispersed all over the country. For instance, in Neurostatica site, as I mentioned in my earlier talk, that we
1:03:50
had only one center in Iraq and then three centers. And now we have, every province has a center and with many good neurosurgeons all around. So consulting to these surgeons with any complaint
1:04:06
neurological, it would be easier And then you can detect the disease early. With the facilities available all over the place, all over the country, it is going to be easier. At that time, we
1:04:19
didn't have CT scan, we have just
1:04:23
nothing in fact. CT scan solved the problem on the clinics, right? And then nowadays it will be easier. So 10, 20, maybe I would put it in that range. So 10 or 20 really wind up
1:04:38
in more intensive hospital and more extreme carers, what you're saying, yeah, the rest can be taken care of. Yeah, that's right. Very good figure. So what we need to do is get people to
1:04:48
recognize that stage and then maybe try to get that earlier, is that correct? Yes, absolutely right, yeah. Okay, then we have drugs that treat them. Dr. Ghazi, what's the cost of El Bendazole
1:05:01
in Iraq? Is it something everybody can afford? That's a very nice question, Dr. Osman. Actually, Vermok's brand name is no longer available because Vermok's brand name is no longer available,
1:05:14
because Vermok's brand name is no longer available, because Vermok's made as a generic made by many companies all over the world, and it's much cheaper. In the United States, the price has gone,
1:05:23
like, I don't know how many times fold, like 100 times fold, recently 10 years ago, it went to, like, a thousand of dollars for a thousand of tablet,
1:05:41
a dollar per tablet, which was not that much before. That is the lobby of the giant pharma. When they consider something is no longer available as a brand, they increase the generic price.
1:05:54
Al-Bintazole and Verbox generally are cheaper. I'm retired now. I don't have a current price these days, but I know they were nice, good prices But the use of these two medications for
1:06:10
Al-Mintazole, I mean, for tinnia, sagenata, or high that it's. In America, it's less than the
1:06:16
usage it for other worms, like other kind of intestinal worms. It comes as a four tablet dose of Mintazole, Al-Bintazole, Al-Bintazole, Al-Bintazole. I don't know the price, but for tinnia is
1:06:33
like a long-term treatment, like three or four cycles. There is a break between these cycles that use it for three weeks and then you stop it for 14. That is for long-term treatment, Dr. Rosman,
1:06:46
but I'm not sure about the prices. The prices went higher than before when the brand name Vermox has been stopped. Very interesting, very interesting response.
1:07:01
And
1:07:06
it talks to, it addresses how the pharmaceutical industry is trying to take advantage of the healthcare system and the patients. It's true in our country and in a great deal. So if I'm a farmer and
1:07:14
I'm in rural Iraq and my child gets infected with high data disease, can I afford to treat him?
1:07:24
And well, in my time, everything was free. Everything in the hospital name and health service was a free drive out. What about now? Dr. Ghazi, is it is it is it is the drug so is the drug so
1:07:39
cheap that it can be treated or now is it I'm unable to treat it because it's too expensive and I don't make that much money.
1:07:47
Dr. Osman, as you said, giant pharma, what to make money? And they get the chance to increase the price by changing the patent for nothing important, but they even changing a color of of the
1:08:01
shape of the dosage form will make it as a new patent. And Iraq, the price is compared to the US dollars. Yeah, they are very cheap and they can easily be afforded by many people. The income of
1:08:14
the Iraq people these days is higher than 20 years ago. And I think it's very affordable and it comes from different. You know, India is the pharmacy of the whole world. Most of these medications,
1:08:28
If not the active medication, the pro drugs are made in India and China, most in India, and the prices are very low. So I think it's very affordable in Iraq. Okay, so the key is education,
1:08:42
sanitation, getting people to the doctor earlier if it becomes more complicated, Heidi. Obviously the drugs are available, but it still means that the pharmaceutical companies and other people
1:08:54
trying to deprive people of healthcare because they raise the cost is intolerable It's a crime.
1:09:04
Absolutely. It's an absolute crime and the physician should be united to oppose that. That's costing the country money, it's costing them lives. If you wanted to rate the cost of what they
1:09:16
increase costs of drugs out of the people when they don't have to be raised, that's a national crime, should be punished.
1:09:26
It's a punishment of the people, I think that's unfair. Well, if I had something, if you don't mind, I don't mention the name that's one of the CEOs or the owner of a pharmaceutical company. I
1:09:40
think went to jail for increasing the prices like several hundred falls. I will not mention the name of the drugs. I'm very sorry. It's true everywhere. And in our country, they haven't been
1:09:52
punished, but I think you're absolutely right. And I'm very happy to hear what you said Hadi, I think to me, and that was a very interesting talk. And
1:10:03
obviously, many doctors, they're not a treat the disease. They don't recognize it. When it gets very complicated, they need help. And that's perfectly understandable. If I'm a government
1:10:14
official, I'm going to be asking all the questions I was asking. Yeah. For that, it is important to go back. I disagree also with the Minister of Peru It's not citation, it's education. And the
1:10:29
education is the broad thing. One education is also the education of the physicians, the political education of the population, the education of everybody involved, and sanitation as well, no?
1:10:45
To which, I want to rescue from sanitation the importance of neurological diseases. Neurological diseases per se, everyone, including psychiatric, are the most important a cause of days living
1:11:02
with disability in the world. Except sub-Saharan Africa. Except that belt, that around Congo, Mali, Mauritania, Sudan, everywhere else in the world, the neurological diseases are. So it is
1:11:21
important also for us to, at the focus, not only in the area. what what can we learn from the outcome or from the evolution of the patients if we make a longer or at a shorter incision because that
1:11:38
we are causing disability and not only in that particular individual but in our overall understanding of the brain.
1:11:49
Any question or comment from
1:11:54
presenters final thoughts final comments for the closing remarks
1:12:01
no one okay so I just want to let you all that the recording of this
1:12:08
meeting will go first through editing then peer review and then will be available at the SNI digital hopefully as soon as possible and we will share also the recording with you for those who want to
1:12:24
share it and also for those who want to and attend the presentation again. And thank you everybody for being here. It's an honor to listen to all of those. I'd like to
1:12:39
ask, I'd like to ask one thing. I wish everybody here would send their comments. We can't do better. I left the operating room, asked everybody, what could we do better? And that's what we need
1:12:51
to ask here. What can we do better? To teach you better, to help you better, to help the patients better, and send the comments to Sam. That would be immensely helpful. We're spending a lot of
1:13:04
time and effort trying to bring this to you. We wanna know if it's worthwhile, if it's not worthwhile, what can we do better? And I thank you very much. Thank you all. Thank you, Professor.
1:13:16
Thank you all, thank you for everybody, thank you for your time. And yeah, see you again at the next meeting and have a great day, have a great time. Thank you.
1:13:31
Goodbye. Thank you. Thank you. Bye, bye, bye. Thank you. Bye, bye. Thank you so much. Thank you. Thank you. Thank you, bye, bye. Appreciate it, bye bye. Thank you so much, bye.
1:13:38
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