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Welcome to the 16th SI and SI Digital Bagdad Neurosurgery Online meeting
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held on August 7th, 2022.
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The meeting originator and coordinator is Samir Haas of the universities of Bagdad and Cincinnati.
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Introductory remarks on the program will be given by Sam Erhas and Heidi L. Kalale
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The program will consist of a report on the Iraqi board of neurosurgery,
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experience with neurosurgery in Solemonia in Iraq,
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the Gamanife experience in Iraq, a report on three young neurosurgeons and students
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on their research and their mentorship,
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an lecture on the future of neurosurgery and medicine by 2100.
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The first speaker is on the topic we'll speak on the topic of neurosurgery in Iraq and the Iraqi Neurosurgery Board. It will be given by Professor Obd Almer,
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Al Kafaji, he was president of the Iraqi Neurosurgery Board and also in the Department of Neurosurgery neurosciences teaching hospital in Baghdad, Iraq.
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The next speaker will talk about the status of neurosurgery and Kurdistan. It will be given by Professor Ari Sami of the Department of Neurosurgery at the University of Sallemani in the College of
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Medicine in Sallemania, Iraq Bruck.
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The next speaker, we'll talk about the status of neurosurgery in Baghdad, the game and life experience there.
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It'll be given by Professor Yasser M. Hamandi of the Department of Neurosurgery of the Al Narayan College of Medicine in Baghdad, Iraq.
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There'll be three young neurosurgery residents and students who will make short presentations The young neurosurgeons and student speakers include Sally M. Mary, senior neurosurgery resident of a
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Rocky board of neurosurgery, neurosciences hospital in Baghdad.
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Octemol Elcafagie, Department of Surgery, College of Medicine, University of Baghdad, Baghdad, Iraq And Hanine Selah, Department of Biology, College of Science, the Mustang, Syria,
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University bagged at Iraq.
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Final speaker. We'll talk about the future of neurosurgery and medicine to the year 2100. It'll be given by James Osmond,
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creator, surgical neurology, international, and SNI digital, also associated with the UCLA Medical Center.
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Video editors are Mustafa Ismail, the
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College of Medicine University of Baghdad, and Fatima Ayyad, fourth year medical student, University of Baghdad,
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and the resources of the foundation supporting this program.
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I think we will be ready according to the program. We have Dr. Amir Jazim, he's already there, professor, and Dr. Yasar Hamandi, Dr. Arisami.
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and Dr. Saleh, the resident from Iraq also already. Dr. Exam has already, Hanin has already, those are the presenter, the initial presenter, then the last talk will be with Dr. Osmond and
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also he's there. So we already and I opened the share, it's now recorded, and now you can start Dr. Osmond Okay, thank you very much, Sammer. It's an honor for us to be here.
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I'm just going to make a few comments and then Dr. Kalili is going to introduce the speakers and I didn't run the session. So anyway, we are Jorge
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and I are associated with this and I, which is a surgical neurology international and we're helping you all and Samara.
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develop an education program for people in Iraq. And this is a second meeting. It's already double the size of the first meeting, which is a tribute to Samir and all the organization he's done to
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do this. So I'm going to introduce Dr. Lazareff, who's one of our guests, everybody. Jorge, so
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Dr. Lazareff Dr. Lazareff is from Argentina. He's in the United States. He was head of pediatric neurosurgery in the United States at
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UCLA. He's one of our members. The second is Dr. Kansari, who you see up on top. He's originally from Iran. He also came to the United States as working at UCLA, is deeply involved in, deeply
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involved in in some basic research and also clinical work. And so we have people in this call, I don't know how many are from other outside Iraq, but from which you mentioned in the papers and last
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time, we have people then from around the world here. And that's a great achievement. Everybody wants to know what's happening in Baghdad and Hadi, Dr. Kallalik, I'll leave it to you to go ahead
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and with
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the meeting here, we are honored to be with you. Thank you, sir. It's a great honor to be with you and Dr. Lazares and Dr. Ali and everybody. It's a real pleasure to see our colleagues in Iraq
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again after all these years. I haven't seen them since 2004,
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I think except Ari came once in the ninth in the 2000s. 17 or 16 perhaps. It's my honor and pleasure to to join this interesting group and important group and thanks to Samur for his dedication and
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of course Dr. Osman for your leadership, sir.
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This meeting today will start with three leading figures in Iraq near the surgery Dr. Adlemir Jazim and Dr. Yasser Hamandi and
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Dr.
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Ari Sami. The three of them are professors of neurosurgery at their universities. The first speaker will be Dr. Adlemir Jazim who is a professor of neurosurgery and he's the head of the Iraqi world
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of neurosurgery. He graduated from the medical school in 1986 and
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he got his Iraqi board in 1994. and being attending consultant neurosurgeon 2008. And he headed the department of neurosurgery at the Nharan University and got his FRCS in 2020, the Fellowship of
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the Royal College of Surgeons. And he has written many papers and his leadership really was so important, so productive. And you can see so many young neurosurgeons with his guidance, with his
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leadership, now filling many centers in the country. So the floor for you, Dr. Lamir, please, present.
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This is
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the 16th SI, an SI digital Baghdad neurosurgery online meeting. Held on August 7th, 2022, meeting originator and coordinator, Samer Haas
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Speaker is Professor Abdell on the error.
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Al Kefaji, President of the Iraqi Neurosurgery Board, Department of Neurosurgery, Neurosciences Teaching Hospital and Baghdad. And he will talk about neurosurgery in Iraq, the Iraqi Neurosurgery
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Board.
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I only will talk a few minutes about the Iraq Board of Neurosurgery, okay? Yes. Yes.
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Board for Neurosurgery Training for
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first year, first year, the students, they are in post rotation, coming to us as an example of competition, which is including neurosurgery practice and neurosurgery, some texts of the Reddit
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and they go for example, then the mark of the success is 50 and there are for, this is only limited number of students.
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Also, we have an equation for the situation of the this student in his college and his mark in the college with the mark of the exam. This is example for our competition exam. Then,
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the Iraqi Council of Neurosurgery consists of five persons who are in degree of birth, four of them from medical college and one for the Ministry of Health. Centres are four in Baghdad, three in
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North and three in South. We have in Iraq only two hospitals
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specialized in neurosurgery. Each center has its trainers in the degree of consultant or assistant or abroad. There are
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trainers. And each center has its theoretical program daily for practical and theater and surgical procedures Now first, your examination.
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including in your anatomy, neurophysiology, neuropathology, and basic and neurosurgical handbook and neurosurgery text. First year training, six months in general surgery, two months in your
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neurology, two in RCU, one month in neuroophthalmology, one month in psychiatry, and then the exam. Success is mandatory to go to second
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stage During the year, training in hospitals, as first call, they master, they should master trauma, emergency, medical and surgical consultation, life-saving or seizure-advance, life-saving,
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including thercustomy, chest tube, center means lion. At the end of this, you go to the third a year, but without examination.
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A third year, training as a second assistant in theater, prepare patient for surgery, important figure and team at that level. He is a hard morning and nine tour posts operative follow up at the
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end of the year. He should master clinical examination and they we exam them a practical examination long short case and oral exam at the end of this year He should be a neurologist beside the
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neurosurgeon and the fourth year our student now master clinical examination. He has full basic anatomy physiology pathology trauma life saving major and life saving doctor. Now he is also assistant
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in all the clinical might be his senior and and some of procedures
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take that to the glioma alone, he can doom and go seal. VP. Shunt, the Congress of Lamnectomy,
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also gamma surgery. Here,
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we concentrate on surgical personality and give more time to contact with his senior old time. He passed the last year without exam, but here he have all the discussion of ethicists. Last year, he
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is ahead of team surgeon of most cases, nine tool guide, preparation of patients. He
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will be responsible on every defect examination of final exam. We have in final exam, three or two paper, including 200 MCQ, and a practical long short oral slide and Oscar thesis. And the fourth
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year, we have - and this is a three-supervisor and a degree of growth or
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growth assistant or consultant and this is his mandatory.
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centers, in the centers of Iraqi centers of neurosurgery hospitals and centers, we have only two hospitals and other centers belong to Mr. Afhir or they are related to medical college.
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We have orbit surgery, trauma, spine, vascular, gamma, functional, oncology, endoscopy Now we have gamma, exoscopy, entered to some centers, deep
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vaginal circulation and angioin. A text, humans, textbooks, core
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for a class for operative and handbook.
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Now I will show you this picture, this is important I now I talk about the, what is the Iraqi board, the student, the examination, but how the sport board initiated, this figure at one time was
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all the neurosurgeon of Iraq. Here, Brof Abdul-Hadi al-Fani, he is the first brof in neurosurgery in the history of Iraq, and he is also beside he is a neurosurgeon to initiate the orbital surgery
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in Iraq. And here, Brof Abdul-Hadi al-Fani, who won't initiate the neurosurgery board. Other neurosurgeon, Jafar Khadidi, Jafar Napid, Para Khazayin, Samir Hasa Abu, Victor Hakmat, and the
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others.
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This is a surgical photo These, I choose those three figures. Here, above Abdullah Ali and Khadidi, who initiated the
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real branch of neurosurgery in medical college of Baghdad, and he's the first broth. Here, broth, albutry, he initiated the neurosurgery in Iraq, and here,
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our senior
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messenger, he was a pioneer of spinal surgery in Iraq, a pioneer of orbit surgery in Iraq.
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These figures also, from history, here,
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broth, albutry, and broth, seminar has a good, and this photo, and neurosurgical hospital,
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broth, albutry, and our student of Iraqi board also our student and here me and Rolf Jasser and Rolf, I'm at the Salam Taksi and Rolf
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Ayad, the trainers of the trainee. And here in Germany, foreign discovery of the brain will go.
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This is in Java, me and Dr. Jasser, and five
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medical students in
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Narita hospital.
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And this with our student of Rocky board, in this 2021, all the four student
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fires, and one other one absent,
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the annual surgeon, Rocky, no surgeon, here in Gamma Nice.
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This is the Iraqi board, all the branches which are auxiliary, neurosurgery, general surgery,
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radiology, neurology, and all the people here. And those are the chief of all Iraqi board of board.
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This is during discussion of thesis This is pituitary surgery, I think, highlighted which is common in Iraq. This is also pituitary, and this is our student finishing their board. Here, this is
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a historical photo, our broth, I think this is in medical college of Baghdad. And here, our student, in the lecture room, they are Iraqi board students And this is the icon, gamma surgery.
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this is first case we did for gamma surgery. The important things, we are three seniors always working together.
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Thank you.
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I finished the mic. Thank you. Thank you. Thank
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you. This is not my computer. Yeah, you did. My brother helped me.
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Well, thank you for the interesting and important presentation. Tell us about the Iraqi board. If there is any question, please, you want to ask him because we have
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ten more minutes. Could I ask you a question? Yes.
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I'd like to ask you to say
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the neurosurgery residency is in four years in addition to the six years that the student has to go to medical school. I don't, is that, is that how it is? Yes, after he finishing medical college,
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then he, he, he become,
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then after he completed the working, and the hospital for one year and
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his rotation, he, he can come as a competent with others for a
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neurosurgeon. A neurosurgeon here, we accept him and he's success is five
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years. Neurosurgery is five years. Yes. Okay. One year beforehand, after graduation, just as a scholarship or houseman. I understand, okay. In the students, once they finish medical students
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school, I have to compete to be accepted in neurosurgery. Is that how your system works? It's true in our system,
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The, the, the, uh, the student first, uh, go to work in history of, of health as a rotator and, uh, and the main branch is, uh, medicine, surgery, guy knee, pediatric, and then he can
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be accepted. And the Iraqi board. I see Do you have more people who apply for the positions than you have, or can you take as many as possible?
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What do you mean? Uh, if.
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If many students would like to go into neurosurgery, do you have room for them or do you have to select them? No, we have a selection
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on their degree in the exam and there is an equation beside his degree in the exam, his position in his college, if he is the first student, suppose that this college accepted 200 students. He is
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number 10 or number 20, this is different. And
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the number of the student in the college and this equation, plus our mark in our exam and if he has a resency in the neurosurgery, also for one month he take 05 mark and we calculate and we should
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accept as limited lumber. Nowadays, we can accept 20. But after, before many years, we accept only 10. Before this, we accept five. I see. Yes.
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Jorge is a system similar in South America or Latin America? Yes, it's similar. And also, I want to add to one in the comment Also, we have the similar, what the similar system we have in South
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America, I mean, not surprised to find is the same system in Iraq. And I'm sure it's in the Middle East, is why the first surgery that the resident does is a VP shunt, my God,
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no.
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And that's why when we look at the rate of complication of the pediatricians. we don't know whether it was related to the lack of experience of the junior guy sort of stumbling onto the they they
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they they I'm not blaming that I mean please and my the professor is illuminating we do it's sadly the same here
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we do the same what the seven a vp shunt my first surgery saw all on November 7 1979 now will be an anniversary of that is at the village shunt and we always forget I understand the milo at the
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meningo cell and yes
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is similar but we don't have to do the thesis at the end whereas in many countries in central America they do have to do the thesis which is at a very good idea here in the United States we're going
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to do that and excellent and illuminating at the presentation. And I also took a picture, the screenshot of the professors at the presentation of all the people on the board, there is a large
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number of women in that very nice picture with all
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our nice interests for the board. And it's amazing. So I took a screenshot for
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that. Oh, and thank you. Thank you very much. Ali, is it in Europe, you were trained in Europe and France? Is it the same there? Sir, it's only four years at that time that I was there, it
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was four years training, but it was mostly in the operating room. And we had the group who used the ICO, which was done by the Iranian motto or anesthesiologist, but we rotated with them if they
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needed help to do the drainage or any over the
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bed procedures, but believe it or not, the first time you mentioned in one of the conference at UCLA,
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After the surgery, she said, You have to go to do the tractors. Then we have you done it. I said, I know how to do what happened in that. That was the first year. It took me to the bed of the
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patient. He said, Help me, I helped it. And he said, From tomorrow, you have to do. I have done more than 100 cases of the tractors.
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Because my mentor was very special, very one of the greatest hand of neurosurgery. So it depends on the mentors who train
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How do you thank you for allowing us to ask questions? We appreciate that. Thank you. Any other questions please, from the audience to Dr. Adelimir?
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Can I ask a few? Of course, Dr. Adelimir. Yeah. First, thank you, Professor Adelimir-Jasim for this presentation. It's quite orienting for everybody about what is this, the structure of Iraqi
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work. I think it's interesting and I know a lot about the challenges that he faced while planning for the future. I want to put this as a question but I know that there's a quiet challenges. Maybe
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it's helpful to put these challenges here in this meeting so we may figure out what we
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can do for the future. So my question is that, is there a plan for subspecialty to be included in the future for the Iraqi board? And thank you again for the presentation professor.
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Hello Mr. Summers, thank you.
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Yes, we are doing this plan. Now we have a spinal surgery sharing with orthopedics. You know, the spine surgeon should have orthospine and the neurospine. And now
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we have one student and our spinal fellowship.
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And we prepare when the other equipment is available for other things
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I hope
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in the past, when she had the vascular,
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but you know that we had a
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positive or deficient and angiograph.
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Now I think we will take two. And skull base surgery also, I want to start it
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What's - make me sure we can do my colleague. We have a young -
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intelligent neurosurgeon in Iraq and I have a very intelligent assistant in the our centers in north and with me in the board and in our centers. I want to start the skull base and vascular
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but you know also we have a positive of hospitals. All Iraq had only two hospitals and the general hospital the environments in the general hospital not very helpful. It is a negative stick holders
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I think. So with the time
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we can start this and thank you. Thank you thank you.
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Sorry if I ask one question please. Dr. Justin Thank you very much for your nice presentation. There is one question I see. In the last few sessions I was with this group for the Dr. Summer.
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There are a lot of young ladies who are interested in your surgery. Are you gonna go some advantage to help them to get to the neurosurgery? Because now at UCLA, we have a lot of ladies who are in
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neurosurgery residency and other programs. Are you gonna give some advantage to them? Because if they are interested, they have to help them to come up to the, I don't know, each culture and the
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country is different, but maybe you give some advantage to them because I see so many of them are so enthusiastic. Maybe you have to consider some advantage for these young ladies to be involved in
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neurosurgery, although gentlemen are always red-compot. The field is changing. Sorry for that Yes, Iraqi women's and Iraqi doctors,
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interested in neurosurgery because they are sittrons, they can do hard since their rotation,
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they work hard. I think neurosurgery is not difficult, not more difficult than the gynecology calls in Iraq. Also neurosurgery now is developing.
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I see them, they are very interested in gamma knife, they master it. With the
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future, we can brought our
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hospitals, excess copy, and these tools have become more easier. So I encourage them, but they are coming to neurosurgery
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Thank you.
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do you have any intention of starting pediatric neurosurgery or subspecialty soon?
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But the Attrick Board, the Attrick Board for the Attrick Surgery Board has many difficulties because they are a part of general surgery, but the
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Attrick General
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Surgery Now they start to do pediatric neurosurgery and they are very different. I talk with them. They find it very difficult to start now with us for pediatric neurosurgery. We are ready.
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The last question is how many female students in the board and how many graduates from the board as female? Rocky board graduate,
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I think now three.
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and I guess and now we have in first class four and and the
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I think we have seven or eight students now but they are increasing you can imagine that in this and in this year we accept four okay thank you so much for your presentation and for answering the
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questions thank you thank you the
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status of neurosurgery in Kurdistan will be described by Professor Arisami of the Department of Neurosurgery of the University of Soleimani College of Medicine Soleimaniah in Iraq
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Lecture 30 minutes, discussion is 15 minutes, over 100 attendees from 18 countries participated in this conference.
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There was a suggestion that to start Professor Ari at first,
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Ari is
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a graduate of medical school in 1984, and he is fellow of the Iraqi Board of Neurosurgery in 1994,
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1994, and he got his offer CS in 2012, and then he got his FACS, and he's a fellow of the ANS in the United States, and he is the Professor of Neurosurgery at Soleimani Hospital in the north of
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the country at Kurdistan
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I know Ari from a long time, and I'm really proud of him and that Lemire and the answer for what they are achieving now. He's going to tell us about I think the board in his area and his experience
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in that field. Thank you so much, Dixarari. Thank you so much, sir. Thank you so much.
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Good afternoon, those on our side and good morning to the other sides of the world. I'm happy to be here with you. Thank you for Dr. Samar. Thank
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you, Dr. Adi Kalidi for the opportunity you gave me To talk about
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the status of neurosurgery in Kurdistan. So if you allow me, I will talk about the status of neurosurgery in Kurdistan, history, current situation, goals and future directions. Just let me to
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start with some history. I have been privileged to and honored to be trained in neurosurgical hospital. and by that in 1990 to 1994. At that time, our training time was four years. I trained in
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the neurosurgical hospital and in the surgical specialties in the medical city in Baghdad. In 1994, I had the Iraqi fellowship of neurosurgery. I had the privilege to be trained under the great
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neurosurgeons at that time The professor, Professor Haley Lee, Dr. Samir, Dr. Raffet, and Dr. Parek. Dr. Jaffar, and Dr. Hekma, Dr. Samir, and Dr. Parek, and Dr. Parek, and Dr.
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Parek, and the one. In 1994, when I graduated from the board, I was, I assigned to a senior neurosurgeon,
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interspecial surgical specialties hospital in medical city under the supervision of my mentor, my teacher, professor Harili. I,
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with all our colleagues in this hospital, we spent more than nine years under his supervision with his teaching as the ethics, the neurosurgery and the philosophy of working as a doctor. Thank you
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very much, sir. Thank you, sir. Like
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Erica Kudusan is divided into four government rates, the Hoxley Mania Erbil, and nowadays, or the last year's the Halapcha, encompassing about four 40, 000 kilometers square with a population of
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more than six million people This for governorate is the.
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the parts of KRG, we call the Kurdistan region a clean or the region. After the 1990s,
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when August 2nd, the Iraqi invasion of Kuwait, and at that time, the 1991, the exodus of Kurds into the border between Iraq and Iran and
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Iraq and Turkey And then the founding of the northern non-fly zone and the southern non-fly zone, there were two sanctions on Kurdistan, first from the UN sanctions on Iraq, and the second one is
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the Iraqi regime and that's a time section on Kurdistan. So two sanctions were put on Kurdistan at that time
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So many is one of the governorate of the Kurdistan region before 2003.
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Patients with neurosurgery or neurosurgery complaints
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from
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Suleimania, Erbil Dohok, and even from Kirkuk and D'Alla we're traveling hundreds of miles to get access to a new research in Baghdad, which was sometimes unaffordable for a significant number of
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them, either because of economical or non-special socio-political situation those days.
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Neurosurgical diseases and emergencies, most of them almost missed or mismanaged because there were no neurosurgical centers, except at that time the 80s and the 90s, the urban center, where the
38:60
term Muhammad al-Tafiq was practicing neurosurgery,
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of course without any city machines at that time, so he did the trauma cases and the biopsy cases and management of some of the cases, the first department of neurosurgery ever established in
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Swamani University teaching hospital. We also had. August 2003,
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and according to the paper in 2016, where the global neurosurgical workforce published their paper, that in 2000, the global density of neurosurgeon was estimated at
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130, 000 population, which remains the most recent estimate of the global neurosurgeons workforce density. According to this, we started our department and we started to think that this department
40:04
should be a center for training of our colleagues for graduation of more neurosurgeons to be in the figure outed with this paper
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So accordingly, so many populations about 2, 000, 000 and a half. So 11 neurosurgeons should be there to cover all the neurosurgeonial diseases. Now, to end of everything, or every beginning,
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different obstacles and difficulties known for every beginning. For example, lack of facilities and zero team. So I returned back from Baghdad, 2003 There were no facilities, and there were no
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assistant team for me to assist me in
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the foundational of the neurosurgeon. So I started with the help of our friends, our colleagues. And none of these above negative or repulsive points could stop the mission. So with the help of my
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seniors, my teachers, the
41:15
And my colleagues, Dr. Abilimir Jassa, the Pranishachi, the Toriyasir, We established to have a center of Iraqi board in Soleimaniya.
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Then with the help of Professor Sanehassana-Boud and Professor Walid, we established the Kurdistan Board of Medical Specialities, which is six years training. And
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the, nowadays the Torujan is the head of the program of neurosurgery in the Kurdistan board And we are the
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official responsibility of the centers in Soleimani, Arbil and Dok.
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All the neurosurgical department now is in the Shah Hospital.
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During the last 19 years, tens of neurosurgical residents from Soleimani and other cities of Iraq, go trained in this department to become senior specialist. of neurosurgery, most of which return
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back to their cities to serve their people nowadays. Now currently, just in the Soleimani province, we have 17 senior neurosurgeon inside the
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city of Soleimania, one senior neurosurgeon in Wania, and one senior neurosurgeon in Kalar. Those are towns belong to Soleimania and our colleague, Victoria Herro, is the
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FEMA neurosurgeons with the group. 13 residents and both students are in training nowadays. Neurosurgical ward in Shar hospital with 30 beds and 25 nurses, three physiotherapists, six nurses on
43:02
duty 24 hourly. Department of elective surgery has two major operation theatres and one minor operation theatre with, three neuro-anesthesiologists, six anesthesia system nurses. five secret
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nurses and five round nurses with a radiology technician in the elective operation room.
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Emergency department with two residents and one senior specialist of neurosurgery on call 24 hourly. Emergency room operative room with a room allocated for neurosurgical emergency operations. ICU
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of about two or 22 beds in this hospital.
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Average of elective operative cases we do, six to eight spine cases a week, three to five brain tumors, four to six peripheral nerve entrapment cases, three to five injections for pain control,
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two to three patriotic cases, VP Sean's Benigno Milacile. Most of these cases are done in the emergency room or emergency basis. The emergency department on average of 15 to 25 cases of
44:09
neurosurgery is received daily. from minor traumatic brain injury to severe traumatic brain injury and multi-systems trauma, full-frame hydrotraffic accident, motor vehicle accident penetrating
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traumas and et cetera. Cases like extra-dural hematoma, acute subdural hematoma, chronic subdural hematomas large,
44:29
ICH, the preschool fractures are upgraded in the emergency room within minutes to fill hours.
44:38
New needs with spinal disravism from gynecologists and abstracting hospital, pediatric cases diagnosed as brain tumor and having obstructive hydrocephalus from
44:48
pediatric hospital, CVA from the neurology department with massive ICH or IVH complicated by hydrocephalus are referred and operated on emergency base by our emergency team on call. We have the
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discussions of the thesis of our both students in Slovenia with the help of our colleagues from Baghdad. We have visitors from outside Iraq from Jordan for the examination of the Kurdistan board
45:19
students. We have weekly seminars, journal club meetings every week and we attended so many conferences here locally and internationally. We have symposium for our colleagues from outside Iraq,
45:36
from Sweden, from other parts of the world here in Slovenia and we have online webinars, Sunday on 9pm every Sunday for our students, our colleagues, the seniors to discuss the latest
45:57
points in neurosurgery worldwide.
46:01
And of course, the social life outside in Elvig population about three millions. This is in 2020, an average of three new researchers. While nowadays there is about 29 with female new researchers
46:17
and they are distributed among the governor of Arabic.
46:24
And when I search for the hold, I come across this paper in
46:31
2016. Well, this group of volunteers published a paper neurosurgery in Iraqi Kurdistan, an example of international neurosurgery capacity building 2016. And they wrote in this paper that the
46:45
medical infrastructure of Iraqi Kurdistan a semi-autonomous region in the northern part of Iraq lacks this proportionately behind many of the otherwise booming industrial advances of the region.
46:59
Although neurosurgery training is available, the local population lacks trust in its own neurosurgeons. Medical facilities suffer from a lack of basic resources such as high-speed drills, entropy
47:10
and pressure monitoring and still a taxi to care for the research of patients. A part of ERK, good to start, the hope is financially well-endowed, largely because of the national resources of oil.
47:25
It's infrastructural glands with modern roads, buildings and bridges, basic amenities of life, including electricity, water, shelter and clothing, ubiquitous internet and cellular surfaces are
47:39
widely available and affordable, yet development of
47:45
medical infrastructure like
47:49
this version behind the otherwise booming industrial advances of the region. I think this was true for the other government rate in Sremania and Erbil also at that time We like the, the, the, the
48:03
infrastructure of the
48:05
neurosurgery department but nowadays we are getting better
48:12
and at that time the hospitals appear aged and validated medical equipment, dispersed training programs are meager and doctors like the broad training that's often taken for granted in the United
48:27
States. Further the local culture of medical practices and start contrast to the round the clock standard of patient care in the United States and this was true in the late 2000s
48:40
and 2010 but nowadays this situation is different. We
48:50
in Soleimani we have so many private hospitals that for example foreign medical city. Nowadays we have a very well equipped department of neurosurgery with
49:04
modern instruments like
49:09
neural navigation in doscopy, microscopes and so on. The other hospitals in the private sector, they are starting to have their department and in every hospital there are so many neurosurgeons or
49:25
colleagues working there. In the future directions and missions, subspecialty is at the door and even started in the form of endoscopy. We have two to three colleagues that are starting endoscopics
49:40
called day surgery and we have a fellow, one of the colleagues, a fellow of neurobascular surgery. Here he's getting his fellowship from Finland and one of our colleagues started the ability
49:55
surgery, Dr. Hallet and hoping to step towards the following sub-specialties in the close future. Like. which are very highly needed. We started to have some of the functional neurosurgery, the
50:08
vascular neurosurgery, neuro-intervention, one of the colleagues that the lung came back from Australia, and he started the
50:18
catheterization or the intervention and geography, and we need peripheral nerve repair.
50:27
And thank you.
50:31
Thank you so much, Professor Arri, for this wonderful presentation. And we admire, really, all of us, I think. We admire your struggle and your hard work to establish such expanding in your
50:44
surgical department and services from start, from zero, in fact. Thank you very much. Really, we are very proud of what you've done.
50:54
Dr. Osman, do you have any question or comment, please? I think he's done a fantastic job in 20 years to have started from nothing and to build what has happened. I did not like the article that
51:11
was published. I think I've traveled around the world and I've seen people at various stages of development and they're doing the very best they can and
51:26
what he has mentioned was just outstanding, tremendous accomplishments and great strides and everybody needs to do better. But I think you've done a phenomenal job and should be congratulated for it.
51:42
Thank you very much, sir. Thank you. Absolutely, yeah. Yeah, I would like to add, I had the opportunity, the owner, to visit Erbil and Suleimania, but back in 2009 And.
51:58
So when the beginning of your, of your program, I, I was in a, in a operating theater in Erbil. And the, and the plan was to develop something for the mile-meining ourselves because, because of
52:13
the chemical effect of the war that you had 20 past years ago was apparently increased the number of the spina bifida cases in Kurdistan, no?
52:28
And my impression was that at least in Erbil, and then I traveled to Solemania. We traveled by car to Solemania.
52:40
And my impression was that even, of course, you are being strong in
52:49
your assessment of your own abilities. But I am very impressed of the talent that I've seen in a bill, I'm talking back in 2009. And with a few, unfortunately, I mean, I do have the cards in
53:04
here. I will copy and send them to you. I wasn't involved in any neurosurgical cases, but my wife in Soleimaniya was involved in an assistant, she's a neuro anesthesiologist. And she was involved
53:19
with the anesthesia team, with a strong anesthesia team. So Soleimaniya was more on anesthesia And although it's right that you do, that you are critical of your own accomplishments and
53:32
difficulties, and you always feel that you are not up to par, believe me, when I came back in 2009, I told my colleagues in the United States, how would you wear? And furthermore, we were
53:46
talking with a transplant surgeon, with a liver transplant surgeon, in another type of the conference conversation and my wife and I. insisted that the human capacity that we saw in Kurdistan - I'm
54:03
talking about 15 years ago,
54:08
13 years ago - help me with the math - it is incredible. So congratulations for what you have achieved, but as an outsider, I can tell you. You will - you will roll. If you continue like that in
54:20
five, six, or seven years, you will be top of the world You have the human material. Thank you very much, Dan. Thank you. Thank you. Oh, no. I'm just telling the truth. Yeah, this is what
54:33
I want to
54:36
say from that paper, that before that time, we suffered because
54:42
of the sanction. And it is true that in 2003,
54:49
there were non-usagery, a lot of
54:52
non-usagery,
54:56
services here in the north of Iraq. And nowadays, the thing is different. We'll be, I don't think it's obvious our parents, our colleagues, which they are very
55:12
eager to learn, eager to do neurosurgery in a proper way. And I think now these situations is very different from that paper, which published in 2016. Thank you.
55:27
I have a question, Dr. Ari. Did you say that's the up training in the world is six years? Yes, in Condecan Board, yes, six years. In the first two years, the branches, we extend our services
55:44
or our training courses for some of the branches for more than months We think that this is helpful, it is six years now, yes.
56:18
Nice. And that preceded by one year like a houseman after graduation from medical school? Yes, of course, yes, of course. So it will be a seven-year program? Yes, sometimes more than seven
56:18
years, yes, yes. Okay, thanks. Dr. Knight, can I ask you a question? Yes, please, yeah. You mentioned about the number of the meningomy illicit and normal tube defects. As you know, I'm
56:20
sure all of you know that the
56:25
folic acid is recommended to the pregnant woman. Are your general practitioners or gynecologists considering this because that has shown that it lowers the number of the defect, although there are
56:39
many other causes, maybe because of the war and the chemicals which was involved. Are they considering that also to lower the number because that has been a major shift in pediatric neurosurgery?
56:54
Yes, sir, actually in the late
56:57
2009 or 2010, I think around these years, we had with my colleague, Dr. Members and Dr. Nasa, we had a paper of Spanish Befida in here in Soleimania. And we found that point is very interesting.
57:08
So we started that, all the
57:15
cases, and we contact with the gynecology and the obstructions to start this folic acid to all women. Yes, now the trend is to give folic acid to women, yes. Thank you, sir. And we had, by the
57:33
way, we had that paper published under, if you want, I can send you the
57:41
link for meningomyosceals in here in Soleimania. Yes, please.
57:46
Any other questions from our colleagues? I said, How come I say inshallah and say, 'Here's a huge - ' Sorry, shall I say inshallah? Yes, yes, you can say inshallah. The problem is never.
58:02
inshallah. I would like to hear really from our wonderful female ladies. The lady is
58:13
Zainab, Hiba, Huda, Fatma. Just contribute, just ask a question if you want. Any question?
58:22
No,
58:24
there is nothing to be shy. Some questions may not be. You already know. Go ahead.
58:34
Hey, but do you hear me?
58:39
I have a question. If they gave the woman, when they are pregnant, did
58:47
that work? Any cases of pain do you still have the lowering pain or spine of the pita? That's a very good question. Yes,
58:60
yes. Aria, do you have an answer for that? Yes, sir. Actually, there is, there is no evidence based that the polygastin that just only in practice or just in literature that say that the
59:14
polygastin deficiency may contribute to the development of the Spina Dufida.
59:20
We, in our
59:22
paper, we found that this is a very interesting point. So many cases of those women who were with spina befida, they didn't take the fallic acid properly. So we started, yes, we started the
59:39
instructions to give fallic acid to the females of that age After that, I can see you to have something to ask.
59:52
Hi, professors, good to see you. Good afternoon to all and good morning to the other side,
1:00:03
as Dr. Ari said. Actually, I've listened to Dr. Ari and I feel proud about what he did in court this time. I just had to have this question about, as I'm a student from Baghdad,
1:00:16
the competition what they studied in the fifth decade right here. medical student at an university in Baghdad, if I'm
1:00:26
in a competition with another called the Stanley student, so how how the competition is and how can I accept and be in your surgical residency with you? A very practical question. Yes, thank you.
1:00:43
Can I answer? Of course. Yes, please. Thank you. Well, as the colleague, the Mayor said, we have the Iraqi board. We have an equation and according to your ability for the examination of
1:00:55
preliminary or when in production to neurosurgery,
1:01:05
the examination results, the your results in the college and this all the equation will will
1:01:13
be the sum of the degrees you have and the age. According to that, you'll be accepted. Good. Yes, I mean, now we
1:01:26
didn't
1:01:28
have any difference from North and South. I was from North and one accepted in Baghdad and was trained in Baghdad with my colleagues. And we have, as I said, we have so many colleagues from other
1:01:44
sites, from Mosul, from Kirkuk, from Baghdad, they trained from Ramadi, from Ambar, they trained here in Slovenia, and you are welcome. And as the talk, let me say there's an equation you
1:01:60
should be accepted or not. If you don't mind, I have one question. Thank you, please. If you don't mind. About the answer to Dr. Habbe, the lady who asked about the fluency, I see.
1:02:14
Although Dr. Lazaref know more about it, because the topic we teach at UCLA together, the study was done in Canada, and it showed that the folic acid decreases the change of the neural tube defect,
1:02:28
and it was published in New England, you know, medicine years ago. Either you will check on the New England, or I'm sure Lazaref has more experience in that Yeah, Ali, because I'm sorry to
1:02:42
interrupt, there is an article in this issue of the New England in today's issue by Berma Niskandar from, and they are saying folic acid is the answer, but it's not all the answer.
1:02:58
Yes, yes. They're saying careful with giving too much, but it's in today's, today, today means today.
1:03:06
And also because it's the standard of care we give to all the pregnant women in America. That's right. All of them, they have to be on follic acid regularly. And also the CDC and FDA recommends
1:03:19
all the pregnant, all the ladies who may become pregnant should be on follic acid supplement in case they get pregnant. That's the standard up to today. Maybe today the article changes So just the
1:03:33
only thing to answer that lady's question. Take the wrong comment on that. I just want, I thought there was a young lady who had her hand up and I don't think we answered, did we answer her
1:03:45
question or did she ask her question? Yeah, about the follic acid or something else? No, I think after, after was another student. I'm sorry, I haven't seen that. Yeah, it's okay, I guess we
1:03:59
missed it So I think, uh. We'll talk about that a little bit about the future, but I think you've accomplished a tremendous amount. Absolutely. Can I ask? It's good to have competition too.
1:04:15
Yeah.
1:04:17
Do you have something? Yeah.
1:04:22
In short, I'm very thankful for Dr. Arsen for this nice presentation, orienting and giving us how effort or how come one can build capacity from A to Z, exactly. I appreciate that. I have a
1:04:38
question from my little experience on Vascular because I know Dr. I think Dr. Amman Jali is, I think he's the only
1:04:50
one from Iraq that spent six months with the Johar Herniz Nimi And yeah, I think he's very well trained so. with with all the capacity that you have. I'm definitely asking for the future, but I'm
1:05:06
comparing that. Is it the same thing that and Baghdad and all the other government if you have a rapture aneurysm? Actually, we don't have emergent treatment on the same day on the governmental
1:05:20
hospital. Is that the same state with the Soleimani? Yes, yes. Still, we know that
1:05:27
we try to have aneur
1:05:30
in the government hospital, but actually in the far of mythical city, which is the private one, all the equipments and the students is there, and I think you came there one time. I think so. You
1:05:47
came there. And also the equipments and the structures. Yeah, I upright my first aneurysm ever in Faroq, medical city. I know it's very well equipped. But the question is that you might point
1:06:03
there for that for our people that if anybody have a subragmati homogeneous now and back that he can have a treatment in
1:06:12
some way or another but the typical emergency treatment within the first first day or the first three days is not there is not there in the system yet so it's not here yeah yeah still still yet the
1:06:28
same situation here but we started as I said we started vascular surgery we started functional one of the colleagues started functional epilepsy surgery and one of our colleagues is now he's
1:06:42
interested in the pediatric neurosurgery two to three of us interested in spine And, we are,
1:06:53
we are, we are, we are, we are. trying to give the step for the subspecialty in the future. Yeah, congratulations. Actually, we are proud of you, sir. No, I'm sorry, my apologies for the
1:07:06
young lady who raised her hand. I didn't see her. She's ready now to ask the question. Tabarik, if you have a question or you have the same question in mind, you can ask now. Tabarik, so, yeah,
1:07:21
I think - Hi, hi, Dexter Oh, there she is. My apologies for not knowing that you raised your hand. It
1:07:30
was not good.
1:07:33
I want to ask Mr. Summer and Mr. Abdraneer about me as a female medical student. I want to be a part of medical research and neurosurgery. So what's the chances on how you support medical students,
1:07:51
female medical students on. Thank you.
1:07:57
Dr. Ablevier.
1:08:04
Yes, yes,
1:08:08
yes. Are you a medical board student Victor? No, she's medical school, medical school,
1:08:18
yes, you know that the board is not BHD and
1:08:25
we are not academic,
1:08:30
we are not academic board
1:08:35
The country such as USA, medical students in medical school can't have a chance to observe how, how, how could the medical thesis and medical research be done So I was asked if I can observe and
1:08:53
argue about not write a research as a whole. You know that in Iraq.
1:09:02
medical college they have the degree of master and PhD
1:09:10
for basics and all the clinical branches they have no master and PhD they have board and the board is different from even their their thesis is a thesis different from PhD their
1:09:37
research is very practical this is different and in countries they have
1:09:43
BHD,
1:09:46
MD, BHD and they have training for surgery and they have research and to give you and the BHD and
1:09:56
MD who are only give our our our certification and our training is not academic. Yeah, Summer, do you have anything to add? Yeah, actually from a lower profile point, I know Dr. Prof. Abdramer
1:10:13
answering this on the official research, but from a low profile position, let's say, that we are doing this for medical students to involve them in our research. It's a, let's say, a general
1:10:29
research related to neurosurgery, related to education, but definitely it's not in the, let's say, and it's not as part of the official academic pathway as Dr. Abdramer described, but for the
1:10:45
future generation, this may find these courses and workshops. It's not what we are doing alone. There is also another
1:10:57
people make students more and more involved in research, and yeah, we will definitely include you. I have something to add, Tabarek. You may go to the basic sciences research labs in the
1:11:12
neurophysiology and physiology in general or anatomy, and we did a lot of work in that department to the basic research work. So if you show your interest to the professors of physiology, I'm sure
1:11:27
they will involve you with some projects doing that masters. You can help masters students or PhD students, and then you get acquainted with the research spirit. If there is no more questions, I'm
1:11:42
going to move to our last distinguished speakers.
1:11:54
This is the 16th SI and SI Digital Bagdad neurosurgery online meeting held on August 7th, 2022. The meeting originator and coordinator is Samer Haus.
1:12:08
Professor Yasser M. Hamandi of the Department of Neurosurgery of the L. Lorraine College of Medicine, College of Medicine and Bagdad Iraq. We'll talk about the status of neurosurgery in Bagdad The
1:12:22
experience, the Gamma Knife experience across all of Iraq
1:12:35
The lecture is 30 minutes, the discussion is 15 minutes, over a hundred attendees from 18 countries participated in this conference.
1:12:46
Who is the professor of neurosurgery at the
1:12:51
Nahrein University. He graduated from medical school, 1997, and he got his board 2005. And then he, well, he, he got the position of the assistant, scientific assistant for the total Iraqi
1:13:11
board, the whole Iraqi board specialty. And then he is the chief editor of the scientific journal of the Iraqi board in general, not only your research, the whole board of your research. He is
1:13:25
going to tell us about his experience, his leading experience and unique experience in Gamma Knife and Iraq Professor Yasser.
1:13:37
Assalaamu alaykum firstly I want to thank my teacher Prof Abduhadeh Khaledi and my colleague Samir for their invitation for this nice meeting and secondly it's I am honored to be to talk in front of
1:13:54
my teachers and my colleagues and
1:13:59
very nominated international neurosurgeons.
1:14:05
My talk is about the Gamma Knife experience in Iraq.
1:14:13
We have five centers in Iraq, we have Sudhirwittri, neuroscience hospital center, we have in Baghdad and we have a touch private center in Baghdad and there is a few near future unit in the medical
1:14:28
city in Baghdad also. We have two established center in Basran, the north and the south of Iraq and we have a new established center in the, in
1:14:42
Erbil, in the north of Iraq.
1:14:45
The first center with, the
1:14:51
Saudi-wittri government center established firstly
1:14:57
in 2001 but because of the situation of the war, we don't, we can't work,
1:15:04
starting work until
1:15:07
2016. We changed the version of the unit. and starting the work in the beginning of 2016. The version was perfection. Then before a few months upgraded to perfection plus.
1:15:25
We treat more than 5, 000 patients from
1:15:34
2016 to 2022 A target private hospital is the first icon version, which is the version came after the
1:15:46
perfection, working in started
1:15:51
2021. And we treat more than 400 patients, treat it within the first eight months.
1:15:59
The indications regarding the ERB and the Basra Center start before four years, I think. and in Erbil before one year.
1:16:13
The version of Basra and Erbil is perfection.
1:16:19
We treat the indications that treated in our centers is with static brain tumors, single and multiple. We treat benign tumors, meningomas, monomers. We treat gliote tumors,
1:16:32
avial malformations, nasopharyngeal carcinoma, and pituitary adenoma functional and non-functional.
1:16:41
We treat the trigeminal neuralgia,
1:16:44
mucial temporal cyclorosis and clavarnomas.
1:16:53
The tumors are the indications of the gamma knife that we treated, we treat the deep-seated tumors, the focal brainstem tumors, not the diffused, we treat the recurrent tumors, residual tumors,
1:17:08
patients who are poor, candidate for surgery, and we treat the tumor bed after surgery, we do hypovisctomy for painful metastatic bone lesions, we do salvage treatment for aggressive glioma when
1:17:27
there is no benefit from the radiotherapy after surgery.
1:17:34
There is limitations in our centers, other functional indications like tremor, corpus colazatomy for epilepsy, OCD,
1:17:45
uveal melanoma are not doing till now. Because as you know, the.
1:17:50
When we talk about the OCD, it is the selection of the psychiatrist. And also for
1:17:60
the who can go for corpus cholazotomy, it is the decision of the neurologist. And also for the UV-L melanoma and glaucoma, depending on the selection of the ophthalmologist. And now the UV-L
1:18:16
melanoma, coming for UV-L melanoma,
1:18:22
can save the
1:18:25
eye from extraction can save the eye from extraction
1:18:30
These are the two versions, the Perfection and the Icon. The Perfection is a frame based, while the Icon is a frame and a mask based.
1:18:49
The icon
1:18:51
has CBCT, you see the arm built in the CT built in
1:19:00
the gamma knife unit and there is mask on the
1:19:07
frame, there is infrared camera, as you see in the photo, this infrared camera indicate
1:19:16
the infrared indications, indicators, and the tip of the noise and on the side of the head. And this camera protects and to prevent the movement of the head. And there is whenever there's a little
1:19:36
movement, the system will kick out the patient from the treatment and then reinstalling and then to restart the treatment. And this for the
1:19:51
protection of the important and vital structures of the brain. It is smarter software than the version 4 and ability to fractionate treatment. In the previous version, the perfection version, we
1:20:10
can do only single session But in
1:20:15
the icon, we can do hyperfractionation. Hyperfractionation means that we fractionate the same session
1:20:24
into three or four sessions with successive days. This is important to decrease the side effect of the radiation, of the gamma knife, of the gamma arrays, and more potent and more better outcome
1:20:44
outcome on the tumor treatment. and there is flexibility to treat patients with previous cranial surgery to use non-vasives to
1:20:57
attack the procedure. In this version, we can do the frame base for some selected cases for functional like trigeminal or pituitary, which is the tumor that you are near the optic nerve or when the
1:21:18
tumor on the brain stem, we don't use the mask because there is lateral movement in the
1:21:28
mask and we don't need that for these indications. But sometimes when there is the patient
1:21:40
needs hypofractionation or there's many previous cranial surgeries and there's no place for the for the screws, we do the mask which cannot be done with the previous version. And there is a safety
1:21:57
features as I talked before, that camera and these indicators, safety features that prevent any wrong
1:22:09
targeting due to the movement
1:22:13
As you know, these photos, the
1:22:19
indicators of the nose and on the side of the head. The limitation of the mask, when the patient is unstable or uncomfortable, we don't do the mask because of the movement. When the patient is
1:22:36
obese, the indicators not appear for the camera And for the long treatment we don't prefer to do a mask. because like in the functional
1:22:53
for the OCD, for the corpus callizotomy, the procedure may last for five hours. So we don't use the mask. For the lesions that need 70 or 100 gamma angle, we use different angles in the treatment.
1:23:12
We have 90 degree angle and the angle, we
1:23:16
mean, when we talk about the angle, the angle of the neck to the head. 90 degree, it is the standard. And
1:23:28
the 70 is extended neck and the 100 is flexed neck. And this cannot be done
1:23:39
for the mask. And these angles used in the frontal and the two frontal and two occipital. lesions. Sometimes in the trigeminal neurology, it's better to 110
1:23:56
angle to reach the
1:24:00
target. And this cannot be done with the mask.
1:24:05
This is some examples and photos for the treatment. This is a schwannoma. You see the photo before, this is before the treatment. And after six months, you see the central crosses. And after one
1:24:23
year, it's more better outcome. And this is
1:24:32
after six months only.
1:24:36
And this is another
1:24:38
picture for the schwannoma also. This is before and after six months
1:24:44
This case for the focal brainstem lesions, you see, after six months there is this appearance of the tumour.
1:24:56
This is a metastatic CA breast, this is
1:24:59
for the gamma knife, and this after six months. And it's very good outcome regarding this metastatic tumours. And we see the result after one or two months from the session.
1:25:17
And I think Dr. Abdenumir has the case with five or seven lesions,
1:25:25
more than half of them disappeared after two months. Perfect.
1:25:31
We have this is the case of meningioma. You see the
1:25:36
results also after six months. This is
1:25:42
another thalamic tumour.
1:25:47
before and after the six months, thank you.
1:25:55
Thank you so much, Professor. Thank you. Yes, sir, for the very impressive work and results. I'm really impressed with the numbers which you have done with 5, 000 cases and then 800 cases
1:26:09
within eight months. That's really wonderful. So we are building up an experience which is probably unique, I think, with this massive number and with your eagerness and the communication with
1:26:22
other centers in the world because you've been to many centers in Europe and outside Europe for this training. Thank you, sir. Any question? Dr. Osman? Yes, I have a question. Yes, sir, that
1:26:31
was very, very impressive. Do you do a biopsy to establish the diagnosis
1:26:46
do all your treatments, like the metastasis I saw, and that would look like in a schwannoma and so forth. Did you do biopsies to know, should we share what you're up for, what you're trading?
1:27:01
Regarding the guidelines, sir, we do the biopsy only for the glioma. You know, if it's high grade or low grade glioma because the high grade glioma, we shift the patient to radiotherapy, but for
1:27:15
the low grade glioma, we do galvanize. But other religions we don't do biopsy with depending on the
1:27:25
MRI results. And we send the patient for more than radiologists to confirm the diagnosis. Regarding the metastatic tumors, we depending on the diagnosis of the primary lesion because most of the
1:27:42
patients referred for us primarily, say, breasts have previous surgery in the breast, or they have thoracascope for the CA lung or another surgery outside the brain.
1:27:57
Yeah.
1:27:60
This is
1:28:03
for the cases that treated none, which have not doing surgery before, but we treat the residual tumors and recurrent residual tumors with a known
1:28:15
pathology.
1:28:18
I'm sure what you're doing is being done elsewhere in the world. I'm not sure I agree with that, but I remember reporting on a case in which it was a doctor whose wife had breast cancer and had a
1:28:31
lesion in the brain. He thought it was a metastasis and didn't treat it and the lady died and it was
1:28:39
a meningioma And so I think what we're doing in the literature is full of. information that if we rely on a radiological diagnosis, that it's nowhere 100 as
1:28:54
accurate as a pathology diagnosis. So it's obvious that
1:29:01
all over the world, not just what you're doing, but all over the world, if people are doing this, it's going to be a practice which will not be 100 accurate.
1:29:13
Yes,
1:29:15
we are talking about multiple lesions when it is a single solitary lesion or solitary lesion, and when the surgeon can go through. So the surgery can be done if we can't do biopsy for the meningoma,
1:29:30
so why we don't remove it? But I'm talking about the cases that cannot be considered, cannot be done, or it is deeply appreciated, it will mark more lesions. Okay, I understand. Thank you very
1:29:45
much. Very, very good work.
1:29:48
Yeah, Dr. Yasser, thank you very much for this presentation. The Caronniska Institute donated the first gamma night by Dr. Luxen to UCLA,
1:29:60
and I was lucky to do the research on that. We had eye melanoma, rabbit eye melanoma model that I did around 120 rabbit eye melanoma treatment, and we showed that when UV on melanoma is their gamma
1:30:16
knife is their best treatment. We published four or five paper on that, and it's on there with Dr. Rand who was running the gamma knife, and led me to do the research on that. It is published,
1:30:29
but it's really working very well. Those who work with gamma knife, they believe on it, and that's one of them, one of those believer also. Thank you very much to my share. Thank you One. of
1:30:39
our
1:30:42
colleagues, Victoria, is now the most senior Gamma Knife graduate surgeons working in Kaloneska. Yes, we talk about that, but as I told you, sir, it's this election of the ophthalmologist. Now,
1:31:02
till now,
1:31:05
many of the surgeons, even neurosurgeons, they don't believe in Gamma Knife.
1:31:12
So, what about the ophthalmologist or the neurologist or the psychiatrist? So, these are limitations, yes. It needs more awareness about the function and the work of the Gamma Knife. One of the
1:31:31
cases that we did on the rabbit eye, it was done, the pathology was done, and Dr Ren bent one of terminology conference with the
1:31:39
slides of all these cases. at our neuropathologist, Dr. Jan Baran did all the study. There was no evidence of the recurrence when it was done. So there is often monologies for shock to see such a
1:31:47
good result of the Gamma knife for
1:31:55
UVL menanoma. But thank you very much to bring this to the attention of the audience. Thank you, sir. Any other question, please?
1:32:10
Our young doctors, students who are interested in mathematics and physics, any question?
1:32:20
Come on. There must be one.
1:32:25
Can I ask one question? Do you do for thalomatomy also? Because they used to do it for thalomatomy at the first place in
1:32:33
Caroninska, Dr. Lexa was using. Do you do that over there? Or do you just go with the DBS? Because Dr. Heba,
1:32:41
last month on the session, she's doing a great job. I don't know if she's on the audience or no But that's one of the main indications that Dr. Lexa made this gamma knife, and he got a Nobel Prize
1:32:54
for that in 1974.
1:32:59
I think there are two people with questions, how do you find them out? I don't see them.
1:33:09
For questions, so. Leave it, please go ahead, leave it. Yes, hi, doctors. First of all, thank you so much for this amazing presentation about Kalmanife. I think it's very interesting to know
1:33:21
all of these cases and their different - No, excuse me, don't interrupt you. Can you say, tell us who you are, where we are? Oh, okay. I am a medical student. I'm a fifth year medical student
1:33:34
in the University of Baghdad, Iraq. Wonderful I'm very interested in this topic, as I said, the different cases were very, very, very interesting to see you. My question is, does the gamma
1:33:47
knife and does procedures have any effect on the cranial nerves?
1:33:53
Many of
1:33:57
the cranial nerves can be protected. All the cranial nerves or all the vital structures can be protected by risk.
1:34:09
shielding is a software found in our system and
1:34:19
when we are talking about the risk of the cranial nerves, we are talking about the first about the tharmic and the optic chasm
1:34:33
and we can
1:34:36
can deserve 12 to 15 gray without any
1:34:42
risk and we measure the risk and we measure the gamma rays that are reaching the vital structures before approval of the treatment. So, we are
1:34:57
not allowing to give more than the
1:35:03
mentioned gray with the guidelines. But the problem is that when we hitting the tumors, the first month or first two months, there is a odema on the tumor. And the odema may make a pressure on
1:35:22
these vital structures. And we gave a measure to prevent that. And most of the side effects is a reversible side effects. Great Fatima,
1:35:39
Fatima and Dixua.
1:35:43
And good evening, everyone. Fatima, four-year medical students university about that. First of all, thank you, Professor of Disciplinary Presentation, I have my question. What's the most
1:35:57
common cases you deal with in Iraq and what's the impact of Iraq experience on GammaNav and neurosurgeon here?
1:36:06
Most of the cases, not only in Iraq, but I think in the world, it's the men in Joma. And there's some countries have the metastases and the vast color more formations, more that I think in Japan.
1:36:22
But in Iraq, the most is the men in Joma, the men in Joma. And secondly, the glial tumors and the metastatic tumors And what about the question, sorry?
1:36:37
What's the impact of Iraqi experience on Joma knife in your surgeon, yeah? We
1:36:45
have six years experience. We have, we treat more than 6, 000 patients. In Baghdad, I think you're about 500 or more ambassador and maybe a hundred of case in Arabic. Okay Thank you. Thank you.
1:37:06
Thank you, Fatima. Mohammad Amara, please. Yes, thank you everybody for presenting. My name is Mohammad Amara. I'm a first speaker, medical student. I just wanted to ask,
1:37:21
could a technique like Gamma-Nyoy replace DBS and if so, would it improve the area of neurosabernetics? The
1:37:34
Gamma-Nyoy, yes There is a treatment for trauma and the Parkinson disease and the
1:37:43
work of Gamma-Nyoy is ablation like that previous before the DBS. There was ablative surgery and the Gamma-Nyoy working as ablative surgery for the targets.
1:37:59
And I believe in the near future, the surgery, all the surgeries,
1:38:06
only the neurosurgery will be minimal and invasive and maybe in the future there is not invasive surgeries. So I think that will be instead of the DBS in the near future. Thank you. Thank you very
1:38:21
much. We have two more Heba.
1:38:34
Just make it quick, please, yeah. Go ahead.
1:38:43
Go ahead. Okay. Hello, thank you for the interesting topic. I wanted to ask about the safety of this gamma and how many sessions it needs usually. And does it make a full recovery?
1:39:01
Thank you. Regarding the sessions, we treat the tumor or the target only one time Sometimes we need to repeat the treatment after one year or more than one year.
1:39:15
Regarding the safety, it's a safe maneuver.
1:39:19
We do it with the local and seizure. The effect of the gamma is not more than one millimeter from the target And we do safety measures, we plan the risk area, and we told the, the gamma. you at
1:39:42
the gamma knife don't go to that risk area. And
1:39:50
I think it's a very good outcome. There's no perfect outcome
1:39:57
for every maneuver, but I think it is a good outcome for most of
1:40:06
the indications. And the indications is upgrading
1:40:12
for years, not that indications today. And there is many regions now, not yet approved by FDA approval, but
1:40:26
they are working to many
1:40:32
more than indications than I mentioned before. Thank you. Thank you for the answer. Well, at the end of the first session,
1:40:42
Professor Abdul Amir and the Professor Abdul Amir and the answer for the wonderful presentation and enlightening us of what you are doing and your struggle and success. Thank you so much. Now I give
1:40:58
the session to Samar to take over
1:41:04
please. Thank you, Professor, for the presentation. Thank you, Dr Yes, sir, for this, I think, systematic, well-informed patient data. And I think it's definitely a building experience that
1:41:17
we are all proud of. Thank you for participation. I will start, I think now, the good thing that we are catching with the time, thank you, Dr. Khalil for managing that part of the meeting.
1:41:34
It's good. And I think we have one of the
1:41:40
students have a question. We can give this question later at the end of the session. So, and now.
1:41:48
This is the 16th, SI and SI digital bag to have neurosurgery online meeting held in August 7th, 2022.
1:41:58
The meeting originated and coordinated with Samarhaas
1:42:10
This is a section for young neurosurgeons and student speakers. There will be three short presentations
1:42:22
The first presentation will be by Salah Mary, senior neurosurgery resident at the Iraqi Board of Neurosurgery Neurosciences Hospital. And by dad, he will talk about the complications and outcomes
1:42:34
associated with the clipping of ruptured, intracranial, anterior circulation, aneurysms, a single center experience. Now we have
1:42:48
three short presentations One from a resident and two from medical student interested in neurosurgery. Then we have QA and we end
1:43:01
the session with a
1:43:04
presentation that we are eager for, which is from Dr. James Osman about the future of neurosurgery. And so I would like to introduce Sala, who's uh. and.
1:43:19
I'm a final year board resident Iraqi board and he's very brilliant and Yassala you
1:43:29
can share your presentation and please introduce yourself more and you have the stage.
1:43:38
Thank you for
1:43:41
all.
1:43:44
My presentation is complications and outconstrated with the ruptured
1:43:51
clipping of ruptured intercuter circulation aneurysm. Can you make a full sickening please? Yes. The background about the aneurysm is derived from the anterior cerebral circulation approximately 85
1:44:07
of all intracranial aneurysms and due to an interrogated low distribution within the caught up it's just them. And it's a close anatomical connection to the surrounding brain-perincoma and the
1:44:22
cranial nerves. These aneurysms may be difficult to treat even more so following rupture. While the endovascular techniques, such as the pageable coils and flow-diverting devices have improved
1:44:35
patient outcomes and established themselves as an attractive baseline treatment option for ruptured intracranial aneurysms, they remain inaccessible and many developing cancers.
1:44:49
The study was introspective with sharp analysis performed on 81 cases who underwent microsurgical clipping of ruptured aneurysm and tear circulation in period of October 2019 to October 2021. The
1:45:05
study was conducted at the neurosurgery teaching hospital in Baghdad in Iraq, based on
1:45:13
pre-operative information and operative data and post-operative data. informations. Regarding pre-operative information, patient demographics, comorbidities, clinical manifestations, CT findings,
1:45:27
aneurysm characteristics, regarding operative data, the time from meeting day to the operation day, the surgical approach used whether theronal or suborbital versus internal hemispheric approach,
1:45:43
whether laminative mouse or lilyquist membrane, demonstration, temporary clipping, intraoperative rupture, occurrence, and intraoperative monitoring, intraoperative blood loss and need for any
1:45:52
blood transfusion, papa vireenus, intraoperative and gel sectors resection. The postoperative data, including clinical data, less co-coma screening, positive spasm, weakness, seizure, stroke,
1:45:52
clinical palsy, and dyspasia And.
1:46:16
image finding post-operatively, whether ICH,
1:46:21
IVH, or residual neck neurism on CT scan, CT angiosaurib, hydrokiphalos, CSF
1:46:29
diversion devices, extended ventricular drain or ventricular tretonial shunt ventilator support and the
1:46:39
trichostomy, and formation on other local and systemic complications, such as occurrence of internal infection, want infection, VBT, and pulmonary embolism, chest infection. The follow-up data
1:46:53
question focused on the following, Glasgow Outcome School used discharge and six months interval, and from the last follow-up, and also a residual next stage of hydrokiphalos. All these
1:47:04
informations were classified, related, and analyzed. The aim of our study is to closely Thank you very much. procedure-related complications and post-operative complications and outcomes, and to
1:47:20
look for links between these outcome measures and various patient and then using specific features. The outcome measures
1:47:29
were regarding the seizure at discharge 99 and at the follow-off
1:47:37
13, regarding weakness, 235 and 39 at follow-off, regarding hydraulic if I was 37 at discharge and 13 at follow-off. You can ask how it comes to have a 5-day recovery where 827 at discharge is
1:48:00
increasing to 934 at follow-off. Moderate disability, 99 at discharge and at follow-off, 53. Severe disability, 12. discharge and 13 percent follow-up. Persistent legislative state was
1:48:22
zero and that was five cases.
1:48:27
The following factors, straighted with poor outcome, the glass cloud comes for a discharge and lost a lot. The weakness with p-value less than 0003 is significant factor and post-operative versus
1:48:37
person with p-value less than 0003 and need for ventrator and take systems support with p-value less than 0001 and pulmonary embolism with p-value less than 0002. The final outcome on our study
1:48:43
of
1:49:06
patient with the clipping of certain variations was.
1:49:12
94 alive and 6 good. Thank you.
1:49:21
Thank you. Thank you, Sare, for your presentation.
1:49:28
You can stop the sharing and let's have a comment and the question. Dr. Osman, if you have a comment on. Yeah, I think that this is a very nice, well-submarized study of your experience in
1:49:43
intercranial aneurysms. I think it's a very good example of how you must follow what you do. And record it in detail so that you can always try to do better. I think doctors and neurosurgeons have
1:49:60
a problem in that they look at the data.
1:50:05
You showed slides where you had 94 or 96 recovery people did well, which is excellent. From my point of view, if I'm a patient and I have been a patient, I don't want to be in the 4.
1:50:21
in any of, neither of any of you. And so I've seen presentations at meetings where people say, well, it's expected and we should have a 20 complication rate. If I buy a car in a manufacturer says
1:50:36
there's a 20 complication rate, I wouldn't buy it.
1:50:41
And there's no reason in the world why neurosurgeons or doctors should be satisfied with that kind of an explanation Okay, your job is to do error-free surgery, error-free treatment. And I think
1:50:54
what you show there was outstanding results. And only what it tells me is your desire to do better. To find out the areas where you need
1:51:04
to do better. And because you have to remember you're looking at it from if you were the patient and you walked into the doctor's office and he said you have a 95 chance of survival
1:51:21
I'd be grateful, I've been told that,
1:51:25
what's my 5?
1:51:29
So the goal is to make it zero.
1:51:32
I think that was a very nice shot, I appreciate it.
1:51:37
Thank you, Dr. Osman, if any of the participants have a question, can I raise your hand? Dr. Ali, do you have anything? Yes, Dr. Osman, not only the youth Karnofsky's evaluation for the
1:51:37
performance? And as far as I know, in most of the publication, maybe they have
1:51:47
to use
1:51:57
that one. That's one of the most
1:52:00
prevalent that they use. If you would give police comment on that, you can comment on that one. Karnofsky's score for the students is a score which
1:52:11
evaluates how impaired you are, or how functioning you are.
1:52:17
I think it's another measure, it's okay Uh.
1:52:22
I think that's okay. I think the more information you can put down the better. The goal is to achieve excellence.
1:52:31
That's what the patient wants. That's what I want. Yeah, but regarding Kanofsky, we used it in the '70s in England for assessment of the brain tumor research which we did with the European Cancer
1:52:45
Institute studying their BCNU and CCNU on Procarbazine So it was a must, we have to follow Kanofsky's index to see before and after treatment what happens.
1:52:57
Yeah. In publication, they used to publication, still they use Kanofsky's scales, so that's what I want. Even for aneurysm, that will be great.
1:53:09
For all the performance which happens, damage happens. I don't know, I'm not up to date on that subject, but that's one thing I see in the publication Maybe Dr. Sammy has some. Yeah. You have
1:53:20
to understand in the paper that was presented, and this is not a criticism, 'cause I know what Sam or has done, and I've been in this situation. You were reporting on the people who survived to be
1:53:34
able to go to surgery.
1:53:39
I know from the circumstances you have, I've been, I've done this myself in hospitals in this country I did this, we initiated early surgery as the Japanese did for aneurysms. I watched people
1:53:54
rupture hemorrhage and die in the ward because at that time, people thought you can't operate on a patient with vasospasm, that's not true.
1:54:03
And so you have to be careful that the data that you're getting doesn't apply to all aneurysms. It applies to those people who survived and were able to get to pay to the hospital and we're able to
1:54:16
wait. enough so they could go to the operating room and get treated, and in that selection of patients, the results that you presented are very, very, very good.
1:54:28
We have to remember if we're looking and I'm going to tell you about that in my talk a little bit later. In the totality of patients who come 50 of patients with subarachnoid hemorrhage die,
1:54:41
that's what we've got to work on I'll tell you about that in my talk.
1:54:45
Thank you. Samara, I have a question. Thank you, Salah, for your good presentation and the advice to you for sick to the time. What are the reasons for these mortalities as 6 62 something
1:54:59
percent of mortality? Can you tell us something about
1:55:04
them? This is mostly due to
1:55:08
facilities Were they operated on? Yes. All of them did due to Yani.
1:55:24
Thank you.
1:55:26
Thank you. Thank you, Dr. Halle for a question. I will go through Dr. Ali comment, which is very interesting. Actually, the outcome measure is different. For a researcher, I think he should
1:55:40
see the big series with the same topic, then he's obligated to use the same outcome measure just to compare at the end. But yeah, I think you are right. Maybe Karnofsky has 10 score as compared to
1:55:56
Glasgow outcome of five, even some news MRIS for AVMs. And I think I will start this as a study to compare which one is better for AVM or an aneurysm. Thank you for the idea. I will give you
1:56:12
feedback later. And yeah, I should give the credit for Salah because this is, I think I'm involved as part of the series is our because it has this idea and when I see now the result, I think with
1:56:27
the supervisor, Dr. Yasar Hamandi, they appreciate their work and how they put it in the best way possible. And yeah, I think that's the credit for Salah to go through this tough topic to choose
1:56:44
And yeah, going through complication is lessons. And I think for the question about the outcome from Dr. Khaledi, I already read part of this article. I think
1:57:03
Salah answered that. And it's also maybe related to the GCS at presentation as it's described. So thank you, thank you Salah for the presentation I think it's it's it's It's complete the full
1:57:16
picture
1:57:21
The second talk will be given by Octom O al-Kafaji of the Department of Surgery, the College of Medicine, the University of Baghdad,
1:57:32
on the impact of the neurosurgery mentorship in which he participated. And now I want to introduce Aktham, Aktham was a medical student, sorry, and
1:57:48
he's just graduated from medical school in Baghdad, and he's one of those in the first trunk in the college, and
1:58:00
he
1:58:04
will
1:58:12
present his experience till now, and the have you, yeah stage, Aktham. Thank you, Dr. Summer Thank you, professors, esteemed colleagues, and residents, and everyone who's written.
1:58:20
the opportunity to present my experience with
1:58:27
you. So as Dr. Sammer said, I graduated from the Dad University School of Medicine in 2021. And I was fortunate enough to be an alumnus of the sixth Haas Neurosurgery Mentorship Program in 2019.
1:58:45
So today I'd like to talk to you about how that program helped kickstart a potential career for me and my colleagues in that mentorship in neurosurgery and in medicine in general.
1:58:58
I hate to talk about myself, so I'm sorry. You have to bear with me. But this is about navigating life and navigating our medical lives post the Haas Neurosurgery Mentorship Program. So here's a
1:59:12
picture of me and my colleagues during the mentorship in 2019 I just want to point out here that's every single one of us. found his own pathway, whether it be neurosurgery, neurology,
1:59:26
neuroradiology, medical education, and other medical fields that we were introduced to through the mentorship program. So the mentorship started in late 2019 and had a great focus on clinical
1:59:44
exposure bridging the gap between theory and practice for us, for us. As many of my colleagues know, this is kind of hard to come by in classical medical education through medical school in Iraq.
1:59:59
So it was very unfortunate, very fortunate for us to be able to attend web labs, simulations, and even chances to observe and scrubbing on complex neurosurgical procedures. And to be honest, we
2:00:14
took these experiences, we took these connections that we made through the mentorship. And we built upon them to get more and more clinical exposure. So that me and a lot of my colleagues who were
2:00:27
with me had the chance and the privilege to attend hundreds of hours in neurosurgical OR to attend neuro ICU, to be in the wards, to see patients, talk to them, to have shifts in neurosurgical
2:00:44
emergency rooms, even to be involved and to see, be involved in cath-suite and in geographic procedures, neuro-interventional procedures. So that was in terms of the clinical exposure. The other
2:01:01
big part of the mentorship program focused on education and specifically peer education was a big thing for our mentorship program
2:01:12
It had a focus on giving us the confidence to present in front of an audience whether it be large or small. And we took that and went out there. Some of us, this helped them kickstart their career
2:01:24
in peer education, in medical education. Some gave talks on neurosurgical TV. Others, including me, got the great opportunity to present on SNI meetings in front of such esteemed audience, such
2:01:38
as this one. So it was a really big opportunity to get us past the stage fright that a lot of medical students have and present on an international level, which was something we had never
2:01:54
participated in before. And you can see here, this is my colleague, so much. She was a first-year medical student. So she was at least three, four years behind every other participant in the
2:02:05
mentorship, and here she's explaining the Venus system to us. So peer education was a big thing in our mentorship program. And then comes research, which is, I think like the biggest part of of
2:02:17
the law's neurosurgery mentorship program and something that Dr. Haas has strongly instilled in each and every one of us, a focus on the scientific process, a focus on publishing new ideas and
2:02:31
making your voice heard in the world, which is something that also Professor Osman emphasizes on a
2:02:37
lot. So the story starts like this. The topic of this research is very rare. It's not something that we see a lot in clinical practice, but we were fortunate or unfortunate, I don't know enough,
2:02:55
to encounter a case of a patient who presented to the neurosurgical teaching hospital with classical features of subarachnoid hemorrhage. We did a CT angiogram, which you can see here, and the CT
2:03:09
angiogram showed an ACOM aneurysm, secular aneurysm in the anterior communicating artery, but it showed something else, surprising to us, which was that there was no internal carotid artery on one
2:03:22
of the sites. It was obliterated. It was a plastic internal carotid artery, which was later confirmed by angiography. OK. So as you saw in the CTNG, he had an e-colonurism, and the ICA was
2:03:39
missing. Now, one thing that we usually do in open clipping of aneurysms is that we need to achieve proximal control, proximal and distal controls. And sometimes we have to do temporary clipping
2:03:54
to achieve that control, especially in cases that the aneurysm ruptures intraoperatively, or the flow is very high, and we need to control it to be able to clip it safely. So that is something we
2:04:06
have to do in
2:04:09
aneurysm surgery. And usually in e-colonurgery, we can do that safely because there is a collateral network because the circle of bliss does its job. and the patient gets blood from the other
2:04:20
internal carotid artery. In our case, we had a problem because
2:04:27
our patient did not have an internal carotid artery, okay, on one side. This was absent. So this presents a problem for my younger colleagues. I'm sorry for the professors, but I have to explain
2:04:38
this for the younger colleagues. If you don't have an internal carotid artery on this side, then all the blood to this side of the brain is coming from the contralateral internal carotid artery or
2:04:49
from the posterior circulation. So it becomes kind of a problem if you have to temporarily clip this artery, which is the first segment of the anterior cerebral artery because there is no ICA here
2:05:03
and you clip this one, you are basically cutting off the blood supply through the a-comb that goes to the other side of the brain because it doesn't have an internal carotid artery. So this was a
2:05:13
major issue This was a problem for us. So what did we do? We went back to the literature. We tried to look at things from a new perspective. And we found two interesting things in the literature.
2:05:26
First off, we found that there are very few, if not at all literature, on the subject of internal carotid artery being absence with an anterior communicating artery aneurysm. We tried all our best
2:05:43
We found about 34, I think, case reports and technical notes on this particular condition being combined with an acolyne aneurysm. So we didn't have a lot of evidence to start off with. We had to
2:05:57
depend on anecdotal evidence, so to speak. And secondly, we found a wonderful classification by Dr. Lai, which classifies the patterns of anastomosis and collateral flow in the context of an
2:06:08
apoplastic internal carotid archery.
2:06:14
we saw that in something called a Li-type A, the
2:06:18
MCA gets its blood supply from the posterior circulation. In Li-type B, we found out that the anterior communicating artery provides, from the other contralateral site, provides the blood supply
2:06:32
to all of the brain on theipsilateral side that has no carotid artery. And so as such, as can be found in the full classification of Li So the task was simple. We looked at all the reported case
2:06:47
reports on this condition, in particular, in terms of their light classification. We modified it to just the ones that are relevant to econonurisms. And we proposed a treatment algorithm to clip,
2:07:02
as I said, to clip or not to clip the aneurysm, based on the risk of compromising the collateral flow to the part that has no internal carotid artery And that's it.
2:07:14
article, we just had to write it. The idea was complete. So it was written by me and my colleagues under the supervision of Dr. Summer. And lo and behold, it was published in SI. It was my
2:07:27
first neurosurgical article that I had contributed to to be published, and it was a very proud moment. And since then, I have had the great honor and opportunity to participate in over 10
2:07:39
neurosurgical papers with Dr. Ho's and his team. So that is something great for me.
2:07:48
At last, all the lessons I learned, how to share knowledge from Dr. Ho's, how to appreciate research, and how to be enthusiastic about it, all drove me and my colleagues to start a new project
2:08:01
by Statistics Central. Where we aim to share a passion for the scientific process with a wider audience, sharing knowledge and experience in the research in a modern way. and matching people with
2:08:14
mentors in different medical specialties, so they can all start and accomplish their aspirations to be young researchers, to be the physician scientist model.
2:08:26
That's all. Thank you all for listening to me and I hope my presentation was not to boring. Thank you very much.
2:08:35
Thank you. Thank you, Arthur. You can stop the share Yes. Thank you for this nice presentation. I am biased definitely with your achievement and proud of it. I will wait for comment from the
2:08:54
panel and the colleague of
2:08:57
anyone who have a comment. Do you have a comment after Osman? There is a comment from Musama. There is a question
2:09:09
Assume and introduce yourself first and please go. Sure. Hello, everyone. My name is Usaman De Lal, a four-tier medical student at RCSI behind so much work from for the presentation. And that
2:09:22
was really fascinated by the unilateral absence of the internal coronavirus.
2:09:27
My question is, like it's well known that the primary collateral pathway is from the alternate circulation through the AECOM and the EECOM. So what about the secondary collateral pathways for the
2:09:42
ophthalmic and
2:09:48
leptaminin-geal collaterals? Were they present? Yeah, thank you for your question, Asama. The secondary collateral pathways were not really mentioned in the literature. We tried to look at it
2:09:53
from that perspective, and even looking at Dr. Ly's classification, it does not mention secondary collateral. It mentions some remnants of fetal pathways such as the trans cavernous pathway, but
2:10:07
there was no of secondary collateral because maybe they don't contribute as much. And we haven't seen it in our patient either. So yeah.
2:10:17
All right, thank you so much again. Your most book. Thank you, Osama. That's a brilliant question. Maybe you will. I'll just, I'll just make it. I could talk about this for a long time, I
2:10:29
won't. But the reason you didn't find much in the literature is because most people don't do four vessel angiograms.
2:10:37
And the literature is filled with that, which means it leaves you with only information about the anterior circulation and not the posterior circulation. So it was Samus' question is excellent. And
2:10:48
what I think you would find particularly if that occlusion is chronic, that there would be collateral circulation, which is what Samus' referring to, through the vertebral otters through the
2:10:58
posterior communicating arteries, probably even in the hemisphere. And even the carotid end-order rectumae trials that were done with randomized controlled studies the 1980s did not require. for
2:11:12
vessel angiograms, that's not a useful study, but major decisions were made on that basis. So unless you know all of the things you can about the circulation, it's very difficult to make a
2:11:25
conclusion. The second thing is the reason why you have aneurysms developing is because the flow patterns have been changed and the flow will contribute to aneurysm formation and you'll find that in
2:11:40
people who have absent carotid arteries. If it's an acute occlusion, which I doubt because it have been asymptomatic, it's probably chronic, my guess is there were colitis. So I think it's a very
2:11:52
good outcome, it's very good. I enjoyed hearing about your experience. I think it reflects the experience of all the people there and you should continue to do what you're doing. Thank you, sir.
2:12:04
Much appreciate it Very, very impressive presentation, really, in all aspects, including your time.
2:12:14
Yeah, thank you. I'm very proud of this group which you have the Oz mentorship, really proud and it is an opening, opening a gate for braille and sound way of developing research and studying
2:12:34
medicine in the proper way and that will be hopefully to be an example for other specialties to follow
2:12:42
So thank you both. Thank you. That is the hope. Thank you, sir. Thank you, Professor. Thank you, Aktem. I should give the credit to Aktem. This paper, exactly, I give him the idea, the
2:12:52
case and receive it as it is. That's the first paper for him. So, you know, it's what they say that it's from the egg. It's there, the chicken is there. So, yeah, he's from the first writing
2:13:08
that he put, He's at the front level. And I'm really happy with the time that he spent. And I'm really more proud now that he has his project and he's advancing toward it. And he has the full
2:13:26
support from all of us. All the best, thank you, Aktem. And I will go rapidly to the next step. The last talk in the Young Neurosurgeon and Student Speaker section
2:13:39
We'll be given by Hanine A. Salla of the Department of Biology, College of Science in the Muston, Syria,
2:13:49
University in Baghdad, Iraq. Presenter will be Hanine. Hanine is a
2:13:59
student and she will take less than 10 minutes. I think around seven minutes also And from that, we will go to Dr. Osmond presentation and the question answer then. Yeah, honey, you can share
2:14:16
the screen and start your presentation. Thank you, Dr. Summer, everyone. My name is Hanyin and I'll tell you about my story with the house nurse surgery mentorship. I joined this mentorship in
2:14:28
2021, while I was a solo senior student. I think I have some poor connection.
2:14:36
We can hear it clear So it's not the beginning of any email that I sent to Dr. Sammer. He was very kind that he sent me his phone number to talk about it directly. So at the beginning of the
2:14:47
mentorship was intensive lectures of neuroimaging and neuroanatomy. They were very, very helpful. Another effective way of learning, I have found this mentorship was the student's feedback because
2:15:01
each student's after they attend the operations, they have to write
2:15:06
a description what the cases and they send. pictures and videos of MRI's and CT scans until my time came to attend. These are the students feedback and I don't know if you can see here. This is the
2:15:21
videos and the pictures they sent.
2:15:29
Okay, so I think that was very helpful to learn more even if you weren't there.
2:15:38
Until my time came to attend the operations was about after five months after I joined this mentorship. I attended these operations and also I have attended many diagnostic and therapeutic and
2:15:51
geographic character catheterizations. I'll tell you today about my favorite cases. The first one is the motor cartic cover novel. What's a 30-year-old male referred to the hospital go to two-month
2:16:03
history of focal seizures. This is the peer part of MRI, such Just our section shows a couple of normal deep to the. right, pre-central gyrus. And this is also a preoperative MRA. It shows the
2:16:17
relation between the cover norm and the cerebral vasculature. So the
2:16:23
intracellular dissection was done with the age of the entraural birth of ultras and everything or navigation to detect the exact location of the lesions so they can start the intracellular dissection,
2:16:32
the
2:16:35
intracellular dissection. And also the motor cortical mapping was done with the age of the
2:16:44
functional mapping and the intracellular physiological monitoring. As you can see here, this is the bipolar mode because most of these area was a facial motor area so they use the bipolar mode to
2:16:55
detect a lesser facial activity so they can start the intracellular dissection without causing any damages. That was integral part of this surgery,
2:17:09
the pre-central geroscovernoma is one of the most challenging operations because of the bleeding and the severe defects, but the outcome of this case was very successful and the team submitted a case
2:17:25
report about it a few weeks ago I'm very excited about it and I hope it will be published soon.
2:17:33
So my second favorite case was the Vibromosclar dysplasia was a 53-year-old near referred to the hospital to the history of Afrikaans transatlantic attacks with the upper left cilampionous. This is
2:17:46
the pre-operative angiography. For those who are not very familiar with the Vibromosclar dysplasia, it's a rare vascular disease that causes a regular cellular reproduction and causes this cause.
2:18:00
This is a regular deformed of the arterial wall, as you can see here. This is the right extracranial ICA with multiple synopses. The treatment of
2:18:11
choice for this case was the
2:18:14
extracranial intracranial bypass to improve the blood flow and to prevent any further strokes. This is the pre-operative T1 MRI.
2:18:26
It shows the CSF blood cleft extended from the frontal horn of the lateral ventricle to the sodium fission. This is also pre-operative T2 weighted MRI.
2:18:37
It shows the CSF blood cleft from a frontal region. So the last one is the recurrent glioblastoma. This one is my favorite for so many reasons. One of them is I actually assist in the operation.
2:18:52
This is me with the normal saline And this is with the bonaflep at the end.
2:18:59
So attend the operations is at different feelings and be in this close and be in part of the team as I use different feelings. I think it was outstanding experience. And also I was very stressed
2:19:12
because, you know, you don't wanna touch the surgeon and you don't wanna touch the microscope. You don't wanna do any damages, but it was outstanding experience.
2:19:24
So that was a bright description of the, what I have learned from the anatomy and brain imaging. I learned also some life skills, for example, the teamwork skills. So when you attend the
2:19:36
operations, you see there are four surgeons working on the same case and there are also residents and students all working on the same case and also not just that. And there are papers and there are
2:19:48
books, everything is a teamwork effort. I think this is a unique part of this mentorship.
2:19:55
everything is a teamwork efforts, and also I have learned many other skills like leadership, communication skills, networking, and so many other skills.
2:20:07
So I'll tell you that was a brief again description of the mentorship. I'll tell you a little bit about myself. My
2:20:20
name
2:20:45
is Fanny and Salah. I have graduated from the biology department, college of science. I am the only non-medical students in this mentorship, and I think I am the only one who attended the
2:20:45
surgeries in my country. I think mainly my interests came during my teenage years. I was fascinating and very inspired by Dr. David Eagleman ideas and Dr. Sergio Canaderas, the human machine
2:20:45
interactions, the idea of making a human more than humans I think that was fascinating. It shows that there is no limit of what we can achieve and there is no limit of what we can be as humans. I
2:20:59
think that what's got me hooked up with neuroscience. And I said, I want to become a neuroscientist. But unfortunately, I live in a country where we do not have a neuroscience departments. We do
2:21:11
not have a facilities to study the brain. But also, I was lucky enough to live in a country where we have someone like Dr. Summer with his unconditional support and his limitless opportunities.
2:21:24
I'm forever thankful for this opportunity, Dr. Summer.
2:21:30
So one thing I have learned about this mentorship is that I wanted to - I was mainly interested in science just because I was curious, and I wanted to know why and how things works. But attending
2:21:42
the operations and seeing the patients and their families, it's a very emotional experience, I must say. So basically we're not doing research because we're curious, we're doing research to help
2:21:54
people less suffer. This is all to create a better life. Currently, I am working to apply on a post-graduate school and I want to establish a neuroscience department here in Iraq. Dr. The current
2:22:10
situation with the market and the job, it's not a very wise decision, but I want to establish a clinical neuroscience research center because we have so many neurological conditions and this will be
2:22:24
very helpful to learn about these cases and maybe help them in the future.
2:22:31
Again, thank you Dr. Sammar and the team for this outstanding experience. I can't thank you enough for this. Thank you
2:22:43
Thank you, Hanin. Actually, the thanks is for you and what actually did nothing except just
2:22:51
support you and you're really not enough. Let's take a comment just I want to say that yeah honey it's different from us us the student before they go to medical school they go to biology two years
2:23:09
maybe then they go to medical school and Iraq it's different either you go to medical school directly from high school or it's not there so that's why her experience is different she's from biology
2:23:22
college by the way she's one of the first on her college as around people but has a specific interest that obligates us we cannot say anything except okay come on come on and try this is for medical
2:23:37
student but why not let's involve you and it was a nice experience to have you actually hanging and I we are pretty sure that you will excel in the future I will have be happy to have any comment from
2:23:51
the panel? Well, I'm really very, very impressed. Most impressed with Hanin and her courage and her dedication and her interest in neurosciences.
2:24:06
And thank you, Sam, again, for your mentorship, and for guidance for such wonderful young scientists and doctors Hanin, there is in Moustesh for Jirahat Jirahat Hospital, a good scientist who is
2:24:24
doing neurophysiology, and he is really deep down to earth with his science and ability. I would like you to meet with him, his name is Abden Nasser in the neurophysiology department, which is
2:24:38
part of the neurosciences or neurosurgical department at the Agira Heart.
2:24:44
I would love to meet him. Yeah, if we communicate, give me your email and I speak with him and I'm sure you'll find him very helpful and very inspiring too.
2:24:57
So thank you so much for your presentation. Thank you Professor. Do you have a comment Dr. Osman?
2:25:05
No I think I'm very happy she's I'm very happy and Nina's happy and this has been satisfied I think that's that's that's to go. Yeah yeah.
2:25:19
Actually from my side I should say that they are they are efficient enough that make you think okay let's support them they they have the courage and they have the will that's that's the most
2:25:32
important and I'm thinking all the other students are there they are showing themselves and act them and honey and I think they will do even better in the future thank you that's that's the end of
2:25:45
President's and the student speech
2:25:49
We will go to a professor, James Osman
2:25:55
speech. I cannot introduce you, professor. Actually, the message for all the new in this meeting, especially for the student-resident, go and Google Dr. Osman name
2:26:12
and see his CV. And now we want to enjoy his presentation the stage is yours.
2:26:22
This is the 16th SNI and SNI Digital Bagdad Neurosurgery Online meeting
2:26:29
held on August 7, 2022.
2:26:34
The meeting originated in coordinator Sam Erhas
2:26:39
The lecturer will be James Houseman who will talk in the future of neurosurgery and medicine by the year 2100. He's the creator of Surgical Neurology International and SNI Digital and the professor
2:26:52
of neurosurgery at the UCLA Medical Center
2:27:02
Lecture 30 minutes and discussion is 15 minutes, with attendees from 100 countries, 100 attendees from 18 countries
2:27:21
I want to thank everybody
2:27:25
for
2:27:27
attending. There's still a hundred people coming to the meeting who started with 120. A
2:27:35
lot of my mate, my family asked me to talk about the future of
2:27:43
neurosurgery in 2035 and what would it be? That's a difficult subject I'm gonna try to tell you from my perspective what I think it's going to be in 2035
2:27:59
and what it's gonna be in 2100. And I'm gonna give you some specific examples. There's no way I could do a thorough analysis in 15 minutes but we'll see what you think about this, okay? This is
2:28:16
the first slide. A patient comes 60 years old, it comes to you with a sudden
2:28:25
hemiparasus, arm and leg.
2:28:29
You examine him, that's what he has, he's got a hemiparasus. At that time you have a CT scan, you do a CT scan which shows these two little circle, red circled dark spots in the brain. They're
2:28:33
basically called lacunar infarcts And at the time
2:28:48
of 40, 50, 60 years ago, nobody knew what to do with them. Nobody knew much about them. There wasn't much angiography being done. We had CT scans as you could see at this time. And then there
2:29:01
were some MR scans. Questions, what do you do?
2:29:07
There was a professor at the time who was a neurologist. He was at Mass General Hospital. His name was C. Miller Fisher man was outstanding. This is a paper you'll get to. the copy of the speech,
2:29:22
when it's put up on the SNI digital website with this talk.
2:29:29
This is one of the finest papers I've read in medicine. Archives of Neurology, 1979, C. Miller Fisher, Capsular Infarts.
2:29:41
He had these patients, and he asked a question. He said, What's wrong? What do they have? What's happening to them? He had 11 of them that died. They autopsied the patients, and what he did is
2:29:54
he went ahead and he sectioned the brain from the lesion,
2:29:59
so he could find out what the artery was. Section the
2:30:04
brain from the lesion, 1, 000 to 4, 000 sections per patient, 1, 000 to 4, 000 sections a patient, an incredible amount of
2:30:16
work. What he wanted to do is to trace the source of that infarction, and this is what he found. In doing that, what he found is, here's the middle cerebral artery, you see it's marked MCA. And
2:30:31
off of that is coming a branch. It's called one of the lenticulostriat arteries, which you know, and you see the branch is filled with some blood, but most of it is filled with anatharoma.
2:30:44
Anatharoma is made up of macrophages that are filled full of fat. There are other blood vessels around. You see the dark blood vessels that have blood in them. This blood vessel is almost blocked.
2:30:58
In the cases that he examined, you see in the right panel here, he sees a blockage occurred in the lenticulostriat arteries within millimeters of the origin from the middle cerebral artery.
2:31:12
Horizontal, that's a middle cerebral artery.
2:31:16
midline of the brain here is where you can see that. And if you look at all these different, as you're 10 cases reported, he's got lesions in a number of these cases, all were within reach of
2:31:32
being able to be seen. And they were seen, I'll show you what. Here's another case. This all vessel here is filled with macrophages, atheroma is filled with lipids This was reported in 1969.
2:31:47
That's 40 years ago. And it's because of the fact that here was the middle cerebral artery. You can see that
2:31:56
the lympholyticulose strides come off this vessel. And they're irrigating the basal ganglia, which you see here in the picture on the right-hand side.
2:32:05
Well, what's the cause of this disease? And as you see on top, 20 of strokes are related to this disease Nobody knows how to treat it. Nobody knows how to diagnosis. This is now 40 years later.
2:32:24
This is something anybody in Baghdad can do. Dr. Miller Fisher did something that you could do, did a wonderful study, outstanding study. He had patience, he had an idea. He went ahead and
2:32:37
revealed this information. We did some experiments in the laboratory where you're looking at the surgeon's view, looking down with the frontal lobe elevated. You see the, in the yellow and blue,
2:32:50
the middle cerebral artery. You see white, the internal carotid artery labeled ICA. You see red, the anterior cerebral artery. See the optic nerve. So what we did is we isolated the anterior
2:33:02
cerebral artery, the proximal middle cerebral artery and the distal mental cerebral artery. We injected them with yellow dye for the distal, blue dye for the proximal and red dye for the Interior
2:33:15
Service. because we wanted to see what the distribution of those blood vessels was to see if we could understand this disease.
2:33:26
And this is another specimen showing that it all isn't exactly what the textbook says. Here you see the yellow, the yellow vessels, there aren't many of them. There's only two coming off this
2:33:38
metal cerebral proximal segment in blue. And there's only two coming off the anterior cerebral that happens, that each of these are major vessels.
2:33:50
So what is the blood supply? When we sectioned the brain, we found, and this is a section you see the lateral ventricles here, the
2:33:59
frontal lobes here,
2:34:02
and the occipital is back in the down in the bottom. This is the basal ganglia, which you see, a ghost, palace, and the and the
2:34:11
putamen, and you can see that the red from the A1 fills both sides, not completely. You see a little yellow here on the left side. And there's a here, a spot of blue on the left side, which is
2:34:26
in the internal capsule. So what kind of symptoms would that patient present with? This patient would present with an isolated, pure
2:34:37
hemiparasus. The patient would have some other symptoms, some sensory symptoms. We don't know from the yellow where it's going to be, but you see in the same patient the distribution is different.
2:34:47
And then what we did is sectioned a whole series of different brains, you could do this. You can do this in Baghdad, you can do this anyplace. And you find, if you look at each brain, you see
2:34:57
that the distribution here is red, it's different on one side of the brain than the other. And the rest is you can't see it well, but it's in yellow on this next picture on the bottom. You see
2:35:08
it's blue and it's a mixture of yellow, blue and red up here in the top it's mixture of. yellow, blue, and red. And what it means is that the vascular supply to the brain, to the basal ganglia,
2:35:23
is different in one patient and among patients. So if these patients come and they present with an embolus to the middle cerebral artery, they're going to present with different clinical syndromes.
2:35:38
And the only way you can find that out is to demonstrate it,
2:35:42
to know what it is. So here is an example, a summary, using a new kind of technique that is only available in a few hospitals in the United States. It's not available around the world. It's a
2:35:56
seven Tesla magnet MR in which you're able to see tiny blood vessels. These are sub, these are micron, four to 800 micron blood vessels.
2:36:11
And this is what a seven Tesla scan looks like. This is the scan we started with. Actually, I started at a time where there was no scans.
2:36:20
And then in the 1980s, we developed CT scans and we developed MR scans.
2:36:29
And here you see the definition we were thrilled to see what it was with a little resolution MR scan. You probably have these in a bag diagonal and a three Tesla or in a rack And it shows you the
2:36:42
increasing detail that you're seeing. And now here's when the seven Tesla, there's very few of these around, which shows the incredible detail that you're seeing. What's the message from here?
2:36:56
The message is, if you don't see it, it doesn't mean it's not there. It just means we don't have the technology that allows you to see it.
2:37:10
That's why I asked about the gamma knife and the tumors that they were treating with gamma knife. Before we had MR scans and CT scans, we had numeral encephalograms. We didn't check air around the
2:37:22
brain. And if we found that the brain stem was enlarged, Dr. Hadi would know about this brain stem, it was large, we would assume that the brain stem had a tumor and many of those people were
2:37:36
treated with radiation. There was no diagnosis made because it was too dangerous.
2:37:41
And it turned out many didn't have that diagnosis and received the treatment anyway. So you have to know what you're treating before you're treated. So you do the very best you can. And this is
2:37:53
what's happening. This is what's coming in the future. This is gonna change the way neuroscience and medicine is practiced because we are gonna see things we have never seen before and it will
2:38:04
change your life and it will change patients' lives.
2:38:09
a 15 Tesla scan showing virtually very few blood vessels. Then we get a three Tesla scan, you see the blood vessels and look at the seven Tesla scan, filled with blood vessels.
2:38:21
Can we use the seven Tesla scan to tell us what's going on in the lenticular stride arteries in those 20 of the patients who are about to have a stroke because of the fact that one of those vessels is
2:38:33
included like Dr. Fisher showed. Are we gonna be able to peak that disease up ahead of time and treat it?
2:38:41
Well, there's one way on the way, seven tuft of scans. Nobody's using it for that check. Well, we have angiography.
2:38:50
And
2:38:53
Dr.
2:38:55
Arisami was talking about that in his hospital. Samner is an interventional neurologist. Interventional neurology isn't doing this
2:39:08
Regular angiography can only show you a vessel about a millimeter and and hires maybe sometimes
2:39:17
500 microns or 800 microns. It can't show you the blood vessels that are micron diameter. Those are the size of the lenticular stride vessels. They are micron vessels, some 50 microns I went to
2:39:32
the buffalo
2:39:36
and they had an buffalo and an angiographer was able to have a tiny catheter that he was able to put up the lenticular stride arteries. So you could do an angiogram though. We did them by blocking
2:39:47
off the corona of mental cerebral artery and injecting slowly to see that so you can make the diagnosis. And once you made the diagnosis then the question is what are you going to do? How can we
2:39:59
save these 20 of the people that everybody has written off? Nothing I can do for you. That's not not good enough.
2:40:09
are the ways to treat that disease. I'm gonna talk to you about that. This is an example of a 45-year-old man. He's from Japan, he had dizziness. He had visual field deficits, which means the
2:40:21
occipital lungs were involved. He had an occipital lung infarction. They treated him with aspirin.
2:40:28
Came back six months later, he was dizziness. He had less consciousness. He had an MR angiogram, which showed both vertebral arteries were occluded.
2:40:38
One of the students presented one of the residents presented a case today of
2:40:45
an aneurysm, and they didn't know what the vertebral arteries were.
2:40:48
I'll show you.
2:40:51
This is an, and these are a set of studies from this man. There's nothing you could do to treat this man. Nobody knew. This is this carotid angiogram up here in the upper left-hand corner. You
2:41:03
can't see opposed to your communicating area Or you can't see an enter choroidal artery. You can't see the basilar artery filled here.
2:41:12
And you go to the other side, it's the same. Here is a little swath of filling of the basilar artery. I'll leave it on the line in just a minute. So there's no communication, virtually no
2:41:23
communication between the posterior circulation and the anterior circulation.
2:41:30
And now we want to head into the seven tests of the Japanese that a seven tesla integrand. And what do they find? They find this very unusual corks, this twisted vessel coming off the carotid
2:41:43
artery and going back to the posterior circulation. And if you look up in the upper right here, you see it coming off of both arteries, going back and filling the posterior cerebral arteries. Oops,
2:41:56
and I got to go back You see it filling both posterior cerebral arteries here. And that's how you receive the circulation. We didn't know that without an MR angiogram, the angiogram didn't tell us,
2:42:12
does anybody want to do any more on the patient or did they give up? You can't give up. This is you, this is your family, you cannot give up.
2:42:24
You have to find the answer. And there are people all over the world in rich countries who give up
2:42:32
There are people we heard of three weeks ago in the 15th meeting who never gave up.
2:42:38
The two doctors, the doctors who made their presentation before me didn't give up. They persisted. Students didn't give up. You can't give up. Just because you have money and you're in a big
2:42:51
country and you're in a
2:42:54
developed country doesn't mean you'll have the smartest people in the world You don't.
2:43:03
The smart people are on this call. They're in Baghdad, they're in Iran, they're in China, they're in everywhere in the world. They're in South America.
2:43:15
And don't let the people in the developed world make you think what you have isn't that good because what you have is outstanding. You have talent, you can't buy talent. You make talent, you
2:43:27
create talent. So this man had this deficit. It explains why he had loss of consciousness It explains why he had an occipital lymphar 'cause he didn't have enough blood going to the brain. And this
2:43:39
is a blood flow test. If it shows red and yellow, it means there's a lot of blood going there. If it shows blue and green, there's not. And so here after being challenged, this blood flow went
2:43:49
down in the occipital lobes. That's why I lost consciousness.
2:43:55
So there was a treatment for this man with blood vessel disease ended a bypass
2:44:02
So here we are back to how do we solve this problem of 20 of people who have strokes. Nobody knows yet, but this is something you can work on.
2:44:15
This can be solved. And it turns out that the disease is atherosclerosis. I'm going to come to that. Now, when you get an MR scan, you also see the white matter of the brain that you can't see.
2:44:27
We didn't see this 40 years ago We didn't see it 20 years ago. We're seeing it now, 10 years ago. What fiber-tracked imaging?
2:44:36
Does this tell you what's going on in the brain, how complicated it is? And what is it that we don't see because there are magnets out there that are 23 Tesla?
2:44:48
What don't we know?
2:44:52
So don't be so.
2:44:54
It's true in our country. Don't be so confident that you know all the answers because you don't.
2:45:01
just because you don't see anything doesn't mean it doesn't exist.
2:45:09
What about atherosclerosis? This disease is common everywhere in the world. It's been treated for the last 70 or 80 years.
2:45:21
Still, nobody until recently knows what this is. And this is what it is. It's an inflammatory disease And here's an example of what happens. What happens, this is a break in the endothelium. And
2:45:35
inside, there's a macrophage that goes inside the blood vessel. And the macrophage goes in the blood vessel. You can see down here where the macrophage is engulfing all these lipid particles,
2:45:47
which are in the blood. And it's becoming a foam cell. It's filling the blood vessel underneath the endothelium with these yellow cells that are laden with fat It gets bigger and bigger, eventually
2:45:60
it breaks through. and when it breaks through a blood clot forms then the blood vessel occludes.
2:46:07
Up to now we were treating these people with statin drugs that doesn't treat this disease. Everywhere in the world was treating them that way. That's not the treatment for this disease. Well,
2:46:17
we're in antibiotic street, this disease they tried not to fail. I'll show you something. So maybe we have to find a treatment that's not the macrophages from going in there and diminishing the
2:46:28
patient's blood fat level Maybe that's the treatment for these diseases. Maybe that's the treatment for the lacunar infarction said Dr. Miller Fisher talked about.
2:46:44
what about cerebral aneurysms? Do we know about them? We don't know. We don't even know how they originate.
2:46:50
And we don't know why they grow. We don't know when they're going to rupture. We don't know how to treat vasospasm. In Japan,
2:46:57
they're concerned about because 2 to 5 of the population has
2:47:02
aneurysms. 10 of the stroke deaths are from aneurysms. 50 mortality. That's when I asked Sammer about their paper on this. 50 died before they got to the hospital. That's not very good. And
2:47:16
that's not very good everywhere in the world, because everybody's got that statistic. In Japan, they're worried because there's a large number of people who have uninterrupted aneurysms. And
2:47:27
they're going to be subject to this disease. What do you do about it? Well, they found if you look at some of the pathologies, there's some inflammatory cells around the aneurysm. Well, there's
2:47:37
a paper. You'll see this. It came out of Japan. Japanese are outstanding in vascular neurosurgery, better than Americans.
2:47:47
And they found that the aneurysms were a macrophage-mediated inflammatory disease. And I'll show you a diagram. But there's a blood vessel in the bottom. Here's a blood vessel getting through an
2:47:60
endothelial cell. As it gets through, there's some inflammation that's formed and up here is this green macrophage. And once it gets through, there's a whole bunch of inflammatory cytokines and
2:48:11
all kinds of small molecules and signaling molecules that are released that says to the macrophages grow bigger and bigger. And when it grows bigger, what happens is it destroys the smooth muscle in
2:48:23
the aneurysm in the wall of the vessel in an aneurysm forms and it keeps getting bigger. Well, how can you stop it? Well, there's some drugs out that'll stop it. And they've shown this in the gut
2:48:35
diagram And there's some genetic. Mechanisms that once the macrophage is growing, you'll tell it to keep growing.
2:48:43
So how do you treat that disease? Now we have an idea of what's happening. It's a macrophage disease. Well, here's a picture showing in purple. This is a stain which shows muscle in the blood
2:48:55
vessels. And you can see here, there's very little muscle, there's very little muscle, there's an aneurysm.
2:49:03
Now, they were able to go back and use a drug that essentially stopped this whole mechanism 'cause it was centered right here on this gene. Turned the gene off.
2:49:16
And they gave it to the patients and that's in red. And they had another control group where they just let it go. And that group turned out to group that have aneurysms. The other group, you can
2:49:29
see there's smooth muscle all the way around. The wall's been repaired.
2:49:35
Does that mean the treatment for aneurysms by the 2100 is gonna be treating a macrophage-induced inflammation of the brain that can be stopped by drug treatment?
2:49:50
Is that the future?
2:49:59
Now, the Japanese wanted to go further. They said, Well, I want to know if I macrophages are there, how do I tell this? How do I tell this aneurysm exist? So they went and did some more
2:50:08
experiments. See, people are terrific. So they went to the laboratory, they injected some iron particles into the blood vessel, and if there are no macrophages involved with the
2:50:19
aneurysm, none will show up. But they found if you're their macrophages, the iron particles are taken up by the macrophages that show up in the aneurysm, and they'll show up in the MR scan.
2:50:33
So what did they do? They did an MR scan. And here's the MR scan. This is an MR scan shown in a macrophage. This is before the treatment before giving the iron. That's what this word up here
2:50:45
means, ferromoxyl. I put it up here iron.
2:50:49
Now they give the patient some iron so that you can see it You can see all the iron particles in the shells. that are around the macrophage. And this is the subtraction view, which means you take
2:51:00
this view on the pre, you subtract it from that view in the post and you get what's left over. And these are the cells with all the iron in it.
2:51:10
And so now what you do is you go down and they do it. It's a form of an MR scan. And here's the aneurysm where the white arrow is. Here it is after they give the iron. And when they do the
2:51:23
subtraction film, they take the pre-films subtracted from the post film. What do they find around the rim of this aneurysm are these dark spots, those are in red. What are they? Those are the
2:51:36
macrophages with iron.
2:51:39
And if you look where the yellow is, it's not there, which means there is muscle there.
2:51:45
It means they've found a way to diagnose this disease using MR scan before it becomes and kills 50 of the people. Now the problem with this is that the iron used for diagnosis is too toxic, causes
2:52:02
an allergic reaction. So they're working on
2:52:08
that. This is outstanding work. So that all comes from working and looking into the biochemistry and molecular biology of what's happening with the disease. There's some people, young people in
2:52:20
this talk who aren't going to become neurosurgeons They're going to become neurologists, so they're going to go into medicine. These are things you can do, no matter what field you go into.
2:52:30
Neurosurgeries go, I have to get up to speed on this. And you're going to have to have a team of people who are involved in doing this, not just the surgeon.
2:52:42
And what you're going to find in the 21st century is that inflammation is a major disease in the 21st century If you go back in history, 10, 000 years ago.
2:52:53
to Mesopotamia, which preceded Iraq. The major disease was infection, and people died by the age of 30. Then they began to cure infection. That took a while, it took to the 1850s or 1900s, and
2:53:10
we were able to cure some of that. To infect this disease, they went away and people were living longer. So they got atherosclerosis and cancer in other diseases. Do you think that's gonna be true
2:53:21
100 years from now? I don't think so.
2:53:27
And here's an article published by a good friend of mine who's a neurosurgeon who's very interested in molecular medicine and has studied the subject in great detail. He wrote about it before many
2:53:40
other people, went through the same experience Dr. Howdy did. Dr. Monir went through and everybody said, no, you can't do this, you're crazy He said, Parkinson's disease.
2:53:53
is caused by an inflammation in the brain. And what's happening now? He said this 10 years ago.
2:54:02
And now people are beginning to understand it's chronic inflammation, repeated insults to the brain by toxins, by infections. What it does is it enhances the microglia, which are the defense cells
2:54:18
in the brain. It enhances the microfages to go into the brain I just talked to you about microfages in aneurysms and nathrosclerosis. And I showed you that from Dr. Fisher.
2:54:32
These cells are now hypersensitized.
2:54:35
And if more insults come to the brain, then what happens is they become degenerate and wind up discharging. They have what's called immuno-excidoatoxicity. where they release all kinds of various
2:54:50
chemical substances and messengers which then go and affect the surrounding nerves and astrocytes and they kill the nerves. It's a chronic inflammatory disease.
2:55:03
That's what you're gonna find. But you're not gonna find what's written about it. But more and more is coming out of it. Why? People don't wanna believe it.
2:55:12
Your diseases that are gonna be caused. Parkinson's, Alzheimer's I had a good friend as a neurologist who loved to develop his own pictures in his own laboratory. And he got inhaled, the toxins
2:55:19
that gave him toxic neuropathy and he died of that
2:55:28
disease. Immuno, and psych, cyto, and toxicity, chronic inflammation of the brain. Nobody knew what he had, that's what he had. I've told you atherosclerosis is insane. Everybody is suffering
2:55:39
from
2:55:42
COVID around the world. Now we're talking about long COVID. long COVID involves the brain. What is it? It is repeated insults to the brain by not only the virus, but now by the vaccines. And the
2:55:57
vaccines continuing to spike protein have alarmed the immune system so that it's hyperreacting. That was one of the causes of early deaths. It was excessive release over release of toxins in an
2:56:13
allergic reaction, but nobody wanted to talk about it.
2:56:20
arthritis. Arthritis is common around the world. Almost half the people in the world will get it in their lifetimes. Nobody knows how to treat it. The surgeons do it. They go cut it out. Is that
2:56:32
what it's going to be? There's some studies out there which show that if you stop cartilage loss, you're going to stop arthritis because the bones won't rub together There's also studies out there
2:56:43
that show that if there's stem cells in the end plates of vertebral bodies that can be stimulated to regrow the cartilage. Why don't we see that in the spine literature? It doesn't make money.
2:56:59
Rheumatoid arthritis, the disease been cured. I had the disease. I was treated with a molecular agent called enterosep Enbrom, autoimmune diseases So chronic inflammation is going to be the major
2:57:13
disease in your lifetime. It's going to be found everywhere, but nobody's paying attention to it.
2:57:21
What about precision medicine? That's what is called in our country. It's called molecular medicine or genetic medicine. What's happening? Phenomenal things. People with sickle cell is enemia or
2:57:33
some blood disorder, you know about that telesemia. They can go in and they can cut that abnormal gene out and cure the disease. What they do then is they take the patient's cells out, they get
2:57:45
the stem cells, they cut out the abnormal genes, they wipe out all the
2:57:51
blood cells in the body and then they put these stem cells back in their growth, the disease is cured.
2:57:57
Cavernous malformations now have been found to be caused by a series of molecular events. And it's related to the same
2:58:08
signaling chain that causes meningiomas,
2:58:12
a physician in France, a neurosurgeonist on it, outstanding work Way ahead of everybody else.
2:58:20
Here's the paper. Mutations in sporadic cavernous malformations, 80 of malformations are cavernous. They can rupture. They can hemorrhage as a way. We can treat them with some drugs that will
2:58:35
stop this cascade, this genetic molecular cascade. Here's the CRISPR, which is the technique used to essentially cut genes out of that are abnormal. We can't be done by inserting viruses.
2:58:53
So what's neurosurgery in the 21st century going to look like?
2:58:59
First of all, the disease at the end of the 21st century, all these diseases are going to be gone.
2:59:07
Most of you, if you have the right diet, you live appropriately,
2:59:11
are going to live to over a 100 years old. Your average age in Iraq now is over 70.
2:59:20
Bascular disease, I just showed you a ways it's going to be cured. Neoplasia,
2:59:26
tumors, they're going to be cured. Degenerative diseases, I just showed you inflammatory degenerative diseases of the brain. They're going to be cured. Spine, we've got to get the spine surgeons
2:59:37
to think differently. That's going to be hard.
2:59:42
Right now, you have to do that. But we have to work on some of the basic reasons that causes a major disease involving all people in the world. Trauma will be with us, must be with us forever.
2:59:56
But there are people who are making progress. They're finding ways to limit the amount of damage in the brain. They're finding ways to regenerate nerves. There was a presentation we had a year ago
3:00:09
on repairing the spinal cord, cutting it in half, cutting it totally, putting it together Dr. Hadi presented this three weeks ago and having it regenerate. It can happen.
3:00:23
Stereotactic and functional. We've seen talks last week about it, incredible talks. And today,
3:00:31
I think it's the wrong name for the disease. It should be neurocellular intractic surgery. That's a frontier in neurosurgery. It's gonna be explosive. It's gonna tell you about psychiatric
3:00:41
diseases, all the kinds of diseases I just presented here today. Many of them that you can't treat A quarter of the people in the world are on anti-depressant drugs. I don't need that. Infections.
3:00:54
We've already started the end of the beginning of the 19th century, 1930s with antibiotic treatment.
3:01:03
Pediatrics we talked this morning about folate. Yes, it is very important. It doesn't help everybody. The article in the New England Journal of Medicine is this article right here. Came out
3:01:13
yesterday. And what they're doing is they found that if you can operate on the fetus in the womb with a myelamininic seal and treat it, you reduce the complications of that disease before birth and
3:01:30
after birth by 50.
3:01:36
50 percent. What about the 50 percent of people are dying from aneurysms? Can we fix that? Yes, we can.
3:01:46
I'm sorry to tell you, I think skull-based surgery is going to disappear. It's a means to a disease, not a treatment.
3:01:55
I think we're going to have to look at medicine differently.
3:01:60
My father grew up. He was a private practitioner. Dr. Hadi was in private practice. There was many of the other people here. That's what they're doing now. But things are getting complicated.
3:02:10
We're going to need to have lots of people involved treating a problem. I just showed you that today. These are complicated problems. We need teams of people, researchers, neurologists, medicine
3:02:20
people, all kinds of different specialists working in teams.
3:02:26
Diagnosis of medical disease is going to be made by computers IBM made a computer where it was able to diagnose medical diseases. wasn't accurate enough.
3:02:37
We've got telemedicine, people are now using telemedicine. You can now reach all parts of Iraq by telemedicine, treat people.
3:02:46
We'll be using remote surgery because in the rest of your life, people are gonna be going to space. We're gonna have space diseases and space medicine. You're gonna have to operate on people in
3:02:56
space.
3:02:60
So that's, if you can't see it, if you can't see anything, it doesn't mean it doesn't exist. And this is a picture just taken three weeks ago from the newest telescope, the web telescope,
3:03:16
looking out into space, and that picture shows you in a very narrow view of space, thousands of galaxies, just like ours, thousands.
3:03:30
What does that mean for the future? hundreds of thousands of galaxies surrounding us.
3:03:42
So what's the future? 50 of your population is under 20 years of age, and 75 is under the age of 50. That means you're young. That means by the age by the 2100, the population of Iraq is going to
3:04:00
be 100 million people from 40 million today. That means you need a lot of doctors. That means you a lot of need a lot of people working to be able to take care of that.
3:04:15
We have one principle. I followed this principle my whole life. We have one principle in surgical neurology. One should think about this. There are no characteristics by which we judge a paper
3:04:29
except scientific fact.
3:04:33
I don't know who sends the paper in. I don't know if it's a male or a female. I don't know what country it comes from. It doesn't matter to me.
3:04:47
And that deals with all of the talk about bias I hear about in the world. It doesn't matter, particularly to a doctor. And the reason is because you're treating a patient and it doesn't matter what
3:05:02
religion the patient is, what skin color the patient is. It doesn't matter what they believe. It doesn't matter what they practice. Your obligation is to treat that patient. The very best you can
3:05:16
than 50 mortality isn't good enough
3:05:22
So, thank you very much. If you want to write me that's it. I hope that's been helpful to you. That's one person's view of the future. Thank you. Well, thank you so much for this mind-blowing
3:05:38
talk telling us what's going to happen in the future. It's amazing, really. And comparing it to the web telescope is very appropriate to think What we don't see, it's not necessarily as it's not
3:05:54
there. I remember a
3:05:57
paper written by Richard Dwin and Matthew Hart in the Lancet in December 1999 about neurosurgery in the coming hundred years.
3:06:12
Of course, it's not as elaborate as what you presented, really, some new things, which I'm sure I'm sure they didn't know anything about that at that time.
3:06:24
Sorry. And they went through
3:06:29
the steps which is going to happen to neurosurgeon. They said the first half of the century, you will have the mechanical surgeon, mechanical neurosurgeon, and the robotic and other things,
3:06:41
mechanical things. And then the second half would be as exactly what to have said, the biological surgeon, the BS, and neurosurgeons would be redundant They don't have much to do. And he said
3:06:54
that, what they said, that when you have some problems with mathematics, you can go to the neurosurgeon and you put the chip of mathematics on your head, and then you go back home, and then you
3:07:05
have your good mathematics. And also they can take at night your memory, they record it, and then when you have stroke or head injury, and then they can put the memory back to you when you recover.
3:07:19
It's amazing. It's just, I think that's just theory, but what you are telling us, you are telling us facts and amazing facts. And we are really so much thankful for your effort to get all these
3:07:32
things together and to tell us about that. So thank you so much again.
3:07:39
Thank you. Thank you, Dr. Osman. I will wait if there's a comment from panelists. Also, actually it's a stimulating dog and it's an eye-opener. Do you have a comment? I think Osama
3:07:54
has a question. Osama?
3:07:57
Yeah, Osama.
3:08:06
Hello, Dr. Osman. Thank you very much for the fantastic talk and thank you to the organizing committee
3:08:13
for making this conference and Dr. Hus for inviting us. I have a bit of a personal question to Dr. Osman if that's all right. My question is, What got you to where you are with this level of
3:08:24
knowledge and the comprehensive knowledge about like everything, even outside of like medicine?
3:08:34
Yeah, the question was, how could you say that? How did I get that knowledge or? What got you to where you are? Well, what got me to where I was?
3:08:46
How do you can answer that question? And so, so could Yasser or Abdullah or anyone else? It's uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh uh or anyone it's it's um
3:09:03
I always wanted you to do better. The most important thing is to be the very best you can.
3:09:10
And excellence is the goal.
3:09:14
You're growing up in a world where mediocrity is a goal. That's where everybody's got to be equal.
3:09:27
That's not gonna lead to excellence
3:09:31
I learned a long time ago that there are people all over the world who are very smart, smarter than I am.
3:09:39
And those are the people who you're competing with. Those are the people in the United States that they don't understand. They're not competing with the best people in the United States. Their
3:09:51
competition is the best people everywhere in the world. Some of those people are in Iraq on this call today. Outstanding people, done outstanding things.
3:10:04
So I think the answer to that, no matter what field you choose, is to be the very best you can to work very hard and to achieve excellence, and that's what you should do.
3:10:19
Thank you very much, Dr. Osman. Thank you, Osama, for the question. I wonder if Dr. Ari or Dr. Abdrami have a comment also.
3:10:33
Yes. Yes. And one thing
3:10:36
I had,
3:10:39
it's very hard to find very open-minded
3:10:44
to work and to talk, and
3:10:48
Dr. Osman is one of the exceptions. I have to tell you, I have worked around the world with many people. I was lucky to work with very great mentors. But one thing is very special with Dr. Osman.
3:11:01
It's very open to anybody. Because unfortunately, in the US, pretty doesn't make this. I have gone through a lot myself Not too bad, but I had great people to work with. But prejudice exists.
3:11:18
but I have to work hard, as he mentioned. And that's why I'm sitting here. Don't give up, if they don't like you, they don't like your religion or your nationality. I have gone through all of
3:11:29
those, but there are
3:11:34
people like us who support you. I love you young people know that, just do your best as he mentioned. Thank you, Dr. Ali. Thank you. I'd like to, I think we should just take a minute or two
3:11:46
dash, Dr. Ari and Yasser and
3:11:59
see if they would answer, until I don't. See if they would answer the question that Osama asked is how do you get to be where you are? And also my good friend, Hadi, because the young people
3:12:14
should not just hear from me I should hear from them. as to what, how do you get to be successful?
3:12:24
Ari, do you want to start and answer that question?
3:12:32
Yeah, you're muted. Yes, yes. Thank you, sir. Thank you. Well, we
3:12:37
face these problems. My personal experience, we face difficulties during the
3:12:49
sanctions on Iraq and my mentor, my teacher knows at that time what difficulty we face. Even though we tried our best, we
3:13:05
entered with
3:13:08
struggling to get information from here and there, because we thought at that time, we should practice neurosurgery as the best we can.
3:13:23
Even we faced difficulties at that time because of the sanction, because of the war, because of the condition or the circumstances at that time, it has been faced. But we
3:13:37
believe that neurosurgery is our way and you should be succeeded in this way, yes.
3:13:60
Also, the disease will progress itself. After 100 years, we were facing a new disease. Now, we are our thoughts or thinking in the present diseases which we can't
3:14:21
success in treating like all the oncology. We don't know what the exact pathology is. If we treat it by these ways, what are mentioned, in the future, the disease is also intelligent and will
3:14:38
develop cells, not only the viruses, bacteriology, bacteria, also other disease. And it is
3:14:51
the whole type of treatment, medical, surgical, biological, and might be another technological, advanced technological progress in treatment. It is a battle. And thank you.
3:15:09
Yeah, well, my life trip is full of
3:15:17
difficulties and I really overcome these difficulties and put that in my memoir. At the age of 11, I decided to be a doctor. And I worked hard for that, but then I failed in the third day. year,
3:15:31
the intermediate. So I had to go to the commercial side rather than science. And then I went back to science. I lost one year of my life, but I didn't mind that because my goal is to be a doctor.
3:15:44
And then in the high school, I did not score the enough total of my marks to get to the medical school. So I went to the engineering. And then for first week, they opened the gate for other people
3:16:02
to come to the medical school. And I went there. And then in the first year, I failed in biology. But then I passed, okay, when I came to the clinical, that's my passion. And then I progressed
3:16:15
until I was the top graduate of the medical school when I finished in 1966. So the hurdles in my life, there are a lot, you can't possibly see them in the memoir. But determination to overcome
3:16:30
them, to reach your goal, is the most important thing in life. So you may be pushed sideways sometimes, away from your path, but you have to struggle to come back to your path and fulfill your
3:16:44
aim in life
3:16:47
One thing, Dr. Osmond, you are saying about, you don't mind, you don't care about who said something, but you care about what he said, we have, in
3:16:55
fact, a saying in our culture, exactly the same. La tondo de la mancar, we'll act an undo de la macral, don't care about who said, but care about what it was said
3:17:10
On standing, send that, send that to America, they need to hear that.
3:17:18
How easy do you have a question, Ari?
3:17:22
Yes, sir. What about stem cells, sir? What about stem cell? No.
3:17:28
makes stem cell progress in neurosurgery?
3:17:35
I'm not really very knowledgeable about that. I don't think I can answer, but you're right. Some of the things I read had to do with stem cells that they were able to reactivate. I'm just have to
3:17:45
confess, I'm not know what you go about. Yes, yes, there's some progress, but even though it is not so much in neurology. It's been used in the court to repair, but not very, very exactly
3:17:46
promising results. Yes, it's correct. Cardio, another person has your question. Yeah, Cardio, you do this yourself, please. Yes, Cardio, you may not know me. I'm
3:18:21
an neurosurgeon happily I'm an orthopedic walking in Sweden with spine. Thank you for your presentation, Dr. Osman. I ask you or add to your view that maybe in the next 50 or 100 years, we need
3:18:40
to do again, all the researchers who has been, has been publicated now, because I am questioning the result and the outcome of most of the research that has been already publicated I believe we
3:18:58
need
3:19:06
to do it again, again and again, because this is the first thing. Second thing, I learned in this country, coming from the arrival of course, from Silemonia, if you want to be a good surgeon or
3:19:14
a good doctor or a good engineer, you have to question the opinion of your mentor. Don't believe in your mentor 100 I try to question, because. As you said, you have to struggle to the best. By
3:19:32
doing that, you have to question what's your mentor saying and try to discuss with him or her about other opinion. Thank you.
3:19:44
Thank you very much. Very, very thoughtful. Well said, yeah, thank you, yeah. I just want to make a comment. I first saw it was very nice of everybody to be here And I wanted to particularly
3:19:59
tell
3:20:01
Dr. Amir and Dr. Yasura and Dr. Arisami that
3:20:07
what you saw today, we've worked with Sam or, but as an I would like to be very happy. Our goal is to get you all together, work for all the people in Iraq, all the students in Iraq
3:20:23
I think you ought to feel that.
3:20:28
that this is an effort to be made to benefit everybody. And if there's a way we can be of help,
3:20:38
Adi is a member of a board, or as an I board, and he can help us with this. And what we're here to help, our goal is to help people. That's what everybody in this call wants to do. I wanna help
3:20:54
people
3:20:56
And that's what we're trying to do. So I thank you for coming. I thank you for listening. Well, Dr. Osman, the moment I spoke with the three of them, in fact, even the other group would come
3:21:08
coming next for next meeting, they were so much eager to join. They were so happy to be invited. I'm sure they will be very important part of the team and the leading other junior and their
3:21:21
department, juniors in their departments to join as well So I'm really thank you. to the three of them, and they did a really great job and presented wonderful presentations. So thank you, Ari.
3:21:34
Thank you. Thank you.
3:21:37
Thank you. You've all done a terrific job, outstanding job of accomplishing things that most people would give up
3:21:50
at. And you're the models for the all the younger people. You're right there in Iraq So thank you.
3:21:58
Thank you very much.
3:21:60
So at the end, we close the summer. Yeah, I think we are ready. I should thank you, Professor Kelly Lee, and for this, like, you pull your slaves and go in the meeting in the details and make
3:22:17
it happen perfectly with the timing. I should thank you for that and your comments. Also, for our speaker today, it's not only thank you. It's the feeling that we are really proud of what you are
3:22:30
giving and what you represent. That's the honest feeling that we have now. And for sure, we are happy with the participant student. I think I counted it's we have 16 and different nationality in
3:22:45
this group of people today. And we are proud to have you here. And we hope that you get some benefit and actually some ideas for the future. And thank you for the SI panel, Dr. Lazarf executes us
3:23:02
that ego early just for an emergency. Thank you, Dr. Ali, for your comments and your vision. And thank you, Dr. Osman, for the leadership and for the very interesting presentation. Thank you
3:23:17
all.
3:23:20
Yeah, yeah, I just I want to say that our plan is to you. continue one meeting a month. So we will meet the next month. Yeah. All our speakers, by the way, they stuck to their time. They did
3:23:35
not exceed their time. So our extra time was by the session, they're in question. I think that's true. Thanks for all the speakers for really keeping to the time. Thank you. Thank you all.
3:23:48
Thank you. Thank you, Harry. Thank you, sir. Thanks so much. Thank you. So see you next month Thank you, professors. Thank you, colleague, and thank you. Thank you. Thank you students.
3:23:58
Bye bye. Bye bye. Bye
3:24:01
bye.
3:24:06
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3:24:59
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