ht, and now we are back to our,
0:05
our main speakers for today. Again, as I mentioned at the beginning, are incredible.
0:11
Fellow team. The hall have a number of projects
0:17
ongoing and had been presenting all around the country in the world. So we get to hear some of their recent work
0:23
that was presented at the CNS and Kitano, I think you're going to be going first. Is that correct?
0:30
Yes, sir. All right.
0:40
Let me share my screen.
0:57
All right. Good morning, everyone. So today I'll be presenting on our final results of procedure and treat
1:04
mental post-op or the CSF leaks. We do ultrasound guided epidural about batch. And this is a talk that I gave us
1:10
an oral presentation on C and S in Austin. And really was the work of the entire spine theme here,
1:16
Mayo Clinic, Florida, as well as Dr. Dan and James West.
1:23
I don't have any disclosures relevant to this talk. And as you know, incidentally,
1:28
the rod them it is a very well-known complication of spine surgery. And if left untreated, it can lead to a persistence CSF leak course
1:35
to the meaning or seal the report. Their rate of incidental rather me ranges from four to 16 percent
1:41
depending on the index operation. And if patients develops symptoms of persistence,
1:46
CSF leak, first-line treatment, bed dressed. Other options include over solving the wound and placement of a lumbered train.
1:53
And there is the potential need of having to go back to the OR for direct repair.
1:59
While epidural blood patches are routinely used post anesthesia or LTBI CSF leaks.
2:06
They are not often use after spine surgery for their alchemy repair. The problem is that the ultrasound
2:13
is a great technique that allows radiation free and direct real-time visualization of the meaning of a seal,
2:18
the dura, and the toy needle. By this application in the native spine is often very limited.
2:23
That's magnified in the bus stop at the spine thanks to the bond work that has been done by
2:29
removing the bony anatomy and the ligamentous there, which allows a window for the ultrasound
2:34
and for the need of to be visualized properly. So in our study, we did a retrospective analysis of
2:41
patient than they were when the USC BPM, Mayo Clinic, Florida from 20092024 syndrome,
2:47
I think to the meaning the seal secondary to spine surgery. We collected demographic, procedural, and outcome characteristics.
2:54
The primary outcome of our study was ultrasound, EBP success. The final resolution of
2:59
the initial sync them, their brothers to them in English to clinical attention such as postural headaches, institutional leak.
3:07
So for our technique, patients that position prone, that ultrasound is used
3:12
to localize the pseudo, meaning the seal and the color Doppler can also be adopted to determine if there are any active sites
3:19
of leak of aggression. Under ultrasound guidance, 18 gauge toy needle
3:25
is advanced into the syllable, meaning the seal, and the content is aspirated, but neither is then advanced
3:31
into the epidural space. And about 30 a mile of autologous blood is injected into early in
3:36
five to ten and aliquots under continuous ultrasound guidance after waiting for five to ten minutes to
3:43
allow that blood backs to see it. The ultrasound is then used again to confirm the placement of the patch
3:49
and the color adopt. There can also be used to confirm an absence of CSF egress if there was previously identified.
3:56
So overall, we add fourth-year patients who underwent a total of six to one USC bps.
4:02
And you can see that the most frequent index operation was a laminectomy, 24.5%.
4:09
And about 36.7% of these cases where revision surgeries. And also there the
4:15
incident that the relative me was unrecognized during the surgery in about 22% of cases.
4:24
You can see here that the median time from Sir did the symptom development it was seven days.
4:30
And the most frequent presentations seen thumbs-up presentation where headaches in 64% of
4:36
cases and institutional leak in 26.5% of cases. Here, looking at the results of
4:43
the EBP under ultrasound guidance, you can see that 51% of patients experience resolution
4:49
of their seen them after their first blood batch. And you can see in the medium volume I separated
4:54
from the meaningless it was 34 and Mao. And also that another 20 percent
5:00
of patients experience resolution or they're seen them after subsequent attempts of blood patches.
5:07
We're talking about complication. We had about 14 percent complication in our series.
5:13
Send the most people. One was one infection in patients followed by meningitis. All seem to patients.
5:20
Get us a couple of illustrative cases. You can see here patients that present throughout AB fistula.
5:26
And here on the teeth of sagittal MRI you can see a fairly large to them in English seal.
5:32
After the patient had undergone laminectomy, it's a number variation or the AV fistula. And then Dipesh, and then when
5:38
they know if they're sound epithelium, but actually the contents of the pseudo, meaning the cmos aspirate to them but batch placed.
5:43
And then you can see on the post-operative MRI sagittal cut, there was than one month after the procedure,
5:50
complete resolution or the pseudo meaning Lucille. This is another case of
5:55
a patient that lemon Act. And as you can see here on the CT scan, on the level of bullet previous fusion construct.
6:01
And there is an IPO density, there have a collection fluid collection. There was also again identified under
6:07
ultrasound where you can see the star there. And then the color Doppler was used to identify the active CSF aggression there.
6:14
The toy needle you can see here in white where this big arrow is, it's inserted the continents
6:20
zooming basileus aspirate as you can see in figure E. And then the blood patch is placed.
6:25
And this is a post-operative scan, documents resolution or the pseudo meaning the seal.
6:30
So our study carousel delimitation of all single institution or retrospective studies therefore fired
6:36
their prospective them with this enter establish that are needed to confirm the generalized ability of our data.
6:42
But our study is the first and the largest series describing the adoption of us EBP.
6:48
Impatient percent thing with persistence to the meaning the seal and CSF leak following spine surgery,
6:54
we've found an overall success rate of over 70 percent with the first attempt success rate of 50 percent.
7:01
So this suggests that the utilization of us guided EBP in expert Han may allow for targeted treatment of
7:07
a large portion of symptomatic post-operative sort of meaningless seals. Thank you. Okay, tunnel
7:18
and it's excellent work. Congratulations. That's a novel treatment for these non uncommon problems.
7:25
Well, one thing that I realized I never asked Dr. Miller, Dr. Clinton, and what's the consistency of
7:30
the blood that you're using is the patch and how long is it in-between obtaining the autologous blood
7:37
and actually injecting it? I don't know about the time between
7:43
when the blood is drawn and Jack this or buy most of them. I believe it may have been dying
7:48
this at the same time with the procedure, sir. Yeah. But I mean, they they aspirate
7:54
and immediately give it didn't I was just curious about how thick the blood is. Maybe a layered I see doctrine Mahasi,
8:02
like Yeah, I do some of these as well. How can we go right away for the blood?
8:08
So it's right from an IV catheter into the epidural space. But what's really helpful
8:13
is the tissue fibrin glue. So it's like an IRA, you know, human hybrid components that
8:19
we inject and that solidifies much, much quicker and it's much more firm. So you know what the blight,
8:25
It's thinner and can get into different crevices while the firearm lose a bit more firms, you try to get
8:30
both properties and they're right at the week. Excellent. Yeah, thanks. Thanks Tiana crushing the inlier.
8:35
Did you want to Here hand up there, you want to make a comment? Yeah.
8:41
Yes. Sorry. I can't join on camera because I'm I'm tied up in the hospital.
8:47
But I will like to second-most comments I've done this cup, this case is Dr. Quint then
8:53
and a lot of times what we do is we place an arterial lines so that way we can reliably draw blood right away as soon as
8:59
axises identify with the ultrasound machine. And you have fiber
9:05
and who is also been something you that's very helpful for this cases. One question that I had,
9:11
and it's something that we always worry about is the risk of infection and meningitis and
9:17
is interesting from the data present. It's too, I believe. Any thoughts stone,
9:24
you're looking at the data and it's anything that we can do to make things better or reduce that risk score is
9:30
contributed directly to the to the block itself or how their circumstances are
9:36
most patients, they got infections. Thank you. Yes, sir. Excellent question as he said.
9:42
Oh yeah, we have about two patients and by 4 percent, for our cities, small cities is difficult to generalize
9:49
if that's really a 4% for the procedure itself. But it was assumed to be array was
9:54
many jaggedness seem to be related to the procedure, not like a UTI or any other infections.
10:05
Let's see. We have a question from
10:11
Dr. Vargas about what what about the presence of fibrous tissue after the procedure?
10:17
I think. Yeah. So hold it down and I have a scar and that sort of thing. Yeah.
10:22
So these are usually done right after the procedure. It's not too long and that's why it's very difficult to
10:28
do them anatomically guarded. That's why they used facade. The ultrasound really helps to visualize the anatomy.
10:34
And that's far we didn't have any issues as far as fiber going through a fiber species. Are the patches.
10:41
Great. Well, thank you so much. Tana. Yeah.
10:46
A couple more points here, Dr. Dean mentioned would emphasize the need to make sure the patient is a febrile and has
10:52
normal white blood cell count prior to the blood patch. And I know that's that's part of
10:57
the protocol. And a good point. Some of these patients are immediate post-op prove.
11:03
They have an immediate postoperative status. So they might have an elevated white blood cell count just from surgery.
11:08
But yet very, very good point. So I'll relax.
11:14
So excellent workday Taino, and we will go on to the next presentation.
"SPECT-CT as a
11:21
We have Dr. Garcia who's going to be presenting next.
11:27
Can you see this darker folks? Yes. It's advancing by itself.
11:34
Alright. So morning everyone. Today I'm going to be presenting on SPECT CT is a pretty curved pain generators and patients
11:40
undergoing intra-articular injections for neck and back pain. I think most of you already know this project.
11:46
It's a project that we did with the spine group and on the particular mentorship up to our body Yammer. And we presented it at
11:52
Austin at the Commerce Search. And so as you know, low back pain and also neck pain.
11:58
But there's a lot more literature on low back pain is one of the main leading causes of disability in general.
12:04
And yet, the identification of painful generators is still difficult, spite of use of multiple morphological base studies
12:12
including X-ray, CT, MRI. And also compounded by the fact that sometimes structural abnormalities are found
12:19
on scans have no direct correlation with the actual pain of the patient, which makes the correct identification of
12:26
the painful generator difficult and therefore, the targeted treatment for that painful generator
12:31
also difficult and limited. With this in mind, there have been some interest in functional based tests
12:37
like SPECT to accurately identify those painful generators.
12:42
And more recently, a scan has been a valve which is called hybrid SPECT CT,
12:48
which at Mayo we have been fortunate, have available for a number of years and we're good quality as I'm going to show
12:54
and one of the examples camps. So the idea here was to look at for set joint injection started
13:00
injections and see whether or not the hypothesis that injections targeted ad positive sites of uptake
13:07
would do better than injection was targeted for sale without uptake. So to accomplish this with design,
13:13
the study was single institution retrospective, in which we compared both short and long-term outcomes
13:19
for patients undergoing a saturated injections for neck and back pain. And given the large sample size,
13:25
I was able to do a propensity score match to adjust for age, gender, BMI, hypertension, and multiple target injections and
13:31
injection location did exclude sacroiliac joint injections. Given that they're a bit
13:37
different and they should not be grouped how the same with cervical, thoracic and lumbar injections.
13:43
So these were our main outcomes. We looked at immediate positive response, change in VAS two weeks after injection,
13:51
improvement in VS above 50 and 70 percent after injection and needs for additional treatment,
13:56
both injection and surgery. Importantly, add mayo. We have people who do call these patients to
14:03
access the procedure who are not implicated in the research. So they're able to give us
14:08
an unbiased feedback from the patients with our official report outcomes, which allowed us to
14:13
really objectify this outcomes. So as you can see, we have a large number of patients,
14:19
2849 patients that were evaluated with SPECT CT. Within five years out
14:25
of this one as we had three for 340 with the set injections within a 150 days after SPECT CT.
14:31
Why a 150 days? We had to choose a threshold. There is no specific
14:36
literature on the threshold. We just had to come up with a threshold that would allow us to look at outcomes that
14:41
were associated with injection, not associated with something else I could have happened in the interlude.
14:47
So we had a total of a 140 surgical injections, 21 thoracic injections,
14:52
and 207 lumbar injections. Importantly 265. Where uptake targeted injections by this
14:58
we mean that all the injections with targeted for Sarah, Bob take all of them. That was our definition
15:04
of uptake target injections and 75 or none uptake targeted injections. So as you can see here, just an
15:09
example of a SPECT CT and male with in this particular patient or ride L4, L5.
15:16
If I said join having uptake that was targeted by injection, this is actually one of the cases there was included in the study.
15:22
So here just some demographics and characteristics of the location and characteristics of the injection.
15:28
As you can see, even though there's nothing that is statistically significant, they can always compound and have an effect,
15:34
a confounding effect on the variables. Hence, why we did the propensity score match to adjust for all these variables.
15:41
And what you can see here is that both on a unit variable analysis and the multivariable analysis,
15:46
we did not find statistically significant differences between not non uptake
15:52
and uptick targeted injections. But when we did look at patients who already had a failed injection before
15:58
the SPECT CT in which the surgeon or procedures was able to change the target page
16:03
based on the information of the SPECT CT. Here below, what you can see is that in those patients we do have a benefit.
16:10
And the benefit was particularly greater if there was any change made on a target. So that is very
16:16
suggestive that for a particular set of patients. Adequate patient selection, you do see a benefit with SPECT,
16:22
CT to guide, etc, and injections. So basically our conclusions seem to
16:29
support that pending adequate patient selections, satiety has a benefit
16:34
in guiding facet injections. There are limitations, of course, with our retrospectives
16:39
seeing institutions study, but we did use a propensity score tonight for confounding variables. We have a large sample size.
16:45
But of course, a future directions would have to be prospective, multi-site,
16:51
hopefully double-blind clinical trial to accurately discern the impact of SPECT,
16:57
CT and routine clinical practice. And I'll take any questions.
17:07
Excellent Diego, really fabulous work. And I think this is yeah,
17:14
there's so much potential applicability to using imaging biomarkers
17:19
for better delineating patient's pain. In this, even with
17:25
the precision of these specs studies, it shows how challenging it can be
17:32
to figure out pain generators in the spine. And I think this is incredible work with
17:37
a lot of promise based on what you've seen so far. Could you think, I mean, do you think they
17:43
should we should be doing this more or less? Or do you think people should have, have this up front of me?
17:48
How do you recommend we use this based on your knowledge of the technique in our everyday practice.
17:54
So in a patient with IDC have a benefit where patients in which there were had already been an attempt at an injection.
18:01
So because my understanding is that's equity is but not necessarily specific.
18:06
So it's difficult to figure out which of those facets are lighting up are the ones that are actually causing pain.
18:12
So when we have the benefit of having a patient that already had a procedure, it had failed. We do know which of
18:17
those joints to light it up, but it's not the actual painful generator. So we can take those out and pursued next ones.
18:24
So I do see FAT City are not as unnecessary first-line for any patient that has the first procedure.
18:30
But for a recurrent setting injection per patient who has not benefited from a percent injection,
18:35
I will definitely see benefit there. But of course, I think to actually make a recommendation would have to have double-blind clinical trials
18:42
so it can make a recommendation. Hopefully coming, Hope we felt
18:48
the end and we'll continue to learn more about these imaging biomarkers, which I think will be very helpful.
18:53
Dr. Dean makes a great point in the comments as well that we have extremely high-quality SPECT study.
18:58
Is it Mayo which I completely agree at UF, we didn't do this at all. So this was, this was something novel to me
19:05
senior and very impressed with the quality of the studies. So excellent work. All right.
19:12
I think we can move on now to our next presentation.
19:17
Dr. Be vesper try though, who is going to be speaking about supramarginal resection impact on
19:24
overall survival for IDH wild-type glioblastoma. Okay. Perfect. Can you hear me now?
19:31
Yes. Yes. Thank you. Try today. Let me share screen here.
19:37
All right. Are you seeing my slide? Yes. Perfect.
"Supramarginal
19:46
Good morning, everyone. Thank you for attending this lecture today. So I'm going to present our study that
19:54
started presented in October this year and CNS. And the title of the study support margin our resection
20:00
impact on overall survival for IDH1, blah, blah. So my according to their cell density distribution
20:05
on the protection profile, the same month on bottom. So we have now these contours
20:13
for this lecture. So a bit of background regarding the center of our section on glioblastoma.
20:18
We know that no long ago they must come on, Sorry, NCA recommendation for
20:24
glioblastoma to perform only a biopsy. And this was not only in the United States but worldwide,
20:30
but seeing that too tough since we started seeing very important studies from doctrinal
20:36
across from Dr. McGurk, from Dr. Sinai, from UCSF with Dr. Berger,
20:45
and from China and split this data from updates that of
20:51
these studies favor or perform a more extensive surgical resection
20:57
on patients with glioblastoma. And their results were pretty much homogeneous.
21:03
Identifying that at resections about 78% of a contrast enhancement and T1,
21:10
where we were associated with a significant improvement in
21:16
overall survival in patients with GBS. But furthermore, we see that
21:23
the gross total resection is days, you say, is
21:28
this complete surgical resection or the contrast and husband component of the tumor.
21:34
And you can see up here. But what about day blur? I'm putting a T2 sequence
21:40
that we have now and for, for a while already that there are infiltrated GPM cells within the brain tissue
21:47
that most of the time is being taken care of,
21:54
resected because of day. People traded behavior of this,
22:01
of these cells within the brain. That if you were saying that I do can cause a devastating
22:07
dimensionality of the patient. So we end with other group and may have
22:12
plenty to start looking at the extent of the supramarginal resection, be John, the margins of
22:18
the contrast enhancement and tumor. And we have seen that regarding this topic,
22:24
that is B has been replaced by results from the from the boot,
22:31
results from external precession beyond the margins in the luxury player them as we see here,
22:38
very important papers from the MD Anderson, from Hopkins, from Cleveland Clinic, and from UCSF.
22:46
And not all of them have homogeneous results as we
22:52
found before in the, in the Coursera restriction for the T1 contrast.
22:59
So we're going to give it a shot. And thanks to all of the data
23:05
that we have made a clinic without the high flow of patients we were, we were able to do
23:11
this study in which we identify more than 800 patients and we selected
23:17
only those patients that were IDH mutants. This is the most aggressive type of
23:22
GBM that has a, a, a, a less overalls Bible in total only selected those patients.
23:30
That had a grocer urbanization of the contrast enhancement.
23:36
And that they did present before the surgery with some degree of pre-operative pillar.
23:44
So in total we including 101 patients, we we perform all photometric analysis
23:51
on all the sequences in the, in the contract and constant in DNA cross is part and in differ for all the patients.
24:00
And we did find a univariate, multivariate analysis that the increase
24:06
in SMR as a continuous viral for the first time we showed that is that is statistically
24:11
significant for an increase and improve overall survival in our patient population.
24:18
And furthermore, when we perform a nutritional analysis, we found that those restrictions
24:24
about 20 percent and 60 percent of words that were related with a significant increase in number algebra,
24:31
Bible. So to summarize our findings, we did this illustration that
24:38
shows that the green part and they were in proportion, or the percentage is from
24:44
above 20 and 60 percent were related. We can improve plurals for Bible. And we didn't find a significant benefiting
24:51
those restrictions about 60 percent, that is the red portion of the figure here.
24:57
So now we know that increasingly summarize beneficial for, for, for,
25:03
for finding profiles for wavelength in our patients would IDH type wild-type GPM.
25:09
But we know that there's a falsely high variability in their ideological presentation of
25:16
our group in general and GBM, but also in ideation. So we partner with
25:21
the mathematical neural colleague laboratory. I may have been the Arizona with Dr. Christina. So insulin to try to
25:29
further personalize they they they are to try to be more specific with
25:38
using a specific patient characteristics from their ideological data.
25:43
And we can see that follow in our hypotheses at the center of the, of the, of the, of the lesion.
25:51
They wonder is in close proximity with the contrast enhancement our acid greater or more burden.
25:58
So our concentration over there. And once you're going to the periphery, you see that the low density,
26:04
the density of these tumor cells is, is slower. So this is the formula that we
26:11
use in our patient population. In summary, for dangerous or down, you can see that in the one with contrast,
26:18
devolving was approximately one is spherical shape. And we saw that they, these hard,
26:25
this portion has a greater cell density compared to the cell density in the T2 flair.
26:33
So with these results, we classify our patient population
26:38
in three groups that were nodular, moderately diffuse, and highly diffuse according to their,
26:44
to their, to their, to their tumor cell density and distribution profile.
26:50
So this is a representation from some of the patients that were
26:56
selected and classify and including this. Groups, you can see here and binocular, they have more contrast enhancement
27:04
than blur and seeing them well it'll diffuse. You see that there is a, some more player in the patient's surrounding
27:10
a tip as well lenient on T1. I think the highly perfused you see that
27:16
the variance is greater than the other groups. So producing the univariate analyses,
27:23
we saw that the US seem statistically significant only for moderate
27:29
and diffuse and highly diffuse. Okay. But it wasn't significant or not there.
27:34
This is in univariate. And the same results were obtained for a multi-barrier now that we see was
27:41
statistically significant for monetarily and how they diffuse or another by when we perform a treasure analysis,
27:48
we saw that the nodular there is actually a benefit only in
27:54
resections from 10 to 10 percent. And this is kind of
27:59
logical because the Northern learned there is not much clear as we showed you in the in the MRI before.
28:07
So there's no much benefit in extending the intersection beyond the
28:12
20% of the contrast enhancement. And they know the red group in their motherly diffuse,
28:18
we found benefits from all the way up to 50%. You can see here in the highly diffused,
28:25
we only saw benefits beyond 30 percent, all the way up to 90 and 90 plus percent.
28:32
So this is very important because now we can, based on this study,
28:38
at least in these results, we see that there is a very important benefit in the,
28:44
in the supramarginal resection of these patients. And of course, based on
28:50
their biological characteristics before the surgery, the surgeons can decide
28:56
how much the patient can need a, need a resection, and extent of resection base and decent.
29:02
For example, in these highly tumors, we found that this is the maximum SAMR really
29:10
correlated with Albert DeSalvo. So bible, you can see that the patients that had every section
29:15
above 90 percent with they once had a better overall should, why would that be one that
29:21
had less than 90 percent? And these patient populations had a greater survival of, let's see.
29:29
If I remember correctly, almost nine months greater than the patient that had a resection or with less than 90 percent.
29:37
For them modally diffuse, the highest SAMR percentage was 50.
29:42
And these patient presented with a benefit. I'm opening up an additional seven months.
29:50
And in the nodal or patients, the highest maximum significantly co-related would be shallower
29:57
as Weber was 20 percent. And these patients had a, a, an additional overall survival or 10 months.
30:04
So to summarize, for all our findings, they might go it's an iron or elsewhere Bible in ideas,
30:09
whilst the CAPM is influenced by the degree of tumor invasiveness, a result showed an increase
30:15
in SMR is associated with they suddenly become beneficial overall survivor in moderate and highlight the idea that GBM,
30:22
I did that in traditional analysis 90, 50, and 20 percent work on the upper limit,
30:27
That's MR. percentage associated with They'd been a pizza overall survival and kind of diffuse mode earlier refused.
30:33
I know that are timeless respectively. So that's all that we have for today.
30:40
Thank you very much for attending any questions.
30:49
Great work. Really interesting stuff. And I don't really do tumor work anymore.
30:56
But one question I had from my perspective is this all seems to make really good sense to me given the nature
31:01
of gliomas and how invasive they are into the brain. If you're able to resect the rim around the tumor,
31:07
you'd have better survival. I'm just curious. Do you think there is any kind of
31:12
selection bias as to who does better based on just where the tumor is. Because if you're next to an eloquent area,
31:19
of course he can't do that. Or how did how do you mitigate that isn't does that mean more awake
31:24
surgery for these tumors, which I know we do a lot of here, but maybe other places don't do so much.
31:31
So what do you, what do you recommend about that? Yes, of course, we will
31:36
talk about beta for dangerous of time. We've already included here, but yeah, tumor occasional was so associated with it.
31:43
The overall survival of patients and of course, obey of the tumor,
31:49
they were located you plug child areas are where we had a deeper location or proximity with the actual ventricles
31:56
had a a worst prognosis. And and of course, I mean, it is easier to add
32:02
to a greater restrictions on, on, on those tumors that are located a non elephant
32:07
parts of the brain, of course. So, but yeah, but to mitigate those challenges,
32:14
we recommend that, you know, most of the cases that can be should be
32:20
performed with an awake brain surgery, you know, in, in correlation with
32:25
narrow physiological monitoring and all these two to try to prevent any further functional.
32:33
Now, BAM machine, the patient has been proven also.
32:39
And he doesn't matter how great the restriction that he said
32:44
accomplish if they don't cost that much in the functionality of the patient. All these benefits will be overcome by day.
32:53
They decrease overall survival and the quality of life of the patient. If they have a a a baby up their surgery.
33:00
Yeah. I mean, that's a really good point because that data is out there with the, with the neurologic deficit there,
33:06
any survival benefit goes away. Watching the tight rope between
33:12
resection and maintaining neurologic function. And very interesting, great work.
33:17
Well, congratulations to all three of you. This is truly amazing as I put in the chat, I'm, I'm,
33:23
I'm frequently blown away by what our fellows are doing, how hard you guys all work in
33:30
all three shields and your dedication is truly incredible. So it's
33:35
a real pleasure to work with you guys. And I made them feel very fortunate to to have that opportunity.
33:42
So there are not any other questions. I think we're 759,
33:47
we're right on time and hope everyone has a great week. Thank you for joining us and see you soon