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hundreds of case-based microlearning courses

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Today, we're honored to welcome

0:41

Dr. Alka Singhal for a lecture entitled, "Role of

0:44

Ultrasound in Pediatric GI Emergencies."

0:47

Dr. Singhal is a radiology postgraduate from

0:50

SMSMC, Jaipur, India, and has over 28 years

0:54

of global radiology experience and has worked

0:57

and trained in Sydney, Australia, and the US.

1:00

She is currently Associate Director of Radiology at

1:02

Medanta Hospital, Delhi, India. And beyond radiology,

1:06

she's also a quality champion working on

1:09

constant improvement of services and training.

1:12

She has various publications and presentations in

1:14

national and international journals and conferences

1:17

to her credit, and is also the Associate Editor

1:19

of the Indian Journal of Radiology and Imaging.

1:22

At the end of her lecture, please join her in

1:24

a live Q&A session where she will address

1:26

questions you may have on today's topic.

1:29

Please remember to use the Q&A feature

1:30

to submit your questions so we can get to

1:32

as many as we can before our time is up.

1:35

With that, we're ready to begin today's lecture.

1:38

Dr. Singhal, please take it from here.

1:41

So, welcome all.

1:42

So today we are going to talk about the role

1:45

of ultrasound in pediatric GI emergency.

1:47

So, I'm mainly going to focus on

1:48

non-traumatic, the bowel area.

1:51

I think that's the focus of

1:52

our, uh, learning today.

1:56

So, and that—

1:59

However simple it may sound, it is one of

2:02

the most challenging examinations for the

2:05

even most experienced, uh, radiologists.

2:08

So why? Of course, for obvious reasons—the

2:14

child is not going to be able to give the history.

2:16

Pain is the most common presentation.

2:18

And of course, there are numerous differentials,

2:21

and you cannot definitely communicate, right?

2:24

So, however, there is a learning curve to it.

2:28

The good news is there are characteristic features,

2:31

which once we know how to understand and evaluate,

2:34

it does get simplified.

2:36

Let's understand what they are.

2:38

So basically, what is our focus?

2:41

Our focus is to diagnose the

2:44

conditions into the medical and surgical.

2:46

63 00:02:48,015 --> 00:02:51,225 So, those requiring urgent surgical intervention.

2:51

So they must be promptly diagnosed. Accordingly,

2:54

the intervention can be done, right?

2:57

And ultrasound is the primary tool,

2:59

right?

2:59

So let's have a look.

3:01

The commonest modalities that we encounter in

3:03

our everyday practice—of course, most common is

3:06

appendicitis, followed by intussusception, hypertrophic

3:09

pyloric stenosis, depending on the age of the baby.

3:12

And of course, other rarer causes

3:14

could be volvulus or diverticulitis.

3:16

And of course, a long list of abdominal differentials,

3:19

which often overlap with mixed clinical picture,

3:24

and making our evaluation a little more challenging.

3:28

So we have different ways to look at them,

3:30

depending upon the age of presentation. Because when

3:33

the child presents to you, the first and the foremost

3:36

feature that is there with you is: How old is it?

3:40

What's the age bracket?

3:41

Is it neonate

3:42

you're dealing with less than a month?

3:44

Are you dealing with less than one year?

3:46

Are you dealing with a child between

3:48

zero to two years, or two to five, or five

3:51

to 12, and so on. Up to two years of age,

3:55

what are the components

3:56

differential diagnosis? Surgical emergencies are

4:00

intussusception, intestinal malrotation, pyloric stenosis,

4:04

duodenal obstruction, and incarcerated hernia.

4:07

And of course, these all have very characteristic

4:10

symptoms, so if you have a caregiver/parent to

4:13

give you the history, that's very, very helpful.

4:16

So, you have red currant jelly stool for intussusception,

4:19

intestinal malrotation—vomiting, distension.

4:22

This is, of course, again a very common overlap.

4:25

Pyloric stenosis is projectile non-bilious vomiting.

4:28

That's very characteristic.

4:29

Duodenal obstruction is again a bilious vomiting,

4:32

and incarcerated hernia is, of course, swelling, and distention, pain,

4:36

and there may be signs of obstruction, right?

4:40

Obvious.

4:41

So between two to five years of age, you

4:43

have—depending upon the type

4:46

and the location of the abdominal pain—

4:49

commonest differential in this area is

4:51

of course acute appendicitis, and you have

4:54

intussusception, malrotation, volvulus, and others.

4:57

And medical differential diagnoses,

4:58

however, are hepatitis, pyelonephritis,

5:02

constipation, mesenteric adenitis.

5:04

Right? Now, coming to five to 12-year group.

5:07

Again, appendicitis is the top on the list, followed by

5:10

intussusception, volvulus, or intestinal obstruction.

5:15

So, over 12 years—almost with an

5:17

overlap with an adult clinical picture—

5:19

so you can have appendicitis and renal or

5:24

ovarian torsion, rarely, ectopic or extra-abdominal causes,

5:28

acute torsion of the testis and other

5:31

abnormalities. Various other abdominal

5:35

differential diagnoses are there in the clinical spectrum.

5:38

Now coming to our focus— the ultrasound technique,

5:42

and how do we go about the approach, and how do the differential diagnosis. Right?

5:48

So, adults, we've all practiced and begun ultrasound

5:52

scanning. A child, of course, is a challenge.

5:54

The size is small, the depth is small.

5:57

So, of course, we'll use the highest frequency transducer

5:59

that gives us the required depth of penetration.

6:02

We will use both curvilinear transducer and the linear

6:04

transducer to get the required depth of penetration.

6:07

The most important thing to evaluate

6:09

the bowel is whatever area you want to evaluate—

6:13

So, we may often have a little bit of fluid in that area

6:16

to distend that area and then do the scan.

6:20

So this is a simple logic that we apply,

6:22

even if you're wanting to evaluate the

6:23

pancreas, I want to have a nicer window.

6:25

I may get the adult patient to drink water,

6:28

or get a water bottle for the baby ,

6:31

so that I have a nicely distended stomach,

6:33

so I can visualize the pancreas behind it.

6:36

Similarly, if I'm trying to evaluate for a pyloric

6:38

obstruction or any other obstruction—provided the

6:41

surgeon has not put an NPO on the child already—

6:45

as they're very strongly

6:46

clear of the diagnosis clinically,

6:48

so you can always ask the child to drink

6:50

a little bit of water. That will help you.

6:52

And what about the ultrasound technique?

6:54

We'll adopt a graded compression technique, right?

6:57

So we are trying to displace the bowel, and we

6:59

are trying to use gradual compression to actually

7:02

narrow down to the area of interest and

7:05

evaluate the area of pathology in great detail.

7:11

Of course, we will do longitudinal and

7:13

transverse, and we'll use all modalities—color

7:16

Band Doppler, right? Before looking at abnormal,

7:20

as you've all learned, we should know what is

7:22

the normal and what is the normal gut signature.

7:24

As we all know, we have a central lumen,

7:27

which is hyperechoic, and the innermost

7:29

mucosal layer may be hyperechoic.

7:32

And then we have a muscular layer, and then you have

7:35

an outer serosal layer, which is echogenic, right?

7:38

So this is what we broadly are able to see

7:40

on ultrasound imaging, and the same area is

7:43

replicated on the transverse image as well.

7:46

Uh, so what we have—we have in the central,

7:49

the lumen, the echogenic mucosal lining, and

7:52

the submucosal lining, and then you have

7:54

the muscular layer, and then the echogenic layer.

7:59

So once you understand this—

8:02

this becomes very important when you're trying

8:03

to evaluate your appendix perforation, right?

8:06

So there'll be, of course, when there's

8:08

perforation, there'll be loss of this mucosal lining

8:11

continuity, as we will see in the cases to follow.

8:15

Right?

8:16

So let's have a look now.

8:20

Uh, so let's discuss each pathology in detail.

8:24

And one second.

8:26

So the commonest, or the first and the foremost of

8:28

our concern is the acute appendicitis, and it's the

8:33

commonest cause of acute surgical abdomen in children.

8:36

As we all know, characteristically, of course, is

8:39

the right lower quadrant pain and tenderness, and—

8:45

Okay, so common is—of course there's pain,

8:49

vomiting, fever, leukocytosis. Ultrasound is the

8:52

most important modality in diagnosis here, of course.

8:56

Um, and it is diagnostic actually, if it's done very—

9:01

uh, well. Graded compression technique is adopted,

9:05

and you can see inflamed appendix as an ap-

9:08

peristaltic, non-compressible, thick-walled, tubular

9:12

structure of more than six millimeters in diameter,

9:15

hyperemic, which you'll see

9:17

with color Doppler imaging.

9:19

And you may or may not be able

9:20

to see an appendicolith.

9:22

And in cases of any perforation or complication,

9:24

you'll see an abscess or a lump alongside.

9:27

And of course, the peripancreatic fat stranding

9:30

and echogenic fat may be noticed.

9:33

Local ileus may be seen. Free fluid,

9:35

ascites—mild or localized—may be seen, right?

9:40

So.

9:41

Why is there a challenge?

9:42

Because of the varying presentation,

9:47

clinical presentation, varying location of the

9:50

appendix, and of course, varied chronic

9:55

and acute and various other clinical scenarios.

9:59

As you all know, we see a tubular, blind-

10:01

ended structure, which is non-compressible,

10:04

and that's how we see it on a transverse.

10:06

So we should try and get a perfect true

10:09

cut—transverse, not oblique—so we can get

10:12

a clear picture of the pathology. Clinical

10:16

presentation, as you've already discussed.

10:18

So, ultrasound by literature, of course, is

10:21

highly accurate in the diagnosis of

10:23

appendicitis, with a sensitivity of 44 to 94%—

10:28

a great range suggesting there is a lot of

10:32

operator experience that is involved in this.

10:36

So in experienced hands, you can have

10:38

very high sensitivity and specificity.

10:41

However, there is a learning curve to it.

10:44

So, as we discussed, graded compression is

10:48

used, so we displace the bowel loop and compress,

10:51

and see. And we can—we should be able to

10:55

see the iliac vessels, psoas muscles, and

10:57

appendix, which will usually be found anterior to these.

11:00

And of course, we'll look in both

11:02

transverse and longitudinal images.

11:05

Now, where is the normal appendix located?

11:07

Simple logic.

11:08

That's where our scanning will begin

11:11

when we are looking for appendix, right?

11:12

As we all know, the appendix—we

11:14

have to go to the ileocecal junction.

11:17

So we'll begin with the identification of

11:19

the ascending colon, which appears as a non-

11:22

compressible structure containing some fluid, and then

11:24

you move it inferiorly to identify the cecum,

11:28

which is easily compressible

11:31

in the space at the dentate status.

11:33

And there you will find the appendix

11:37

as another tubular structure coming out of it.

11:40

Right?

11:41

So, what are the typical findings of appendicitis?

49:51

You can have acute pancreatitis as another

49:53

differential diagnosis, and acute on chronic

49:56

pancreatitis, where you can see stones formation.

50:03

Colic can be another differential diagnosis

50:06

where you can see stones in the lower abdomen.

50:10

They could be at the renal pelviureteric junction.

50:14

They could be seen lower down, uh, at the

50:19

ureterovesical junction with edema.

50:22

They could be the site of the, uh, uh,

50:25

at the prostatic urethra, and they

50:28

could be again in the penile urethra.

50:31

So at various levels, you can see. Of course,

50:34

these are not pediatric patients, but just,

50:36

uh, uh, to give an idea what you can expect.

50:40

Ovarian torsion can be seen in as young as, I think,

50:44

I've seen a 9-year-old, and I think you can see there

50:48

are cases that have been seen much younger. So, right.

50:53

There have been case patients who have been

50:57

referred for per appendicitis, and I remember

50:59

a 9-year-old and I calling the diagnosis, rather.

51:04

So, like we have a 2 per 3 with no

51:08

flow, peripheral echogenic follicles.

51:10

You can see and diagnose, and you can also demonstrate

51:13

the whirlpool sign of the twisted pedicle.

51:16

And of course, that is very

51:17

confirmatory, very reassuring.

51:19

And, uh, again, the whirlpool sign.

51:23

In that same case, viability of the—

51:25

we must try and diagnose as soon as

51:28

we can so we can operate it and save.

51:31

Save. Other differential diagnoses which can

51:35

mimic and confuse and, uh, challenges could

51:39

be lung pathologies, could be testicular,

51:42

torsion, lower abdominal pain, which could

51:44

also confuse us in the differential diagnosis.

51:47

So, coming to the conclusion—approach and differential

51:50

diagnosis in the pediatric acute abdomen depends

51:54

upon the age and the symptoms, and ultrasound

51:58

is supportable, easily available, non-invasive, and plays a

52:01

pivotal role in the diagnosis of GI pathologies.

52:06

And it's simply a learning curve, and

52:09

it's easy and it's very rewarding.

52:12

Thank you so much, everyone.

52:14

Thank you so much, everyone, for joining in.

52:16

If there are any questions, I'm happy to take them.

52:19

Thank you.

52:24

Thank you so much for sharing your lecture.

52:25

At this time, we'll open the floor

52:27

for any questions from the audience.

52:29

You can submit a question through the Q&A

52:31

feature, and Dr.—you could see, yeah, I see

52:34

seven questions in the Q&A. Awesome.

52:38

So I go ahead to reading the questions.

52:42

Absolutely.

52:44

So some—we find it difficult to decide whether there

52:47

is intussusception or is it a transient twisting, whether

52:52

we should follow up, as ileal is transient mostly.

52:55

Yes, that is correct.

52:56

So you just re-scan after—oh, one second.

53:01

I just, uh—

53:11

I'm back.

53:13

Okay.

53:14

So yeah, of course you would like to, uh, redo it.

53:17

You have to redo it, right?

53:19

Uh, 30 minutes, as I shared in my talk.

53:22

Right.

53:22

Thank you so much.

53:23

So, coming to the next question, um, uh—

53:27

by, uh—when do you do MRI in a patient

53:31

suspicious of appendicitis?

53:33

Um, we haven't really—we usually do a CT, so.

53:40

So I think ultrasound pretty much is very helpful.

53:43

The CT is also less often done in the pediatric

53:46

age group, but yes, we—was—thank you.

53:50

So, and, uh, that's done.

53:54

So next is, what's the outer cutoff diameter—

53:58

appendicitis of more than six millimeters

54:00

is what we—what the literature says.

54:03

Okay, thank you.

54:05

So, are the surgeons comfortable taking

54:08

patients to surgery based on ultrasound alone?

54:10

Like, there are clinical findings, there are

54:13

clinical parameters, and there—of course there's a lot

54:16

of, uh, things with the confidence of the radiologist

54:20

and the confidence of the surgeon that he has.

54:22

So, depending upon your confidence

54:27

in diagnosis, demonstration

54:29

of the pathology,

54:30

I'm sure the surgeons will definitely

54:32

get the patient up to surgery.

54:33

If you have those nice clips to demonstrate

54:35

that that's what's happening, and you have those

54:37

nice images to demonstrate and they come and

54:40

they see the pathology, they're very convinced.

54:42

They'll definitely trust you and take you.

54:45

I mean, like, I know I do a lot of neck,

54:47

thyroid, parathyroid ultrasound work.

54:49

The people take my—I'm very glad

54:52

to have, uh, come up to that level of

54:53

confidence, that when I communicate it's very

54:57

effective and it's taken with a lot of trust.

54:59

So, uh, again, it's a lot.

55:02

Ultrasound is such an operator-dependent modality.

55:05

So a lot depends upon the confidence.

55:08

So the range—44 to 95%—so the

55:12

sensitivity and specificity range for

55:14

the diagnosis of acute appendicitis.

55:16

So there is a lot of difference because that

55:19

difference actually is coming from the learning

55:21

curve, the experience, settings, and eye. So, to my

55:27

answer to your question, are the surgeons comfortable?

55:29

I would say yes, depending upon

55:31

your confidence level.

55:34

Okay.

55:34

Thank you.

55:35

So this is all done.

55:36

That's also done, uh, as it pertains to

55:39

bowel obstruction seen in intussusception

55:42

or internal pediatric cases.

55:43

Is there a standard objective measurement

55:45

to classify obstruction based on age?

55:47

Is it a subjective assessment?

55:49

We, we already discussed the numbers, right?

55:51

More than three millimeters or more than four

55:53

millimeters is the thickness of the—uh, oh,

55:57

that's, uh, you're talking about intussusception?

55:59

No.

55:59

Yeah.

55:59

You can actually see the—it's the, it's

56:02

the target sign and the sandwich sign,

56:04

basically the subjective assessment.

56:06

Yeah.

56:07

Okay.

56:08

Thank you.

56:09

Next, is there any ultrasound

56:11

criteria for mesenteric adenitis?

56:13

Oh, you see the lymph nodes, right, and you see the

56:16

size, and you see the character, and then you report

56:19

them, and you report the location because these can,

56:23

uh, of course they need to be treated and followed up.

56:28

They can—as you see, they can become lead

56:30

points for further pathologies to happen, right?

56:35

Okay.

56:36

Uh, can you show slides for

56:38

preparation of hydrostatic reduction?

56:40

Do you do X-ray abdomen, not

56:42

perforation before the procedure?

56:44

Uh, it's, uh—perforation is

56:47

clinically, uh, suspected.

56:51

We, uh, we haven't normally done, uh, our

56:54

pediatric department—uh, pediatric doctor

56:56

joins the ultrasound department, and that's

56:59

where we do the hydrostatic reduction as a team.

57:03

So normally X-rays are not done

57:06

unless they are really suspecting it.

57:08

I mean, then they would probably just attempt

57:10

it in the OT only and then take a call there.

57:14

Okay, thank you.

57:16

Uh, please explain more about hydrostatic reduction.

57:20

I think we had a nice long—I added lots of

57:23

slides for the same, so thank you so much.

57:28

Um, uh, madam, node size criteria

57:32

for mesenteric lymphadenitis—uh, I

57:35

mean, lymph nodes can be as small.

57:38

The SADs are up—three millimeter, four

57:41

millimeter, five millimeter, six millimeter.

57:43

We just measure the SAD—short axis

57:46

diameter—and we quote them.

57:48

There is no size criteria, as, uh,

57:51

as per literature that I've seen.

57:53

So whatever I see, I report, because even those

57:56

tiniest of those lymph nodes—hypertrophic Peyer’s

57:58

patches—those can also become the lead point.

58:01

So we just have to document them

58:03

if you see.

58:05

So how many you see?

58:07

Are there clusters or bunches, or what do you see?

58:10

Just gives you an idea of what's

58:12

going on inside for the physician.

58:17

Okay, thank you.

58:19

The next—explain pyelospasm again.

58:23

Pardon me—right, so that's like

58:27

a spasm, like a uterine contraction.

58:29

Like it's transient.

58:30

So you just have to wait and you just have to

58:33

evaluate it again and you'll see a different

58:36

reading of the length of the ureteric canal.

58:39

So when you go, "Oh, it was—now it's this."

58:42

"Oh, now the reading is changing."

58:43

"Now the reading is changing."

58:44

So that's when you go, it's probably just a

58:47

temporary spasm which is coming and going away.

58:49

So that is something you must always exclude

58:52

before you give a diagnosis of, uh, HUN.

58:58

Okay, so that's done.

59:00

Next is—please explain hydrostatic

59:03

reduction slide once more again.

59:06

Okay, I think we'll go to the recording for now.

59:09

And, uh, it's, uh—how easy it is to find an

59:12

inflamed appendix, and it's loaded with a scan alone.

59:15

Like I said, it's easy.

59:16

First of all, we need to know

59:17

the normal anatomy—where is it?

59:20

And then what are the possible

59:22

locations of the appendix?

59:23

Of course, uh, as we all know, by

59:26

anatomy, you can have a subhepatic,

59:29

pelvic, or characteristic location.

59:31

So you will look there.

59:34

So basically, the idea is to go to

59:35

the terminal ileum–ileocecal junction.

59:38

That's where you'll find it.

59:39

And it can be pointing in any, uh, direction, right?

59:43

So once you start with that area and you do the graded

59:46

compression technique, it is—it's possible to do so.

59:51

To answer how easy it is—

59:52

find it, it is easy.

59:54

We can exclude it with the scan again, uh, alone.

59:58

However, it is challenging.

60:01

It's easier said than done.

60:03

And of course, whenever you are in a dilemma,

60:06

seek support from your colleagues. There

60:08

is a learning curve. Your confidence level

60:10

will increase as you do more and more

60:13

cases, and you get more and more follow-up.

60:15

And, uh, you'll be able to give a confident diagnosis.

60:19

So use the transducers—use the linear, the

60:22

curved, and the other transducers—whatever

60:24

gives you the tip, and, uh, follow it gently.

60:28

You'll be able to. It requires

60:30

patience and evidence—your support.

60:33

And, uh, is there any clinical

60:35

significance of minimal pyloric thickness?

60:37

No.

60:38

So, it just says over a certain point.

60:43

So that's why they said the smaller,

60:44

the borderline ones—they may just

60:46

resolve over a period of time.

60:48

You just do a follow-up and you just

60:49

measure because the child may—they may be

60:53

like between three millimeters and none.

60:55

There may be something in the middle, right?

60:57

So which may, uh, recover or which may

61:00

go to pyloric hypertrophy or stenosis.

61:02

So you just need to follow them up.

61:05

So—

61:05

yeah, that's it.

61:07

Thank you.

61:08

How long does intussusception take to become obstruction?

61:15

Depends on the symptoms, and I haven't known of this.

61:19

It, it depends upon the clinical

61:20

condition, duration.

61:21

How long does it usually take?

61:24

I, I would say—but varying from case to case,

61:28

not that I've ever, ever observed this finding.

61:30

So how much time can you wait?

61:33

I think that's probably—

61:35

clinicians may know better.

61:38

And can you confidently differentiate between EO and—

61:44

I mean—

61:45

It's basically what we are talking—

61:47

is small bowel inside small bowel and

61:49

large bowel inside large bowel.

61:51

So one is, of course, the anatomy—uh, the

61:55

wall thickness, the outer wall thickness, the—

62:00

mistake in the receiving segment.

62:03

What's the thickness?

62:04

Of course, uh, in cases of ileocecal, that would

62:07

be more, and that would not be that much thick.

62:12

This can vary, though.

62:13

And of course, uh, location in the abdomen.

62:17

So if you see a target sign in the right iliac fossa,

62:21

you’re more likely dealing with ileocolic, and

62:24

usually you'll see that maybe higher up,

62:27

usually often in subhepatic or other areas.

62:32

And, uh, please explain about particular number.

62:36

So when you see—when you see

62:38

just an inflamed appendix

62:40

with or without a lid, and just

62:43

hyperemia—that's just appendicitis.

62:46

However, if you've had any perforation or

62:48

any leak or any abscess or any collection—

62:51

or anything—all these we put in,

62:57

then it has to be, uh, managed accordingly.

63:01

Okay, thank you.

63:02

Same lymph node size criteria.

63:04

Again, I said I just measure whatever size I'm seeing,

63:07

and I document that. When you suspect sequelae—is it, is there

63:12

any sign on ultrasound? And next step—I mean, the

63:15

step is definitely to go for a CT, where you really

63:17

suspect but there's a lot of bowel gas in front, and

63:20

you think it's there, but it's right behind there.

63:23

But whatever maneuvers you do to the patient—

63:27

to turn left and right—so you can avoid the

63:28

bowel gas, and then you can try and scan behind.

63:32

But if you can't do it, you just can't do it.

63:34

You have to go for it. If it's clinically—

63:37

there is a very high depth of suspicion and—

63:39

that’s what you suspect, next step is CT.

63:42

CCP scan—beautiful cases.

63:44

Oh, thank you so much, ma'am.

63:46

Thank you so much.

63:47

You should come back in another class

63:49

with the rest of your cases—more time.

63:51

Oh, thank you so much.

63:53

That's so encouraging and so refreshing.

63:55

Thank you so much.

63:56

And thank you to all my colleagues who

63:58

supported with these wonderful cases.

64:00

Thank you so much.

64:01

Thank you.

64:03

Okay, so—wonderful.

64:05

So—excellent conference.

64:07

I'm a professor of medical sonography.

64:10

Oh, wow.

64:11

Thank you so much.

64:12

That's wonderful.

64:13

Thank you for your appreciation.

64:14

Thank you.

64:16

Like that.

64:17

And pylorospasm and pyloric stenosis

64:19

could be said to be the same thing.

64:22

Spasm will come and go.

64:25

Pyloric stenosis is a hypertrophy of the muscles.

64:27

So if you re-scan after a certain time or over

64:31

a period of time—what disappears maybe that

64:34

was just a spasm, or that was just the early

64:36

borderline scenario. But what you label as pyloric

64:40

stenosis is something which may probably need

64:43

a surgical intervention or another management.

64:45

So they're different.

64:47

They're not the same.

64:48

That's the answer.

64:49

Okay.

64:50

Thank you so much.

64:51

All open questions have been answered, and I really, really

64:55

thank you for all your questions, and I thank you to

64:59

all the 250+ people who logged in and, uh,

65:05

were listening live to this—uh, to this talk.

65:08

Thank you so much.

65:09

To each and everyone, thank you Amara and LINE

65:11

for the wonderful platform and opportunity to—

65:15

Dr. Singh, thank you so much for

65:17

delivering your lecture and all

65:19

the Noon conferences you deliver for us.

65:20

They're always amazing, so we appreciate

65:22

you coming back to give us another one.

65:24

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65:26

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65:29

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65:31

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65:33

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65:36

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65:39

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65:44

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65:50

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