All right, welcome everyone. So today we have the distinct pleasure of inviting Dr. Oli Reza's Somsha Shahz, otherwise known as Shammy. Dr. Shammy earned his MD at the Tehran University of Medical Sciences, prior to completing his residency in OBGYN at the University of Iowa. He then completed two clinical fellowships, one in the maternal fetal medicine at the University of Connecticut, followed by perinatal surgery at Baylor College of Medicine in Texas Children's. He then built quite an impressive career at Texas Children's, whereas clinical interests and expertise focused on providing care to complex high-risk pregnancies and the practice of fetal intervention. He was one of the leaders in the development of the maternal fetal surgery program at Baylor College of Medicine, where he performed more than a thousand fetal surgery procedures. His academic record, there has been quite as impressive as well, yielding over 200 peer reviewed articles and a tenured professorship in the Department of OBGYN at Baylor College of Medicine. He served as a chief of fetal surgery, fetal therapy and surgery, the co-chair of the fetal center for steering, the fetal center steering committee, co-director of the perinatal surgery fellowship, co-director of the maternal fetal surgery program at Baylor, and that was all until his recent move here to Boston and Harvard Medical School. As we look forward to his future here with us as the director of the Maternal fetal Medicine program, we are very excited to hear his talk today on fetal surgery for neural tube defects. Thank you. Thank you very much for the great introduction. Good morning, everybody. And now that we do have a little bit of the time constraint, what I do today is I only give you a little bit of the landscape of what's going on for it in uterus surgery for neural tube defects worldwide. Okay, so far I don't have any conflicts of interest. Objective is most of the focus of the in uterus repair for today. I don't get too much of imaging, you know, majority of people here are surgeon. I do talk about different techniques in the criteria for neural treatments and also some current ongoing research around the world. NCD, common sporadic, and we can prevent some of those with giving the forecast to the mother. There's a hypothesis of a two-hit hypothesis that's why the fetal surgery makes sense. Through that, you know, it's fine. That BFF, if you want to divide it, we divide it to the open and close. I don't talk about the close at all today. On an open one, we had a mitochondrial cell. That means we had a sac and then we had a flat legion called as a mildous chisis. This is on the left side that you can see the mitochondrial cell and then on the right side you can see the mildous chisis case. The two-hit is coming from one. The first-hit has a congenital anomaly and then the second-hit we talk about is the disability, partially due to ongoing damage from in uterus environment. Usually we think about the amythic fluidity toxic to the neurons and that's why the fetal surgery makes sense. About 10 years ago when we started doing the fetal surgery for in uterus repair, you know, the front things came to our mind is, you know, sometimes when we do the surgery on the big lesion and those are the mitamine and the cell, usually the lower extremity outcomes in these kilos are worse. And then we come up with an idea of maybe, you know, there's another mechanism of what we call it as stretching to the nerves. And through that, you know, we had a couple of publications. We figured out the ones that had a cystic entity. We had a worse lower extremity movement and lower extremity activity. And through that, we figured out that if the sag is become bigger, then the outcomes are worse. In the same token, you know, we did a couple of studies that I don't go to the detail, but with that said, we come up with a new hit theory for, we call it a 30-thirty theory for the entity. And then at the same token, the people from Trump did the same type of study and they figure out that when the sag is getting bigger and bigger, then your lower extremity movement will be less. And then you had a club foot, you know, higher when the sag become bigger. Imaging is very important, but because with the imaging, we can stratify which patient needed surgery. And there's a tons of things we can see on imaging. We divided to the ultrasound, that with the ultrasound, we can get some screening tools. And then here, as you can see, is it, is it minus kisis, is it flat lesion. And then with the MRI, you can get more information regarding the key RNA formation and the rest of the information from what we need for a fetal intervention. Again, I don't get to the details, but again, imaging of NCD is another lecture, is one hour lecture for sure. And this is the case, you can see it, that had a sag lesion. And somehow, I don't know what happened, but the OBGYN love about everything is about the food. Therefore, there's banana sign and the lemon sign and everything else is coming down from OBGYN's board. And these are the things that we use for describing the head of the fetus that I don't think is etically right. Coming down to the high-burned head, this is very important for a fetal intervention, you do need to have a high-burned head, this is the fetus that doesn't have a high-burned head, but when you're coming down, you see the different staging of the high-burned head, the other type of the fetus. Ventical omega is very important. Usually, we measure how big is the venticals. And the reason is, we figure out through it years and years that when the venticals are so big, and they're usually cut as a CV ventical omega when we do the fetal intervention, these kilos does not have any benefit for our ventical appearance. We look at the movements, and this is a clave. You almost get the movement on an ultrasound or lower extremities. We look at all of these criteria for the imaging before we want to do the intervention. Now coming down to the technique of the intervention. This is the mom's trial. There was a randomist trial. They look at the in-utriarch treatment regarding post-natal repair, published in New England, June of back in 2011. True that, they did have a primary outcome for a reduction of the shunt that the significantly reduced the shunt by the half. And also the secondary outcome was coming down to the improvement of motor function. And if you look at the motor function, still is it had a very good motor function for these kids at 12 months of age. But the issue is still, when we look at those data, still half of the baby is not independently worked. And the side effect is increased pre-tembirth. This is the issue with the fifth intervention. Increased risk of histrotomy, the histone. This is one of the nightmares that we have. That means in a mom's trial, when we look at the data, one third of the patient at the time of delivery, these had some kind of the histone. And that's a dangerous thing. Because the histone is a proxy of uterine rupture. And by default, all of these patients, when they had an open fetal surgery, they need to have a elective C-section at 36 weeks. And not only is it morbidity to the mom, but also in the future pregnancy, you also worry about the uterine rupture and placenta factor to the spectrum. Open hysterectomy, this is what happened. As you see, this data is back in 2018. It's widespread around the world. The people adopted, the people started doing it. There was a loss of discussion between the mom's trial and the other centers. Especially, the people from the child was very territorial of the thing. It need to be re-ferral, but the other people think it need to be spread out. And through that, we make it some registry to a math net to follow these outcomes and see how this baby do after the surgery and how the mom doing the surgery. The principle of the surgery is we do it, we open the abdomen, be mapped in uterus, make sure we are away from the placenta. We do have some kind of staples that the technique we opened it to the uterus in a way of the anchored membranes to the uterine wall. This is, then we look for a lesion. We bring the lesion to the field that no surgery not can come and do the surgery. This is the lesion you can see is mylaminengocel. The first thing that we do, we give some medication to the fetus for a paralyzed baby, pay medication as usually is dreamy fentanyl and then some astrophobic to prevention of the bradycardia. The entire procedure usually on the open for the repairing the NTV, stick about 20 to 30 minutes. This is the medication that we give also the mom is in a general anesthesia. These uterus are very flock uterus. They need to be re-delivered, not contracting. After giving the medication, usually what the surgeon do is release the plaque as the first step. When they are releasing the plaque, they will try to do a primary closure. Majority of the cases, you can do a primary closure if you can do the primary closure. Some people use some kind of the patch or the other people start using a relaxing season or even the plaque. You can see here is a very nice primary closure at the end. When we finish with it, nor repair then what we do is we put a normal cellar or a lr for it fluid around the baby and then close the uterus in a couple of layers. The caveat is during the entire surgery, we do the continuous monitoring of the feet of heart. Look at it, make sure there is no bradycardia. If we start it having bradycardia, we can put some fluid inside. This is the end of surgery. These are the steps that we take. The biggest point here is the mom's trial started from 2000. Now we are in 2022. There is a loss of loss of modification. There is a loss of advance even in the open feet of surgery for MMC. One of the advance is a myfascial flap. This technique was defined by the people in shop. You see that in the myfascial flap, you should put the two or three layers. The good thing is from the myfascial flap, when you look at the data, many times especially the humburianniation, Majority of the case will have a humburianniation. You do have a very nice closure. Then the hind brain is going back. The CSF leak, if you look at the number that they have, is zero. That is true. When we start doing this technique, then you see a significant change. The other thing is closing the uterus. I mentioned that one of the biggest issues with the mom's trial is the one third of these mom's will have some kind of dehesin or uterine rupture at the time of delivery. When you look at the data now, there is a loss of modification of how we can close the uterus and through those modification. If you look at these data that has come from Colorado, the intact well-heal is now close to 95. When you compare it to the 64 person that was a non-mom trial. I think these data is pretty good. In reality, we get better and better. Repairing of these uterus now is getting better. Therefore, the thinning or the heast still is an issue, but is not as big as what we see in the mom's trial. This is the recent data. This is the drug published. The drug presented a couple of days ago. If you look at it, they put all the data from Open Physiocertior on the United States. Now the number of the patient is more than a thousand patient in registry. We've done more than a couple of thousands in the United States. The thousand data on the registry, we compare it to the data that we have from the mom trial. Again, if you come down to the focal, the heast is significantly decreased. Now we'll talk about only 3.7 percent compared to the 11 percent in a mom's trial. Every metroboture of the membrane, I guess, significantly decreased them. Now in the cohort that we have, this is through the entire country. Some of the centers had less experience and some of them is very well experienced, but significantly decreased to the half. When you come down to the gestation, the surgery is still comparable to the mom's trial that was a well-trial in the focus centers. In the conclusion, what the MFCC Consortium Registry mentioned is the maternal of statric and fetal neonatal outcomes among participants and centers are comparable to or better than the previous reported RCT. This is the reality. This is what we call as a real world. I mean, the real world outcomes even better than what we see in the mom's trial. The reason is all of the modification that I mentioned on the Open Physiocertior. Now I'm coming down to another technique. This is a very interesting technique. The call as a mini-historytomy started from South America. They started publishing these data and get a lot of attention. I know some of our European colleagues started converting to this mini-historytomy technique. In reality, what they do is, instead of you make a 6-centimeter or 5-centimeter incision on the uterus, now they're coming down to the 2.5 to 3.5 centimeter. This is data published from the people from Brazil. And in their cohort, if you see, again, have the same concept of Open Physiocertior, but now you're making mini-mini incision on the uterus. And then through that, the uterus, you move the baby around that you can do the repair on the NCD. This is the data from people from Colombia. And as you can see, sorry, you're still a bit data from people from Brazil. But if you look at the data also, the gestation edge of deliveries is good. It's 35.3. The key area reverse is about 80% of the patients. People from Brazil is not that high. And then the reason one of the things we worry about is still is pretty low. That means we're now talking about 3.5 centimeters, 3.5% in their population. And then when we come down to the other studies that you can see is again, this is a study from the people from Colombia. Also they have interesting concepts. The user Alex is, you know, everybody knows how we can use this. Alex is an everybody user. But you can see that they make it 2 or 3 centimeters incision on the uterus. And then through Alex, they give a very good exposure to the noris surgeon for repairing the back and then they close the uterus. Outcomes against still good. That means the pre-promise good gestation edge of delivery in the Colombia team is about 36 weeks. That's pretty good because you know, you do need a C section at this patient at 37 weeks. The reason in their population was zero. Coming down to the data from people from Mexico. These people are also going down to 1.5 centimeters. There is an incision that makes it a uterus is nothing. Again, data is good promising promising. And then they did some systematic review and at the end, they mentioned that they pre-tem delivery, P-prom, oligot, they he sent, and the he sent of the histrotherm is pretty low in their data. This is how they do. Again, with the same concept, you first anchor the membrane to the uterus on a 2 side. Both between slowly come down to the membrane. And the uterus, as you see, is a general anesthesia of very large uterus. They put the anesthesia down and then they start stretching the uterus. And that incision. You see that sign, and the fluid is coming out. You want to make an incision, you definitely map and make sure the delusion is closed to the place that you want to make an incision. And here is the entity that you can see under. The next step of the intervention that we do is what we call as a log-proscopyacid sythospefic. This is what we developed in Texas children, work for it in 10 years. The technique that we did using the TCH was that we call as a two-port technique. Starting from pink ball, again low-fidelity simulation, we worked for years in this low-fidelity figure out what is the best thing. We cut the head off the doll because it was not completely get to the ball. And then we used the chicken skin for training the pediatric neurosurgeon ourselves. Use the first series of data back in 2017. Again what we show is you drain the fluid out. First you open the album and you bring the uterus out, you drain the fluid, you put the suit you gas, it's the same concept of what you do on a log-proscopy. And then you expose the fetus to the neurosurgeon and with the helping of, you know, fetus surgeon, we release in the fly co and then we close it. This is the uterus that you can see is like a ball in your hand. And at the spare stage we started doing the primary closure but then we converted the technique that they're using to chop as a, you know, trillayer closure with a myfascial fly. And this is at the end. I mean, you see a two very small incision on the uterus. And the first and another modification that we make it is one wetting the membrane because you know, we know the CO2 guests for a large tumble will be dry in the membrane. And also the anchoring, I think the anchoring, the port side is one of the more important things that we done and then was adopted through all of the other fetus sensor on the country. Outcomes are good. We show the feasibility it gets happen but then we get a lot of criticize. the people thought, you know, you're praising, how can you put the CO2 gas inside the uterus environment because these babies can get acid, they'll take it then, you know, everybody can die and they can add brain damage and all of those stuff. Therefore, true those, you know, the first thing is acid-based balance in the fetus is what the UX was to the CO2 data from the people from Hopkins, you know, during the surgery they did some court of synthesis and the data for the peatation, all those stuff, everything is predestable. People from California, Roman Schmied also did the same thing, they did some blood sampling during the surgery and everything looks pretty good on the data. What we did is also, you know, our team during the entire surgery, we did an echo, look at multiple darker studies and we see some transition to change during the surgery, but in reality, you know, and the wall was transition, nothing was permanent happened to this kiddo. We look at the amyritic membrane very carefully, there was not too much damage to them, in the commemorine brain. We also look at the brain of these kiddos after the surgery, we couldn't see any kind of the, you know, significant brain damage of the kiddos. We look at the growth of the baby, there was no difference on the growth of this baby that was exposed to the CO2. And then, you know, the good thing is, you know, through our cohort, you know, we figure out that a good number of these patient-cadaivational delivery, I mean, it's more than a half of the patient would have a vaginal delivery. And this is, again, from the maternal side, is a less morbidity than you expose them to the elective cessation at 36 weeks. And then, you know, as I mentioned, you know, we come down to the tree layer closure, on the tree layer closure, this is the technique that we use, we put a patch, we did it on my fascia of flap, and then we close this skin. The gestational age of delivery, you know, our cohort is pretty good, you know, we're getting to the term, is a 37 weeks compared to the, all other techniques that are 35 or 36 weeks. And then, from the point of the reverse of the handbrain, handbrain, you know, when we did tree layer, you know, again, we go closer to the more than 90 percent. And the CSF leak of these kilos after surgery was become zero. Therefore, I think good repair is a key for, you know, for no research called standpoint. We look at the, you know, the outcome of the neonate in these kilos and see, you know, how the baby do with that set, again, because gestational age is become pretty good. There is a bit of a distress in the neonates for significant decrease. And we put it as a two-port technique or, you know, phytoscopy as a general can have a much benefit to the, to the neonates. The other side effect of the phytocergery, especially the open phytocergery, is coming down to this uterine dehesin and subsequent pregnancy. What happened to the, these moms, when they get pregnant again? And this is a study that came from the data consortium from OpenNCD. And in the consortium, what is the, the, the cell is, they cell about a 10 percent of uterine rupture in the subsequent pregnancy. And this is disaster. I mean, you know, uterine rupture is the worst thing you can do. The issue with the uterine rupture than those series is, is the not rupture at the end of the pregnancy. They can rupture at any point. And therefore, you is moving targets very hard. Recent data, you know, they didn't publish it yet, but recent data happened. It decreases it down to the five percent. I think it because of over the evolution of the technique now, they're getting better and this effect of the subsequent pregnancy. We also look at our data and say, you know, when you do the loprotomy and cystic phytoscopy, then what will happen? That means, you know, what is the subsequent pregnancy in our population? Is the small cohort? Then this is only 12 patients in the cohort, but, you know, 80 percent had a vaginal delivery and there was a zero, you know, side effects for subsequent pregnancy. And that makes sense. And you know, you make it to a small hole, you know, nothing will happen for your future pregnancy. And now we're coming down to the another technique. We call it the pre-tutainous phytoscopy. Then, it's now as completely loprotomy. There's no loprotomy, nothing. You know, everything do, this is the first group started as a tomoscool in Germany. Interestingly, you know, the tomoscool is a pediatric cardiology. And I don't know how the pediatric cardiology can do that, you know, open fetal surgery, but this is what happened in Germany. You know, if you tell the people you can do it, you can do it. And you only need to be a physician. But with that said, again, you know, we tried to contact him multiple times, not a very reliable person. That means, you know, we couldn't find him. But could it to the dentist, Pedro? She's from Brazil. She did a great job working with the Raminis Mide and Robert Coincero. And they started from animal model. They bring it to the human. And she did an incredible job. I mean, she's a very strong woman. And this is the technique they use them is, you know, they usually use about two or four ports, all percutaneous. And this is how they do it. I mean, it's the same principle. I mean, you get to the uterus, you drain the fluid, you put this to your two gas. And then through the ports, you manipulate the baby. Here is releasing a plaque. Or as you can see, on the both side, after releasing the plaque, or then you dive sticks on under the skin to find it that good on the both side. And here you do the my fascia flap. That means, again, the concept of the surgery is the same. They make the my fascia flap and then it closes it. They put the patch and after the patch, they close it and they close the uterus. We dastard again, there's some problems and counts for each one of these interventions. You know, if it were percutaneous compared to loprotomy, from maternal side, definitely percutaneous, I think is better, which is still you don't make that kind of incision. And the general anesthesia that you make is not that deep as general anesthesia, you do it on loprotomy one. And on a fetus side, one of the things still had a problem is the current 34-week gestation. That means the technique that we did use as a loprotomy assistive with 37 weeks, those guys are still on 34 weeks. These are some of the techniques that they use it. This is the kilos after the birth. This is the skin on the mound. I'm using again, there's two small, three small incisions. They put some data of international together, all the different centers that do and adopt this type of the technique, conclusion is CESF diversification is good, amulation of these kilos good, bladder capture is good. The outcome is pretty reliable and is good outcomes. Recently, they come up with anodity and this is called as a mini loprotomy. What that means that means in a mini loprotomy, one of the issues with the complete percutaneous is anchoring the membrane. We almost had that issue. But with these techniques that they come, this is what they do. Before you want to put the post, you make a very small decision on the abdomen. Use the Alexis, go around the place that you want to put your post, your anchor the membrane, and then put the post. I think it's interesting. They just published the data, talked to the ramen. The outcome is getting better. When it comes down to the gestation age of the prom and also gestation age of delivery and vaginal delivery is good. I think they are getting these kilos to the term and their techniques getting more mature. Then the follow-up of these patients. I talk about the mom's trial, we come with the mom's two following these patients to the time that they get bigger and bigger. Still we see it's significant difference between the prenatal surgery and the postnatal repair of the babies that had in uterus surgery, had a much, much better outcomes. There are different aspects, quality of life, family impacts, scores, everything is better under one that had a surgery. Then we come down to the inclusion exclusion criteria. This is belong to the RCT. This is a discussion I have all over the world. I think we need to stick to the conclusion and exclusion criteria where we don't need to so tightly because many of these things are changed during the time. This is what they did as a in a current selection criteria and they see the loss of different pattern of practice around the world. Then again, different institutions had a different thinking. One of the things that Sarah, American people don't, the surgery above in 26 weeks. That's one of the cutoff point. They went up to the 28 weeks. I did review myself this manuscript, but I think the good thing is from that is in a Sarah, America, the issue is screening. There is many times the patient gets to them, it's pretty late. But even on those ones that they get late, above 26 weeks, the surgery is still a consistent benefit. I know that the people are in California. The cutoff point is that 27 weeks is not 26 weeks. The other discussion is, and this is it, you know, Ethical Framework, I did work on it, is a regarding of excluding the moms, but HIV, hepatitis B and hepatitis C. Again, through Ethical Framework, we prove that you cannot exclude this patient. The discussion between the team decided to do the surgery. They're opted to do the surgery. Interestingly, after we publish it, then we start instinct that in a case report around the board that they started offering the surgery to the hepatitis B. The first one of the other one is the HIV and the outcomes of the kiddos was pretty good. None of them was infected during the surgery. Feet of surgery, definitely you get about outcomes. This is the reality. This is the issue with the fetal surgery. This is my own outcomes. If you look at the extremist premature, it is forward. 25 weeks, that's the worst thing you can do. You can do the surgery, you can do 25 weeks. The next case, 25 weeks, and we did a fetal that does the reality. It's a fetal surgery, you know, prematureity, p-prong, you know, infection. All of these can cause the fetal that. And this is what you need to do. The difference in it, we need to have a very good counseling and preparation of this patient almost is a balance between the family resource, maternal health, and what we offer to the patient and access to the care. These are very important in the fetal surgery. It's a way to offer the in-euteral repair for this type of patient. And now it's coming down to the ongoing research around the world. One of the things interesting, late, the working on is a plus center of the Zankimus from cells. This is a Dianne Bianche in a usage Sacramento. They do have a R1. And this is the N-T-D repair that, what they do is, it's an interesting concept. That means, you know, they do it CVS or Amnya, the first, second trimester, and then they grow these cells. They put on a patch, and at the time of the repair, they put the patch, and then they close it. There's a couple of cases so far. I interestingly, you know, in their study, you need to do one case. They maybe need to deliver and then do the another case. But I think it's promising. I mean, you know, as one of the things that I show you guys, the issue is still with the lower extremist movement. In the best scenario, you only can get to the 50% independent movement. Therefore, I think the meat is, you know, pushing more and more and focusing more of how we can increase the effect of the surgery. And I think the same cells, you know, make sense in this trial that they are doing it. The other thing that the people are doing is a cryopraser of human and medical court. And this is done by the people on UT Houston. Again, they develop a new patch. They believe that it will be very helpful, especially for lower extremity movements. The concept of the closure is pretty close to what I mentioned in the previous surgery. But this is how they do it. They also had R1 and they are pushing it. Definitely through all of these new invention, you know, I think the lower extremity movement will get them better and better. But in the conclusion of all of those, you know, techniques that I mentioned is, as you can see, is it is a different type of techniques now as well, four or five techniques outside. Outcomes are good. That means, you know, the reality is, is centered. They picked their own recipe. They put everything together and they come up with the idea of what is the good for their centers. Is it moving targets? The people are moving around. They're doing better and better from how they do the surgery, how to take care of these mommy, how to get anesthesia, how to get to the postnatal, and how to take care of these kid or after postnatal. But if you look at the map, and I think this is the most important part of my talk is adopted worldwide. If you look at it, now is more than 100 centers, fetus centers around the world is offering it, offer the NCD, and if you look at the data of more than 1000 of the keto-satellar in future surgeries, the biggest question is where we are in the map. We're behind. We definitely can catch up. We definitely can push forward. Definitely can come up with a new idea in our situation. But we need to be fast, flexible, innovative, and we need a space to clean, to cut it work. Thank you very much. I have a good day. Well, Shamy, thanks so much. Some of the many of us were at a prior ground round, where Shamy gave us an overview of field surgery and we talked about the many different, or a handful of different procedures that are done and diagnosed as a treated that was whirlwind. I thought just seeing one topic at a time, it would be less overwhelming, but there's so much information just done on mild and negative still, but it was really spectacular to see history and appreciate so much how you give credit to all the people around the world who have done the innovations besides your own group. And we are, as we say, behind. We're not behind in understanding the fetus and understanding the pregnancy, understanding the diseases we've been doing, real-class imaging, counseling, postnatal care for decades. We've been ahead of the curve at that. We've not been at table at all, with exception of cardiac procedures is in procedural intervention. And this is now the time for Boston. And we are so fortunate to have you and I'll join us to to bring this to reality. We have no doubt that we will be heading to those thousand babies very shortly and that innovation and advancement. Our institution didn't decide to join the fetal intervention world to catch up. We decided to join to catch up and make these things available to families in New England, but also to make advancements. This is the place where extraordinary advancements can happen, and although not ready for prime time to discuss, in the short time that Shem is been here, he's already met with all sorts of clinicians and scientists around our institution who treat rare and complex diseases that have not been contemplated to be treated in the fetal environment that he's already working with them to develop these possibilities. So, I'll start first question and we'll turn over to others. I think the obvious question is, Steve, before you want to ask the question, the first thing I need to say is having this type of intervention is not only adding a one surgery to the men of the surgery in the war. This is not even a program. This is a multi-disfefaring program to the entire enterprise. Therefore, there's tons of tons of people working together to do one surgery and then follow them very carefully. Therefore, this is bigger than a person or a team. This is a multi-team need to work together very closely. The last thing I definitely need to say is I need to code through my two research fellow. I beat them up pretty hard in the past week to put all these slides together and thank you very much. Perfect. Thank you for help. I should mention that Shem is already done procedures here in Boston at our two neighboring maternity hospitals at the Brigham and the B.I. The obvious question has done myelons. The obvious question we want to know is, so when do we start? That's excellent question. The first thing is we are, you know, a talk with the people in Chicago. We are traveling next Monday with a part of the team to the Chicago to see the landscape. We take the North Surgeons, some of our foreign citizens, some of our old group to see it. I talk with the people since in the early and talk with the people in California and definitely we had a couple more traveling the next couple months to see. Look at them. We did order some seem high-fitted. It's the same from people from Toronto. Probably they arrive in the next one or two months. Regarding the NCD, we, you know, after they're working on a scene, then we decided what technique we want to use as a team and we move on. Interestingly, you know, last week I was in a covo, Mexico, for an IFM assist meeting and I did have a very interesting discussion with a guy named Yandra Press is very prominent in the field of surgery and, you know, we went there and Belgium a couple of years ago to help him for developing of the Phytoscopy NCD. He sat on the table and we had a long discussion for hours and hours and he was telling that he converted to the mini-destructing now because he thinks it's a better technique. I never saw it. I talk with people, you know, when I came back and followed people in Brazil, they were willing to accept us to go and see their technique. You know, myself and I, you know, worked for 10 years in developing the La Crosca Piazisit one, but I'm not strict. I think, you know, this is a moving target therefore we need to adapt quickly and see what is best for us if you're our team and how we can pick it up. I'm strongly going to individualize patients selection. Therefore, you know, maybe, you know, we offer a couple of techniques. None of us are in our institution. Therefore, we're not very proud of any of these techniques. We, you know, we just offer it to the patient if that's the best for a patient. Thank you for a war one overview and update. I had a question about the long-term outcome of essentially like retathering or scarring because I know that's a big challenge. With the initial neurologic outcomes, bowel and bladder function are reasonable and then there can be a decline over time. Has there been enough time in the acquisition of the different techniques to know if that has been impacted? You know, as you know, you know, the tethering is a long-term outcome, but all of these evolving new techniques is hard to exactly. None of the techniques can come and say we're betting for the tethering, but as the promising of putting a different type of the patch type of the techniques you bear in a repairing, majority of neurosurgeons believe that they can decrease it significantly in the future, but this is something that definitely more and more time and more data. Thank you. Other questions? I'm going to answer a question that that Shami Arthly, the question I asked, the Arthly dodged. So he answered the question specifically about my hominingo seal, but the question about when will Boston Children's be ready to do any fetal surgery? I think we'll be doing procedure before we're ready to mount a single. It's definitely, you know, I'm pushing it before the end of the year. Guys, I told my wife that you go Christmas, I will stay here and you know, figure out how can I find a patient? And that type of operation would most likely be it, most likely be it laser for twin-chain transfusion or putting any kind of the chance. So we have the equipment. The team is being trained, nursing, periprocedral maternity equipment, and we'll be doing this. We won't be doing the myelot quite yet, but we'll be doing twin-twin transfusions very, very shortly and shunts. Any other questions? I'm having trouble liking on there. There might be some online. If anybody is online, is Catherine? Are there any online questions? Great. Okay, I think we are all excited to see where this is going to go. We know that you have other conditions. I think the fellows can just keep asking you to do grand rounds because you can do like one every month on a different condition and we'll never run out. But we really look forward to the maturation that you bring us. And thanks very much. Thank you. We're being kicked out of this room because there are more activities here. So the departmental town hall will be in a hybrid, be in person in the department library on the Honeywell extension of Fegin 3 and also on a different zoom. We'll see you there at 8.
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