ut it turned out to be a foreign body it was attempted removal elsewhere but what has happened was it has distally impacted more so once it gets distally impacted all your balloons the baskets will fail because they don't have any place to open up and extract it so the best tool if it is an organic and distally impacted foreign body if you can safely finish the surface with a cryoprobe so it can be easily extracted so this was the as you can see so that's the initial place where it got impacted so because it was distally launched it was somewhere in the right level of segment 10 so what you can see once it goes inside that's the segment 10 segment sub sub segment the foreign body was impacted that's the segment 9 so in the sub sub segment that's the foreign body which is deeply impacted so in that whatever the instrument balloon basket there is no way I mean distally open up and extract it so we have to use a cryo and extract it I'm just going to speak up another challenging case an open safety pin at the level of subglottis and upper trachea so what we did in this case was we did a tracheostomy and we went retrograde all the hinge joint and extracted it so we were discussing how to extract this safely but we felt that this is the easiest way in one shot we can extract it so we did a retrograde bronchoscopy, hold the hinge joint and extract it it must not much of any issues so another case I'll just skip this case it's a multi-modality approach what was where was initially what we thought there is some kind of consultation in the right level what we went inside there was a polyp which is sitting there in the right intimate bronchus polypid is a granulation tissue so we did a snare retrocortory, removed the granulation so once we removed the granulation we saw there was an impacted foreign body there so we used a basket to open up and extract it so another interesting cases these foreign bodies can be very very tricky and this was an isophageal foreign body at Panicab so initially they did an isophagoscopy they could not see anything because the color of the foreign body is the same as the mucosa but in that case we did a bronchoscope inside the isophagus we could see a plastic of it, we removed it with a faucet another case non-resolving obstructive pneumonia in an elderly lady so we were seeing some kind of floppy material inside the airway so we were just thinking what was it so it finally turned out to be red chili so you can also have an isophageal foreign bodies mostly this is very very common these are the coins inside the isophagus so with the same instrument your rigid bronchoscope and optical forces you can safely extract it but case should be taken to maintain the ventilation so once you maintain the ventilation this foreign body does not have much time so this is my last step this is an impacted chicken bone in the left main bronchos you can see this just past the bronchos mucosa then there was no significant subcutaneous embossing or anything so you could safely extract this foreign body rigid optical forces to summarize we have seen multiple types of foreign body presentations each case of foreign body is a challenge we need to choose the right instrument and the right technique for the safe procedure so foreign body aspiration should be provided to children when they have sudden onset of lower respiratory symptoms history of choking is highly suggestive but actions of choking does not rule out a foreign body aspiration the presence of asphyxia indicates need for immediate resuscitation and examination of the airway normal chest radiograph do not exclude the presence of an aspirated foreign body and the radiology may alien diagnosis the bronchoscopy should be performed if you suspect a foreign body even if the radiology studies are normal for short foreign bodies secure the foreign body inside the airway for safe retrieval there is no single best instrument for all foreign bodies rigid or flexible, either one can fail no one is superior to others so this is another case of obstructive hyperinflation subcutaneous embossing initially we thought it was a foreign body and once we went inside there was a large tumor sitting in the right main bronchos in the carina and the left main bronchos please be cautious you should have the right to expect this was the BNED tumor we safely debugged thanks a lot for your patience listening nice illustrations thank you very much sir for your presentation any questions any questions any questions questions, comments how you want to comment thank you Thanks to God Hi Dr. Sulakar he is not only a man behind this program but also my inspiration, because I was supposed to join this hospital sometime back at start intervention program here and then we had bought up these questions and I am very happy to see locations establishing state of darts also doing very critical vices and this is the beginning of the in this area and we expect more and more in forward for future collaboration. So I was asked to talk on and also I would like to thank the chairperson's boundary commitment and all the seniors, my teachers are also sitting around Krishna sir. So I was asked to talk on future of area strengthening. So I will be a little practical. So we will not deal with a lot of theories, papers and all because since this is a very serious session of digital oncoscopy, it is very good to listen these things like an ideal strength doesn't exist or strength is never placed. Patients get married to the doctor when he puts an annual strength and surgery remains the mainstay of treatment for women and industry. So let's look at very practically. If this is the real world scenario, why all of you are sitting here listening to talks on annual strengths. So practically, there is a need for annual strength in many of our patients and this needs a lot of education and also practice. Coming to surgical aspects in the area stenosis, how many of our surgeons really like we don't have good experience in doing any of the stenosis management especially in these areas. And we don't have surgeons like Mohan sitting in Vijayawada or Hyderabad. So there is a role where you move stenting in these patients, bridge these patients and then send to the surgeon. So in my opinion, area stenting remains a very important aspect when it comes to interventional oncology and digital oncosis. So why? I will substantiate my statement with this case also. Now in the middle of the night you are called when you are sleeping and then the resident calls you saying the patient had undergone an OGD scoping and then the ADG shows like pH of 7.6 PCO of 100. The patient was sent to the emergency room after the procedure. In the middle of the night they will call you and say that the anesthetist was not able to intubate the patient. And then when we were called for an emergency bronchoscopy, the attitude is there and then when you pass beyond, this resident of the year was bagging these patients for almost 2 hours by the time you reached it. So you come across these scenarios. Hardly I was able to push my bronchoscope through the ET tube what they have put in the trachea and then you can see almost there is a complete closure of the trachea there. If you cannot go and place a stent in the middle of the night where the availability of stenting is not very easy in our hospitals and these are the kind of scenarios we come across. So this case also shows you the importance of airways stenting in these patients because there is no other treatment available for such patients unless you put a stent and release obstruction. So we have to take this patient on an ECMO support and then do an airways stenting and then discharge the patient. So if you ask me really, I am not very happy to do such a case in the middle of the night counter with all these bleeding and then try to save this patient. So these are flight stenting procedures where airways stents become a very important aspect. So why they make these statements is choosing the right stent like just because you finish an intervention pulmonary fellowship or something because why we place stents there are lot of reasons. So the spectrum of airways stenting is like if you are an intervention pulmonologist like the IT fellowship doesn't come complete like once you finish you want to put a stent and then you get the feel of this is practically true. And these aspects every one of us have gone through that phase and then we develop some wisdom over period of years like if you ask me personally in my first three years of practice I placed around three to four wide metal stents but if you see the last four years none of the patient we placed a wide stent. That's because we have seen the complications that happens once we place these stents. So wisdom develops after some time and then you try to choose the best stent that is available and place these stents. So why those statements were made is because not to create these kind of problems where you put metal stents and the surgeons need a lot of time to remove these stents because of the complications. So instead of a silicone you place a metal stent and then that complicates and then creates a scenario like this. So this is why we and also when it comes to lung transplantation very important area where you definitely have to make a decision that you have a transplanted patient here and then there is a stenosis. So you initially deal with dilution and all these things but again and again there will be a recurrence. So this is one area you put a stent and release the obstruction. So in my opinion definitely there is a role of area stenting in some cases. So let's talk on the future of area stenting. So the future is very brief because there is not much going on when it comes to area stenting not much research is going on and whatever is happening in area stenting developments is happening in the best not in an Indian scenario.  But are we all happy with these stents? Look at the computation. They have granulation mainly as a computation and then if you place some uncovered stents again there will be tumor involved into the stents and mucus which is the main problem after placing stents. And if paper was published from Kether and the Russian they looked at different practices of putting stents. Again area stenting doesn't have a universal approach like some are trained in rigid bronchoscopy or flexible bronchoscopy approaches. So it again depends like what is the operator experience in placing a silicone stent. So you tend to do something to relieve the obstruction. Nobody wants to put a stent just to place a stent. They want to help the patient but based on their experience sometimes they have to make decisions to relieve that obstruction temporarily. So if you look at the survey they did there is lot of variations in area stenting practices of growth not only in India even in the US if you see some use rigid bronchoscopy some use flexible bronchoscopy and some use both the techniques to put stents. So then Eric Faulk has mentioned in his paper what is an ideal stent. So in theory first we should understand that this is all in theory not in real life practice. So ideal stent should be stable strong enough to withhold an extensive compressive force and it should be biocompatible available in all necessary sizes resistant to migration and easily deployed and removed and can act as a barrier to in growth of the tumor. So if you practically think of all these characters you will not find or will not will never be able to make an ideal stent. That doesn't mean that you don't place a stent for a needy patient. And currently the available stent materials include silicone, methanol, stainless steel and hybrid stents. And recent advances Locust told like Dr. Harre was speaking on so I am not going through this. And what we should ideally be doing is like we should sit as a group and then discuss on how to develop stents that will help our patients so that we are not doing and we are trying to use stents that are made in the western countries and not because if you look at the development of products like mostly before it was China and now it's all Indian. So there are good companies coming up in the Indian market as well where they are customizing stents within 2-3 days. So we need to make a form and then tell them these are the things we need and these are the things we should keep in the market because I think most of the faculty who are doing every stent they know the difficulties of procuring a stent. So if you need it if you have a patient in the year and you ask for a stent it can come up to 3 days. What was the patient base for many times the patient's base during these procedures. So these things we should address. So if you look at instead of talking on not putting a stent let's talk on how we can develop good stents. What are the problems with the currently available stents? So the currently available stents usually if you see the structure it has got an outer sheath and then the stent is either folded inside a small cotton wire over the stent which once you remove the cotton wire and then the stent gets deployed. So the usual problems what happens is why it is difficult to place the stents or why these are not ideal is because some have like if you look at the Boston stent, the discolour of the stent has got a very long end. So sometimes if you are trying to go into the left wing bombast and replace the stent if it doesn't go into the upper row or the lower row you will not be able to place the stent properly. And look at the y-stent design here. So if you look at the y-stent design, the outer diameter of the y-stent is so big sometimes the stenosis is small and you will not be able to place the sheath to expand the stent. So these are the common problems that is where people are looking at developing newer stents. So if you talk on every stent that are being studied widely and one of them also got an FDA approval mostly in the U.S. not in India that is a customized silicon stent and second one is biodegradable stent. So if you ask me in the coming 3-5 years if once the approval comes for biodegradable stents, India will be one of the primary managing patients, biodegradable stents what we have to tuberculosis. So in tuberculosis biodegradable stents are played a very important role. Just because we don't have the availability we are not studying them properly and then there is a concept of observable stents that are coming coming up in coronary diseases that also will translate into pulmonary medicine. So these are customized ARB stents again if you ask me position statement or if you ask me the clinical guidance usually these are not included in the there is no point talking when we don't have a normal silicon stent talking on a given customer stent is of no use in our country and then this is one thing we are actually looking at like how this will shape up so this is how the biodegradable stent will act. You place the stent you don't have to remove it or anything so once removed you see the last picture the material gets absorbed into the mucosa and that is a biodegradable material so that doesn't harm the patient. And what are the recent advancements that are coming in practically possible advancements that are coming up is one is called a bonus stent so these are called through the scope stents so these stents you will be able to place them through the flexible bronchoscopy. So the only problem is the deployment will be from proximal distance so you should not place the stent beyond the stenosis and then deploy you have to see that the stent is above the stenosis and you push the stent otherwise it will go fall in the sub segments and you will not be able to deploy. So this is one good advancement that is coming so this will be very useful for those patients who want to go lung transplantation and all. What happens in lung transplantation once the LMS denotes it happens ideally you have to place a silicone stent there but sometimes the rigid bronchoscopy barrel will not pass through the LMS denotes because the lumen is very small so that is one application where you can put these bonus stents temporarily removed in 3-4 weeks and then place one more stent until you get a lumen. So this is one advancement that is practically possible and also if you look at the way they make this stent so usually the wrapper is inside the stent not outside the stent so that adherence of the stent also will be very good when the sticker is inside not outside the covering is inside that is one thing and through the scope stents and one more company is coming closely is these mini stents you see the size of the capitals that we deployed are becoming less and less so to make them more easy to deploy so now we have mini stents for the bronchus as well so if you have a bronchus problem you can just put these stents through the flexible bronchoscopy so these are new things that are coming up which we can use in our clinical practices so every stenting once these kind of stents come it becomes easy for everyone to manage a problem when they have a simple flexible bronchus scope and they don't have expertise in rigid bronchoscopy but that doesn't mean that again complications of stent should also be understood when you are trying to place a stent so the numbers will increase and at the same time the complication also will increase if you don't handle them properly and literature on these bone stents there is one paper that looked at the utility I'm not saying this is the ideal stent but they also had some problems like fracture is little more common with bone stents because of the diameter it is a very thin diameter stent more in the bronchus than in the trachea and then when it comes to silicone stents this is one area where there is no development that has happened and this is the first time developed for trachea bronchial tree and then there are new silicone stents that are called genus stents where the stents can be like usually that woman stent has studied in this fixed way so these new genus stents will have either forward or backward stents to prevent migrations so this is one advancement that is happening in silicone stents and coming to white stents there is one Indian group that is evaluating this white stent so what happens is white stent the main problem is the outer sheet many a times you will not be able to push the outer sheet so this company called Medora which is an Indian India concept so they have designed a very good stent which has got an ODI of 6mm so 6mm ODI will be very very useful to deploy a white stent this is how so we clinically evaluated the first stent and then you can see how small the white stent they have already improved so it is very easy to place the white stent also now with a thin bronchoscopy so you have two links here so the decoing mechanism remains the same but you can use a flexible bronchoscopy and then deploy the stent and then once deploy decision so this is one development that is happening so my take home message is every stenting will remain to be a very important role in management of airway for especially for the intervention people who are practicing the interventions and the practice of airway stenting should be patient centric then looking for an ideal stent or talking about the complications of airway stents and decision making mainly depends on the operator's experience, availability and training there is a lot of scope and interest in research and development especially in the coming 3 to 5 years so there should be a forum that needs to sit and discuss on possibilities of new concepts in airway stenting and there are a lot to do in that and as I said ideal stenting can never be developed and there are some areas where lung transplantation and post intubation process is so before surgery stents will remain an important factor and biodegradable airway stenting the airway stents are going to play a very important role in philistinosis and lung cancer again there will be a debate between stent and silicone but usual practice is stent but once you get experience and start putting silicone stents in this way you will understand the use of the patients so with this I would like to end my welcome all of you to bronchus 2023 in January 28 and 29 at Hyderabad so any questions I have to answer just now for your nice innovative talk on the future of stenting in between and I hope with the 3D printing and all these things and the biodegradable airway will be available I think in the way he has going forward I think we should come up with some answers for this Parvita Thao, he is all known as all known as the treatment pulmonist at Naseh Chants over 30 years exposure in the philistinosis personality he was past president of the world association of international pulmonology 20 and 22 and he is the president of intervention bronchus and he is the field of research and nutrition and it is a pleasure to invite him and listen to him of manipulation last session for the live series thank you for inviting me to your course on international pulmonology and what to say in the master of my Indian colleagues and well I remember when you stayed in my unit you and Shiba another Indian colleague you particularly like one of my editorial sorry I have to define your editorial that I wrote with David Fila Pogman David Fila Pogman is also famous American medical physician in Baltimore and I'm happy that you like it because I like to write editorial so editorial is not really scientific it's not very science but for me it's very important to because it's a way for me to give my vision of my activities my work and the role that getting older and so you like this work which is called international pulmonology between ambition and wisdom and I'm going to summarize what are the ideas behind this title this is the editorial that was published in Europe and as part of the review in 2020 again with David Fila Pogman and so in this editorial we emphasize the fact that since I started pulmonology more than 30 years ago I have seen granted changes in our specialty a lot of new technologies came to our practice like mainly I would say mainly in diagnosis of pulmonology which are focuscopy electromagnetic navigation retrosome demographic even now, robotic focuscopy we treat now patients like COPD patient as a patient after the patient and when I started pulmonology now it's 30 years ago asthma for instance was almost a contra-education to contra-education to focuscopy and now it's not an indication that we are going inside of the area of vision so I told you few interactive focuscopy few maybe I could have prior evaluation of cetrolymer absorption by malignancies that can be done with prior products but one of the most important are the relation in standing it's really the second part of my talk in standing we have different way of evolution and one I would insist on is a 3D printed stance but also we are buying the valuable step and not really now in our practice but people are working on active stance so stance cover these pharmaceutical drugs not only have mechanical properties but also pharmaceutical properties eventually also in the training of patients of physicians it's much more structured than in the past with a lot of insulation and also not changing the scientific communication when I started with my mentor at that time almost on the case report where in which you had 3D post-imaging so the author would say look it's better after so it works it works at least in picture but it wasn't proven scientific so we have a lot of retrospective students and now we evolve to more more scientific prospective and modernized scientific students that's a big change also in our knowledge Daiso wisdom why wisdom wisdom in the way that any new technology is not always sure to be successful in the in the future so we have to be very careful with this new innovation we have to prove that it changed the course of the disease or at least to improve quality of life of patients to imagine survival but this innovation are very costly and they require a dedicated and guaranteed and very well organized infrastructures which is generally seen in tertiary reference so unique, very good organization and this innovation are very costly so many innovations in terms of diagnosis of post-imaging patients and if I just mention them for instance Kotlin City which is around 5,000 euros and I don't even speak about disposable and materials that has to be had as the robotic is also 500 1,000 euros again you have to have more disposable things etc and this is the clearly issues that cannot be ignored and the very only economically aware countries can afford this kind of technology and sometimes even before they are clinically in school or have impact on the course of some diseases for instance I can use an example of the solitary peripheral module which is suspect of malignancy again isolated to the scan and the question is do we really need to have diagnosis of this module do we really need it so do we have to buy a robot or Kotlin City to get diagnosis and if the diagnosis is positive for malignancy then the second step will be surgery for patients that can be operated if you cannot have the diagnosis because even with the robot with the U.S. pro you can reach only 80% of positive diagnosis so imagine if the diagnosis is negative what will be the next step generally next step is to again surgery because you cannot let the patient with a suspect in the module without diagnosis so surgery with the diagnosis is an achievement so what I mean is that when you consider starting a biological terminology taking into account all these steps and taking into account also your surroundings I give you the example of Marseille a location that knows quite well here in Marseille we are and it's not a new world it's a reality we are very close to all specialties like to the surgeon we are friends we are very close to the international radiologist so in fact in Marseille we have decided that we won't spend money for expensive technologies to diagnose peripheral modules because we are surrounded by very good international radiologist who can do neither in the this kind of course in a 5mm module with quite close 100% of diagnosis and this is very important so if in your institution you have very good colleagues of other specialties take that into account this is what we have done in Marseille and in each case this is my last sentence it's like it's really part of this is pretty routine approach in which we frankly want our colleagues for the best of the patient and not for the best of international radiologist and I don't know if you notice if you are interested in the world of international radiologist we have different kind of colleagues we have colleagues international radiologist who claim that in the future we won't need any more disorders that international radiologist have diagnosis of radiomania is a kind of treatment you know the treatment so non cancer, non state non cancer I have this kind of international radiologist I don't claim that we can do everything alone we really have to work as a team and a multidisciplinary team again for the good of the patient is the best option for someone ok let's go to surgery let's say if again one of our colleagues can reach more easily let's go I don't want to do everything because when you do everything I don't think you're doing good so don't forget to trust your colleagues but that doesn't mean that we we have to be ambitious of course we have to improve our techniques we have to innovate like our new ones and we also have to be confident in sharing strong data without colleagues so like changing practice from this is the way we have always done it the way we do it now international radiologist take into account the strengths weaknesses and needs from other institutions is what I was saying before considering which techniques and technologies should be required this is I'm going now to show you the history of the history of international epidemiology for those who are interested in all of those famous names the first physician who was performing in 1819 then she went to to study the microscope in the 16th of the previous century my mentor, Dr. Dumont in 1982 was one of the first pioneering to do at the nuclear laser therapy so if you see all these names the one who was invented the transformation the emotion from the years for the therapy again my mentor, Dr. Dumont in 1990 is a silicon stand but also a metallic stand it's not nothing but it was a physician who was a surgeon that came with a new probe and a delegation combined in both the US target information all this information but really when I look at that at this timeline I realize that for me the only technology who has really really changed our practice about all these techniques is a double-coil ultrasound not for instance total fluorescence is almost no longer used but even as now actually dramatically changed the approach of the diagnosis of the ultrasound and even the TVA is now almost abandon even yes this has really changed the practices in the national community so just to say that you will see a lot of new technologies you will be probably obsessive to use them but at the end only a few of them will remain as a tradition I would say and I would say that a tradition is an innovation that has been successful it's a progress that has been successful and it has become successful it becomes tradition and this is the process of being a part of timeline but still we are using re-proposcoping to treat central brain function as you can see on this timeline I have a picture here with this physician he collected there he collected there from France which is my best place France is now the president of the French speaking group of the national community but he is also a very smart guy very nice guy and he is one of the pioneers in 3D printing stand and this is my second part of my talk is about 3D printing stand but before that I would like to illustrate how the wisdom of 30 years of regular standard aerospace printing has evolved to an innovation which is 3D printing stand so another editorial again I love to write a tutorial because I can summarize a lot of things and this one is particularly special for me I have published an index that I have written with my manager so it was in 2017 and in 2017 it was the 30th birthday of Airways printing because the first Airways stand placement was achieved in Marseille in 1987 so in 2017 I will show you all this name from Kiva told me to write an editorial and in this editorial I have summarized all the experience we have acquired with Airways printing and first I want to start with this slide that shows the evolution of Airways printing in Marseille from 1987 to 2017 so look at that look at the curve it started so the number of standplates in Marseille increased a lot to reach the plateau of 600 standplates imagine that 600 standplates in France in a small country compared to India so 600 standplates in India means almost 3 tenths place in the day in total case when I was at the time with Dr. Dumont I have seen almost 3 tenths place in the day why? because of course Marseille at that time was the only centre you were to do that so a lot of French patients were referred to Marseille and all around Europe even from other countries outside Europe and as a good technology also Dr. Dumont has told me over in Marseille it's a new technology so you won't try it to any type of such a railway pathology and generally I call this Carpet Barrier why Carpet Barrier? it's because when you clean your house and when you have dust you know where to put the dust you put it below the carpet and in a certain way because any abnormality in the airway were covered by the stand at that time like simple idea that just by hiding the pathology it was true and of course it's not the truth so the second period started and this second period you see the decrease of the stand in numbers in place in Marseille also because a lot of centres in France but in Europe and in the world we know from some our experience and from disease we have told just to give you some example of the stand freckle recombination at that time someone who had a collapse especially collapsed at the stand place and the direction now is 3M on the fact that even if you face a stand short-term improvement but mid-term you have a lot of complications so freckle recombination for instance is no more limited in Marseille another indication freckle recombination b9 freckle recombination b9 freckle recombination in Marseille so how to do the procedure first, see the scale of the patient then reconstruction 3D reconstruction and same to the 3D reconstruction then design the stand according to the exact direction, exact angle of the patient the problem because of the sequence test a silicone set cannot be printed with liquid so you cannot print the stand directly with silicone so you have to print with mold you make the mold, print it with mold and then you inject the silicone inside and you see different kind of stand can be produced and then like something set to original purpose so the results 10 patients 4 are post-transplant recombination 2 patients have recombination from interstitial surgery 1 patient has access for recombination and 3 patients have post-transplant recombination so let's start with the post-transplant and with the business you see this is the case I showed you before that's the purpose of this which is closed here and you see on the prostration and at the end of the step you see a nice shooting step going to the right tutorial here and this is the purpose of this so this patient improve systematically and this can also improve after 3 months because after 3 months unfortunately this is the start of this patient this is the start of this and now this can still be done after 3 months so you see this is just the first case we realize that even if it's perfectly adapted to the airway stay in the front for the night then you see some complication of standing out second case it's left which was treated with this helipad system again the microscopic aspect is very nice after 3 months you almost never see the step almost but you see how it adapts when you prepare to do what there is a status on the left side of the calamity almost don't see so technically it's done it's a nice fitting on the surface then 2 patients with complication for intracerectal surgery one has a paortic aneurysm and one has a helipad so this patient you see images with standard steps in place and you see this can go back to the compression that's a paortic aneurysm you see a great direction here you see clearly the axis of the trachea and then with a free distance in place which I have very well that will be meant to curve the magnetic trachea to get improvement of the complication this one is simply it's a positive C-elementary so C-elementary is probably a re-platation of the focus to the right eye and again a nice fitting scan in the C-scan so and now one patient has extensive aneurysm but it's rather recombination while a system has been designed but this one is fake because of poor variance my understanding was they moved to a free mass so again remember regarding the regular standard step in tracheal recombination but even free distance in this don't seem to be the ideal solution to treat tracheal recombination and last, tracheal system is so you see the patient with the tracheal system to do free distance you have a simply the design perfect congruence and this patient is still standing in place with no complication what case it may be another one had a good numbers to be congruent but by virtue that they sent him to a new place and again removed the system so this one was a success one was a fail even after treatment the congruence was good but by way of two months after what I may be able to tell you you don't know is that tracheal system have a approval after the FDA approval of tracheal state that have approval in Europe but they are approved only for bifurcated states not for straight states because straight states seem to have the same rate of complication which is in a different respect to the states you cannot order but on the e-by-50 states in January in this kind of situation when you have false utility states so the conclusion of this table the serious the subject of high decompression proves the feasibility taking into clinical community that they are just complying with that congruence are very good the efficiency is 8 to 10 complication still is there to improve our technology we have had some breaking, migration and one curve because of that congruence so what will be in France we are going to take a new trail which is a prospecting to lose because we are one of the biggest centre to enforce the placement still in France and so we are doing a trail with more patients or with minor obstruction learning more on the congruence system thanks to 40 so consider that we collapse when we receive this test to reduce migration when we are forced after the test is always range with even three participants we prove with treatment surface of the test and this is not a job but one dream that in the future may be produced freely printed by another test for new strategic education in my mind we are going to think about the transfer of patients so this is my conclusion and I hope that I give you an interesting overview about future of the restency Congratulations the next session that is panel welcome Rad I think it will be a very good session so unlike the normal panel which we have we usually panel for ILD we hear about tumor board but today we have a stenosis board so we have five excellent people who manage area stenosis so we will request some of these things other than that we request Dr. Popal Dr. Mohan Vishwesh here is Dr. Vishwesh Dr. Hari Sathi come in the frame so we have designed this as a we have four cases which will be presented by Dr. Lokesh and we will take the opinion of the parades ask you how to go about with these cases I think we just wait for a couple of seconds for Dr. Vishwesh and Dr. Hari to join and then we can start the next session like in intervention program we started 30 years back so in literature if you see we have only case reports case series expert opinions and also retrospective observation studies but we don't have prospective randomized control studies to say this is correct and this is obviously from experts so we have a best of experts in the field sitting here so we listen to the case how to approach from them so let's start first case in this case little tough you can see the CT scan the coronal and surgical cuts is showing retrosthenal mass you can see it is extended beyond the sternum even if you for tracheology it is tough to do it and even though lumina is completely blocked apart from tempers the CT you can see here an intrinsic repression is here in this tumor the tumor completely up to 80-90% of the women a small phase with which flexible diagnostic, flexible bronchoscope could be able to negotiate beyond the tumor so I think at this point we have the opinion of the panelists so we have a lady with a malignant type of obstruction so first I would ask Dr. Bowman so what would be the indication of surgery in cases of such malignant type of obstruction in forward answering this question just I need to know the histopathology of the idea because probably the proglustigation and the decision actually may depend on so which kind of because this is a turret mass integrated with the trachea papillary CA follicular CA, anaphylastic CA but as we said it is a a huge long history of the gorilla so most probably it could be that the possible this is a papillary's carcuma thyroid although this patient has liver metastasis we do such regularly such kind of cases in association with our redundic oncology team the presence of liver metastasis is not an action or indication for any kind of for the quiet removal and also trachealization so it is showing that it is involving approximately as per the CT what the understanding is approximately 2-3 sentiments of trachea is involved and although it appears that this trachea was being compressed by the mass, I doubt it is actually infiltrating the trachea in that region so how am I going in this case the mass region bronchoscopy just debunk the intratracheal component study for the papacy we will wait for the papacy to see what kind of pathology it is because we have actually cross the emergency and then at one stage we can do the thyroidectomy with regular sessions I think this is for the general interest of everyone here so this is a thyroid medicine which probably has some good outcome after surgery so we will have other than thyroid we have other would you still recommend a such contraception Surgical contraception is the best mode of treatment if surgery can be performed surgery can be performed that is the best mode of management whether it is anodic acid or neocupyramide castuma if it can be performed that is the best way of management even the scum is the best way so again that comes to the component of 50% mark so if you are crossing the 50% mark then of course the thyroid so if it is less than that you can go ahead and get this I think this is an important point because most of us say that if it is a malignancy then the surgery cannot be done everything more important is a given in surgery if it is a resectomy lesion probably still the surgery may happen with a basic disease and there will be a problem now I will request Dr. I the prescription is there where we have to establish a loom in it just before just I need to add incorporate because this patient is also having a retrosanal kind of extension so thyroid to me along with him this patient may require a partial upper strenuous drift to remove the retrosanal I think even in our center sometimes for thyroid malignancies they do critical resections especially for thyroid malignancies now I will request Dr. Ihar so what modality would you would you prefer for the procedure here the extension looks very long for a surgeon the end of the improvement of the care that is already said what we are able to see is probably 2 to 3 second details but once you develop it you will probably have a better first will be the debulking and then probably if it can be done then it is the best one so now the next question is if we have to establish juvenile patency I am looking at the range in these cases in this case apart from this endocrine lesion beyond this lesion is inflicted with the tumour we will discuss that part also how to extend the sub-neucosal extent of see you can see the sub-neucosal completely interact with the tumour adding options to develop the tumour ventilation wise I don't think it's a difficult thing here you can just use your rigid barrel just to just rotate the barrel in such a way that the tumour will get off the wall usually thyroid tumours don't do much and when you are doing with the rigid barrel that scope also will act like a damper that is one option otherwise if you want to do with a simple this name would be a good option here so put a snail in the tumour lesion and then whatever this thing is doing in FTC depends on what you have on the day but establishing movement patency in this case would be very easy with any of the other things so in the end of the procedure usually what is superior that discussion you can see snail or legy from scope the finally you should be establishing patency what you use as a known doesn't really matter I think it's probably a very good point that what you use to achieve movement patency would depend more upon what you have as your centre and what your experience says so I think with this discussion this one is very important to us which is tumour it's how to actually how to determine the extent of involvement so what we are seeing is the obvious quality but many times we see this of mucosal so I will now ask Dr Vishwesh to comment on any role of NVI or any of this newer process of imaging techniques to try to watch the extent of the sub mucosal spread of movement patency because that might have an impact on the extent of surgical perception and again before you do a surgical perception for such cases would you also want to use these techniques to extend all of the visual inspection of the normal VITHAID process so what we are seeing is the VITHAID process so in this case I think it shouldn't matter much because if we are dealing with a metastatic disease already the patient is having a metastatic disease I think you can say even if there is small metastatic disease it wouldn't be a conflict not a conflict the point which is only do you also try to look at the sub mucosal extent to see if there is any impact definitely there are few studies which are done with these different narrow band imaging and even FICE and other things to look into increased vascularity being a marker of probably an abnormal tissue but when you have such and those are all done for cases with carcinoma in situ where you find a relatively normal because except in one spot you can obviously improve carcinoma in situ but in a case like this where there is an extensive involvement of the mucosa you cannot say with certainty even with the FICE that this is the margin at which we are moving from a normal tissue to a cancer tissue so I don't think in such an extensive mucosa involvement it is better to assume it to be a cancer rather than taking a FICE and saying that this is the point at which the cancer ends and beyond this it's normal this is my personal feeling I think these modalities are brought for early detection of lung cancer mostly as a screening rather than establishing the point of saying whether it is a medicancy or not maybe one thing which our oncology generally uses the frozen section but again that cannot be applied in this case because we are dealing with the case of a tracheal so you cannot take lot of these biopsies to say that the frozen section is negative so the section margin I agree with the one of the issues but I still like my heart really says is that the neurovascularization of the endemic valve of the trachea it can be due to the pressure effects may not be that actually yeah of course you cannot differentiate so there are so many non-flying flight biopascos not only what we see is the biopascos so most of the companies have this now newer technologies like ice cat technology and we also tend to identify this abnormal plastic part this has not yet been proven enough to be European use of infant pregnancy I think now we will ask Mr. how we manage that case this is the case so it came to us with the spider imagine she came to us with hypoxia so obviously we need to do a medicancy procedure there is two minutes to take up the test he didn't tell us what is the list of the I am more interested in that I don't know after doing the biopsy so that actually I am not revealing it we will just see when she was not done she came inside so we need to take her directly I can't forward directly so we intubated this patient with rigid bronchoscopy the first step was obviously after we placed the rigid bronchoscopy above the level of tumor and with the flexible bronchoscope I tried to snare that it was half cut then after that it was bleeding heavily so what we did obviously vision is gone after vision is not so clear so with the rigid bronchoscopy we code the tumor I don't have complete procedure video so I will record the system as it was not recording after placing, pouring placed the rigid bronchoscopy above the level of carrier to control the bleeding for 15 minutes then bleeding was stopped so after that what happened was bleeding and there were actions in combustion yes there is a question whether to stand or not this patient my thoughts of standing for this patient were one is that it was bleeding we had to put rigid bronchoscopy for 15 minutes to stop the bleeding you can see that such this video of the trachea after this was bleeding heavily because of in the anterior the trachea was you can see even after standing you can see this so much of bleeding from the surface the one reason for standing in this case and also one action is in operation so you want the patient once you do the procedure you want to come out of that procedure that is one reason we thought we will see to stand this case she is doing well to stand out of the procedure so she was doing well actually so in this case as Dr. Harid has suggested also a combination of peripheral photore and the rigid coring are used to initially to achieve local pregnancy in fact the rigid bronchoscopy the coring is not the fastest way wherein you can achieve a lumen and the barrel itself will act as an outlet so it also gets in the airway and also causes symptoms at the same time now the second question for the panel is this it is a family to see a thyroid and HP after that now the second thing is many times you come across these cases where you develop the tumor in the airway lumen now when would you want to stand a person with a malignant airway obstruction I think this is something which we will again take into account as Dr. Hopal so after the debugging procedure when would you want to place a sense or a silk constant to achieve or to maintain lumen once after debugging I will look the lumen once the lumen is ok there is no idea collapse of the airway so usually I don't prefer to go for standing so I will look after the biopsy report if it is susceptible tumor lumen patency is achieved and I can refer the case to the searcher suppose if it is patient is having some amount of creatio malacia we cannot be able to maintain the patency of airway lumen then we will prefer the stand since it is a malignancy so we will go for stand later we will send a case for airway lumen for the malignant airway if the airway lumen is adequate and it is not collapsing there is no special extension in compression it is not necessary then always we have to place a center I think in this case we will also send a significant extension in compression so probably a sense was placed so I will ask Dr. Lokesh what happened after this the HP was pampered we referred to such a long policy he advised that what Dr. Rangte said that was the plan to accept extension but unfortunately they were two families and they couldn't defer so in 10 states the CA also they couldn't defer to develop palliative chemotherapy palliative treatment only after that they will go for surgery I think we were able to give an initial palliation of our symptoms and the patient went home without that yes one of the important things whenever we have a patient coming to us to try to at least improve her symptoms for as long as we can if we can cure her then I think like that but if we cannot at least if she goes home it is a question to the states any role of positive in this case since I think you have done two cases we have only limited experience two cases we did but definitely there is a I don't know whether for this case it could be really helpful because already we know that the tumor is arising it is invading the trekking palliative and it is having an internal component also so even if you do an OCT in this case we we know that it is an infiltrating tumor but OCT what we use was the high quality is so good and if you have really good experience you can even differentiate the sub-leucosus layer you can clearly see the cartilage and even the expel beyond the cartilage and there are a lot of articles which has evaluated the role of the OCT as well as the role of a high frequency radial probe initially the radial probe when it started it was mainly used for the trekking now we are moving into the periphery so both have been used to the cartilages especially for such tumors which are higher so it plays an important role whether it can be a surgically removable tumors or not OCT yes would help but not in this case because in this case it is a clear bit that there has been a trekking formation and there has been an intra-rubinal extension but if we have a tumor which is without an intra-rubinal involvement then probably OCT can clearly say that whether the cartilages are infiltrated or not so this is the second case I think so this is the final discussion but if any audience has any question also you have to do more than to stop us and ask a wonderful case location just for the panelist and especially to the surgeon now what you said that probably it can be a congestion that is causing hypervascular issues so my question is so the next case if you see the congestion extending much beyond down so that means the length of the trekking probably infiltration or condition is more the surgical resection is going to be a challenging in this case if the length increases so would you recommend us to do a biopsies in that point to find out is there any infiltrative lesion there when you plan your resection or did you any time experience this kind of situation so I think it is a very valid question also so how exactly to determine the extent of when you plan your edges that is what I am saying so where you resected and how you plan your edges why I am saying this is congestion because if you go to the converse cooking over the kerain also there is this there is near oscillation even though so with all the kerain this is not right so it is very unlikely that the trekking, infiltration and the kerain are causing this so so should we do biopsies do we do biopsies you can do the second we don't go biopsies I think for lack of time we go on to the second case so it is a totally fair old bank manager had any fever with the air ds he was a ventilator for one month and wouldn't recluse me he was present with stride after one month after recanning the recluse me too very calm scenario we see in our daily practice groundless could be upper trekked so we do biopsies spying around 1 cm so this was the case it is shown showing stenosis and also probably around 1 cm so from the scope of the video close to the vocal cords we came to a strider can you also tell us the distance between the vocal cord and the approximately 4-5 cm now I request Dr. Rakesh to describe the stenosis and what would be your initial management strategy right so looking at the patient's history that it is a benign post-intubition tracheal stenosis and here so first of all we see that the length of this stenosis is 1 cm and the distance so it is critical stenosis in term of the symptomatic because the patient is strider second thing is there the good thing about because it is distilled to the subplotic part so and the segment is very short and third one is that it is the cartilage we need to look into really the cartilage is damaged or not it's a one thing and first we will offer the patient the bronchoscopic because the patient is symptomatic so we need to go for the bronchoscopic dilation of the segment once that we can use for that the cartilage along with the balloon bronchoplasty and later on the same thing with the bronchial variant corner once that this is achieved then I will refer this patient for the surgical part because it's a short segment and it's a small one so the surgery has a definite once the symptoms are resolved after that the surgical definitive treatment is done initially because the patient is symptomatic the initial irritation would be done and then he would be referred for surgery if the person remains symptomatic because this is a force to take care of some of the patients mostly the cartilage would have been involved and would not be as simple as the other nurses Harim would you like to apply on the management strategy yes money that has been practically we should think such a patient coming from the village is admitted in ICU with their BS all his money is gone the surgery will not agree so first what we do is bronchoplasty short segment very far away from vocal cord very easy for surgery to operate so for Dr Harim the first case also a CD to ventilate second case is also easy that is not in such cases I think it is partly correct because it is not very sublottic so you have 3-4 second meters below the vocal cord so doing the procedure is not as challenging as in an upper tracheal but a stenosis so would the panellists agree that when the first sitting you would only dilate and leave or how would you want to do you want to discuss with the patient we will see how the surgery will be you don't have to try to understand in this case you can just put the pressure column and dilate if the room is okay if he is willing for surgery he will wait for a few minutes if the room is okay you do the dilatation first and you wait for a few days at least 3-4 weeks and if it is wrong if necessary you can go for one more dilatation if it is a surgery or a surgery what would Dr Mohan say would he be comfortable with us doing one dilatation or would he want the surgery straight away one dilatation is okay I think he is very considerate he has let us do one dilatation so one dilatation alone if surgery because surgery what all surgery we have to take a minute now we have one chance with us before the patient goes and remains so the thing that I want to emphasize in this case is that so usually these patients are put on steroids to decrease the edema and all that maybe few days so in our study when we actually we analyzed the anastomotic complications the patients who are on steroids more traditional steroids at the time of surgery actually had post-operative complications so stopping steroids at least 2 weeks before 1-2 weeks before doing the surgery is the critical component of regular treatment one last question for all the steroids some patients usually don't have it last question we have to put the steroids so you have to take a needle and then you take steroids no that doesn't work because anyway we are going to remove it patients are actually we got referrals who are actually one month, two months steroids no Dr Mohan I would agree with you that many centers after dilatation give a course of steroids with a hope to if not if necessary the edema which is part because of the procedure maybe a little better last round of the wish page to comment on his practice of prescribing the course of steroids after a dilatation session how long would you give and if you give how long would you give we do give steroids course procedure so we generally anyway when on the day of surgery we put them on injected with steroids but the very next day general most of these patients go home once we have dilated adequately enough in their symptoms we put them on a tapering dose of steroids at least for 15 weeks that has been the practice till now but it is not a very heavy dose we start with methyl pretensivone 30 mg like 5 days then we taper it off very fast by 15 with the almost the steroids off this is mainly if you ask us for an evidence we don't have an evidence to say whether it really works or not but it has been the rationale which we follow even for any sort of an obstructive aggravated server where we have manipulated so I don't feel any problem in giving this short course duration of steroids in fact if let's say that we have manipulated so much and next day the patient presents with an edematous airway and again that is a more challenging thing for us rather than subjecting the patient to just a short course of steroids I think it should not harm the patient anyway provided if you are taking on for surgery yes you can wait for it would Rakesh Mohan give the comment on his practice and then maybe just summarise it for the benefit of the audience so as I agree with Dr. Nagar that the steroid for the paring procedure for 3 to 5 days is kind of a because to decrease the luma and the kind of the procedure but 2 week is so I think see so the point which I want to say is that there are so many gray zones when we talk about the prophesopic therapy for the there are so many questions that I can answer so our attempts to try to prevent osteoarthritis Dr. Hari was talking about interrelationsal steroids now we are talking about the short course of oral steroids none of these have been actually proven to say that you can prevent resealers I was talking about my talk by saying some people have used to try out relations so many things we do in an attempt to prevent resealers none of them are actually proven scientifically so each one will have their own preferences nothing is correct nothing is wrong but steroids as Dr. Bohan said 1 to 2 months ago somebody would practice how that person was taking but you have to tell them to stop so that is how probably the person would have come I would request Dr. Nagar to this case and whether the person responsible for that case I will start with that sir obviously we spoke to the family they are obviously terrified with this but they immediately came to home after suffering for 1 month of interrelation then we optioned what are the options available one option is through prophesied dilatation and stenting I have only dilatation dilatation plus stenting surgery so all three options we explained them what are the chances of frequency we explained them surgical 90% success rate related to 90% in best hand so only in best hands not in every hand and we don't have modern dilatation in our hospital in our city that was one problem second thing obviously we told balloon dilatation and in my experience usually if I grew one balloon dilatation I had experience of coming back very fast within 3 weeks again coming back with the same problem so I counseled him for this is the option 50 to 70% success rate if you keep it for 18 months if you keep longer terms for 18 months 70% success rate you can get so I told him 50 to 70% the lowest then 90% 80 to 90% highest chance of success rate with the tracheal surgery obviously I explained the complication I didn't want the procedure I want to do obviously we explained everything then he opted for the tracheal stenting because of his personal reasons then we proceed with the procedure that we play the video and since it is upper tracheal stenosis so there is a chance of migrations on the stent so after the after the placer stent we play the stitch to prevent migrations that was one of the most complication after doing the upper tracheal stenting we can migrate and so far it's been I think 12 months every one month he comes to the follow-up there is no migration and there is no migrations for his person the plan to remove the stent after 6 months later by God's grace if it heals on it's very good but doesn't heal one hundred days he is there I am saying that is the plan that's what we are thinking it happened to me in December 30th of last year we did this procedure it was like he came inside so I think the stent had to be beautifully placed I think it was discussed with the person so once the person leaves the inform concept then I think it's not wrong to place a stent and till 1 year there are no stent complication no stent complication so I have two questions for the analyst one is the it's stitch so I personally develop productivity of person because there is more signatures from the open course and we put it in the criteria of the so if at all you want I would request for the vocalist comments on when we would place a stent it's stitch if you know the teaching especially in the practical part of the criteria I go for stitch because there is a high chance of stent displacement you know we cannot place a stent so that is the one situation and you probably if I found the difference between the stent and the practical you will be with the stent the stent opens up too easily without manipulation that is also one indication that probably it might I have written about the hurry also what other techniques can we do to defend migration it's experience with our class stents because that is one thing which is also there now it's a very good candidate for our class because it shorts the but again you see Malaysia in the posterior beyond the stent so once you place our class sometimes the compression of the posterior starts pressing the distal area and then starts to granulate in the wall so you serially call the patient and they do cryo or something because this sometimes I have patients who got cured even without searching to place our class so that is one option I will try but again availability of our class is not everywhere so I am okay because I need to recommend this in this case so what do you do a big stitch for this case I usually my practice is I can patient and operator preference it's not like it goes to the idea you place a stitch for all it's never become like this so my practice is like I put a stent in send the patient there is a problem then you place a stitch I am little not pro towards putting stitches right if not here that is my own preference it's not like you should do like this there is no right thing I think again this is one area where we don't have any consensus so what Dr. Hari says is that if the stent you place it then you will be position and place is stitched I think that becomes on patient factors also like if your location is from far away place see what happens is after you place a stent it's not easy for you sometimes you get dreams also that water doesn't fit that's good seriously if you are because if you have a high volume of patients what happens is some this is life and death question because once you place a stent and this guy goes to a peripheral center if they have to do an emergency tracheostomy and there is a stent here which they don't want like it goes to pulmonary or some area so they are patient again who presents to strider you won't come to a visual order so they have to cut open and do a tracheostomy sometimes the doctors may not understand how to remove the stent in patients space so in a preventive aspect putting a stent in such patients is not wrong again it depends on many factors not just what we have learned so actually I have learned basically we are still conscious we expect for the person of migration in the head which are so when we place an upper trachea assume that it will migrate up for the person of the cases that's how I got trained I assume that it will migrate then I will put the stitches which is the system of counseling patients for this kind of because we take a sign that this fellow will come for review with me only so every 15 days we have a phone call recently only one patient missed that patient so we usually don't lose their contact every week our PG's or fellows they call them and ask how the patient is doing and if they don't have money also sometimes they call them for free from this call I think it brings out a very important point of following up stents that will end as we discussed in the morning talks also once you place a stent it is your responsibility more than the patient's responsibility to make sure that the patient is surviving when the stent and the stent is surviving when the patient so the same thing I agree with Dr. Ali that first of all you have memories of that patient and what happens because two patients and I have one patient I put a stent and then after one month and he died in a kind of a remote area he moved the stent and then it was kind of a small metallic stent part was there the family sent me the 14th photo and then he said that you charge me this much for this small thing and it stuck in my patient's and my patient died because of this one so at that he started using me so this is because and then he didn't come for the follow-up any kind of this bronchoscopy and two months and he got stuck here and he was not able to pay I think this is a very very important thing that you have to educate the patient before you place the stent so it is important that you have to educate them that if you are not able to the stent itself can cause more misery than the other stent so as Dr. Ali has said we also have a very strict protocol that we educate the patient and then we make sure that they come for regular surveillance so I will come to that so this one we keep on calling because one patient in 2019 I put a stent it was a large endoprotein tumor and then I called because you need a bronchoscopy and then you need to check it 3 months, 6 months, it didn't come again 9 months, 12 months and he said that I am doing fine what is your problem so ok what is your problem why you are calling me I have to pay for that suddenly after the 2 years of the metallic stent he called me and said I am not able to breathe so then what should I do


I've been growing peppermint in the garden specifically for the purpose of making peppermint loose leaf tea with. It's one of my favorite teas to enjoy, but buying organic tea leaves from the bulk food store can be quite expensive, and I go through the tea leaves relatively quickly, enjoying peppermint tea on a regular basis. In summer, I like to infuse my peppermint tea with fresh pomegranate juice, making a delicious, refreshing iced tea recipe. After learning how to dry mint leaves and stems at home, I found it to be a great way to preserve mint for longer. Plus, it's usually fresher and better tasting than the store-bought varieties. Best of all, there are tons of ways to use the dried mint leaves, such as in spice mixes, sauces and dressings, or mint tea, in a homemade, remineralizing tooth powder as a flavor enhancer and antibacterial herb and more. The best time to harvest the mint leaves is just before their flower, so late spring, early summer usually. This is when their oil levels are at their peak. It's best to harvest them in the early morning before the sunlight and heat evaporate the oils. Choose leaves that are fresh, bright and green to use for drying. There are three main ways to dry mint, which include using a dehydrator, oven, or to simply air dry, and I'll be showing the air drying method in this video. It's important to wash and carefully dry the mint leaves before dehydrating, just to get rid of any insects and germs. To wash the mint, add the leaves to a bowl of water and swish them gently around. Once finished, drain the water and pat the leaves dry with a tea towel or paper towel. It's important to ensure all the excess moisture has been removed before drying the mint, otherwise mold can set in. Air drying provides a low heat option for drying out the leaves, helping to preserve the nutrient profile and beneficial compounds in the mint. It's important to note that air drying will really only work in warm climates that aren't humid. A room that sits around 15 to 20 degrees Celsius or 60 to 68 degrees Fahrenheit will work best. Cold, humid climates may lead to mold growing on the mint. If you live in this type of climate, my recommendation is to use a dehydrator. To air dry the peppermint after harvesting, gather the mint, stem still attached, into a bouquet and tie the stems together with a piece of twine, string, or rubber band at the bottom. Hang the bouquet of mint in a warm, well ventilated area, away from direct sunlight. You can create a hanging apparatus, tying the bouquet to a coat hanger, or simply using a herb drying rack. Allow the bouquet to dry for one to two weeks, or until the leaves feel dry and crumbly when touched. If you like, you can place a brown pepper bag lightly over the mint to create a protective covering which can help prevent dust settling on the leaves. Once dried, transfer the leaves to an airtight jar for storage. The leaves can be stored whole, crumbled by hand or in a food processor or blender, or as a powder, which can be achieved using a coffee or spice grinder or blended in a food processor or blender for longer. The peppermint can be stored in an airtight glass jar and will keep for up to 12 months in a cool, dark dry place. To make the peppermint tea, add one to two teaspoons of the crushed dried mint leaves to either a strainer, infuser, teapot, or reusable teabag. Place the teabag, strainer, or infuser into the teapot or saucepan and add one to two cups of boiling water. Allow the tea to steep and infuse for three to five minutes before pouring into a teacup to serve. The longer the tea steeps, the stronger the flavour will be. I hope you enjoyed this video tutorial. Let me know if you try this recipe yourself and what you use the peppermint leaves for. I'd love to know. I hope you have a wonderful day and I'll see you soon again.


Hi, I'm Rachel Stein, the Research and Instruction Librarian at the Latin American Library at Tumán University. For the library's National Poetry Month celebration, I've chosen to share one of my favorite poems, Romance Sonamulo, also known as Verde que te quiero verde, by the Spanish poet Federico Garcia Lorca. Lorca was born in Granada, Spain in 1898, and he was tragically killed by nationalist forces at the beginning of the Spanish Civil War. His legacy lives on in some of the most beautiful and profound literary works ever written in the Spanish language. Several parts of the poem I'll be reading have been enshrined in popular culture as well by way of flamenco music. This poem has stuck with me for more than a decade. I first read it as a freshman in college at West Lane University in Connecticut. The first verse repeated throughout and the green imagery are unforgettable. I hope you'll enjoy. Verde que te quiero verde, verde viento, verdes ramas, el barco sobre la mar y el caballo en la montaña. Con la sombra en la cintura, ella sueña en su baranda. Verde carne, pelo verde, con ojos de fría plata. Verde que te quiero verde, bajo la luna gitana, las cosas la están mirando y ella no puede mirarlas. Verde que te quiero verde, grandes estrellas de escarcha vienen con el pez de sombra que abre el camino del alba. La higuera frota su viento con la lija de sus ramas y el monte gato gardeno eriza sus pitas agrias. Pero quien vendrá y por donde ella sigue en su baranda verde carne pelo verde soñando en la marga.


All right folks we're back again with another 20 bucks another $20 recipe let's go into the DG and see what we can find. Shrimp $7.50. Flower tortillas $2.35. Salsa verde $2. Cilantro lamb rice $1. A $1 packet of the Danos $1. Mexican style blended cheese $2.75. Shredded lettuce $2.50. It's time to go make some shrimp tacos. Give them a little flip set them to the side a little bit of oil a little bit of butter add in the shrimp grab your packet of Danos and give them a sprinkle we're ready lettuce a little bit of cheese our salsa verde time to dig in that is not bad at all give Danos a try for a buck we'll see you next time keep sprinkling my friends