Good afternoon and welcome to Turning Pets in the Cattle the stickiness of data My name is Chris Cannon. I'm with Hewlett Packard Enterprise work on the cloud engineering team I'm Leon. I'm well for Intel. I'm a senior cloud architect And my name is Gert Prussman. I'm with Mirantis and the cloud solutions team and the three of us are members of the Enterprise working group here for the OpenStack community and we Are collaborating on this presentation today and one of our goals here is to Foster more participation from you. So when we get to the Q&A section We hope to be asking you questions so that we can help forge Enterprise community solutions Forward with with future presentations and learnings So with that a couple of things about what this session is not about First, it's not about CICD second, it's not about deployment techniques or automation tools And third it's not a discussion about agile development practices All of those things are important, but we remain focused specifically on data and how it applies into application architectures today So our agenda for this session First we wanted to start off with a recap of a session that was delivered in Tokyo where we sort of teed up this Conversation to give you a little bit of history if you weren't there for that one Then we'll jump into our discussion of data and this is where we would really like your participation and assistance Talking about some of the challenges of data and moving it to a cloud world Also some of the strategies off the top of our minds for possible ways of doing that and we hope that you will help us there as well and Then at the end we'll have this Q&A session where we hope that we're asking you questions and you're providing answers So with that the recap Dr. Sun Thanks. Thank you Chris. So I'm Leon as I mentioned just now So I just want to give you guys a quick recap of what we have done in the last summit in Tokyo So I have a co-presentation with Stephen Wally so from HPE so we talk about Turning paths into cattle, but during that presentation We're focusing more on the web here and the app here so in this talk We'll be focusing more on the data here So I just give you guys a quick recap of what we have done last time So in the last presentation we talked about the differences between pads and cattle So pads basically referring to the traditional conventional workload and the cattle basically referring to more towards the club native or club Oriented application. So yeah, if you're interested in that presentation There's a references on at the bottom of the link there So we can just go to the link and this presentation slide we have published this online after the talk So we can get the link there And we also talk about the differences between virtualization and cloud so in the virtualization world, right? I mean most of the structure that we use is more like a scale up model is a horizontal is a vertical scaling model So we rely on the infrastructure for the resiliency, but in a cloud-based model The application tends to be a very disputed model disputed Dispute architectures and it's a very horizontal scaling model and the application itself is designed to be responsible for their own Resiliencies and not sick or independent of the underlying infrastructure. So that's the key differences between virtualization and cloud And we also talk about the design principle the differences of the design principle between the conventional app and cloud-aware app So I also provide a link there Published by the open data center alliance talking about how do we architect cloud-aware applications? So these are some of the key Design principles that for conventional applications that it tends to be monolithic centralized state But in the cloud aware app is more disputed use microservices and one of the key things is about this Eventually consistent. So this is a very new concept when compared to conventional applications So in the previous talk we talked about multiple strategies that how can we turn the past applications into a cattle? cloud native model so basically what we suggest is Look at your application don't look at application as a whole when you want to migrate the app to treat your application as a multiple components So one strategy that we sorry So one of the strategy that we propose a suggest is you can actually move in it in the conventional application Conventional models you have your own web VM web here and app here Those are in the VMs right you can migrate those VM as a whole to the cloud That's fine. That's one strategy that you can adopt and this strategy the benefit for using this strategy is it doesn't require too much of Re-architectures, but it doesn't give you the best benefit of the cloud features So there's another strategy that we propose is actually we suggest that it's actually using Kind of like microservice model So you you treat your applications a web here or the app here as a different sub components so you only migrate certain components to the cloud and slowly one by one and you can and one of the Example and we use in the demo is we can actually host the static content if you're using a treat your apps, right? You can actually host the static contents like images or html files or jet JavaScript files in the cloud Using an object storage. So this are three different strategy that you can consider when migrating application from Pat's model into into cattle So with that today, we are just we'll talk about the data here data stickiness So let's jump in data stickiness First let's level set a little bit about some of the challenges that we face with data sets as they're utilized by Applications whether they're legacy applications or cloud native applications. They deal with the same set of data requirements in many cases The first point is every pet is different as we all know the data set that they're Using the way that they manipulate that data how it's processed. Is it ephemeral or static? The data sets are different for every sort of application. So every pet has its own unique dependency on data As such there's some challenges in dealing with existing data sets One of the largest problems from the technical side is how do we move data into the cloud? You've got the technical aspect of it. Do we migrate it somehow through file copies or import export? Do we set up a replication scheme somehow? Do we make? Carbon copies of machines and set up a parallel environment To be able to move this data There are as many different possible paths to that as there are technologies available today So this is an interesting technical challenge in Migrating data the second piece is after you've done that you need to ensure that your data is accurate So there's a dependency on on making sure that things are consistent and the integrity of the database still there Depending on the migration path that you choose you may encounter licensing problems Perhaps you can't stand up a parallel System because of the unique licensing for the database technology that you're using Also downtime copying large data sets requires a lot of time Perhaps your business your organization your customer doesn't have the luxury of of being able to to consume that much downtime The second challenge is also about how we virtualize data as composed to a typical Legacy sort of database that we know and love today Some of the things that you need to think about are the SLAs that are related to accessing this data Customers are concerned about data access policies that may be different in a cloud model the performance virtualized databases May not be as performative as your highly tuned legacy enterprise class databases that you have as well the recovery time objective and recovery point objective Data is really important as well for for most enterprise SLAs Etc etc. You can there are many arguments In multiple directions for the complexities of getting your data migrated So this will be the first question that I'd like all of you to think about for the Q&A at the end of the presentation Consider this with the customer years you're working with or the challenges you're facing today the experience that you've had doing this to date and At the end of the presentation, we would like to hear from you if we've missed something on this list If there are items on this list that are more important than others How can we as an enterprise working group help create? additional training collateral reference Documents ways that we can help expose information so that we can all make this migration a little bit simpler so we discussed that we would present three different options for possibly moving your data today and I'll take the first one and it it at simple Explanation it looks like the easiest one. I would offer that actually It's not necessarily any easier than the other two that you've seen But there are some pros and cons to each of the options that will present this afternoon The first being don't do anything with your data preserve your existing legacy database infrastructure many businesses have made a significant investment in enterprise class databases and Part of this is not just a reluctance to get off those things that they've been so comfortable with over the years Whether it's an administration training usability Focus or whether it's a reliance on the types of SLAs that they get around Using enterprise class database products But I would offer that that you can also realize a less risky migration path by Focusing on moving your applications to a cloud native platform first and Then pulling your data along in a phase two approach So that you're mitigating the migration risk to some extent To support this we're finding that most most applications and Customers that are using a pass layer whether it's cloud foundry or or most of the others Those products have capability to connect to legacy databases easily so there's no reason for Customers to expect to have to port their data at the same time that they transform their legacy applications The third data point that we've learned through through our research here is that you can continue to leverage Some of the capabilities that you have in your existing enterprise databases that might not necessarily be available or fully fleshed out or at parody today with some of the cloud based database applications and Gert will be covering some of those considerations in option two So why should I move my database to the cloud? Probably because I want to benefit from the advantages the application guys Profit of I want to have horizontal scalability for example on-demand database instances scalability and elasticity and For this I need a solution for the database on the cloud. This is one example how I could try to achieve that We picked one example here With my sequel and the Galera library to have the opportunity to use scalability with a Galera cluster and Galera offers you active master master replication and We have here the applications on top cloud native applications scalable horizontally elastice elastically scalable and you need a load balancer to Load balance the the traffic from the application to the database and then you could scale out the database cluster the advantage for the for the Project is that you know the technology you know all the tools you know how to manage the The database because you might already use it for your application anyway, for example on-premise In the past you know all the operational tasks necessary to maintain the database and The gap between the old technology and the new one is very very low And it brings you the scalability that you want to have on the cloud But there are some limitations on the other hand as well. So for example You need explicitly Primary keys on your on all your tables the update on schemas is different and some other other limitations as well like it's only possible on the innoDB database engine but Not all and not all engines are available, but at least with this subset you could work The operational tasks remain so there is no automation you have the scalability you could scale out the cluster You could provision new instances, but you have to do it by yourself. It's a manual task So obviously it's not the level of automation that you Probable you are looking for on the cloud All the automation efforts that are necessary to automate it have to be done by yourself Another option could be to use The open stack project trove which is in fact database as a service It provides you with a self service to provide to provision your own database instances It's a very easy-on-demand database consumption and It offers you a lot of databases as of today For example Cassandra and MongoDB my sequel and a lot of others The advantage advantage of trove for you would be that it would automate a lot of the tasks that are necessary to Deploy the database maintain the database Make backups from the database and all the different and various tasks In fact not all of these databases are currently considered as stable in conjunction with trove Because the data store that is used for the databases It's only considered stable for my sequel currently and on a technical preview level for Cassandra and MongoDB And all the others are considered as experimental and the whole project is But I'm not very major stable I'm not very major level from my point of view. It's considered as a very very young project But on the other hand it offers you a lot of functionality So there are currently some gaps and limitations with respect to the self provisioning services and all the the functionality that it delivers to you we compile a short list of functionalities that fulfilled by that we consider as major and with trove But for example some of the operational tasks that you are required to do are not very major So for example push button compute scaling That is not automatically done It requires you to intervene manually the same with the migration to a new database And that's normally something that you would expect from the cloud out of automated cloud environment that it does it for you It requires an external backup solution there is a backup possibility with respect to swift but It delivers not all the functionality you would expect from a full blown backup backup software in case that you are Required to change your database engine, then it's a good idea to have a close look to your application We did this for example for WordPress WordPress is a well-known software and It uses a very my sequel century code base So what would be necessary to use another database for example no sequel database Then in fact you have to fork the application and introduce all the functionality again And refactor it for a new database, and that's a lot of effort needed. That's a lot of costs Because you have to maintain these fork in the future as well. So if there is a new functionality in the application you have to Develop these this functionality on your fork for your database as well you could introduce An abstraction layer for the databases for all databases, but that needs a lot of work as well So it would be required to invest a lot of work and money in this this task The other possibility would be to have a full database abstraction layer It's again a lot of work that needs to be done to achieve this So it depends on the application and the database that you are currently use if the two options are Possible for you or viable options. Okay, so the third options that we would like to talk about here is Migrating converting our DBMS into no SQL. So before we do that, right? We always have to ask ourselves one question. Why do I need to migrate from our DBMS to no sequel? Is there such a need for us to do so or not? So I think there's nothing wrong with our DBMS, right? So but the things is in today's world I mean most of the new use cases coming out right if your mobile applications you're doing big data stuff. You're doing IOT stuff Architectures is widely distributed. It's a very very widely on horizontal scaling architectures And we have to dealing with a lot of structures as well as unstructured data But those unstructured data is just not satisfied I mean just not you just can't meet those requirements if you continue continuing using the our DBMS system If you are coming into that situation whereby you need to support those use cases That will be the point whereby you need to consider should I re-architect my applications? The data tier layer from our DBMS into no sequel and of course and if you still focusing on those OLTP transactions and structured data are very concerned about the ASIC model of the traditional models Then that might not be a good choice for you to move into no SQL. So it all depends on your applications so Okay, so when you talk about migrating our DBMS to no sequel, right? There's some other things that you have to be aware of because in the our DBMS system basically have to design a schema and you run a lot of different SQL query thought procedures and But in no SQL, you basically don't do those things anymore, right? Generally, you don't do those thing animals and escape the way that we model the data the data modeling will be different as well In the our DBMS, so everything is more than being like two dimensions data is right the rule and columns of data, but in the No sequel you talk about key values things you kept talking about Documents based so those data modeling will be totally different so if you're considering migrating to no SQL you've looked about how we we have to change the way that we model the data and other things like Integration if we integrate in your applications in the our DBS model you we run a lot of we have asked you a lot of different SQL query You do a select you do update do all those things, but we come to no sequel Those are no longer valid for you, right? So you basically have to build that into your application doing like a DB dot insert DB dot update something like that so there's a totally different model and Of course when you migrating to no sequel the concept of foreign key might gone So you might not have no it when you do the data modeling all those things the foreign key might not be exist anymore and Definitely the node AC the AC more is gone and in the no sequel that basically the model tends to move towards the Ideal about eventually consistent. I'm not sure you guys heard about the CAP theorem in a distributed application the disputed architectures consistency Availability and partition tolerance the concept about this CAP right? I mean in a disputed application you can only choose two of them You can't achieve tree at all you can you cannot achieve tree at the same time You either have consistency availability and sacrifice the partition tolerance and in a no sequel model the time to move on towards Availability and partition tolerance. So that's why this we have this concept about eventually consistent So you are not always getting the database right? You're not you might not be always getting the same data at the same time, but eventually you will get consistent So that's a new concept about moving into no SQL So if you if you really want to migrate into no SQL right there are few migration tactics that we can consider here So one thing is how do we move? I mean how do we move the data from our DB as to? No, no sequel for example, my mongoDB. You can build your own script to retrieve all your database data and then put it into the No SQL database can use some of the ETL tools that you can use and some of them actually Actually considered using Hadoop so I wish they actually run a Hadoop clusters and Hadoop using some Hadoop mechanism to retrieve the data from your RDPM systems and then use a Hadoop to do the processing and then put them into the No SQL database and another strategy that you can people consider is Do a snapshot and do an incremental transfer and other things that I want to talk more about is this application driven model so what I mean by application driven model is One thing keeping the data in both RDPMS and node SQL concurrently during the transition period So when you're migrating the application during the transition period, right? You just have your application just have to write two things one write to the RDPMS Also at the same time right through the node SQL So keeping two data at the same time and the second op and in fact this such these options I mean these tactics have been used by a lot of companies today and Another thing is what I call on demand So when I mean on demand side basically what I mean is your applications, right? For example, if you want to read a data from image data, okay you first read from node SQL the new database that you're pointing to the node SQL and If that data doesn't exist in that node SQL, right your application logic has to be built to Can be built to consider fallback to the old database and then when you fall back to the old database You copy that data to the node SQL on demand and the return the result to the use So that's like an option But of course these options right you're involved more Transaction time because you basically reading the you first try to read from the new database first It's not found there and try to read from the old database and it might copy that that are over to the new database and then Return the data to the users. So there's a second tactic that people can use can consider using that of course It all depends on your use cases. What is your application? And this are a few tactics that we put up here and for your considerations to summarize what we would be provided until now You need to understand your pet applications have a look at the source code the options With respect to the databases and the different models Some technologies that you already know probably with the with the old applications and the old databases are Available on the cloud some are not so they need replacement and this has Consequences for the management of the operation of the database or the schema or the technologies that you use There are different design principles with respect to SQL and no SQL you have to take this into consideration as well and There is a transformation necessary from the traditional culture to the cloud culture with respect to the technologies and the processes that you that are required and your devs dev teams and operation teams need the skill set to Change either the application or the schema or the technologies or maintain and operate operate all these technologies With this I would like to ask you what are your experiences with the data migration or migration of data and databases to the cloud We have a microphone up here For those of you that have experience you'd like to share please do so Hello, yeah, I've got an interesting use case I work as a workflow analyst in research science computing We've just adopted open stack and the pets problem I have is that our researchers basically deal with really large collections of flat files. They're like 55,000 images for example of earth science Models and things like that. And so we have in there very attached to them just like your pets analogy here so we're trying to figure out the best way a combination with Seth an open stack of Figuring out the best way to manage that as we go forward. I'm I don't know We don't have the answer yet, but the best I can do is come up with an idea where we have Physical hardware in the middle to handle them the computational side the workflow then on the pre-processing and post-processing side Have persistent storage on either end of that that we bridge into the middle Which might be ironic or however we do that. I'm not we haven't really figured it out yet But that's our use case, and I don't know if you have any Observations on that but it's it's a tricky one because it's really orthogonal to your example of the rdb mess kind of idea But it's Another one out there. Thanks. I work for rock space and as part of one of the projects. We had to move it up from Posca's database into my sequel database be using mongo and one of the departments we had was the two different applications and At the end of the day if we had a legacy application That was removed to the new application. They both need to have the access to the same data one of the key departments we had was Users using both the system they need to be able to see data in both the systems So one of the biggest challenge we had was we tried a two-way sync that more copies data from MongoDB Into the post this database and that was the biggest pain we had So I think in this case is the customer business requirements they dictated what kind of strategies you need and Moving the data from no sequel to a relation database. That was the biggest pain we had basically moving from no sequel to True my sequel to my sequel post-graph my sequels I'm gonna do a two-way sync Yeah, so some new applications reading that one and I also need to read it Right, so we had users are both that both the applications and The good critical give the criticality of the application. We could not do a fast cut over or hard cut over So way to do transition of way of time the system was in beta for some time But you make sure that we could support both the systems Yes, we mentioned just on every application just different characteristics, right? So you really have to understand what your data is and what is the best strategy for you to consider the transactional model So I could respect the might because I try to recall the sessions So the legacy application was built long time ago. It was built on relation database using All technologies the new system we're building. We had to move to cloud application cloud basically run everything in the cloud We didn't want to spend We didn't want to use ID BMS that new system you're building need to have flexibility for making change in future So instead of doing ID BMS relation of this set to go with no sequel Hey, so I work for a solid fire now part of net app But in a previous lifetime I've done most of the things that you discussed and encountered the challenges there and In moving from a traditional DVMS to no sequel What we found with our application architecture as we were we were having explosive Scale growth at that time and during that transition we moved to a service oriented architecture Because that was actually I was a data-driven decision because as we moved out of the DBMS out of my sequel We found that there was a subset of data that truly Needed to exist there. That's where it made the most sense. This is user file information And so we made a basically user file service that Remained Responsible and was the access the web access point for that particular You know piece of data whereas the event information all the geographic locality information for for tracking eventing was moved into Mongo and you know so that so the bulk of the data moved into the you know this kind of Document store and you know kind of cloud-enabled You know type of structure Because it actually it was all JSON data and made the most sense to put there rather than you know sticking in the blob in a traditional Data store Whereas you know the user file stuff that we've been doing for decades You know user accounts information like that just it deserved to remain in the DBMS because that's where it made the most sense we just simply Architect the service architecture around those two different needs use the right tool for the job for the migration pattern we used a live migration used a Shunt method and then a backfill a verification backfill to make sure that all the ideas have been transferred over so that took like You know week or so to move many many terabytes of data, but that's how we accomplished that Thank you Great observations Anyone else we still have time We thought we would put this information slide up in the background so you could take notes write some things down our open-stack enterprise working group Has a mailing list we have regular Regular calls we'd invite you all to participate in of course as you think deeper about The questions we're asking here and and some of this subject matter. We would love to hear your experience And thank you for for those of you that have shared your experience so far so Others you please use the microphone I'm just kind of curious about what type of support models that you have for using Databases inside of open-stack, but yet You know usually inside of an enterprise you have the open-stack team, and then you also have a Database team that handles pretty much everything else. I'm kind of curious What you're all's experience has been in order to actually provide You know a homegrown solution To transition to get additional teams to support the databases that the open-stack Is going to be using so Really good point. I think you'll find that In the network space You might see the same sort of challenge right where you where you're adjusting your your staffing for your cloud Administration to adopt the practices that oftentimes were broken out to a specific Team or tactical unit, but I think that's a fabulous topic for a future presentation. So Anyone have an answer for this guy your own experience I know there's a couple of sessions one that I heard earlier today that you might be interested in around supporting Open-stack cloud that they did talk a little bit about the challenge of moving from a Dedicated support team that was deeply focused on things like databases or networking, etc. To to a more holistic cloud-centric More of a breadth support team if you have ideas for topics That you would like to hear about in Barcelona Please send your ideas to this list as well, and we'll try and take your feedback and and prepare for round three At the risk of being verbose and talking twice to answer the previous question having made the transition from a traditional operations environment database administration environment to transforming my own skill set as well as Hiring a team of ops people and turning them into dev ops people That was a similar experience that was along the same time frame as As the transition I talked about earlier with the migration we went from a traditional monolithic architecture vertical architecture To a horizontal architecture and in doing so we had to Stretch and make uncomfortable the operations folks who had a few gray hairs on their heads like myself As well as bring in the more operationally inclined development guys who really wanted to get into the guts of the system so we created a dev ops team by bringing in folks from both the old school and the new school to kind kind of you know Create and and transform into a dev ops team that could manage a breadth of environment and we did specific cross-pollination exercises to to increase the breadth of people's skill sets because it becomes more of a matter of Knowing where to go to find out the answer rather than having everything in your head for a specific Area of expertise you have to be quick and swift and be able to move back and forth and track it down quickly All right, I think we are at the end of our time allotment so On behalf of my distinguished colleagues, and I thank you so much for your time. Thank you for remaining here Thank you for your feedback So we are the enterprise worker we published to e-book So we talk about what is open stack why open stack and second you would talk about how to implement open stack in your enterprise Company is fairly available is that we have printed copies here So foundation print of a couple of copies here you can come and get it if you want and there's also e-book version If you need an e-book version just reach out to us Thanks everybody enjoy the rest of the conference


So I was just to talk about the use of point-of-cuter sound outside the opera, you know, that's my field as a non-anesthesiologist. And I will try to show you how I use in my practice and a little bit of literature on this. This is my disclosure is that the main disclosure I have is as you can see here I'm so passionate that my daughter has been practicing ultrasound when she was essentially one year old. Time is a problem because in 20 minutes there's no much opportunity. Happy to answer a question at the end. And I saw that does that has been posted in literature. This is a great way of providing more material for the audience. I know that you all know about when we talk about Pocos, especially in a group of very expert anesthesiologists that do transasophageal and you are considered the expert in the field. What do you think about Paul to kill ultrasound. This is the definition that I like the most is where every time you think about the political ultrasound is that he's a clinician that perform an interpreter and ultrasound based on a problem. So it's clinician perform is very limited in scope and go directed. He's done at the bedside and I will show you cases. The interpretation is real time not hours after the fact that the findings are recognizable and definite is mostly a yes no often characterization. And of course it's part of my momentarium is that I still use a lot my status scope. I still use a lot my hands when I assess in the patient and of course the training it's something that we can talk at the very end. So to explain and show you how this concept can work is that I'm just going to present you one case is that it was a patient that I saw a few years ago. In 1962. She has history schizophrenia and the series order. It was admitted to the psychiatric ward hospital day seven was part of the rapid response team and we were called because of the critical consciousness to be honest is that they told us we think she's when I arrived on the floor. She was cleaning shop take a cardiac with a 30 pulse so we could not get a saturation. No idea access present the skin skin was modest she was still obeying but honestly quite drowsy. I was clearly facing under freshened in shock in a almost on a style environment as a psychiatric war with no much resources and no have the access. So the first thing I did is that looking at the VC and Andre presentation was clearly showing how you can actually use this contrast elastic contrast of a jail in my case was transatlantic. And in all surprises that was expecting us collapse in a VC the vast majority of the situation that we see on the floor when we are called is usually sepsis. Hypovolemia. This was a very surprising VC to be honest. And for the audience that will be more expert you can immediately see that was something that you immediately call my attention at this level all the right. But of course is that because as a congestive I VC pattern I immediately and quickly turn to this cost of view. And this is what I saw is that an RV that is dilated and something floating or it looked like floating in the right atrium and an under fill of the quickly moving to the parasternal the shape of the septum there was a presentation this morning talking about RV dysfunction the estimated indexes was clearly showing me pressure of a load of the right ventricle and in RV in flow view, you can clearly see here that it was a trombos or at least a ecogenic mobile mass, coming from the infinite cable what I showed you at the very beginning, because it's not just ultrasound echo cardiography, but this critical ultrasound from my perspective is that I quickly moved to the groin, and I found the confirmation my hypothesis that there was a trombos in the common femoral vein. I use ultrasound to put a central line in this patient on the floor, we quickly transfer the patient to the issue she got TPA at arrival in the ICU because I called the team to prepare for TPA. And the patient managed to be not intubated and leave the ICU in two days with shock resolution in less than 24 hours. We later did a CT chest that they confirm our findings and the radiology called us very what about the findings and we thought that we know already and the patient already got treatment for this. Really, if you think is that I was the clinician, and I did it. My question was, what is the shock here is obstructive is hyperbolemic. I did it at that side, not even a ICU but the only psychiatry word I interpret the findings in real time and they were pretty simple and definite. And of course that they was part of my physical examination as I started with the vitals and observing the patient. And what is the literature on this is that this is a systematic review method analysis the city published on the use of point of ultrasound for diagnosis shock etiology. And look at the likelihood ratio is that if you add point of ultrasound to your clinical momentum, your likely positive like ratio negative like ratio they are significant and you will dramatically improve your diagnostic accuracy for any form of shock. But it's not just the diagnostic accuracy because again is that life is not so simple is that this patient was very straightforward from a certain way and the diagnosis was unique. But we do know that a patient are complex and often these multifactorial. So in this study, published in critical medicine 2015 they use a very interesting index is a sort of the explorer, the concept of reduction in diagnostic uncertainty. Think about our clinical reason right is that we often have a patient that he is a shocky and we start thinking about all this would be this this and this. And the reality is ultrasound may not be able to give us the smoking gun, the single diagnosis, but definitely we'll be able to rule out other causes will be able to reduce our diagnostic uncertainty and showing this in the study where for all the diagnosis of shock, there was a 27% reduction in diagnostic uncertainty. So when you think about the point occur ultrasound is this is fast, because you have it at the bedside and the previous peak and even discuss about the user on crazy emergency like difficult airway management is quite accurate. And when he's not perfect, he still help us by mitigating the diagnostic uncertainty. I show you already briefly by doing basketball to sound this is not just echocardiography. I really use the ultrasound as my status copper, even more is that I use it for brain chest diaphragm airway heart abdomen and basketball applications for the wonder interesting. Great consensus and expert recommendation. Manuscript that we publish last year in collaboration with the ESICM. Just to show you two very quick cases about how this is all body ultrasound is Christian Azora talk about in the pregnant patients. This was a gentleman. He was generally admitted to our world with post severe traumatic brain injury. And the team on the floor called us because the patient was to keep me. And they even called the nephrologist because it was having increased creatinine and they were thinking about some form of kidney injury. The patient arrived to the world, the patient was again in shock to keep naked clearly without 30 pulse hypotensive and the IVC was collapsing. As I look at the admin. I noticed that there was free fluid in the admin is that Andre show you how you can assess free fluid from a trastophogea is that in transport is even easier. And it was not just free fluid there was, as you can see here, some ecogenicity inside the free fluid, something very strange. So, at that point, I asked myself why a patient with traumatic brain injury now is showing a free fluid in the admin associated with sepsis. I quickly ask the nurse at the bedside that if any procedure had been done in the past 48 hours and the patient to now that he had a very challenging in social gastro stomach tube. And at that point, I, I immediately suspected the amal position in my end of the g tube with essentially feeding into the patronium the patient went straight to the operating room after being debated and resuscitated. And there was misplacement of the tube with several essentially liters of feeds in this particular cavity. And here's another gentleman. It was a multi system trauma that unfortunately develops to be respiratory failure with the PF pressure less than a hundred. There was some concern about his brain. He had of course sinus and multivariate as a part of the multi system trauma, and the neurosurgeon they wanted to repeat a CT imaging decide if it was indicated or not to insert. And then they came and monitor for ICP measurement. The problem was it was very unstable. And we were insured it would have been safe for him to be moved to the or to the city, sorry. So what I did I did to brain ultrasound of a technique transclerial Doppler on the side and here opt in a sheet diameter assessment. And just for the one that are not familiar here I'm at the level of the middle silver arteries. And this is a very concerning flow. This is a patient that has a very reduced the story flow. If I see this, this is a levator will call positive index that is being associated to be delegating the kind of attention. At that time, he was very easy at the point for me to discuss with the surgeon and decision was to insert an ICP monitor. Unfortunately, the patient progress over the course of the next few days in terms of his intracranial hypertension and this is again the mca at the level of here is in terms of artery here and recently mca. Just to tell you is that that usually there is a sister that started flowing means that there is a continuous flow at the level of this vessel and you can see here there is a possibility you only see stroke volume essentially flow during sisterly and on parts where Doppler the flow change dramatically compared to the one I showed you before. This is now an auxiliary flow when you have flow reverse under the Astrid and suggestive an extremely elevated ICP and unfortunately the patient progress to bring that. Again, without moving the patient to see T we were able to immediately identify life threatening condition and have a proper discussion within our social team. This is a very interesting study that was published this year, the impressive to study where they look at the transcanial Doppler use as a screening test to exclude intracranial hypertension and then you can see here there is an excellent negative predictive value. And the idea is that if I do transcanial Doppler in a patient where I'm suspecting or I'm afraid of intracranial hypertension and I don't see any. There is a formula in this study that is used to estimate the ICP and if the ICP is not elevated according to the transcanial Doppler unlikely the patient will actually have intracranial hypertension. So again, it's a very useful tool when there is some uncertainty, and you want to increase your likelihood of doing the right thing for the patient. From this few initial example you can see how point okay ultrasound can be used essentially in two big categories is that one is that you know the ultrasound may help you but it's not prompt available. So, when there is an emerging eugenie for clinical evaluation and your cardiovascular anesthesiologist that is excellent. or your cardiologist colleague are not available. One of the biggest findings from Pocos facet of physical examination essentially is that I'm expanded my physical exam. A low for water more rapid triage. I thrombolyzed the patient in less than 20 minutes from my initial call. And of course is that the clinical management was very very directed and for focus. The only way of using this is that when it's not practical right is that I cannot ask the cardiology team with a collab to come every day multiple times a day to do an ultrasound in my issue patient. And so when I need frequency examination to follow up on some findings or really as a physical examination and chance. To give you again a little bit more example is that how you can use these in the situation is that he was a patient that the nephrology team call me. I have known a institution disease on dialysis and meet the night and I prior to an emergency department for respiratory failure. And the nephrology was concerned because the pressure was a little bit softer, and they asked me to meet the patient today see you for facilitating a sled, because they told me I don't think she can tolerate. So I went to see the patient she was bet space on a surgical world because there were no beds in the nephrology world and to my surprise. Look at this ABC this ABC is very different from what you would expect in a patient that has fluid overload and she skip dialysis session and everyone thinking that she is overloaded from a fluid perspective. So, I initially say okay this is nice make sense so of course I look at the heart. And if you look at the heart is that there we doesn't look particularly dilated. And you start to appreciate that there's something strange on the mitral valve the battle but doesn't look normal and again at that time actually the there was nothing in the admission note talking about vulgulopathy. I moved to the apical for chamber view and again this mitral valve is clearly no normal and when you look at the Doppler, there was even flow assertion and Pisa at velocity to 61. So give it a per second and so clearly suggesting a severe model to severe mitral stenosis. And you can see also here in the process on the long axis view of this mitral valve into now that the patient had a known mitral stenosis it was in a model to severe spectrum and she recently transfer to another dialysis center and that was not known to our nephrology team. As I was performing the Paracena long axis view, I noticed something on the background that's why I keep this 20 centimeter deep Paracena long you can see here is that again not just hard one or so long is that there is something in the left over a space that is ecogenic. So there was a consolidation there so I moved my attention to the lung. Let's keep this. I move my attention to the lungs and that this is on the right side the right side was absolutely normal is that Christian show you patient with be lines and I think you saw so this morning and one of the first presentations is that this patient the right lung was completely normal again completely the initial diagnosis of fluid overload. But when I moved to the right side here I'm at the apex okay this is the apex of the lung. And here is the basic and appreciate here is the diaphragm and this is the screen. This patient had a complete collapse and consolidation of the left lung. At the point I knew that the patient was a very different diagnosis on what she was sold to me. I transfer today see you I order for a Texas Ray and this is the new chest x-ray, less than 10 hours after the initial one. And it turned out that the patient had MSSA bacteria with a left lower non pneumonia and mucous blood that had in left main step. And this again in less than 20 minutes by performing ultrasound. What do we know about the effect the efficacy of using a point of care ultrasound for patient with respiratory symptoms is that this is a study from Kristen Lawson in from the Denmark. And the medicine when emergency medicine patient presenting to the emergency department with respiratory failure were randomized to a point of care ultrasound multi organ ultrasound approach versus standard care whatever standard care. And what they clearly found is that the point of care ultrasound was associated with the better diagnosis, faster diagnosis. Most of the patients should be so far they were patient that was involved as a part of the rapid response team so not necessarily in the ICU. And this is a study from friends where they implemented a point of care ultrasound sort of a protocol in their rapid response team. When they look at the boat respiratory failure and shock. And what they found is that in the patient that they have a point of care ultrasound assistant assessment. There was much higher. Correct immediate other diagnosis correct diagnosis. And again, this was a small study so I don't think we can make any inference or mortality but they show some more type of difference but honestly it was a small group. Small numbers so we can really make this such an inference for this. What about this second part right is that when frequency as ammunition and follow up with some findings so the physical summation agenda. We are finally awfully coming out of this long COVID era. And this is one of the patients that we saw during I think way two or three. We were again call on the floor was on the medicine world patient with the initial disease, COVID positive. The team consulted us because they thought it was progressing on COVID pneumonia. So they called us if we need to need to bring it down because the patient is with a common pneumonia. I started with my ultrasound assessment. And this is what I found on the right side. So, quite dense consolidation some pro-refusion and if you notice this is first of all this is not a typical characteristics of a COVID pneumonia. COVID pneumonia has very different characteristics online ultrasound usually if you the consolidation are not large and massive. And on top of that also, there was a few pay attention here that are multiple sort of nodural lesion. This is a typical characteristics of a necrotizing pneumonia. These are all multiple lung abscesses and the patient turned out to have been a staff or pneumonia. On superimposed on his COVID infection for sure, but this was not a simple COVID pneumonia. As a part of the assessment we look at the heart and as you can see here out the heart was hyper dynamic with a very small RV is the patient at a very, very poor parasitic of you so I turn out doing a soup costal short axis view. It's now day three, and the patient is now having worsening shock so again, being able to repeat my ultrasound and also to take advantage of the fact that I knew already how the patient look like on ultrasound prior. He's now on significant shock is that is on norepinephrine vasopressin and epinephrine. So something has changed. I have a question for ultrasound. So I start with my problem is a cardiac ultrasound here because it's in shock. And if I don't have the answer on the cardiac ultrasound what I do is that I look at other areas. And you can see here that we see is very different from septic patient. And when I look at the soup costal view and Parastinal view is that the RV dramatically change. This is not anymore on an RV that is small and under fill. COVID pneumonia, as you know, is associated with the increase got on Moses, I immediately move. I immediately moved to the groin and I found a clot again in 10 minutes. We had a different diagnosis. Of course something that he was in our differential but at that time moving a patient with COVID pneumonia was very difficult and CT as you may remember is that the world in fashion prevention control quite different at that time. And we started treatment right away. It's now day nine, same patient. And again, as I told you, as a part of my physical examination, if I can, I always bring with me ultrasound, not every patient, but especially patient particularly challenges. It's a little bit small here, I apologize for this, but if you can see here with this was on May 7. Okay, May 7. On the right side that is sliding and trust me, if it is smaller, there was some sliding here. But when I look at the new image on May 10, I could not see sliding paths of vertical artifact. At that point I had suspicion of a complication there is new motor access. And as I moved down and laterally, I found what we call the long point. This is a very interesting one point because it's not just air and air, but he's hydro long point on this side, the air in the porous space and here also a fluid in the porous space. And of course, at that point, our order not just say we don't do it in the anymore just excited in the ICU, and clearly we identify the new motomics. This is a patient that we, we omitted the last year in terms of what you can do with ultrasound in terms of decision making the ICU is that you can see is a dense consolidated lung is a patient unfortunately was a near drowning in Lake Ontario. Very toxic and difficult to manage what I tried to do I tried to do a quick recruitment maneuver with ultrasound visualization and you can see is that by increasing my people and doing a 30 by 30, but a very simple sustained inflation. I noticed immediately that the lung was from being density consolidated was moving to a be pattern with multiple be like clearly telling me that this patient was recruitable and I felt more comfortable even in the context of a shock to increase dramatically. In this study from 2022 and this is a study from a group from the Netherlands, will they look at the look at the across different departments and show me new ICU but there are also medicine and emergency department in their study. I showed us how performing lung ultrasound in these populations in these settings can dramatically change your diagnosis and also lead to a therapeutic impact change 40% more than 40% of the patient. The lung ultrasound in your ICU will lead to the most change think about the patient just described to you and also management change increasing people decreasing people doing a bronchoscopy or, for example, doing a recruitment maneuver or putting a chest you don't forget that it's focus is only one piece of the puzzle. Be very careful because what can lead is that you can actually cause harm if you use ultrasound as the only way of assessing your patient. This was a guy that was admitted a few years ago when I was still working at Toronto Western presented the magic department with abdominal pain a little bit of elevator lefties, and a new onset at affibulation. Apocos was done in the magic department. And there was a reporter in the chart say normal just on fraction, no original motion or martyrs and the patient will refer to general surgery for pancreatitis. This is day three, and our rapid response team is called because of worsening respiratory status was in Takicardia. This is is paracetamol long axis view is Takicardic in the concept of a fair but you can see here maybe a little bit reduced ejection fashion monoterval. This is Paracetamol short axis again very good. This is the apical for chamber view. Again, something that an ESO cost of you something that very consistent with the initial purpose that was done in the magic department so what's the problem is that what's happening here is that at the time that the fellow was a wonderful anesthesiology actually that was working with us and is now in London Ontario is with Fredo Quentus and with Fredo put his status cop on the chest of the patient. And he heard a significant murmur. So, what will further that is that he continues examination and he found a flail valve. The patient has a rapture cord and it was a quick identified transfer to the general went for surgical repair and he did extremely well. And this patient is elevated lefty examiners was actually cardiac congestion, leading to liver congestion. So, it's a great tool, but we need to be very careful, because as just one piece of the analysis puzzle, of course, is that focus funding may corroborate the support of a pre test hypothesis, but can also dramatically mislead us. If you're not aware of our limitation. They can also be completing consequential and not supported, but not changing the hypothesis plan. It's okay. Well, I will continue with other tests. And in extreme in very not very rare but in some circumstances that completely changed the protest hypothesis and lead to something completely unexpected think about the lady where I was really not thinking about pulmonary ambulance to be honest. I was mostly thinking about 70 shock or bipolar. So in terms of take home messages is that you can use point of culture son when you don't have access, rapidly to the expert sonographer, or where really is that this is not practical because you can only have your cardiac sonographer or your cardiac cancer is coming every day multiple times a day to do your physical exam for you. Parkers may narrow differential diagnosis. And if, even if it's something that is not really changing my hypothesis definitely to give me more confidence. Now for repeat monitoring can lead the remembering I see you more than 40% of those only to the management changes. And of course the system for procedure. What we don't have yet is create data on patient outcomes. And so, I think is that we need to be very careful with the perspective and that's to be some of the work that we all should consider for the future is to really show that there is a benefit for this patient. There is a statement for endocrine Patrick that is an intensive is a trauma surgeon from Alberta that the years ago wrote the greatest benefit of the patient will be realized when these diagnostic technology is incorporated into tough for patient assessment your physical exam your history your pre test and incorporate your possible information consider the patient physiology. This is the hour I think when I approach point okay ultrasound, I asked myself with the patient as if the probe as a question for the probe if I can answer something with the sound if that son is not. I just go straight for MRI CT or whatever. And then I focus on the acquisition. I need to get good views, and only when I have good views, I proceed with interpretation, and then I put all the pieces of my puzzle together. And I'm happy to take questions. And I hope that you found the top useful. Thank you very much. Thank you, Alberto. As always, amazing topic. Really practical. I, I've watched it like your presentation so many times and I, you always bring something new to me. Thank you so much. Before, before we start the focus case and Q&A sessions. We have a few like questions. The first question goes to the Dr. Dono, Dr. Bola can and also to you, Alberto. The question is any pearls on distinguishing atelectasis from pinion from pneumonia and ultrasound. And also, Dr. Dono, Dr. Bola. How difficult it is to do this diagnosis using T. I missed the question was going to open the camera. Okay, no, no problem. I'm going to repeat. So the, the Odyssey is asking any pearls on distinguishing atelectasis from, from pneumonia or ultrasound. And also for you two guys that talk about tea. Is it possible to make this diagnosis using tea instead of tea tea only. So, I think I took a yes at the similar question this morning, regarding how to differentiate pneumonia from atelectasis. One of the way that people have taught is that when you have atelectasis, you have epoxy visual constriction. Okay. When you have pneumonia, you're going to have a shunt. That's why the patient will will be so that will have epoxy. So, so in the case in some cases where I clearly had a pneumonia, when you put color Doppler on the long tissue, you're going to see flow everywhere, everywhere. On the other hand, when you have atelectasis, you don't see as much flow probably because there's a visual constriction of this. So that's, that could be one way. One of my colleague was looking at seeing if he could use Doppler velocities or signals, you know, to differentiate the two, but that's that's about that's about it. As Alex was mentioning, what's very useful. When you have an area that you wonder, is it a immatoma or blood clot, or is it a tissue long tissue. And if you see flow, you know it's not an immatoma. You know it's a tissue, it's long tissue. But if you don't see any Doppler signal that could indicate that you're having a blood clot over there so that could be some some of the ways that you could use Alberto you're doing a lot of long ultrasound would you like to comment. Yeah, if I can share my screen for a second I'm going to show you is that it is a study published from a group from the Netherlands and I was the reviewer that's why I know this study quite well. And what they did is what they did is that they use a sequential approach. So it's not just one finding my integration of three separate findings. They look at the presence of absence of dynamic program. They look as as you were mentioning Andre is the presence of absence of flow. And then that's what I like in also in the study is that they integrated the clinic presentation of the patient so they calculated this score right this CPS is a score that we use my routine in when we try to identify the diagnose happen but in the ICU. And what they show is that by using this integration, they were able to significantly increase the ability to differentiate pneumonia from a telekinesis. And it makes sense if you think and I think is that again is that the what I like is that the fact that we need to think more about it's not just one single finding often, but he's not. So our pre test probability and the use of our status code to be honest or hands our blood works. It's not a holy grail is a great tool in our momentarium. And I like what Alex presented this morning and said, when you have an unstable well, I would say I would say like you. You have a trans thoracic but in the or if you have already a T probe in, you should take full advantage if you decide to put the T probe to get as much information as you can. And as you mentioned, when you have a pneumonia, you can have RV dysfunction and you can have live intraculomal cordial depression. It can be in a patient with cirrhosis you'll see a sideways. So I think the same way that you use the trans thoracic probe to do your physical examination. I would say, and especially when you you're not under pressure you have times, which has happened in the IC, I think, take full advantage of the T probe get all the information that you can get. I had one case I didn't have time to show it, but was in the middle of the night were called because this patient was in shock lactate was increased. This patient already had LV dysfunction, but there was no reason why she would got worse. So finally look at the heart nothing look at the long nothing look at the abdomen, and then I look at the liver, and there was air in the portal way. So basically this patient was having this enteric ischemia, and there was air in the portal vessel. And the reason, and this this marker this is misenteric ischemia was creating a cardio intestinal syndrome, it was releasing cytokines which was making the heart worse. I think the right and the left heart worse. But the reason, you know, if you just look at the outside world the heart doesn't look bad but it was already bad that it was worse because there was misenteric ischemia. And then we only we got an autopsy and we confirm the findings, something we've published. So, so there's, there's always a reason. There's always an explanation sometime.  So that's my definition. But if you look for you'll find it. And, and T is not just a T broke to look at the heart. You can look everywhere, but always start if you cannot get the information with transfer I think I would always start with transfer I think but if you cannot get because the IC has no acoustic windows, then I go with TV. Thank you so much, Dr. Donald. Thanks so much, Alberto. Dr. We have a question for you in patients that have cardiac arrest the risk is like is higher to have a esophageal perforation. Do you think that's this like the risk go up even higher with T in place. Yeah, this is a very interesting question. And it's a frequent concern about the use of TV during cardiac arrest so my answer would be yes but as for safety issues we don't have any specific literature available regarding the risk of injury during CPR with a T probe in place. And to my knowledge no adverse events specific to T use during cardiac arrest have been reported so far. So we can only in fear from ambulatory settings. But there's a very interesting study published recently in 2020 I think in the Journal of American College of cardiology. And they looked at T safety during structural project heart procedures, mainly my microclips and LLA closures closer device. And in their study they had a very high rate of esophageal and gastric lesion. And about 86% of patients and 40% for 40% sorry of these lesions were classified as complex, meaning that they were intramural hematoma or mucosal lacerations. And interestingly independent factors, independent risk factors for those complex lesions were identified as being a longer procedural time under T manipulation, and also poor image quality. So we could in fear that during resuscitation with a T probe in place, we could have a longer procedural time and also a harder time with image acquisition so with this study I think we could say that the risk may be higher during cardiac arrest when we have a T probe in place yes, but I don't have any specific data for as a visual perforation per se. Okay, now thank you there is another question here that I just received. How do you guys practically put put in the tea. Do they pause the CPR and how long does it take to to start this examination with the CPR in place. It's a very good question. It depends on if you have a protocol or not. If you do T rescue later during the rest station you put the program, the patient is already intubated the data show that it takes about 12 minutes before you have the first image acquisition and you have a great feeling Thank you. And, and when, when you have a more of a protocol, usually you can put the probe during the intubation so you don't necessarily need to stop the CPR, but some pay some physician just asked just for a little pause when they put the tube in so we could use the same post to put the probe just after. So yeah, that would be my answer. And if I can add, because we're getting more and more emergency physician that we train for T insertion. And in fact, that's what I do in my practice and that's what I teach is that when you take camera lowering ghost code, and you do your intubation the T probe is already ready. The machine is already open. And then you put the tube you put the T probe at the same time on the direct vision. There's been a recent study from India, and which they compare the old arrangoscopic insertion of the probe versus blind, and they clearly demonstrate reduce So at least you're going to eliminate the or reduce significantly the pharyngeal complication. So, so the idea is to be your have your T probe ready. And the tube ready, and you do both at the same time. So then it takes just a few seconds. And I always recommend also that when you insert the probe. You should always well when you do it under direct vision, you see that you're in suffocates but if you have any doubt. You recommend to keep your image open. So then you know exactly that you'll see the Arctic arch and you'll see that the anatomic the normal anatomic structure as you insert. As you insert the probe that's something we teach when we do workshops with team because sometimes just upon the insertion you'll see the Arctic dissection you'll see the pathology. So, you don't want to miss that information. Thank you so much. Thank you so much. Thank you so much. We have a few more questions. And doctors also since everything that you said is pretty much based on artifacts on ultrasound. Do you have any like, do you change how do you do you optimize the settings for those like, do you have any tips like how to make this image better since you're just looking at artifacts. Do you like change harmonics you turn off harmonics do change anything to make those image better. So when you look into into the identification of the crackle type of membrane. Most of the time the image is very clear because you don't have so many space in the neck. Of course you're looking to interface where you want to see bright so increasingly a little bit the brightness will be something that will be helpful. We normally use the linear probe, the simple linear probe for that so that's very straightforward. The imaging acquisition is not the biggest problem, even if you have like patients with high BMI is not as challenging normally a little bit more challenging with but like with a moderate level of experience in the technique you're going to be able to to identify with no problem. But there is a question in the Q&A about indications and I think that my, my, my thought about this is that is very, very unlikely that they're going to be able to use these in the emergency setting that's how it was like at the beginning, I believe more in pre-marking the membrane. And people have said okay crackle type of me will be like a very rare procedure but of course, if you're looking to the net for from UK, that the major complication is postponing like major complications that have been from from array management and leads to brain damage or death is because people keep postponing doing the crackle type of me so if you have it pre-market is going to help to make the decision so a lot of things that will direct you to into the right way. One thing that we do currently at Sinai we're using this technique to improve our, this is not in the literature actually but we are using the crackle type of membrane identification to improve our awake intubation techniques so we, we start to do like our trans tracheal blocks guided by ultrasound on real time. But like we mark the membrane and we can even like measure the depth and then this was going to give us like a more feasible block and more a higher success rate for that and our, our the quality of block that we get and the freezing that we get is very, very satisfactory for, for of course, the providers and the patient. Okay, no perfect thank you so much Fabrizio. Dr. Arzola, I noticed I would like to add something to what Fabrizio was mentioning about pre-marking the membrane and sometimes something new when you do it in the in the war. But I remember we have had a few cases in the past, for example, the typical case, preclincial, difficult airway, full stomach in the OR for a C-section. In those cases, we usually wouldn't do a way for abrupt intubation to those pregnant patients, we mark. Of course, the first time we did it, people say, well, what are you going to do? Are you going to do? No, no, no, it's just pre-prevented just to know before you get to the point where you're no way rather than surgical airway. So we mark and then Fabrizio, we do the transmembrane installation of Lidocaine in a very nice, safe manner. So when you're doing your wave fiber optic, it's very elegant, you get into the care and that is not really rejected much by the patient. So it's elegant, you save because you can mark and it's something we advocate. And probably we go to the extreme, but we believe that every time you do an awake fiber optic intubation is the final step because you may be in a situation of not intubating, not bagmasking. So in that case, we always tried at least to scan and have an idea. But of course, have the kid for critical fiber membrane at puncture, which we have already customized kid ready next to us in case. So put yourself in the worst scenario in order to be prepared for that situation rather than actually attempted to do it. That makes total sense. Yeah. Thank you so much. And I am actually I was about to ask you a question as actually this question you already answered on the Q&A on the messages but for those who didn't have a chance to look at in patients with preeclampsia. I want to ask what's the mechanism of the pulmonary gema and related to the focus on on this type of patients. Do you see any sort of like a systolic or just follow this function on patients with pulmonary gema having preeclampsia? I want to be very honest and straight because there's a lot of research. And we know a lot of information. We know that in preeclampsia the pulmonary gema can be multifactorial. But when you read certain research, they still say it's still controversial decrease in oncotic pressure decrease in increase in permeability and also systolic or diastolic dysfunction. And all of those things is something you can check even an increased BMP can be a predictor for cardiac problems, cardiac complications in preeclampsic patients. So there's a lot of things you put together and what we do usually we try to do a screening like Alberto always is teaching us just to have an screening of the patient to have part of your physical examinations. So every time I have a preeclampsia patient that is severe, the blood pressure is not well controlled, urine output is not good, so they need to give fluid. We go there, we put the probe, a standard simple language of sound, we say, yeah, we're okay, we can give and then we come back later and we check again language of sound is still okay. In that way we can qualitatively listen from the practical point of view qualitatively know how things are going. Sometimes patients already come with some interstitial syndrome. And we know that it's a pre is a state before eventually pulmonary edema. But that is the situation sometimes we have systolic dysfunction, sometimes we have diastolic dysfunction that can be direct cause of the pulmonary edema. But again, at the bedside, if you're doing just pattern recognition, of course, you need to start doing pulse wave Doppler tissue Doppler to know the diastolic function, and it's something probably is beyond the bedside, the basic basic bedside. Okay. Okay, thank you so much. We have time for like just one other question. Um, Alberto. What are the features that you're looking brain pokers to exclude increased ICP. So the idea here is for Traskinia Doppler is that I can post in the chat that the impressive to there are cities of formulas that they've been published in the literature. The study they were mentioning my in my presentation essentially uses what they do is that you always look at two key features is that the flow velocity. It's very important to the diastolic velocity. The overall idea is this one is that in the brain is a continuous flow. Okay, so if the Astoli flow if you think about it is that our brain is a low resistant circulation. I'm expecting to have a quite high elevated diastolic flow. If I start developing intravenous hypertension. My resistance at the level of the capillary will go up and therefore the resistance of flow will lead to progressive reduction on the desktop flow. So, very simple thing is that just visually is that I show you is that if you're a systolic and that's all the flow velocity is very, very broad. That's a bad sign. The formula that been published. They all try to to regression formulas is to estimate either the CPP or estimate the right to the ICP. They are not the greatest to be honest and I think that that's why the imprecise to try to show truly show that that they're okay to rule out. Okay, and that's how I use it. I do it. If I see a great flow and with the formula there's nothing telling me that the CP is elevated. It's not unlikely that the patient has elevated ICP. But if I see an elevated ICP with the transgeneral Doppler, then I have to ask myself, is it real? Do I really think that this patient has CT features or pathophysiology and I've discussed with the children. But again, he's great at ruling out with a ruling in. But it will ultimately is all about the features of this desktop flow coming down. And then there are there are other more complex as you can do but that is a very simple one. Okay, no, thank you so much. I appreciate. This concludes the Q&A session from our afternoon session. Thank you so much, guys.