👉 El médico especialista en neumonología y gerontología, José Manuel Viudes,explica en términos sencillos qué es una neumonía bilateral, cómo se desarrolla a partir de una virosis y cómo afecta a los pulmones. Además, discute cómo la pandemia ha revolucionado el campo de la neumología, mejorando las imágenes médicas y revelando nuevas correlaciones entre enfermedades como la obesidad, sarcopenia y las respuestas inflamatorias del cuerpo. También se abordan los parámetros de inflamación ocultos que pueden ser medidos por un clínico para evaluar el estado de salud del paciente.
🗣️ Antonio Laje
👉 Seguí en #OtraMañana
📺 a24.com/vivo
🗣️ Antonio Laje
👉 Seguí en #OtraMañana
📺 a24.com/vivo
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NewsTranscript
00:00Doc, how are you Jose?
00:02What's up, how are you?
00:04Can you tell me, in our simple language, what a bilateral pneumonia is?
00:09Bilateral pneumonia is the consequence of a picture that begins with a virosis,
00:15which is the first domino effect that occurs in these patients, the first one that falls,
00:20and when the body does not solve that, it ends in a more extensive infection of both lungs in this case,
00:28and it is due to the overgrowth of bacteria, that is, of a virus, which is what we all have in winter,
00:33and the Pope frequently has it because of the antecedent it has,
00:36his defenses were not able to solve it in this case, every year he solves it well,
00:41and he ended up with a bacterial infection, which is something more complex than what we call pneumonia.
00:46And what does it do in the lung? Do you see the lung with pneumonia? What is it?
00:52Well, that's why it was said yesterday that it was pneumonia.
00:55What we do in humanology, when they said it had a polymicrobial flora, 48 hours ago,
01:01we understood that on Friday they took a sample of the catarrh and found that instead of having a virus,
01:06which is what we look for in viral pictures, it already had bacteria,
01:09and that means that if it is found in the catarrh, it means that it is overproducing,
01:14that bacteria produces many secretions, which people call catarrh,
01:18and that covers some lung areas of the patient, especially in this case in both bases,
01:23which 48 hours later has a delay, and the tomography, we always wait a little,
01:27first the physical exam, we confirm with the tomography, which was confirmed yesterday,
01:31that it has the two bases of the lung occupied by secretions, which would be something like catarrh,
01:37which means that when oxygen enters, it cannot pass to the blood because there is an obstacle,
01:41and that is what we call pneumonia.
01:43Well, then, he breathes, but that oxygen does not pass to the blood.
01:48Of course, not everything happens, that is, the lung, the truth is that an extended lung,
01:52if we extend it ...
01:53So, it's not that you have a respiratory problem,
01:55you start having a problem of lack of oxygen in the blood.
01:57Of course, and that's what, that's why we say it's a serious picture,
02:01but the gravity depends on the physical exam, of oxygen saturation, do you remember COVID?
02:05Yes.
02:06Of how he breathes, if he has a good mechanics, if he uses the muscles he has to use,
02:10which are the respiratory muscles of the thorax, or he already uses other muscles, which are the abdomen,
02:14and there, if the Pope has a problem that has been accumulating, and here already as a gerontologist,
02:18he is a 75-year-old adult, which for gerontology now ...
02:2175? I thought he was older.
02:23No, no, he's 88, but after 75, now in geroscience,
02:28four years ago in Harvard he decreed that 75 is now the age of gerontology.
02:32Umbrandia.
02:33Of course, that's where the fragility begins.
02:35And he already has 10 years accumulated, and he has several pathologies.
02:39The problem with the knee, which for me is the most problematic,
02:43because we now know that a patient leaves an internation faster,
02:48if he has muscle mass, according, if he was walking previously,
02:52and the performance status of him is already deteriorating,
02:55that is, he is fragile not only respiratorily for the history of the 21 years,
02:59if you want to take a part of the lung, but he has a pathology that we call sarcopenia,
03:03which is muscle weakness, but for three reasons.
03:05He is using corticodes for frequent relapses, which is a double-edged sword,
03:10it serves to make the patient recover his picture faster,
03:13in fact, what changed the history of COVID was dexamethasone,
03:16in England the work he did, from there he changed the mortality of COVID.
03:20Then the vaccine was the most important thing, so it works.
03:23What is the problem?
03:24Two, they increase in weight, look at the Pope,
03:27and second, it infiltrates the muscle and produces muscle weakness,
03:31the corticode, apart from the fat infiltration, the increase in weight.
03:35So he's a man who has muscle weakness.
03:37Today he hardly moves, before he walked a lot and today he hardly moves.
03:41And that's what worries us, as you said, it's not just a respiratory picture,
03:44the problem of the Pope is general, he is a man who is in muscle weakness,
03:49that is, the rehabilitation is going to be slower.
03:52What he has in favor is that he is a man who has good genetics,
03:55he has good immunity, he went through several,
03:57but obviously for us, nephrologists, especially chronologists,
04:00the pictures are accumulating and each one leaves you a sequel
04:03and you are subtracting aerobic respiratory capacity.
04:07Now, you tell me this, it started with a viral virus,
04:12and today it has bacteria.
04:14The feeling that gives me is, well, it's easier in everything,
04:18because you don't attack the viral with antibiotics, the bacteria do.
04:22Yes.
04:23Why is it more serious that it has bacteria instead of viruses?
04:26The good news is that they were very precocious
04:28and took a sample of sputum that is not usually done,
04:31and we already know from Friday that he entered,
04:34that he actually entered through a virological picture
04:36that becomes bacterial.
04:37Why is it more serious?
04:38Because bacteria is the consequence of his failure,
04:41of his immunity to solve the virus.
04:44That's why I told you that the first card that falls in all adults,
04:47that's why the anti-flu vaccine is very important,
04:49the respiratory syncytial vaccine, which is a new vaccine that is already in Argentina,
04:53and the COVID vaccine.
04:54That is, patients have to get three vaccines before the beginning of winter,
04:57because any of those viruses throws the first card,
05:00which seems like something and not,
05:01COVID is not what it was before, but it is a trigger.
05:04But then, if the body does not solve, and especially after 75,
05:07that is much more difficult, a pneumonia ends,
05:10which is the immune failure of the lung,
05:12which could not solve that, and the bacteria that he has inside his body,
05:16and there is the issue of the Pope that nobody talks about.
05:19He, at 21, had a lung resection due to a probable tuberculosis.
05:22At that time, what was done, apart from antibiotic treatment,
05:25was to dry that part of the lung that does not serve.
05:28But what happens?
05:29That part that dries up first, which ceases to function,
05:31that is, it has less capacity to function.
05:33But the second thing that happens is that scars remain in the lung,
05:36that if you make an analogy with asphalt,
05:39there is a patch where when it rains, the water is stagnant in a patch.
05:43Well, the lung is like a little hole, we call it bronchiectasis.
05:47The mucus is trapped there,
05:49and the cilia that should sweep, because of that injury they have, are not effective.
05:53And the bacteria are accumulating.
05:55They wait for the moment when they lower the defense to the patient,
05:59because for a long time there was an immune balance,
06:02but the corticosteroids on the one hand, the age on the other,
06:05the little mobility it has, and the inflammation that produces obesity,
06:08it seems that today we already know that obesity is an immune cause,
06:11that is why in COVID we had so many obese deaths.
06:14It was not because we thought before that the respiratory capacity decreased,
06:17as in 2009 we thought that with the H1N1,
06:20but what we learned is that chronic inflammation produces obesity,
06:24it produces immunosuppression.
06:26The body is very busy in that inflammation,
06:28and it sends us to the soldiers where it should send that it is in the lung in this case.
06:31Now, from now on, we already know the origin of what is happening to you,
06:35how is the treatment and what happens if the initial treatment does not work?
06:40What is the next step?
06:42Well, the good news is that they started early,
06:44because when they analyzed the bacteria, they not only know that it has bacteria,
06:47but they know the sensitivities to bacteria.
06:49So the picture is already directed by antibiotics, I think since Friday.
06:53What happens is that they tell it today because we cannot talk about pneumonia
06:56if we do not have a tomography that evaluates it.
06:58As I told you, we wait 24 hours because the image of the physical exam has a delay.
07:02So it is already with antibiotics on Friday,
07:04so I think I am an optimist, it will go very well.
07:07I know that it is using oxygen, but it is not with other types of problems.
07:11And the evolution is expected 48 hours,
07:15so let's say that if it started with this picture confirmed on Friday,
07:19let's say we are at 48 hours, we should see the favorable evolution.
07:24As I heard today, he had breakfast,
07:26that means that he can handle the airway, that he can talk.
07:29With oxygen, but not with a respirator.
07:31Exactly.
07:32So it is a slightly moderate picture for now,
07:35but the problem of older adults and more with this concomitance of problems that he had,
07:41that give him the fragility, one must be very careful
07:44and wait, let's say here on Friday, to see how his respiratory system resolves,
07:48especially fatigue, because his respiratory system struggles against those secretions
07:52that are obstructing the airway,
07:54and he has to solve it with other parts of the lung
07:57so that they take that oxygen and take care of the work that the entire lung does.
08:01That produces a wear on a worn man, who sees him worn.
08:05So the treatment is antibiotics, corticosteroids again,
08:09and oxygen and rest and wait.
08:12And kinesiology to help him solve that problem of the secretions that can eliminate them.
08:18So I think, I'm an optimist, I think he's going to be fine.
08:22But well, it depends on him.
08:24And forward, leaving the Pope.
08:28We are in February, we have to think about what is coming.
08:32That's it.
08:33That's the subject that would be good to talk about,
08:36because let's say in March the vaccination begins.
08:40For what vaccination? Antiripal?
08:43Antiripal.
08:44If the respiratory system is not in the free calendar,
08:47but there are already two vaccines from last year.
08:49It is a virus that produces a lot of pathology.
08:52Thanks to COVID, more swabbing is done,
08:54and before we did not have so many samples.
08:56Now in the samples from last year we find 40% of the infections are due to this virus.
08:59Children are given.
09:01This is the famous vaccine that was given to the pregnant woman.
09:03The bronchiolitis of the child.
09:04The bronchiolitis of the child.
09:05Now we know that the adult, thanks to the swabbing we do,
09:0740% of the serious infections are due to this virus.
09:10It is a very aggressive virus,
09:12whose vaccine we already have.
09:13They have to talk to the doctors.
09:14There are two vaccines.
09:15They are private, but the effect lasts five years.
09:17So you really have to get it.
09:19The flu, the COVID and the syncytial.
09:22The good news is that those three.
09:23You have to get those three.
09:24Yes.
09:25Depending on your age, right?
09:26And your risk factor.
09:27Yes.
09:29In other words, people with overweight are people with a risk factor.
09:33Overweight is already an immunosuppressive pathology.
09:37And the truth is that it worries us a lot.
09:39But above all, there is an interesting thing that happened to the Pope,
09:41that no one saw.
09:42And I, as a gerontologist, always worry.
09:44The knee.
09:45The knee is the most fragile point of the adult.
09:47Because the arthrosis, the aging of the joint,
09:49makes it age and one has to debate whether or not to put on the famous prosthesis.
09:54And there is a myth.
09:55And why do we want to put on the prosthesis?
09:57Because a patient who does not walk, who does not do physical exercise,
10:00is a fragile patient, who will have a hard time recovering from this.
10:04And it all started with this knee, let's say.
10:06In other words, we are more concerned about his muscle strength and aerobic capacity,
10:09than actually the lung.
10:10The lung is going to solve it.
10:11The lung is as big as a tennis court.
10:13Because what happens is that it is compressed like an onion layer.
10:16But if we open it, it's a tennis court.
10:19Really?
10:20Yes, clearly.
10:21If you open a lung.
10:22Yes.
10:23It's as big as a tennis court.
10:24What happens is that it's like the onion, which has layers.
10:26If you take layer by layer and expose it, it's as big as a tennis court.
10:30So the lung is a very noble organ.
10:33It's going to respond.
10:34It's a normal organ.
10:35Yes, yes, yes.
10:36But everything happens around there.
10:37That's why I did neurology, because everything happens around there.
10:39And it all starts there with oxygen.
10:41But the lung is going to respond, I think.
10:43The problem is that we are forgetting about the rest, which is the muscle skeleton.
10:48How much did the pandemic revolutionize this field of medicine?
10:53How much new has been learned?
10:55Everything.
10:56To give you an example, now we are in a stage of artificial intelligence that I think will be revolutionary.
11:02And it all started with telemedicine, computerization.
11:06Do you remember that we could do it alone?
11:08I did a lot of telemedicine.
11:10And now I tell you that telemedicine…
11:12We presented a job and we followed 200 COVID patients in the long run.
11:17And we had zero mortality because we were able to predict with heart rate data loading programs
11:24how to release the patient and when a tomography had to be done.
11:27And we were able to predict in time the early treatment that corticosteroids were at that time.
11:31So the pandemic revolutionized all this a lot.
11:34And above all, it improved the images a lot.
11:36The images today are…
11:37Okay, but that's from a technological point of view, if you will.
11:40Yes.
11:41What was learned?
11:42What was not known?
11:44This, obesity and sarcopenia.
11:46We found young patients who were doing very badly and older adults who were doing very well.
11:52So before the pandemic, we used to say that 65-year-old older patients had low defense
11:57and that they had a higher chance of dying.
11:59Now, after the pandemic, we said…
12:01With the word Bill Clinton, it would be…
12:03It's inflammation, stupid.
12:04In other words, the inflamed patient is the one who is suppressed.
12:07So there were 40-year-old young people who were doing very badly.
12:10And when you checked, they had an exaggerated weight gain,
12:14an unbalanced diet and little physical activity.
12:17And another interesting thing that we found in the pandemic,
12:20and that we are still suffering from,
12:22we learned that the happiness and the state of mind
12:25have no doubt an impact on immunity.
12:27In fact, there is a work in Harvard…
12:29The state of mind.
12:30The state of mind.
12:31There is a work that a Harvard scientist did.
12:34He is an 80-year-old doctor who continues to work at Harvard.
12:37He did something very simple that we were finally able to show scientifically.
12:41He put rats in a laboratory where the box was crushed every day.
12:46So they suffered from stress and sadness.
12:48And he put other rats in a happy place,
12:50in an open place, living with their mothers and children.
12:52And he took blood every day.
12:54And what did he see after two months?
12:56That the stressed rats, their white blood cells,
12:58when he exposed them to an infection,
13:00did not respond in the same way as the white blood cells of happy rats.
13:03So we also saw that in the pandemic.
13:05Of course, in the pandemic you had a chronic depression.
13:08And there was the mistake of exaggerating the quarantine.
13:10We did not see that.
13:11Do you remember that we talked about the golden hour that was established in Europe?
13:14That letting an adult in Bayor go out at noon to walk,
13:16because it was very important?
13:18Well, today science has already shown it.
13:20Or, of course, cutting ties between grandparents and grandchildren.
13:23For example, what does it mean for a grandfather to be with his grandson?
13:26I had many detractors because I talked about the inspiratory hug.
13:30Well, a lot was talked about that.
13:32The healing hug.
13:34Of course, but because we said…
13:36And I swear, I am one of the first who said
13:38that COVID was infected by air travel,
13:40it was not by hand contact.
13:42So why not hug the adult?
13:44Inspired by amnesia.
13:46I told my patients, go and hug him.
13:48Do you remember that there were hugs with…
13:51Yes, right?
13:52Like with panels or something.
13:54Yes, with plastic bags.
13:57Of course.
13:58And do you know who is to blame?
13:59The Japanese.
14:00Because the first, you will remember,
14:02the first cruise was called Diamond Prince.
14:04Of course, Diamond Prince.
14:05Well, the Japanese, obsessed as they are,
14:07took samples of the whole ship
14:09and found that there were samples on the pianos, on the stairs.
14:12But it was like finding DNA from a dead bone.
14:14They found COVID DNA.
14:16But in the face of doubt and emergency,
14:18they said, there is COVID everywhere.
14:20And it can be infected by contact.
14:21Impossible.
14:22Of course.
14:23But zero chance.
14:24And what happened to us?
14:25We isolate ourselves from the elderly.
14:26And I gave my word that I was one of the great promoters of the inspiratory hug.
14:31That we had to go and hug the elderly.
14:34We knew that the elderly was going to suffer.
14:36And one more thing we learned about COVID.
14:38What happens is that depression,
14:40obviously affects the elderly,
14:43but it affected all ages.
14:45Yes, yes, yes.
14:46And one more thing we learned about COVID,
14:47which was very interesting,
14:48the broken heart.
14:49I don't know if you've ever heard that,
14:50but we were able to document it in COVID.
14:51Now we know that extreme sadness,
14:54or extreme stress,
14:55releases a series of substances,
14:57for example, adrenaline and cortisol.
14:59The heart has large receptors,
15:01that is, it has a lot of activity with those receptors.
15:03And a patient who was isolated,
15:05an older adult,
15:07and they told him that he was going wrong,
15:09and that he couldn't see his family,
15:10he gets very sad,
15:11he had monitors,
15:12and they were able to see that the heart made that famous rhythm,
15:14and that the heart,
15:15from having a vertical shape,
15:17changes shape,
15:18and becomes concave and transverse,
15:21and stops functioning,
15:22and has a heart attack.
15:23But since it was monitored,
15:24an echocardiogram could be done,
15:25and it could be shown for the first time,
15:27to a certain degree,
15:28that extreme sadness,
15:30or extreme stress,
15:31produces a broken heart.
15:32And it produces heart failure and death.
15:34Many people died of sadness,
15:37and not only COVID,
15:38COVID was an epiphenomenon.
15:40That is to say that if one,
15:43moved forward,
15:45went through another pandemic,
15:48like COVID,
15:50we imagine that there would not be such a level of isolation.
15:53No way.
15:54In fact,
15:55we would have to check the numbers,
15:57how many people died of isolation,
15:59sadness, stress,
16:00or the feeling of imminent death,
16:02in solitude.
16:04Clearly,
16:05that was what we had left.
16:07Obesity is not negotiable.
16:09And an interesting thing.
16:10Obesity is the lack of exercise.
16:12Exactly.
16:13Because one can be overweight,
16:15but healthy.
16:16We see very healthy blood tests
16:18of patients with overweight,
16:19because they exercise and diet,
16:20and well,
16:21they have genetics,
16:22and they are overweight.
16:23And very inflamed,
16:24skinny patients,
16:25who do not eat well,
16:27and who do not go on a diet,
16:28and who are stressed,
16:29and are not happy.
16:30An inflammation, sorry,
16:31that is not seen there.
16:32That is the issue.
16:33There was a lot of controversy
16:34from a doctor who said
16:35that routine tests did not help at all.
16:37I don't know if you know about that discussion.
16:38No.
16:39Societies went out to kill him,
16:40and what he meant is what I think.
16:42We measure inflammation
16:43thanks to COVID,
16:44in another way.
16:45Normal tests
16:46don't work for me.
16:47The parameters are normal.
16:48I am full of patients
16:49who come to me and say,
16:50my electrodes are normal,
16:51my blood pressure is normal.
16:52And one sees it
16:53and takes measurements of muscle mass,
16:55of aerobic capacity,
16:56which is called
16:57oxygen consumption,
16:58which we do.
16:59Did you see the football players
17:00who put on a mask?
17:01We do oxygen consumption,
17:02spirometry.
17:03And the patient,
17:04the patient has parameters of inflammation.
17:06And that's what we started to measure.
17:08Define parameters of inflammation.
17:10What is it when you refer to inflammation?
17:12Inflammation is that your body,
17:13what happens to the Pope,
17:14your body is losing a lot of time
17:16and a lot of energy
17:17in solving something
17:18that is not solved,
17:19which is the adipose cells
17:21produce hormones
17:22that are ghrelins
17:23that make the whole body
17:24start working faster
17:26but in an ineffective way.
17:28That is, it stresses the body.
17:29And how do you do that?
17:31Because if you tell me,
17:32that person is thin,
17:34does not have parameters of obesity
17:36and yet ...
17:38We expose it to stress.
17:40Yes.
17:41For example,
17:42a stress that we do in the laboratory.
17:43Glucose can be normal,
17:44but what happens
17:45if we measure you
17:46at two hours of giving you
17:48a high concentration of glucose
17:50which is called
17:51oral glucose tolerance test?
17:52There we put it to the pancreas,
17:54which is one of the organs
17:55that suffers the most stress,
17:57to the stress of ...
17:58Of insulin.
17:59Of course,
18:00to release all the insulin you have,
18:02to see if it is effective
18:03to lower the concentration of glucose
18:04in two hours.
18:05And what do we see
18:06in these thin patients
18:07who are not able
18:08to return to normal values
18:09of glucose?
18:10However,
18:11that patient on fasts,
18:12the glucose was normal,
18:13but you put it to the pancreas
18:14to a stress,
18:15of an overdose of sugar
18:17and it did not work.
18:18Who told you
18:19to do a review like that?
18:20Of course,
18:21that's what I'm thinking.
18:22There is the question.
18:23Who told you
18:24to do a review like that?
18:25Well,
18:26and this is what we are discussing,
18:27that this doctor
18:28who had all the societies,
18:29the medicine,
18:30the cardiology,
18:31they expressed themselves
18:32against him
18:33and what he meant
18:34is this,
18:35that we are not measuring ...
18:36And an interesting thing
18:37that people do not know,
18:38inflammation,
18:39they know that it is the same
18:40as aging.
18:41And there is the issue
18:42of what we learned from COVID.
18:43I mean,
18:44he's killing me.
18:45No,
18:46the good news
18:47is that we are on time.
18:48I mean,
18:49I say this about the Pope,
18:50when he started with the knee,
18:51they should have seen it
18:52as a result
18:53of a more serious problem,
18:54which is the loss
18:55of muscle mass.
18:56In a case like this,
18:57one would say,
18:58a prosthesis is justified
18:59there.
19:00100% agree.
19:01So that he can have
19:02a mobility
19:03that can then
19:04lengthen his life.
19:05Of course,
19:06that's what we don't know
19:07how to explain to him.
19:08Why do we make him
19:09a prosthesis
19:10with all the problems
19:11that a prosthesis has?
19:12My father is 90 years old,
19:13I'm thinking with him,
19:14we were discussing
19:15the prosthesis,
19:16I'm 90.
19:17Why?
19:18Because he can't ride a horse
19:19that gives him happiness,
19:20for example,
19:21we have to think,
19:22doctors and patients,
19:23that mobility
19:24is not negotiable,
19:25nor overweight,
19:26nor happiness.
19:27No,
19:28and much less
19:29at a certain age,
19:30where it is
19:31the little things
19:32that make your life
19:33cold.
19:34And there it is,
19:35for this talk,
19:36it should be based
19:37on the Pope's gerontology
19:38and not on the lung.
19:39Because what we are seeing
19:40and what normally happens,
19:41we on the internet
19:42presented a work
19:4320 years ago,
19:44we did a work
19:45on endoscopy
19:46in patients
19:47over 90 years old,
19:48against endoscopy
19:49in patients
19:50over 90 years old,
19:51against endoscopy
19:52in patients
19:53over 90 years old,
19:54against endoscopy
19:55in patients
19:56over 90 years old,
19:57against endoscopy
19:58in patients
19:59over 90 years old,
20:00against endoscopy
20:01in patients
20:02over 90 years old,
20:03against endoscopy
20:04in patients
20:05over 90 years old,
20:06against endoscopy
20:07in patients
20:08over 90 years old,
20:09against endoscopy
20:10in patients
20:11over 90 years old,
20:12against endoscopy
20:13in patients
20:14over 90 years old,
20:15against endoscopy
20:16in patients
20:17over 90 years old,
20:18against endoscopy
20:19in patients
20:20over 90 years old,
20:21against endoscopy
20:22in patients
20:23over 90 years old,
20:24against endoscopy
20:25in patients
20:26over 90 years old,
20:27against endoscopy
20:28in patients
20:29over 90 years old,
20:30against endoscopy
20:31in patients
20:32over 90 years old,
20:33against endoscopy
20:34in patients
20:35over 90 years old,
20:36against endoscopy
20:37in patients
20:38over 90 years old,
20:39against endoscopy
20:40in patients
20:41over 90 years old,
20:42against endoscopy
20:43in patients
20:44over 90 years old,
20:45against endoscopy
20:46in patients
20:47over 90 years old,
20:48against endoscopy
20:49in patients
20:50over 90 years old,
20:51against endoscopy
20:52in patients
20:53over 90 years old,
20:54against endoscopy
20:55in patients
20:56over 90 years old,
20:57against endoscopy
20:58in patients
20:59over 90 years old,
21:00against endoscopy
21:01in patients
21:02over 90 years old,
21:03against endoscopy
21:04in patients
21:05over 90 years old,
21:06against endoscopy
21:07in patients
21:08over 90 years old,
21:09against endoscopy
21:10in patients
21:11over 90 years old,
21:12against endoscopy
21:13in patients
21:14over 90 years old,
21:15against endoscopy
21:16in patients
21:17over 90 years old,
21:18against endoscopy
21:19in patients
21:20over 90 years old,
21:21against endoscopy
21:22in patients
21:23over 90 years old,
21:24against endoscopy
21:25in patients
21:26over 90 years old,
21:27against endoscopy
21:28in patients
21:29over 90 years old,
21:30against endoscopy
21:31in patients
21:32over 90 years old,
21:33against endoscopy
21:34in patients
21:35over 90 years old,
21:36against endoscopy
21:37in patients
21:38over 90 years old,
21:39against endoscopy
21:40in patients
21:41over 90 years old,
21:42against endoscopy
21:43in patients
21:44over 90 years old,
21:45against endoscopy
21:46in patients
21:47over 90 years old,
21:48against endoscopy
21:49in patients
21:50over 90 years old,
21:51against endoscopy
21:52in patients
21:53over 90 years old,
21:54against endoscopy
21:55in patients
21:56over 90 years old,
21:57against endoscopy
21:58in patients
21:59over 90 years old,
22:00against endoscopy
22:01in patients
22:02over 90 years old,
22:03against endoscopy
22:04in patients
22:05over 90 years old,
22:06against endoscopy
22:07in patients
22:08over 90 years old,
22:09against endoscopy
22:10in patients
22:11over 90 years old,
22:12against endoscopy
22:13in patients
22:14over 90 years old,
22:15against endoscopy
22:16in patients
22:17over 90 years old,
22:18against endoscopy
22:19in patients
22:20over 90 years old,
22:21against endoscopy
22:22in patients
22:23over 90 years old,
22:24against endoscopy
22:25in patients
22:26over 90 years old,
22:27against endoscopy
22:28in patients
22:29over 90 years old,
22:30against endoscopy
22:31in patients
22:32over 90 years old,
22:33against endoscopy
22:34in patients
22:35over 90 years old,
22:36against endoscopy
22:37in patients
22:38over 90 years old,
22:39against endoscopy
22:40in patients
22:41over 90 years old,
22:42against endoscopy
22:43in patients
22:44over 90 years old,
22:45against endoscopy
22:46in patients
22:47over 90 years old,
22:48against endoscopy
22:49in patients
22:50over 90 years old,
22:51against endoscopy
22:52in patients
22:53over 90 years old,
22:54against endoscopy
22:55in patients
22:56over 90 years old,
22:57against endoscopy
22:58in patients
22:59over 90 years old,
23:00against endoscopy
23:01in patients
23:02over 90 years old,
23:03against endoscopy
23:04in patients
23:05over 90 years old,
23:06against endoscopy
23:07in patients
23:08over 90 years old,
23:09against endoscopy
23:10in patients
23:11over 90 years old,
23:12against endoscopy
23:13in patients
23:14over 90 years old,
23:15against endoscopy
23:16in patients
23:17over 90 years old,
23:18against endoscopy
23:19in patients
23:20over 90 years old,
23:21against endoscopy
23:22in patients
23:23over 90 years old,
23:24against endoscopy
23:25in patients
23:26over 90 years old,
23:27against endoscopy
23:28in patients
23:29over 90 years old,
23:30against endoscopy
23:31in patients
23:32over 90 years old,
23:33against endoscopy
23:34in patients
23:35over 90 years old,
23:36against endoscopy
23:37in patients
23:38over 90 years old,
23:39against endoscopy
23:40in patients
23:41over 90 years old,
23:42against endoscopy
23:43in patients
23:44over 90 years old,
23:45against endoscopy
23:46in patients
23:47over 90 years old,
23:48against endoscopy
23:49in patients
23:50over 90 years old,
23:51against endoscopy
23:52in patients
23:53over 90 years old,
23:54against endoscopy
23:55in patients
23:56over 90 years old,
23:57against endoscopy
23:58in patients
23:59over 90 years old,
24:00against endoscopy
24:01in patients
24:02over 90 years old,
24:03against endoscopy
24:04in patients
24:05over 90 years old,
24:06against endoscopy
24:07in patients
24:08over 90 years old,
24:09against endoscopy
24:10in patients
24:11over 90 years old,
24:12against endoscopy
24:13in patients
24:14over 90 years old,
24:15against endoscopy
24:16in patients
24:17over 90 years old,
24:18against endoscopy
24:19in patients
24:20over 90 years old,
24:21against endoscopy
24:22in patients
24:23over 90 years old,
24:24against endoscopy
24:25in patients
24:26over 90 years old,
24:27against endoscopy
24:28in patients
24:29over 90 years old,
24:30against endoscopy
24:31in patients
24:32over 90 years old,
24:33against endoscopy
24:34in patients
24:35over 90 years old,
24:36against endoscopy
24:37in patients
24:38over 90 years old,
24:39against endoscopy
24:40in patients
24:41over 90 years old,
24:42against endoscopy
24:43in patients
24:44over 90 years old,
24:45against endoscopy
24:46in patients
24:47over 90 years old,
24:48against endoscopy
24:49in patients
24:50over 90 years old,
24:51against endoscopy
24:52in patients
24:53over 90 years old,
24:54against endoscopy
24:55in patients
24:56over 90 years old,
24:57against endoscopy
24:58in patients
24:59over 90 years old,
25:00against endoscopy
25:01in patients
25:02over 90 years old,
25:03against endoscopy
25:04in patients
25:05over 90 years old,
25:06against endoscopy
25:07in patients
25:08over 90 years old,
25:09against endoscopy
25:10in patients
25:11over 90 years old,
25:12against endoscopy
25:13in patients
25:14over 90 years old,
25:15against endoscopy
25:16in patients
25:17over 90 years old,
25:18against endoscopy
25:19in patients
25:20over 90 years old,
25:21against endoscopy
25:22in patients
25:23over 90 years old,
25:24against endoscopy
25:25in patients
25:26over 90 years old,
25:27against endoscopy
25:28in patients
25:29over 90 years old,
25:30against endoscopy
25:31in patients
25:32over 90 years old,
25:33against endoscopy
25:34in patients
25:35over 90 years old,
25:36against endoscopy
25:37in patients
25:38over 90 years old,
25:39against endoscopy
25:40in patients
25:41over 90 years old,
25:42against endoscopy
25:43in patients
25:44over 90 years old,
25:45against endoscopy
25:46in patients
25:47over 90 years old,
25:48against endoscopy
25:49in patients
25:50over 90 years old,
25:51against endoscopy
25:52in patients
25:53over 90 years old,
25:54against endoscopy
25:55in patients
25:56over 90 years old,
25:57against endoscopy
25:58in patients
25:59over 90 years old,
26:00against endoscopy
26:01in patients
26:02over 90 years old,
26:03against endoscopy
26:04in patients
26:05over 90 years old,
26:06against endoscopy
26:07in patients
26:08over 90 years old,
26:09against endoscopy
26:10in patients
26:11over 90 years old,
26:12against endoscopy
26:13in patients
26:14over 90 years old,
26:15against endoscopy
26:16in patients
26:17over 90 years old,
26:18against endoscopy
26:19in patients
26:20over 90 years old,
26:21against endoscopy
26:22in patients
26:23over 90 years old,
26:24against endoscopy
26:25in patients
26:26over 90 years old,
26:27against endoscopy
26:28in patients
26:29over 90 years old,
26:30against endoscopy
26:31in patients
26:32over 90 years old,
26:33against endoscopy
26:34in patients
26:35over 90 years old,
26:36against endoscopy
26:37in patients
26:38over 90 years old,
26:39against endoscopy
26:40in patients
26:41over 90 years old,
26:42against endoscopy
26:43in patients
26:44over 90 years old,
26:45against endoscopy
26:46in patients
26:47over 90 years old,
26:48against endoscopy
26:49in patients
26:50over 90 years old,
26:51against endoscopy
26:52in patients
26:53over 90 years old,
26:54against endoscopy
26:55in patients
26:56over 90 years old,
26:57against endoscopy
26:58in patients
26:59over 90 years old,
27:00against endoscopy
27:01in patients
27:02over 90 years old,
27:03against endoscopy
27:04in patients
27:05over 90 years old,
27:06against endoscopy
27:07in patients
27:08over 90 years old,
27:09against endoscopy
27:10in patients
27:11over 90 years old,
27:12against endoscopy
27:13in patients
27:14over 90 years old,
27:15against endoscopy
27:16in patients
27:17over 90 years old,
27:18against endoscopy
27:19in patients
27:20over 90 years old,
27:21against endoscopy
27:22in patients
27:23over 90 years old,
27:24against endoscopy
27:25in patients
27:26over 90 years old,
27:27against endoscopy
27:28in patients
27:29over 90 years old,
27:30against endoscopy
27:31in patients
27:32over 90 years old,
27:33against endoscopy
27:34in patients
27:35over 90 years old,
27:36against endoscopy
27:37in patients
27:38over 90 years old,
27:39against endoscopy
27:40in patients
27:41over 90 years old,
27:42against endoscopy
27:43in patients
27:44over 90 years old,
27:45against endoscopy
27:46in patients
27:47over 90 years old,
27:48against endoscopy
27:49in patients
27:50over 90 years old,
27:51against endoscopy
27:52in patients
27:53over 90 years old,
27:54against endoscopy
27:55in patients
27:56over 90 years old,
27:57against endoscopy
27:58in patients
27:59over 90 years old,
28:00against endoscopy
28:01in patients
28:02over 90 years old,
28:03against endoscopy
28:04in patients
28:05over 90 years old,
28:06against endoscopy
28:07in patients
28:08over 90 years old,
28:09against endoscopy
28:10in patients
28:11over 90 years old,
28:12against endoscopy
28:13in patients
28:14over 90 years old,
28:15against endoscopy
28:16in patients
28:17over 90 years old,
28:18against endoscopy
28:19in patients
28:20over 90 years old,
28:21against endoscopy
28:22in patients
28:23over 90 years old,
28:24against endoscopy
28:25in patients
28:26over 90 years old,
28:27against endoscopy
28:28in patients
28:29over 90 years old,
28:30against endoscopy
28:31in patients
28:32over 90 years old,
28:33against endoscopy
28:34in patients
28:35over 90 years old,
28:36against endoscopy
28:37in patients
28:38over 90 years old,
28:39against endoscopy
28:40in patients
28:41over 90 years old,
28:42against endoscopy
28:43in patients
28:44over 90 years old,
28:45against endoscopy
28:46in patients
28:47over 90 years old,
28:48against endoscopy
28:49in patients
28:50over 90 years old,
28:51against endoscopy
28:52in patients
28:53over 90 years old,
28:54against endoscopy
28:55in patients
28:56over 90 years old,
28:57against endoscopy
28:58in patients
28:59over 90 years old,
29:00against endoscopy
29:01in patients
29:02over 90 years old,
29:03against endoscopy
29:04in patients
29:05over 90 years old,
29:06against endoscopy
29:07in patients
29:08over 90 years old,
29:09against endoscopy
29:10in patients
29:11over 90 years old,
29:12against endoscopy
29:13in patients
29:14over 90 years old,
29:15against endoscopy
29:16in patients
29:17over 90 years old,
29:18against endoscopy
29:19in patients
29:20over 90 years old,
29:21against endoscopy
29:22in patients
29:23over 90 years old,
29:24against endoscopy
29:25in patients
29:26over 90 years old,
29:27against endoscopy
29:28in patients
29:29over 90 years old,
29:30against endoscopy
29:31in patients
29:32over 90 years old,
29:33against endoscopy
29:34in patients
29:35over 90 years old,
29:36against endoscopy
29:37in patients
29:38over 90 years old,
29:39against endoscopy
29:40in patients
29:41over 90 years old,
29:42against endoscopy
29:43in patients
29:44over 90 years old,
29:45against endoscopy
29:46in patients
29:47over 90 years old,
29:48against endoscopy
29:49in patients
29:50over 90 years old,
29:51against endoscopy
29:52in patients
29:53over 90 years old,
29:54against endoscopy
29:55in patients
29:56over 90 years old,
29:57against endoscopy
29:58in patients
29:59over 90 years old,
30:00against endoscopy
30:01in patients
30:02over 90 years old,
30:03against endoscopy
30:04in patients
30:05over 90 years old,
30:06against endoscopy
30:07in patients
30:08over 90 years old,
30:09against endoscopy
30:10in patients
30:11over 90 years old,
30:12against endoscopy
30:13in patients
30:14over 90 years old,
30:15against endoscopy
30:16in patients
30:17over 90 years old,
30:18against endoscopy
30:19in patients
30:20over 90 years old,
30:21against endoscopy
30:22in patients
30:23over 90 years old,
30:24against endoscopy
30:25in patients
30:26over 90 years old,
30:27against endoscopy
30:28in patients
30:29over 90 years old,
30:30against endoscopy
30:31in patients
30:32over 90 years old,
30:33against endoscopy
30:34in patients
30:35over 90 years old,
30:36against endoscopy
30:37in patients
30:38over 90 years old,
30:39against endoscopy
30:40in patients
30:41over 90 years old,
30:42against endoscopy
30:43in patients
30:44over 90 years old,
30:45against endoscopy
30:46in patients
30:47over 90 years old,
30:48against endoscopy
30:49in patients
30:50over 90 years old,
30:51against endoscopy
30:52in patients
30:53over 90 years old,
30:54against endoscopy
30:55in patients
30:56over 90 years old,
30:57against endoscopy
30:58in patients
30:59over 90 years old,
31:00against endoscopy
31:01in patients
31:02over 90 years old,
31:03against endoscopy
31:04in patients
31:05over 90 years old,
31:06against endoscopy
31:07in patients
31:08over 90 years old,
31:09against endoscopy
31:10in patients
31:11over 90 years old,
31:12against endoscopy
31:13in patients
31:14over 90 years old,
31:15against endoscopy
31:16in patients
31:17over 90 years old,
31:18against endoscopy
31:19in patients
31:20over 90 years old,
31:21against endoscopy
31:22in patients
31:23over 90 years old,
31:24against endoscopy
31:25in patients
31:26over 90 years old,
31:27against endoscopy
31:28in patients
31:29over 90 years old,
31:30against endoscopy
31:31in patients
31:32over 90 years old,
31:33against endoscopy
31:34in patients
31:35over 90 years old,
31:36against endoscopy
31:37in patients
31:38over 90 years old,
31:39against endoscopy
31:40in patients
31:41over 90 years old,
31:42against endoscopy
31:43in patients
31:44over 90 years old,
31:45against endoscopy
31:46in patients
31:47over 90 years old,
31:48against endoscopy
31:49in patients
31:50over 90 years old,
31:51against endoscopy
31:52in patients
31:53over 90 years old,
31:54against endoscopy
31:55in patients
31:56over 90 years old,
31:57against endoscopy
31:58in patients
31:59over 90 years old,
32:00against endoscopy
32:01in patients
32:02over 90 years old,
32:03against endoscopy
32:04in patients
32:05over 90 years old,
32:06against endoscopy
32:07in patients
32:08over 90 years old,
32:09against endoscopy
32:10in patients
32:11over 90 years old,
32:12against endoscopy
32:13in patients
32:14over 90 years old,
32:15against endoscopy
32:16in patients
32:17over 90 years old,
32:18against endoscopy
32:19in patients
32:20over 90 years old,
32:21against endoscopy
32:22in patients
32:23over 90 years old,
32:24against endoscopy
32:25in patients
32:26over 90 years old,
32:27against endoscopy
32:28in patients
32:29over 90 years old,
32:30against endoscopy
32:31in patients
32:32over 90 years old,
32:33against endoscopy
32:34in patients
32:35over 90 years old,
32:36against endoscopy
32:37in patients
32:38over 90 years old,
32:39against endoscopy
32:40in patients
32:41over 90 years old,
32:42against endoscopy
32:43in patients
32:44over 90 years old,
32:45against endoscopy
32:46in patients
32:47over 90 years old,
32:48against endoscopy
32:49in patients
32:50over 90 years old,
32:51against endoscopy
32:52in patients
32:53over 90 years old,
32:54against endoscopy
32:55in patients
32:56over 90 years old,
32:57against endoscopy
32:58in patients
32:59over 90 years old,
33:00against endoscopy
33:01in patients
33:02over 90 years old,
33:03against endoscopy
33:04in patients
33:05over 90 years old,
33:06against endoscopy
33:07in patients
33:08over 90 years old,
33:09against endoscopy
33:10in patients
33:11over 90 years old,
33:12against endoscopy
33:13in patients
33:14over 90 years old,
33:15against endoscopy
33:16in patients
33:17over 90 years old,
33:18against endoscopy
33:19in patients
33:20over 90 years old,
33:21against endoscopy
33:22in patients
33:23over 90 years old,
33:24against endoscopy
33:25in patients
33:26over 90 years old,
33:27against endoscopy
33:28in patients
33:29over 90 years old,
33:30against endoscopy
33:31in patients
33:32over 90 years old,
33:33against endoscopy
33:34in patients
33:35over 90 years old,
33:36against endoscopy
33:37in patients
33:38over 90 years old,
33:39against endoscopy
33:40in patients
33:41over 90 years old,
33:42against endoscopy
33:43in patients
33:44over 90 years old,
33:45against endoscopy
33:46in patients
33:47over 90 years old,
33:48against endoscopy
33:49in patients
33:50over 90 years old,
33:51against endoscopy
33:52in patients
33:53over 90 years old,
33:54against endoscopy
33:55in patients
33:56over 90 years old,
33:57against endoscopy
33:58in patients
33:59over 90 years old,
34:00against endoscopy
34:01in patients
34:02over 90 years old,
34:03against endoscopy
34:04in patients
34:05over 90 years old,
34:06against endoscopy
34:07in patients
34:08over 90 years old,
34:09against endoscopy
34:10in patients
34:11over 90 years old,
34:12against endoscopy
34:13in patients
34:14over 90 years old,
34:15against endoscopy
34:16in patients
34:17over 90 years old,
34:18against endoscopy
34:19in patients