Hi, everyone, and welcome to today's webinar from Pixels to Patients. Today, we're going to talk about how simulation, video, analytics can aid in improving surgeon training and performance. My name is Orley Bogle, and I have the pleasure of being your host and moderator today. Before we get into the good stuff, there are a few disclaimers. First, this webinar is being recorded and will be distributed to participants. The touch surgery enterprise is not intended to direct surgery or aid in diagnosis or treatment of a disease or condition. Lastly, the opinions expressed by our guest speakers today are theirs alone and do not necessarily reflect those of Medtronic. We'd love for you to ask questions throughout the webinar. If you could please do so by finding the Q&A button at the bottom of your screen. My colleague, Christine, will be monitoring questions throughout the webinar. We're going to kick things off by introducing our panelists who will then cover some key topics such as providing an overview of the state of surgery today and how digital solutions can make an impact on training through simulation and surgical video. We'll then discuss how data and analytics can help support performance improvement. And finally, we'll finish off by taking questions from you, the audience. So let's meet our panelists. As I mentioned, my name is Orly Bogle, and I'm the medical affairs director here at Digital Technologies Business Unit, which is part of the surgical operating unit here at Medtronic. I'm joined by two of my colleagues, Daniel Smallen and Dr. Karen Kerr. Daniel is our content director and leads our creative studio that develops and delivers content through the touch surgery app or immersive technology. And Dr. Karen Kerr leads our AI and analytics franchise that is focused on extracting additional value and insights from surgical video. Next, we are very honored to welcome Professor Bijan Patel, who will share his experience as an educator and why simulation is important for medical education and training. He'll also tell us why he uses the touch surgery app and its modules to teach novice surgeons. Next, we also have the pleasure of inviting Dr. Jason Lee, who is an assistant professor at Toronto General Hospital, which was the first site in Canada to use the touch surgery enterprise system in their operating room. Dr. Lee will give us his perspective on how he uses surgical video for post case review, coaching and mentorship opportunities. So to put context into the discussion that we're having today, we're going to start by asking you the audience this question. How many hours a week do you think surgeons lose due to inefficient technology? You should see a zoom poll pop up in the middle of your screen and we'll give you a brief moment to answer. So before we get to the answer and how you've responded, let's level set to where we are today. So it's no secret that healthcare systems across the world are facing unprecedented challenges. We have aging global backlogs. We have aging global populations. We have accumulated backlogs due to the global pandemic. And still with the boom in technology, many healthcare systems are antiquated and have not adopted digital solutions to meet their needs. Collectively, this is having a significant impact on efficiency and training in hospitals today. At Medtronic, we wanted to understand more and quantify the burden of outdated technology to surgeons. So we conducted a census wide survey of 300 UK surgeons and asked them the same question that we asked you at the beginning of the webinar. For them, we asked them how many hours a week. Does it do you lose due to inefficient technology? Kristin, if we can show the results of how the audience responded, please. Okay, well, majority of you guessed one to two hours. Well, it's worse than you think. Our research has actually shown that outdated technology costs UK surgeons up to four hours a week. So that's two full business days a month. We then asked surgeons, well, if they had that time back, what would they spend that time doing? Well, over half of UK surgeons said they would focus this time on either upskilling themselves or training their teams. We're lucky to have a surgeon from the UK on the panel today and a surgeon from Canada. So I'd like to pause and ask Professor Battelle and Dr. Lee, does this data resonate with you and what you've experienced either in your own hospital today or a hospital that you've worked in the past? Professor Battelle, maybe I'll start with you. Thank you for inviting me to this webinar and congratulations on capturing this data, which when I asked chat GPT, there was no response because there is no data. So congratulations on this. Now, we all don't function at the same level in terms of speed and efficiency and it's widely recognized that improvement in technology and workflow optimization can help reduce inefficiencies in healthcare, including surgery. So the four hour, I mean, I can agree that into the four hours is about the time we waste because of inefficient technology, which is a session a week. So, you know, I'm quite surprised that you got this figure right. Thank you, Professor Battelle. And welcome Dr. Lee, how about you in Canada? Do you see similar trends in your hospitals? Yeah, thanks again, Orly for the invite. Sorry about the technical glitches there in the beginning, but happy to make it on. But I wholeheartedly agree. I mean, I think in some cases it may be a bit of an underestimation depending on what you're doing that particular week. And, you know, with technology being reliant on technology when it works well, it's great. When you've got inefficiencies or things go down, it can really kind of mess up your entire sort of flow. You know, the planned activities for the day can affect patient care. So, I wholeheartedly agree with what you discussed. Thank you both. That's really insightful and it also echoes with what we're hearing from our customers that this is a problem, not a UK problem, but it's one that's experienced globally. So what are we doing about it? At Medtronic, we are focused on building easy to use digital solutions that are designed to help maximize your time and provide you with insights into your performance so that your focus can be dedicated towards learning practices for yourselves or to others, as you said Dr. Lee, in order to optimize patient care. Daniel, I want to pivot to you as the Training and Education Content Director. Can you tell us how simulation can also play an important role in solving some of these problems? Yes, sure. Thank you, Orly. When we refer to simulations, we're talking about the digital tools we develop to support the training and education journey of surgeons and surgical teams. Just a few of their benefits are that they help to scale medical education globally and help to maximize time spent at in-person training events with the use of pre-learning to build foundational knowledge and post-learning for attention and recall. They provide a unique learning experience for surgeons and their teams in anatomy training, procedural workflow training, device training, and scenario-based training or rehearsal. I come from a healthcare background, having trained and practiced as a podiatrist. I left clinical practice to work in visual effects and the film industry for about 15 years, where I worked on films such as Iron Man and Harry Potter and James Bond. Now, at Medtronic, together with a team of medical experts, creatives, and engineers, we are evolving training and education. The training on touch surgery is accredited by the Royal College of Surgeons of England and has been validated through 25 independent academic studies and peer reviews, where studies show users scoring higher following learning on the app compared to those using more traditional methods like textbooks or PDFs. And so we develop four types of training and surgical video is crucial to our process and forms the foundation of all of our digitized training assets. We use sections of video coupled with clever use of CGI, which is computer-generated imagery, where we add learning points to the existing video, as in the video on the left of the screen. These could be highlighted or labeled critical anatomical structures or parts of a device. And then on the right, you can see some examples of where we reference video to create fully animated procedural training simulations, anatomy training, as well as our device training simulations. There is a lot of detail that goes into developing this training content and many people that contribute from our medical science liaison team supporting medical accuracy and the surgical storytelling. Our quality team helping to maintain best in class training and our subject matter expert and KOL authors who share their experience and expertise to train others. And the creative and technical team who also come from backgrounds in film and TV game development and medical visualization who pay particular attention at the pixel level on the realism visual quality and interactive experience. And then we have our immersive VR training, as you see on the video on the left, which is really useful for rehearsal to gain proficiency in those repetitive tasks that take up a surgical team's time and for perfecting the use of a device like a surgical robot. This could be solo practice or through co-presence where it could be useful to join a peer proctor or training workshop in virtual reality. And of course we use annotated video for training surgical teams on the full workflow of any given procedure. As you see in the video on the right of the screen. This is a tool which comes with several useful features to clip, annotate and share video, including adding special surgeon tips, and then to benefit from the video analysis, which you'll hear more about in the next section. All of these digital training tools are an important asset in a surgical in a surgeon's training journey. And not only are they slick, immersive and beautifully presented, not only do they facilitate bite sized chunks of learning on the go in your pocket with a mode for learning and a mode for testing or assessment, but they also necessary to capture and analyze and individualize where you are in your training journey, where they need to pay more attention or where you need to get some additional support. And I'll now pass back to Oli who has some practical questions on the subject for Professor Patel. Thanks so much, Daniel. Some key takeaways that I hear here is the ability to customize the training content to meet the learner at various stages of their career. And also removing the barrier of access and allowing them to learn and train anywhere, anytime. Professor Patel, I know that you've been using the touch surgery app for a while I'd welcome your thoughts on the use of different types of simulation and medical education. How do you use this technology in your current practices. I feel more confident in the contents quality of touch surgery app. Now that it has been validated by Royal College of Surgeons of England, however, from my own personal experience I can say that I've been using touch surgery even prior to this validation by RCS England. And for me, the two most important elements of this digital education is number one, it's free therefore it's ideal global platform for scaling surgical education. And the second thing, which is important for me is it requires active user participation. Therefore, more concentration span, less distraction, which I believe translates into a high impact learning and better knowledge retention with shorter learning curve. Therefore, you know you save time, which are the obvious benefits of this. We talk a lot about globalization and democratization of surgery. However, high cost, long duration of surgical training means we cannot scale surgical education to keep up and meet the demands. We've seen WHO data and targets on global workforce deficit. We've seen the Lancet commission report on global surgery. These targets are not achievable and just like a global zero emission target. All this remains work in progress and a good aspiration. Now, technology and hands learning and simulation can fast track training surgical training. And if you look at the literature almost every published paper has shown that this and the impact on learning curve reduction training by simulation. I see a simulation and in particular touch surgery as a Netflix of surgery or a digital textbook of surgery, where you've got catalog of surgical procedures, you can rehearse and practice in your own time. I see this as a high impact exercise a bit like running marathon versus textbook reading which I see that just simply taking a walk in the park. I like to refer to touch surgery as my daily those of vitamin or an exercise regime for boosting cognitive skills and improve knowledge retention, which is what I tell my students. Because it not only helps build your cognitive skill but retain knowledge and minimize the de skilling because it's so easy and immersive and interactive to use. It facilitates touch surgery facilitates self directed learning and deliberate practice. It's immersive and interactive these features allow group participation therefore it can be used by anyone at any skill level. I use it across medical students junior trainees novices and experts and let me give you some examples. For novice and junior trainees, I use it for as a pre class preparation and in class group discussion and following this post class use the app for assessment, including revision and retraining if required. With expert group intermediate and expert group, I use it for group debates and interactive audience discussion and conferences and small classrooms and tutorials. A moderate conference session with two or three panels panelist and go through a surgical procedure with audience active participation is a bit like surgical masterclass where you learn tips and tricks apart from doing the procedure on touch while sitting in the audience with your panel and this generates a lot of questions and queries and discussion and debates around surgical approaches and controversies, etc. I love that I didn't know about the group debates, Professor Patel. I'd love to hear more about those stories. In your current teaching practices you say that you use the touch surgery app across novices, as well as experts. Do you see that touch surgery or even simulations in general who do you think derives the most value from simulations. As I said, you know, I believe and I've seen the benefits across the spectrum that doesn't matter whether you're a novice or a training but obviously the maximum benefit is during the early phase of your learning curve. So it's extremely valuable when you are just on the steep part of your learning curve and subsequent to that. It's about, you know, learning complex cases or something which is not common and you want to rehearse. Use for that as an expert, whether it's mental rehearsal or with touch surgery, you do physical rehearsal before doing some rare case or a complex case. And how about the use of surgical video.  I love surgical videos and it's a shame that sort of I didn't have surgical videos when I was a trainee because we didn't have a high definition stacks and devices to sort of record your performance. We've seen video rehearsal in every industry, you know, any any any sort of motor skills where you require motor skills. It's an obvious advantage to just simply look at your performance sit back after the match is finished look at what what went well, and what can be done better. So you can use surgical videos when trainees are, you know, when they first come into the simulation lab and they're practicing and they just sort of struggling with simple tasks, pectron so pattern cutting suturing and all. And those videos are priceless when you want to give feedback. So just a review and rehearsal videos, you can give them feedback on site online, whatever you like. So just in relation to simulation training with regards to surgery and operative performance I use videos to just simply reflect and look back what went well, especially when you have had complication. So, I think it is one of the most powerful tool to improve your practice and training. That's amazing. Thank you, Professor Patel and I think that's a beautiful segue into to you, Dr. Lee. I know that you are a very strong supporter of using surgical video for training purposes. Could you tell us why you use surgical video and how has digital solutions like the touch surgery enterprise solution help you save time. I, for the longest time, since I've been in practice last 15 years or so I've always tried to record cases. It's not an easy process as I'll talk about in a few slides here but you know I think there's as as Professor Patel mentioned there's educational value and I've been reviewing and utilizing these surgical videos but there's also, you know, feedback and coaching opportunities that you can use to improve surgeon performance so not just learning how to do the surgery, but how to optimize patient care outcomes because ultimately at the end of the day. That's what we're here to do is improve patient outcomes. And so I think there's a sort of a, you know, dual sort of focus on utilizing this video and I think it's paramount. And I must say, doing a lot of robotic surgery myself that that platform lends itself well to recording surgical videos. I think we still don't do a great job of recording open surgery. But obviously, these minimally invasive platforms are really optimal situations for that kind of thing. Amazing. Okay. So I'll hand it over to you. Talk through some of your slides. Perfect. So, despite my, what my, my dad bought is saying at one point I was a bit of an athlete when I was younger. I am joining the gym again to try to get back into shape here. But, you know, I always thought that surgeons, you know, were like athletes, I never really got super far and never made any money playing any hockey or baseball but you know, these elite athletes, they ultimately are similar to surgeons in that they often, you know, perform in a team environment. They have hours and hours of practice to get to that elite level performance and ultimately they, you know, it can discuss and think about how they're going to do something, whatever it is, how they're going to perform that day. They're going to go out onto the pitch, onto the field and perform. And that's very similar to a surgeon. You can plan how you're going to approach a case, what, you know, a technique you may want to use, but ultimately, on the day of your surgery you need to perform. And, you know, as Dr. Patel and Professor Patel mentioned, I think using simulation or practice to get to that level is important. But what athletes do that surgeons don't really do is, you know, reflect on how we performed and using video. If you ask any elite athlete, they spend hours a day obviously practicing on the pitch, but they also spend lots of time in the film room looking at how they performed. And surgeons, we don't often get a lot of feedback on how we did.  Okay, you didn't do a good job there. That's immediate feedback. But a lot of the things we do, we don't get feedback right away for hours, days, weeks, months sometimes.  But by that time, you have no idea how, you know, how the case went. You don't recall what technique you used. So I think this is where video comes in handy and really allows, you know, surgeons to not just learn the surgery, but improve their technical skills, improve patient outcomes. So maybe we can switch to the next slide there early. And so, like I mentioned, you know, there's lots of benefits to using surgical video. Surgical education is, I think, the most important early on to the trainees, but you know, it's amazing, even experienced surgeons, you know, I'm kind of mid-career. I've been at this for about 15 years, but as a professor could tell alluded to there are cases where I go back and look and say, you know what the outcome on this particular patient wasn't optimal. They had this complication or margins are positive. Then I can go back and look at the video and oftentimes I can actually reflect and say, oh, I know where I made the mistake. I should have cut here and there and sort of, you know, providing that reflection is important. And I think that allows for skill improvement. And then as a program director, I'm constantly sort of providing feedback to the residents and I can describe this scenario.  And so from a coaching perspective postoperative debrief perspective, I think it's very valuable. Next slide. The problem like I alluded to earlier has been access to this, you know, we would have to go through the 17, you know, clicks to get a video recorded then we would have to get a USB download it and put it on my laptop and then I got to go, you know, bring it up and I have no idea where the in the video it's a 45 gigabyte file and I got to find where that, you know, the part that they were doing, where I was doing is it is very tedious, not efficient wasted hours. And to be frank, most surgeons don't do it because we just don't have the time, you know, we don't have an hour to time to take each day to go over this kind of video so up till now, it's been a sort of too cumbersome to really analyze in real time. Next slide please. So, I was so happy when when I started to collaborate with Orly and our team and the metronic team to find out about all the advancements of the DS one platform and the DS one platform is is sort of to two elements it's got the actual brain the DS one platform here but it's also got a little handheld it's like an iPhone kind of thing or an Android I'm trying to be agnostic little handheld smartphone and it's a controller controller device and you can use both of these in the OR. So while you're operating, especially for robotics you're not scrub so you can actually do this yourself. You can record and pause and you can annotate. This AI algorithm built in a program called redacto are that actually will blur as you can see the little video there blur any kind of faces that come into the video screen if you pull your camera out.  So it's a it's a really fast out technology and platform that really allows this kind of video analysis video utilization for for coaching and feedback to really be seamless. And it makes you feel like you're part of a, you know, elite sports team or you get all this easy access to, you know, primetime technology that can allow you to do this so it's quite nice. And when we've been using this for the last little while. For all of our robotics cases. We have both the Hugo and the DaVinci platforms and we've been using this it's actually agnostic to platform you can use it for robotics laparoscopy endoscopy so it's it's quite a versatile platform so we've been really happy to collaborate with metronic on this. Next slide. So there's just some pictures about how we use it or they came to visit us in the OR a few weeks ago. And it's quite easy to use at the end of the day surgeons do not want any kind of distractions we like to get in our zone and sort of like many lead athletes we like to get in our zone and do our thing. And so it's easy it's literally a click of a button. It connects to the video feed coming from whatever proceeds procedure you're doing. And this happened at the end of the case as well like within minutes I would say seconds to minutes, the video of the procedure that I just performed shows up on my cloud. And you download an app onto your your smartphone and literally as I'm scrubbing out and walking out the door I'm showing Orly hey look this is the procedure I just did and it's it's within minutes seconds it's right there and so. If I wanted to debrief with the trainees we literally can step out of the OR and while the anesthesiologist is waking the patient up, we can literally go over the steps of the procedure we just performed so it's no wasted, you know, time it's very efficient platform. And then within a short period of time, hours days, it also provides some analytical data which is, again, a little talk to a little bit about the advantages of that but you know the information that the surgeons are getting through this kind of platform are. You just haven't been able to access anything like that before so it's really exciting. And I know I think Karen will talk about some other future directions as well which I'm super excited about. Next slide. So, in addition to that sort of real time, you know, efficient post performance review which is important. You can also then, you know, share your videos to your peers to other experts so a resident, for example, can push their video of a procedure they did with maybe surgeon X.  On a procedure I did or vice versa someone may do a procedure with me and then want to send it to surgeon Y and, and she can go in and give feedback to the resident as well so it's quite nice to get sort of that delayed expert or peer feedback which again is also very important on improving technical skills. The, the other thing that I've done some work on is the, the, like athletes, the importance of warm up and that, and that can be technical skills warm up so we've done some research looking at surgeons, you know, performing a little bit of the actual surgery they're going to do and it actually improving their, their intraoperative performance which makes sense all this athletes, they don't just walk on to the tennis court and just play they practice right ahead of time and warm up. And there's also research on cognitive warm up and this is I think really important. I don't know if the video is playing there but you know, we often do a surgical time out, not with the patient but with more of an educational time with my residents and I say, you know, Stephanie you're going to be doing this part of the case today let's focus on that. And in the past I'd have to, with my waving of hands describe like how that should go, or painstakingly pull out my laptop and try to figure out where that part of the case is and find that which I would do and just pop up my phone or Android click on the case and let's say they're doing tumor excision today I could click on three four videos within a few minutes and just show them that portion of the case, give them sort of tips and feedback on how to approach, you know, this particular tumor that we're going to reject using those videos as examples and there's no other platform that I've been able to access to date that allows me to do this kind of seamless, you know, preoperative cognitive warm up. Next slide. The last thing that maybe a segue to the next. The. The. Is data and back and as mentioned within a few hours for days. You know, the, the AI algorithm for for these procedures are able to splice up all the video and using the AI technology, break it down into all the different components of the procedure, give you time estimates, and there's also other, you know, exciting functionalities that will be coming down the pipeline with touch surgery that will allow surgeons to really improve their performance so right now we can look at, you know, the metrics of that last case and say, Listen, listen for the renora fee. It took me double the time of my usual, you know, case average wise. Why was that how, you know, how can I prove it was it just the case complexity or was it something that we're doing. We can use that kind of feedback. We can also look at, you know, exciting opportunities like performance scores. So the algorithm can actually give you sort of a quantitative feedback on how you perform certain steps of the procedure. And I can go over that for myself, but also for my trainees and give them feedback and when they're part of a, you know, robotics training curriculum, we can go over all this and use these metrics to, you know, you know, advance them to the next step and use that for proficiency testing and there's also administrative data that the hospital. You do this, you know, average length, you know, Jason doing partial refractory or Stephanie doing prostatectomy so they can start to plan and sort of, you know, optimize or theater or or room allocations amongst the surgeon so I think a lot of valuable information is coming down the pipeline with with this kind of platform technology so really exciting. I'll leave it at that. Next slide I think that's all I the main points I really wanted to sort of highlight on how we use it locally so really exciting stuff and very valuable for for me and for my trainees. That's amazing Dr Lee thank you so much. It's interesting to hear that reviewing and watching your game tape is a practice that is consistently shown to improve performance right whether that's in sports or the arts, or now even in surgery. I want to pivot to Karen, Karen as the leader of the AI and analytics product offering. I'm wondering if you could shed some light into what metronica is doing to help extract these insights that Dr Lee was talking about from surgical video, and maybe give us a sneak peek into what we can expect to see in the future. Sure thing. Thank you. And so yeah thanks early and Dr Lee and Prof Patel for your excellent insights so far so I think Dr Lee did a fantastic job there describing TSE and how easy is to you record and review surgical video so as Orly said I want to talk a bit about what we're going to do what we can do with the surgical video and the information that we give back to surgeons both today and in the future. So as Dr Lee also said it's really hard to get that quantitative the quantitative insights to look at those inefficiencies and to identify improvements in surgery. And this is where our TSE platform comes in. We can provide insights to drive improvements based on trusted data and we're developing the smarts for surgical video. And you can see here both our web and mobile views that we have over our performance insight so we extract information in the form of timestamp data so that surgeons and their teams can review these timestamps and navigate easily in their surgical video in their online library. Both through our web and mobile views and this actually provides information and data from the surgical videos that their teams would not normally have access to. And as as Dr Lee has said we're using AI to do this more efficiently through through automation. Our technology is able to automatically partition. surgical procedures into semantic segments and in this case surgical surgical phases, and these can be used and compared against the surgeons previous cases. On a case by case basis surgeons can now start to understand different patterns, the order of phases the combinations of the surgical sequences that occur during their procedures. We're also able to show and highlight cases where significant variations occur with respect to previous cases. And also on the platform as well as on the DS one controller individual cases can be tagged with information such as complications or different observations that happen during the case. And that can quickly help surgeons and their teams navigate and identify reasons for these outliers. On that you can see here we've got our, I think the view that Dr, Dr Lee sorry showed showed our current view and we're going to be releasing new new views of our on our mobile and web platform soon we're always working to iterate and improve the UI and for surgeons to meet their needs. But in addition to the phase analytics we're really excited to be offering new data and analytics postoperatively on anatomy and instruments and view. Which along with the video and the phase data is going to allow different views and insights that the teams will be able to use, and hopefully will be able to help drive conversations around efficiencies for surgeons and their teams. And we know that surgeons have told us that these analytical and measurable feedbacks can actually vastly improve surgical efficiency. We can help with surgeons review their performance making sure that they perform to the highest of their abilities to reach that athletic level that we've alluded to, and this should hopefully as we all want to do improve patient outcomes. Maybe move on to the next slide please early. I just want to just really give a bit of a snippet and an insight into into what's to come and what's going on under the hood here at Medtronic. We're fully committed to building an ecosystem of digital solutions, and this is going to help streamline the way in which information is connected between our devices, our surgeons patients looking at this from a pre intra and post operative perspective. And the key part of our digital ecosystem that we're building is obviously is our underpinning capabilities that we have in AI. So this slide here shows some of our for the four building blocks for AI development. We're building systems are really going to be capable of understanding surgical procedures that will not only enhance our current analytic offering that we referenced in the previous slide, but they're going to be a crucial part of our future potential product lines for intraoperative support. We've shown already with performance insights, how we can use surgical workflow analysis. What we're really doing with that is we're building up knowledge and that understanding and that intricate understanding of surgical procedures and that's going to enable contextual understanding at any point of the surgery at any given time. Going forward, that's going to really help us to kind of enable other algorithms to be able to find information at the right time back to the surgeon intraoperatively. In the next, the next circle, you can see that we're looking at instrument detection and tracking. There's lots of different ways that this can be can be done and detected over a surgical procedure. This shows a basic representation with our bounding boxes, and it's really demonstrating that we're able to correctly identify, classify and localize surgical instruments and track their location across the short sequences. With this with this data, both postoperatively and interoperatively we're going to be able to look at instrument usage analytics. We're going to understand surgeons movements that are economies of motion, which are all going to feed into areas such as benchmarking competency and skill assessment in the future. And finally with the final two are really looking at kind of strict critical structure identification, we're building this out across a number of procedures and specialties lap and robotic. We're looking, we're going to be providing information to identify specific anatomical landmarks that are critical for the success of the operation. And the example at the end in the fourth circle you'll see a lap coli, which is highlighting the cystic duct and the cystic artery, which as you will all know better than me, the surgeons surgeons on the line that the correct dissection and identification of these structures before clipping is key. So this helps us with identification of these structures will help lead towards identification of the critical view of safety, which is an important safety check during the procedure. And so that's just a little bit of insights as to what we're what we're doing what's to come in the future and we're really excited to be working with surgeons, such as Prof Patel and Dr Lee on the line as we develop our real time applications for a roadmap. Thank you for hearing and further thoughts from them and I will hand back to or Lee now so thank you. That's amazing Karen thank you so much. As you all can see the future looks very bright and full of endless possibilities. Before we take some questions from the audience. I'd like to ask Dr Lee and Professor Patel to take a moment and and dream big. How do you feel still needs addressing and surgical education. And where do you think digital solutions like simulation like a I could possibly be the answer. I don't know who wants to start. Who has some ideas. Maybe I'll start, Professor Patel if that's okay and you know I think the exciting things that are coming down the pipeline with these platforms is is is making surgeons, better surgeons, I think laparoscopy obviously minimized the impact of surgery on patients. And as did robotics and the advent of robotic platforms and they're sort of really blossoming now across the globe. They do improve surgeon performance to a certain degree. But there hasn't been a technology that really makes a surgeon truly better. You know it's almost like, you know, Tom cruise in that movie, something tomorrow where you're wearing like a mechanosuit so you can get certain things that are enhanced but it doesn't get much better. But what we ultimately want is something like Iron Man. So, while he's flying there's data being shown on his in his mask that tells him, you know, how to optimally fly or where the danger is where or where not to go or what you know, this kind of information and I think that's the most exciting thing for me as a surgeon with this kind of new technology is that it's not just another robotics platform or whatnot it's but it's while I'm flying. Can you give me the data that will help me perform surgery better, not just a better tool but actually perform better and I think that's really exciting. From an educational perspective, obviously, as Professor tell mentioned, I think, you know, we have the, you know, luxury of standing on the shoulders of giants and they we, you know, I grew up when video videos were starting to become available online so I could watch a case and start to learn, you know, how to approach a whatever case a personal effect to me, you know, some of my senior colleagues they would remember having to fly down to wherever and watch surgeon X operated, you know, he or she would have to show them how to do it I mean we don't do that anymore right I mean everything is available online and so to be able to integrate that even in the comfort of your own home. You know, through the app, I think it's really exciting to really decrease the, the slope of that learning curve for our trainees so they can get past that safety learning curve much quicker is really exciting. I love that thank you Dr Lee. Professor Patel, any thoughts. In terms of technology we can really get blown away but that all focuses on your technical skill acquisition and improving our performance. In terms of technology making a big impact I see sort of data analytics and predictive modeling from machine learning to identify trends predict outcome optimizing surgical protocol. We will make surgery and surgeons more efficient and effective and improve patient care. In terms of obstacles and problems, what I see that as, you know, globally we talk about again globalization and democratization of surgical education, but we are unable to achieve this at a global scale like aviation where you have uniform international standards for training and performance assessment and everything. And we have that in surgery. There's lack of integration of technology and technology and hence education into your daily routine training curriculum, etc. If you ask me what one thing, one change that I would like to see in surgery the biggest change I'd like to see in surgery would be changing the surgical culture. Where technology would step in would be having a collaborative surgical platform like DS one, you know, a digital platform that will facilitate collaboration among surgical surgeons teams regardless of the geographic location, and can enhance knowledge sharing and expert utilization. And even if you look at across different industry, you know, success comes from people team working and changing the culture it's a good and the soft non technical skill which account for 75% of success in most surgery. The technical skill contribute much less compared to the non technical skills I would like to see technology address that and have more collaborative surgical platform that would bridge this gap between cognitive skill and technical skill. That's a phenomenal answer. Thank you. And you said something about changing culture. Before we take some questions from the audience. One last question from me is, you know, what has to happen to make touch surgery, whether it's our touch surgery free app or touch surgery enterprise part of everyday usage in medicine and in surgical trading. You know what would need to happen from your standpoint. Professor Patel you mentioned the change in cultures are there are other things that I think we still rely on classroom learning and textbooks and lectures and if you look at that is the worst form of learning experience where you sleep. You know I fall asleep in lectures and classroom and I'm sure most of the audience as well. That's not the right way to learn we want immersive education touch surgery offers immersive education. Yes offers. You know, viewing your performance the best you know you can improve if you see if you don't see you'll never improve. So, you know, looking at your video your own video collecting your own performance video and analyzing it and interpreting that that is priceless. Excellent. Dr Lee. Yeah, I know I have very little to add to that I think that's what Professor Patel hit the nail on the head I mean, I think one small barrier that, you know, in some jurisdictions is more of a problem than others is is the whole data privacy and patient privacy issue about video recordings there's some surgeons that don't want their performance recorded. There are a variety of reasons. We've seen that with this platform and other platforms as well that have similar kind of goals and I think that kind of culture. Ultimately, for me, you know, I, I know I'm not doing something heinous. I'm not trying to hide anything I want to improve so I that's why I record all my cases and there is some there's some issues with, you know, litigation concerns and things like but at the end of the day, you know, I think if you we want to get better as surgeons improve our culture and improve our technical skills, all of it. I think we need to accept that this is the, you know, next best way forward and you know put those fears aside and ultimately move towards improving patient care and patient outcomes. Thank you both. So, we have a few minutes for questions. So let me go through and Kristen has curated some questions from the audience. So the first one here and this is for both Professor Patel and Dr Lee. What do you think is the most valuable data that can be extracted from surgical video. Dr Lee you want to go first because you've got more experience in this. Sure, I think I'm you know ultimately. It depends on who the audience is I think when you're early trainee, you're getting a lot more educational value by reviewing the videos, you know, some of the high level feedback that I give some of the more senior trainees. I don't give to the genius because they're just not at that level they don't comprehend all the little nuances, because they don't even know how what the steps or the procedure are so I think it's really targeted depending on who your audience is. But ultimately I think one thing that we're excited to do at our hospitals to start to correlate, you know, surgeon performance some of the other data that is coming out of these videos and correlating with patient outcomes such that we can have a an algorithm down the road that you know helps guide us on improving postoperative continence rates decreasing margin rates and correlating actual technical approach and performance and maybe looking at certain patient demographics and how to best select certain approaches and things like that so correlating. Not just the performance just not just scoring the performance itself but correlating those scores and those that data to actual patient outcomes I think that is, you know, the key and so, and that's the next step we there's not too many folks that have that I've really taken it to that level yet so it's really exciting to be part of that journey. And what I would add to that is, as a first step, looking at just the soft data rather than the hard data, you know instrument movement, economy of movement pathway identification structures the soft data is simply reflecting on your performance, which is what Dr Lisa you know record your feedback and watch and see what went well and you know just critique that and use your own video and somebody your colleagues videos that have you know peer to peer learning feedback and all that. That would be the first step on this journey we don't use video then recorded performance for just learning as much as you know some other industry like sports and athletes and all that. I think we need to just really accept and embed that into our training and culture. Thanks very nice. Dr Lee, we have another question for you. Do you have any tips for working with administrators at your hospital to acquire solutions like to surgery enterprise. Well, I mean I think I think obviously depends on which health care system you're in in Canada were part of a sort of universal single payer health care system so the economics of it may differ than somewhere where they've got a hybrid model or if it's a hospital system that's standardized things like that so obviously that you need to take that into consideration but I think, you know ultimately if the hospital administration is focused on improving patient care, this is a no brainer, we have data to support that but you know sometimes it's not just about improving patient care it's about cost effectiveness etc. And I think I alluded to it earlier. I think there's also some administrative data on patient flow operating room resource utilization things like that that can really improve, you know from a hospital admin perspective, you know, improve the use of our resources in an efficient effective manner so I think there are there are some data points that can come out of platforms like TSE that can be used for multiple purposes right surgeon improvement education but administrative staff as well. You know, not to get too much in the weeds but you know we often have, you know, administrators tell us a Jason you can't book those three cases you're going to go over time and, and, and you know this we have we will have surgeon specific data on the type of case okay you know 56 year old male for this kind of page well based on all this data, that case would likely take you X amount of time. I can book three cases, you know this is not going to go over time they can, you know, help schedule human resource appropriately and that kind of thing but a lot of, you know, it's important outcomes from this data I just, it's just a matter of collecting it analyzing it properly and looking at effective uses for it and you know this is why people like Google are worth such, you know, so much money they have so much data on everyone and utilizing that data to optimize, you know, us moving forward I think is key so this is really exciting. And there's two follow ups to that particular question. Did you encounter any concerns about adopting a cloud based solution in your hospital or did you have one already existing. We have internal storage for surgical videos patient care related data but for the cloud for especially working with a outside company like my chronic there were some initial concerns. The big thing was that it was basically all redacted data right there there's no information about a patient name or data birth going out onto the cloud. It's interoperative video. We don't recognize who someone is by their guts and the way their bowel looks I mean great good for you I mean that would be unbelievable. So there were some initial concerns and obviously there are some concerns when we want to start to correlate some, you know, data that that TSE is providing with patient outcomes because we do need to link the two. We've been doing a lot of that in house and so the hospital, you know, data privacy folks weren't that concerned based on analytics that we're providing and providing in house and, you know, down the road I think they'll be a little less concern about some of this other thing as we all move towards adopting, you know, you know, recording interoperative footage but also, you know, there's a lot of platforms that can record communication in the or and as as Professor Patel mentioned I think some of the those kind of non technical skills are important. There is data to suggest surgical teams that communicate well have better outcomes and those that don't so I think all that kind of stuff will be important moving down the road. Okay that's that's great to hear. So I am mindful of time, because this has been a absolutely fantastic discussion I really want to thank the panelists for their time and their consideration and thoughtfulness and their responses. And I also want to thank all of you for engaging and and feeding in the questions. So thank you all very much, wishing you all a fantastic day and and have a good day. Bye bye. Thank you for having us. Thanks everyone. Bye.


At Yale University we work a lot around resource recovery and we use electrochemical and bio-electrochemical methods to achieve that. So where does that fit? If you think about it 30 years ago or so, anaerobic digestion started really taking off. And now biogas plans are everywhere in the world. So it's been a big success, but it was also a big mind shift. People started realizing that what goes in a digester is no longer a waste. In many cases it becomes a resource for energy. So in the future we'll be able to take this water and with very innovative techniques get the plastics surrounding your mobile phone out of it. So there's a lot of opportunities there for new researchers and new developers and new engineers to enter the water sector and really do new things but really look at it from a different perspective. We're no longer treating waste. We are taking a resource and we are turning into a product. And the product in the end, that's what counts.


Good morning, so welcome to UVitis subspecialty day rounds the title of our Presentation our infectious posterior UVA to these Diagnoses not to miss we are going to present some Common posterior UVA to these that are vision-threatening some Uncommon ones that are definitely ocular emergencies and some more unusual Posture UVA to these and some that are ubiquitous and you should always test for So really the question that you need to ask yourself when you're confronted with a patient that you think is Has inflammation in their eye is is it infectious or is it not this is a very important question? And this is answered really through an accurate and thorough history Complete ophthalmic and physical examination and then of course the key is the formulation of differential diagnosis And then laboratory testing and or intraocular fluid sampling is used to confirm or exclude the diagnosis Of certain infections or non infectious diseases There are certain key considerations. Those are the exposure risks for example sexually transmitted diseases HIV status tuberculosis exposures Systemic illnesses these are things that you would glean on your examination review of systems constitutional symptoms organ other organ system involvement The nutritional status of the patient and their their immune status so whether or not this is acquired or iatrogenic or Through age as as we age our immune status wanes a little bit and then of course local factors including recent surgery and trauma the anatomic location of the UV is is extremely important particularly with respect to Where in the back of the eye what tissue is involved for example? Is it a retinitis as you might see in a patient with a necrotizing herpetic retinitis? Or is it a corridor to say for example where tb would more commonly present is it a Unifocal or posifocal disease as such as you might see in toxicoplasmosis or Multifocal as you might see in certain types of herpetic infections and then are the vessels involved Certain certain types of UV entities will affect the veins more than the arteries And then is the optic nerve involved is this a neuro retinitis because your differential diagnosis for a neuro retinitis Will be different than it is for other infectious Ideologies Lotterality is important in that many infectious UV entities will present unilaterally for example necrotizing herpetic retinitis Frequently will present unilateral it although it may become bilateral toxicoplasmosis toxicoriasis are frequently unilateral Other associated signs on the examination such as elevated intraocular pressure Stigmata herpetic infections such as insectile iris atrophy corneal scarring can give you a clue to the diagnosis But laterality is obviously not always helpful as there are some patients with b-27 associated UV it is it can present with hypopia on UV it is The differential diagnosis like to think of it in just broad categories Is it viral is it commonly viral such as herpes over the most common thing and then less common I Infections such as emerging infections depending upon whether we're in the world the patient might be coming from bacterial infections fungal infections I Particularly endogenous type of fungal infections protozoal infections such as toxicoplasmosis and then helmetic Interocular fluid and tissue sampling is very important particularly in presentations in which it is really difficult to just make the diagnosis based on pattern recognition so in the case of Here this no one would mistake this for diagnosis of toxicoplasmic retinocortitis or in an immunocompromised patient In the correct clinical time to context this is CMB retinitis However, you cannot tell just by looking at this what this might be and in immunocompromised patients. This could be many different Diagnoses as is this multi focal sub retinal infiltrates in an elderly patient could represent infection non-infectious UBI's or malignancy so that in UV it is in which the etiology is unclear or the Response to therapy is atypical or the systemic workup is an inconclusive Interocular fluid analysis either from the anterior chamber of the vitreous or sampling the retinor of the quarry can be helpful in distinguishing between an intraocular infection or malignancy where the differential between this is Extremely important in terms of treating the patient and may impact on the systemic health of the patient therapeutic principles Obviously, you do not want to treat an infection with steroids without appropriate specific Antibiotic cover The basic principle is to think about this in the broad differential diagnosis So if you see a patient with a Indeterminate diagnosis You will obtain laboratory testing And you will maybe sample their vitreous or their anterior chamber, but you want to treat broadly treat the infection that could most likely Destroy the eye frequently treating with multi antimicrobial treatment and then withdrawing therapy as your laboratory Laboratories become available or more information becomes available on the patient Corticosteroids are useful particularly topically to treat inflammation But should never be used as monotherapy in patients with infectious UVA that being said corticosteroids can be very helpful in treating the inflammatory component of infectious diseases after the appropriate installation and commencement of Microbial therapy and generally do not treat Intra vitreal with intra vitreal steroids as this can result in the unbridled viral replication And then it is always important to reevaluate your your patient On a regular basis and reconsider your diagnosis if they are not responding in the way that you think so our first presenter is going to be Dr. Shakur we have the Honor of our entire UBI's division presenting here, so I hope you Enjoy this Where's the computer? All right now after Laura the mic Al's it has a little bit of a height advantage here, but I'm going to present a couple of patients, but the first one is is Residents, I'm sorry a fellowship nightmare. We've all had a few of those in this one We really were at a loss of As to how we could have proceeded differently A 61 year old gentleman African-american with a history of systemic sarcoidosis presented to us in California in 2010 in August And for two months he had a history of blurry vision and photophobia in The left eye and he been diagnosed a few weeks earlier by a local ophthalmologist with anterior uveitis He's diabetic Hypertensive has gout chronic renal disease and in late 2005 he complained of progressive fatigue ataxia falling and confusion He's diagnosed with neuro sarcoidosis based on a thoriscopic biopsy of his hyalur lymph nodes Which showed non-KZ 18 granulomas He came in with hydrocephalus Meninger encephalitis and a lymphocytic predominant pleocytosis He was initially treated with steroids and methotrexate at a fairly low dose and In 2007 began to have worsening pulmonary sarcoid with restrictive lung disease In 2009 he was started on treatment with cell sept to a final dose of three grams a day And he began to develop cardiac conduction abnormal Anomalies that were presumed secondary to sarcoidosis Don't forget to check people's hearts when they have sarcoid his past ocular history was really only significant for cataract extraction in the past and a history of Zoster to the First division of the trigeminal nerve on the left side His examination was significant for a Little bit of a affron pupillary defect, which I thought may just be my imagination and For the residents which appendage is this? Anybody Ashley yes, and what do you see on the nose? Yeah, so it's a nodular kind of Dermal or post dermal rash And what do you call this in sarcoidosis anybody? Very good. Yeah, so this is very good. So it's so this is lupus pernia Which is a have a hallmark of cutaneous sarcoidosis He had that His anterior chambers should one plus cell three plus flare he had one plus seven these anterior vitreous and a lot of haze so And you can see a little bit of posterior vitreous cell in the OCT on both sides He's diagnosed with anterior and intermediate uveitis Likely secondary to sarcoidosis with a small small affron pupillary defect His infectious labs were negative so a few days later we injected him with a subtenon skin log in the left side He was seen in follow-up. He removed at reported improvement in his photophobia, but no improvement in vision and now Although his vision was the same at 2,200 He now has a 1.2 log affron pupillary defect and I cannot stress how important it is to actually measure an affron pupillary defect Judith Warner, and I would agree on one thing here But Measure them because they do change and when they change it's important to image His cell has improved his uveitis has improved his OCT shows a little bit of swelling But we recommended an MRI to look at his optic nerve this gentleman does have neurosarcoidosis Lee What do you see on this MRI? It's part of his brain missing or is this something else Well, it looks like that, but it's actually it's a flow artifact from his ventricular shunt So when things flow rapidly In T1 you end up with a void a flow void Anyway, that's just cool. And then his optic nerve over here this pre-chiasmal optic nerve You can see a little bit of contrast enhancement So he was diagnosed with an optic neuropathy in consultation with our neuropathy Ophthalmology colleagues in San Francisco and with neurology. We presumed that this was sarcoid optic neuropathy You're treated with IV-soluble medrawl for five days started on ramicade a week later continued on cell sept and transitioned to oral prednisone at 60 milligrams His vision continued to decline until two days later. He was no light perception in the left eye bad and Then he disappeared for a month and When he comes back a month later, he complains of decreased vision in his right eye as well as unsteadyness of gait He is now no light perception in 2040 in the right eye. It's got a complete aphrodiputile defect and What do we see here? Conradie so whitening of the retina but what do you see in Somebody with uviatus would you expect such a clear view? No, right, so that's something to keep a note of and you can see in the periphery has got areas of retinal whitening here as well and Is OCT? Chris if you can tell me where the location of the whitening is So the inner retina so you can see like there's a complete loss of retinal architecture over here So could this be sarcoid pan uviatus that's unlikely on so much immunosuppression and you certainly don't expect to see red little whitening Could it be viral retinitis? So we performed a vitreous tap. We admitted him to neurology for IV acyclovir Lumbar puncture was also performed and This PCR of his vitreous and CSF was positive for varicella zoster virus We recommended stopping the solid medrawl and switching from IV acyclovir to Gans acyclovir and Foscarnet and We started intervitural injections of Gans acyclovir and Foscarnet alternating at high dose unfortunately over the next three days he continued to progress progress and The retinal whitening is now splitting his fovea so This is a gentleman with systemic sarcoidosis presenting initially as neuro sarcoidosis He has anterior and intermediate uviatus. He has retrovulver optic neuropathy It's presumptively treated with high-dose steroid and immunomodulatory therapy as you would in somebody with neuro sarcoid and optic neuropathy And he ends up with a necrotizing herpetic retinitis in the right eye and worsening optic neuritis in the left so optic neuropathy and an immunocompromised person with neuropathosis and this is progressive outer retinal necrosis in a patient with severe autoimmune disease with An iatrogenic component so progressive outer retinal necrosis Is a rapidly progressive necrotizing retinal Retinitis usually caused by various ill-asostovirus in about 70% and 30% caused by herpes simplex one or two It's typically seen in patients with a CD4 count of less than 50 Visual outcomes are poor. This is this has an abysmal prognosis even with antiviral therapy It's been reported in other immunocompromised states as well including after bone marrow transplant after lymphoma after high dose steroid and Classically seen in patients with HIV and AIDS It's been reported as well just a few years before I saw my patient When optic neuropathy which was presumed to be Inflammatory in nature ended up being infectious and treated with systemic corticosteroids This is a patient treated by dr. Davis at Baskin-Pammer So was the optic neuropathy secondary to sarcoidosis a very slow disaster I think we very well proved to ourselves that it was infectious unfortunately How do we treat this patient without exacerbating his systemic disease? Neurology did not want to stop Steroids did not want to stop remiccate and did not want to stop cell sept Cardiology didn't want to either this patient was quite ill With that level of immunosuppression treatment of this patient's eyes is doomed to fail What's his prognosis well, I can tell you now five years later. He's still 2040, but his visual field is less than five degrees So necrotizing viral retinitis is include acute retinal necrosis Progressive outer retinal necrosis and CMV retinitis. I'll leave out the last three in the interest of the last one in the interest of time This is a 54 year old gentleman referred to us Some years back for iritis When you look in the back you can see that there's a little bit more going on Eric you're going to be my fellow next year somebody will pick on you. What do you see here? So kind of this retinal whitening in the periphery multiple foci started to become confluent With some hemorrhage, but not a lot. So this is Acute retinal necrosis It's an necrotizing retinitis caused by herpes simplex or varicella zoster patients with RNA usually immunocompromised But it may also be seen in immunocompromise But it may be seen in the immunocompromise Patients come in with hot eyes moderate to significant retritis optic discidema and an optic neuropathy if not treated promptly Bilaterality will happen in 70% after after a month It's a clinical diagnosis, but it can be fortified by using PCR for verse for the herpes viruses and for toxoplasma because there is a atypical toxoplasma with retinitis that can mimic armed Conventionally you treat this with IV acyclovir Without treatment there will be involvement in 20s to 70% in the other eye Systemic acyclovir reduces that risk to six that to 13% other treatment protocols the one that I favor Oral valacyclovir to a dose of two grams three times a day gives you IV equivalent levels Intravitrile gas acyclovir or Intravitrile foscarnate may be used oral prednisone may be added aspirin may be associated with better visual outcomes late findings do include Pigmentary changes retinal detachment does happen in about 70% Barricade late barricade laser. However is controversial And retinal detachment is complicated lots of PVR. You need a buckle. You need oil Here's a arn Retina that seems to be clearing a little bit. You can see that there's very vascular clearing of the retinitis and Ultimately, this progresses into kind of this Swiss cheese appearance with pigmentary changes resolving retinitis That's why they get retinal detachment Here's a 34 year old patient with HIV and the CD4 count at 10 You can see a lot of retinal whitening a little bit of blood but not very much But what stands out here is how clear the view is the absence of vitritis Make makes you think about immunocompromised states This is progressive outer retinal necrosis a better example a more typical example than the patient I presented in the beginning This is a herpetic retinitis in immunocompromised patients with rapidly progressive multifocal lesions lower level of vitritis and vasculitis and whereas aren't spreads rapidly this spreads like Well, like nobody's business this this can wipe out the entire retina in a couple of days The treatment for this is either a cyclone or foscarnate organ cycle for IV treatment is recommended high-dose Intervitual Gans cycle or foscarnate or their combination and these progress despite treatment So in conclusion remember viral retinitis is not always something you see That you did not cause Viral retinitis can be iatrogenic we do immunosuppress more and more patients in this era and Do look for infectious uvea to these in the immunocompromised and then most importantly just as a Kind of a wide Statement always dilate the pupil in an eye with uveitis and to uveitis is often not anterior Thank you to the photographers you


Where I work, I'm around people smarter than I am all the time. I constantly fact-check my assertions, and I'm prepared to be wrong if the evidence goes against me. This is what it is to be a research scientist. We learn not to value our own intellects too highly. There's always someone smarter, more knowledgeable, or with data not yet published. Humility before the truth is a professional requirement. That holds true on YouTube as well. I'm not very well-read on certain topics, I'm politically adrift, and I don't know much history, philosophy, and I'm a mess with languages other than English. Even within my field, I frequently make mistakes, and I'm not ashamed when I do make one. I learn by listening, not by talking. I try not to have too much ego because it gets in the way of my education. Then, there's Nephilim Free. What can I say? He's the opposing end of the spectrum.   What makes my skin crawl is that he's so very proud of his ignorance that he actually thinks he can bluff a professional scientist with incorrect usage of technical terms he doesn't understand, and can't even spell or pronounce correctly. Some of you may know the Dunning-Kruger effect. Named for the psychologist who first formally documented it, it refers to the tendency for relatively inexperienced people to overestimate their proficiency in a topic, usually to their detriment. A young driver overestimates their ability to navigate in traffic. A new pilot takes inappropriate risks in landing because they can't accurately assess their capabilities. And a freshman college student often believes they have a mastery of a field based on a single class. As experience progresses through mistaken correction, additional education, the initiate begins to understand the limits of their knowledge or experience. They become more cautious, more conservative, and more willing to adjust to new information. Part of education is to teach us how much more we have to learn. Ask a simple question like, what is a gene to a freshman biology student? And you get an immediate, very straightforward answer with a confident demeanor. A grad student would be more cautious, adding exceptions to rules. A full professor might need a nice cup of coffee, 45 minutes staring out the window, and a research grant to answer fully. Now, when I view Nephilim Freeze, a recent response to my video about him, I see an uneducated buffoon. He rants for about an hour and a half about my 17 minute video, and it would be painful to list all the places where he makes simple factual errors. It grates on my nerves because he's so painfully unconscious of his own mistakes. I know he'll never learn anything more on the topic because his own ego gets in the way of his education. He already knows everything. You really see it in the number of times he simply asserts something is true on his own authority, no citations, no supporting data. So rather than go through his video and identify every one of his mistakes, I'm just going to pick three clips where he is provably wrong in fact. I could choose any 32nd clip, but these are some of my favorites. Similarities in, say, for example, proteins from one kind of life don't provide evidence that that organism is related to another. 80% of the proteins in human beings are different from those of any ape. Where's your phylogenics related to molecular similarities there? You see, if human beings were closely related to apes by a common ancestor, instead of 80% of our proteins being different from any ape, we should have 80% exactly the same proteins. 80% of the human proteins should be found in apes, but that's the opposite of the truth. So you see, your idea is completely bogus.  He's referring to a paper in the journal Gene by a group at Penn State. The title is 80% of proteins are different between humans and chimpanzees. Hey, if all you ever read was the title of the article, you might make the same leap old nephew is making. However, if you actually read the article, you'd see that they're saying that 80% of proteins differ by at least one amino acid between chimps and humans. In certain key proteins, like cell signaling components, 45% of the human proteins tested had an identical protein sequence to chimps. There is no way to tell them apart between chimp and human. If we allow for a 99% sequence match that is nearly identical, the number goes up to 53%. Why is anyone writing articles about a few amino acids different between chimp and human proteins? Because the DNA is an even closer match. Chimps have almost all the same genes that humans do, and the DNA for those proteins is almost identical, usually between 99% and 98% identical to human. But between chimps and humans, there are a surprising number of variations in protein sequence, suggesting that the small number of DNA differences are having a bigger impact, albeit small, on protein divergence. So, Nephi is vocalizing rectally here. He has no idea of the facts behind his assertion. He's never read the paper the figures come from, and he's hopeless on genomics. Up to 10% of your genome are the littered remains of failed retroviruses. Wow, you really pack in a lot of lies, don't you? I'm going to read something for you about the subject of retroviruses. What are claimed to be retroviruses in the DNA of human beings and other creatures, such as apes, which supposedly demonstrate ancestry between those phylum and various phylum is not viral at all. There are examples. Do you remember my MS-DOS programming code example? That's what they are. Elements of common design, nothing more. For example, the PTERV1, quote, retrovirus, is found in the rhesus monkey, olive baboons, and African great apes, but not in humans. This makes it clear that ERVs are not evidence of evolution, that they are actually evidence of a common designer. This one is hilarious. The PTERV he's talking about stands for pan-troglodides endogenous retrovirus. It appears to have infected chimpanzee four million years ago, about the same time the human line separated from the chimp line. There are about a hundred insertion sites found in chimps and some other apes, but not in humans. Why don't we have this ERV? Is it proof we're unrelated to chimps? Well, no. Humans possess a protein that specifically deactivates this ancient virus, called APOB EC3. It's a cytidine deaminase, similar in action to AIDS antiviral drugs. Chimps lack this gene, which makes them more resistant to lentiviruses, but more susceptible to certain other types of retrovirus. In short, we evolved defense mechanism that among the ape line was unique to the human. So, Nefi uncovered a really interesting anomaly, but rather than actually learning what scientists have discovered about it, he rushes to the wrong conclusions. Typical. In comparison to those in chimpanzee genome. The Human Genome Project has verified what evolution once called junk and retroviruses are not junk and not retroviruses. They're transposable elements that have specific function. If Nefi had taken my molecular biology class, he would have just received an F. Nefi has just said, cars are not cars, they're automobiles. Transposable elements, properly called transposons, are a general class that include class one, retro transposons, and class two, DNA transposons. Class one transposable elements include the endogenous retroviruses that he's dismissing. His first point was that the ERVs can't move around in the genome. Therefore, these sequences are actually jumping transposons. How do these sequences move? Well, they have a viral reverse transcriptase, viral promoters called LTRs, and sometimes even make weak or broken viral antigens. This is why I can't take him seriously. He has no idea what he's saying. So those are my three favorite moments of Nephilim-free self-ponage. I don't intend to waste any more time on him, but he's always good for a bit of a laugh. I'll leave you on one final note. Not only is he ignorant of biology and genetics, he also lacks any proficiency in spelling and lacks the technical know-how to use this recent innovation called spell check. Or perhaps I'm wrong and he wants to make sure that his creationist chorus can find his videos. I imagine they're doing keyword searches for frequent genetic phylogenics or phylogy, assuming they're also obtuse enough to believe that autism is a belief in odds. Thanks for watching.


You have the Holy Spirit, but it's in the surrendering to the Holy Spirit that what we have in us manifests around us. You already have your spiritual gift. You already have an anointing from on high. You already have the ability to understand the Word. You already have your preaching gift. You already have boldness for evangelism. You already know how to pray, but it's untapped power that rests within you. And the only way you tap into that power is by surrendering to the Holy Spirit in greater depths. For every level of surrender, there is a level of power that comes.


I think it's vitally important that we do invest in apprentices, not just in construction, but in any sector, because that's the future. And I think it's good for the local economy that we can get young people working for local contractors, local employers. I think the main thing for the apprenticeship programme first is that they get the right training opportunity in the workplace. That's why we do move them around, that they can gain the necessary experience against the MVQ. And really what's important is the job outcome after the apprenticeship programme. I think that's key.


Everybody forced here ripping six box out of them extra 23 mosaic hobby choice and no huddle number four random teams We're gonna run them right now and get right into it. Good luck It's two two and two in this hobby. No huddle choice Five and two seven one two three four five six and seven Billy beat down to Bruce be and then the teams now one two three four five six and Commander's Giants down to Jaguars All right, Billy be commander's Giants Jonathan L Packers Josh H bears Alexandros Rams Patrick G Steelers Nicholas O Texans Michael H Eagles John W Jets Patrick C. Bill's Travis B. Niners Alexandros Bucks Cardinals Gregory C with the Bengals Clinton T Panthers Ryan K Cowboys Nicholas. Oh Patriots Theodore chiefs Robert B Saints Nathaniel Charters John W Lions Pacapong Colts Robert D Vikings Andrew P Falcons Dakota D Browns Guillaume with the Titans Nathaniel has the Dolphins Mark K Broncos Brian B Ravens Brandon H Raiders Pacapong with the Seahawks and Bruce B with the Jags All right, I think it's time for the discussion about Thanksgiving food Is it time? I think it's time. We're gonna be talking about it all week, but Thanksgiving food, where do we start? Turkey's overrated. Where do we start? That's my first hot take Turkey is overrated You eating good turkey? What kind of turkey do you eat? What's going on here? Sorry, no hotels Not great turkey apparently. I love turkey I like like leftover turkey and stuff though cranberry.  You like lunch meat turkey.  Yeah This guy likes Oscar Mara, bro It's probably Oscar Mara, but Not knocking lunch meat turkeys fire. Come on. Right. I agree. It's good, but like I Disco Joe Thomas from the Browns Slover Ingram Jags disco for the uh herbie there rolls and mashed potatoes top two Thanksgiving food Pretty good pretty good pretty good Gravy's up there Just eating gravy bro Does gravy count as like a item or is it like it's like a it's condiment, isn't it? uh, blue disco rookie rally moss from the Broncos out of 75 Disco baker moments in time for the rams Juicy turkey. Come on Mike. Everybody use that word. Come on, man Sweet potatoes fire. I kind of like it all. I'm I'm uh, I like I like all food though I like every pretty pretty much every food eight shan rookie Disco rookie is henley for the chargers Supertales are pretty good. That's the sugary. That's sugary than some of the pies though It's like sweet potato pie Supertale pie is fire.  If you do it right Purple disco kyle pits falcons out of 50 silver goblin bucks. That guy's right next to me. There he is Disco waddle Pierogi's pierogi's that that sounds fire I've never had a pierogi in my life I want to try one so bad. Dude. They're they're amazing. They're fantastic. Disco lauren taylor giants This guy's never had pierogi's y'all My uncle has a prime rib. That'll be pretty fire for Thanksgiving Always good mashed potatoes with toasted marshmallows, huh? Supertatoes, right? Uh debut Stroud blue disco mean joe to 75 Steelers Gonna roll a die for all of the carbon copies unless there's a numbered one All carbon copies are gonna go one two three left or four five six right There's a number one will random it instead One left side they all go left. This one goes to the chargers You guys do you guys do mac and cheese at Thanksgiving? Oh, yeah have to Uh disco grung for the bucks. I feel like that's like a mess like I'd be sad if there's no things a mac and cheese at Got to be something cheesy Or like the cheesy potatoes or something dude One time we did mashed and like the like different like like somebody did like actual like scallop like Potatoes like cheese on that's so good pink disco derail riva is 20 for the jets Smoked gouda mac and cheese sounds pretty good Usually mac and cheese you do a few you got to get some sharp in there with some some smoky stuff Disco debut quentin johnston chargers Sounds pretty good I like I'm pretty much like it all though. Like I said all the if green bean casserole I like but i'm pretty particular like it needs to be good. Can't just be can green bean Can't be that lions hendon hooker on the blue disco rookie auto Nice hit lions blue disco is the base in uh, no huddle. There's a stroud base Good packed air rookie disco cliford for the packers Need a red cliford cliford the big red qv Monkey bread was monkey bread. Is that a Thanksgiving dish? Silverest chile for the cardinals disco bijan introductions for the falcons I had some Thanksgiving food Sarah makes Sarah late makes really good Thanksgiving. I had some over there a couple years ago That was uh, yeah, that was great. I was great. He like Want to go over there, but I have the family I'm not I'm just not gonna make it this year. I went a couple years ago I did a Thanksgiving like earlier Then went over there to have like a couple drinks and have some dessert and stuff. That was fun, man I think a lot of people going over there It's like a lot of their family and friends Rookie disco is mayor for the Raiders Yeah, I wish this era invites, uh, they have a lot of their family stuff come down, but They also invite like all the employees. Which is pretty cool Silver is marino dolphins disco erin rogers jets montage Gotcha mill. I don't think I've ever had that before That sounds really good. I've heard of it I think I've seen it made on like tiktok or like youtube or something It all it looks amazing any type of bread is pretty much a w and any bread Downs debut disco, same brown lions I guess last year they didn't invite people who was rock. It was still like infant They didn't really do Thanksgiving last year I think Disco kishan johnson jets out of 75 really did like a small one Um, my home's in Hertz carbon copy And Texas Roadhouse Does have very good bread. It's pretty solid Yeah, originally barbers truck I'm just kidding. Uh disco damn marino dolphins I mean I talked to rich more than like my mom and brother, so May as well be Torian Thompson Robinson. Good time to get this one rookie auto for the browns Brought him back brought him back Silver down and cook vikings disco nick chub Oh, yeah, we're reacting nine total brake spots left for tonight y'all. Yeah, three on 29 six on 30. Yeah Disco is Drake london falcons Pink disco is tiki barber to 20 for the giants Borough disco man a mastery stroud base Disco rookie cj shroud nice. There we go houston There we go Anderson enjoy your brown Blue rookie bijan robinson falcons. Good box here number to 75 Yeah, I'm saying heat Silver rookie is trend simpson for the ravens Disco jamar chase for the uh mangles as I throw nothing Oh ps2 pick The flag though Disco curco chains vikings Maybe I'm gonna do a pop ice thing saving that's what I'm gonna do Sounds fire Bryce young debut panthers with a purple max cross v. Raiders the 49 Can't you like go get it 50 or something? Chandler jones moments in time. Yeah, they do the cage in turkey I think you have to order ahead of time though because they deliver it frozen and you're gonna like thaw it out And then you just bake it for a little while Is it too late pop eyes? Can I get one delivered just after Thanksgiving just to have a rounds? Yeah, honestly That sounds fire right some cage in turkey Make some sandwiches jake some sandwiches make some sandwiches My opinion pop is one of the better fast food places I think I don't like the I don't like the very very large chains that you can find pretty much anywhere I really haven't had pop eyes either to me. I can't count places like cookout and raising canes in and out because they're not everywhere Gold to tan icky woods auto get some cold cuts get some cold cuts We're talking about turkey cold cuss everything.  Do you do the icky shuffle? No gold auto to tan is icky woods for the bangles Get some cold cuts. Get some cold cuts. Come on red turn it over with galway silver aj dylan packers Uh Silver introductions is strowed for the texans Well, of course, I know you can do the icky shuffle I can't I don't I don't know it Just watch the commercial. I don't have time. I don't I don't have time morgo Man well mosaic damien pierce texans randy maus vikings and a moment in time baker rams baker Almost had him today, dude Tampa Bay better than san francisco bay Blue disco cleel mac chargers Number two nine and nine silver ricky jayward minnesota minnesota Chick-fil-a is definitely solid. I think you play solid I think I prefer poppies and the only reason is literally the red beans and rice You prefer poppies at your foot. Yes. What? mosaic rookie is witherspoon seahawks Reds are on pain for the commanders Uh brice young introductions in a silver alligir Yeah Yes, it is. We are breaking that tonight orange do 199 tarkens and vikings silver party niners And splash mosaic white, right? Yeah to 25 is justin jefferson from minnesota. Nice Cuckoo cuckoo changes Yeah, stuff is fire.  Knee on yellow mac and cheese. I know they did when I went there Hainer to 199 to rookie auto for the saints. I think for limited times they do it every now and then Jake Hainer to 199 to the saints mosaic debut levis with the titans Red pacheco chiefs or they didn't have her all that he brought it back. I don't know pick it in mac That was a solid you get called you're not gonna get it. I haven't we haven't it's a good I don't think we don't want to get a jake mosaic christ jones chiefs silver young blood for the uh rams It's basically like they took the most recent really like actual release and just made a big dlc for it young debut Levice mosaic watson for the browns purple cooper cup for the rams pretty much what they did out of 49 And mosaic derrick car only chicken factor That'd be amazing. I'd be all about that I had mcdonalds tractor and top show mcdonalds all-american mosaic rookie charlie jones going out to the bangles silver mix and bangles and silver ridder audible Popeye shrimp, I don't think I've ever had Popeye shrimp. I can never not get chicken when I'm there mosaic rookie is lacy for the jags orange rookie mazy smith to 199 for the cowboys Although for those of you that are like like a like a fried fish sandwich or something They did that limited time fried flounder fish sandwich like the cajun flounder. That was actually pretty damn good Pretty good, man. I had it a couple times That was a few years ago though, I think All right y'all be sure to like the stream. We appreciate everybody watching hanging out joining breaks Talking about food. We always talk about food It's like it has to happen once so once a night Was we get hungry like an hour into the stream chicken factor one-on-one That's what i'm talking about yo chicken chicken tendies orange party to 199 nice second-year party Ninus silver atoms and purple swagger jt for the cults jonathan taylor to 49 I think I got my swagger back That whole clip is so funny. I just do that in college. Oh It's so ridiculous, man That is a bijan rookie auto out of 99 atlanta For Taco Bell. I gotta get them both. Shepham. I love them both rookie auto bijan falcons rookie mosaic schoonmaker cowboys red rookie mappu patriots silver hurts for the eagles I actually had a breakfast crunch wrap yesterday before I started doing definitive with rich That's the best thing at pot at uh, I don't know if it's our taco bell is a breakfast crunch wrap sausage Never get bacon It's hash brown sausage egg cheese and jalapeno sauce. It's like the quesadilla almost Dude, it's so good legendary mosaic is darik henry for the titans silver jaylon hurts eagles Gotta get pat ahead for the bills.  I know there's a gold There's a gold coming up. Maybe that's a bill could be could be Could be any team a chain debut dolphins mosaic aeronaut rams followed by Gold dan hampton for chicago dub bears number to ten Dub bears splash mosaic of dianichre swift eagles Yeah, chicken quesadilla taco bus is good That's how the breakfast crunch I kind of is it's like a mix between A breakfast item that has like egg and stuff and the quesadilla honestly Regular crunch wrap stinks now. They only put like a little bit of beef in it shroud debut mosaic, uh fields for the bears silver david card texans Talk about remove the night in front of the menu that was like the only thing I got from there And that's why I hate them. What'd you get? The beefy nacho griller That's a pretty good one. They have a beefy nacho burrito now It's I think it might be like the same thing a little bigger though It's like beef cheese like fritos Like a little bit of rice. I think a little bit sour cream the only thing that throws me off is the rice I don't like the rice You'd ask for without it, but yeah, I know what you mean. I know what you mean Don't don't don't just get it without it. I mean I like you can't trust that though mosaic drum baddest for the stealers rookie orange rashi rice to 199 for the chiefs Rashi rice nice card But yeah, I've had that what you're talking about. It's called like It's called a beefy beefy rice Not beefy rice beefy Beefy beefy burrito. Yeah, that's what it is It's exactly what it's called the beefy beefy burrito. Yeah, there's a bill's hit. It is a autograph of don bb Yeah, bb red macabre nine silver airlock her bears Here we go, uh, silver herbert chargers. We'll go pat Yeah, if you've 50 50 percent off or sorry ea, uh Is something honeycomb now we did gold now we got a honeycomb Also top five cereals honeycomb. Is that a hot take? It's not hot take is that's delicious cereal mosaic okoye chiefs Echler honeycomb chargers. It's kind of a color match too. Nice hit bolts dang Echler honeycomb sp And a mosaic bossa metamastry. That's sick. That is niner's bossa Lane, you gotta you gotta let shawn know place fiefa a lot apparently Yeah, he has I think a lot of people have to shut yeah, it's a 50 off I'm gonna get it blue mosaic addison debut viking. It's really good box here six of 99 Hey Silver rookie ojolari cardinals They're gonna buy any uh baseball cards that open on black friday might See that I heard I heard Really? Yes, so be prepared Oh I'm gonna have to get some right song debut panthers I will let you know if that when that becomes official, but I believe I'm gonna get that I heard that thrown around uh mosaic thurman thomas bills red hurts eagles Yeah, I'm gonna my plan is to buy a bunch of someone black friday that can rip on I guess christmas eve this year because christmas day. I'm flying pennsylvania I guess I can see if like new years or something I heard some stuff shrive He heard some good stuff Tell you that Can I divulge? I will not mislead because if if if if my mind has changed then They're gonna do it I'm gonna buy some sealed stuff on black friday Uh silver derriusly eagles make sure you guys sign up for sms for black friday ricky mosaic detavis martin for the commanders Make sure you guys are enrolled in the sms service two autos first one is red and yellow robert brooks for the packers And then there's a j caner sainz ricky auto out of uh base base auto second one Red and yellow of bettis to 88 for the uh for the stealers there sorry to 80 sake one to 80 giants Zach martin uh to 80 for the cowboys now do tsa probably take the cards Red and green levis nice card titans And joy porter jr for the stealers Sold out on the first origins is five to go in number on 30 wow all the way well five teams left for tonight Let's go y'all appreciate it We lit Every day we lit silver lamar jackson ravens with a mosaic of mccaffrey for san francisco Heck yes drive there you go man. That's the way to do it To 25 black and green ricky auto broncos drew sanders Uh some for sure is tim like mosaic football has solid um like blaster boxes and stuff if you can find them For like retail price Some of the top scrom stuff is good too For for the price anyway, I mean I hear the update ones are pretty good top scrom update I think those are here those are solid Red and yellow ricky to 80 is detavis martin for the commanders Ray lewis to 80 again for the ravens chimera to 80 for the saints red and greens of rookie saints brian brissy And mazy smith for the cowboys Yeah, like you ever you have a realistic shot of hitting some decent stuff and those like tops chrome ones They they can be good. They could be good the merlin chrome blasters for soccer. We're pretty solid too But some of it some of it's not the best Some of the pinini stuff in particular can be like Not the best But the mosaic football ones are pretty solid. I hear It's not definitely not as bad as it was You know when they started jumping prices and people were paying crazy stuff, you know They've raised price, but I think they've raised odds for certain things Yeah, that's a good that's a good advice from spencer avoid basketball The doner's optic ones were like, okay I ripped like two I did okay But no if I if I'm gonna rip it if I'm ripping most stuff to be honest for me I'm ripping hobby. I'll just save up for hobby or like a jumbo whatever some sort of hobby skew but I will not rip retail honeycomb is eclair White mosaic splash is jefferson for the vikings Kind of 25 gold hampton to 10 autos of bb dtr hendon hooker The dtr and hendon hooker are not numbered. They're blue from blue disco or like the base robert brooks jay kainer jay kainer to 199 so Bijan the 99 that's a nice one falcons sanders to 25 and a gold auto of icky woods for the bangles That is gonna do it. Thanks again everybody moving on now to more football


Next, two months will decide the war in Ukraine. The main problem is the direction of Kharkiv. The advance of Russian troops along the front line and constant missile strikes on Ukraine's energy infrastructure are preparations for something more experts believe. Ukraine is now experiencing an acute shortage of ammunition and manpower to cover all 1,200 kilometers of the front line, Bloomberg writes. If the situation does not change, the front line may fall and the Russian army will begin to advance deep into the country, which is why the next two months will be the hardest for Ukraine. The residents of Kharkiv suffer the most. At the same time, the Kremlin really hopes for the depressed psychological state of the city's residents, allegedly they can simply leave Kharkiv on the eve of a major offensive. At the same time, most military experts believe it will be difficult for the Russian army to capture the city. In 2024 alone, the Russian Federation can receive up to 6 million shells, both through foreign supplies and through its own production. On the one hand, a number of American politicians believe that the front line will not fall so fast. But another agrees that the morale of Ukrainians is severely undermined. Now, more than ever, Ukraine is vulnerable to missile strikes by the Russian Federation. The enemy intensified along the entire front line, and target number one was the capture of Chasiv Yar. Colonel Iroh Rebo, the head of the General Staff of the Defense Forces of Estonia, has stated that Russia continues conducting active combat actions in Ukraine, despite significant losses, while the Ukrainian troops experience fatigue and lack of ammunition. Rebo indicated that the army forces of Russia conduct mechanized attacks by units to the battalion level, trying to benefit from the positive weather change and local landscape. Despite the losses, the Russian Federation has kept up the pace of advance and maintains the initiative in the combat zone, Rebo stated. He added that Ukraine's main problem is that it has not received the expected large Western ammunition supplies and the troops experience fatigue more and more. Yet, as of now, there are no signs that unplanned withdrawal of forces occurs in Ukraine or that any of the Ukrainian units refuse to fight, Rebo said. A rocket attack has been launched on Ukraine's occupied city of Luhansk, local telegram channels reported. An explosion occurred on the territory of the machine building plant where the armoured vehicles of the occupying Russian army were stationed as a result of the strike from storm shadow slash scalp missiles provided as a military aid from the United Kingdom. One of the rockets reportedly landed in the area of the bus station. Overall, the city was hit by three missiles. There have been no reports about casualties and the destroyed military equipment.